CONNECTING WITH THE PATIENT IN NINETY SECONDS: CONSISTENT, CONCISE DIALOGUE FOSTERS AN INVALUABLE PATIENT CONNECTION AND IMPROVES

PATIENT SATISFACTION Lynne Route daVinci Consulting Vince Pelote daVinci Consulting Julianne Mazzawi, Brigham & Womens Hospital

Introduction Two things are irrefutable in todays healthcare system: nurses are the cornerstones of patient satisfaction and nurses are overworked. They face a constant battle to achieve a balance between patient care needs and the growing quality performance standards. We can no longer hope that the nurse-to-patient ratios will improve and solve this conundrum. Nor can we expect nurses to work harder. We need to build in time-efficient structures that will focus on what nurses excel at, and ultimately crowd out the current time management problems. Our program, Connecting With The Patient In 90 Seconds has proved successful in meeting both challenges. Background Studies have documented a high correlation between nursing care and patient satisfaction. Patients who are satisfied with their nursing care are generally satisfied with their care in general and, are more likely to understand, comply and benefit from the services provided by all healthcare providers. In a comprehensive, large-scale study conducted by Press Ganey Associates, 1,007,612 patients surveyed indicated that they would recommend a hospital based on the nursing staff response to their needs. We need to find a way to enable our nurses to care for patients.

Caring Caring is an essential component of the nursing profession. Taking the time to form caring relationships with patients and family members is a central tenet of the nursing profession and the pivotal aspect of their success. Nurses who are caring possess four senses: compassion and concern for others; doing for others what they cannot do for themselves; using appropriate knowledge and skill; and, competence in providing the right care at the right time, in the right way. When patients feel they are listened to, respected, and seen as an individual, they feel they are uniquely cared for and are most amenable to comply and benefit from prescribed therapies. In a nurse patient relationship, connecting with the patient is an important element of the experience. To create this imperative connection, the nurse listens with empathy and intent and the patient feels that they are the most important thing to that nurse in that moment. Establishing presence is the pivotal ingredient to making this connection, especially within the time constraints nurses face. Consider two scenarios. In the first scenario the nurse enters the patient room with her stethoscope, chart, mobile computer, blood pressure cuff, thermometer and pulse oximeter. She greets the patient with a smile and introduces herself while gathering data. She spends 5 minutes with this task. How do you feel as a patient? In the second scenario the nurse enters the room with no equipment not even a stethoscope. She greets the patient with a warm

smile, makes eye contact and addresses the patient by name. She asks about any concerns or needs. She spends about 90 seconds. How do you feel as a patient? Making another person feel that they are important is the foundation to successful relationships. In day-to-day relationships this is apparent because the other person really is important to us. This foundation is not, however, necessarily based on the amount of time we spend. In fact, being present, can reach the same means. Nurses can establish therapeutic relationships with their patients without spending large amounts of time. The Connection We posit four key factors in the cycle of successful nurse-patient connections: positive view of self; positive view of patient; connecting with the patient; and, receiving positive patient feedback. (See figure 1). Positive Attribution Cycle
daVinci Consulting

Positive View: Self as Clinician

Positive Patient Feedback

Clinician/ Patient

Positive View: Patient

Connect with Patient Figure 1

Within this model, there exists a basic equation: Positive View of Self + Positive View of Patient = Connection. This connection is what drives the cycle. In addition to the basic equation, if you factor in positive feedback from the patient, the clinicians positive view of self increases and perpetuates the cycle. Clinicians that are trained in methods to look for the best in others and possess the tools to do so can quickly elicit and identify

strengths and tendencies in others thus forming a positive first impression of the patient. In the Positive Attribution Cycle, this quickly translates into a connection between the nurse and the patient. When this connection is genuine, by the nurse being truly present, they receive more instantaneous positive feedback from the patient. Positive patient feedback is important to nurses, but unfortunately it does not often come until late in the relationship or at the end of the hospital stay. Immediate positive feedback drives the positive view of self and pushes the connection through the entire cycle again. Each time one passes through the cycle their appreciation for others become richer and they are able to connect on a deeper level. For the nurse, this continues to build and each patient interaction becomes deeper, richer, more genuine, and occurs more quickly. Positives In everyone there exists positives. In order to make a nurse-patient connection, one needs to find and draw out these positives in others. We help the nurse explore their own means to appreciating the positives in themselves and others by using Appreciative Inquiry. The basic tenet in David Cooperiders Theory of Appreciative Inquiry, is that a situation will move in the direction of the first questions asked. Once the connection is moving in a positive direction the nurse can stand in the patients shoes and draw out strengths. This allows the nurse to create possibilities of caring needs throughout their time together. Presence Even more desirable than creating possibilities is co-creating possibilities. We help nurses understand the art and skill of presence in patient interactions by introducing the work of Senge and Scharmer et al in their book Presence. Nurse-patient connections are not merely a collection of parts. The relationship is continually growing

