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Ellen B. Ceppetelli, MS, RN, CNL Ronald P. Ceppetelli, PsyaD, PAL, MSW, LICSW VHA CNE March 24, 2011 Receptive Listening©in a Nurse Residency Program.

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Presentation on theme: "Ellen B. Ceppetelli, MS, RN, CNL Ronald P. Ceppetelli, PsyaD, PAL, MSW, LICSW VHA CNE March 24, 2011 Receptive Listening©in a Nurse Residency Program."— Presentation transcript:


2 Ellen B. Ceppetelli, MS, RN, CNL Ronald P. Ceppetelli, PsyaD, PAL, MSW, LICSW VHA CNE March 24, 2011 Receptive Listening©in a Nurse Residency Program 1

3 ANCC Magnet Recognition Program 2

4 Objectives  Describe the DH Office of Professional Nursing as a structure that empowers innovation.  Describe implementation of Receptive Listening © in small facilitated groups of nurse residents during the first year of transition into practice.  Analyze the impact of Receptive Listening © on nurse residents and facilitators in a year-long residency program  Dialogue about the implications of Receptive Listening © groups for all nurses 3

5 The Role of Organizations  As they were  As they are  As they might become  As they ought to be Dee Hock Authentic leaders are not made nor are they born; they are enabled or disabled by the organizations in which they work. David Leach 4

6 New CNO Idealized Design Nurse Focus Groups Outcome: Practice, Research, Education Support Creation of Office of Professional Nursing 5

7 Setting the Stage in 2000...  Preplanning & effort to influence outcomes  Maximize ability for reasoned & informed judgments  Create our preferred future 6

8 A Culture for New Nurses  Predicted dearth of experienced RNs and dependence on advanced beginners 7

9 Table I. 2000-2010 Initiatives for Nurse Residents Year00-01 01-03 03- 04 04-05 05-0808-0909-1010-11 Orientation Unit Based CentralizedHPSHPS/HRSA UHC/ Receptive Listening Receptive Listening Receptive Recep Listening Preceptor Program Generic DHMC 1-Day RN/VNIP ModelOPN 1-Day OPN 2-Day DH History of Support for Residents 8

10 Setting the Stage  2003:  EB Preceptor Program implemented  Designed a NRP with HPS  2004:  3-month NRP with HPS implemented  2005-2008  NRP funded by HRSA

11  End of HRSA research protocols  DH Retention had improved, but the UHC benchmark was 9.5% for 3 years.  By June,2009, 35% of the 290 residents hired (7/05-2/08) had left DH.  Why were NLRNs leaving 1st jobs & nursing at rates of 13-70% nationally? An Opportunity Existed in 2008 10

12 Journey to Professional Formation and Authenticity Transition into Practice 11

13  A developmental trajectory from beginner to expert  Practice as a way of knowing in its own right  Socially embedded knowledge  Skill of involvement Benner,Tanner,Chelsa 2009 Transition into Practice

14 Open to the vulnerability of our patients and where that will take us in action… This emotional connection motivates advocacy, a key aspect of the expert nurse. Skill of Involvement 13

15 To improve the Nurse Residency Program (NRP) by implementing receptive listening © in monthly, 90-minute small groups during the first year of practice. Purpose 14

16 What would happen if nurse residents were consistently provided a safe environment to put thoughts and feelings into language? Question 15

17 Design  After successful completion of a 3-month NRP, residents met for 90 minutes monthly, for the next nine months, in small groups that were facilitated by DH nurses trained in the use of Receptive Listening ©.  Facilitators received training and met monthly for 2 hours as a group facilitated by a licensed psychoanalyst. 16

18 Design Concerns  Integrating a year-long residency into the clinical setting and work schedule  Recruiting facilitators  Training facilitators before and during the process  Supporting facilitators and residents in this process  Getting residents off the units to attend

19  Purpose is to provide a safe environment where nurse residents can put thoughts and feelings into language.  Facilitators listen without judging, valuing helping, or changing. Receptive Listening © in Small Groups 18

