Fundamental Care Guided By The Careful Nursing Philosophy And .

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Accepted: 23 January 2018DOI: 10.1111/jocn.14303S P E C I A L IS S U E F U N D A M E N T A L C A R E - RE V I E WFundamental care guided by the Careful Nursing Philosophyand Professional Practice Model Therese Connell Meehan PhD, RNT, RGN, Adjunct Associate Professor1PhD, MSc, RGN, Associate Professor2Professor Fiona Timmins Jacqueline Burke PhD, RPN, RGN, Assistant11School of Nursing, Midwifery and HealthSystems, University College Dublin, Dublin,Ireland2School of Nursing and Midwifery, TrinityCollege Dublin, Dublin, IrelandCorrespondenceTherese Connell Meehan, School of Nursing,Midwifery and Health Systems, UniversityCollege Dublin, Dublin, Ireland.Email: therese.meehan@ucd.ieAims and objectives: To propose the Careful Nursing Philosophy and ProfessionalPractice Model as a conceptual and practice solution to current fundamental nursing care erosion and deficits.Background: There is growing awareness of the crucial importance of fundamentalcare. Efforts are underway to heighten nurses’ awareness of values that motivatefundamental care and thereby increase their attention to effective provision of fundamental care. However, there remains a need for nursing frameworks which motivate nurses to bring fundamental care values to life in their practice and strengthentheir commitment to provide fundamental care.Design: This descriptive position paper builds on the Careful Nursing Philosophyand Professional Practice Model (Careful Nursing). Careful Nursing elaboratesexplicit nursing values and addresses both relational and pragmatic aspects of nursing practice, offering an ideal guide to provision of fundamental nursing care.Method: A comparative alignment approach is used to review the capacity of Careful Nursing to address fundamentals of nursing care.Conclusions: Careful Nursing provides a value-based comprehensive and practicalframework which can strengthen clinical nurses’ ability to articulate and control theirpractice and, thereby, more effectively fulfil their responsibility to provide fundamental care and measure its effectiveness.Relevance to clinical practice: This explicitly value-based nursing philosophy andprofessional practice model offers nurses a comprehensive, pragmatic and engagingframework designed to strengthen their control over their practice and abilitytoprovide high-quality fundamental nursing care.KEYWORDSCareful Nursing, fundamental care, Ireland, NANDA International, philosophy, professionalpractice model, spiritual, standardised nursing languages1 IN TROD UC TI ONnursing practice. Aspects of care considered fundamental are thosethat focus on personal safety, human dignity, self-care and comfortThere is growing momentum in the literature urging nurses to recon-within a healthcare context. Often these involve minimal technologi-sider fundamental nursing care as a crucial component of goodcal intervention; or technology is used as a tool to assist nurses inJ Clin Nurs. 2018;1–14.wileyonlinelibrary.com/journal/jocn 2018 John Wiley & Sons Ltd 1

2 MEE HANETthe provision of fundamental care, for example recording body temperature. Always they involve emphasis on the nurse–patient relationship andnurses’ ability to engagedirectly withpatients insensitive and respectful ways. Examples of fundamental care needsinclude those that are physical, such as assistance with toileting, skincare and mobility; those that are psychosocial, such as recognisinghuman dignity and fostering calmness and hopefulness; and thosethat are relational, such as nurses being respectful, empathic andcompassionate (Feo & Kitson, 2016; Kitson, Conroy, Kuluski, Locock,& Lyons, 2013; Kitson, Conroy, Wengstrom, Profetto-McGrath, &Robertson-Malt, 2010).Growing awareness that fundamental care must be highlightedas an essential element of nursing practice is due to a variety of circumstances. First, several widely published national and mediareports in the United Kingdom (Department of Health, 2013), theUnited States (Gallagher, 2011) and elsewhere internationally (Aikenet al., 2012) point to deficient fundamental care. There is evidenceof “care erosion” whereby core elements of care are overlooked,What does this paper contribute to the widerglobal clinical community? Provides an explicit philosophy and professional practicemodel framework which can comprehensively structureand guide fundamental nursing care and measure itsongoing effectiveness. Highlights the vital importance of using the standardisednursing languages of NANDA International, Nursing Outcomes Classification and Nursing Interventions nsistently and to guide comprehensive assessment ofpatients’ fundamental care needs. Highlights spirituality as a historically inherent aspect ofhow nurses practice and as an important aspect of hownurses may currently practice, particularly in relation toproviding fundamental care.possibly due to organisational constraints, and become ignored (deVries & Timmins, 2016, p. 5). There is also international evidencethat “missed care” is a real phenomenon whereby fundamental carereasons for this, focused solutions to improving practice are alsois regularly not attended to because of nurses’ competing demandsneeded.