From SMR Consulting, as Clinical Technology Consultant; Resurrection Medical Center in Chicago, IL as Clinical Information Systems Coordinator; and Lewis University, Romeoville, IL as adjunct faculty.
The work was a result of the efforts of the Caring Advocates at both Holy Family Medical Center in Des Plaines, IL and Resurrection Medical Center, in Chicago, IL under the direction of Linda Ryan, RN, PhD. The Resurrection Health Care Clinical Documentation Team was directed by Connie Yuska, RN, MS, Vice President of Patient Care and Oncology Services, and facilitated by Tammy Scalet, Lead Application Specialist, who also participated in the efforts.
Corresponding author: Susan Rosenberg, RN, MSN, Clinical Technology Consultant 7435 West Talcott Avenue, Chicago, IL 60631 (e-mail: email@example.com).
Senior nursing executives in a Chicago-based healthcare system comprising eight hospitals decided that a new standardized nursing philosophy would be adopted for use by all facilities. At one facility, a 434-bed hospital, the nurse executive was encouraged by a doctorally prepared nursing director to consider using nursing theory as a guide to practice. They decided that nursing theory should be part of the nursing philosophy and determined that the organization's mission and core values is congruent with Watson's Theory of Caring. The facility's vice president brought this information to her colleagues, and these nurse executives agreed that Watson's Theory of Caring would be adopted as part of the system-wide nursing philosophy.
According to Watson,1 this theory is an attempt to find and deepen the language specific to nurse caring relations and its many meanings. Watson2 further asserts that the 10 carative factors are dimensions that provide a structure and guide to the theory (see Table 1). They can be used as an expressive tool while directing the assessment, interventions, charting, and full engagement of caring human dimensions of nursing practice. Ference3 described ways in which nursing administrators can adopt nursing science theories, especially caring theories, to provide nursing services within healthcare organizations. She recommended that the application of nursing science theories occur in a mutual process for administration as well as practice.
The nursing practice of concern during this documentation system development was the language used to express the patient experience. The North American Nursing Diagnosis Association International (NANDA-I)4 states that the important judgements nurses make and the language that expresses them are deeply valued. Yet, during the implementation of the theory within the setting, it was discovered that there was no mechanism within the currently used electronic documentation system for clinical nursing staff to document the patient experience using any language specific to this theory. In the disparity between the newly developed nursing philosophy and documentation, nursing members recognized an opportunity to develop a new context in charting during an extensive clinical documentation system upgrade. Presented here are a discussion of the steps taken and the results achieved within the clinical documentation system to support the newly adopted caring philosophy.
Factors that precipitated the change included the adoption of Watson's theory of caring within nursing philosophy and practice, and the decision to install an upgraded version of the clinical documentation system at all of the hospitals in the healthcare system. Limitations of the current computerized documentation system were that it did not contain the language required to represent the patient experience within the context of the new philosophy and practice, and only 16 characters were allowed for each item documented. Therefore, nursing leaders set out to enhance the system during the upgrade by incorporating the ability to document using language within the context of Watson's Theory of Caring (Figures 1 and 2).
For the new philosophy to become part of nurses' daily practice, leaders of the healthcare facility recognized the need for education regarding the theory. Nursing staff also needed opportunities to participate in this growing process. A group of staff nurses, managers, and other leaders from the facility, known as "The Caring Advocates," was developed to assist in the education and implementation of the theory throughout various clinical settings. Information from the group was shared at unit meetings. Staff were also given the opportunity to communicate theory-related unit endeavors at nursing quality council meetings. Both of these events reinforced education about and adoption of the theory.
One other opportunity taken was to present a lecture by Jean Watson during Nurse's Week 2004. Nurses from the facility as well as throughout the system attended. Nursing leaders from the clinical documentation group, which included members from all hospitals in the system, and selected information service professionals were also invited, because knowledge about the theory would assist in system implementation.
At this lecture, Watson5 discussed hospitalization as an event that can lead to the loss of human dignity, and stated that it is the nurses' duty to help maintain and restore that dignity. She also described many of the interventions nursing staff can make use of to promote the caring environment. This lecture, along with a review of Jean Watson's other works, provided the support required to build the framework that transformed the current documentation system from a purely technical basis to a system that incorporated information about caring.
During development, the clinical documentation team recognized the required use of a standardized language. According to Werley et al,6 the Nursing Minimum Data Set (NMDS) was designed to facilitate the abstraction of the minimum, common core of data to describe nursing practice. The nursing care elements of the NMDS include: (1) nursing diagnosis, (2) nursing intervention, (3) nursing outcome, and (4) intensity of nursing service. It was decided that these elements would be considered part of the framework for development of the new caring documentation system.
Review of current literature demonstrated disparity between the ability of the nursing standardized languages, specifically (1) NANDA, (2) Nursing Interventions Classification (NIC), and (3) Nursing Outcomes Classification (NOC), to document the humanistic elements within the patient experience. Baumann7 discusses the text of nursing notes and their relationship to the patient experience as more than an account of vital signs, weight, height, pain assessment, sleep, and output. He further asserts that these notes should reflect the story where there is a character, another person who in a knowledgeable and understandingly present way was with the patient-in short, a nurse. Brown and Crawford8 identified difficulties using NANDA as interaction with patients and stated that nursing diagnosis can never be value-free. They further state that although classification systems may advance professional nursing practice, they may not assist in documenting all the sociological aspects of care.
