Relationship-Based Care

From Advance for Nurses

When a patient enters a hospital, she enters an alien environment. 

Her personal things, even her clothes, are set aside. She is given to wear a billowy gown that is not merely unflattering but starkly revealing if one's free hand isn't vigilant about keeping it cinched.

Inside this linoleum landscape of wheelchairs and rolling beds, where strangers in scrubs politely jab and weigh and probe her, the only haven that offers her a modicum of quiet in which to gather her thoughts and to reclaim herself, to semi-relax, to take stock, or just to escape into the beams of an innocuous sitcom floating overhead - the only personal space in this impersonal world is that humble but all-important retreat, the patient room.

Respecting the sanctity of the patient room is the first lesson Pam White, RN, gives when teaching the basics of relationship-based care (RBC).nurse to patient therapeutic relationship

"When I talk to nurses, I tell them 'We all have busy lives taking care of many patients, but before you walk across the threshold of a patient's room, pause, take a deep breath, let other things go and prepare to focus on that patient's needs,'" said White, director of nursing administration at Mayo Clinic Health System in Eau Claire, WI. "I always reinforce the need for them to reintroduce themselves to each patient every time they enter the room."

RBC - a philosophy based on honoring and respecting your relationship with your patients, your co-workers and yourself - is fast emerging as the care delivery model of necessity.

Experts say respecting patients will become more and more important as healthcare adopts its new culture of accountability. Reimbursement will hinge, in part, on patient satisfaction.

A Way of Being

RBC as a concept appeared in 2000 and coalesced in 2004 with the publication of Relationship-Based Care: A Model for Transforming Practice by Creative Health Care Management Inc., Minneapolis.

"It's a model, a philosophy, a framework and a way of being," said Mary Koloroutis, RN, who co-authored and edited that text. "RBC creates a methodology for aligning values and operations within a healthcare system so clinicians can establish relationships with patients," Koloroutis explained. 

Finding time to develop relationships with patients isn't easy for nurses, though. 

"Time is a nurse's greatest challenge," Koloroutis acknowledged. 

"You are dealing with large volumes of patients with highly complex medical needs," she said. "We don't have a long time to spend with a patient. It could be just 5 minutes at the bedside to learn about the person and plan their care."

However short, interpersonal time with patients is crucial for a successful outcome. 

"The role of the primary nurse is to understand who this patient is, and what it will take to prepare her and her loved ones to take ownership for her own care after discharge," Koloroutis said.

Family members "will be the village surrounding the patient, so they need to be every bit as supported as the patient is," she added. 

"The likelihood that a plan of care will be followed increases with their learning and understanding."

HCAHPS Survey

Communicating with patients is becoming as vital as vital signs. Officials from the Center for Medicare & Medicaid Services care so much what patients think they instituted the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

HCAHPS asks patients to rate their hospital stays on a scale of one to five through a series of questions such as: How well did doctors and nurses communicate with you? How well was your pain managed? How clean was the hospital? How quiet?

"As of 2013, there will be reimbursement attached to HCAPS scores, so this is a strong push right now and part of why the patient experience is so potent and important," Koloroutis said.

ThedaCare, an integrated care delivery system in northeastern Wisconsin, increased its patient satisfaction scores by working with a firm called Simpler Consulting to adopt Toyota-inspired "lean" initiatives to streamline its processes and allow nurses to spend more time with patients.

For example, it implemented a variation of a Toyota production strategy called "kanban," so nurses have all the supplies they need at their fingertips.

"We have designed patient rooms so that 90 percent of all nursing supplies are stocked by a central stocking person, using the kanban system," said ThedaCare CEO Emeritus John Toussaint, MD"Nurses are at the bedside nearly all the time. Medications are delivered directly to rooms in portable supply cabinets called nurse servers. There are no central nursing stations. They've all been eliminated."

Thanks to such changes, 95 percent of ThedaCare patients in 2011 gave top approval ratings when asked to assess their stay.

Eye-to-Eye Care

More time spent at the bedside "brings you to the heart of nursing," declared White, who instructs her nurses to sit down when interacting with patients.

"We typically stand up and over a patient," she said. "But research shows if you sit down and speak with them eye-to-eye, patients feel you spend more time with them - even if the amount of time you spend is the same."

She continued: "As a nurse, my needs for the patient are important, but they may differ from the patient's needs. For example, patients need to walk so many times a day, take so many pills. But those are not necessarily the goals of patients. We determine those goals simply by asking them. They could say 'I would like my hair washed,' or 'I would like to call my granddaughter.' Those things are important to them."

For hospitals thinking about instituting RBC, Koloroutis had this advice:

"Recognize that transformation is not a quick fix. It is a cultural evolution. Some aspects of RBC are already alive and well in every organization. Use them and build on that success. Commit to a 3-5 year process."

Healthcare workers, she concluded, "can grow weary of hearing about new programs. They'll ask, 'Is this another flavor of the month?' I say no. This is a way to get back to the basics, back to the care and service of patients."

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