Introduction
Philosophies, conceptual models, and theories continue to be used in real-life practice scenarios with the view to provide solutions to the challenges facing various departments within the hospital setting (Watson, 2009). Within the context of our emergency department (ED), there exists a mounting concern that patients are becoming more difficult to handle, abusive, and non-compliant, presumably because of the fact that nurses are not taking adequate care of them due to their extremely busy and often haphazard schedule.
Available literature demonstrates that regardless of the reasons that may cause patients to exhibit such behavior, the fallout from these practice situations exhibits in ineffective care, dissatisfied patients, and enhanced staff burnout and frustration (InFocus, 2009). Drawing on this knowledge, therefore, the present paper purposes to apply Kristen Swanson’s middle-range theory of caring to develop a strategy of care within the ED, with the view to minimize situations that make patients become more abusive and non-compliant out of inherently misplaced beliefs that the nursing staff are ignoring their needs.
Swanson’s theory of caring is grounded on the assumptions that caring is a fundamental nursing phenomenon but not unavoidably unique to nursing practice (Andershed & Olsson, 2009), and that caring is a complicated process which is continuously exists within the cyclic dynamism of the patient-nurse relationship (Wiman & Wikblad, 2004). The process of caring is seen as cyclic in that it should always be in place, replenishing itself by viewing the patient as a whole person rather than a detached individual, and by constant proactive steps taken by the nurse to help the client achieve health and well-being (Tonges & Roy, 2011).
Consequently, this theory has been earmarked for analysis following the rationale that caring is not only a core characteristic of nursing in ER practice situations (Wiman & Wikblad, 2004), but there exists a coherent relationship between caring processes in nursing practice and patient well-being and satisfaction (Tonges & Ray, 2011).
The paper will proceed as follows: First, the characteristics of the population visiting the ER will be delineated followed by an explicit exposition of the researcher’s role in the emergency department (ED). In the application of theory, the researcher will address how the rationale for how the concepts and propositions included in the theory of caring will achieve the outcomes desired in the ER, as well as how this theory integrates all four concepts of the metaparadigm. The next section will detail the process of change required, followed by insights gained from the application of the theory to ED settings. Lastly, the paper will conclude by summarizing the learning outcomes.
Characteristics of the Population
The demographic and health characteristics of patients who recurrently visit hospital EDs vary across a wide range of socioeconomic, cultural, and health indicators, but the spectrum of variation is limited to individual institutional settings (Peppe et al., 2007). In analyzing the health institution’s patient data, the researcher found that most people who frequented the ED (inclusive criteria was those individuals who have visited the ED for four or more times over the last two years) demonstrated a characteristic higher need for health care services, with persons living with chronic illnesses (ischemic heart disease, mental and/or substance abuse problems, diabetes, kidney failure, etc) leading the pack of frequent visitors, followed by the elderly and the poor, respectively.
It is important to note that such a population of patients requires high level of care not only to prevent the probability of self-injury and violence prevalent in most patients with mental conditions (Luck et al., 2009; Nicholls et al., 2011), but also due to old age (Kihlgren & Nilsson, 2005), and extremely sensitive and potentially fatal health conditions as demonstrated in patients having various heart conditions and kidney failure problems (Peppe et al., 2007).
My Role in the Institution
A strand of existing literature (e.g., Davis, 2012; Kihlgren & Nilsson, 2005; Luck et al, 2009) demonstrates that ED nurses must be endowed with the capacity to meet the full range of needs of patients presenting with a multiplicity of health problems and/or substance abuse problems. In my capacity as an ED charge nurse in a busy hospital unit, my role spans from taking the history of patients presenting with various health challenges using patient-centered approaches, to providing primary care and clinical advice to the patients, as well as directing them to more appropriate care alternatives upon establishing their levels of needs through careful assessments.
In the case of mental health and/or substance abuse problems, I have a duty to collaborate with other social services staff to find discharge destinations and also to report the patient’s needs to managers so that they are addressed successfully. In the context of patients presenting with acute health conditions such ischemic heart disease and diabetes, I have a role to not only listen attentively and communicate to the patient effectively, but also to initiate focused assessment and diagnostics of their medical conditions, provide health promotion and education resources, and use computer-aided assessment software in assisting the patients. Overall, I have a duty to ensure that patients in the ED receive the right kind of care and advice on the appropriate follow-up management.
