Theory to Practice

Assumption 1: Meanings Unfold With Deliberately Innovating

“Meanings are explicit-tacit knowings that are the cocreated reality of the moment surfacing in the messages given and taken among all persons present that confirm and at once do not confirm with speech, silence, movement and stillness in leading-following situations” (Parse, 2014, p.133). “The essence of this assumption is deliberately innovating, which is committing to a vision with vigorous energizing(Parse, 2014, p. 133).The vision was to create a direct link from theory to practice, engaging the clinical faculty members and nurses from the various clinical areas in the students’ project activities. The faculty members and nurses recognized that there were limitations with the current communication tool and were open to engaging in the process. “The processes are committing to a vision and vigorous energizing” (Parse, 2014, p. 133)

When the project was introduced in the first class, the students voiced many concerns and identified some challenges within the current environment. They were fiscal constraints, the increased demands on nurses’ time, and receptiveness of nurses working with them on this project.

Committing to a vision is being passionately present with something of value by inspiring collaboration about the vision as specified in the mission, clarifying the intentions of the mission and contemplating the beauty surfacing in the becoming visible-invisible becoming of the emerging now. (Parse, 2014, p. 133)

As the details of this project were put forth, the students expressed enthusiasm for a clinical project that could potentially change their student practicum as well as the future work environment they would be entering within the next 16 months, demonstrating vigorous energizing.

“Vigorous energizing is an enlivening commingling that arises with arousing the imagination of others about what could be while intensifying the intrigue by forging a path for realizing the possibilities with the innovation” (Parse, 2014, p. 133). In early discussions of knowledge and theories the nurse students considered how this course would influence their practice as nurses, what nursing knowledge is, and the nurse’s unique contribution to the patient’s journey in the hospital setting. In discussions, the students recognized the potential of this project for their practicum experiences as students as well as their future professional practice. The students talked of researching their clinical patient assignments and identified that although they read the chart, reviewed the Kardex™ and would meet the patient prior to their clinical day, their concept maps (care plans) were not initially individualized to the unique patient’s context. Some information uncovered was not current and once they had the opportunity to connect with the client they would refine their concept maps based on learning of the patient’s values, beliefs, and priorities each day. The students expressed their frustration with the incompleteness of the existing Kardex™. When asked, nurses in these clinical areas readily acknowledged that the Kardex™ does not meet their needs, and most of the time is not accurate or complete. The nurses had come to a place where they no longer relied on it to communicate relevant patient information and had found alternate informal ways of sharing valuable information. The important information continued to be shared between nurses, and this was accomplished in a number of ways, through shift-to-shift reports, actively seeking out and connecting with the nurses who looked after the patient previously. The students, nurses, and faculty members each gained new insights into the challenges of the situation and through dialogue expanded understanding “seeing the familiar in new light” (Parse, 2014, p. 133). “Insights surface with imagining the possibles, dialoging, listening carefully, anticipating challenges, and being attentive to the tones, postures, and configurations of all those present with the becoming visible-invisible becoming of the emerging now, as surprises command recognition” (Parse, 2014, p. 133).

With all the various communication methods available today, clear communication still remains an elusive goal. Rodgers (2007) reported that communications errors are the root cause of almost 70% of sentinel events and 75% of the patients involved died in the United States (US). It is acknowledged by the Canadian Patient Safety Institute (CPSI) that the data in Canada is not complete related to these numbers. Many organizations in the US and Canada, including the Institute for Healthcare Improvement, Safer Healthcare Now! CPSI, and others are striving to put processes in place to eliminate the root causes that could potentially result in an adverse event for patients. As professionals it is an obligation to respond to strategies that are introduced to minimize risks to patients and to professional practice by keeping informed, by practicing and adopting the new strategies recommended by nursing organizations and national standards committees. As professionals we develop communication formats and styles of the profession, these are acknowledged to be significantly different among the professions. In the book Crossing the Quality Chasm (Institute of Medicine, 2001), it was determined that excellent listening skills are required in managing the clinical-patient relationship and are especially important in patients who have complex healthcare conditions.

Assumption 2: Changing Patterns Surface With Potent Engaging

“Changing patterns arise with living rhythms of disclosing-not disclosing, potentiating-restricting, and attending-distancing in engaging with others (Parse, 2014, pp. 133-4). In the first class the students were asked to write a personal narrative on their philosophy of nursing, briefly discussing their personal values, beliefs, and assumptions about nursing, clients and the world in general. They were asked to consider how their philosophical beliefs influence their nursing practice. The students shared their values and beliefs and their influence on their practice with some hesitancy, not altogether confident in their current philosophy or how it might change over the course of this semester. “The essence of this assumption is potent engaging, which is willingly risking and living with ambiguity. The processes are willingly risking and living with ambiguity” (Parse, 2014, p. 134).

