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Measuring caring--the next frontier in understanding workforce performance and patient outcomes.

A RECENT META-ANALYSIS OF the outcomes of staffing ratios reviewed all that we know within contemporary literature about how staffing relates to outcomes (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Within this very comprehensive and well-done study there was no identification of caring as an influential or contributory variable for patient or organizational outcomes. This is not surprising as the idea of caring as a major influencing factor is likely a far stretch to many. Caring is, after all, not generally considered in structured and scientific analysis of situations. But this may well be a mistake. Underneath it all is the very basic act of one human being taking care of another human being in need. Today more and more scientists and researchers are looking into this very fundamental aspect of health care. Early investigation is promising and the potential far reaching. We may well find within the basic concept of caring there are many answers to otherwise difficult and illusive solutions.

Caring likely has a return on investment (ROI) that surpasses all other technology, pharmacotherapy, or system that has been developed to date for health care. The ROI potential is great because all employees can create a caring moment and possibly create a cumulative and/or potentiating effect of caring on the internal healing cascade of both employee and patient. This is important to understand within the current context of dwindling resources, which has created the mandate to examine what resources provide the greatest return and/or to identify existing resources that are under-utilized.

Caring science from a group of researchers who are in pursuit of measuring the concepts, moderators, potentiators, and outcomes of caring will be summarized within this article. Several of the findings within this summary are derived from a recent book (Nelson & Watson (2011) which delineates 41 of the studies conducted by 80 participants or associates of the Sigma Theta Tau International community called the Caring International Research Collaborative (CIRC). All are invited to join CIRC, including students, academicians, clinicians, administrators, and staff from any and all professions within and outside health care. Each brings knowledge that adds to the building of the science. In addition, this approach is consistent with Kuhn's (1962) assertion that science will exponentially grow when we begin to share what we know. This requires absence of ego as this all too real dynamic hampers sharing and learning.

Global partnerships within and around CIRC are facilitated by sharing research and resources. This approach has helped minimize cost while deepening understanding about how caring is an intervention of healing for self and others. Findings reviewed within this brief article include pain moderates patients' perception of feeling cared for (Herbst, 2011); nurses perceive addict and nonaddict patients differently (Clubb, 2011); and internal and external processes of caring evolve as clarity of self, role, and system evolve within those who are providing care (Persky, Felgen, Romana, & Nelson, 2011). Findings such as these are currently being pieced together to understand the dynamics of caring.

Step 1: Theory

The process of measuring caring begins with clarity of intention; an understanding of what behaviors and/or actions will result in the experience of feeling cared for. This is where theory comes in. Within CIRC it is often referred to as the "hunch" the investigator proposes will have an impact in perception of caring. "Hunch" is an over-simplified word for "theory" people readily connect with and thus use. Dr. Kristen Swanson, as an initial example of theory, qualitatively examined five caring behaviors, including knowing, being with, maintaining belief, doing for, and enabling. The five behaviors have been placed within a measurement tool called The Caring Professional Scale (Swanson, 2009), which she developed within her trajectory of understanding outcomes of caring. Two subscales were revealed, being a Compassionate Healer and Competent Practitioner (K. Swanson, personal communication, June 2, 2011). This appears to be the art and science of nursing. This art and science of caring does not only relate to nursing, of course, but the science illustrates how statistics can be used to demonstrate how certain behaviors can be shown to hold together mathematically within proposed theory.

Scott, Scott, Miller, Stange, and Crabtree (2009) used grounded theory to examine what is important to patients within the relationship with their caregivers and uncovered several dimensions of caring. The dimensions are referred to as the Healing Relationship Model (Scott et. al., 2009). The construct of a caring physician comprises several concepts, beginning with making the patient feel valued. Second, the patient wants to know there is shared power in the physician-patient relationship between the physician and patient. Third, the patient appreciates when there is an abiding component to the relationship, which means the physician has been present through many events of the patient's life. It is these first three components that are important for the patient-physician relationship to develop and be sustained (Scott et al., 2009). Fourth, within the model proposed by Scott et al. (2009) is the patient's perception the physician can be trusted. Fifth, it is important the patient has hope for continued well-being. Sixth, it is important the patient feels the physician knows the patient's unique responses to interventions for healing. Finally, it is important for the patient to have confidence in the physician's clinical skills. This grounded theory work has provided a way to measure the construct of caring of physicians as an outcome. It is now desired to understand more deeply not only what the concepts are within the construct, but also what occurs before and is subsequent to this outcome of feeling cared for. These data are currently being examined more intensely within this seven-concept construct of caring of the physician.