(Ausserhofer et al., 2014; Jones, Hamilton, & Murry, 2015). WhatThere are isolated examples of approaches underway aimed atthese studies have uncovered is that internationally, and particularlystrengthening fundamental nursing care. Such initiatives includein the context of limited resources or poor working environments,identifying research priorities focused on improving fundamentalnurses leave professional care responsibilities undone. Ausserhofercare, for example respecting and maintaining patients’ dignity; assist-et al. (2014) observe that typically nurses choose to prioritise careing with nutrition, hydration and elimination; protectingsuch as physical treatments, procedures and medication managementskin; improving communication; and examining nurses’ attitudes toat the expense of oral hygiene, skin care, re-positioning patients withand relationships with patients (Ball et al., 2016). Initiatives are alsolimited mobility, and communicating with and comforting patients.taking place to help nurses strengthen their expression of valuesThere is also a belief that modern health services are more focusedsuch as competence, compassion and commitment (Department ofon managerialist efficiency and budgeting priorities rather thanHealth, 2012, O’Halloran, Wynne, & Cassidy, 2016). The importanceessential human relational aspects of care delivery “with the beliefof nursing education necessary to support nurses’ control over theirthat a competitive, business-focused ethos will somehow create apractice and delivery of high-quality patient care has also been high-better environment for care” (Crawford, Gilbert, Gilbert, Gale, & Har-lighted (Kitson et al., 2013). Work has begun to help nurses reframevey, 2013, p. 719).their thinking in ways that better enable provision of fundamentalAt a practice level, fundamental care is also not given the atten-patients’care (Feo, Conroy, Alderman, & Kitson, 2017). Kitson, Athlin, andtion it requires as nurses may carry it out in a ritualistic way, ratherConroy (2014) argue that for nurses to meet their challenge to pro-than an individualised relational way (Thompson & Kagan, 2011).vide for patients’ fundamental care needs, there is an urgent “needResponsibilities completed efficiently in the name of quality andfor an integrated way of thinking about the fundamentals of carecost-saving targets may be lacking in interpersonal attentiveness, forfrom a conceptual, methodological, and practical perspective” (p.example assisting patients with eating and drinking, which are also332); a way of thinking that not only addresses pragmatic aspects ofsocial activities. Many older people are already malnourished onnursing practice but also provides a structure for nurses’ thinking,admission to acute care hospitals and often feel intimidated andreflection and assessment of patients’ fundamental care needs.fearful about asking nurses for assistance with selecting food andThis is an interesting argument because the deficits in funda-eating and drinking (Best & Hitchings, 2015). Best and Hitchings pro-mental care that exist have arisen at a time when confidence inpose that this example of a fundamental care needs requires particu-nursing conceptual models is at an all-time low in thelar attention because poor nutrition and dehydration can lead to lowStates (Jacobs, 2013). Most attempts to implement a nursing con-Unitedblood pressure leading to increased risk for falls, risk for depressedceptual model in the United Kingdom and Ireland have led to itmood and confusion, and risk for skin damage and pressure ulcera-becoming mainly synonymous with paperwork (McCrae, 2012) andtion. While there appears to be widespread agreement that failureincreasingly replaced with care pathways or other quality initiatives.to provide fundamental care exists with much debate about theMost nursing conceptual models do not emphasise nursing values

MEEHAN ET AL.(Cody, 2015) even though values are the main drivers of compas-nursing values into their organisation’s values such that nursing prac-sionate, high-quality health care (Dewar & Christley, 2013). Recenttice excellence becomes the essence of the organisation (Jacobs,healthcare scandals that highlighted deficits in fundamental care in2013).the United Kingdom (Department of Health, 2013) and IrelandProfessional practice models are well suited to provide a value-(Aras Attracta Swinford Review Group, 2016) led to implementationbased conceptual, methodological and practical structure for nurses’ofstrategiesprovision of patients’ fundamental care needs. In fact, use of a pro-(Department of Health, 2012; O’Halloran et al., 2016). The ssional practice model has been recommended to help addressstrategy emphasised the values of compassion, care andcommit-fundamental