Reigniting the Caring Fever in
Nursing
Nursing Leadership Institute, South Carolina
June 5-7, 2013
Dana Nelson-Peterson, DNP, MN, RN
Virginia Mason Medical Center, 2013 ©
Objectives
By the end of this session the participant
will be able to :
 List the five caring principles of Swanson’s
Nursing Caring Theory
 Describe one way to use a caring principle
in daily nursing practice
 Understand how one medical organization is
using a management system and nursing
theory to implement a nursing professional
practice model
Virginia Mason Medical Center
Strategic Plan
© 2011, Virginia Mason Medical Center
Virginia Mason Medical Center
•Integrated health care system
•501(c)3 not-for-profit
•336-bed hospital
•Nine locations
•500 physicians
•5,500 employees
•Graduate Medical Education
•Research Institute
•Foundation
•Virginia Mason Institute
Virginia Mason Production System
The Virginia Mason Production
System (VMPS) is a management
method that seeks to continually
improve how work is done by
identifying and eliminating waste and
inefficiency in the processes that are
part of the health care experience.
Foundational Elements
• Geographic assignments
• Documentation near the patient
• In room handoffs
• RN:PCT integration
• Huddles every shift
• Hourly rounds by caregivers
• Daily Leader rounds
• People Link Boards updated and staff
huddles done monthly
© 2011 Virginia Mason Medical Center
Results
Decreased walking
Decreased “hunting and gathering”
Decreased time for morning cycle of care
Decreased falls
Increased throughput
Increased communication with RN, PCT, and
Patients
Increased patient and staff satisfaction
Conditions were optimized for the
extraordinary patient experience…
What’s missing at VM?
• No common language for talking about caring
• No shared model of professional nursing
•
•
practice at VM
Many models of professional nursing practice to
choose from
Opportunity for VM to define what our model of
nursing care is using the tools of VMPS
Great Thinkers
Nursing: What it is and What it is not
Nursing Theory
Nursing theory is the term given to the body
of knowledge that is used to define or
explain various aspects of the profession
of nursing
 Dorothea Orem (Self Care Deficit theory)
 Virginia Henderson (Need Theory)
 Rosemarie Rizzo Parse (Human Becoming
Theory)
 Hildegard Peplau (Interpersonal relations)
… and many others
Nursing theory
In general…
• Provides a basis to improve practice
• Provides standards for practice
• Shared mental model
 Purpose for nursing
 Guides education, research
Caring
“A nurturing way of relating to a
valued other towards whom one
feels a personal sense of
commitment and responsibility.”
Kristen Swanson, 1991
Caring
• Patients and their families
• Teams
• Self
Caring Principles
• Knowing
• Being With
• Doing For
• Enabling
• Maintaining Belief
Knowing
• Striving to understand an event as it has
meaning in the life of the other
•





Avoiding assumptions
Assessing thoroughly
Seeking cues
Centering on the other
Engaging the self of both
Being With
• Being emotionally present to the other





Being there
Conveying availability
Enduring with
Sharing feelings
Not burdening
Doing For
• Doing for others what they would do
for themselves if it were at all
possible





Performing competently, skillfully
Comforting
Anticipating
Protecting
Preserving dignity
Enabling
• Facilitating the other’s passage through
life events and transitions





Informing/explaining
Validating/giving feedback
Supporting/allowing
Focusing
Generating alternatives/
thinking it through
Maintaining Belief
• Sustaining faith in the other’s capacity to
get through an event or transition and face
a future with meaning





