key: cord-0920421-zux29tz1 authors: Daphney, St-Germain; Lynda, Bélanger; Valérie, Côté; Caroline, Gagnon title: The INSÉPArable portfolio tool: the art of bringing out the invisible for a full scope of nursing practice and sustainable patient safety date: 2020-10-21 journal: Int J Nurs Stud Adv DOI: 10.1016/j.ijnsa.2020.100011 sha: 5aabdad12067d49a4f0e0c8d8ea616e31fa6739f doc_id: 920421 cord_uid: zux29tz1 BACKGROUND: Despite widespread recognition of the undeniable impact of nurses on patient safety, important barriers relating to the organization of health systems still hinder the full expansion of the role of these professionals. In Quebec (Canada), nurses work overload and increased adverse events are preoccupying and point to a possible lack of contemporary tools for continuous professional development. Innovative training tools should stimulate reflective practice focused on a holistic view of the patient in order to support a full scope of nursing practice and ensure continuous improvement in the quality of care. Such tools would make it possible to better understand their practice, according to their own perception, as well as its applicability in the emergence of a professional conscience essential to lasting safety competencies. This study's overarching goal was to propose a model and a portfolio prototype to support nurses’ training. METHOD: Based on a humanistic and reflective perspective on patient care and safety competencies, a design approach was used to develop a portfolio prototype. A qualitative approach was used to collect and analyse data using shadowing observations of 10 nurse/patient dyads, followed by individual interviews about their care experience. The research was conducted in acute and long-term care settings of the Quebec City area. The iteration process resulted in a first version of the prototype that was then presented to various stakeholders during a co-design workshop aimed at better understanding the clinical applicability of this prototype and improve it. FINDINGS: The INSÉPArable project, which closely links nurse, safety and patient, is illustrated in two interrelated steps. An iceberg as a metaphor for nursing practice where the essence of care where the « art of nursing » is hidden and a spherical model that depicts how the portfolio tools aim at consciously directing learners towards optimal conditions that support the full emergence of nursing practice in an inductive perception of sustainable patient safety promotion. DISCUSSION: More than an individual reflective perspective, INSÉPArable highlights the need for a collective awareness among nurse managers regarding underlying the optimal conditions for the application of this tool. As well, this implies a renewed mode of governance and the implementation of more humanistic processes in optimization mechanisms that redefine the contemporary professionalism of nurses, which are closely linked to patient safety. This research work has been supported by Canada Social Sciences and Humanities Research Council and Université Laval's Bureau de la recherche et de la création grants. Since the turn of this millennium, North American health care systems have engaged in a major quest for improvement in addressing patient safety and quality of care. The 1999 Institute of Medicine [1] report "To Err is Human" undoubtedly made its mark by revealing the alarming number of patients who die each year because of hospital care. That was all it took to focus the attention of Canadian researchers on this issue, especially since many of these deaths were considered as preventable. Several avenues were then explored to better understand the risks involved in health care settings. The structure of the organization of care and the quality of health care practice became key factors to be examined. The International Council of Nurses (ICN) [2] , a federation representing more than 20 million nurses worldwide attention to the facts that nurses save lives, reduce costs and improve patients' health, and their impressive work has been demonstrated throughout the current COVID-19 pandemic [3] . Nurses are the healthcare professionals who have the longest contact with patients and families. This closeness to patients gives them a key role in assessing, detecting and preventing changes in health status and advocacy which leads to optimal interdisciplinary coordination of care [4] .Through a holistic view of patients, nurses are able to better prepare patients for discharge and, by promoting their empowerment, avoid complications and readmissions. The impact of nursing care on patient outcomes are very well documented in the scientific literature, with some studies reporting that the more nurses are present on a health care unit, the lower the patient mortality rates are and the more experienced and educated nurses are, the lower this rate also tends to be [2, 5] . Lack of recognition of the complex nature of nursing and lack of organizational support can lead to fragmented nursing practices which limits the provision of safe quality care, which in turn minimizes the human aspect of care [ 6, 7] . Threats to quality of care and patient safety could become increasingly serious in the coming years. In this respect, Canadian Nurses Association [8] assesses that there will be a shortage of 60,000 full-time registered nurses in Canada by 2022. In the meantime, accident and adverse events remain a concern, especially among the elderly [9, 10]. Considering the negative impacts of care organization on both nurses and patients, some academic institutions have evoked the need to strengthen nurses' training in order to alleviate this situation [11] . Given