care-related patient safety issues and care erosion inment while the United Kingdom strategy emphasised the values ofthe United States (Stallings-Welden & Shirey, 2015) and Irelandcare, compassion, competence, communication, courage and com-(O’Ferrall, 2013).mitment, heralded as the 6C’s strategy. Commentators on the Uni-The Careful Nursing Philosophy and Professional Practiceted Kingdom 6C’s strategy (Baillie, 2015) observe their remarkableModel (Careful Nursing) (Meehan, 2012; Murphy, Mc Mullin,similarity to the 5C’s strategy; compassion, competence, commit-Brennan, & Meehan, 2017) offers one possible conceptual andment, confidence and conscience; proposed twenty years earlier bypractice solution to current fundamental care erosion and deficits.Canadian nurse theorist Simone Roach (1992) but little recognisedCareful Nursing is designed for use in any hospital or healthcaresince that time. Indeed, Gallagher (2013) questions whether statingsystem internationally and appears to be the professional practicethese values is enough. Nursing has a long history of a strong value-model that emphasises incorporation of standardised nursing lan-based core. What nursing needs is a conceptual, methodolog- icalguages and found to be effective in accurately identifying and doc-and practical structure that will bring nursing values to life in nurses’umenting patients’ care needs, interventions and outcomes (Tastanpractice, particularly in their provision of fundamental care (Feo &et al., 2014). Developed in Ireland, based on the skilled practice ofKitson, 2016).early to mid-19th century Irish nurses (Meehan, 2012), CarefulIn contrast to nursing conceptual models, recent and emergingNursing has been used and evaluated both nationally (Murphynursing professional practice models originate directly from and areet al., 2017) and internationally (Ellerbe & Regen, 2012). In a recentinformed by nursing practice. Nurses who wish to develop a profes-study of implementation of the philosophy and dual clinical practicesional practice model for their organisation establish a committeedimensions of Careful Nursing, nurses demonstrated increased con-which represents all levels of nurses. The committee’s aim is totrol over their practice and increased adherence to hospital nursingdevelop and implement a strategic plan designed to enhance thedocumentation standards, compared to before implementationorganisation’s nursing practice environment and nurses’ control over(Murphy et al., 2017). Qualitative data indicated that implementa-and delivery of nursing care (Basol, Hilleren-Listerud, & Chmielewski,tion of Careful Nursing made nursing more visible to nurses,2015). All nurses are asked to reflect on their professional practiceincreased their attention to patient assessment and allowed themand values and the mission and values of the organisation. The nurs-additional time to spend listening to and talking with patients, alling literature and a range of nurse leaders are widely consultedfactors known to help prevent erosion and omission of fundamen-regarding concepts such as relationship-basedleadership,tal care. Over a subsequent 12-month period, Careful Nursingshared governance, evidence-based decision-making, professionalwards demonstrated on average an 11% improvement in nationalindependence and collaborative practice. The committee’snursing quality care planning metrics, compared to non-Carefulcare,analysisand synthesis of this information enables it to formulate a profes-Nursing wards (Donohoe & Dooley, 2017).sional practice model which is then used to guide nurses towardsachieving the aim of the committee (Basol et al., 2015; Slatyer,Coventry, Twigg, & Davis, 2016). Thirty-six of the 38 professional1.1 Aimpractice models identified in the literature have been developed inThe aim of this study was to provide a pragmatic response to funda-this way; but professional practice models can also be developedmental care erosion and deficits by proposing and elaborating thewithout reference to a specific organisation as long as they arecapacity of Careful Nursing to expressly provide an integrated waydesigned according to professional practice model principlesof thinking about and addressing fundamental nursing care needs.andaims (Jacobs, 2013; Slatyer et al., 2016).The original purpose of professional practice models was toframe and specify the standard of nursing knowledge and practice2 METHODrequired for the American Nurses Credentialing Center (2014) Magnet Model recognition programme, internationally recognised as aA comparative alignment approach is used to review the capacity ofdefinitive standard for exemplary nursing practice. Professional prac-Careful Nursing to address fundamental care. Key elements of Care-tice models are designed to achieve their aim by embracing the cen-ful Nursing are introduced in alignment to key concepts of the Fun-tral role of nursing in a healthcare organisation’s structure. Indeed,damentals of Care Framework (FOC Framework) (Feo et al., 2017;the core aim of professional practice models is to merge theirKitson et al., 2013, 2014). In addition, fundamentals of care needs as