Believing in/holding in esteem
Offering a hope filled attitude
Going the distance
Offering realistic optimism
Helping find meaning
Project Proposal
Bringing Nurses and Caring Back to the
Bedside with the Virginia Mason
Production System
Goals:
 Improve Patient Experience
 Improve Staff Satisfaction and
Engagement
 Improve Patient Outcomes
What We Have Done So Far:
• Curriculum development and education
using the tools of VMPS
 Innovation, visioning, idea generation,
standard processes, newspapers
• All inpatient units and across Oncology
•
•
•
Service line
12 Off Site Retreats with Kristen Swanson
14- 2 Day Off Site Collaboratives
~550 team members have participated
Putting it all Together
Bringing it all to practice
Concierge
Cart
Huddle
Cards
Applause
Cards
Examples
Badge
Hangers
Internal
Website
Further Work
• Unit Level Caring
•
•
•
Boards
Caring Moments in
Daily Huddles
Caring Exemplars
Caring Standards
 Team Pledges
 Unit Quiet Time
 “Get to know your
team members”
monthly exercise
Virginia Mason Nursing Model of Care ©
Bringing Caring Back to the Bedside
Connie Hirnle, MN, RN-BC; Deborah Kelly, MN, RN; Niki Kirby, BSN, RN; Shirley Klakken, BSN, RN; Dana Nelson–Peterson, MN, RN
OVERVIEW/BACKGROUND
Virginia Mason Medical Center is developing an innovative nursing
model of care that integrates key elements of The Caring Theory,
created by nurse theorist Kristen Swanson RN, PhD, FAAN, with
the Virginia Mason Production System© (VMPS) 1.Virginia Mason
Medical Center has used the tools of VMPS to reduce waste so that
nursing staff can increase time spent at the bedside.
Swanson’s Caring Theory 2
RESULTS
Before you began the Retreat:
After you completed the Retreat:
I had a good understanding of how my caring impacts
I have a good understanding of how my caring
the patient experience.
impacts the patient experience.
Strongly
Disagree
Agree
Strongly Agree
Strongly
Disagree
Agree
Strongly
Disagree
2
27
8
Disagree
0
2
Agree
1
0
36
I had a good understanding of the caring concepts and
felt I role-modeled them well.
Strongly
Disagree
0
Disagree
12
Agree
23
Strongly Agree
3
I have a good understanding of the caring concepts
and feel I can role model them well.
Strongly
Disagree
0
Disagree
0
Agree
13
Strongly
Agree
25
I was comfortable in maximizing caring moments and
I am comfortable in maximizing caring moments
coaching opportunities as they relate to service
and coaching opportunities as they relate to
excellence.
service excellence.
Strongly
Disagree
Agree
Strongly Agree
Strongly
Disagree
Agree
Strongly
Disagree
11
24
3
Disagree
0
17
Agree
0
0
21
Patient Experience:
GOALS
The goals for the project focused on three areas:
•Improve Patient Experience
•Improve Staff Satisfaction and Engagement
•Improve Patient Outcomes
METHODS
• “ staff worked really well together, everyone pitched in regardless
of their job description or title”
• “you definitely took care of my concerns and I thank you for
hearing me, and taking my concerns seriously:
• “every staff member were professional, caring and encouraged me
every step of the way”
Staff Satisfaction and Engagement:
• Renewed passion and engagement for nursing practice
• A tangible change in the culture of caring on the units
• Significant change in staff engagement scores (Press Ganey)
across all units
•Identified three inpatient medical-surgical nursing units as pilot
areas; the Unit teams consisted of Unit Nursing Directors, Clinical
Nurse Leaders, RNs, and Patient Care Technicians
•Participants attended two day off-site Caring retreats with follow-up
via cohort learning collaboratives where they report their progress
•Reflective practice strategies were used to role model caring
experiences and elicit reflective narratives from participants
•Teams designed caring practices using VMPS tools during the retreat
for testing and implementation on their units
•Guidance team conducted on-going Caring Rounds
CONCLUSION
In a highly technical and fast paced medical environment it is
possible and imperative to include basic caring principles to
improve patient care and staff satisfaction. An unexpected outcome
is the engagement of staff to create a legacy for future professional
nursing practice at our organization.
C. (2011). Transforming Health Care. Virginia Mason Medical Center’s pursuit
of the perfect patient experience. Productivity Press , New York, NY.
2 Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nurs
Res. May-June 40(3) pp 161-66.
1Kenny,
This work was made possible through a grant from the Arthur Vining Davis Foundation
Compassion Fatigue (CF): Evaluation of a CF Intervention Using Swanson’s Theory of
Caring and The Virginia Mason Production System (VMPS)
Dana Nelson-Peterson, DNP, MN, RN; Deborah Kelly, MN, RN; Niki Kirby, MSN, RN
OVERVIEW/BACKGROUND
Caregivers of patients who are facing life-limiting illnesses are particularly prone to compassion fatigue, a
gradual lessening in compassion over time due to inability to help their patient’s disease progression
(Vachon & Huggard, 2010). Compassion fatigue remains a fairly new phenomenon in nursing. As a
model of care was implemented across the Oncology service line, education and strategies to recognize
and alleviate symptoms of compassion fatigue were included to optimize our team’s ability to care for
patients/family, team members and self.
RESULTS
The following questions were asked of the Oncology Service Line participants to evaluate the effectiveness of the
intervention surrounding compassion fatigue.
I have a good understanding of how my caring impacts the patient experience.
Before Retreat
Strongly
Agree
36%
The project focused on development, planning, implementation and evaluation of an intervention to
address compassion fatigue and care for self, teams and patients across the oncology service line at
Virginia Mason. The intervention focused on creating a shared model of nursing care blending Dr. Kristen
Swanson’s (1991) Theory of Caring with interventions for addressing compassion fatigue using the
principles of the Virginia Mason Production System (VMPS).
After Retreat
Strongly
Agree
Agree
33%
Agree
62%
66%
I am comfortable in maximizing caring moments and coaching opportunities as they relate to service excellence.
After Retreat
Before Retreat
Strongly
Agree
Agree
18%
Study Question: Does an educational intervention influence the participants’ ability to understand the
impact of caring and compassion fatigue on both the patient’s experience and the participant’s delivery of
care?
Strongly
Agree
38%
60%
Agree
74%
I have a good understanding of compassion fatigue and the impact it might have on my care delivery.
DESIGN/ METHODS
Before Retreat
After Retreat
Strongly
Agree
23%
Agree
Strongly
Agree
36%
Agree
64%
63%
I have a good understanding of the caring concepts and feel I can role-model them well.
After Retreat
Before Retreat
19%
Design: Descriptive non-experimental pre-post design
Strongly
Agree
Agree
Strongly
Agree
Agree
39%
61%
68%
Methods: Oncology service line (Hematology-Oncology clinic, Oncology Infusion Center, Radiation
Oncology Clinic and the Oncology inpatient nursing unit) team members (n=111) participated in a two
day retreat that included education regarding compassion fatigue while creating a model of care delivery
incorporating the theoretical framework for caring using the tools of VMPS.
• During these retreats and subsequent collaboratives, opportunity for self-renewal and team building
was created through individual and group work.
• Creation of a shared vision and definition of foundational elements of a care delivery model that focus
on caring for patients, self and teams occurred.
• Identification of strategies to identify, mitigate and prevent compassion fatigue were developed.
I have a good understanding of compassion fatigue and how it might impact the patient experience.
Before Retreat
24%
Strongly
Agree
Agree
64%
After Retreat
Strongly
Agree
Agree
37%
62%
OUTCOMES/CONCLUSIONS
Outcomes: The effect of the intervention was evaluated through data analysis using the 2 x 4 chi square test
applied to the pre-post evaluation questions surrounding caring and compassion fatigue which resulted in statistically
significant shifts at the p<.0002 on all data points with an enhanced awareness and application of incorporating
strategies around demonstration of caring and mitigation of compassion fatigue into their practice.
Visioning
Exercise
Implementation
Plan
Conclusions: Results of this project suggest the need to be cognizant of the burden and consequences associated
with compassion fatigue that may be experienced by the oncology caregiver. Designing interventions directed
towards addressing and alleviating compassion fatigue has a positive effect on both the delivery of care and the
patients’ experience
Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nurs Res. May-June 40(3) pp 161-66.
© 2013 Virginia Mason Medical Center
Vachon, M., & Huggard, J. (2010). The experience of the nurse in end-of-life care in the 21st century: Mentoring the next generation. In B. Ferrell & N.
Coyle (Eds), Oxford textbook of palliative nursing (pp. 1131-1155). New York: Oxford University Press.
Results
• Standards for care developed around:




