Professional Caregiver Risk and Despair: A Unitary Appreciative Inquiry

1

2
Using Unitary Appreciative Inquiry Reflections
on Praxis and Dissertation Research

• Thomas Cox
• Doctoral Candidate
• School of Nursing
• Virginia Commonwealth University
• November 15, 2003

3
(No Transcript)
4
Risk Induced Professional Caregiver Despair?

• Great changes have occurred in healthcare finance
  
• i access to quality healthcare.
• Disrupted bonds between RNs and clients
• i Character, quality, rapport of relationships
• Issues neglected - need new tools/understandings
  to play a significant role in reshaping HC
  environment
• Some RNs despair over i environmental quality
• RNs had rich stories of negative effects of
  working under fiscal constraints risk transfers

5
Professional Caregiver Insurance Risk

• Insurance risk transfers occur in financial
  contracts and intra-organizational budgets that
  inadequately fund caregiving functions and
  transfer insurance risks
• Risk transfers cause financial, professional,
  spiritual, and affective disharmonies i service
  quality
• Recognizing and healing the spiritual and
  affective wounds is critical to the well-being of
  nurses, nursing, nursing clients, and the
  healthcare system as a whole

6
How Risk Induced Professional Caregiver Despair
Developed

• Social work
• Nursing
• Insurance professional, social researcher,
  actuary, and biostatistician
• Peers at conferences, classes, Christmas
  parties.
• Reflecting on roles, duties, and responsibilities

7
Risk Induced Professional Caregiver Despair

• RNs experiences, perceptions and expressions of
  despair about their careers and working
  environments
• Reasons for despair - not biological/chemical/Rx
  deficiency
• 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 anew the meaning of their
  experiences by blending art, science, perception,
  feeling, and intuition into organic and
  meaningful wholes, representing and revealing
  their unique constructions of the world

8
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

9
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

10
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

11
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

12
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

13
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

14
Correlates and Corollaries of Professional
Caregiver Despair

• Burnout Depression
• Unhappiness Anomie
• Angst Dissatisfaction
• Alienation Suffering
• Stress Poor Attitude
• Ethical Conflict Moral Distress

15
(No Transcript)
16
Unitary Appreciative Inquiry I
Theory generating, practice-enhancing, and
research method Appreciation of humans and
phenomena as wholes Co-researchers shared
experiences, perceptions expressions, from
their unique vantage point and without the need
to justify themselves, their thoughts, beliefs,
actions, or decisions Goal Appreciation of
co-researchers' experiences of RIPCD Researcher
sought a healing appreciation of the
co-researchers, not just capturing data about
the experience Praxis not just research
17
Practicing Unitary Appreciative Inquiry
Researcher approached co-researchers with
acceptance and validation - in an empathic and
appreciative manner, empathizing with, seeing
through the eyes of, and gaining a deeper
understanding of the co-researchers wholeness,
and with the healing intention of assisting the
co-researcher toward freer expression, greater
insight, and greater integration (research on
sexual offenders) The researcher dwelt in
preconceptions and assumptions favorable to the
co-researchers, fostering rapport and promoting a
sense of harmony and mutuality. Ontologically,
co-researchers are wholes but may see self as
not-whole. Researcher assists co-researchers
in the healing appreciation of their own
wholeness, hopefully facilitating growth, and
transformation not just data collection IRB
issues
18
RIPCD A Unitary Inquiry

• Experiences, intuitions, reflections of RNs RIPCD
  experiences
• Collaborative, theorogenic, research, and healing
  journey
• Opportunity to reveal, explore, and represent
  effects of HC financing experiments, adding
  substance, humanity, faces, and feeling to the
  soulless explications dominating the landscape
• Participants shared experiences that highlighted
  the breadth and depth of the impact of risk
  transfers on nursing care and nurses
• OPERATING ROOM ONCOLOGY
• MATERNITY AND PEDIATRICS
• PSYCHIATRY and MEDICAL-SURGICAL
• RNs

19
Why UAI Was Important

• Wholeness and healing occurred because sufficient
  time and energy were devoted to free,
  unstructured expression
• Most co-researchers thankful for opportunity to
  discuss their experiences until THEY were
  satisfied, citing prior inabilities to achieve
  any sense of closure
• Some felt peers superiors prematurely reacted
  designed interventions or saw their legitimate
  concerns as staffing problems to fix or them
  as problem employees
• Appreciative profiles may be helpful to other
  disciplines and settings, addressing fundamental
  features of modern life and mismatches between
  expectations and capacities in the face of
  unanticipated and unplanned variability and
  unpredictability