this, it would be desirable for nurses to benefit from full academic and professional development so that they can better apply up-to-date knowledge in patient safety. A sounder preparation for continuous education between school and healthcare settings could imply utilization of reflective approaches to support the development of patient safety competencies in a humanistic perspective [12] . In that sense, the more reflective the nurses' practice is, the more willing they are to acquire knowledge to treat their patients in a holistic way. One of the starting points would be the renewal of available tools for training. These tools could be oriented towards the identification of their optimal professional development, starting with academic training, in order to strengthen patient safety competencies throughout their professional life. It is generally recognized that Millennials are more likely to place greater importance on connectivity, meaningfulness of their work and feeling aligned with their academic experience [13] . In developing innovative strategies, schools and healthcare settings should work together to better target the tools needed for Millennial nurses to optimally integrate the healthcare system. To our knowledge, no study has used a design approach to conceptualize nurses' daily professional activities and experiences in order to incorporate them in a learning portfolio, which would offer a more explicit perspective than more traditional tools [14] . In the context of this project, the design approach [15, 16] as a methodology of innovation, was used with the aim of understanding realities of nursing practices in context and translating them in an explicit work activity map. In more acutely illustrating some elements that must be taken into consideration in daily nursing practices, learning tools could benefit from the design approach insights to propose a reflective understanding of the conditions underlying improvement of patient safety competencies, anchored in nurses' own experiences. The objective of this paper is to propose a model of nursing practice that combines the insights of a design approach with a renewed perspective on nurses' professional consciousness. Watson's Caring Philosophy of Care [17, 18] , as a humanistic perspective, supports the "art of nursing" focused on establishing an authentic care relationship based on trust, which considers the uniqueness of each patient's body and mind. Nurses adopt a true presence to maintain a caring care relationship based on reciprocity, and develop longer-term thinking which influences their capacity to anticipate and prevent potential risks to patients. When nurses create an environment conducive to such a care approach, this promotes the development of patient empowerment who then become more actively involved in their care, as suggested by the patient partnership approach [4] . As a result, this partnership between nurse and patient contributes to a sustainable environment which supports healing and recovery in the actual illness episode, but also influences future episodes. This is in direct line with the notion of patient safety as defined by the World health organization [19] which proposes a multidimensional concept including health promotion and global well-being as means to empower patients. The Canadian Institute of Patient Safety [20] also considers clinicians' preventive actions as well as curative actions as determinants of the development of patient safety competencies. Through the use of a reflective practice, nurses could become more aware of different everyday aspects of their care approach, thus leading to the promotion of sustainable patient safety in their work. Reflective practice encourages self-reflection, needed to look back upon oneself and know oneself authentically [21, 22] , enough to be aware of personal strengths and limitations in order to respond adequately to patient needs while respecting one's unicity. A reflective approach, with inherent psychological aspects, is then considered a useful method to foster meaningful commitments from healthcare professionals, placing an emphasis on raising conscientiousness and humanism when taking care of patients' overall well-being. Since existing continuous education portfolio formats tend to be more conventional, and often fail to address contemporary issues, updated portfolios targeting transitions between academic knowledge and application of professional knowledge, reflective practice, humanization of care, and patient safety competencies are needed. With the study of both the material and emotional environments of nurses and patients' experiences, a design methodology should allow the development of tools that could be more relevant and adapted to actual realities of nursing, while aiming at developing competencies associated with a reflective attitude. An ethnographic qualitative research approach was used to collect and analyze data related to nurses and patients' experiences, organizational culture and the physical environment. Ten care situations (nursepatient dyad) were observed using the shadowing technique (continuous observations). Following the observation phase, 20 interviews with both patients and nurses were conducted to obtain in-depth information, five nurse-patient dyads from a short-term general medical setting and five from a longterm rehabilitation setting. The project was approved by the CHU de Québec' ethic committee. Posters and pamphlets were used to recruit participants. Unit managers directed the research team to potential volunteer participants who met recruitment criteria. Since the study required immersion in daily care