Application of Theory
This section describes how Swanson’s caring theory can be operationalized to change nursing practice and ensure consistently high standards of patient satisfaction with the care process, therefore reducing instances of difficult-to-handle, abusive, and non-compliant patients within the health institution’s emergency department. It is imperative to note at this stage that the care model developed for the institution’s ED is designed to actualize Swanson’s theory of caring not only by outlining and supporting practices that enhance patient satisfaction and transform cultural norms but also by embracing healthcare delivery practices that embolden the patients’ ED experience and facilitate desired outcomes (Tonges & Ray, 2011).
As a middle-range theory empirically developed from three phenomenological studies in separate perinatal contexts (Andershed & Olsson, 2009), Swanson’s structure of caring avails a logical elucidation of the links between caring processes and patient well-being (Tonges & Ray, 2011). From interviews with women who had experienced miscarriages, parents and professional caregivers who provided care to the newborns in the intensive care unit, and mothers who were participating in a health intervention, Swanson developed an overall definition of caring as “…a nurturing way of relating to a valued other person, towards whom one feels a personal sense of commitment and responsibility” (Andershed & Olsson, 2009, p. 599).
In her contributions to the theory of caring, Swanson not only stressed the importance of viewing patients not as detached individuals but rather as whole persons who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors (Swanson, 1993), but also postulated that nurses’ ability to demonstrate that they care about patients is as imperative to patient well-being as caring for them through health-based activities, such as preventing infection and administering medications (Tonges & Ray, 2011).
It is important to mention that Swanson’s theory was formulated based on a structure of caring composed of five interrelated caring processes, namely “…knowing, being with, doing for, enabling and maintaining belief as characteristics of the caring relationships” (Andershed & Olsson, 2009, p. 599).
These processes can be briefly described as follows: 1) Knowing – striving to understand events as they have meaning in the life of the other; 2) being with – being emotionally present to the other; 3) doing for – doing for the other what they would do for themselves if possible; 4) enabling – facilitating the capacity of others to care for themselves and family members; and, 5) maintaining belief – sustaining faith in the capacity of others to transition and have meaningful lives (Tonges & Ray, 2011). In her theory, Swanson also “…described the underlying assumptions to caring related to the concepts of person, environment, health/wellbeing and caring actions” (Andershed & Olsson, 2009, p. 599).
A deeper analysis of this middle-range theory demonstrates that Swanson not only outlined the theory in more predictive terms, with the patient’s well-being as the intended outcome but delineated how the five processes relate to each other, suggesting that “…caring begins with a fundamental belief in persons and their capacity to make it through events and transitions and face a future with meaning” (Andershed & Olsson, 2009, p. 599). In this context, Swanson implies that maintaining belief in an individual is the foundation or basis of nursing care.
The researcher also postulates that “…caring is grounded in maintenance of a basic belief in persons, anchored by knowing the other person’s reality, conveyed through being with, and enacted through doing for and enabling” (Andershed & Olsson, 2009, p. 599). In this context, it can be argued that Swanson necessarily locates the role of nursing within the process of “becoming”, that is, the nurse becomes not only the dispenser of clinical treatment but also a valued partner in assisting the client get closer to their goals of well-being (Swanson, 1993).
The current practice situation is that patients visiting the ED at the health institution are becoming more difficult to handle, abusive, and non-compliant. Consequently, the metaparadigm of ‘person’ in Swanson’s theory is represented by patients presenting in the ED, who despite their normal health problems, exhibit undesirable patient behaviors as described above.
According to Luck et al (2009), the ED is a recognized area at special risk of abusive and non-compliant patients “…because of its contextually and environmentally unique circumstance, including: long waiting times for consultation or admission; the unanticipated nature of illness; 24 h opening; intense interpersonal interactions; adverse unexpected outcomes, such as death; and high levels of stress for patients, their families and friends” (p. 205). These variables best describe the characteristics of patients visiting our ED, and who end up becoming abusive and non-compliant to health instructions or advice.
Compelling evidence from my practice situation in the ED demonstrates that the negative behavior predispositions may arise due to failure by the medical and nursing staff to meet the patients’ psychological needs, inability to create rapport with patients, lack of professional caring arising from differences between nurse and patient perception of good caring, shortage of staff, and lack of adequate training.
