The information, opinions expressed in this presentation is solely those of the author/presenter and not those of The Metro Health System or any affiliated company or organization. The Metro Health System does not guarantee the accuracy or reliability of the information provided here in. The call to provide meaningful high quality care driven by the needs of patients and their families are forcing stake holders to rethink care delivery. Federal guidelines, Congress and non-federal stakeholders (Institute of Medicine, Centers for Medicare & Medicaid, National Quality Strategy three aims, Joint Commission) are forcing hospitals and health systems to make strategic changes to ensure compliancy, efficiency, and quality improvement for cost effective care. Nurses spend the most time caring for patients and have the most influence than any other healthcare givers in relation to patient outcomes. The patient is the focus for everything we do. This presentation explores strategies to improve patient satisfaction by understanding the patient perspective throughout the care continuum and improvements that could be made for staff and the patient to make it a more efficient process. How staff should engage with the patient during admission, treatment and discharge.

Keywords: caring, caring behaviors, collaborative management, communication, cost-effective care, culture of safety, holistic caring, human caring, interdisciplinary care, nurse-patient relationship, nurse’s touch, patient engagement, patient safety, patient perspective, quality of care, patient satisfaction, quality of care, safe staffing, person, environment, health, nursing

1. Understand the patient perspective throughout the care continuum.
2. Explore how staff should engage with the patient during admission, treatment, discharge.
3. Discuss the improvements that could be made for staff and the patient to make it a more efficient process.

A 61 year old male patient came into the ER with an acute episode of CHF, SOB for 2weeks wanting to ride it out because of his social situation.

1. Complaints: Syncopal episodes while cutting grass, SOB on min exertion, CP 3/10, increased swelling    of bilat lower extremities (knees to toes) 4+ pitting edema, fatigue, poor sleep, depression.
2. Diagnosis: Afib, CHF, Acute on chronic Systolic/Diastolic heart failure (NYHA Class 3), renal failure Ascites.
3. Medical Hx: CAD, MI (2002, 2005), CVA-2008 (no deficit), Pulm edema, Afib, HTN, renal failure, COPD   (former smoker x 40years), sacro-iliac joint disfunction – L side.

Interdisciplinary care

1. Medical Goals of Care: Medical mgmt, IVI diuretic drip, stabilize-get back to baseline, ongoing monitoring/testing; possibly paracentesis.
2. Consultations: Psychiatry - evaluate depression & assess for suicidal ideation.
3. Social Work: Work on financial resources & living arrangements.
4. Case Manager: Oversees all issues related to care.
5. Respiratory Therapist: Work on SOB issues, plan of care to improve work of breathing.

Patient perspective throughout the care continuum

1. PT/OT & Cardiac Rehab consults - was evaluated, not appropriate for either.
2. Psychosocial: Stressed about his personal situation, declining health-struggles with ADLs, poor dietary intake-not following CHF dietary recommendation because of financial issues; struggled with depression-some thoughts of suicide, (had) at one time while listening to sad music contemplated suicide (owned a gun), called a friend-told him how he was feeling & friend took the gun away & kept it.

This patient “just wanted to get better & go home”, but he had no “home” to go to; find a way to get some financial help & get his life back on track…

Why is patient satisfaction so important?

Let’s recap

1. The Institute of Medicine (IOM), 1999 sentinel report, To Err is Human: Building a Safer Health System,made national headlines with its report on medical errors and patient safety issues. The IOM made recommendations for improving patient safety (developing a culture of safety would improve outcomes). Congress, the AHRQ with its federal partners, non-federal stakeholders started the process for a remedy to the patient safety issues…
2. The National Quality Strategy three aims include: Better Care, Healthy People/Healthy Communities, and Affordable Care.¹
3. The Joint Commission standards regarding “Behaviors that undermine a culture of safety”² essentially recommends employing strategies that promote a culture of safety for improved patient outcomes.
4. The American Association of Colleges of Nursing (AACN) answering the call for improved patient safety/outcomes, quality of care: recommends DNP nurses must be well-prepared to utilize evidence-based practices, synthesize evidence, implement into practice and effectively utilize health systems and technology, (2006) – Essentially be “knowledge equipped”.

