Principles and Practices of Integral Care: The Future of HIV Nursing 22 nd Annual ANAC Conference “Reaching Beyond: Collaborating to Build Capacity” Jacksonville,

Principles and Practices of Integral Care: The Future of HIV

Nursing

22nd Annual ANAC Conference“Reaching Beyond: Collaborating to Build Capacity”

Jacksonville, FloridaNovember 19-22, 2009

Foresight

“Images of the future are the blue prints that we use in constructing our lives”

Cornish, E. (1977). The study of the future. Bethesda, MD: World Future Society.

Alpha Leadership

Anticipate

Align

Act

http://www.alphaleaders.com/

http://www.alphaleaders.com/

Wonder

If a time traveler from 50 years in the future could give you the answer to

one question, what would it be?

Pride

If you were looking back 10 years from now and telling the tale of the

organization’s greatest success, what would the story be and why?

Shame

If you were looking back 10 years from now and telling the tale of the

organization’s greatest failure, what would the story be and why?

Memory

What does the organization need to forget?

What must it always remember?

Imperatives

What are the most important strategic decisions we will have to make as an

organization?

Obstacles and Dangers

What will prevent us from succeeding?

What are the greatest risks and dangers?

Priorities

If you had the power to do one thing for the organization, what would it be, and

why?

Future Pacing

• What concepts, tools, techniques are most useful?

• How can information be used?

• Why is information important?

• Why care about the information?

Outcomes

• Identify and apply futures research methods to support advances in the field of HIV nursing

• Describe and discuss and integral care model for HIV Nursing.

Foresight ~ Future Blind

Knowledge ~ Research

Learning ~ Education

Service ~ Practice

Kelso, Scott & Engstrom, D. (2006) The complementary nature. Bradford Books, MIT Press, Boston, MA.

Future Blind

• Lost and trapped in yesterday’s decisions, choices and consequences –become risk aversive

• Betrayed by expectations -must negotiate the expectations of youth with the experience of life

Hudson, Frederic (1999). The Adult Years: Mastering the art of self-renewal. Jossey-Bass: San Francisco.

Future Blind

• Social systems once protective are destabilizing

• Overwhelmed with information and decisions• Bewildered by change, complexity and

discontinuities• Develop discourse of regret versus hope

Hudson, Frederic (1999). The Adult Years: Mastering the art of self-renewal. Jossey-Bass: San Francisco.

Crossing the Quality Chasm

A New Health System for the 21st Century- The Century of

Complexity

http://newton.nap.edu/books/0309072808/html/

http://newton.nap.edu/books/0309072808/html/

Health Care PerformanceCharacteristics

• Safe

• Effective

• Patient- centered

• Timely

• Efficient

• Equitable

A 21st Century Health Care System

• Evidenced based, planned care

• Reorganization of practices

• Systematic attention to patient information needs and behavioral change

• Ready access to clinical expertise

• Supportive information systems

Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Institute of Medicine, National Academy Press, Washington, D.C.

Redesign Challenges

• Redesign care processes

• Effective use of information technologies

• Manage clinical knowledge and skills

• Develop effective teams

• Coordinate across conditions, services, settings, time

• Use of outcome measures for improvement and accountability

Four Futures

• Possible

• Plausible

• Probable

• Preferred

“What the future holds for us depends on what we hold for the

future.”

Mikela and Philip Tarlow

Navigating the Future

Future Studies

The purpose of future studies is not to predict the future, but to envision desirable futures and avoid or prevent catastrophic ones.

Becoming A Futurist

• Pay attention to time and time-spirits.

• Learn about the future.

• Understand people’s reactions to learning about the future.

• Actively monitor industry trends and forecasts.

Becoming a Futurist

• Discern logical consequences of trends using futures thinking tools and techniques.

• Use emotional intelligence in change efforts.

• Create vision-based scenarios.

• Stimulate strategic conversations about espoused visions.

• Consider the value of an integrally informed future.

