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 Nurses Transforming Nursing (NTN) Toolkit
Introduction
Nurses Transforming Nursing is a program within the Professional Practice Advocacy Coalition (PPAC) of the North Carolina Nurses Association (NCNA) to transform the nursing culture through Appreciative Inquiry (AI). It continues PPAC’s goal to promote healthy workplaces for nurses across North Carolina and promotes the vision that “partnering with consumers increases the likelihood to optimize change within the health care system.”
Nurses in North Carolina value and honor caring for others, caring for each other, and caring for ourselves.
Using This Toolkit
This toolkit is intended to be a collection of resources that can be used to assist health care organizations, nursing staff, and others in understanding the cultural shift of Nurses Transforming Nursing (NTN) through use of Appreciative Inquiry (AI). It is important to note that simply reviewing and understanding the resources in this toolkit is not sufficient for implementing NTN. NTN implementation is a significant cultural shift that will take considerable time and effort and should be done in collaboration with peers who are willing to share their experiences. There is not a “one size fits all” approach to adoption of a NTN, so the experience and expertise of others should be shared as nurses in North Carolina embark on the journey of transforming the culture of nursing.
Reference Proposal
Presented to and adopted by the North Carolina Nurses Association House of Delegates on October 8, 2010.
Nurses Transforming Nursing
Appreciative Inquiry (AI)
AI promotes change through creative dialogue, excitement, and a focus on what works well versus problem identification and negativity. The AI approach includes four phases, which are Discovery, Dream, Design and Deliver. All of these phases are important in effecting change.
http://www.clevelandconsultinggroup.com/pdfs/appreciative_inquiry.pdf
http://appreciativeinquiry.case.edu/
Nurses Transforming Nursing (NTN) and Appreciative Inquiry (AI)
Discover: Discovery Agent Questionnaire and Discovery Agent Tips
Deliver: NTN Commit to Action Form
Presentations:
The NTN Speakers’ Bureau is a group of NCNA members who have volunteered to provide a NTN presentation to you, at your location. In addition to the items listed below that will be included in the presentation by the NTN Speakers’ Bureau member, the presentation will provide a venue for a lively conversation in which nurses have the opportunity to share in the NTN story and contribute to the forward movement of NTN. NTN presentations include: PPT on the history of NTN; Information about discovery agents/questionnaires, and commit to action pledges; speakers’ bureau sign-up; and stakeholder identification.
NTN presentations can be provided for continuing nursing education credit through NCNA.
Contact NCNA to schedule a presentation from a member of the NTN Speakers' Bureau.
The North Carolina Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Caring for Ourselves
Definition: caring for ourselves is nurturing ourselves as valued whole persons to a place of optimal well-being.
Being aware of ourselves, being aware of what is working well or not, and caring enough to attend to our own needs is part of self-responsibility. We cannot be fully responsible to care for others and each other if we are not responsible for ourselves first. We honor ourselves through our individual awareness of self-care, energy, and life balance, and striving to achieve optimal levels in each of those areas. We need to start where we are.
Questions to ask yourself:
- What am I attending to?
- What am I ignoring?
- Where is my energy going?
- How are my thoughts and actions serving me (or not)?
- Where is my life out of balance?
- How do I maintain the areas I feel are already “in balance”?
Each individual must discover and define what “caring for self” means to them.
Steps to self-care:
- Permission: give yourself permission to practice self-care. Give other nurses permission as well. The organizational culture needs to support this.
- Awareness: before a change toward self-care can occur, awareness must be heightened. Start where you are.
- Education: after one is aware of “where they are now”, education shows them how to get to self-care. This education (knowledge and resources) is individualized to what each person needs. Ex: nutrition education, spiritual guidance, exercise expertise, coaching, relaxation techniques, etc.
- Choice and setting intentions: you make the conscious choice to practice self-care and set your intentions. Intentions are stronger and more powerful than “goal setting” (the why behind the goals).