The common goal: safe care, high quality care, cost effective care = improved outcomes.³

 Improving the patient care experience, population’s health and reducing costs…

1. Are the three aims of the National Quality Strategy developed from the Institute for Healthcare Improvement goals in its quality improvement efforts for national health care reform?
2. Patient evaluations of their care are reflected in patient satisfaction scores.
3. Patient satisfaction is the driver of health care delivery in the 21^stcentury and as such experts suggest we must consider this factor when designing strategies to improve quality of care.
4. Nurses spend the most time caring for patients and have the most influence than any other healthcare givers in relation to patient outcomes.

Nurse-patient relationship & it’s effects on quality of care

The nurse-patient relationship begins from the moment of that first meeting, the patient requiring care to heal, attain better health, and the nurse as provider of therapeutic care advocates for the patient for good outcomes.

1. Caringis a key quality integral to the profession of nursing. If we do not communicate caring how can the patients we are caring for feel it, (perceive it)?
2. There is a significant behavioral component in “caring attitudes” and error prevention.
3. There is a connection between nurse-expressed empathy & patient outcomes.⁴
4. Strategies for error-prevention align with evidence-based practices.

The patient is central to (focus of) everything we do in healthcare - this means involving the patient and designated family in the decision-making process by being considerate, communicating and collaborating, respecting their wishes.¹

Nurse-patient relationship… (theoretical basis-nursing is an “art and science”)

We’ve gone from “a nurse’s touch” to “high tech” mode, utilizing modern technology - essentially from a patient centered approach to spending increasing amounts of time manipulating technological applications; somewhere along the way we have lost the humanistic aspect perceived in patient satisfaction scores as lack of caring in attitudes/behaviors.

1. Caring can be effectively demonstrated and practiced only interpersonally.
2. Caring consists of carative factors that result in the satisfaction of certain human needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept the patient as he or she is now, as well as what he or she may become.
5. A caring environment is one that offers the development of potential while allowing the patient to choose the best action for him or herself at a given point in time.
6. A science of caring is complementary to the science of curing.
7. The practice of caring is central to nursing.⁵

Let’s put the caring back into clinical practice (i believe “caring” in nursing is related to our behaviors in the clinical environment)

1. Caringhas always been the core value of nursing – the foundation for Florence Nightingale’s work more than a century ago.
2. Nursing is a caring profession; it takes a nurse’s “touch” with a blend of “caring behaviors” to create a healing/helping environment for our patients.
3. We cannot fake a “caring attitude”. Patients are astute, besides families are present & recognize the nurses, caregivers whom are truly 
4. Using caring behaviors and effective communication supports therapeutic relationships, as such helps the patient achieve harmony in mind, body, and spirit.⁶

How should staff engage with the patient? (it takes a nurse’s “touch”)

1. Be authentic, empathetic, kind, compassionate, professional.
2. Engage with the patient, listen attentively (be fully present); Validate their feelings, complaints.
3. Patients describe interaction, interpersonal aspects of communication demonstrated in a caring manner is important to them – attributes of quality of care.⁴
4. Treat the pain/discomfort; follow-up to re-evaluate, document (caring, accountability, responsibility)
5. Involve the patient in the decision making process.
6. Answer their questions, follow-up when you say you will.
7. Q 1 hourly rounding - the 5 P’s.

How should staff engage with the patient?... (when patients are sick they are at their most vulnerable)

1. Communication between patient/caregivers, amongst disciplines, provide information & facilitate moving from one area to the next, for tests, consultations, change in plan of care, transfers (eg. to nursing home).
2. Communicate/Teaching - review discharge instructions at level of patient’s understanding, medication reconciliation, follow-up appointments, what to do if all does not go well. Make sure patients understand what you are telling them (decreases readmission).
3. Case manager to make sure all things are in place before discharge.

Remember its all about the patient not about you, me or our egos!

There is a nursing theory behind all this! (Jean Watson’s theory on human caring/transpersonal caring (2006, 2008))

1. Nursing’s phenomena of interest relates to the person, environment, health and nursing.

When I think of caring, I think of Jean Watson’s.^5,8 Theory on Human Caring, can be used as a guide and applied to many different aspects of nursing.
Her belief: holistic health care is central to the practice of nursing, the person is cared for holistically (the human aspect of caring) for which she explicates caring is related to our behaviors; caring comes from “within”.

