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TRANSLATING CARING THEORY INTO PRACTICE:

The Carolina Care™ Model

Mary Tonges PhD, RN, NEA-BC, FAAN Chief Nursing Officer, UNC Hospitals

October 17, 2014

Virginia Organization of Nurse Leaders

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Across the Continuum to Ambulatory Care

Carolina Care TM

Tonges Translational Model

Swanson Caring Theory

TRANSLATING CARING THEORY INTO PRACTICE

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Across the Continuum to Ambulatory Care

Carolina Care TM

Tonges Translational Model

Swanson Caring Theory

TRANSLATING CARING THEORY INTO PRACTICE

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“Caring is a nurturing way of relating to a valued other to

whom one feels a personal sense of commitment and

responsibility.” K. Swanson, 1993

Swanson Caring Theory

Swanson, KM 1991, Empirical development of a middle range-theory of nursing, Nursing Research, 40(3) 161-6.

• Knowing

• Being With

• Doing For

• Enabling

• Maintaining Belief

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• avoiding assumptions

• assessing thoroughly

• seeking cues

• centering on the other

• engaging the self of both

• Knowing:

• Being With

• Doing For

• Enabling• Maintaining

Belief

striving to understand an event as it has meaning in the life of the other

Swanson Caring Theory

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• being there

• conveying availability

• enduring with

• sharing feelings

• not burdening

being emotionally present to the other

• Knowing

• Being With:

• Doing For

• Enabling• Maintaining

Belief

Swanson Caring Theory

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• performing competently/skillfully

• comforting

• anticipating

• protecting

• preserving dignity

doing for the other as they would do for their self if it were at all possible

• Knowing

• Being with

• Doing For:

• Enabling• Maintaining

Belief

Swanson Caring Theory

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• informing/explaining • validating/giving feedback• supporting/allowing• focusing • generating alternatives/

thinking it through

facilitating the other’s passage through life events and transitions

• Knowing

• Being with

• Doing For

• Enabling:• Maintaining

Belief

Swanson Caring Theory

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C A R E S Y S T E M sustaining faith in the other’s

capacity to get through an event or transition and face a future with meaning

• Knowing

• Being with

• Doing For

• Enabling

• Maintaining Belief:

• believing in/holding in esteem• offering a hope-filled attitude• ‘going the distance’• offering realistic optimism• helping find meaning

Swanson Caring Theory

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Across the Continuum to Ambulatory Care

Carolina Care TM

Swanson Caring Theory

Tonges Translational Model

TRANSLATING CARING THEORY INTO PRACTICE

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1. Theory

2. Innovation

3. Application

4. Testing

5. Dissemination

6. Evaluation

7. Sustainment

Tonges Translational Model for Theory-Driven Practice

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Dr. Kristen Swanson

1. Theory: Swanson Caring Theory (SCT)

Tonges Translational Model for Theory-Driven Practice

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2. Innovation: creating value through new ideas

Tonges Translational Model for Theory-Driven Practice

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3. Application: putting ideas to a specific purpose/use

Tonges Translational Model for Theory-Driven Practice

• Moment of Caring

• Multi-level Rounding

• Hourly Patient Rounds

• No Passing Zone

• Words and Ways That Work

• Blameless Apology

• Proposed Links between

Carolina Care and SCT

• Framing the Culture of

Carolina Care

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Across the Continuum to Ambulatory Care

Carolina Care TM

Swanson Caring Theory

Tonges Translational Model

TRANSLATING CARING THEORY INTO PRACTICE

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Carolina Care TM

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• Each patient each shift

• Nurse sits with patient

• 3-5 minutes of touch and

therapeutic listening

Moment of

Caring:

Knowing

and

Being With

Carolina Care TM

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Multi-level Rounding

Hourly Patient Rounding

Health Unit Coordinator

(HUC)

Director

Interdisciplinary

NurseManager

Carolina Care TM

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Hourly Patient Rounds

Are you comfortable?

Other side? (Does patient need to turn?)

Use the bathroom (Does patient need assistance?)

Need anything

Door/curtain open or closed for privacy

Safety (Call bell will reach and no tripping hazards)

R

O

U

N

D

S

Associated Swanson Caring

Theory Component: Being With and

Doing For

Carolina Care TM

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• Answer call light regardless of assignment

• “Road Signs” posted in hallways

No Passing

Zone:

Being With

and

Doing For

Carolina Care TM

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• Alternative to “scripting”

• Key points to cover in interactions

Words

and

Ways

that Work:

Being With

and

Enabling

Carolina Care TM

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• Listen to patient

• Apologize without placing blame

• Take action to address problem

• Follow-up with patient

Blameless

Apology:

Being With

and

Enabling

Carolina Care TM

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Proposed Links Between Carolina Care and SCT

Carolina Care TM

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SCT: Framing the Culture of Carolina Care