The students were in a third year acute care practicum in which the expectation was the linking of a nursing theory to clinical practice on a week to week basis.” Willingly risking is daringly venturing forth, which is advancing on the edge when the way is not precisely clear (Parse, 2014, p. 134). There were six clinical groups in the areas of internal medicine and oncology, general surgery, orthopedics, cardiology, and pediatrics. In the first few weeks students were exposed to a variety of theories and spent time developing an understanding of the theoretical information that set the stage for these groups to decide which nursing theory best fit with their values and beliefs and would readily fit the patient population served in their clinical specialty. Students expressed discomfort in the examining their personal nursing philosophy and the notion that this frame of reference might change. Students communicated concern about how would they know which theory to choose for themselves, their clinical group or their clinical practicum specialty demonstrating the second process of living with ambiguity. “Living with ambiguity is abiding with vague potentials and propelling with the not-yet-fully known explicitly to untangle the knots of obscurity (Parse, 2014, p. 134). During this time students were encouraged to be open to their clinical experiences, consider the various nursing theories, to focus on their patients and their journeys, to note the challenges they were experiencing with the Kardex™ and the communication of key patient information, and to listen for cues that the nurses were also feeling the challenges. The clinical groups considered the possibilities and committed to a theory. Each group presented their chosen nursing theory to the class which included the following: a biographical sketch of the theorist; an explanation of how the theorist defines the concepts of the nursing metaparadigm (person, health, environment and nursing); key concepts of the theory, and how they are connected. The presentations included a one page diagram or picture of the theory, and finally an analysis and rationale of the theory chosen in terms of relevance to their nursing practice in this clinical rotation. The medical and oncology group chose Parse’s humanbecoming theory; the cardiology group chose Johnson’s behavioral system’s model; the group in Orthopedics chose Orem’s self-care framework; the group in general surgery chose Roy’s adaptation model and the two pediatric groups chose Leininger’s theory of cultural care, diversity and universality, and Levine’s conservation model. The students considered a number of nursing theories and models in relation to their unique clinical contexts, and struggled with choices before engaging with their theory of choice. The presentation supported students and affirmed the group decision made in choosing a specific theory. In presenting various rationales for their nursing theory choice, the students came to understand that there was no “right” theory for any specific clinical area and continued “living with ambiguity” (Parse. 2014, p. 131).

Assumption 3: Infinite Possibilities Emerge With Persistently Pursuing Excellence

“Infinite possibilities are the illimitable options for affirming and at once not-affirming others and ideas present with each leading-following situation, where the givens are cocreated by those present with the becoming visible-invisible becoming of the emerging now (Parse, 2014, p. 135). The clinical groups shared their experiences with the existing Kardex™ and their observations of the nurses and their comments which included the following. “I wish I knew if the patient is aware of his diagnosis.” “What does this admission and illness mean to her?” “I wonder if they have anyone to support them, or if they need supports when they go home.” “How are we working with them to help them prepare so they can go home?” The students demonstrated, “Revering others is ‘honoring the uniqueness of individuals by not expecting each person to contribute to the vision in exactly the way’” (Parse, p. 135).

There is limited information in the literature on how an effective design and layout of a communication tool can lead to good care planning. The updating of the Kardex™ utilizing the SBAR format was to augment standardized shift-to-shift nurse reporting, enhance predictability of communication, and thereby improve the patient experience by facilitating continuity of care, and minimizing task uncertainty. The current communication tool had a few major drawbacks: it was only as useful as nurses made it, not all nurses’ patterns of logic “fit” this model, and in its current iteration it did not appear to support use of current nursing knowledge or theoretical frameworks. Kardexes™ are not part of the permanent patient record, so the nurses needed to make sure that the information on the Kardex™ was found elsewhere in the patient’s chart. It was acknowledged that the Kardex™ is most effective when it was tailored to the needs of a particular setting or unit.

The vision for this Kardex™ project was to inspire nursing students to develop, critique, implement, and utilize documentation guidelines within the context of a theoretical framework. Students recognized the limitations of the current communication tools and the need for flexible and efficient documentation processes that supported their use of nursing knowledge and theoretical frameworks in their daily hospital practice. Students recognized the value of updating communication tools prior to moving to the electronic care plan for documentation, to ensure that nursing knowledge would thrive. Quality reporting and documentation processes have the potential to improve patient outcomes through the reporting and recording of the meanings of patients’ situations to them and their families, their hopes, dreams, and wishes, in addition to their current medical condition, treatments, and responses to nursing care. It was recognized that the Kardex™ was an important tool in communication among healthcare professionals, and this underlined the advantage of a standardized format. Highlighting the patient’s voice ensured that the patient’s perspective was always present. The patient’s own view, with important aspects for example, spiritual state, pain assessment, mood, experiences, preferences, decision-making and involvement would be included in a manner that facilitated the sharing of nursing knowledge, highlighting the nurses’ role in being with the patient on their healthcare journey.

“Vigilantly attending in leading-following situations is cautiously witnessing with wisdom the emergence of ideas and programs and heeding with graciousness the surprises that unfold with the inevitable uncertainty that accompanies new endeavors” (Parse, 2014, p. 135).