Caring for Ourselves Resources
Dorothea Orem's Self-Care Theory
Compassion fatigue:
THE SELF-CARING NURSE
http://www.compassionfatigue.org/index.html
Online relaxation tools:
http://www.relaxedandalert.com/ (tai chi, qigong, breathing exercises, relaxation techniques, simple meditation)
www.yogaglo.com (yoga home classes, simple meditation)
ANA Resources
Caring for Ourselves Resource List
Caring for Ourselves Stories
(1) After my sister was diagnosed with breast cancer, it was recommended that I be tested for the BRCA gene which she carried. Our family has a long, and sorted history of cancer, so when my test came back BRCA-1 +, it took very little deliberating to decide to have prophylactic bilateral mastectomies. I was already a 20+ years survivor of Burkitt's Lymphoma, I had no intention of adding breast cancer to my list of battles. During the recovery from my mastectomies, I had a lot of time to really consider how many other ways I was taking care of myself and minimizing my risk of suffering from the same conditions that I help people care for everyday. It was then that I realized that though I had undergone a major surgery to "keep myself healthy", I had bigger issues that needed to be addressed. I was grossly overweight (and still hate to admit it), a terrible insomniac, borderline hypertensive and so out of shape that, after surgery, it was usually all I could do to stand up without using my arms. That was November of 2008. In January of 2009, I decided things were going to change. No more excuses about travel and stress. I travel 2-3 weeks out of the month for my job and the stress of some of those weeks can be extraordinary. That used to mean a very nice dinner and a couple glasses of wine at night to "unwind", but no more. Now, I start every day on the road in the hotel gym, and sometimes I end the day there as well. (At home, I work out from an hour to two and a half every day.) I search for hotels with full kitchens and on every occasion possible, make my own meals including brown bag lunches. In August, I took another step and became a vegetarian to aid the battle with my genetically high cholesterol the way that nature intended, rather than the pharmaceutical companies. Surprisingly enough, 3 days after I gave up the meat, I slept all night long. I rang in the 2010 New Year 60lbs lighter, well rested, with perfect blood pressure, borderline cholesterol levels but no medications, and the ability to run, (yes run!) several miles. I can't say I never enjoy a nice dinner and some wine, but now, it's not coping, it's celebrating!
(2) As a nurse manager, I gave up our conference room to turn it into a tranquility room. My nurses are caring, giving, and very hardworking. I felt it was important to give them a place to rest, meditate and renew their energy. The tranquility room provides this place for nurses. Movies, pretty pictures, music, a window, and a massage table were incorporated into the room. A program for healing touch was initiated and training provided to the nurses so that they could do healing touch on each other. Staff has learned how to take care of themselves, so when they are stressed, they can engage in healing touch in the tranquility room. A favorite patient was about to die and I was able to call the healing touch staff to give myself some time away and a sense of relaxation to help refocus on the patient when I returned. When I resumed taking care of my dying patient, I was able to be more energized and more able to cope again. As nurses we typically don’t take enough time for ourselves so that we have a greater capacity to care for our patients.
(3) Feeling the need to be more energized and take care of myself, I signed up to take a fitness boot camp course at the gym. I decided to recruit four of my nursing friends. None of us had exercised in a long time. One of us hadn’t exercised in 25 years. After participating in boot camp every one of us was feeling so much better physically. Boot camp gave us more energy, made us feel better about ourselves, and gave us a chance to support and spend time with each other. Everyone could definitely feel a big difference. None of us would have continued exercising without the others’ support.
(4) My mother worked 2 jobs and looked after neighbors and her family very “admirably”. Every now and then I saw her cry because she put herself last. I learned that I would never put myself last in any situation. “If I don’t look after me, then I won’t be there.” We need to look at ourselves.
(5) I was diagnosed with breast cancer in 2008. I was a workaholic and felt that I always did many things for others instead of myself. It was a life altering experience because now I have a structured self care process. I put myself as number one on my list. “We have to look after ourselves because no one else will.”
Caring for Each Other
Definition: caring for each other is nurturing and valuing each other as whole beings; supporting the well-being of each other so that we can better care for our patients.
Nurses are consistently voted as the most trusted professionals by consumers; we are their rock, their constant, in an ever changing health care environment. Yet, the history of nursing has shown that nurses have not always been encouraged to care for each other. The health care environment is continuing to change, now more than ever. In order to continue the strong supportive role that we have played for our patients, we need to be supportive of each other to ensure that we maintain a healthy nursing workforce that role-models strong collegiality and continues to promote excellence in patient care.
