By Colleen P. Campbell

Helene Hudson Lecture
Positive practice change using appreciative
inquiry in oncology primary care nursing
By Colleen P. Campbell
Abstract
Ambulatory oncology nurses struggle to meet the increasing
demands placed on them. Increased volume of patients, more complex treatments and symptom management, an older population with multiple co-morbidities combined with fiscal and human
resource restraints has created job dissatisfaction and the feeling of powerlessness in the current environment. The Appreciative
Inquiry process enables nurses to become engaged in planning and
creating positive change based on their knowledge, experiences and
clinical expertise, as oncology professionals. Through surveys and
group work, nurses in this project were able to turn theory into positive practice change, inspiring a new paradigm of primary oncology nursing. Through the promotion of innovation, we have inspired
hope while advocating for our profession.
Introduction
Nurses throughout Canada have experienced an increase in the
number and acuity of patients diagnosed with cancer. On average,
500 Canadians are diagnosed with cancer every day with five-year
survival estimated to be more than 62% (Canadian Cancer Society,
2012). Population growth, aging and rising cancer incidence have
caused a doubling of new cases of cancer in Ontario from 1982
to 2006. Survival rates for all ages have improved (Cancer Care
Helene Hudson—1945–1993
About the author
Colleen P. Campbell, NP, MN, CON(C), Advanced
Practice Clinical Coordinator, Simcoe Muskoka
Regional Cancer Program, Barrie, Ontario
L4M 6M2. Tel: 705-728-9090 ext. 43349, Fax:
705-719-4934, Email: [email protected]
doi:10.5737/1181912x232117120
Ontario, 2007). With the growing number of patients requiring
chemotherapy, the majority of treatment has moved to ambulatory departments in community hospitals or cancer centres. The
complexity of treatment delivery and symptom management is
increasing with chemotherapy given in neoadjuvant, adjuvant or
palliative intent over a number of years. Nurses in oncology struggle to cope with these increased numbers compounded by: an aging
society with multiple co-morbidities, declining experienced human
resources and budget restraints for material and educational
resources (Davidson, Halcomb, Hickman, Phillips, & Graham, 2006).
In Ontario, cancer care workers have demonstrated a high rate of
burnout related to volume of work and a sense of diminished personal accomplishment (Grunfeld, Whelan, Zitzelsberger, Willan,
Montesanto, & Evans, 2000).
The nursing model of care for oncology outpatients has become
fragmented with specialization in radiation, chemotherapy administration, navigation, survivorship and outpatient clinic visits. A
variety of nursing models exists within these subspecialties and
include shared-care, case management, nurse-led, patient navigation and interprofessional team (Canadian Health Services Research
Foundation, 2012). Lee and colleagues (2012) found a lack of empirical evidence for these models of care within the ambulatory cancer
system. Current oncology nursing work is driven by patient numbers, complexity and resource constraints (Lee, Fitzgerald, Downey,
& Moore, 2012). In many outpatient oncology clinics, nursing has
evolved through necessity to a primary model. This model initially
complemented the physician through answering phone calls, directing patients, filling out requisitions and assisting with procedures
(Porter, 1995). Through education and utilizing professional ideologies, many oncology nurses have evolved the primary care nursing
model linking the interdisciplinary team. Various responsibilities
include: direct care, supportive care, patient education and navigation of the system, accountability for professional practice, working
collaboratively and using evidence-based guidelines (Cancer Care
Ontario, 2011).
Interdisciplinary team involvement of the oncology patient has
become the standard of care, where available. Many patients have
a social worker, a dietitian, and access to community services. They
may also involve their primary care physician, surgeons, possibly
physiotherapy, palliative care or pain management services. These
services may or may not be in one centre or community with a
number of people living in rural communities throughout Canada.
Communication between providers can be onerous at best. The primary care nurse often becomes the contact person for many inquiries or concerns regarding treatment effects and management.
