Creating a Culture of Patient- and Family-Centered Care
by Rebecca Proch
During rounds in the Weinberg Intensive Care Unit (WICU), nurse clinician Rhonda Wyskiel, BSN, RN, noticed that visiting family members often sat in the corner in patients’ rooms, reading or watching television. She thought they seemed anxious and uncertain about what to do while she provided care. “I started asking them to assist me, like turning the patient or applying lotion. Families responded to that.”
Wyskiel saw an opportunity to more formally involve families in their loved ones’ care. She began conversations with the unit’s nurses, developing an engagement exercise that asked them to picture themselves in the hospital bed and list the top ten things they’d want their healthcare providers to do. “Overwhelmingly, I heard having the families at the bedside and engaged in their care,” she says. Next, she talked to patients’ families and asked if they were helping with any aspects of care, and what they’d be interested in doing. Most families, she found, were very interested in being engaged but were not currently helping the nurses.
The outcome of Wyskiel’s project is a family involvement “menu,” a laminated checklist placed in every room of the WICU, which describes ways family members can be involved. The bedside nurse reviews the list with them to answer any questions, and the family can mark anything they feel comfortable doing, such as walking with the patient, feeding them, or assisting with grooming. When a patient’s family is engaged in this way, notes Wyskiel, they are often better able to notice any changes in condition and are therefore more likely to bring them to a nurse’s or physician’s attention.
“It gives us new insight into what’s normal for that patient,” she says. “We used to think about patient safety as separate from family-centered care, but now we see having the family present is tied to safety.”
“When you include patients and their families at the center of care,” says Deborah Baker, DNP ’11, MSN ’97, Accel. ’92, CRNP, director of nursing in surgery, “it’s clear that everything is interdependent—patient safety, patient comfort, patient- and family-centered decision making.”
Baker, who has taken the lead on a gap analysis project to assess patient- and family-centered care in the Department of Surgery, and, specifically, the degree to which patients are included in discussions of their care plans, points out that there are many aspects to a truly patient-centered culture. Some are logistic: Is there sufficient signage? Are the bed chairs provided for visitors comfortable? “Based on patient-satisfaction surveys, we discovered that patients were often confused about who was in their room—was that a nurse, another healthcare provider, or support staff?” she says. “By simply standardizing staff apparel, we will be able to eliminate a lot of confusion.”
For Margie Burnett, BSN, RN, CNRN, nurse clinician on Meyer 8 and clinical informatics lead in the Department of Neuroscience Nursing, one practical discovery made by the Family Engagement Committee she chaired was to ensure all patients received the same information upon admission. The solution was to develop a four-minute patient-orientation video shown to all new patients.
Burnett’s inspiration for forming the Committee, and its purpose, was to learn what prevented nursing staff from engaging with patients’ families at the bedside. While time constraints were a factor—and the video was partly intended to help streamline the tasks involved in orienting new patients—another obstacle was anxiety. “Nurses worried about not having the answer to a family member’s question,” says Burnett. “They were concerned about handling complaints, wondering if they’d be prepared for everything they might encounter.”
She feels it’s critical to support nursing staff as they’re encouraged to engage with patients’ families, to foster those connections, and to evaluate work flow to make it easy for staff to balance technical work with the caring aspects of nursing. Wyskiel points out that she was able to implement the family involvement menu partly because she’s in a unit that’s been actively committed to patient- and family-centered care since it opened a decade ago.
Baker emphasizes the need to address the total culture of a unit in order to put patients at the center of care. “We spent a year just sharing these core concepts of patient- and family-centered care,” she says. “We had to be using the same vernacular. What does it mean to say respect and dignity are important to patient care? Now, we’re focused more on behaviors. What does it look like to be patient-centered in the course of your work?”
A retreat on the “Language of Caring,” held in September, addressed an important aspect of patient-centered behaviors: communication style. Attended by nursing leaders and nurse “champions” who will be peer trainers for their units, the full-day intensive workshop led participants through discussion, role plays, and interactive learning to allow them to practice speaking “from their hearts and heads,” says Joann Ioannou, DNP ’09, MSN ’05, MBA, RN, assistant director of medical nursing, who worked with Baker on the gap analysis survey. “They’re learning to say things like, ‘I’m sorry you’re in pain right now. Tell me about the pain so we can discuss it with your physician.’ It’s not giving the patient different information, just phrasing it in a more empathic way.”
“Our communication skills have to be as strong as our clinical expertise,” says Baker. “This is evidence-based practice, a set of seven or eight tools that allow us to develop a culture of understanding.”
Burnett sums up what’s at the heart of that culture: “Every visitor is somehow important in a patient’s life. We need to understand who they are to the patient, and we need to build trust and a rapport,” she says. “It’s those things that make the patient experience personal.”