The importance of nurses caring for each other has been recognized at the national level. Recommendation #3 in the 2010 report by the Institute of Medicine/Robert Wood Johnson Foundation titled, The Future of Nursing: Leading Change, Advancing Health, states that it is important to implement nursing residency programs, including residency programs outside of the acute care setting. The authors of the Future of Nursing report recognize the need for nurses to be prepared for roles in which they provide chronic illness management expertise in the community-based setting, and that a supportive learning environment through nurse residency programs is essential to promote best practices for nurses to develop these expertise and achieve success.
Questions to ask each other:
- Why do we need to care for each other?
- What do my colleagues need in order to feel cared for?
- How will caring for each other impact our care of our patients?
- What tools do my colleagues and I need in order to care for each other?
- What outcomes to we expect to see when caring for each other is fully realized in this nursing care environment?
Caring for Each Other Resources
Welcome Letter
Team STEPPS
Caring for Each Other Quick Intervention Recipe
Caring for Each Other Resource List
OJIN Caring Articles. March 2011 Issue
JCN Caring Articles
Caring for Each Other Stories
(1) A nurse colleague’s son had died and was going to have his organs harvested at our organization. As his mother, she wanted to be present for the harvest of her son’s heart. I was the Director of the OR and no family members had ever been allowed into the OR during a harvest. Even though this had never been done before, I decided that this was an important request to honor for a fellow nurse. I notified all the OR nurses and the nurse anesthetist that the mother who was a nurse was going to be present for the harvest of the heart. There were no objections. When her child came into the OR, I realized that he was a red headed teenager just like my own. This made it even more of a meaningful experience for me. As the heart was about to be harvested, the mother and I walked into the OR together. She began to sing a lullaby to him that she used to sing to him as a baby. I as well as all the other nurses in the OR began to cry. We left the OR and hugged. She thanked me so much for letting her have this closure that she needed. I knew that if she wasn’t a nurse, this would have never been allowed and was so glad that we could grant her this opportunity in her time of need.
(2) My thoughts on Caring for Each Other relate to Swanson's theory. Empowering/enabling or facilitating each others' passage through life occurs through emotional support at work. In my experience, even if nurses have nothing in common with colleagues, they discuss life events and either by just sharing their personal experiences or by eliciting advise from others, their own path in life is made clearer. Nurses care for each other during work hours by validating nurses' feelings about life experiences by being emotionally supportive.
(3) From a Psychiatric Nurse Practitioner: After all of these years, nearly 35 now, a nursing assistant, then learning to be a nurse, working as a nurse, in some capacity, a nurse. I have been an educator, a researcher, an administrator and now an Advanced Practice Nurse....and I believe that the one thing that always sticks out in my mind about caring is when it is random and unplanned. Nurses are forever talking about caring for this and that: writing care plans, implementing nursing care, evaluating patient care and promoting self care. But what about random acts of caring? Like random acts of kindness, there are moments when we as nurses can truly be in the moment and recognize that caring can transcend beyond planning or projecting or maintaining.....to something that is just "being" in the moment and recognizing that it is missing from that moment. Random acts of caring are so powerful and meaningful not only to those who we take care of, but for ourselves. Think about it and try it....randomly!
Caring for Others
Caring is defined as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson reference).
Definition: caring for others is assisting others to attain, maintain, or regain the optimal level of living or well-being they choose given their personal and environmental demands, constraints, and resources (nursing as informed caring for the well-being of others; Kristen M. Swanson).Caring for others requires technical skills/knowledge and compassion (the attitude in which we apply the technical skills and knowledge that provides for the holistic care of the other). In order to care for others, nurses must also have a healthy work environment in which to deliver high quality nursing services (Hallmarks program/Magnet program). Specifically, the component of a system of support for nurses is needed within the healthy work environment (systems of support for nurses include safety and wellness protection for employees, and the opportunity to provide quality service).
Questions to reflect on when caring for others:
- What is my patient’s definition of optimal health/wellbeing?
