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Unitary Appreciative Inquiry: Praxiological Investigation of Risk Induced Professional

Caregiver Despair: Reflections and Implications

Thomas Cox RN, BA, BSN, MS, MSW, MSDoctoral Candidate

School of Nursing

Virginia Commonwealth University

International Society of Psychiatric Mental Health Nurse

St. Louis, Missouri

April 30, 2004



Who am I & What Will I Cover Today?

Psychiatric NursePsychiatric Social Worker

StatisticianMathematician

Insurance ProfessionalResearcher

Doctoral Candidate

Professional Caregiver Insurance RiskUnitary Appreciative Inquiry

Risk Induced Professional Caregiver Despair

Questions - Answers

Copyright 2004 Thomas Cox



Professional Caregiver Insurance RiskRisks to health care providers in arrangements like capitation contracts, DRGs, Medicare/Medicaid fee caps, & preferred provider relationships that inadequately fund needed/rendered care

Risks arising in budgeted nursing units subject to high variability in patient acuity, resource demands, equipment, supply shortages, mismatched patient needs/RN skills, and time constraints

Average Cost Based Reimbursement Plans (ACBRPs) force RNs into the roles of insurers – simultaneous clinical and financial decisions – who is minding the store? What are the ethical issues?

Bedside RNs forced to decide what services clients get and distribute scarce time and resources over too many patients, discharge acutely ill patients, manage gaps in care that are programmed in as recurrent & persistent features of care environments




Professional Caregiver Insurance RiskInsurance risk transfers occur in financial contracts and intra-organizational budgets that inadequately fund caregiving functions and transfer insurance risks

Risk transfers may cause financial, professional, spiritual & affective disharmony on nursing units

Risk transfers may cause service quality

Recognizing and healing the professional, spiritual & affective wounds is critical to the well-being of RNs, nursing, nursing clients & the whole healthcare system




Risk Induced Professional Caregiver Despair?RIPCD

Possible impacts on RNs of changes in healthcare finance mechanisms

access to quality healthcare.

Disrupted bonds between RNs and clients

Character, quality, & rapport of relationships

Issues neglected - need new tools/understandings to play a role in reshaping HC environment & finance issues

Some RNs despaired over lack of resources, workloads, unfamiliar staff, patients discharged too early

RNs had rich stories of the impact of working under fiscal constraints & risk transfersCopyright 2004 Thomas Cox



How RIPCD Developed

Social work experiences

Nursing experiences

Insurance professional, social researcher, actuarial analyst and biostatistician experiences…

Peers at conferences, classes, & Christmas parties

Reflecting on roles, duties, and responsibilities of caregivers working under constraints and the similarities to insurance risk transfers

I needed a dissertation topic….




Risk Induced Professional Caregiver Despair

RNs experiences, perceptions and expressions of RIPCD about their careers and working environments

Assumed there were good reasons for despair - not simply a biological, chemical, Rx deficit, or depression

Unmet expectations, unfulfilled hopes & dreams, opportunities lost, challenges too hard to meet, harsh and uninviting futures, and a past impossible to replicate or resurrect

Many RNs created new meanings for their experiences through their sharing,the researcher’s witnessing, and collaborating on developing their appreciative profiles, seeing themselves as wholes, representing & revealing their unique constructions of the world & their futures




A Priori Assumptions about RIPCD

Burnout Depression

Unhappiness Anomie

Angst Dissatisfaction

Alienation Suffering

Stress Poor Attitude

Ethical Conflict Moral Distress

Mostly wrong!




Unitary Appreciative Inquiry ITheory generation, practice & research method

Rogers Science of Unitary Human Beings

Appreciation of humans and human phenomena as wholes

Participants share experiences, perceptions & expressions, from their unique vantage point & without justifying themselves, their thoughts, beliefs, actions, or decisions

Goal – Appreciation of participants wholeness

Researcher sought a ‘healing appreciation of the participants’, not just capturing data about the experience

Praxis – not just research – RIPCD is a vehicle




Unitary Appreciative InquiryCowling suggests that UAI has four (4) dimensions:

Pattern

Appreciation

Praxis

Power

and these advance and integrate four forms of unitary-transformative knowledge of particular concern to nursing:

Experiential

Presentational

Propositional

Practical

(Heron & Reason, 2001)




Practicing Unitary Appreciative InquiryAcceptance and validation of participants

Empathy and appreciation: seeing through their eyes,

Seeking deeper understanding of the participants, as wholes

Healing intention - assist participants to freer expression, greater insight, and greater integration

Dwell in preconceptions & assumptions favorable to participants, fostering rapport & promoting a sense of harmony & mutuality

Participants are wholes but may feel ‘not-whole’

Assist participants in their healing appreciation of their wholeness, facilitating growth & transformation

Not just data collection – IRB issues




RIPCD – A Unitary InquiryExperiences, intuitions, reflections about RNs RIPCD experiences

Collaborative, theorogenic, research, and healing journey

Opportunity to reveal, explore, and represent effects of HC financing experiments, adding substance, humanity, faces & feeling to the soulless explications that dominate

Participants shared experiences that highlighted the breadth and depth of the impact of risk transfers on nursing care and RNs in varied settings




