Nightingale to Watson Nursing Quality Research and Caring

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Nightingale to Watson: Nursing Quality, Research, and Caring Coming of Age 32 nd International Association for Human Caring Conference San Antonio, Texas - June 4 th, 2011 Donald D. Kautz, RN, Ph. D, CNE, CRRN Associate Professor of Nursing UNC Greensboro ddkautz@uncg. edu

Publishing Quality Caring Intersections 7 - B Practice/Clinical 32 nd International Association for Human Caring Conference, San Antonio, Texas June 3, 2011 Donald D. Kautz, RN, Ph. D, CNE, CRRN Associate Professor of Nursing UNC Greensboro ddkautz@uncg. edu

Publishing Quality Indicators of Caring • Formal reporting of quality care indicators is a requirement for all health care facilities • Focusing ONLY on Quality Indicators without ensuring caring may promote mechanistic, technical care. • On the other hand, no matter how caring staff are, if they are not competent, and quality is not ensured, care may become dangerous. • I have had the privilege of assisting nurses to publish their work, and from 2007 – 2011, I am a coauthor on 30 published articles…. and am currently working on 30 more, which are in various stages. • In the next few minutes, I will highlight a few of these articles. A more complete list is on your DVD, I will be happy to e-mail you any of these articles if you e-mail me.

Don wants you to Promote Family Integrity • Kautz, D. D. and Van Horn, E. (2009). Promoting family integrity to inspire hope in rehab patients: Strategies to provide evidence-based care, Rehabilitation Nursing, 39, 168173. Kautz, D. D. & Van Horn, E. R. (2008). An exemplar of the use of NNN language in developing evidence-based practice guidelines. International Journal of Nursing Terminologies and Classifications, 19, 14 -19 Van Horn, E. R. & Kautz, D. D. (2007). Promotion of family integrity in the acute care setting. Dimensions of Critical Care Nursing, 26, 101 -107.

Don wants you to Inspire Hope Kautz, D. D. (2008) Inspiring hope in our rehabilitation patients, their families and ourselves, Rehabilitation Nursing, 33, 148153. Kautz, D. D. (2007). Reading children’s books to awe and inspire nursing students. Nurse Educator, 32, 223 -226. Smith, A. D. & Kautz, D. D. (2007). Case study: A day with Blake: Hope on a Medical-Surgical unit. MEDSURG Nursing, 16, 378382.

Don wants you to Address Sexuality and Intimacy Concerns Kautz, D. D. , Van Horn, E. R. , and Moore, C. (2009). Sex after stroke: An integrative review and recommendations for clinical practice. Critical Reviews in Physical and Rehabilitation Medicine, 21, 99 -115. Kautz, D. D. (2007). Hope for love: practical advice for intimacy and sex after stroke. Rehabilitation Nursing, 32, 95 -103.

Don wants you to meet patient’s spiritual needs Williamson, W. and Kautz, D. D. (2009). Let’s get moving, let’s get praising: Promoting health and hope in an African American Church. ABNF Journal, 20(4), 102 -105. Hubbartt, B. , Corey, D. , Kautz, D. D. , and Rasmussen, B. (2009). Nurse, please pray with me. RN Journal. Available at http: //rnjournal. com

Published Caring Quality Intersections Montana C. & Kautz, D. D. (2011). Turning the nightmare of complex regional pain syndrome into a time of healing, renewal and hope. MEDSURG Nursing, 20(3), 139 -142. • Christina is a nurse anesthesia student who has had CRPS since 2004 • The article tells the story of her illness and treatment with excellent recommendations for providing high quality nursing care, to ensure “a hospitalization that helps the patient to heal and experience renewal and hope”

Montana & Kautz, continued In addition to aggressively treating pain, preventing post-op complications, and providing individualized comfort measures, we recommend taking a few minutes to sit and talk with the patient to provide hope and renewal. “Margo Mc. Caffery…wrote more than 30 years ago, ‘when your patient’s still in pain don’t just do something: sit there. ’ She recognized the importance of a nurse’s presence with a patient in pain to provide comfort and hope for both of them. ”

