Professional identity and patient-and-family centred care

Question 1

Empathy series - The Cleveland Clinic

Answer 1

• Making the human connection in healthcare
• If you hear what they hear, would you treat them any differently?
• Notion that you need to understand their complexities
• This understanding will make your caring better

Question 2

Client-centred care

Answer 2

• An approach in which clients are viewed as whole persons
• It is not merely about delivering services where the client is located
• Involves advocacy, empowerment and reporting the client’s autonomy, voice, self determinism and participation making

Question 3

Patient-and-family centred care

Answer 3

• An approach that recognizes the importance of family in a patient’s life and the importance of active involvement in planning and making decisions on health care, services and
  treatment and health system reform
• Key here is active involvement
  presenting the information
• You’re allowing the patient and family to make the decision

Question 4

Person-and-family centred care

Answer 4

• A person-and family-centred approach to care demonstrates certain practices that put the person and their family members at the centre of health care and services
• Respects and empowers individuals to be genuine partners with health- care providers for their health
• Overall umbrella term which include client and family, patient and family
• All about partnership

Question 5

“A patient’s voice” - Colleen’s story

Answer 5

“…decisions and actions that have, at their

heart, the welfare of patients and their families.”

Question 6

Eight dimensions of patient-centred care

Answer 6

• Research study conducted by Harvard medical school
• Get further understand of what matter to most people in the health care experience
• What behaviours would ensure a quality patient care experience; help them heal better and faster with decrease risk of returning

1) Patient’s Preferences
2) Emotional Support
3) Physical Comfort
4) Information and Education
5) Continuity and Transition
6) Coordination of Care
7) Access to Care
8) Family and Friends

Question 7

Respect for patient’s values, preferences and expressed needs

Answer 7

• Treating individuals with respect, in a way that maintains dignity and demonstrates sensitivity to cultural values.
• Keeping them informed
• Quality of life
• When one is in the dark one gets anxious, no control, feels devalued and suspicious
• Keeping them informed, even if it’s still waiting (acknowledging) goes a long way

Question 8

Emotional support and alleviation of fear/anxiety

Answer 8

• Anxiety over clinical status, treatment, & prognosis
• Anxiety over the impact of the illness on self & family
• Anxiety over the financial impact of the illness
• When it comes to anxiety or providing emotional support important to acknowledge that patients are in state of flux
• Presence is important; you don’t need ton know what to say, but need to be present to patient and family
• Acknowledgement of anxiety is important, can offer resources as needed - support groups, websites, referrals, etc.

Question 9

Physical comfort

Answer 9

• Pain management
• Help with activities of daily living
• Surroundings and hospital environment
• When a patient is in pain; they can’t think of anything else
• Adjust their pain management; help with ADLs as needed
• Is there something you can do in the hospital room that makes it more welcoming? whether is personal items, something to remind them of family and home
• Can also mean the flexibility with regards to visiting hours; most places have 24hr visiting hours (before was set hours)
• Now more open because they’re trying to accommodate families and various schedules

Question 10

Information and education

Answer 10

Complete information about:

• clinical status
• progress and prognosis
• processes of care
• Progress and prognosis of ongoing care; providing continuous updates
• Acknowledging what’s happening and let them know’ even if you’re still waiting for results

Question 11

Continuity and transition

Answer 11

• Information
• Coordination & planning
• Support
• Information is key
• Coordination and planning; discharge planning, transition of care, are things being said for them
• i.e. hip repair into rehab; is that all set, when is the ambulance coming, are they ready for them
  OR
• They’re going home; has there been a home inspection, have community resources been acknowledged and mobilized, what needs do they have and are they met?
• With discharge planning; usually in acute care there’s a template to go over when someone gets discharged;
• Need continuing support and that they’re not left on their own

Question 12

Coordination and integration of care

Answer 12

• Coordinating and integrating patient care and services to reduce feelings of fear and vulnerability
• Transitions of care is important
  unfortunately that’s where a lot of things get dropped
• Want transitions to be a smooth as possible so patient isn’t left vulnerable