20
How The Research Unfolded

• In the early stages I wondered if people would be
  able to help me connect the dots and if they
  would
• These RNs wanted to share their stories
• Each RN provided new insights, confirming earlier
  stories about how difficult bedside nursing has
  become
• 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

21
The Participants I

• 8 Registered Nurses
• Self-identified as experiencing RIPCD
• Volunteered to collaborate in an inquiry into
  effects on practice of changes in HC financing
  mechanisms
• Variety of nursing settings experiences
• Oncology
• Psych
• Peds
• Surgery
• Transplant
• Agency RN
• Medical-Surgical

22
The Participants II

• Only one participant, someone with business
  experience, really understood insurance risk
  aspect
• Most co-researchers misinterpreted significant
  features of the environment
• Record keeping Billing/Revenue enhancement
• More Patient Services Billing/Revenue
  enhancement
• In some cases opportunities to dialogue on
  effects of risk transfers was available
  sometimes would have interfered with the flow of
  the conversation
• Most participants asked questions about my work
  explained it after in-depth interviews

23
Recruitment and Opening Dialogue

• Co-researchers were solicited through key
  informants, professional colleagues, flyers,
  presentations, and from attendees at researchers
  past presentations
• The opening question was What does risk induced
  professional caregiver despair mean to you?
• Sometimes added 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 in redundancy, inadequate staffing,
  and scarce supplies

24
Some Thoughts on the Research Process I

• 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 easier to interact with co-researchers than
  to get to be able to interact with co-researchers

25
What Are The End Products?

• A hopefully soon to be completed dissertation
• Two abstracts for presentations on PCIR related
  topics influenced by the dissertation research (1
  accepted)
• Articles about the research findings, method,
  PCIR, nursing MISs, financial management
• Presentations on research, methodology, PCIR
• Development of tools for monitoring and
  forecasting nursing surplus under changing
  conditions of supply and demand
• New venues for collaboration with other nurses,
  researchers, practitioners, educators,
  administrators

26
During and After Inquiry

• Allowed to freely consider, explore, and express
  the essence of their experiences, most of the RNs
  developed new ideas and attitudes about
  themselves and their experiences
• Researcher gained important insights into how RNs
  respond to environmental impediments to caring
  practice
• New theories and strategies for preparing RNs in
  their roles have emerged greater need to
  understand how to deal with insurers, how to read
  and understand budgets and management reports,
  ethical reasoning regarding quality of care
  issues
• New ideas about healing for individuals, groups,
  and systems

27
Some Guiding Principles of Healing Synoptic
Narrative Construction

• Allegorical Metaphors encompass past, present,
  and future
• Collaborations, incorporating multiple methods of
  cognitive, affective, aesthetic interpretation,
  and representation
• A reaching forward, grounded in the past,
  present, and alternative possible futures
• Researcher as guide, reference point, healer, and
  co-inquirer, journeying with co-researchers
• Embrace contradiction, dissimilarity, and
  incoherence as birthing the future

28
Appreciative Profiles I

• Profiles based on co-researcher suggested
  sources
• The Scream Home Alone (Macauley Culkin)
• OR Nurse
• I really liked Munchs The Scream but had never
  connected it with the movie Home Alone in
  pursuing this theme I found that it was a pretty
  common comparison.
• The really interesting thing is that the scream
  in the movie actually appears unrelated to
  feeling either overwhelmed or dismayed

29
Appreciative Profiles II

• Voltaires Candide
• Oncology Nurse
• Events in source materials woven with the events
  described by co-researchers as interpreted by
  researcher tremendous anxiety source for
  aesthetically challenged researcher
• Profiles approved by co-researchers
• Both co-researchers really liked my hypothetical
  profile as did several other co-researchers

30

31
A Hypothetical Unitary Appreciative Profile
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
Some Guiding Principles of Risk Induced
Professional Caregiver Despair

• RIPCD is rhythm, flowing in out of despair,
  hope, joy, and pessimism
• RIPCD not observable - must engage
  co-researcher
• Naturalistic setting - where people are
  comfortable
• RIPCD may be rare or never resolved, emerging,
  shifting, changing, reforming coherence from time
  to time as different patterns form with an
  ever-changing environment Most loved jobs,
  peers, and nursing
• For some, flooding their experiences out, seemed
  to dramatically alter their lives, impelling them
  to action