activities, great care was taken to ensure free and informed consent from all participants, from which written informed consent was obtained. Data collection took place from July 2018 to April 2019 in two Quebec City healthcare settings, a university teaching hospital (CHU de Québec-Université Laval) and a physical rehabilitation center (IRDPQ). Three data collection strategies were used to develop the prototype: shadowing, individual interviews, and a co-design workshop. Shadowing required to observe nurses and patients/families for about three hours during their care experience over three work shifts (day, evening, night) including weekends, to create an inventory describing practice-related locations and settings. After this first phase, a semi-structured interview (approximately 1 hour) was held with each participant (nurse and patient separately) to record perceptions and emotions regarding the care experience that were observed through shadowing. The interview guide was developed based on Watson's Caring Philosophy of Care [18] , the Canadian Patient Safety Institute's Competency Domains for Patient Safety [20] and Balas' Reflective Practice approach [21] . A thematic analysis of shadowing observation notes and interview verbatim was conducted. A first draft of the data analysis, which presented a synthesis in the form of a conceptual map integrating patients/nurses' experiences in illustrated contexts and of nurse and patient profiles using the persona technique, was developed by the design team. This mapping was a part of a portfolio prototype delivered in different formats (professional notebook and management chart). Finally, a codesign workshop, similar to a focus group approach, helped push this version to a first validation stage and allowed for improvements. Sixteen participants from different backgrounds: bedside nurses, managers, patients, nursing educators, and researchers (nursing, design, and psychology) were involved in the workshop, which relied on dynamic visual participatory material previously developed by the design team who led the discussions. This visual material illustrates and synthesises the data in workplace contexts. The participants helped review and modify the representations before suggesting improvements to the continued education material. This co-construction between the research team and stakeholders using role-playing strategies and clinical vignettes aimed to target the relevance of the portfolio prototype. Themes and main ideas which guided data collection, observations and theme interviews are presented in Table 1 (appendix 1) . The data analysis strategies aimed at better understanding the following: • Analysis of human feelings about workload and care organization; • Perceptions and relationships between individuals • Work environments, i.e., space and objects, along with behaviors within these spaces and objects The research team came up with the name « INSÉPArable » for the project. It invokes the dynamic interaction and close connection between nurse and patient. The acronym in French is a word meaning inseparable and can be broken down into: IN for (infirmier/èrei.e. nurses in English), SÉ (sécuritéi.e. security in English), PA (for patient same word in both languages) forming an inseparable unit. We aimed to highlight the full spectrum of a nurse's work and her interactions with the physical environment (space, furniture, equipment, warmth, smell, etc.) and human environment (patients/family, colleagues, etc.), which place equal demands on her functional, material, relational and emotional environment. Based on the synthesis of in-depth analyses of nurses' verbatim proposed by the design team, we refer to a metaphor of an iceberg to illustrate the complex "art of nursing" and interactions between the nurse's professional practice and reflective conscience and an illustration which we named the Sphere of Nurse's Professional and Reflective Conscience (SNPRC). The aim of the SNPRC tool, which should guide the further development and design of the portfolio, is to stimulate nurses' reflexivity by bringing them to anchor their practice towards their professional conscience and orient them towards optimal conditions and move away from problematic conditions (see arrow linking the iceberg and sphere). Thus, they become able to mitigate the problematic zones, where essential parts of nursing practice are hidden (as in the iceberg metaphor). In this spherical illustration, nurses' perception of their level of involvement in their practice varies from "rooted" to "superficial", which is depicted by the Y axis in the sphere (and represents the tip of the iceberg), and their perception of the level of care varies from "global" to "instrumental" and is represented by the X axis. The level of professional awareness and reflexivity is particularly critical in their perception of the optimal conditions needed to sustain patient safety in their work environment, and this may vary over "time". The importance of "time", which allows to represent the sphere in three dimensions, echoes Bronfenbrenner's "chronosystem" [23] which considers the social-political-historical effects and transitions that each nurse may experience in their professional life. This illustration of the SNPRC is still preliminary and needs to be improved to really incorporate the work of the design team and the conceptual model of nursing practice proposed in this paper. It is also important to note that it was developed in French, some elements were translated in English for the benefit of this paper. Nursing practice is illustrated here through a metaphor of an iceberg in which these components