Patient-centered Care: Part 1

You hear about it in all areas of healthcare lately. The move from disease-centered care to patient and family-centered care has taken over the healthcare industry. As patients and families have become more savvy healthcare consumers the direction of healthcare has also changed.

The Institute of Medicine defines patient-centeredness as healthcare that establishes a partnership among practitioners, patients and their families. Its purpose is to ensure that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they require to make decisions and participate in their own care. The days of keeping diagnoses, prognoses, and treatment plans confidential for “professional eyes only” are gone. Engaging the patient and family in their care is paramount to patient-centeredness.

There are many components to patient-centered care; my hospital has adopted several of these. But it has not gone as smoothly as one might have hoped. It seems that this concept would be readily embraced by healthcare providers. But even when presented with the research and evidence behind the effectiveness of patient-centered care, nurses have not embraced the idea.

The components that we have adopted include bedside reporting: team nursing that includes safety huddles and hourly rounding on patients. Each of these components has benefit for the patient and the nurse. Bedside reporting includes giving a full report—not at the nursing station or report room—but, as the name suggests, at the patient bedside. The research shows that patients like to be included in the report process. It helps them to feel confident that all the nurses caring for them are on the same page and everyone knows the plan. Patients have said that it’s nice not to have to repeat themselves with each new nurse assigned to their care, and even nicer to know that the nurse is well informed of their treatment plan. Patient-centered care also allows the patient to set goals for the day as well as the duration of their hospitalization. Healthcare professionals can help a patient verbalize their wishes and set short- and long-term goals. In addition, bedside reporting forces nurses to be more accountable for the care they give. If you know someone is going to be right next to you in front of the patient checking IV fluids, medications given, and tasks completed, you are certainly more apt to make sure they are all correct and well.

Finally, it has been shown that bedside reporting actually shortens the time taken for report and allows people to get out on time more consistently.

But opposition was strong to this new concept. Part of the issue is that this new model doesn’t allow for a lot of socialization time during the time that patient report is supposed to be happening. Socialization certainly is an important part of the way a nursing unit functions, but now we have to be more cognizant of appropriate times for that. Another aspect that has gone away is the ability to complain about difficult patient or family situations. Again, although it is important to discuss difficult issues that arise with patients and families in order to provide the best possible care, we are forced, with this model, to do that in a more constructive rather than destructive manner.

But even with all of that, there was one thing that I’ve heard nurses say that I never would have guessed: they just don’t want to talk about the patient in front of the patient. They feel uncomfortable saying a patient has stage IV colon cancer in front of that patient. They don’t want to say a patient is having a difficult time with pain or nausea. They don’t want to talk about how the patient’s condition has declined since their admission or just how weak, debilitated or fatigued the patient has become. I was amazed at this revelation.

It was surprising that nurses would think a patient didn’t know these things already. Certainly they know they have cancer; they are coming to us for treatment. Certainly they know they have pain; it’s their pain. Certainly they know that their condition is declining. Maybe it’s more our discomfort with admitting that we haven’t been able to fix the situation. Maybe it’s more our discomfort with knowing we might not be able to cure this patient and that we will be a part of the end of their life journey. Maybe that’s what we need to focus on and talk about before we can really make patient centered care work effectively.

Bedside reporting is only one component in our model of patient centered care. There are also nursing teams with safety huddles and hourly rounds. Stay tuned to the next installment of this blog for more on those components.