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Is Polite “Doing For” Really Enough? January 17, 2009

Posted by mariemanthey in Professional Practice.
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One of the consultants at Creative Healthcare Management recently sent me this description, written while her daughter was receiving care at a major medical center in the Midwest. My question to readers is this: if you see yourself in this description, what can you do to “be with” rather than just “do for” your patients?  Or does anyone want to explain why “doing for” is really enough? Responses are welcome.

“Care has been fine, but not extraordinary.  They  received Magnet designation in 2007 and have a great deal of pride.  Everyone asks each time they leave the room if there is anything else we need — and they have clearly received customer service training (AIDET).  The manager just visited our room and was gracious and emphasizing that we let them know if there is anything they can do.  The trouble is, they are doing … But there is no “curiosity”, no whole picture perspective — when asked the nurses rarely know the plan — I rarely see a therapeutic process; the nurse comes in to give meds, check if there is anything needed.  So very nice, polite — but detached.  I found myself charting my perspective using the boundary diagram from my article in the field guide on boundaries for the therapeutic relationship. Underinvolvement is the main descriptor I would use.

We have had some lovely exceptions. The pharmacist, who we know from the transplant team, spent 20 minutes with us yesterday making sure that we had all questions answered and providing some background information. A physician sat at eye level and began by asking Alicia about her and what this means in her life right now.  She was able to talk about school, and it went on from there.  He was extremely encouraging — reminding us that it has always been the case that my daughter would outlive the life of her kidney, and that we will take each challenge as it comes.  We do not have the biopsy results yet, but if it is early rejection we are dealing with, that can be treated and the kidney can continue to serve her.

I try to stay clear and unemotional about the lack of professional consciousness I see in so many nurses.  I feel so sad, because when they only focus on the things they are doing, they lose sight of the human being and the power of their care and they lose the amazing satisfaction that would come from a connection.  I am clear that it would take no more time to connect and involve the patient than to come in and out doing for the patient.  I believe the nurses on this unit like their work, and that transplant nursing would be extraordinarily satisfying.  So, the nursing care is fine.  The question is, is that enough?  I have nothing I would complain about, and I believe most patients would say the care was very good because the staff is responsive.  My daughter asked why so many people (nurse,  physician, nurse practitioner) give her the same information as though she is hearing it for the first time.  Not one nurse has asked Alicia about herself or what this hospitalization means to her — what she might be worrying about — what is most important to her.  This morning as I walked for my coffee I noticed no one looked up anywhere through the hallways to the cafe, so I began initiating and spoke to people even when they were looking at the ground.  I got responses in return and I am teaching my daughter how to be the initiator of relationships so that she can be seen and receive what she needs.  I have also had to work with her to monitor her responses (she got rather hysterical when experiencing pain and not feeling heard by the nurse — who I understand called her a whiner– I was out of the room at the time) — I followed up with the nurse and worked to help her feel safe and less defensive, we came up with an approach to Alicia’s pain and by the end of the day it was managed.  I had to intervene though, because I could see that the nurse was irritated with her and I want Alicia to learn how to care for relationships so she does not get written off.  She will need to be an expert as she will be needing care all of her life. “

Comments»

1. Chris - January 19, 2009

Thank you for this post. I wonder how much of caregiver’s “doing for” is a result of what many in the working world do – go into autopilot and just get the job done, etc. I know as a worker, that I get into task mode and phone calls can seem to be interuptions. I have learned that when I open myself to the person on the other end of the line – I am transformed. My work is about relationships and when I forget that, I am indeed lost.