Time and Time Spirits

Domains of Work

SharedMeaning

Creating valuein the present

Adding valuefor the future

Sustainingvalues

Quality indaily work

Processmanagement &

improvement

Process/systemdesign

Innovation & transformingwork

Strategicdevelopmentof physical &

intellectual capital

Strategic intent asdirection

Strategic intent asviability

Corporate citizenship& stewardship

Meeting present needswithout compromising

future generations

Keith McCandless, 1998Adapted from Hoebecke &

BIOSS

Time Span Responsibilities

Creating valuein the present

Adding valuefor the future

Sustainingvalues

Quality indaily work

Processmanagement &

improvement

Process/systemdesign

Innovation & transformingwork

Strategicdevelopmentof physical &

intellectual capital

Strategic intent asdirection

Strategic intent asviability

Corporate citizenship& stewardship

Meeting present needswithout compromising

future generations

Keith McCandless, 1998Adapted from Hoebecke &

BIOSS

20-50 Years

10-20 Years

5-10 Years

2-5 Years

1-2 Years

3 Months-1 Year

1 Day-3 MonthsMastering the directtouch & feel of worktasks & patient care

Improving step-by-stepdiscrete processes

Connecting & finetuning parts of a system

Modeling & mappingalternative ideas/

practices

Imagining & creatingnew rules & fields of

knowledge

Weaving social, political,economic, global

intelligence

Sensing/perceiving theinterconnectedness of

all things & envisioningnew forms oforganization

50+ Years

Core Work Capabilities

Engaging Stakeholders in Each Domain

Learning About the Future

World Future Society

http://www.wfs.org/

http://www.wfs.org/

Global Health EconomyMap of the Decade

http://healthmap.org/en

http://healthmap.org/en

Future Web Forums

http://www.wfs.org/inter.htm

http://www.wfs.org/inter.htm

Future Forces Affecting Education 2006-2016

http://www.kwfdn.org/map/background.aspx



Reactions to Learning About the Future

• Patterns of Mind

• Patterns of Heart

• Patterns of Soul

Actively Monitor Trends and Forecasts

Scanning

Scanning involves searching information resources, consciously (active) or not (passive), for a particular kind (directed) of information which is then subjected to special attention.

Trends and Consequences

• Personal

• Professional

• Organizational

ANAC Future Scan

• Funding and Resources

• Health Care Reform Policy and Politics

• Health Care Provider Person Power

• Patient, Family, Community Response to Treatment

• Medical Advancements in Treatment

• Technology: Electronic Medical Records

• Education, Training, and Research

Discern Consequences of Trends

Trend

• What does this really mean?





Futures Wheel

A futures research method that draws out the consequences and expands the impact of an identified trend or event.

Futures Wheel

The search for consequences continues until three unanimously agreed-upon consequences have been developed.

Cross-Impact Analysis• A futures method

technique used to make judgments about relationships among identified trend consequences.

• A matrix is developed with the identified trends.

• Judgments are made about the positive and negative impact of the trends in relation to one another.

Future Health Scan

• Globalization• Cost containment and outcomes• Advanced personalized therapies• Information infrastructure advances• Human genome project• Predict-and-manage paradigm

Old ParadigmChronic Disease Management

Life ThreatLife Threat

Symptoms EmergeSymptoms Emerge

0

DiagnosisDiagnosis

SalvageSalvage

TreatmentTreatment

AgeAge

Inte

ns

ity

Inte

ns

ity

Source: Health Futures

Diabetes - The Harvest Scenario



0

InsulinInsulindependencedependence

DialysisDialysis

DiagnosisDiagnosis

TimeTime

Ac

uit

yA

cu

ity

CataractCataractremoval/removal/new lensesnew lenses

AmputationAmputationof limbsof limbs

CardiacCardiacSurgerySurgery


Diabetes - The Prediction & Management Scenario



0 TimeTime

Ac

uit

yA

cu

ity

Biosensors/regulationBiosensors/regulationArtificial pancreasArtificial pancreasIslet cell transplantationIslet cell transplantationImmunotherapyImmunotherapySerum marker testingSerum marker testing

GeneticGeneticscreeningscreening


• The future happens at the intersection of knowledge and services……

Influence Change With Emotional Intelligence

Emotional Intelligence

• “The ability to sense, understand and effectively apply the power and acumen of emotions as a source of human energy, information, connection and influence”

Cooper, Robert & Sawaf, Ayman. (1997). Executive EQ: Emotional intelligence in leadership & organizations: Grosset/Putnam: New York.

Integral Theory: A Meta Theory and Framework for EvolutionWilber, K. (2007). What is integral theory?

http://in.integralinstitute.org/integral.aspx

"Integral" means comprehensive, inclusive, balanced, not leaving anything out.

http://in.integralinstitute.org/integral.aspx

Integrative Principles"Integral" means comprehensive, inclusive, balanced,

not leaving anything out.

Nonexclusion : acceptance of truth claims that pass the validity tests for their own paradigms in respective fields

Ennfoldment: sets of practices that are more inclusive, holistic and comprehensive than others

Enactment: various types of inquiry disclose different phenomena depending on the quadrants, levels, lines, states and types of the inquirer.