A final theory as an example, Watson's theory of Caritas, asserts that when divine love (Caritas) is perceived, it is because the 10 concepts of Caritas are present (Watson, 2005). The person providing the care is clear and intent in which of the 10 concepts of caring should be applied, thus the patient feels cared for. As a result, there is a cascade of healing biochemical markers within the patient (e.g., decreased cortisol, increased oxytocin, increased IgA, etc.) that is reversing or halting the degenerative impact the physical, mental, or spiritual illness is creating. Further, the release of the internal cascade of biochemical markers also allows the recipient of caring to access his/her most complex thought portion of his/her brain, the frontal lobes, thus making better judgments regarding health and life.

The testing of these theories and more are the focus of CIRC and associates of CIRC. Over time, studies brought forth via this networking of invested professionals will reveal how the theories perform to illuminate caring for self and others, mainly the patient. It may be all or part of the theory survives testing, or it may be a combination of theories. Once the theory ("hunch") is selected and methods devised, then data collection begins.

Step 2: Data Collection

The research collaboration within CIRC in caring science began in a research study at Inova Health System (Drenkard, 2011). Findings within the data that were not within the published study by Drenkard (2011) revealed a curious negative relationship between the caring as reported by the patient and the work environment as reported by the staff nurses. This negative relationship inferred the units with nurses who were least satisfied with co-worker relationships and professional growth also had the highest scores of caring. There were two instruments measuring caring and both instruments revealed this curious negative relationship. The tools were both tested for validity and reliability and considering both instruments behaved psychometrically sound, the finding was deemed spurious (by chance) despite being statistically significant (using an alpha of 0.15 as the sample size was only 8). However, this curious finding was pursued further in another study at New York-Presbyterian (NYP) Hospital, using the same instruments, but the sample size was increased to 86 and the level of measure was not units but rather 86 nurse-patient dyads. In Inova's study, both the Caring Assessment Tool II (CAT II), developed by Duffy, Hoskins, and Seifert (2007), and the Caring Factor Survey (CFS) (Nelson, Watson, & Inova Health, 2008) were used. However, at NYP only the CFS was used to decrease responder burden for the patient. The same negative relationship between caring and work environment variables was found (Persky, Watson, Nelson, & Bent, 2011). When this curious finding was posed to nurse managers at NYP as an effort to make sense of the data, a nurse manager stated, "It is those nurses who are clear in what it takes to care who understand what is needed to make it happen. However, the nurses effective in caring feel frustrated that the system does not support these needs to provide caring interventions." In other words, the nurses were clear in their intention for caring.

The study at NYP continues. Nurses who were most dissatisfied and effective in caring learned they were dissatisfied as they were trying to control things outside of their responsibility. Their knowledge was acquired within Relationship-Based Care which enabled them to rise above the frustration of the work environment as they became clearer in not only self and role, but system as well (Persky, Felgen et al., 2011). They learned to control what they could influence and bring forward to the appropriate systems person the things they, the staff, could not control within the system. This understanding of the evolution of the work environment has been described elsewhere (Persky, Felgen et al., 2011).

These findings were presented at the Caritas Consortium in 2009 where many other research studies in caring science were taking place. The Caritas Consortium is an annual conference of Watson's Caring Science Institute (WCSI). The networking between CIRC leaders and WCSI participants provided an opportunity for more exciting research, expanding to measure the competence of caring of the staff nurse (Johnson, 2011). Replication studies testing the competence of the nurse revealed nurses report they provide loving kindness to patients as the first of 10 caring behaviors (Julian, 2011; Tinker, Sweetenham, & Nelson, 2011). Nurses around the globe tend to report their own problem solving to be low as a caring behavior for patients. This is interesting when compared to patients around the globe who report problem solving of nurses to be among the highest caring behaviors of nurses (Nelson et al., 2011). It is also interesting to note nurses tend to report their spiritual care about 5th of 10 caring behaviors globally but patients consistently report spiritual care as the lowest behavior, again globally (Nelson et al., 2011).