2. Mike Skobba - January 28, 2009

This post is a great reminder and call to action for me. As a nurse manager of a large unit in a Magnet hospital I am challenged everyday to create an atmosphere where my colleagues can go beyond ‘doing for’ the patients and families to a place of connection and relationships. All the fruits of our profession will only be realized when we have spaces and places where the relationship between nurse and patient/family are encouraged to grow and deepen. For me, this means being present to know my colleagues in a way that I can model, encourage, and even push them to risk and then realize the reward of being fully present with their patients. I believe much of my work is to create a healty work enviroment where we can examine and grow ourselves and our professional relationships so we can use this place of safety to step out and be fully present in our profession. Nurses cannot sustain a level of satisfaction or effectiveness if they stay and live in a practice described as ‘doing for’. I see my job as keeping our focus on the power of the relationship between the nurse and patient because when we keep that at our center we can more easily build a meaningful connection to the patient. Organizationally this can be a great challenge for the nurse leader as the majority of my work can easily become task and administrative focused. I must be vigilant to keep my eye on the reason I am there which is to build and facilitate healthy relationships and connections that can support our focus on the patient. A big job and most days difficult to see even incremental movement in the right direction.

3. Lisa Ruth-Sahd - March 7, 2009

This post is a great reminder and call to action for me as well. As a nurse educator, of very beginning nursing students, I am constantly challenged to create an atmosphere where my students recognize the need to form relationships with their assigned patients and recognize the importance of holistic, patient-focused care. New students are so consumed with getting their tasks completed that they forget about the patient being at the heart of their care. Encouraging them to move beyond ‘doing for’ the patients and families to a place of connection and relationships is the challenging aspect of my job. For me, this means being present to act as a role model and encourage them to realize the reward of being fully present with their patients. This was especially wonderful for me to read and be reminded of a key element in patient care that I must instill in my students.

mariemanthey - April 22, 2009

Lisa…thanks so much for your comments. That is exactly why I asked permission of my colleague to share it on the blog. In our work on Relationship Based Care….we emphasize a few basics….like the concept of ‘intentional presence’….or in other words connecting with the patient rather than the tasks first…..and another thing I really like to encourage is having nurses, right after report, visit each patient and sit down at the bedside. This cannot be accomplished standing up….it just doesn’t work. Spend a few minutes (2-3) talking to the patient about the day’s activities, remembering to ask them what they would like to see happen on this day. This interaction will do more to focus a nurse’s attention on the person of the patient that any other single use of a few minutes. It lasts all day!

4. Mary Koloroutis - May 8, 2009

It is with gratitude that I read the comments this morning. I spoke with a nurse leader yesterday who is inspiring and leading her entire organization in a cultural transformation to Relationship Based Care. She was excited to share the following stories as evidence that transformation is happening. In addition to her stories from the bedside, she also was grateful to report that their Press Ganey scores have shifted from a sad low of the 7th percentile to the 81st percentile in the past few months. Transformation is happening at both a macro (cultural) and micro (individual) level. It is both complex and simple. The complexity is in transforming the culture in the huge industralized system that of health care. A huge machine that is driven by processes, systems, regulations, etc and has a life force of its own. The simplicity is that at the end of the day it is about seeing and touching and caring for people who are suffering, vulnerable and in need.

Story 1: The patient and family were not on the same page. It was a busy day, yet I stopped and with intention and purpose sat down with the family and patient; I listened to their story, and asked what was most important and what they wanted accomplished for the day. I was busy and not in the room alot. But at the end of the day, the son sought me out and said he really appreciated what I had done. That no one else had taken the time to be with them in that way and help them calm down and get clearer about what was needed. In the past, I would have done the same thing — go into the room and find out what was going and see how I could help — but it would not have with the intention, purpose, and presence. I would not have sat down and listened, I would have “listened on the run” taking care of the doing and with one ear out the door. I am getting the difference.

Story 2. I am practical and have to admit I am not quite sure how much I “buy in” to this Relationship Based Care stuff. But, I had a friend who was hospitalized a few weeks ago. She had been in our hospital a couple of years ago and did not want to return. She told me that something is clearly different. During this hospitalization nobody talked over her, nobody complained to her about how busy they were or said they didn’t have time. Something is happening.

Something is happening. Blessings to all. Mary


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