Building a caring environment
Creating a climate of emotional support
Developing caring relationships
Mistake proofing communication and
commitments to optimize care
Results
Staff Satisfaction and Engagement:
• Renewed passion and engagement for nursing practice
• A tangible change in the culture of caring on the units
• The “Caring Fever”
• Significant change in staff engagement scores (Press
Ganey) across all units
Patient Experience:
• “Staff worked really well together, everyone pitched in
regardless of their job description or title”
• “You definitely took care of my concerns and I thank you
for hearing me, and taking my concerns seriously”
Professional Practice Model
• Using VMPS tools, creating a Professional
Practice Model for nursing care delivery
throughout organization:
American Academy of Critical Care Nurses
(AACN) Synergy Model for Patient Care
+
Swanson’s Theory of Caring
Principles of the AACN Synergy
Model for Patient Care
• “a conceptual framework describing a patientnurse relationship that acknowledges the
primary importance of nursing care based on the
needs of patients and their families.”
• “The fundamental premise of the Synergy Model
is that patients’ characteristics drive nurse
competencies. When patient characteristics and
nurse competencies are in synergy, optimal
patient outcomes are more likely to occur.”
AACN Synergy Model
Patient
Characteristics
• Stability
• Complexity
• Predictability
• Resiliency
• Vulnerability
• Participation in
•
•
decision making
Participation in care
Resource availability
The eight patient
characteristics
span the continuum
from health to
illness.
AACN Synergy Model
Nurse Competencies
• Clinical Inquiry
• Caring Practice
• Response to Diversity
• Advocacy/Moral
•
•
•
Agency
Facilitation of
Learning
Collaboration
Systems Thinking
The eight nurse
competencies span
the continuum of
skill levels from
competent to expert.
AACN Synergy Model
In the synergy model, when the skills of
the nurse are matched with the needs of
the patient, the care is “synergized” and
optimal patient outcomes are achieved.
Innovation event
• 2 day event
• 18 Nurse leaders throughout organization
• Attention, escape, movement exercises





Voice of the patient
Current state
Word play
7 Ways from Nature
Fishbone exercise
Conceptual Model for Care
Management Services-draft
.
The Future
• Service Lines/Organizational Spread
• Nursing practice throughout VMMC
 Orientation/On-boarding/Residency Program
 Integrated plan of care
 Professional Development and Recognition
Program
 Nursing Documentation
… and beyond Nursing through
Regional presentations, Publications, Academic
partnerships, GME, Virginia Mason Institute and
others
Questions?
Thank You!