4 MEE HANETthey are provided for by the duel clinical practice dimensions ofalignment to related key elements of the FOC Framework (Feo et al.,Careful Nursing are aligned to definitions of fundamentals of care2017; Kitson et al., 2013, 2014). This alignment allows for appraisal(Feo & Kitson, 2016).of the capacity of Careful Nursing to address fundamental care.2.1 sional practice model in the neo-Aristotelian intellectual tradition ofThe three philosophical principles explicitly inform the profes-DesignThis descriptive position paper is informed by Careful Nursing, high-Aquinas (1265-1274/2007) and contemporary and modern philosophers in this tradition, for example, Maritain (1966), DeYoung,lighting use of its dual clinical practice dimensions to operationaliseMcCluskey, and Van Dyke (2009) and MacIntyre (2016). These prin-clinical nurses’ pragmatic provision of fundamental care.ciples are important because they provide nurses with a frameworkfor understanding human persons as unitary (holistic) beings, and for2.2 Careful Nursingthinking holistically about themselves, the people they care for, andtheir practice. In emphasising the nature of human beings as persons,Since the initial publication of Careful Nursing (Meehan, 2012), revi-in the original philosophical meaning of person, these principlessions have been made to enhance its specificity and clarity (Murphymake Careful Nursing profoundly person-centred. Further, nurses areet al., 2017) and are included in Figure 1 and Table 1.guided to think and practice from a philosophical perspective that isFigure 1 illustrates the schema of Careful Nursing with its threeconsistent with the nature of nursing as a nurturing, relational pro-philosophical principles surrounding its professional practice model,fession (Meehan, 2012), rather than being dominated by biomedicalcomposed of four dimensions and their total of twenty concepts.thinking prevalent in healthcare organisations (Mazzotta, 2016).The philosophy and the professional practice model are integral andCareful Nursing supports the vital importance of nurses’ collabora-inseparable. Table 1 lists these key elements of Careful Nursing intion with biomedical care but is concerned primarily with how nursesFIGU RE 1The Careful Nursing Philosophy and Professional Practice Model

MEEHAN ET AL.TABL E 1Key elements of Careful Nursing as they are proposed to align to key elements of the Fundamentals of Care FrameworkKey elements of Careful NursingKey elements of Fundamentals of Care FrameworkThree philosophical principlesNature and inherent dignity of the human personA unitary (holistic) being with a deeply relational spiritual nature andinherent dignity. All persons are equal in inherent dignity, the highesthuman value. Within their unitary being persons have twodistinguishable realities, an outward reality of body and senses and aninward reality of mind and spiritA holistic approach to care that combines the physical, psychosocial andrelational dimensions of care. Recognition of and respect for humandignity. Seeing the patient as a person; person-centred careInfinite Transcendent Reality in life processesThe creative, abundantly loving spiritual source of life which can beperceived intuitively through brief daily meditative practice of“stillness.” Stillness predisposes nurses to be calm in all circumstances.Calmness enables nurses’ patience, kindness, generosity of spirit,compassion and desire to help and heal themselves and othersSpirituality or the human spirit is not a recognised element.Still, a holistic approach to nursing care encompasses a body-mind-spiritunity, suggesting logically the presence of spiritualityHealth as human flourishingAn expression of the natural human desire to flourish despite, frailty,illness, disability or unavoidably difficult living circumstances.Flourishing is motivated by values such as hope, patience, courage,perseverance and prudence, by which persons’ desire and seek thehighest human good and to find meaning and purpose in lifeBio-psychosocial-relational integrity. Encouraging patients to participatein decision-making about their care. Guiding patients to set goals thatwill help them feel hopeful about their situation, care and well-beingFour professional practice model dimensions and their concepts[1] Therapeutic milieu (TM): A nurse-created, nurse-led safe and healingculture, rich in therapeutic interpersonal relationships andcooperative attentiveness to patientsContagious calmnessRespect for inherent human dignityNurses’ care for selves and one anotherIntellectual engagementCaritasSafe and restorative physical surroundingsContext of care: The immediate and wider care environment.Relationship established. Meaningful nurse–patient encounter[2] Practice competence and excellence (PCE): Nurses’ attitudes/activitiesof direct clinical care, using the nursing process with renewedmeaning and greater depthGreat