- What is my role in assisting my patient to work toward that goal?
- What resources are required to provide the optimal care to my patient?
- What can I do to contribute to an optimal caring environment for the provision of quality care to my patients?
- What outcomes do I expect to measure if I have been successful in providing quality nursing care to my patients?
Caring for Others Resources
Nursing caring theories:
Swanson ; Watson's Theory of Caring ; Sister Callista Roy's Adaptation Model
Caring for Others Resource List
Strength for Caring Stories
Caring Quotes
Presentation: Nightingale to Watson: Nursing Quality, Research, and Coming of Age
Caring for Others Stories
(1) From a Psychiatric Mental Health Nurse Practitioner/Psychiatric Clinical Nurse Specialist: After all of these years, nearly 35 now, a nursing assistant, then learning to be a nurse, working as a nurse, in some capacity, a nurse. I have been an educator, a researcher, an administrator and now an Advanced Practice Nurse....and I believe that the one thing that always sticks out in my mind about caring is when it is random and unplanned. Nurses are forever talking about caring for this and that: writing care plans, implementing nursing care, evaluating patient care and promoting self care. But what about random acts of caring? Like random acts of kindness, there are moments when we as nurses can truly be in the moment and recognize that caring can transcend beyond planning or projecting or maintaining.....to something that is just "being" in the moment and recognizing that it is missing from that moment. Random acts of caring are so powerful and meaningful not only to those who we take care of, but for ourselves. Think about it and try it....randomly!
(2) From a nurse manager: I witnessed a nurse anesthetist colleague of mine do something that was truly wonderful. There was a man who was uncontrollably crying because his wife was being taken to the operating room to harvest her organs, as she was brain damaged from a bad accident. Acting in the moment, the nurse anesthetist stopped with the patient in the hall to give the husband some final moments with his wife. Unbelievably, a woman in the waiting room just started singing Amazing Grace, and soon everyone joined in. It was such a simple thing for the nurse anesthetist to just stop, but extremely important and caring. I can only imagine the difference that made in the husband’s grief experience.”
(3) I've thought about caring for others and how broad it is. Isn't that what nurses do is care for others as part of their job description everyday? Each of us can share a story from everyday we go to work or go through life. Here's a favorite story of mine that I will always remember: I used to be a pediatric oncology nurse and loved it. The hospital facility where I worked practiced primary care nursing so that whenever a patient was readmitted, they would have the same nurse for continuity of care. This was about the third admission for a little 5-6 yo girl diagnosed with cancer. Since she was diagnosed, she hadn't spoken for months to anyone, even her mother. One night I came to work in my glasses when I usually wore contacts. I went into this little girl's room, did my assessment, made some small talk and of coarse didn't get a reply. Then as I was about to leave the room, she says, "Are those new glasses?" I said, "Yes, they are, do you like them?" She says, "No, I think they are really ugly!" Her mother was so embarrassed that this was her first words in months and tried to tell her that it wasn't nice to say that. I just thought she was telling it like it is! This is what I truly love about children; they will tell you exactly what they think. We all kept very straight faces and just kept right on talking- a little teary eyed. She talked from then on.
(4) From Group member Kathy Heilig: “Caring for others is what nurses are trained to do….its what the profession is all about. The traditional way of thinking about that type of ‘caring’ is in the treatments and procedures that we do to the patient or consumer. But nursing is more than that…The most loving type of caring for others we can do is to help people understand that nursing extends beyond the boundaries of the things we do to people—that it’s more comprehensive than that. The real skill in caring for others is to help redefine the image of nursing in the dimension of thinking, planning, and interpreting healthcare; to help people understand that nurses are change agents. Nursing’s real talent is in the ability to integrate healthcare needs of others into a plan that includes a patient centered focus AND the skill to interpret that into a language that’s universally understood by all. Nurses can help legislators understand the barriers to receiving good care to enact legislation. Nurses can help mothers to understand why babies need immunizations and how it impacts an entire community. Nurses can help spouses grieve and understand the loss of a life partner and help them to access the resources they need to face their future. Advocating for the profession of nursing is the highest level of Caring for Others.
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