20  Receptive Listening© is an intentionally focused method of listening developed to embrace negative emotions/behaviors.  60 years of Modern Psychoanalysis research  Developed by psychoanalysts and social workers to work with schizophrenics and difficult people  All interventions, concepts and techniques focus on the intrinsic development of self- esteem raising behaviors. Receptive Listening©

21  Contact function  Techniques:  Object oriented question (OOQ)  Joining/Mirroring  Reflecting Framework of Receptive Listening©

22 The listener is always thinking:  Why is this person saying or doing this right now?  What is the emotional function of the contact? Receptive Listening© and Contact Function

23 The goal is to respond by reflecting or joining the contact in order to help the individual speak of her resistant behavior. Responding to the Function of the Contact

24 What is the Contact Function of this log? “I guess I am struggling with feeling the need of these meetings. Maybe in time I will find them more beneficial, but right now I do not feel or see the benefits of them”..

25 What is the Contact Function of this log? “ Especially since, in the small groups, we are all from different areas of the hospital. 2 from OR whom have one another for support and to talk to, 2 on 4West whom also are friends outside of work (went to nursing school together), so they have each other as a resource and then myself in a totally different environment in XXX”.

26 Techniques of Receptive Listening ©  Object Oriented Question: (OOQ)  Joining/Mirroring  Reflecting – to coax new information

27 Why Joining / Mirroring? It makes us similar. We are like one another. Example: NHR: “I like you. You think just like me” NHR: “The love I have for you is the love I wanted from my father but never got”

28 Joining  That’s right.  That’s infuriating.  That’s frustrating  “You” avoided because we “think alike” about the emotion

29 Joining (Advanced) R: She left me alone for two hours while she had lunch with her daughter. F: That’s infuriating. F: It’s scary -- joining R: Yes F: What makes it scary? -- OOQ R: He’s going to get angry F: That’s scary -- Joining (Pause) Can it be scary and you still do it? -Reflection

30 Why Reflecting? Encourages the subject to “say or do more” and/or have new thoughts about a topic.

31 Examples of Reflecting  Say more  R:Tell me what to do with her!  F:How would knowing what I would do be helpful?  Can you not be motivated and still write the paper?

32 Conclusion Receptive Listening© creates an atmosphere of “similar” people that eventually evolves into a “worldview”. “Similar” people have the understanding that others in the group, organization, hospital “think alike”

33 Conclusion Also, when with people who “think like us” we are open to listening, report thoughts in a respectful manner and, most important, gain access to the positive parts of our personalities..

34 Result Natural mitigation of conflict and a natural increase in cooperation and loyalty to each other and the organization that facilitates an increase in intrinsically motivated self-esteem and creativity.

35 Expectations of Facilitators  Able to express their thoughts and feelings in language in a safe setting.  Create the container to “say everything”.  Participate in their own monthly group that creates its own meaning.  Be genuine, caring, and receptive, with receptive by far the most important attribute.  Commitment: 9 months, 4 hour /month; logs 34

36  Facilitators did create a safe environment for residents to put thoughts and feelings into language.  Outcome: An intimate glimpse of the lived experience of advanced beginners at the sharp edge of care What Happened Initially? The Fuure Revealed 35

37  Recognition of value of NRP,HPS, preceptors, educators and unit support  Compassion for patients and their families  Teamwork: Intergroup collaboration  Rewards of being challenged and supported simultaneously  Joy of recognizing the developing expertise of each other Initial Voices of Residents 36

38  Continuous fear of the responsibility for lives of high acuity, unstable patients  Disruptive behavior with experienced RNs & MDs  Challenging patients/families  Systems issues as interruptions  Disappointment/ Disillusionment The Journey was Difficult 37

39  Anxiety related to performance, fear of making errors, killing patients  Developmental and personal changes  Leaving work at work  Physical and emotional symptoms due to work stress The Journey was Difficult 38

40 Physical or emotional suffering that is experienced when constraints (internal or external) prevent one from following the course of action that one believes is right. Pendry (2007) Moral Distress 39

41 Socially emotional climate… foundation of trust, mood,and sense of possibility in the group. 40

42 DHMC Nursing Vision  Creating an environment where patients and family can heal. CNO Personal Vision  Creating an environment where nurses can do what is right. DHMC Commitment to Excellence 41

