By Debra Wood, RN, contributor
While it seems intuitive that nursing care should center on the patient, completing all the necessary clinical and administrative tasks sometimes takes precedence over listening to the patient and tailoring care to his or her priorities. Now many hospitals have launched initiatives to put the patient and family first in an effort to improve patient satisfaction scores.
Deborah L. Krueger, MSN, RN, CNRN, has witnessed the success of relationship-based care at Wake Forest University Baptist Medical Center, and attributes the success to the one-to-one connection that the nurses have with their patients.
“We have gotten to be so technologically advanced and centered,” said Deborah L. Krueger, MSN, RN, CNRN, interim Magnet program director at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. “Sitting at the bedside on a busy day—when you need to pass meds, chart in the computer — is something we have gotten away from—the use of touch. I came out of nursing school 30 years ago and was graded on the type of backrub I gave.”
The Institute of Medicine recommended in Crossing the Quality Chasm: A New Health System for the 21st Century, published in March 2001, that facilities adapt patient-centered care, which it defined as providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
“There are two pieces of quality and one is outcomes,” said Karen Sweeney, RN, MSN, chief nursing executive at Alegent Health Lakeside Hospital in Omaha, Nebraska. “Our community, patients and families expect positive outcomes. But the piece they haven’t always gotten is the customer care, taking care of the whole person, which includes the family or significant others.”
Patient-centered care involves creating a culture that accepts people for who they are and where they are in life, and meeting their needs at that point, Sweeney said. That approach meshes well with the health system’s mission to care for the body, mind and spirit of patients.
“Our nurses like patient-centered care and the freedom they have to impact the patient experience,” said Sweeney, acknowledging that at first nurses had a difficult time adjusting to families being present at all hours. Now nurses make up beds for family members. Patient satisfaction ranges in the 98th to 99th percentile and the nurse vacancy rate is only 4 percent.
Karen Sweeney, RN, MSN, reported that patient-centered care is working very well at Alegent Health Lakeside Hospital in Omaha, Nebraska.
“You cannot get high patient satisfaction without a philosophy of patient-centered care,” said Lillee Gelinas, RN, BSN, MSN, FAAN, chief nursing officer at VHA, a national health care alliance that helps hospitals with performance improvement. “When you focus the organization on the patient and the staff on the patient, the processes change and activities change.”
Nurses begin to focus on the patient not the tasks.
Wake Forest piloted relationship-based care about a year ago and has now rolled it out systemwide through the professional development council.
“Relationship-based care seems very successful,” Krueger said. “The original three units are all above the targeted goals, into the 95th, 96th percentile.”
Nurses at Wake Forest give reports in the patient’s room and the incoming nurses set goals with patients at the start of shift. They ask patients to verbalize the one thing they want to work on over the course of the next 12 hours. The nurse writes that goal on a white board in the room. Everyone on the team focuses on accomplishing the goal, be it walking in the hall, shampooing hair or visiting with the patient’s dog on the parking deck.
The nurses or nursing assistants round on patients every hour to check on pain, position and bathroom needs. On some floors, nursing assistants pass trays, so they can assist the patient immediately.
With relationship-based care, it is important that the staff demonstrate caring behaviors. For example, if a nurse says, “I will get a cup of coffee or blanket for you,” the caregiver must keep the promise. The nurse should make eye contact and show the patient how important he or she is.
“Patients are not an interruption to our work. They are our work,” Krueger says. “It’s a one-to-one connection of how we care for the patient we are involved with.”
MCGHealth in Augusta, Georgia, began the patient and family-centered journey in 1993 and has pioneered open visitation, even in its intensive care units. It has found that involving patients in their care empowers patients and encourages them to actively engage in their care.
When The Heart Hospital Baylor Plano in Plano, Texas, opened two year ago, it did so with a patient-centered model, incorporating the patients’ cultural traditions, personal preferences and lifestyle into its care plans.
“It’s not a task-driven world anymore,” said Melissa Winter, RN, MSN, vice president of patient care services and chief nursing officer at the Heart Hospital Baylor Plano. “We instill a culture of thinking above and beyond starting an IV. It’s talking to the patient, telling him why it may hurt and explaining the procedure.”
The Heart Hospital has open visitation so families can participate in the care and rounds. Patient satisfaction has remained at 99 percent since it opened.
Vanderbilt University Hospital and Clinics in Nashville, Tennessee, also has implemented open visitation. Nurses engage patients and families in the patients’ care.
“Once you let visitors sit at the bedside and know what’s going on, oftentimes they don’t stay, because they’re comfortable going home,” said Terrell Smith, MSN, RN, director of patient/family-centered care at Vanderbilt.
Transitioning to patient-centered care, she said, requires nurses to welcome families and to become more transparent in the way they give care and provide information. Nurses can ask families to remain quiet for a short period of time while adjusting drips or providing other care that require full concentration.
Patients who have experienced an in-hospital stay at Vanderbilt assist the facility in planning for better care delivery. Patients may round on units with administrators pointing out issues hospital leaders may overlook, such as possible privacy breeches. The hospital also involves patients and families in selection of furnishings for new units.
After researching the literature and receiving feedback from its patients and an advisory board, Coral Springs Medical Center in Coral Springs Florida implemented a patient and family-centered model a few months ago. The move represents a major shift to involve families in the care process, recognizing that family members can be helpful in sharing information the care team needs.
“It has to do with teaching, educating and keeping patients up to date about what is going on and giving them a say in what is happening to them,” said Kim Graham RN, MBA, CNAA, chief nursing officer at Coral Springs. “We’re trying to shift our care approach to being inclusive to those people in the patient’s life they want to be included.”
Gelinas anticipates patient-centered care and the resulting improvements that can occur in patient satisfaction scores will drive more hospitals to adapt the model, now that the Centers for Medicare & Medicaid Services measures patients’ perspectives of hospital care with the Hospital Consumer Assessment Healthcare Providers and Systems Hospital Survey.
“[Putting] the patient at the center of what we do is not only the right thing to do, it’s a must thing to do, because reimbursement is now tied to it,” Gelinas said. “Hospitals that chose not to invest the time, energy and strategy in the relationship side of care are hurting their balance sheet.”
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