The role of the nurse and importance of nursing knowledge tended to be invisible to the reader of patient records; this invisibility has its price, as these nurses did not make known their active role in the patient’s healthcare journey. There needed to be greater emphasis placed on connecting with clients, working with them in partnerships to meet their needs with an evaluation of progress toward their goals. There were significant benefits to working with clients in planning, documenting, and evaluating their experiences, and checking with the clients on their progress. When writing about nursing care in the passive voice nurses gave the impression of being invisible in their own profession. It not only leaves the nursing care hidden but leads to confusion: who is doing or who is taking? Nurses generate a great deal of important information concerning patients’ care in their day-to-day contact and this should be recognized and appreciated in healthcare settings. Good client care depends on access to high quality information. Access to this information would minimize confusion around patient care and help nurses to plan their daily interventions with their clients. The nurse’s ability to report a client’s problems, concerns, complaints, additional clinical signs and responses is important for patient safety and wellbeing. Poor documentation is often reflected in poor patient outcomes, as insufficient and disorganized documentation dilutes the quality and safety of patient care.

Reisenberg, Leitzsch, and Cunningham, (2010) in their systemic literature review noted, “the lack of published research on structured handoffs, and the need to demonstrate the value of mnemonics. In addition there are risks in implementing interventions without evidence to support their effectiveness (p. 202), calling for evidence to support SBAR. In some lawsuits, nurses have been charged with failure to communicate or failure to rescue, and not responding appropriately to patient deterioration” (Austin, 2010, p.17).

Classroom discussion encompassed a variety of observations and critiques. Shift-to-shift nurse reports were at times unsystematic and incoherent. While expert nurses use the nursing process in a flexible way that their reasoning may not always be clear to other nurses or to novice nurses. Nurses had routines and “invisible” care activities that may not have been visible in the nursing plan and documentation. These activities may have been crucial to effective decision-making, safety, continuity, and quality in the client’s care. Any healthcare professional should be able to pick up a plan of care and recognize the person’s priorities and needs. For the care plan to fulfil this need it is essential that all the information is together in an organized and understandable format and should include what is important for people to know about the client and how the client likes to spend the day. A good plan of care will be easy to read and follow, and anyone reading it should know exactly how to respond to a person’s needs by understanding the person’s context. It will flow like a good story and as you read it you will start to get to know that person.

The next step of this learning was in the actual application of a nursing theory to problems, recognizing that real problems are often too complex for single discipline approaches, and require multi-disciplinary or multi-perspective approaches. Nurses need to accept the social responsibility of being involved in interacting with others. How nurses interact with members of the clinical team has a huge influence on patient care, the healthcare team, and the staff members within the clinical area. The students were to work within their groups and create a patient scenario to test out their new and revised communication tool utilizing the framework of the nursing theory that they had chosen. The acquisition of relevant knowledge and coaching from nurses and healthcare professionals was encouraged.

This project provided an opportunity to integrate and apply theory to solving the relevant practical problems in the real-world communication with a well-developed theoretical framework. The students recognized that in challenging clinical situations, their chosen nursing theory provided a valuable guide to the exploration of perspectives that they might not have considered. Each clinical group of students created a “Patient’s Kardex™/Individualized Health Plan/Nursing Kardex™” and utilized whatever language they determined best suited their theory of choice. There were two main objectives for this assignment, the first was to be able to identify the individual within the Kardex™ (often referred to as patient-centered), and also to depict the specific contribution of the registered nurse and the nursing knowledge present in the individual’s care plan, while also acknowledging the contributions of other team members.

The final presentation built on the work of the semester as student groups presented at the hospital on the various units. All nurses were invited to attend from all clinical areas. The nurses voiced their appreciation for the review of the theory and the application to a client scenario from their clinical area. Some nurses were able to stay for all presentations. Once completed, the students voiced their pleasure at being able to present in a professional venue, not just to the class. This challenged them to put their best work forward.

Becoming Visible-Invisible Becoming of the Emerging Now

As the students applied nursing theories to their practice, new meanings unfolded, as they identified the new perspectives they were guided to consider by their specific theory. They identified that their views had shifted from the task-based focus of the old communication tool to the possibilities of what a new communication tool could offer. The nursing students appreciated the application of nursing theory to clinical practice which facilitated their understanding of the theories. “Becoming visible-invisible becoming of the emerging now is the living moment that brings to the fore the idea that meaning changes with each unfolding living experience incarnating the remembered with the prospecting all-at once” (Parse, 2012, p. 44). Descriptions in student feedback included: “I recognize that I view my patients differently now, I am more attentive,” and “I ask more questions and consider different perspectives because I am working within a theoretical perspective.”

Conclusion

This project created learning opportunities based on real-life problems where theories and methods are challenged and used to broaden understandings. The students had the opportunity of working with rather than developing for the nurses in their clinical areas. The students valued the project and readily identified it as “much needed and valuable” work. By drawing on the expertise of nurses and staff members, the students were able to gain knowledge from the richness of experience and reflective possibilities. They appreciated that the project developed over the semester with each activity building on the other until the final presentation.