The unremitting growth of patient volume and acuity, increased
nursing sub-specialties and isolation with reactive models of care,
communication demands of team members and diminishing material and human resources have put a strain on the amount of time
the nurse is available for true collaborative primary care practice.
Frustration, feeling powerless among competing demands and lack
of job satisfaction is infecting oncology nurses in many centres.
The purpose of this paper is to describe the Appreciative Inquiry
methodology and how it was used in a quality improvement project
to enhance the oncology nursing model of care and improve nursing experience.
CONJ • RCSIO Spring/Printemps 2013 117
Methodology
Appreciative Inquiry (AI) is a theory of collective action that
encourages change through the strengths and vision of individuals.
The aim is to search for new knowledge in a cooperative and positive way, therefore directing the vision and actions of the individuals involved. There are five central principles that move the theory
to practice (Cooperrider, Whitney, & Stavros, 2008; Lind & Smith,
2008).
1.Constructionist principle: Looks at the ways individuals and
groups participate in the construction of their preserved social
reality. In an organization, the question asked would direct the
thinking and inquiry of individuals.
2.Principle of simultaneity: Recognizes that inquiry and change
happen at the same time. Through discussion we generate and
gather data, therefore directing change and formulating the outcomes we seek.
3. Poetic principle: Organizations are living and directed by their
employees. They are composed and engaged by the experience,
learnings and interpretations of the organization. As an organization, there is a choice of what to study and how to interpret
our findings.
4.Anticipatory principle: The vision we have for the future
directs our thoughts, actions and behaviours in the present.
Organizations exist because of the collective vision for the
future, such as is developed in strategic plans. Those visions
drive our goals and actions in the present.
5. Positive principle: Organizational systems respond to positivity.
They are empowered by inspiration and hope. If an organization
engages employees in a positive nature, then a more sustainable
future will exist.
Contrary to problem-based inquiry, AI causes individuals to
consider what is working well. Through focusing and gathering data on our successes, we envision a superior future, collectively inspire motivation and create excitement moving forward.
This approach is unique in its ground up approach, facilitating
empowerment, positive relationships and collaboration around
common goals. Initially a theory of organizational development,
this approach has been successful in a number of organizations
and settings to facilitate change management. It has emerged
with increased frequency in health care literature. In recent years,
AI has been used to effectively facilitate knowledge translation
(Yoon, Lowe, Budgell, & Steele, 2011), enhance collaborative practice (Havens, Wood, & Leeman, 2006), reorganize health care services (Richer, Ritchie, & Marchionni, 2009), improve staff retention
(Challis, 2009), enhance patient safety (Shendell-Falik, Feinson,
& Mohr, 2007), and improve practice and transformative change
(Carter, Ruhe, Weyer, Litaker, Fry, & Stange, 2007; Lazic, Radenovic,
Arnfield, & Janic, 2011).
Appreciative Inquiry identifies common goals and values of
individuals. From those goals, themes are developed utilizing
group dynamics. There are four essential stages. Discovery is used
to determine what is positive and meaningful. Dream is used to
envision a new future. Design assists in planning and implementing change. Destiny is the stage of evaluation and sustaining
progress.
Many oncology nurses are experts in the care they provide. AI
utilizes nurses’ clinical expertise, knowledge, experience and compassion through reflection on what has worked best. Through the
four-stage systematic method, nurses envision what their work
could look like in the future, and then determine processes to make
the vision a reality. Progressing on a continuum, nurses realize the
change created, combining individual skills to create more complex
care plans and focus on excellence.
118 CONJ • RCSIO Spring/Printemps 2013
Methods
The objective of the project was to explore the practices of
oncology primary care nurses that gave them job satisfaction; to
build on those positive practices and enhance our model of nursing
care. This was done through surveys and group work.