According to Wiman & Wikblad (2004), patients may become abusive and agitated, thus fail to comply with treatment procedures, when they form a perception in their minds that the nurses are not only inhumane in extending care to the patients, but are also disinterested, insensitive, and cold in meeting their needs (Luck el., 2009). Whatever the case, it is clear that the metaparadigm of ‘environment’ in the practice scenario is represented by the physical surroundings of the ED and the social-cultural and economic conditions of patients (Masters, 2011), which makes them develop a perception that their psychological, emotional and care needs are not being met to their satisfaction.
As Swanson suggested in the theory that patients are in need of much more than standard medical care (Swanson, 1993), nurses in the ED should go ahead to provide strong emotional support and encouragement to patients in efforts aimed at assisting them get closer to their goals of well-being. This way, the goal to achieve well-being becomes the desired health outcome for the patients, and therefore represents the health/well-being metaparadigm in Swanson’s theory of caring.
Tonges & Ray (2011) argue that Swanson’s five caring procedures, “…grounded in a culture of maintaining belief, combine nursing compassion (knowing and being with) and competence (doing for and enabling), leading to intended outcomes of patient healing and well-being” (p. 375). In this respect, it is strongly suggested that the problem of abusive and non-compliant patients will cease to exist if ED nurses in our unit start to view them not as mechanistic objects in need of a ‘quick fix’, but as normal human beings with flesh and blood who, like the nursing staff, have ideas, needs, challenges, and experiences that make them who they are.
In equal measure, patients visiting the ED are likely to experience positive satisfaction and enhanced perception of quality of care, leading to reduced instances of abuse and non-compliance, if – as suggested by Swanson in the theory of caring – nurses combine elements of the caring processes of being with and doing for by not only emphasizing a mutually-fulfilling nurse-patient relationship (Andershed & Olsson, 2009) but also viewing their profession in terms of both fulfilling the roles of dispenser of medical treatment to the patient and partnering with them in the pursuit of assisting them edge closer to their goals of wellbeing (Swanson, 1993).
Such a practice predisposition, in my view, will definitely assist in meeting and satisfying the patients’ psychological needs, maintaining rapport, and juxtaposition of quality nursing care and appropriate diagnosis strategies in an ED setting.
Process Change
Additional training is needed, particularly in expanding the knowledge base of emergency nurses not only to instill meaning to the lives and health challenges facing patients presenting in the ED (knowing), but also to extend their emotional attachment to the patients to curb instances of abuse and non-compliance (being with).
Inflexible hospital rules should be repealed to provide ED nurses with a “moment of caring” with each patient due to long waiting times and unanticipated nature of illness that are characteristic of an average ED. Additionally, spending adequate time to proactively listen to patients’ descriptions of presenting health challenges and expressions of their emotions, feelings, and concerns not only coveys presence and availability of the emergency nurses to cater for the needs of patients, but also sustains their faith in their capacity to transition and have meaningful lives.
Lastly, the hospital administration and relevant government agencies need to avail more funds to hire additional emergency nurses as the ED deals with high-risk and vulnerable groups of the population, who may die or lose control when forced to wait for longer periods of time.
Insights Gained & Conclusion
Taking action to address these concerns, in my view, enables ED patients to demonstrate a greater sense of control of, and satisfaction with, their environment and thus reduces instances of heightened irritability and non-compliance among the patients.
ED nurses can take that action through: Establishing “moments of caring” with their patients; not only acting as the dispenser of clinical treatments but also as valued partners in assisting clients get closer to their goals of well-being; spending time to actively listen to patients’ descriptions of health challenges and expressions of their feelings and concerns; facilitating the capacity of ED patients to care for their health challenges, and; assisting to sustain faith in patients’ capacity to transition from ill health to desirable health outcomes through the establishment of caring and loving patient-nurse relationships. These insights exemplify the basic tenets and assumptions of Swanson’s theory of caring.
Overall, it has been established that nurses who are enlightened with caring relations as proposed in Swanson’s theory are not only capable of developing loving, caring, kind, and sensitively purposeful relationships with their clients (patients), but are also in a position to assist them seek wholeness and spiritual connectedness for their health/well-being outcomes, not just barren, insensitive and depersonalized medical intercessions, void of deeply fulfilling human-to-human caring relationships. Consequently, it can be safely argued that Swanson’s theory of caring can be effectively used in my practice situation to solve the problem of difficult, abusive, and non-compliant ED patients.
Reference List
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