The Attending Caring Nurse Project

from Caring For Our Future, Spring 2003

Nurses and other health-care professionals who are participating as volunteers are engaged in a collaborative research project on 3 North at The Children’s Hospital. The study was designed to pilot a theory-guided, evidence-based, collaborative practice model. It is called the “Attending Caring Nurse Model” (ACN) and it is being piloted with health-care professionals who care for hospitalized children in pain. This study is the first to apply Caring theory to interdisciplinary pain management through an advanced practice model. Specific aims of the project are to explore the effect of integrating Caring theory into pain management practice, and to examine the feasibility of the ACN model as a method of care delivery for hospitalized children in pain.

Study participants were introduced to Caring theory in a 3-day workshop led by Dr. Jean Watson. Content included the philosophy, theory, and science of Human Caring; the carative factors; consciousness, intentionality and caring–healing modalities; and self-care practices (Watson, 1999). Additional support for caring practice has been provided through discussion groups with Dr. Watson and the ongoing involvement of Terri Woodward, RN. Woodward, who will soon complete her master’s degree in Family Holistic Nursing, is a Clinical Holistic Nurse Consultant on 3N. Her background in Caring theory and her availability to model caring and healing modalities have been critical to the project. As one participant told Woodward in a recent discussion group, “When we see you doing it, we remember all of these things that you’re saying.”

Woodward’s expertise is only one element of the project’s success, however. Each participant has contributed in important ways and several innovations can be credited to collaborative efforts among the participants. One of the novel aspects of this research is the participatory action research design (Reason, 1994; Torbert, 1981a, 1981b). Unlike experimental designs where the researchers carefully plan and control all aspects of the study, participatory action research is guided by ongoing, collaborative efforts among researchers and participants. In this study, the researchers provided Caring content and support, but participants decided what to do with the information. Once participants completed the content workshop, they began to explore their personal experiences with caring practice and to implement their ideas about how Caring theory could enhance the way they care for children in pain.

Study participants have initiated a number of new caring practices on the unit. One popular new practice is the availability of massage for families and staff. Woodward provides seated massage for night staff at change of shift four days a week, a modality that helps staff relax and prepare for restful sleep when they get home. Interns from the Heritage College massage program provide seated massage for families and staff during selected daytime hours. The massage intern’s hours and other caring/healing activities are posted on the unit to inform families of available resources.

Another new practice is the initiation of Quiet Time from 1 p.m. to 1:30 p.m. each day. Lights are dimmed on the unit and staff is asked to avoid disturbing children and families during this time. Participants have commented that the dim lights provide a restful atmosphere for the entire unit and the noise level decreases.

The healing room provides another oasis for families and staff. Created from the former conference room, this beautiful new area features wall-sized murals by artist Cynthia Tesley, whose son was formerly a patient at TCH. The soft colors and captivating images transformed the nondescript room into an inviting place to read, reflect, relax, and take advantage of the family-centered materials provided by the Recreation Therapists and Child Life Specialists.

The blessing basket is another innovation. Families and staff are invited to offer names for blessings by writing initials on a slip of paper and placing the paper in wicker baskets found at the nurses station. An accompanying sign informs those interested that Chaplain Claudia Schmitt and Woodward observe a 15-minute period of quiet reflection weekday mornings to ask for peace and hope for all whose initials have been placed in the baskets.

Nursing care practices have changed as well. The researchers have encouraged participants to write guidelines on the order sheet to better coordinate interdisciplinary care. Guidelines can involve such things as which of the ordered analgesics has been effective for this child, preferred coping strategies with procedures, or patient and family preferences. Participants have commented that these guidelines improve collaboration and consistent care among interdisciplinary caregivers. For example, one nurse commented, “I was involved with a patient one day and wrote the orders [caring guidelines] and it really felt like, ‘Wow,’ now this discussion that [my colleague] and I had is going to continue on shift after shift.” Another participant noted that writing guidelines on the order sheet rather than the Kardex also helps to “legitimize” the notes and increase the chance more caregivers will read them and follow them.

Individualization of care has been another focus for study participants. One individual commented:

“We’ve done a lot of individualizing care for kids — things that the families and the kids want. A lot of times I’ll go and talk to the kids or observe a dressing change and give them some suggestions. And we’ll talk together about what they think would work. I’ll go type it up, put a little picture on it, take it back to the room and the families look at it. We make any necessary changes and then we post it in the Kardex and in the room. And I’ve heard a lot of comments from families and from the nurses that it’s really helped.”

Importantly, research-initiated practice changes are affecting not just study participants, but are changing care across the 3N unit. The unit’s strategic goals for 2003 were based on the carative factors and included a specific goal about caring. Interviews with nurse applicants now include questions about their philosophy of caring and caring experiences. Unit leadership is optimistic that these new interview strategies will enhance their ability to choose applicants most likely to be successful in the 3N environment. Staff new to the unit learn more about caring practices in unit-specific education classes that include strategies for self-care.

Participants in this study are leading the creation of a different kind of milieu, a healing environment, and they’re inviting families and other practitioners to participate. Although the research study will soon be completed, investigators and participants are optimistic that innovations in Caring will continue on 3N. Results of qualitative and quantitative data collection still in progress will support a grant application to expand research with this professional practice model.

References

Reason, P. (1994). Three approaches to participative inquiry. In N.K. Denzin & Y.S. Lincoln (Eds.), Handbook of qualitative research (pp. 324-339). Thousand Oaks, CA : Sage.

Torbert, W.R. (1981a). Why educational research has been so uneducational: The case for a new model of social science based on collaborative inquiry. In P. Reason & J. Rowan (Eds.), Human inquiry: A sourcebook of new paradigm research (pp. 141-151). New York: John Wiley.

Torbert, W.R. (1981b). Empirical, behavioral, theoretical and attentional skills necessary for collaborative inquiry. In P. Reason & J. Rowan (Eds.), Human inquiry: A sourcebook of new paradigm research (pp. 437-456). New York: John Wiley.

Watson, J. (1999). Postmodern nursing and beyond. London: Churchill Livingstone.