Nursing Practice: Finding, Defining, Preserving and Extending the Good

During her State of the Department address in May, Mairead Hickey, PhD, RN, senior vice president for Patient Care Services and chief nursing officer, focused on the nursing vision of “excellent care to patients and families” by highlighting Finding and Defining the Good, the process that the Department of Nursing has been engaged in for the past three years to identify and reflect on what BWH nurses describe as the essential components of their excellent nursing practice.

“The Department of Nursing began studying the strength in the practice of BWH nurses in order to describe, acknowledge and build on the strength that’s here,” Hickey said.

This multiphase initiative sponsored by the Nursing Department began in summer 2006 to identify strengths in the practice of BWH nurses. “As a department, we have learned about the characteristics of excellent practice and continue to learn from BWH nurses who are known for excellence, about what needs to be in place in the practice environment, in programs and in systems to ‘preserve and extend’ this excellence to benefit all patients and all nurses,” she said.

Phase 1

Using Appreciative Inquiry, an approach focused on the analysis of the “positive and successful” rather than the “negative and failing,” more than 300 nurses identified by their peers and managers as the nurses known for giving excellent care gathered in focus groups to describe what good care looks like, what enables them to deliver good care and how frequently they are able to provide good care. They were asked to describe what good care looks like from the patient perspective.

More than 1,000 responses from these focus groups were analyzed and four common themes emerged: relationship with patients and families, relationship with the team, civil and respectful communication and safe environment. Within each theme, nurses’ comments were compared to the practice literature and a summary description of each theme was developed and compared again to the responses made by BWH nurses. A small cohort of the original focus group participants validated the themes.

The lessons from this first phase of Finding and Defining the Good were that relationships with patients and families are central to the practice of excellent nurses at BWH. Knowing patients and their families was a theme that was repeated over and over in descriptions of the practice of excellent BWH nurses.

Phase 2

Looking to learn more from BWH nurses about their practice, the next phase of Finding and Defining the Good occurred during summer 2007. Essence of Nursing recipients and finalists from the previous three years were invited to focus groups to discuss a time when he or she made a difference for a patient. Eleven of the 15 essence of nurses participated. From the stories of these nurses from across specialties, five common and compelling characteristics of excellent nursing practice emerged. These included: 1. knowing the patient and family; 2. making clinical judgments specific to the individual patient; 3. caring practices including interactions and interventions guided by strong notions of good care; 4. providing care in an individualized way; and 5. working with and leading others to act on patient’s/family’s behalf.

An audio recording of a narrative from 2008 essence finalist Corrine Cyr Prior, BA, RNC, IBCLC, of the NICU, was shared with the audience in which Cyr Prior spoke of delivering culturally competent care to a family with a premature infant. “This narrative shows how Corrine knows the patient, stays engaged and makes the care all about meeting the needs of the patient and the family,” Hickey said. “Nurses usually don’t think of this as a big deal, but it is foundational to developing expertise in practice.”

The recently formed Practice Committee recommended that a narrative audio recording of a nurses’ story be included because it is so powerful to hear the story in the nurses own voice.

Phase 3

The Practice Committee formed in November 2008 with the charge of advising on how to Preserve and Extend the Good as described and embodied by the excellent nurses at BWH.

“We will learn more about what these characteristics look like across the different stages of practice development and how they show up in practice. We need to make sure it’s not random, making it possible for every nurse to be their best and every patient to have a relationship with a nurse who knows them and makes them feel known and cared for,” Hickey said.