and changing along with their elements to continuously recreate itself. In Connecting With a Patient in Ninety Seconds, presence is the ability to see, sense, and realize new possibilitieswithin the nursepatient connection. This enhances the genuineness of the interaction and helps the connecting become more beneficial for the nurse as well as the patient. Both parties in the nurse-patient connection appreciate each other and can work together to co-create possibilities for meeting future patient needs. This co-creation increases patient satisfaction. In the Co-Creating Caring Connections Model (See figure 2) nurses and their patients will anticipate future requests and co-create a plan for meeting those needs in advance. Co-Creating Caring Connections
Adapted from the work of Otto Sharmer

Downloading
attentive hearing

= Capturing information

II

Precise Listening
open-minded

= Noticing Differences

III

Empathetic Listening
open-hearted

= Connecting Emotionally

IV Generative Listening open-willed

= Co-Creating Possibilities
Figure 2

With large nurse: patient ratios and busy time schedules, nurses often only have time to listen attentively to patients and capture information. They keep an open mind and are skilled at recognizing needs and anticipating problems. Often the patient does not know that the nurse was really listening and has no idea that the nurse has anticipated needs. The caring connection is not there. Empathetic and generative listening generally requires taking

more time with the patient to establish a relationship and explore what their needs might be. However, if you combine appreciating positives with being present in the moment, the establishing trust and respect part of the relationship is established instantaneously. The Positive Attribution Cycle (figure 1) begins to spin. The emotional connection is established within seconds and the nurse is able to share with the patient her conclusions from listening attentively and precisely. Since the emotional connection has already been establish, they are able to co-create possibilities for their caring needs. We have found that the use of call lights has decreased when nurses have implemented this program. So now we know that appreciating positives and being present can jumpstart a therapeutic relationship when key elements are in place. How can we be sure we remember to use these elements with each patient interaction? Nurses need to understand the concepts, see examples of success and practice the skills until they become part of their routine. We accomplish this through scripting. Scripting We help clients build in the structure and space for appreciating positives in others by using scripting. Scripting is a set of statements and or actions that include all the necessary components for sending the right message to those we communicate with. Scripts are drafted and built upon the positive successes that already exist between nurses and patients. It is a tool for establishing a genuine relationship with patients and sending a consistent message. The art and act of scripting also utilizes and builds upon the years of individual staff experience often an underused and wasted resource. A Service Excellence initiative to address these issues was implemented at Brigham & Womens Hospital in Boston, in a program titled, Meet and Greet. The program assisted nurses in developing a script for

making an initial connection with patients at the beginning of each shift. The scripts included introducing themselves to the patient, inquiring about patient needs and closing on a positive note. The program dramatically improved patient satisfaction scores. We have gotten lots of positive feedback from patients during the past few months, said Nurse Manager Julianne Mazzawi, RN. A staff nurse at Brigham & Womens Hospital writes, We now feel better because we know that if we focus on a couple of things that are important to the patient, then our scores will better reflect our overall effort. Summary Nurses are the central figures in patients healthcare experiences. The connection between the nurse and the patient has a direct impact on the quality of nursing care. Quality nursing care, in turn, is known to directly increase patient satisfaction scores. Therefore, by providing nurses with an effective means to improve their patient connections we will afford patients better quality care and improve their satisfaction. Although the link between nursing care and patient satisfaction is not a new idea, this approach to strengthening that link is different. Instead of focusing direct efforts on improving quality we focus on improving the connection which positively impacts the equation in both directions. In addition to the approach, the strategy and methodology is novel. Rather than teaching nurses a new and better way to do their job, we examine what they already do well and help them isolate the must have pieces for a therapeutic relationship. Time does not have to be a barrier to the nurse-patient connection. It may take less than 30 seconds for a nurse to go through the script, but it is effective for patients. They remember that the initial contact included an introduction and genuine concern for their needs. The