and themes are transposed [24, 25] . Building from this metaphor as a starting point, our results provide a mapping of nursing practices that is substantially dependent on different aspects of the organizational and physical structure of the care environment. One of these aspects is the hypothesis that the usual working tools do not appear to fully support the entire full scope of nursing practice. The observation that nurses may realize that they are at the visible tip of the iceberg regarding their practice corroborates the work of Déry et al., [24] who highlights the limited scope of nurses' actual practice through the little attention placed either on the optimization of quality and safety of care, on communication or coordination of care in their practice. The more nurses will invest the full scope of their practice, by emphasizing these dimensions in particular, the more proactive they will be regarding continuous improvement of quality and the more they will exercise their professional role with all the autonomy that their title confers them. The importance of autonomy as defining nurses' professional role is supported by Freeman [25] who also supports "professionalism" as a lever for positive actions to sustain quality of care. In accordance with the standards of practice of the American Nurses Association (ANA) [26] , nurse managers are responsible, amongst other things, for supporting the full and complete application of the scope of practice [27] . They have the obligation and power to establish a culture of safety that can, at various levels, lead to continuous improvement in the quality of care. The more nurse managers, representing the organizational structure, promote a humanistic perspective of care, the more they should advocate the use of efficient and effective humanistic nursing tools to sustain a comprehensive approach to the patient. This implies the need to move away from a generic management style to a more specific one, where the fundamental mission of nursing resources in health care, by returning to its essence, will be central [28] . In this sense, a formal sensitization of nurse managers to the concepts underlying the INSÉPArable project, such as reflective practice, humanistic approach to care, sustainable safety and continuous quality of care improvement, will put forward a new management culture, conducive to renewed clinical governance [29] .This renewed governance proposes to bring together the organizational and professional perspectives in a collective strategic effort to make actions more integral parts of continuous improvement of quality rather than just a short-term objective regarding safety. This should leave more room for professional commitment, which is essential to the full scope of nurses' practice while aiming to achieve the organization's performance objectives. It is recognized that healthy work environments promote positive care outcomes that contribute to the safety and quality of care. Furthermore, the ANA [26] defines a healthy work environment as one that is safe and facilitating autonomy, empowerment and job satisfaction. As advocated by the WHO [19] , the concepts of health and safety must be considered with the same holistic (global) vision where the physical, psychological, social and spiritual well-being are taken into account. A healthy environment will therefore lead to a multidimensional sense of well-being among stakeholders. To this end, nurse managers, in collaboration with the management team, have a key role to play in implementing healthy work environments as catalysts for nursing innovation by demonstrating transformational leadership. This rather complex role requires that the data on the INSÉPArable project be further developed and validated on a larger scale. The role of nurse managers is particularly crucial to enhance nursing care. In healthcare settings, various management methods, mostly from the manufacturing sectors, have been adopted, including the Lean approach, which is widely used in Quebec hospitals. This approach aims to improve the organization's performance by seeking to create value for the patient [30] . This approach includes a strategic component aimed at alignment between the organization's objectives, the true north, and actions undertaken by each, through a bottom-up and top-down communication approach. While this resonates through the role of the SNPRC, with respect to the optimal nursing conditions to be preserved, the Lean approach does not well integrate the humanistic and caring essence of nursing practice. The INSÉPArable project could contribute in an innovative way to introduce humanization of care within this approach to future nurses in their academic curricula. This study is not without its limitations, and it is possible that its credibility and transferability may be affected by the following. The fact that the study was conducted in only two types of care settings, in one city only and the short duration (two years) limit the transposition and understanding of the data according to different organizational cultural contexts. In addition, although patient profiles were created and illustrated, the in-depth data analysis leading to the SNPRC focused mostly on nurses' experience and less on patient experience. A future study could focus more on patients' experience in the nurse-patient interactions, since they were duets in the same space and time. Also, the development of this project could go further in its interdisciplinarity (design-nursing-psychology) and co-design methodology, in particular by increasing the number of analysis and co-design workshops with stakeholders. Despite these