Carolina Care TM

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Tonges Translational Model for Theory-Driven Practice

making a preliminary evaluation before embarking on a course of action

Model Units

• Medicine Service

• Surgery Service

4. Testing:

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Model Units: Medicine

& Surgery Service

•Less than 20 beds

• Combination of

private/semi-private

rooms

CNO chaired Carolina

Care Steering

Committee to provide

high level direction,

integration and

support

Voice of the Patient

Rapid Cycle

Improvement:

Design & Implement

Nursing &

Interdepartmental

Unit-Based Teams

Data Driven Action

Plans/Performance

Tracking

4. Testing: Preliminary Evaluation

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BaselineN=34

Q1 2009N=49

4/3N=38

4/17N=47

5/1N=55

5/15N=59

5/29N=65

0102030405060708090

100

Courtesy of person served food

Courtesy of person cleaning room

Accommodations and comfort visitors

Staff include decisions re:trtmnt

Perc

entil

e

Data Driven Action Plan Areas

Discharge Week

Implementation of Carolina Care

TM

4. Testing: Model Unit Results

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BaselineN=34

Q1 2009N=49

4/3N=38

4/17N=47

5/1N=55

5/15N=59

5/29N=65

0

20

40

60

80

100

120

Promptness response to call

Staff addressed emotional needs

Response concerns/complaints

Discharge Week

Implementation of Carolina Care

TM

4. Testing: Model Unit Results

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Tonges Translational Model for Theory-Driven Practice

spreading information and/or practices

• Carolina Care Guidebook

• Pre-Work Unit Assessment

• Pre-Work Teams

• Roll Out

• Recognition for

Outstanding Performance

5. Dissemination:

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5. Dissemination: Carolina Care Guidebook

– CNO charge

– Lessons learned from Model Units

– Defined key staff roles and responsibilities

– Pre-Work

– Implementation sequence

– Defined Carolina CareTM

Interventions

• Moment of Caring

• Hourly Rounds

• No Passing Zone

• Words and Ways that Work

• Blameless Apology (Service Recovery)

‒ Discharge calls

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Patient satisfaction interviewPart I

Self assessmentPart II

Call bell activityPart IV

Environmental assessment Part V

Part III

5. Dissemination: Pre-Work Unit Assessment

Analyze one year of unit performance on Press Ganey data

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5. Dissemination: Pre-Work Teams

Carolina CareTM Implementation Oversight Committee

• CNO

• Nursing Directors

• Nurse Managers

• Director, Environmental

Services

• Director, Food and Nutrition

• Data Analyst

Nursing Teams

• Nurses• Nursing

Assistants• Health Unit

Coordinators

Interdepart-mental Teams

• Nurses• Housekeeping

• Nutrition & Food Service• Plant Engineering

• Other Support Services

Action Plans

• Assign process owners

accountability for specific

items• Team approves

action plan

Unit Implementation Led by Nurse

Mangers

• Nurse Manager held

accountable for improving

inpatient satisfaction at the unit level

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5. Dissemination: Roll Out

Simultaneousroll out on all

acute care units

8 Week Implementation Sequence

• Monday morning Nurse Managers’ meeting

• Weekly focus areas• Rounding• Words & Ways that Work

• Bi-weekly nursing & Interdepartmental team meetings• Building Action Plans• Tracking performance measures• Discharge calls

• Daily huddles• Bright ideas• Implementation Oversight Committee

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5. Dissemination:Recognizing Outstanding Performance

“Carolina CareTM Dollars”

Unit recognition for Press Ganey goals achievement

Unit Celebrations

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Tonges Translational Model for Theory-Driven Practice

6. Evaluation: ascertaining value or worth

• Press Ganey Scores

• HCAHPS Scores

• Effect on Pressure Ulcer Prevalence

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6. Evaluation: Results - Annual Mean PG ScoresOverall Inpatient Satisfaction and Satisfaction with Nursing

2004 2005 2006 2007 2008 2009 2010 2011 2012 201378

80

82

84

86

88

90

92

94

Overall Nursing

Carolina CareTM implemented in July

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6. Evaluation: Results - Mean PG ScoresConcern with Privacy, Meeting Emotional Needs and Attention to

Special/Personal Needs

2004 2005 2006 2007 2008 2009 2010 2011 2012 201374

76

78

80

82

84

86

88

90

92

Concern for privacy Meeting emotional needsAttention to special/ personal needs

Carolina CareTM implemented in July

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6. Evaluation: Results - Annual Mean PG ScoresSatisfaction with Pain Control and Prompt Response to Call

2004 2005 2006 2007 2008 2009 2010 2011 2012 201381

82

83

84

85

86

87

88

89

90

91

Pain controlled Promptness response to call

Carolina CareTM implemented in July

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6. Evaluation:Results - HCAHPS Scores

