By Susan Sportsman, PhD, RN, ANEF, FAAN
Recently, three of my friends have described a health care experience of a loved one as they transitioned from care in an acute setting to rehabilitation, and ultimately home. The patient in each of these situations was elderly, and although each ultimately returned to their home in satisfactory condition, the journey through the health care system was traumatizing for the patient and their families. The themes in each of these stories included poor communication with the patient and the family regarding all aspects of care, inappropriate medication administration, and inadequate preparation for transitions from one level of care to another. One of my friends described plans for transition from the acute care setting as centered totally on the convenience of the health care team, with little regarding for the concerns of the patient or the family. In each situation, my friends described unkind treatment—in some cases, the communication could certainly be described as abusive—and a feeling of frustration that no one was listening to either the patient or the family members.
These stories have haunted me—I felt sad that the health care experience was so poor for my friends’ families and embarrassed that the system in which I have worked for so many years failed their patients and families in such a fundamental way. I recognize that three examples of poor care in a period of a month is not an indictment of the entire health care system. Certainly, intertwined in my friends’ stories were examples of caregivers who were kind, who listened, and who advocated for the patient. However, since each of these examples happened to families with sufficient knowledge and resources to provide support for their family members, I expect that families across the country, many with fewer resources and knowledge of the health care system than my friends, are experiencing similar problems.
The Problem of Poor Quality of Care
The problem of poor health care quality is not new. In 2001, the Institute of Medicine (now the National Academies of Medicine) published a consensus study, Crossing the Quality Chasm: A New Health System for the 21st Century, highlighting problems in the U.S. health system and strategies for improvement. This examination led to the identification of six domains of health care quality, including Patient-Centered Care, 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.”
Nursing has participated in the movement to improve the quality of care through a variety of initiatives. For example, the Quality and Safety Education for Nurses (QSEN) initiative identifies competencies and related knowledge, skills, and attitudes (KSAs) needed by all nurses (and health professionals in general) to continuously improve the quality and safety of health care. One of the six QSEN competencies is Patient-Centered Care, defined as recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and need. As you are aware, QSEN Competencies are integrated in most nursing curricula.
With this emphasis on quality and patient-centered care, why do examples of poor care like my friends’ experiences exist? Paul Rothman, MD, Dean of the School of Medicine at John Hopkins University, suggests several reasons that compassionate, patient-centered care might be difficult to implement on an individual basis. Below are some influencing reasons framed for nursing practice.
- The amount of highly technical information required to care for patients
- The time constraints of a busy nursing practice
- The distancing effect of increasingly sophisticated technologies
- Increasing bureaucracy and complexity of the health care system
- Burnout or disillusionment of providers
These influencing reasons were identified before the COVID-19 pandemic. Imagine how much more devastating these factors, particularly burnout and disillusionment, may be now!
The Role of Nurse Educators
Nurse educators serve as facilitators of patient- or family-centered care by helping students develop the knowledge, skills, and attitudes necessary to focus on the patient or family. While we cannot solve all the structural problems of the U.S. health care system, we can focus on providing students with relevant learning experiences that emphasize the patient’s and family’s perception of needs. The QSEN website provides a plethora of teaching-learning strategies (many of which focus specifically on Patient Centered Care) that you might use to emphasize determining and acting upon the patient’s (or family’s) perceived needs.
Simplicity is often the key to integrating concepts into action, so I would suggest that two concepts, Kindness and Listening, may be at the core of Patient-Centered Care. How then, can we help students integrate the use of kindness and listening into their nursing practice? Here are some strategies that I believe have merit as we help students to value these concepts enough to overcome the systematic organizational and structural processes that serve as barriers to implementation.
- Integrate the development of valuing kindness and listening into Student Learning Outcomes and course objectives.
- Require students to think about what behaviors indicate kindness and effective listening.
- In teaching-learning activities throughout the curriculum, ask students to consider ways that kindness and listening (and acting upon what is heard) is experienced by patients, families, and colleagues.
- Emphasize the need for kindness when working through case studies in class or in simulation, as well as in actual clinical experience. Post-clinical conferences which focus on examples of kindness in care (or lack thereof) and the impact of these actions on patient and family experiences make for excellent discussion.
- Provide multiple opportunities over the course of the curriculum, in class, lab and simulation, and clinical experiences, to practice listening. Ask students to analyze what they heard and what action they would take based upon what they heard. Does what they heard and acted upon match the patient/family response and expectations? If not, why not? How might understanding the patient/family’s perception inform the nurse’s actions? Such an activity will allow students to make adjustments to their listening skills on an ongoing basis.
- As practicing nurses, students will supervise others providing patient care. Thus, giving students the opportunity to provide feedback to others regarding the extent to which they demonstrate kindness and listening in specific situations will improve their supervisory skills.
- Although one nurse may not be able to change the structural complexity of health care, teaching-learning activities should focus on analysis of the impact of barriers in health care to determine ways kindness and listening can help patients and families to have a positive experience in health care.
There are many other strategies we might use to prepare students to effectively implement patient- and family-centered care, some of which I will discuss in subsequent blogs and presentations. However, I challenge each of us to consider ways that the values of kindness and listening in caring for patients can be emphasized in our teaching-learning activities and student evaluations. I look forward to hearing from you about your experiences.
Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. https://doi.org/10.17226/10027. Accessed, 2021.
Rothman, P. (2016) Teaching Patient- and Family-Centered Care: 21st Century Medicine that is respectful and compassionate. John Hopkins Medicine. News and Publications. March 24. https://www.hopkinsmedicine.org/news/articles/teaching-patient–and-family-centered-care. Accessed, 2021.