limitations, the understanding of the nursing practice pathway, through this innovative methodology, has yielded an interesting conceptual basis and anchored groundwork that will guide the development of a full professional continued education portfolio with professional consciousness and reflective practices as central concepts. The promotion of patient safety will increasingly need to go hand in hand with healthy work environments that support highly skilled work and further linked to continuous learning. Millennial nurses are the professionals who may be most affected by the organizational structure of their environment and, where appropriate, may have the greatest impact on sustainable patient safety. New paradigms imply the need for continuous learning in the workplace to address the barriers that we will have to overcome one day. Nursing will not escape this trend, which will require systems' agility. With these current challenges in mind, we aimed to conceptualize a reflective portfolio prototype destined to sustain continued education and professional development for nurses to enhance patient safety competencies. This is the first study of its kind that brings together disciplines such as nursing, design and psychology around this goal and to use a design approach to deepen the understanding and develop innovative tools to support continued education in nurses. Our results suggested that nurses may only be aware of a small part of their practice, mostly associated with the more technical care. This part seems visible to them, notably because it is what is recognized and valued in their environment. The INSÉPArable project was developed with the overarching goal of looking for what is invisible yet essential to nursing practice, and as a basis for the visible part, in order to bring out the full potential of nurses' professionalism. By actively contributing to establish a culture of sustainable safety and humanization of care, this will undoubtedly promote full nursing practice. Full extension of nursing practice through a project such as this one illustrates how it would be possible to reconcile humanism and science as the foundations of the nursing profession. By fostering the implementation of creative tools that promote these values, it will potentially promote healthy environments, in which patients will be the primary beneficiaries and in which key stakeholders will implement renewed governance that will enhance nursing professionalism and prevent suffering in the workplace. As the world has seen during the COVID-19 pandemic, and across other past health challenges humanity has faced, the tremendous work that nurses do is a pillar of healthcare systems and this cannot afford to be underestimated especially when thousands of lives are at stake. This research, with its innovative methodology and emerging results, raises deeper issues about ethics and professional consciousness that need to be continuously nurtured, both in academic and professional settings, for a more holistic vision of patient safety. The INSÉPArable project deserves to be refined and Institute of Medicine (US) Committee on Quality of Health Care in America To Err is Human: Building a Safer Health System Les données probantes montrent que les infirmières sauvent des vies, réduisent les coûts et améliorent la santé des patients COVID-19 has seen nurses around the world do what nurses always do: step up NursingStandard La pensée infirmière: Chenelière éducation Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The lancet Increasing nurse staffing levels and a higher proportion with bachelor's degrees could decrease patient mortality risk. Evidence-based nursing Improving patient safety by optimizing the use of nursing human resources Canadian Nurses Association (CNA). Resolutions presented to the CNA Annual Meeting of Members La formation des infirmières, un aspect évacué dans le débat The INSEPArable Research Project: A Transdisciplinary Caring Approach to the Design of a Portfolio for Reflexive Nursing Practices What Does Millennial Loyalty Look Like In Today's Workplace? Ryan Jenkins speaker Implementation of a professional portfolio: A tool to demonstrate professional development for advanced practice Learning from others: a five years experience on teaching empathic design Holistic nursing and caring: A value-based approach Watson's Philosophy and Theory of Transpersonal Caring. Nursing theorists and their work-e-book Patient safety curriculum guide: Multi-professional edition Canadian Patient Safety Institute. Canadian Incident Analysis Framework La pratique réflexive: un outil de développement des compétences infirmières Health care providers can use design thinking to improve patient experiences Strengths-Based teaching and learning: An instructor's manual L'étendue optimale de la pratique infirmière Le professionnalisme: quelques réflexions. Presentation à la faculté des sciences infirmiéres American Nurses Association Calls for a Culture of Safety in All Health Care Settings Standards de pratique et compétences: Editions JFD La qualité du soin infirmier: de la réflexion éthique à une pratique de qualité Introduction à la gouvernance clinique: historique, composantes et conceptualisation renouvelée pour l'amélioration de la qualité et de la performance des organisations de santé Problem-solving behaviour of nurses in a lean environment further exploration of its applications in nursing ecosystems are needed to pursue the development of a complete professional portfolio which represents a promising continued education tool for today's students, who will be tomorrow's nurses and managers promoting holistic health for all.