Published Caring Quality Intersections Ziel, R. and Kautz, D. D. (2009). The highest priority in the Emergency Department may be a patient’s spiritual needs. Journal of Emergency Nursing, 35, 50 -51. • Ruth, the charge nurse in a busy ED, received a call that they were getting a transfer to their E. D. of “John, ” a gravely ill elderly man. • At the family’s request, Ruth arranged for a priest to be present when “John” arrived at the E. D. to administer last rites. The hospital chaplain conveyed to the family who lived hours away, that last rites had been administered.

Ziel & Kautz - continued “John survived to be transferred to the ICU after resuscitation in the emergency department, and Ruth went on with the day’s work. While we do not know his outcome, we reflect on this sequence of events and feel certain that Ruth’s small act was critical for this patient and his family. This act, on that busy, busy day, is the one that she will always remember, and the memory of this event gives us hope on particularly frustrating days. ”

Published Quality Caring Intersections Levigne, D. and Kautz, D. D. (2010). The evidence for listening and teaching may reside in our hearts. MEDSURG Nursing, 194 -196. Debbie describes the care of the Mrs Logan and her husband in the special care unit (ICU step-down) • The expert care of bathing, turning her, ensuring there are no wrinkles in the sheets bothering her shingles lesions, as well as administering medications and treatments. • But also taking the time to listen and teach

Levigne & Kautz continued “the primary evidence for listening and teaching may be in the gratitude of patients and families, the nurse’s knowledge he or she has done the right thing, and a feeling today was a good day to be a nurse”

Published Quality Caring Intersections Kautz, D. D. (2011). Great rehabilitation nurses combine art and science to create magic. Rehabilitation Nursing, 36(1), 13 -15, 24. Published in January 2011 Don describes the care of a new quadriplegic young mother who was especially challenging – helping her cope, aggressively treating her pain, getting her ready for rehab, and truly involving her in decisions about her care – at times using some unconventional methods

Published Caring Quality Intersections In the June 2011 issue of Nursing Clinics of North America, Monsivias writes: “Not only does clinical expertise include knowledge of research findings at all levels but also includes knowledge of the most effective interpersonal approaches for dealing with challenging patients. Kautz provides a stunning example of provider expertise. His knowledge and experience guide his patient interaction in a rehabilitation in a way that won’t be found in any clinical practice guideline, and couldn’t be taught, yet worked in that situation. Expert clinicians have an internalized knowledge and sense of effective strategies and know when an unconventional approach might be effective. ”

The bottom line: • Everyone here has great stories to tell of caring quality intersections • Submit your stories for publication – there are many, many options.

2010 was the 100 th Anniversary of Florence Nightingale’s Death and The International Year of the Nurse

Randy L. Williams, II, RN, MSN, MBA Associate Faculty, Watson Caring Science Institute

Objectives 1. Apply Nightingale’s philosophy & Watson's science to quality, research, and caring in our everyday practice. Nightingale's philosophy, research and practice transformed hospitals and nursing. Watson's evolution of caritas science assists each of us to see the connectedness between nursing quality, research, and our care. 2. Illustrate Watson’s tenets through patient scenarios and story telling.

Plan for this session • Nightingale and Watson – the similarities and how we have come of age. - Research - Evaluating quality care - Caring • Patient scenarios which illustrate research – quality – and caring intersections • A wonderful book Grandad’s Prayers to show that when we reach for unattainable goals, reflect on our practice and are proud, speak from the heart, and remember that when we change ourselves, we change the world

Nurse Educator Vol. 32, No. 4, pp. 223 -226 Copyright © 2007 Wolteers Kluwer Health I Lippincott Williams & Wilkins Reading Children’s Books to Awe and Inspire Nursing Students Donald D. Kautz, Ph. D, RN, CNRN, CRRN-A Reading illustrated children’s books in the classroom to nursing students is 1 way to inspire students to be great nurses. After offering guidelines for the types of books to use and the courses books can be used in, the author describes the effects on student learning.