43 The moral distress incited by competing and conflicting occupational expectations within the workplace is one of the primary factors specified for the exodus of new nursing recruits out of acute care workplaces. Duchscher & Myrick 2008, p.195 ) Impact of Moral Distress 42

44 Advanced Beginner/Clinical Situations Present as a series of tasks to accomplish Opportunities for learning Secondary ignorance A test of personal capabilities…a period of stark terror in which they recognize they are in over their heads. Benner et al (2009) 43

45 The Process of Becoming: Stages of New RN Graduate Professional Role Transition  Although it is by no means a linear or prescriptive and not always strictly progressive, it was evolutionary and ultimately transformative for all participants. 44

46 Uncertain who they can trust and driven by a need to belong, these graduates went to great lengths to disguise their emotions from colleagues and worked to conceal any feelings of inadequacy. Duchscher, J. (2008). Process of Becoming:Stage One 45

47 NLRN Characteristics, Work Attitudes,& Intentions to Work Secondary analysis of 612 surveys of NLRNs, focus on work environment: Theme 1: Colliding Expectations Theme 2: The Need for Speed Theme 3: You Want Too Much Theme 4: How Dare You? Theme 5: Change is on the Horizon Pellico, L., Brewer, C., Kovner, C. (2009). What newly licensed registered nurses have to say about their first experience. 46

48 Using NLRNs to get work done vs using work to develop NLRNs ? 47

49 Value= Outcomes(Quality) x Time Cost Outcomes 48

50 Table II 2003-2010 DH NLRNs Turnover Yr I & Yr II

51  08-09 NRP YR I 12.6% (4 of12) YR II 20%  09-10 NRP YR I 6.2%  10-11 NRP YR I 5.2% Costs >1 st YR 08-09 (n=12) $970,200 09-10 (n=5) $404,250 10-11 (n=3) $242,550 Cost of Turnover>1 st Year 50

52 Residents’ Feedback * Effectiveness of facilitators: 100% Safe Environment Ranking 08-09 NRP 1 2 3 (8 %) 4 (22 %) 5(70%) *91.5% Response rate 51

53 Creating a Safe Environment  A Safe Environment “It was a very nurturing experience. Being able to talk and vent and listen to other new nurses experiencing the same thing was great. The fact that we were in a non- judgmental place was key (everywhere else we are being judged)”.  Trust “What was said there, stayed there”! 52

54 Themes of Residents’ Feedback Professional identity Self-understanding Renewal Learning in dialogue Problem-solving Sense of belonging Connected to the organization 53

55 Examples of themes and enactment of residents’ voices will follow 54

56 Facilitators_Receptive Listeners

57 Lessons Learned  Confidentiality, the foundation of trust in the group, became a barrier to sharing what we heard across the organization.  Facilitators need a group, experiential learning, and continuing education to do this work (BGSP).  Unit leadership and fiscal resources are essential to support residents to attend small groups.

58 Unanticipated Outcomes  Early detection of residents’ with problems.  Clearer understanding of why they leave.  Early interventions to assist in decision to transfer within.  Facilitators’ character maturation  Residents continue to seek this trusted network of facilitators after the year and across facilitators.

59 Surprises  Receptive Listening© revealed an intimate view of what did and didn’t work in the unit/organization.  In retrospect, residents felt supported although the journey was difficult.  Yet, some felt helpless and hopeless.  Experienced nurses can be a barrier, regardless of structure and leadership, through their retention-destructive behavior.

60 Camere by Dom Helder It is possible to travel alone, but we know that the journey is human life and life needs company. Companion is the one who eats the same bread. The good traveler cares for weary companions, grieves when we lose heart, takes us where he finds us, listens to us. Intelligently, Gently, Above all, lovingly, We encourage each other To go on and recover our joy in the journey. 59

61 Implications for Experienced RNs What could happen if all nurses could put their thoughts and feelings into language in a safe environment where they were not judged, valued, changed, or helped ? 60


63 62 Thoughts and Questions

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