March, 2011 – March, 2012#1 Communication about Medications

#2 Discharge Information

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5/2/20

13

12/11/2

012

5/29/2

012

11/15/2

011

5/24/2

011

12/7/201

0

5/25/2

010

12/10

/2009

5/19/20

09

12/2/

2008

6/26/20

08

11/13

/2007

0.09

0.08

0.07

0.06

0.05

0.04

0.03

0.02

0.01

0.00

Rat

e

_U=0.0306

UCL=0.0530

LCL=0.0081

Carolina CareDecubiti Prevention Initiative

Tests performed with unequal sample sizes

Prevelance Survey: Presseure Ulcers/100 Patients (All Stages)

Project: CONTROL CHARTS.MPJ; Worksheet: Skin8_May2013

6. Evaluation:Effect on Pressure Ulcer Prevalence

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7. Sustainment:

Tonges Translational Model for Theory-Driven Practice

keeping in existence, maintaining

• Sustainment Efforts

• HCAHPS Scores

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7. Sustainment: Efforts

Expansion

• Outpati

ent

• Carolin

a Care

at

Home

Infrastructure• Commi

tment

to

Caring

Steerin

g

Commi

ttee

• Big 5 &

Big 6

• Service

Frame

work

New Interventions

• Semi-Private Rooms

• Family Meals

• VP Partners

• Happy Healing Days

• Heart of Carolina Care

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7. Sustainment: Expansion

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Inpatient

7. Sustainment: Infrastructure

Change Management ResourcesD. Kaye, S. Herman,

L. Mandelkher, G. Spivak

Patient ExperienceSteering Committee

Co-ChairsK. McCallW. Rotella

FocusTeam

InpatientExperience Team

Employee Outpatient

Engagement Communication

Co-ChairsD. OlmosT. Garner

ExecutiveSponsors

C. DonohueW. Rotella

Co-ChairsD. BassW. Arey

ExecutiveSponsor

J. Hirneisen

Admitting

Room

Meals

Nursing

Tests – Txs

Visitors&Families

Discharge

PersonalIssues

Co-ChairsL. DanielsL. Kapps

ExecutiveSponsor

M. Tonges

JJ. CampbellJ Strickler

L. Osborne

A. Mojica

J. Ray

C. RegeT. Smiley

M. McCannL. Muss

M. BossertR. Daniels

S. RogersS. Crenshaw

K. Mc Call

J Pomerantz

J. Hadar

D. Lehman

D. Lehman

M. Tonges

M. Rifkin

K. McCall

Co-ChairD. Bauer

ExecutiveSponsors

D. SpencerR. Lafrenaye

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7. Sustainment: Infrastructure

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7. Sustainment: New Interventions

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7. Sustainment: New Interventions

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Jul-1

3

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

FYTD0

10

20

30

40

50

60

70

80

90

100

78.5 80.4 79.2 72.7 83.6 74.3 76.6 77.9 78.0 74.4 76.3 82.1 77.6

8793

89

60

98

69

8185 86

70

80

96

Percentage FYTD Percentage Percentile

7. Sustainment:HCAHPS – Rate The Hospital Highly

FYTD Percentage – 77.6 (84th Percentile)

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Jul-1

3

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

FYTD0

10

20

30

40

50

60

70

80

90

100

81.8 84.5 86.7 81.4 91.2 78.8 84.2 80.8 80.3 82.0 80.3 87.1 83.0

8593 97

84

99

75

92

82 8186

81

97

Percentage FYTD Percentage Percentile

7. Sustainment: HCAHPS – Recommend Hospital

FYTD Percentage – 83.0 (89th Percentile)

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Jul-1

3

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

FYTD0

10

20

30

40

50

60

70

80

90

100

81.6 82.0 81.2 74.4 83.0 81.1 81.5 78.9 79.5 81.2 80.3 84.8 80.8

75 7972

17

8671 74

4955

7263

95

Percentage FYTD Percentage Percentile

7. Sustainment: HCAHPS – Communication w/ Nurses

FYTD Percentage – 80.8 (69th Percentile)

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7. Sustainment:Press Ganey – Inpatient Overall

FYTD Mean Score – 87.7 (79th Percentile)

Jul-1

3

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

FYTD0

10

20

30

40

50

60

70

80

90

100

87.7 87.8 88.3 87.0 87.9 87.5 88.3 87.9 87.8 86.1 87.9 87.8 87.7

77 79 84

60

7973

8480 79

45

82 78

Mean FYTD MeanPercentile Goal Mean Target (88.0)

88.0

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Jul-1

3

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

FYTD0

10

20

30

40

50

60

70

80

90

100

85.2 84.7 85.7 84.1 84.2 83.1 84.4 85.3 84.4 85.0 85.2 85.3 84.8

98 96 9995 95

84

95 98 95 97 98 98

Mean FYTD MeanPercentile Goal Mean Target (84.5)

84.5

7. Sustainment: Press Ganey – Meals

FYTD Mean Score – 84.8 (96th Percentile)

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Across the Continuum to Ambulatory Care

Carolina Care TM

Swanson Caring Theory

Tonges Translational Model

TRANSLATING CARING THEORY INTO PRACTICE