Participants
The project was conducted in a non-academic cancer centre
approximately 100 kilometres north of Toronto, Ontario. In this
centre, the oncology primary care model is used in the outpatient
clinics. Each of the seven medical oncologists and one general practitioner in oncology is assigned a primary nurse. The nurses cover
each other for vacations, illness and other variations in staffing. All
eight oncology primary nurses agreed to participate in the project.
One dropped out due to extended illness.
More than half the nurses (57.2%, n=4) had greater than 16 years
of oncology nursing experience, although 71% (n=5) had been in a
primary care role less than six years. Canadian Nurses Association
Figure 1: Demographics and education (n=7)
Number (n=7)
%
20–40
1
14.3
41–50
3
42.9
51–60
3
42.9
11–20
3
42.9
21–30
3
42.9
31+
1
14.3
6–10
1
14.3
11–15
2
28.6
16–20
1
14.3
21+
3
42.9
1–5
5
71.4
6–10
1
14.3
11–15
1
14.3
Diploma
4
66.7
BScN
2
33.3
Certificate
2
28.6
Certified in Oncology Nursing (Canada)
6
85.7
Out of country certification in Oncology
1
14.3
deSouza Designation
0
0
Current age (years)
RN experience
Oncology experience
Primary Care nursing experience
Highest education in nursing
Highest education in oncology
doi:10.5737/1181912x232117120
Certification in Oncology had been obtained by 85.7% (n=6). The
highest education in nursing was diploma for 66.7% (n=4), which is
representative of the average age group (Figure 1).
Design
A survey was created to explore common themes of interest
and importance. Reflective discussions occurred on a regular basis
to maintain motivation and engage stakeholder input. The survey
incorporated the four stage cycle of iterative phases (Table 1).
A survey exploring the experience of the participants using AI
was done after 10 months.
Data analysis
The survey was sent in paper format to all primary care nurses.
It was offered to other members of the inter-disciplinary team, and
two additional surveys were completed by nurses who worked in
a casual basis in the clinic. Results were put into a table reflecting the phases of AI. Statements made by more than one person
were repeated in the table. Two members of our team separately
reviewed the results and identified major themes in the content.
Line-by-line coding was not done. Discussion regarding the content
interpretation and relevant themes was held and verified with the
larger group to obtain consensus.
Table 1: The four stage cycle of iterative phases
Discovery
Appreciate what is.
What are the key steps to providing
patient care in your area? Give as
much detail as possible.
Reflect on your own experience. Tell
me a story about a time when you
experienced “exceptional patient
care”. Include high points when
you would have wished all patient
experiences were like this. Include as
much detail as possible.
Describe creative strategies you
have learned that facilitate efficient,
effective patient care.
Dream
Imagine what might be.
In your opinion, what is required
from others to better support
exceptional patient care?
Consider resources, environment,
communication, practices and roles.
Design
Determine what should be.
Imagine a good friend is going to
be treated at our clinic. What would
you ask the staff to do to provide
the best possible patient care? Who
do you want included in decision
making? What information or
documentation would you request?
Delivery
Create what will be.
Imagine it is three years from now
and exceptional patient care is the
norm. Please describe it in detail.
What are you doing that is new or
different? What three key changes
have been made? What barriers need
to be broken down to achieve the
changes? What did we do to assure
the changes occurred in a smooth
and rapid fashion?
doi:10.5737/1181912x232117120
Results
Four themes with a strong vision for the future were identified.
Knowing your patient
The nurses enjoyed getting to know their patients. Spending time
through assessment and being available for problem solving was
important to them. Having the information they needed for completeness was imperative. They felt valued when they were included
or were asked for input in the plan of care. Consistency of care provider ran through all the themes and intertwined with communication. Their vision was to have the time and documentation available
to provide personalized care for their patients.
Team approach
Access and input into the plan of care resonated with this
theme, as well. They felt good when they were part of a co-operative
approach between intra-disciplinary team members. Patients were
best served when the whole care team was involved. The future
includes clear role definition and a comprehensible communication
plan.