The CFS was farther adapted to examine caring behaviors toward self (Lawrence & Kear, 2011), caring of co-workers (Lawrence & Kear, 2011), caring of preceptor (Testerman, 2011), caring of the organization (Harley et al., 2011), and caring of manager (Olender & Phifer, 2011). These additional amendments of the CFS were due to the "hunch" of investigators who felt the caring within each respective relationship transferred to other relationships within the organization.

Step 3: Interdisciplinary Interpretation/Collaboration

All the findings from the studies mentioned here cannot be reviewed in this article, but it illustrates the serious effort nurses have taken to test the power of caring as an intervention of healing. Working alongside other professions has exponentially added to the scientific discussion. Architects, for example, have joined the efforts of those involved in CIRC because they have theories that support the concepts of caring. To illustrate, theory and science of architectural engineers assert cross sections and gathering spaces foster relationships. Thus, within the conversations of caring and healing, the question was posed, "Do health care facilities with gathering spaces or cross sections have higher scores of caring for self and others?" Further, do these units have higher levels of oxytocin with lower levels of cortisol? These questions are currently being drafted within research proposals.

Biochemists have joined the efforts of CIRC as well to see if patients who perceive caring and love have higher cortisol, oxytocin, IgA, and testosterone levels (Parcells & Nelson, 2011). A physician associated with CIRC suggested when nurses who are effective in caring are identified using multiple measures (e.g., self-report, patient report, and biochemical markers), MRI scans should be performed on these nurses to see if they have more active frontal lobes. Do caring nurses (for self and others) have better access to the critical thinking areas of their brain (frontal lobes), thus make better clinical judgments and thus have better patient outcomes?

To answer these questions, other types of mathematics and analysis must be utilized. Currently this group has made use of mostly Gaussian mathematics (statistics), but has also used qualitative research, pattern analysis, and Parato mathematics (using outliers, essentially). Use of additional methods has helped the conversation regarding meaning of data. It is desired to move into quantum mechanics, as we know from some studies within this group that time can be the biggest predictor of a variable of interest. In addition, there is interest in using non-linear geometry and patterns of geometry to understand if there are patterns of caring/love on specific units. Science has shown perfect geometric patterns in nature, art, and architecture (Hemenway, 2008). Thus, the question is posed, do units/ wards/clinics of patient care have patterns of caring/love when the staff behaves autonomously and collaboratively within their respective roles? These are challenging questions that can only be answered with multiple professions engaged in theory development/refinement as well as collecting and interpreting data.

Final Step: Showing the Return On Investment

Ultimately, the goal is to show the cost containment secondary to the intention of caring. As the puzzle of caring as an intervention of healing continues to come together, the outcomes of care for self and others will become clear. Do nurses who practice self-care have better access to their frontal lobes and thus have better outcomes? Do they have higher levels of healing hormones, thus call in sick less? Do nurses who have self-care collaborate better with others because they are knowledgeable in self and thus grateful for others to help in areas of their own weakness? Do patients who feel cared for have better internal healing mechanisms that subsequently decrease length of stay? Results from each of these potential outcomes could impact configurations and needs within staffing and subsequent financial outcomes.

In addition to care for self and others, can structure be built to facilitate these concepts? Could this be a new specialty in architecture where they work in health care, helping to research caring outcomes for self and others? Could such structures make care for self and others inevitable because the theory of design has proven true?

Could biochemists help create a blood panel of love? There are groups of lab tests to show functioning of internal organs and systems, could there be a blood panel to test for love? There are tests for stress, why not caring/love? Labs could be used to create a care plan to increase perception of caring/ love, thus increase the internal healing agents to decrease length of stay, increase marketability of the hospital and referral rate. These outcomes are currently hypothetical but science could eventually provide payment to nurses who are competent in caring and thus decrease morbidity of illness.

Such questions, once answered, could provide insight into variables not yet considered seriously as it relates to staffing, healing, and financial outcomes. Resultant data may assist with identifying error within current models of research in concepts with stubborn misspecification not being resolved within current thinking. A cumulative return on investment in caring may be hard to ignore. The group of scientists within and connected to CIRC are seeking to understand this, publish their work, and encourage others to add to the science of caring. It seems this time of scare global resources serves as an opportunity to share information and research worldwide. In addition, the proposal within the United States to design accountable care organizations where systems collaborate may serve as another incentive to pursue the theories and methods proposed within this article. The author of this article is grateful to all in CIRC and associates of CIRC who have helped bring the science of caring to the current state. It is clear by the number of studies generated by just one group, CIRC, that there is a shared belief caring is healing and has a potential for return on investment that has yet to be realized.