tenderness in all things“Perfect” skill in fostering safety and comfort Watching–assessment–recognitionClinical reasoning and decision-makingPatient engagement in self-careNursing diagnoses–outcomes–interventionsPatient’s family, community supportive participation in careHealth educationIntegration of care: Care processes consistent with the nursing processare emphasised and elaborated in detail[3] Management of practice and influence in health systems(MPIHS): Nurses’ support of nursing and key role in system-widemanagement of careSupport of nursing practiceTrustworthy collaborationParticipative–authoritative managementContext of care: Interprofessional coordination of meaningful patientexperiences and nurses’ implementation of core tasksSupport of nursing practice in face of competing demandsInterprofessional, integrative care coordinationRole of nursing assistants not included[4] Professional authority (PA): The power, relative autonomy, andintellectual and political influence achieved when nursing’sdistinctive service is tions calling attention to the nature and importance offundamental care and how its full provision can be achievedKeeping patients calmKeeping patients dignified and respectedCapability to effectively establish therapeutic patient encountersIdeas, facts and tacit knowledge to develop working hypothesisSensitive, empathetic, kind, compassionateKeeping patients safeEstablishing a meaningful clinical encounterKeeping patients safe and comfortablePatient assessment based on working hypothesisOngoing clinical reasoning processKeeping patients involved in their careWorking hypotheses and clinical reasoningPatient and family at centre of clinical encounterKeeping patients informedBeing accountable for careNursing profession takes some responsibilityResearching, debating and writing about fundamental carethink differently about patients and have a different sphere of pro-through [4], with their twenty respective concepts, indicates howfessional responsibility.they relate to one another. Although distinct, the dimensions andIn the schema of Careful Nursing shown in Figure 1, the layoutconcepts are not mutually exclusive but are interwoven with andof the four professional practice model dimensions, numbered [1]complement one another as they are implemented in practice.

6 MEE HANETImportantly, each dimension and concept is considered a nursingcontagious calmness which, in turn, enables nurses to enact othervalue, that is, a motivating factor (Stein, 1922/2000) which con-Careful Nursing concepts.tributes to its meaningful implementation in practice. ForeachCareful Nursing could also contribute ontologically to clarifyingdimension shown in Table 1, its listed concepts indicate how it isthe meaning fundamental care has for patients’ experience of health.operationalised. All dimensions and concepts are proposed to beHealth and health care are mentioned frequently in the FOC Frame-important for fundamental care, however, the dual clinical practicework and a nursing-related definition of health is important. Thedimensions; the therapeutic milieu (TM) and practice competenceCareful Nursing definition of health as human flourishing gives addi-and excellence (PCE); are highlighted in this study because they aretional meaning to the patient–nurse mutual engagement in the needproposed as the core of Careful Nursing’s pragmatic response tofor, and provision of, fundamental care. In this engagement, patientsfundamental care erosion and omission.and nurses can share in seeking to flourish or achieve the highesthuman good; for patients, well-being despite frailty, illness and dis-3 THE C APA C ITY O F C AREF UL NURSINGTO ADD R E S S F UNDAME NTAL CAREability and for nurses the happiness of practicing nursing well. In3.1 Careful Nursing as a wholesophical assumptions. Spirituality is considered an unrecognised3.1.1 to care.The philosophyIn beginning the body of work underway to strengthen the conceptualisation and implementation of fundamental care, Kitson et al.Table 1, the three Careful Nursing philosophical principles arealigned to key elements of the FOC Framework that imply its philoassumption of the FOC Framework because of its holistic approach3.1.2 The professional practice model(2010) discuss the importance of ontology in this process. ToTable 1 also shows how the Careful Nursing professional practiceexplore the essential meaning of fundamental care and how itmodel’s four practice dimensions and their total of twenty conceptsrelates to human existence, Kitson et al. (2010) developed a list ofalign to the FOC Framework’s three dimensions and associated con-terms proposed to represent fundamental care as a philosophicalcepts (Feo et al., 2017). However, the details of how the respectiveconcept. The Careful Nursing philosophy, summarised in Table 1,Careful Nursing and FOC Framework concepts are defined andmay also contribute to the ontology of fundamental care because itimplemented differ in some ways. The Careful Nursing practiceexplores the