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Accentuating the Positive

What things should always occur when patients interact with healthcare providers?

One day last fall, Anna Ivy Park, BSN, RN-BC, OCN, a staff nurse who works in the hematology-oncology special care unit at Dartmouth-Hitchcock Medical Center (D-H) in Lebanon, NH, was busy assessing a newly admitted patient. Suddenly, a woman burst into the patient's room in a state of great distress.

"I thought, 'Where did she come from? Who is she?'" Park recalls.

The woman was a member of the patient's family, and she was very upset. She didn't know that her loved one had been transferred to this room, and she had been trying frantically to find him.

It took Park several minutes, but by using reassuring behaviors such as touch therapy, listening and making eye contact, she was able to calm the woman down.

For Park, the incident was a learning experience - in every sense of the term.

The "family member" was actually an actor, the "patient" was a simulation mannequin and the whole scenario is part of an innovative pilot research project designed to teach D-H's frontline clinical nurses a set of behaviors that will enhance their ability to provide patient- and family-centered care (PFCC).

The project is funded by a $50,000 challenge grant from the Picker Institute and is part of Picker's trademarked Always Events initiative.

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The Opposite of Never

Most nurses are familiar with the concept of Never Events.

The term, introduced by the National Quality Forum, refers to serious, preventable adverse events that should never occur in the delivery of healthcare, such as medication errors and wrong-site surgery.

But as the old song goes, you've got to accentuate the positive, not just eliminate the negative.

In 2010 the Picker Institute, an independent nonprofit organization dedicated to the advancement of patient-centered care, developed the complementary principle of "Always Events," i.e., positive aspects of the patient and family experience that should always occur when patients interact with healthcare providers.

To showcase the value of Always Events and collect best practices that can be disseminated nationally, Picker is currently funding demonstration projects at 21 leading hospitals and healthcare organizations.

Not surprisingly, many of these studies involve nurses, because of their unique role as not only caregivers but patient advocates.

The 12-month project at D-H, which began in May 2011, is a prime example. It focuses on training nurses to communicate more effectively with patients and families by making sure their interactions always include behaviors such as:

  • introducing themselves and explaining the reason why they are there;

  • addressing and referring to patients by the name they choose;

  • welcoming and respecting all people defined by the patient as family;

  • encouraging patient and family involvement in decision making.

"Communication is key to patient safety, quality and the overall patient experience," said Suzanne Beyea, PhD, RN, FAAN, co-leader of the D-H research team. "It's very common for healthcare providers to assume we're communicating effectively without really hearing back from the voice of the patient or family."

MAKING CONTACT: Dartmouth-Hitchcock Medical Center staff nurse Anna Ivy Park, BSN, RN-BC, OCN, practices patient-centered communication skills with a standardized patient as part of the hospital's Always Events training project. photo by Mark Washburn, courtesy Dartmouth-Hitchcock Medical Center

Eventful Orientation

Delivering care that's sensitive to the needs of both patients and their families is an integral part of the culture at Dartmouth-Hitchcock, a 369-bed academic medical center and acute-care referral hospital serving many rural communities in New Hampshire, Vermont and surrounding states.

D-H is also a Magnet facility whose nursing shared governance mission is to develop all nurses as leaders in providing and promoting PFCC.

The nursing department partners extensively with volunteer patient-family advisors (PFAs) from local communities, whose role is to obtain feedback from patients and families about their care experience and make sure those perspectives are heard by clinical staff.

In the demonstration project, D-H is incorporating the Always Events training into its nationally recognized Experienced Nurse Orientation program, which combines classroom sessions with experiential learning in a patient simulation lab, the Patient Safety Training Center.

As of January 2012, approximately 30 newly hired experienced RNs have completed Always Events education as part of their overall orientation to the hospital.

"The focus of the grant," Beyea explained, "is to see whether or not we could embed the Always Events curriculum into ongoing training in a reliable and valid manner."

The curriculum begins with a didactic session, led by PFAs and social workers, in which the nurses discuss what PFCC means to them.

"We ask them if they've had any experiences, good or bad, with family members," said Nancy Bassett, one of three PFAs involved with the project. "Then I give examples from interviews I've had with patients and families on the unit, which the nurses find very interesting."

Making It Real

Next comes the experiential training, which gives the nurses an opportunity to learn firsthand what patient- and family-centered communication looks and sounds like.

Individual nurse learners participate in several simulation scenarios, such as the "distressed family member" scenario and a code scenario. Meanwhile, in another room, the PFAs are observing them in real time.

SHARING EXPERIENCES: The Always Events curriculum at Dartmouth-Hitchcock Medical Center begins with a classroom session where nurses discuss their personal and professional experiences with patient- and family-centered care. Here social worker Toni LaMonica, MSW, guides the conversation. photo by Mark Washburn, courtesy Dartmouth-Hitchcock Medical Center

"We're looking for and evaluating the behaviors we have defined as patient- and family-centered," said Frances Todd, MSN, RN, director of the Patient Safety Training Center.

"For example, are the nurses treating the family with respect? Are they explaining what's going on? Are they giving the patient and family members a chance to ask questions?"

Another part of the PFAs' job is to facilitate peer-learning discussions among the other nurses in the orientation group, who are also observing the simulations.

According to PFA Meg Seely, "We try to not say much and see what the nurses come up with themselves. They often comment on the technical aspects of the nursing procedures. But we also encourage them to think about what they've learned about PFCC and the Always Events earlier in the training."

After each scenario, the whole group participates in a debriefing, with both PFAs and nurses providing feedback.

For instance, said Bassett, "they may notice that the nurse in the scenario didn't leave the foot of the bed while he or she was talking to the patient.

"During the observation, they'll say, 'Why isn't she going up to the side of the bed where she can make closer eye contact?' Then in the debriefing, they'll gently tell the nurse, 'You said all the right things, but something about your body language wasn't conveying your sincerity or level of comfort.'"

Do It Yourself

Healthcare organizations don't have to be Picker grant recipients to implement Always Events initiatives at their own institutions to improve the quality of their patient care experience.

The program's website provides resources to help you get started, such as examples of Always Events, webinars, videos of model programs - including the one at D-H - and strategies for incorporating Always Events into a variety of care settings, such as ambulatory care, pediatrics and long-term care.

But does it really work?

While the D-H researchers say it's too early to measure their project's results, the anecdotal evidence is exciting.

"We're hearing from our unit-based preceptors and PFAs that patients are saying, 'I have this new nurse who has really connected with me and my family,'" Beyea noted.

"And the nurses who have completed the training overwhelmingly report that it has really helped them understand what it means to provide PFCC: that it can be something as simple as always introducing themselves to the patient, and to each and every family member."

Pam Chwedyk is a frequent contributor to ADVANCE.

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