Implementing Careful Nursing in a Hospital

So like us, maybe you've decided to implement the Careful Nursing Philosophy and Professional Practice Model throughout your organisation? Easy, right? But have you found yourself saying things like "Maybe if we just....um...", "Or we could simply....um...", "Okay, let's make a plan and start with, ummm....". Sound familiar?

They're the questions we asked ourselves as we embarked on the task of rolling out Careful Nursing in a major acute care hospital. When enthusiasm meets reality, uncertainty can creep in and the task can seem somewhat overwhelming. But with meticulous planning and a passion to improve the environment that, a) patients are cared for in and, b) nurses work within, anything is possible.

A good plan is one that answers all your questions, and from our experience our plan was formulated by asking ourselves the following questions.

Where are we?

Essentially all hospitals strive for the same thing, therefore making them similar, but each hospital is also unique. This goes for units and departments within a hospital also. Understanding your own strengths and the challenges you face in providing optimal patient care, and in generating the best environment possible for nurses to work within, will make it easier to implement Careful Nursing. Knowing where you are makes it easier to know how to get to where you want to be.

Nurses in each hospital, or ward or unit, will need to begin by taking stock of where they are in terms of factors such as knowledge, skill mix and psycho-dynamics. So like us you need to begin from where you are. Establish and understand your strengths and the challenges you face and develop your plan accordingly.

Who will decide how to do this?

We will. Each nurse at any given hospital, or ward or unit, has chosen to be a professional nurse and has made a commitment to be employed in a particular place. Each can say with confidence that they know their profession, they know their place and they know one another. 

What is our specific implementation plan?

The first question you can ask yourself is "Will we implement the entire model at once or implement aspects gradually?" This will vary from hospital to hospital and will be influenced by; where you're at and where you want to get to; resources; the size of your organisation and the number of departments; the number of staff; the amount of time you have and so on.

Ours is a large hospital with 800+ nurses and we made the decision to roll it out to every clinical area, one at a time. We also made the decision to focus on two of the dimensions, 'the therapeutic milieu' and 'the practice competence and excellence'. As part of the latter dimension we made the decision to completely overhaul our care planning system to incorporate standardised nursing language and nursing sensitive outcomes. This aspect takes a considerable amount of time but is factored into our overall plan. It helps us focus on improving patient care by standardising how we approach it and talk about it. This strengthens our professional nursing identity and confidence and allows us to tangibly measure our nursing contribution to that very care.

What do we need to know to do this?

We need to know the Careful Nursing Philosophy and Professional Practice Model. We need to know ourselves. We need to know one another. Nurses in any given practice setting need to learn all this together. We decided from the very outset that this was to be an inclusive project, so a project plan by nurses for nurses became our mantra. Dare I say it, but sometimes as a profession we can be guilty of a hierarchical approach to thinking and acting; that is one 'layer' of nursing telling another 'layer' of nursing how to best do their job. By knowing and honestly living by the 'Nurses care for selves and one another' concept of the practice model, an inclusive approach should organically evolve. 

A basic mandatory education programme will be necessary and will serve all these needs. But the programme may take any one of a range of different forms. For example, for some hospitals, or wards or units, several of the nurses may have learned about Careful Nursing as part of their formal education programme, while for others, all will have the education programme in their practice setting.

Our approach was to develop a comprehensive mandatory two-day education programme, to be attended by all staff in the particular clinical area where we are rolling it out. For us as the project team, the education component came in advance of the study days. For each clinical area we roll it out to, we develop new care plans specific to that area's cohort of patients. In achieving this we collaborate with the frontline nursing staff in that area. Two representatives from each area are released for one to two full days and we work together in deciding the content and structure of each care plan. We found this to be crucial to the success of the rollout, as from the outset the clinical staff 'own' the care plans and it is not 'us' telling 'them' how to do their job, we're merely nurses caring for ourselves and one another, and practicing intellectual engagement.

The actual 2-day programme we developed comprises of didactic style lectures (for a very small part), meditation sessions, group work, role play, group discussions, scenario based learning and feedback sessions. A large proportion of one of the days is spent on the new care planning system, which for our organisation is a central component of the rollout.

An unexpected benefit we came across while facilitating, these days was the sense of team building/work and morale that ensued. The clinical areas are so busy and shift work means that nurses within a clinical area often don't get to see each other for weeks on end, never mind discuss their views on the nursing profession! So here for two full days, friends and colleagues got to air opinions, discuss ideas, challenge and support each other and once again bond over their professional identity. They also felt listened to and valued, which as a project team was educational and motivating for us.

How will we actually change our practice? 

First off, is to understand what it is exactly you're trying to change. We wanted to change the way nurses approached patient care, it was often ad hoc and reflective of the skills and knowledge level of an individual nurse, so we amended our documentation to standardise the care and ensure it was evidenced based. We wanted nurses to be aware of the environment they were creating for their patients and themselves, so during the study days we asked them to generate 'I will' statements. Basically these were their ideas of how they would activate each concept of the two dimensions into their daily practice and work environment. We then made posters of these ideas and hung them in their clinical area.

We also had a member of our project team spend a full 4-5 weeks based on the clinical area to provide on-going support and to help imbed the Careful Nursing Philosophy and Professional Practice model and new care planning system.

How will we evaluate our implementation? 

Going back to why you implemented Careful Nursing will help you understand what you need to evaluate. We wanted to improve the standard of care we gave our patients, but we also wanted to improve the working environment for nurses and ensure they had more control over their own practice. Our evaluation was therefore multi-faceted. We carried out regular documentation audits to establish the effectiveness of the new care planning system. We amended our audit tool to specifically examine the impact of nursing care on patient outcomes. We have also embarked on a new and ambitious system for measuring the nursing contribution to patient care by focusing on the nursing sensitive outcomes.

We circulated pre and post 'Control over Nursing Practice' questionnaires to clinical staff and fed back results. We held on-ward focus groups and on-going education sessions and constantly sought feedback from staff and made the necessary changes to improve the project and amend the plan in time for the next clinical area to benefit from Careful Nursing.

We hope this can be of benefit to you when implementing Careful Nursing in your hospital. We have found it to be challenging but immensely rewarding and we can see that it is making a real difference to patients and our nursing colleagues.

Good luck !

Sinead Murphy