Patient focused
Best care practices involved consistency of care providers
and easy access to the plan of care, facilitating clear messages to
patients. Opportunities to have flexibility for drop-ins, phone calls
or health teaching would be the ideal. To facilitate team-based care,
they need and expect access to various team members.
Knowledge and skill
Treatment plans, goals of care, and advance care planning are all
important to nurses. Having the knowledge and skill to contribute
to these plans, along with nursing history and physical examination
are important to nurses. They value leadership support in guiding
them in their career development.
The four major themes were taken back to the nurses and
validated.
We decided on three themes, knowing your patient, team
approach and patient focused, as our centre of attention. Knowledge
and skill sat in the “parking lot” to be incorporated into each of the
other themes, as we went along. Nurses created projects that interested them and would contribute to improved patient care. They
worked individually or in groups to come up with projects that
would reflect the collective themes. Two nurses focused on the
breast population to improve access and knowledge about lymphedema. Two nurses focused on palliative care referral processes and
resources for patients in the community. Other nurses are working
on flow sheets to standardize nursing processes and clarify their
roles. In order to maintain momentum we met every two weeks to
review plans, give collegial support and input.
A qualitative survey was done 10 months after the project was
initiated. Two nurses completed the survey. The experience had
been favourable overall. Nurses expressed frustration at not having dedicated time to complete their projects. They gained an
understanding of the expertise each nurse brings to the team and
the common goal of quality patient care. Nurses were encouraged
that they were being listened to and were part of positive practice
changes.
Discussion
The initial surveys were sent out to all disciplines of the
cancer program. Only eight primary nurses completed and
returned the survey. At that time, the cancer program was anticipating a physical move from an 8,000-square-foot space to a
75,000-square-foot cancer centre. The computer platform used
was undergoing change for which all employees would have to
CONJ • RCSIO Spring/Printemps 2013 119
be re-trained. All staff was anticipating change to where and how
they worked. An Employee Experience survey done at that time
demonstrated staff morale below the provincial average. Over the
course of the project we had staff off for surgery, critical illness
and bereavement.
The nurses pulled together and shared their visions for a better future. Due to financial restraints and competing priorities, the
nurses were unable to meet in a large group to share experiences
and encourage momentum. In order to facilitate a collective vision,
a workshop away from the work environment may have helped create more excitement and momentum moving forward (Ruhe et al.,
2011). Being committed to the process by having an AI summit, as
suggested by Cooperrider et al. (2008), would have provided the
opportunity to collectively spur the energy and creativity for action
plans. We have met for a 45-minute meeting every second week. The
need to reflect and stay solution-focused has required strong leadership, building a climate of trust (Keefe & Pesut, 2004). Persistence
in communicating our vision, goals and commitment to enhance our
model of care at regular intervals has been essential (Reed & Turner,
2005).
The number of nurses involved in the process was small and
there were staff changes during this time. The project was done
with the clinic nurses only. It may have benefited from involvement
of all nursing at the centre. There may not be one solution. It is
quite possible that there will be multiple models of care within
oncology nursing depending on the setting and area worked. The
very nature of the AI process is ideal to utilize the strengths, experiences and creative potential of oncology nurses regardless of the
setting. Further nursing research is warranted.
The model of care is evolving. Nursing leaders need to utilize the
experience and commitment to care inherent in all oncology nurses.
Collectively, nurses have a loyalty to their specific population and
the future generations of oncology nurses to create a better future.
Conclusion
The number of patients requiring ambulatory cancer care is
growing, and will continue to do so. Many oncology nurses are overwhelmed with the workload and lack of clarity in their role or model
of care. The AI methodology was used to evolve the model of care
utilizing a ground up approach. It has provided the clinic nurses
with autonomy and some control over their destiny. In focusing on
positive solutions, they are gaining momentum and moving toward
a more interdisciplinary model of care within disease sites. There is
a feeling of empowerment and enthusiasm within the team. We haven’t got it quite right yet, but we are definitely moving in the right
direction.
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