Wilber, K. (2002d). "Excerpt D” The look of a feeling: The importance of post-structuralism, unpublished manuscript

Kosmic Address: Altitude and Perspective

– Magenta/Red Magic egocentric, the world of magical powers, sacrifices and miracles

– Amber Mythic ethnocentric, the stage of absolute traditional truths, tribal/ethnic beliefs’ myth

– Orange Rational world centric, the level of universal regard, reason and tolerance

– Green Pluralistic –multi world centric, the stage of divinity within all beings, all paths are equal

– Teal/Turquoise Integral –Kosmo centric can shift between all previous levels and see relative truths there

Four QuadrantsSelf and Consciousness

Interior-Individual

Experiences

Subjective

Truthfulness

I

Brain and organism

Exterior-Individual

Behaviors

Objective

Truth

IT

weJustness

Intersubjective

Cultures

Interior-Collective

Culture and Worldview

ITSFunctional-Fit

Interobjective

Systems

Exterior-Collective

Social Systems and Environment

Esbjorn-Hargens, S. (2006). Integral research: A multi-method approach to investigating phenomena.

Constructivism in the Human Sciences,11(2), 79-107.

Integral Methodological Pluralism

Esbjorn-Hargens, S. (2006). Integral research: A multi-method approach to investigating phenomena. Constructivism in the Human

Sciences,11(2), 79-107.

Eight Zones and Methodologies

Esbjorn-Hargens, S. (2006). Integral research: A multi-method approach to investigating phenomena. Constructivism in the Human Sciences,11(2), 79-107.

Phenomenological Inquiry

• Self-Inquiry

• Phenomenology

• Reflection

• Prayer

• Journaling

• Shadow work

• Mindfulness practices

• Truthfulness

• Honesty

• Authentic Expression

• Sincerity

• Integrity

• Identify assumptions, acknowledge bias

• TransformativeEsbjorn-Hargens, S. (2006). Integral research: A multi-method approach to investigating phenomena. Constructivism in the Human Sciences,11(2), 79-107.

Structural Assessment

• Psychometric measures

• Developmental tests

• Video tapes

• Notice speech and behavioral patterns

• Interviews

• Use of established developmental models

• Psychological tests

• Descriptions with analysis

• Triangulation


Hermeneutical - Interpretive

• Interviews, role playing, small group work

• Story telling

• Interpretive analysis, textual analysis

• Collective reflection

• Focus groups

• Gives voice to other

• Serves community

• Mutual understanding

• Resonance

• Meaningful

• Emancipatory

• Symbolic


Ethnomethodology

• Participant Observer

• Appreciative inquiry

• Cultural anthropological techniques

• Coaching

• Mentoring

• Forms of structural analysis

• Cross cultural

• Observation of group dynamics

• Symbolic coherence

• Well documented observations

• Member checks

• Acceptance by group


Empirical Observation

• Surveys, documentation, exams

• Fieldwork observations

• 3rd person description, charts, statistics

• Case studies, gap analysis,

• Capacity development

• Repeatable,

• Controlled conditions

• Empirical, logical

• Measurable

• Use of multiple senses

• Representative samples


Systems Analysis• Statistical analysis

• Mapping

• Scientific studies

• Library research of previous studies

• Monitoring and evaluation

• Functional fit

• Repeatable

• Controlled conditions

• Empirical

• Logical

• Reputable and multiple sources

• Direct experience with the system


Create Vision Based Scenarios

A scenario is a method for telling a story about the future. It can be based on reliable or speculative data.

Scenarios: The Back Side of Vision

Scenario Planning Resources:http://www.well.com/~mb/scenario_planning/

Strategic Conversations

• How plausible does the scenario seem?

• What thoughts does it bring to mind?

• What feelings does it generate?

Strategic Conversations

• What are the implications for society, healthcare and nursing?

• If parts of the scenario are desirable what actions need to be taken to increase the chances of it happening?

• If parts are undesirable what actions need to be taken to prevent them form happening?

Being and Becoming a Futurist

• Pay attention to time and time-spirits.

• Learn about the future.

• Understand people’s reactions to learning about the future.

• Actively monitor industry trends and forecasts.

Being and Becoming a Futurist

• Discern logical consequences of trends using futures thinking tools and techniques.

• Use emotional intelligence in change efforts.

• Create vision-based scenarios.

• Stimulate strategic conversations about espoused visions.

• Consider the value of an integrally informed future.

Future Pacing

• What concepts, tools, techniques are most useful?

• How can information be used?

• Why is information important?

• Why care about the information?

Contact Information

Daniel J. Pesut PhD RN, PMH- BC, FAAN

Professor and Associate Dean for Graduate

Programs, Indiana University School of Nursing

1111 Middle Drive NU 136 Indianapolis, IN 46202, USA

317-274-3115

[email protected]

Principles and Practices of Integral Care: The Future of HIV Nursing 22 nd Annual ANAC Conference “Reaching Beyond: Collaborating to Build Capacity” Jacksonville,

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