caring clinical wisdom and ethics in nursing practice

CASE STUDY

This case study from the peer-identified nurse expert project illustrates Benner’s approach to knowledge development in clinical nursing practice (Brykczynski, 1993–1995, 1998). The project was undertaken to identify and describe expert staff nursing practices. Exemplars were obtained and participant observations conducted to yield narrative text that was interpreted through Benner’s multiphase interpretive phenomenological process (Benner, 1984a, 1994). In the final phase of data analysis, Benner’s (1984a) domains and competencies of nursing practice were an interpretive framework. A critical aspect of using Benner’s practice approach is that domains and competencies form a dynamic evolving interpretive framework, which is used to interpret the narrative and observational data collected. The nurse who described this situation had approximately 8 years of experience in critical care. She shared that her project participation was significant to her practice because it taught her how to integrate care of a family in crisis along with care of a critically ill patient. Thus this was a paradigm case for that nurse, who learned many things from it that affected her future practice.

“Mrs. Walsh, a woman in her 70s, was in critical condition after repeat coronary artery bypass graft (CABG) surgery. Her family lived nearby when Mrs. Walsh had her first CABG surgery. They had moved out of town but returned to our institution, where the first surgery had been performed successfully. Mrs. Walsh remained critically ill and unstable for several weeks before her death. Her family was very anxious because of Mrs. Walsh’s unstable and deteriorating condition, and a family member was always with her 24 hours a day for the first few weeks.

The nurse became involved with this family while Mrs. Walsh was still in surgery, because family members were very anxious that the procedure was taking longer than it had the first time and made repeated calls to the critical care unit to ask about the patient. The nurse met with the family and offered to go into the operating room to talk with the cardiac surgeon to better inform the family of their mother’s status.

One of the helpful things the nurse did to assist this family was to establish a consistent group of nurses to work with Mrs. Walsh, so that family members could establish trust and feel more confident about the care their mother was receiving. This eventually enabled family members to leave the hospital for intervals to get some rest. The nurse related that this was a family whose members were affluent, educated, and well informed, and that they came in prepared with lists of questions. A consistent group of nurses who were familiar with Mrs. Walsh’s particular situation helped both family members and nurses to be more satisfied and less anxious. The family developed a close relationship with the three nurses who consistently cared for Mrs. Walsh and shared with them details about Mrs. Walsh and her life.

The nurse related that there was a tradition in this particular critical care unit not to involve family members in care. She broke that tradition when she responded to the son’s and the daughter’s helpless feelings by teaching them some simple things that they could do for their mother. They learned to give some basic care, such as bathing her. The nurse acknowledged that involving family members in direct patient care with a critically ill patient is complex and requires knowledge and sensitivity. She believes that a developmental process is involved when nurses learn to work with families.

She noted that after a nurse has lots of experience and feels very comfortable with highly technical skills, it becomes okay for family members to be in the room when care is provided. She pointed out that direct observation by anxious family members can be disconcerting to those who are insecure with their skills when family members ask things like, “Why are you doing this? Nurse ‘So and So’ does it differently.” She commented that nurses learn to be flexible and to reset priorities. They should be able to let some things wait that do not need to be done right away to give the family some time with the patient. One of the things that the nurse did to coordinate care was to meet with the family to see what times worked best for them; then she posted family time on the patient’s activity schedule outside her cubicle to communicate the plan to others involved in Mrs. Walsh’s care.

When Mrs. Walsh died, the son and daughter wanted to participate in preparing her body. This had never been done in this unit, but after checking to see that there was no policy forbidding it, the nurse invited them to participate. They turned down the lights, closed the doors, and put music on; the nurse, the patient’s daughter, and the patient’s son all cried together while they prepared Mrs. Walsh to be taken to the morgue. The nurse took care of all intravenous lines and tubes while the children bathed her. The nurse provided evidence of how finely tuned her skill of involvement was with this family when she explained that she felt uncomfortable at first because she thought that the son and daughter should be sharing this time alone with their mother. Then she realized that they really wanted her to be there with them. This situation taught her that families of critically ill patients need care as well. The nurse explained that this was a paradigm case that motivated her to move into a CNS role, with expansion of her sphere of influence from her patients during her shift to other shifts, other patients and their families, and other disciplines” (Brykczynski, 1998, pp. 351–359).

Domain: The helping role of the nurse

This narrative exemplifies the meaning and intent of several competencies in this domain, in particular creating a climate for healing and providing emotional and informational support to patients’ families (Benner, 1984a). Incorporating the family as participants in the care of a critically ill patient requires a high level of skill that cannot be developed until the nurse feels competent and confident in technical critical care skills. This nurse had many years of experience in this unit, and she felt that providing care for their mother was so important to these children that she broke tradition in her unit and taught them how to do some basic comfort and hygiene measures. The nurse related that the other nurses in this critical care unit held the belief that active family involvement in care was intrusive and totally out of line. A belief such as this is based on concerns for patient safety and efficiency of care, yet it cuts the family off from being fully involved in the caring relationship. This nurse demonstrated moral courage, commitment to care, and advocacy in going against the tradition in her unit of excluding family members from direct care. She had 8 years of experience in this unit, and her peers respected her, so she was able to change practice by starting with this one patient-family situation and involving the other two nurses who were working with them.

Chesla’s (1996) research points to a gap between theory and practice with respect to including families in patient care. Eckle (1996) studied family presence with children in emergency situations and concluded that in times of crisis, the needs of families must be addressed to provide effective and compassionate care. The skilled practice of including the family in care emerged as significantly meaningful in the narrative text from the peer-identified nurse expert study. This was defined as an additional competency in the domain called the helping role of the nurse and was named maximizing the family’s role in care (Brykczynski, 1998). The intent of this competency is to assess each situation as it arises and develops over time, so that family involvement in care can adequately address specific patient-family needs, and so they are not excluded from involvement nor do they have participation thrust upon them.

This narrative illustrates how Benner’s approach is dynamic and specific for each institution. The belief that being attuned to family involvement in care is in part a developmental process is supported by Nuccio and colleagues’ (1996) description of this aspect of care at their institution. They observed that novice nurses begin by recognizing their feelings associated with family-centered care, whereas expert nurses develop creative approaches to include patients and families in care. The intricate process of finely tuning the nurse’s collaboration with families in critical care is delineated further by Levy (2004) in her interpretive phenomenological study that articulates the practices of nurses with critically burned children and their families.

Review:Benner’s Stages by Ashlie Whitt (Links to an external site.)Links to an external site.

QUESTIONS

1. Regarding the various aspects of the case as they unfold over time, consider questions that encourage thinking, increase understanding, and promote dialogue, such as: What are your concerns in this situation? What aspects stand out as salient? What would you say to the family at given points in time? How would you respond to your nursing colleagues who may question your inclusion of the family in care?

2. Using Benner’s approach, describe the five levels of competency and identify the characteristic intentions and meanings inherent at each level of practice.

 

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