nature of patients as human persons who need funda-model concepts are highlighted as values which motivate nurses andmental care and posits how fundamental care relates to their exis-are grounded in the Careful Nursing philosophical understanding oftence. For example, Careful Nursing views human persons ashuman persons and the spiritual in nursing, and on the assumptionunitary beings, highlighting the original meaning of holism, oftenthat at least some nurses have adopted the personal practice of still-overshadowed in nursing by interpretation of holism as an additionness each day, a practice which has a positive influence onof parts. While some fundamental care activities concern apparentnurses implement the TM and PCE dimension concepts (Donohoe &parts of patients, patients’ experience their care as unitary beingsDooley, 2017).howand the all-important nurse–patient relationship is experienced byThe first two professional practice model dimensions listed innurses and patients as a unitary process. Careful Nursing also pro-Table 1, the TM and PCE, are considered dual clinical practicevides an ontological explanation for inherent human dignity as adimensions because they complement one another closely in theircentral nursing value, why all human persons are equal inherentimplementation. A similar dual relationship is evident between thedignity, and how dignity relates to human existence. These contri-FOC Framework relationship established and integration of carebutions could be important, considering the central importance ofdimensions (Feo et al., 2017). The TM dimension of Careful Nursingholism and human dignity in the FOC Framework.reflects the traditionally established responsibility of nurses to takeCareful Nursing could contribute to exploring whether spiritualitythe lead in creating and managing the protective, healing quality ofhas meaning in fundamental care. Although spirituality is nothospital wards. In this respect, the TM dimension aligns with keyincluded in the FOC Framework, it is widely recognised as beingelements of care included in the FOC Framework’s third dimension,integral in holistic nursing practice (McSherry & Jamieson, 2013).context of care, focused on the importance of the environmentalMcSherry and Jamieson found that nurses express spirituality incontext within which nurses practice and their coordinating role inpractice through core values, particularly through attitudes and beha-supporting this context (Feo et al., 2017). The TM extends this coor-viours which reflect kindness, compassion and respect for humandinating role to a leading role.dignity, qualities particularly meaningful in fundamental care. Impor-The six TM concepts listed in Table 1 focus mainly on the sub-tantly, Careful Nursing is inclusive of all conceptions of spirituality;jective, relational aspects of nurses’ practice and aim to strengthenwhether nurses have a theist, polytheist or atheist worldview, all canand support nurses in themselves in order to enhance their capacityunderstand themselves as spiritual beings in their own wayto engage in healing relationships with one another, patients and(McSherry & Jamieson, 2013). Thus, all nurses could practice stillnessothers. These concepts align with key elements of care included indaily, a meditative practice considered essential to developingthe FOC Framework’s first dimension, relationship established, in

MEEHAN ET AL.which psychological and relational concepts are especially empha-skill in fostering safety and comfort, are TM-like relational conceptssised because of their importance in establishing meaningful clinicalthat are predominantly procedural. The aim of these two concepts isencounters between nurses and patients (Feo et al., 2017). The TMto enhance patients’ meaningful experience of procedural aspects ofconcepts align closely with the relational concepts of the FOCcare. The last two PCE concepts concerning patients’ supportive careFramework. However, as Kitson et al. (2014) observe, there isand health education, long-established nursing practice concerns, aredebate about whether nurses should focus on themselves or patientsalso important elements of the FOC Framework.in seeking to establish meaningful, relationships with patients. KitsonThe four central concepts listed for PCE dimension in Table 1et al. (2014) propose that focusing on a patient “requires a capabilitycomprise a critically important practice process which encompass anto effectively establish a therapeutic encounter with the patient” (p.expanded understanding of patient assessment, the complex process336), and it is nurses’ capability to establish this therapeutic encoun-of clinical reasoning and dec

sider fundamental nursing care as a crucial component of good . nursing practice. Aspects of care considered fundamental are those that focus on personal safety, human dignity, self-care and comfort within a healthcare context. Often these involve minimal technologi- cal intervention; or technology is used as a tool to assist nurses in .