Why do I read children’s books to nurses? Years after having one of my classes a nurse told me “I will never forget the book, the Whispering Cloth and how important it is for me to help my patients tell their own stories for them to heal and to be able to picture a future full of hope. ” With that simple line, these graduates not only show their own ability to be great nurses, they also in essence tell their own story and picture their future as nurses, full of hope. As instructors, we are reminded of why we became nurses in the first place, and we are filled with hope as we light the way for those who will come after us. Kautz, 2007, p. 226

Nightingale’s Legacy Believing nursing is a profession Cleaning up the hospitals Changing soldier’s outcomes Statistical analysis of outcomes “Philosophy” of nursing from: Notes on nursing: What it is, and what it is not THUS – “theory & research drive professional practice” And because of ALL of these, she became… • • •

Lady with the Lamp

Before and After

Don’s Mom, Alice (a. k. a. Florence)

In more theoretical terms, Nightingale: Challenged nurses to the “full use of self, by connecting ourselves to: • The divine all around us • All of humanity • Our environment • The nature and cosmos As a means of learning, understanding, caring and healing. Watson, 2010 Illustrated by Amie’s patient… (Smith & Kautz, 2007)

Statistic’s Legacy Mc. Donald, 2010 Nightingale • Was a passionate statistician • Belief based on her faith in a God of order • Used statistics to indicate serious problems, assist in policy making, monitor outcomes Legacy for Nursing • Statistics is a required course in BSN programs Even though. . . • We are all taught, “we must show the effect of our care. . . ”

Unfortunately our data. . • Nursing is still “billed as part of the room charge” • Nurse’s enter data everyday which is never used. . . This data is rarely available to practicing nurses. Legacy for nurses in 2011 • We say that our practice is based on evidence, but much of our care is still based on tradition. • The technology is here for us to now to use ALL the data we collect. There will be more and more changes to come. . .

Is it STILL the Crimean War? Here? Today? NO? Yet we act like it is! Through the continued development of theory, science, and practice – we can continue to REDUCE the rare incidences of: • Nosocomial infections • Patient Falls • Medication Errors I believe Nightingale would be horrified we continue to focus our measurement of quality on the reduction of rare occurrences. But this is where nursing needs to “come of age” We need to truly use the data we collect and enter into the electronic medical record.

A nurse caring for an elderly man who had an elective hip replacement the day before should be able to walk in and say: I see from this morning’s print out that: Your wound was clean and dry yesterday, and the surgeon changed the dressing this morning. You inspected the wound, and told the surgeon how you would care for it at home. You were also able to state all the signs of infection, and when you should come back to see your doctor after you are discharged. Your blood pressure and temperature have been normal. You ate all of your dinner and breakfast without nausea, had a bowel movement, have been up to the bathroom with help, and walked 100 feet in the hallway. Your pain has never been above a 3 by taking Vicodin every 4 hours. Your son, Joe, from Milwaukee is here to stay with you for the next week, and you should be ready to go home tomorrow.

Nightingale’s Personality Type (Dossey, 2010) I (Introversion) Nightingale was an introvert. When she was alone, she experienced her best ideas – her intuition and brilliance flourished when she worked by herself N (Intuition) Nightingale’s greatest gifts came from her intuition – flashes of inspiration, insights into relationships of ideas and meaning of symbols. T (Thinking) Nightingale’s preference was to make decisions based on her logical analysis of the facts – and her own experience. She was proud that she had never been swayed by a personal consideration of another’s feelings. J (Judging) Nightingale loved to live her life in a manner that is decided and settled. Nightingale had a system for everything, a planned life, sustained effort, and acceptance of routine.