information they receive is clear, and they feel listened to. As a result, patients feel more confident in the care they will receive. They expect competence from their caregivers and become more involved in their care. And finally, nurses feel better about what they do and the organization as a whole benefits. References Leebov, Wendy; Scott, Gail; and Olson, Lolma. Achieving Impressive Customer Service: Strategies for the Health Care Manager. JosseyBass, Inc. 1998 Stubblefield, Al. Baptist Health Care, Journey to Excellence: Creating a Culture that WOWs!, Baptist Healthcare Leadership Institute. 2004 Cooperrider, David; Stavros, Jackie; and Whitney, Diana. Appreciative Inquiry Handbook. Lakeshore Communications, 2003 Cooperrider, David; Whitney, Diana. Appreciative Inquiry: A Positive Revolution in Change. Barrett-Koehler, 1999 Senge, Peter; Scharmer, C. Otto; Jaworski, Joseph; Flowers, Betty Sue. Presence: Human Purpose and the Filed of the Future. Society for Organizational Learning. 2004 Biographical Sketches Lynne Route, RN BSN MEd Lynne Route is a founding partner with daVinci Consulting. As an executive coach, instructional designer, and clinical educator, she puts into practice adult learning theories on a daily basis. Lynnes expertise is translating theories, methods, and practices into practical and user friendly tools that help others improve outcomes. She works closely with a variety of clients to help them develop and implement individualized leaning plans as well as

facilitating and leading teams to achieve extraordinary results. During her 20 years of experience in various clinical settings, Lynne has both led and facilitated projects around health care service, safety, leadership development, strategic planning, and team facilitation. Her Master's Degree in Instructional Design compliments her nursing background by bringing expertise in technical writing, information mapping, appreciative inquiry, and needs analysis into the healthcare arena. Prior to establishing her own firm, Lynne had implemented an innovative redesign of nursing education in two community hospitals including developing an innovative preceptor/internship program and supported the design of a pay for performance program. As a frequent coach of new college graduates, hospital nursing staff, and individuals in transition, Lynne finds the knowledge of experiential learning, personality type, learning styles, behavioral competencies, and social motive invaluable on helping others discover their strengths. Currently, Lynne is conducting research with her partner, Vince Pelote, for a best practices book to be published by Jones & Bartlett in 2006, Healthcare Leadership Masterpieces: Lessons from the Field. Vince Pelote, MBA Vince Pelote is a founding partner with daVinci Consulting. He is a senior organizational development professional, author, researcher, and speaker. His professional experience includes coaching physicians and nurse leaders on performance improvement and building high-performing, multidisciplinary teams. Vince has extensive experience building competency models for the selection, development and 360-feedback of healthcare leaders. As the previous Director of the Center for Organizational Learning at UMass Memorial Medical Center, Vince provided

executive coaching for 26 senior executives and academic chairs and designed leadership development strategies and programs for 250 clinical and non-clinical leaders. Vince is an invited research member of the Society for Organizational Learning (SoL), was the lead researcher for a major leadershiptraining grant that was funded by the American Society for Training & Development (ASTD) and Hay/McBer, and also a member of the steering committee for a leadership benchmarking initiative for the University Health System Consortium. Currently, Vince is conducting research with his partner, Lynne Route for a best practices book to be published by Jones & Bartlett in 2006, Healthcare Leadership Masterpieces: Lessons from the Field. Julianne Mazzawi, RN BSN Julianne is a Nurse Manager at Brigham and Womens Hospital in Boston, MA. Julianne is currently responsible and accountable for the overall clinical and administrative leadership of a thirty bed antenatal and postpartum unit in collaboration with medical leadership. She supervises over seventy staff members that include RNs, LPNs and support personnel. Julianne has been a registered nurse for 25 years. Her clinical background has primarily been in Womens and Newborn health with an emphasis on Neonatal nursing. Major accomplishments have included the planning, implementation, and evaluation of a quality initiative to improve patient and staff satisfaction. In addition to her work at Brigham and Womens Hospital she has hosted a local cable television program The Need to Know Show which provides questions and answers to parent and adolescents.