Why UAI Was ImportantWholeness and healing occurred because sufficient time and energy were devoted to free, unstructured, expression

Most participants thanked me for the opportunity to discuss their RIPCD until THEY were satisfied, citing prior inabilities to achieve a sense of closure

Some felt peers & superiors prematurely reacted, missing their legitimate concerns and seeing ‘staffing problems’ trying to ‘fix’ them or seeing them as ‘problem employees’

Appreciative profiles may be helpful to other disciplines and settings, addressing features of modern life & gaps between expectations & capacities under unanticipated and unplanned variability and unpredictabilityCopyright 2004 Thomas Cox



Recruitment and Opening Dialogue

Participants sought through key informants, colleagues, flyers, presentations & attendees at past presentations

Opening question: “What does risk induced professional caregiver despair mean to you?”

Sometimes: “What makes your work as a nurse difficult?”

Most participants quickly focused on particular events in the workplace that dramatically affected them and their clients revealing serious deficiencies, inadequate staffing, scarce equipment, defective equipment, scarce supplies and some dramatically compelling experiences of inadequate and compromised care




How The Research UnfoldedIn the early stages I wondered if people would be able to help me connect the dots. Then I wondered if they would…

RNs wanted to share their stories

Each RN provided new insights, helped to set a context for earlier/later stories about difficulty of bedside nursing

The question “What does risk induced professional caregiver despair mean to you” led to stories of the dramatic effects on nurses and clients of risk assumption and the erosion of what I now call “Nursing surplus” the organized, synergistic, capacity to provide high quality nursing care




The Participants I

8 Registered Nurses

Self-identified as experiencing RIPCD

Volunteered to collaborate in an inquiry into effects on their practice of changes in HC financing mechanisms

Variety of nursing settings & experiences:

Oncology (2) Psych

Surgery Transplant/Oncology

Agency RN Maternity/ Pediatrics

Medical-Surgical

2 – 26 years as RNs




The Participants IIOne participant, with business experience was well-informed on the insurance risk aspect

Most participants misinterpreted significant features of the environment:

Record keeping = Billing/Revenues

Patient Services = Billing/Revenues

Some opportunities to dialogue on my work on but participants and their world were the focus – sometimes would have interfered with the flow of the conversation

Most participants asked some questions about my work – I explained it only after in-depth interviews




Thoughts on UAI as Dissertation Method

IRB – Difficult to explain ‘praxis’ to panels focused on risk reduction in designed experiments

How does one distinguish between healing intent and intervention to accomplish a specific outcome?

I never realized how out of control life could get – Hurricane Isabel helped me to appreciate that…

Much harder to get to be able to engage with participants than to engage with them…Copyright 2004 Thomas Cox



What Were The End Products?

A hopefully soon to be completed dissertation

Four abstracts for presentations on PCIR/RIPCD based on the dissertation research (4 accepted)

Several future publications about the study findings, UAI, PCIR, RIPCD, nursing MISs, financial management…

Presentations on research, methodology, & PCIR

Develop tools for monitoring/maintaining nursing surplus under rapidly changing conditions of supply & demand

New venues for collaboration with other nurses, researchers, practitioners, educators & administrators




During and After Inquiry

Allowed to freely consider, explore, and express their experiences, most of the RNs developed new ideas and attitudes about themselves and their RIPCD

Researcher gained important insights into how RNs respond to environmental impediments to caring practice

New theories and strategies for preparing RNs in new roles emerged – greater need to understand insurers, how to read and understand budgets & management reports, ethical reasoning regarding quality of care issues and conflicted loyalties

New ideas on healing for individuals, groups, and systemsCopyright 2004 Thomas Cox



Some Guiding Principles of Healing Synoptic Narrative Construction

Allegory & metaphors encompass past, present & future

Collaborations, incorporated multiple modes of cognitive, affective, and aesthetic interpretation & representation

A reaching to incorporate past, present & different futures – a new way to focus clinical activity

Serving as a guide, reference point, healer, and co-inquirer, walking with participants on life path

Embrace contradiction, dissimilarity, and incoherence as birthing the futureCopyright 2004 Thomas Cox



Appreciative ProfilesProfiles based on participant suggested sources:

The Scream – Home Alone (Macauley Culkin) OR Nurse

Voltaire’s Candide Oncology Nurse

Events in source materials woven with the events described by participants as interpreted by researcher – tremendous problem for aesthetically challenged researcher

Profiles developed with and approved by participants

Both participants and several others really liked my a priori hypothetical profile




A Hypothetical Unitary Appreciative Profile



Some Guiding Principles of Risk Induced Professional Caregiver DespairRhythm, flowing in & out of despair, hope, joy, pessimism

Not ‘observable’ - must engage participants

Experiences may be rare, constant, or never ‘resolved’

Emerging, shifting, changing, reforming coherence from time to time in an ever-changing environment

Most RN loved their jobs, peers, and nursing

For some, flooding their experiences out dramatically altered their lives, impelling them to action



Http:// Unitary Appreciative Inquiry: Praxiological Investigation of Risk Induced Professional Caregiver.

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