INTJ Personality Type A major legacy for nursing Traditionally, nursing has valued nurses who are independent, individualistic, single-minded, love rules and order, and tough minded with others – and follow the leaders who think and act just like them. The pitfall is that nursing leaders may have difficulty letting go of impractical ideas, ignore the impact of their leadership style on others, and criticize others who strive for the ideal. Some would argue that this personality type has led us to be a profession that… New leadership models are emerging!

New Leadership Models A Caring Leadership Model for Nursing’s Future Williams, Mc. Dowell, and Kautz, 2011 Caring Leadership Model © Exemplar of Caring Leadership: I have two RNs in my department who desire to cut Model of Care back on their work hours. Patient/Family, Team, Self, Community These employees are long. Mc. Dowell-Williams time, seasoned nurses. I sat Core Values of Caring Leadership down with both of these employees and allowed them Always live with kindness, compassion and equality to discuss their concerns and wishes. I could have ignored Generate hope and faith through co-creation their request but instead have worked with them to create Actively innovate with insight, reflection and wisdom work hours that meet their Purposely create protected space founded upon mutual personal needs. I allowed them to “vent” and gave them respect and caring guidance and support. We Embody an environment of caring-helping-trusting for are in a trial period with their self and others schedules. ~~C. M. Shared Decision-Making

New Leadership Models Goldin, M. & Kautz, D. D. (2010) Nurturing Nursing Students During Intensive Care Unit Clinical Practicum. Dimensions in Critical Care Nursing, 29(5), 238 -240. With Marlienne Goldin’s leadership, staff transformed the ICU using Watson’s 10 Caritas processes: • Practice of loving kindness • Staff nurses love having students • Relationship based care (based on Watson science)

New Leadership Models Goldin, M and Kautz, D. D. (2010) Applying Watson’s caring theory and caritas processes to ease life transitions. International Journal of Human Caring, 14, 11 -14. This personal account of Marilienne’s transformed life illustrates how as a clinical expert, confronted by a major change, Marlienne applied Watson’s (2008) caring theory and caritas processes to her life. By sharing her story our hope is that others who find their lives turned upside down can see it is possible to take control, heal and grow.

Nightingale’s Challenge for Nurses Dossey, 2010 Nightingale’s INTJ personality allowed her to be a practicing mystic, mange her chronic illness, and her ability to create new models of nursing care. Nightingale’s legacy is a challenge for nurses to: - educate political leaders to create health reform - integrate healing, spirituality AND technology - respond with the same courage she demonstrated in carrying our vision to the world Nightingale would argue there is still a need for a “rebirth” of the true values of nursing – which is what Watson argues For an eye-opening source on “rebirth of nursing” see the Future of Nursing: Leading Change, Advancing Health (www. nap. edu) (Often referred to as the IOM report)

In summary, Nightingale was: • A nursing theorist • A visionary • A statistician • A nursing instructor • And also believed…

Some of Watson’s Basic Tenets • Art and the artistry of beginning and advanced caringhealing arts • Return nursing and health-care to wholeness • Honoring the unity of body/spirit • Restoration of individuals and systems seeking harmony with environment, nature, and God • Being authentically present • Transformation in the caring moment Illustrated in “Lilly’s gift from Africa” (Kautz & Kautz, 2011)

Lilly’s Gift from Africa • Lilly describes seeing a very poor boy, of 4 or 5 playing in a mud puddle – letting the water sift through his fingers – and laughing. • I wrote: “Lilly’s story reminded me that our patients are so much more than the reason they’ve come to see us. Her story also made me think that in order to recruit teens to nursing careers, we must share the hope, joy, and wonder we experience in our practice. We need to tell them that as nurses, we have the opportunity to experience life in its simplest terms. ”

Lilly wrote: “At that moment, in watching this boy, I came to understand two things. First, happiness is temporary, but so is sadness. This boy’s life was obviously filled with hardship, but for the 10 minutes that I watched him play, this seemed to enter his mind. Second, even though this child might die soon, he’d experienced true pleasure. His mother didn’t have to buy him presents to make him understand happiness. At this point in his life, he was truly and incandescently happy. ”