Aware of the issues regarding the theory and limitations of standardized languages, nursing members began the process of developing new terminology for the documentation system, including a new nursing diagnosis. The diagnosis, as guided by Watson's Theory of Caring, was constructed to assist clinicians in accurately documenting a specific problem, compromised human dignity. It is determined by the patient experience and resulting affects of hospitalization and healthcare promotion modalities. Watson's1 nursing theory of caring insists that maintaining human dignity is a vital nursing duty and function. As nursing practice is based on nursing theory, appropriate means to communicate this particular patient experience is needed. Walsh and Kowanko9 assert that nurses have a commitment to the maintenance of patient dignity and that the lack of dignity may lead to poorer health outcomes. Mairis10 describes the effects of loss of dignity as feelings of ridicule, embarrassment, shame, humiliation, foolishness, degradation, and overt or covert distress. Also stated is that dignity can be affected by a hierarchy in relationships and that hospitals are particularly rich in hierarchies. This hierarchy is illustrated in the perceived relationships as nurses working under the direction of physicians. Soderberg et al11 suggest that nurse professionals develop qualities to maintain or restore human dignity. They further demonstrate that supporting dignity not only benefits the patient, but the quality of the nurse's work life. The nursing diagnosis label developed for use in this clinical documentation system was Compromised Human Dignity and was submitted to NANDA-I. This diagnosis has been initially accepted by NANDA-I and will be presented at the NANDA-I, NIC, and NOC Conference in March 2006.
Review of interventions as well as outcomes within the system in use demonstrated that it lacked a language that would capture the patient or family experience within the framework of Watson's Theory of Caring. Because the vendor is at the time of writing developing new software and its enhancements will include NANDA, NIC, NOC, and links among them, these existing classifications were reviewed. According to the Center for Nursing Classification and Clinical Effectiveness,12 NIC is a comprehensive, research-based, standardized classification of interventions that nurses perform. The Center for Nursing Classification and Clinical Effectiveness13 also defines an intervention as any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. Although use of these languages was considered for this project, the decision was to wait for vendor software upgrades that incorporate the desired languages.
A list of interventions was then developed using Watson's Theory of Caring and was added to those used in the current documentation system. Because the system limited the text of each carative factor to 16 characters, abbreviated legends were constructed (see Tables 1 and 2). The education plans included using a handout containing a list of the carative factors in full text along with its associated abbreviation within the documentation system. A short discussion of each factor with application and example for the clinical setting was developed. Other interventions that demonstrate the caring theory were added. These include reframing, active listening, presence, discussion, and face-to-face interview.
Essential to the documentation process was the inclusion of outcomes. Because NOC will be used in the future when vendor development is completed, reviews of various outcomes and their application were completed using this taxonomy as a reference. The group developed outcome legends that were added to the currently available list, again limited to 16 characters, including (1) decision-making, (2) well-being, (3)spirit well-being, and (4) coping. All of the outcomes developed can be associated with the following indicators as selected by the clinician as (1) improved, (2)deteriorated, and (3) unchanged. These outcome indicators are different from the NOC scales as they do not provide a method of quantifying the outcome. The addition of these outcomes completed the necessary documentation for charting the patient experience as determined within the context of the new nursing philosophy.
Training on the new system included not only the processes to input and change information, but also the new content, including terms associated with Watson's theory. As only 3 hours were given to teach the new system, only 15 minutes were allotted for discussion and demonstration of the theory items. Nurses expressed excitement that the theory was now part of the documentation system. Handbooks were also supplied for nursing units that described how to use the theory for daily documentation of the patient experience. The new system included a query product that allowed extraction of information regarding documentation habits from the system. This product was used to determine if nursing staff were actually using the new theory documentation items. One random search of inpatient records determined that of 274 inpatient documents, 35% had the new label selected and 87% had at least one carative factor documented.
Although many organizations incorporate nursing science theory within their nursing philosophies, nurse administrators must ensure that tools are available for nursing staff to document the theory in daily practice. Reviewing current documentation systems and improving them to incorporate standardized terminology assist the expression of the patient experience in the context of the applied theory. When terminology does not exist within current taxonomies to document this experience, nurse leaders then should take an active role in developing and supporting new terminology, as it is needed. As stated by Clark and Lang,14 "If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy." Further development is now required within current taxonomies to provide NIC and NOC defined as human dignity as this will allow nurses to fully document the patient experience. When nursing interventions are developed using Watson's Theory of Caring,1 intensity of service could include the 10 carative factors, thereby completing the elements of the NMDS within the context of this theory. Including intensity of service will assist professional nursing in quantitatively defining practice. Finally, as nursing pursues better definition and development of the terminology required to document the events of the patient experience within the context of a specific theory such as Watson's Theory of Caring, mutuality between nursing theory and nursing practice will be supported.
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© 2006 Lippincott Williams & Wilkins, Inc.