2. Watson’s⁵ Science of Caring has 4 major concepts: human being, health, environment/ society, and nursing. The nursing model’s focus: health promotion, preventing illness, caring for the sick, health restoration.⁵

Watson’s theory on caring is an adaptable framework that can be used widely from bedside nursing, relationships with patients, co- workers, interdisciplinary team to nursing management and leadership and our personal lives.

Overcoming barriers to make this a more efficient process (improvements that could be made for staff and patients…)

1. Clearly defined Inclusion/Exclusion criteria.
2. Clear protocols for the Obs patients.
3. MD assigned specifically for OBS unit (efficiency).
4. Communication – keep links open and ongoing (Interdisciplinary, nurse-patient), inform patients of change in plans, tests, procedures, possible transfer/discharge.
5. Utilize evidence-based practices to promote best outcomes - Nurses are well trained, prepared & familiar with OBS protocols - ongoing education.
6. Have a “system” for moving patients quickly from ER to OBS unit (avoid overcrowding ER). Have a protocol in place for moving patients seamlessly from Obs unit to inpatient care units, ensure physician admission orders written & change of status done - affects reimbursement (efficiency).

Overcoming barriers to make this a more efficient process (improvements that could be made for staff and patients)

1. Safer staffing - how can nurses be expected to carry out their duties & employ a caring manner in short-staffed high-census situations (eg. in a high volume area - unit off ED).
2. Adequate staffing - Case managers to handle case loads - initiate discharge planning “on admission” - all things aligned for D/C - decrease likelihood of readmissions (efficiency).
3. Case Management rounds early on OBS patients to start planning ahead; If patient is for discharge – decision/determination should be made early on rather than “last minute” & notify Case Managers asap (efficiency).
4. If OBS patient suddenly becomes sicker support/experienced staff is in place to act quickly & initiate higher level of care.
5. Quality of care is provided/maintained just like in the inpatient units.
6. Communication board – facilitates caring & open communication with the patient & family.

Reflection from a nurse’s perspective (bear in mind the challenges nurse’s face on a daily basis: don’t forget about us!!)

According to Watson & Foster⁸ the health care system of the 21^st century has brought the nursing profession’s struggle to the forefront; nurses are torn between the human caring model of nursing that attracted them to the profession in the first place and the task oriented biomedical model, institutional demands that consumes their practice time. Nurses are caught in the middle of this fast paced “tug-o-war” of health care delivery that leaves little time to form an authentic rapport with the patient, an essential component of caring practices for the best outcomes of health and well-being.

The perception of lack of caring is a common complaint in today’s health care system reflected in the poor reviews received from patients’ evaluations of their care, a driver for reimbursement. What is going on in the working environment also contributes significantly to this negative perception and patient outcomes. Duffield & Diers et al.⁹ suggest more complex environment also impacts patient outcomes - more medical consequences. Duffield & Diers et al⁹ reports in their literature review that nurse staffing (numbers and skill mix), workload, and work environment had a direct relationship with patient outcomes; as well, higher RN staffing was associated with lower incidence of mortality, failure to rescue, cardiac arrest, and lowered risk of nosocomial infections (pneumonia, urinary tract infection, sepsis, shock, and falls) in which length of stay was also decreased.^10–17

Person, environment, health, nursing

The domain of nursing has always been the nurse, the patient the situation and environment in which they find themselves. This situation, the health of the patient is the very purpose for the nurse/patient relationship. Nursing has always prided itself on being a caring profession, human caring the nurse’s personal touch cannot be replaced by technology. Watson’s work reflects both the empirical (science) and aesthetic (art) “ways of knowing”. Her model can be used as a guide for integrating theory, evidence and professional practice and easily adapted because of its humanism aspect - healing arts, therapeutic relationships and caring values. The call is to provide meaningful high quality care driven by the needs of patients and their families forcing stakeholders to rethink care delivery. Patient outcome is measured by length of stay and mortality indicators.

To make this work

We have to look at what we must do today to change the current environment. We must identify challenges, work with the opportunities, be creative, adapt, “stay the course” until we find the acceptable solutions to achieve that excellence in “patient centered care” (safe high quality cost effective care, & good outcomes).

None.

The authors declare that there are no conflicts of interest.

None.

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