REFERENCES

Clubb, G. (2011). Nurses' caring attitudes from the USA toward medical surgical patients who have a diagnosis of drug addition. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Drenkard, K.N. (2011). Integrating human caring science into a professional nursing practice model. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Duffy, J.R., Hoskins, L., & Seifert, R.F. (2007). Dimensions of caring: Psychometric evaluation of the Caring Assessment Tool. Advances in Nursing Science, 30(3), 235-245.

Harley, C., Lott, T., Clerico, E., Kosak, E., Hennessy, W., & Michel, Y. (2011). Caring factor survey (CFS) to the Bon Secours St. Francis caring work environment survey. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Hemenway, P. (2008). The secret code: The mysterious formula that rules art, nature, and science. Koln, Germany: Taschen GmbH.

Herbst, A.M. (2011). Impact of intentional caring behaviors on nurses' perception of caring in the workplace, nurses intent to stay and patients' perceptions of being cared for. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Johnson, S. (2011). The relationship between nurses' self-caring using Watson's concepts of caritas and compassion fatigue: A study from the USA. In J. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention (appendix G). New York: Springer.

Julian, D. (2011). "Partners in care": Patient and staff responses to a new model of care delivery. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). Nursing staffing and quality of patient care. Evidence report/technology assessment no. 151 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 07-E005. Rockville, MD: Agency for Healthcare Research and Quality.

Kuhn, T. (1962). The structure of scientific revolution. Chicago: Chicago Press.

Lawrence, I., & Kear, M. (2011). The practice of loving-kindness to self and others as perceived by nurses and patients in the cardiac interventional unit (CIU). In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Nelson, J.W., & Watson, J. (Eds.). (2011). Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Nelson, J.W., Persky, G., Sramek, D., Masera, G., Ga, M.M., Zhu, M.M.X., Lok, G.K.I., Lawrence, I., & Sollami, A. (2011). Comparison of caritas in healthcare facilities in four countries as perceived by patients. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Nelson, J.W., Watson, J., & Inova Health. (2008). Development of the Caring Factor Survery[c] (CFS), an inastrument to measure patient's perceptions of caring. In J. Watson (Ed.), Assessing and measuring caring in nursing and health science (2nd ed.). New York: Springer.

Olender, L., & Phifer, S. (2011). Development of the caring factor survey--Caring of manager (CFS-CM). In J.A.

Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer. Parcells, D.A., & Nelson, J.W. (2011).

Taking the 'quantum leap': Biochemical markers of human caring science. In J.A. Nelson & Watson, J. (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Persky, G., Felgen, J., Romana, M., & Nelson, J. (2011). Measurement of caring in a relationship based care model of nursing--Part 1: New York-Presbyterian Hospital, New York, New York, USA. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Persky, G., Nelson, J.W., Watson, J., & Bent, K. (2011). Profile of a nurse effective in caring. In J.A. Nelson & Watson, J. (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Scott, J.G., Scott, R., Miller, W.L., Stange, K.C., & Crabtree, B.F. (2009). Healing relationships and the existential philosophy of Martin Buber. Philosophy, Ethics, and Humanities in Medicine, 4, 9.

Swanson, K.M., (2009). Caring professional scale. In J. Watson (Ed.), Assessing and measuring caring in nursing and health science (2nd ed.). New York: Springer.

Testerman, R. (2011). Preceptor caring attributes as perceived by graduate nurses. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Tinker, A., Sweetenham, J., & Nelson, J. (2011). Reflective practice as a process to understand caring behaviors during implementation of relationship based care in a community health service in England. In J.A. Nelson & J. Watson (Eds.), Measuring caring: A compilation of international research on caritas as healing intervention. New York: Springer.

Watson, J. (2005). Caring science as sacred science. Philadelphia: F.A. Davis Co.

JOHN W. NELSON, MS, RN, PhD(c), is President and Healthcare Environment Facilitator, Caring International Research Collaborative, Indianapolis, IN.
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Author:Nelson, John W.
Publication:Nursing Economics
Geographic Code:1USA
Date:Jul 1, 2011
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