Lilly wrote: • “As we drove away, I began to laugh. I hoped that one day I’d find my puddle of happiness. When that day comes, I’ll run my fingertips across its shimmery surface and find pleasure in the soft feeling drifting across my fingers. Seeing the joy in that boy’s face, I’ve seen what some people never get the chance to see. I’ve seen life, in its simplest terms, at it’s core. ”

Nightingale and Watson’s work Nightingale’s work expanded: • From thoughts on nursing and guidelines for practice to a Philosophy of Nursing Watson’s work expanded: • From a “theory” of caring with “Caritive factors” • To a “Caritas Ethic/Science” with “Caritas Processes” The major difference between theories and a science or philosophy is… The MAIN difference between Nightingale & Watson

Just as Don believes Our outcomes are better that ever, through care provided every day We often see the connectedness of what we do every day, with everyone else – our spiritual side Don also believes we all need to be reminded… And to help reduce the complexity of Watson’s model… My gift to you is to hear Nightingale’s philosophy and Watson’s caring science in a children’s book.

Grandad’s Prayers This children’s book was written to help a boy who forgot how to pray. As I read the book, think about the times you have forgotten why you became a nurse… Or, think of someone else who has forgotten You will see the connectedness to the earth and to all people that Nightingale and Watson see in what we do everyday

Watson & Nightingale see When we provide care to others, we • Reach with the trees • Are silent with the rocks • Reflect with the lakes • Laugh and Play with the streams • Breathe with the flowers • Sing with the wind

Watson & Nightingale see: There are GREAT rewards as we: • Reach for unattainable goals • Are silent to listen and learn • Reflect on our practice and are proud • Laugh and find humor • Breathe spirit – that we all share • Sing with joy about what we do

Watson & Nightingale see There are GREAT rewards as we: • Greet each new day • Remember what holds us together • Speak from the heart • And remember that when we change ourselves, we will change the world.

Watson & Nightingale also see We will be rewarded when we: • Greet each new patient… • Show through our theory, science, and practice that the care we provide is… • I believe that all of us are GREAT caritas nurses • And if we speak… • But in order to do that… • Because in that moment, when we change • I believe, I…

Articles on Nightingale all from the March 2010 (Volume 28, Issue 1) issue of the Journal of Holistic Nursing Dossey, B. M. (2010). Florence Nightingale: Her personality type. Journal of Holistic Nursing, 28(1), 57 -67. Mc. Donald, L. (2010). Florence Nightingale: Passionate statistician. Journal of Holistic Nursing, 28(1), 92 -98. Watson, J. (2010). Reflections: Florence Nightingale and the enduring legacy of transpersonal human caring-healing. Journal of Holistic Nursing, 28(1), 107 -108.

Kautz and Colleague’s sources Kautz, D. D. and Kautz, L. (2011). Lilly’s gift from Africa. Nursing, 41(4), 53 -54. doi: 10. 1097/01. NURSE. 0000395205. 88237. 5 a Williams, R. L. III, Mc. Dowell, J. and Kautz, D. D. (2011). A caring leadership model for nursing’s future. International Journal of Human Caring, 15(1), Kautz, D. D. (2011). Great rehabilitation nurses combine art and science to create magic. Rehabilitation Nursing, 36(1), 13 -15, 24 Goldin, M. and Kautz, D. D. (2010). Nurturing nursing students during intensive care unit clinical. Dimensions in Critical Care Nursing, 29, 238 -240. doi: 10. 1097/DCC. 0 b 013 e 3181 e 6 cd 55 Goldin, M. and Kautz, D. D. (2010). Applying Watson’s caring theory and caritas processes to ease life transitions. International Journal of Human Caring, 14, 11 -14. Smith, A. and Kautz, D. D. (2007). A day with Blake: Hope on a medicalsurgical unit. MEDSURG Nursing, 16, 378 -382.