Ellen B. Ceppetelli, MS, RN, CNL Ronald P. Ceppetelli, PsyaD,
PAL, MSW, LICSW VHA CNE March 24, 2011 Receptive Listeningin a
Nurse Residency Program 1
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ANCC Magnet Recognition Program 2
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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
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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
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New CNO Idealized Design Nurse Focus Groups Outcome: Practice,
Research, Education Support Creation of Office of Professional
Nursing 5
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Setting the Stage in 2000... Preplanning & effort to
influence outcomes Maximize ability for reasoned & informed
judgments Create our preferred future 6
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A Culture for New Nurses Predicted dearth of experienced RNs
and dependence on advanced beginners 7
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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
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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
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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
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Journey to Professional Formation and Authenticity Transition
into Practice 11
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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
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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
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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
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What would happen if nurse residents were consistently provided
a safe environment to put thoughts and feelings into language?
Question 15
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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
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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
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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
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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
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Contact function Techniques: Object oriented question (OOQ)
Joining/Mirroring Reflecting Framework of Receptive Listening
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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
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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
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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..
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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.
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Techniques of Receptive Listening Object Oriented Question:
(OOQ) Joining/Mirroring Reflecting to coax new information
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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
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Joining Thats right. Thats infuriating. Thats frustrating You
avoided because we think alike about the emotion
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Joining (Advanced) R: She left me alone for two hours while she
had lunch with her daughter. F: Thats infuriating. F: Its scary --
joining R: Yes F: What makes it scary? -- OOQ R: Hes going to get
angry F: Thats scary -- Joining (Pause) Can it be scary and you
still do it? -Reflection
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Why Reflecting? Encourages the subject to say or do more and/or
have new thoughts about a topic.
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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?
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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
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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..
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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.
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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
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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
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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
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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
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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
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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
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Socially emotional climate foundation of trust, mood,and sense
of possibility in the group. 40
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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
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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
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Advanced Beginner/Clinical Situations Present as a series of
tasks to accomplish Opportunities for learning Secondary ignorance
A test of personal capabilitiesa period of stark terror in which
they recognize they are in over their heads. Benner et al (2009)
43
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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
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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
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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
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Using NLRNs to get work done vs using work to develop NLRNs ?
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Value= Outcomes(Quality) x Time Cost Outcomes 48
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Table II 2003-2010 DH NLRNs Turnover Yr I & Yr II
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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
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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
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Themes of Residents Feedback Professional identity
Self-understanding Renewal Learning in dialogue Problem-solving
Sense of belonging Connected to the organization 53
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Examples of themes and enactment of residents voices will
follow 54
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Facilitators_Receptive Listeners
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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.
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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.
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Surprises Receptive Listening revealed an intimate view of what
did and didnt 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.
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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
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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
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WE SHALL NOT CEASE FOR EXPLORATION AND THE END OF ALL OUR
EXPLORING WILL BE TO ARRIVE WHERE WE STARTED AND KNOW THE PLACE FOR
THE FIRST TIME T.S.ELIOT Next Steps