Question 13

Access to care

Answer 13

• Access to multiple health setting and services, specialists and treatments
• Availability of transportation
• Scheduling and availability of appointments
• Are they able to get to where ever they need to get to?
• Understanding that maybe when they leave acute care for home services; need to be clear how home services schedule home visits
• i.e. Colleen’s story; not home bound but needed home care for wound services; put restrictions on her day waiting for care to arrive, wanted advanced schedule; company felt that if you need home care it’s because you’re home bound vs. option to get what she needed to get done at a nearby outpatient clinic - not told this upon discharge
• That’s our job - sharing information
• Give all the information so that the patient can make the decision for themselves
• If there are other options; it’s our job to know what those options are

Question 14

Involvement of family and friends

Answer 14

• Accommodating support persons
• Supporting family members as caregivers
• Involving family in decision making
• Support persons; visiting hours, arranging meetings when they are available and present
• What can we do to facilitate family and support system involvement in the decision
• Is there a way you can present this information to the team
• Start to form your own identity

Question 15

Challenged: patient’s perspectives (Colleen’s story)

Answer 15

1) Competing needs among players
- physicians, vs nurses, vs OP/PT, etc
- their priorities are not the same
- but should be the same because it’s all about the patient

2) Power imbalances
- be aware of a dominace of the biomedical practice

3) Focus on physical aspect of patient care
- focus on the disease as opposed to the person as a whole
- classifying pt as issue as opposed to name
- pt is a person and that comes first

4) Lack of awareness of patient presence
- talking about patient like they’re not there
- talking over them about them
- not addressing the patient
- easy to do; have that awareness

5) Lack of clear definition of what patient centred care means is a big challenge

Question 16

RNAO BPG Recommendations

Answer 16

• 2015
• How to best approach family and patient centred care
• How to promote this type of practice
• BPGs and organized through a nursing process formation

Question 17

BPG - Assessment

Answer 17

• Establish a therapeutic relationship; trusting and respectful partnership.
• Build empowering relationships; an active partner in their health care.
• Listen and seek insight into the whole person; learn their preferences for care
• Document information
• Trusting is key in order for the patient to trust you to speak for them and be their advocate

Question 18

BPG - Planning

Answer 18

• Develop a plan of care; in partnership with the person
• Engage with the person in a participatory model of decision making; right to choose the preferred interventions for their health
• Planning or priority setting
• Respecting the person’s right to choose is key
• One of the more difficult things as an RN; might not be what you would of chosen
• Ensure they all have the options and information for an informed decision
• Important to identify priorities; pt can be overwhelmed
  let them know your priorities; let them tell you their priorities
• Once priority is set by you; ask them what they want out of it
  then explore what that pt already knows; knowledge base, options already represented to them; questions they have
• This is a time where pt would ask “what would you do”; have to turn it back to the pt. “what do you want out of this, what is your priority”
• Probing these questions to help them come to their own decision
• Based on what they’re telling you; you can provide more resources
• Right to choose; the pt know themselves best; use them as a resource to know that the plan suits them

Question 19

BPG - Implementation

Answer 19

• Personalize the delivery of care and services
• Partner with the person to tailor strategies for self-management of care; based on the person’s characteristics and preferences for learning.
• individualizing the plan so that it is driven by the pt
• tailor strategies so that pt becomes self managed
• as you’re trying to understand their priorities and what they understand; learn how they best obtain knowledge
• i.e. phamplets, highlighting the need-to-know
• interventions are about advising, acknowledging what they know, accepting what they choose

Question 20

BPG - Evaluation

Answer 20

• Obtain feedback from the person to determine the person’s satisfaction with care and whether the care delivered was person-and family- centre.
• want constant continuous feedback from pt to determine satisfactoin

feedback addresses:

• were they treated as a partner
• were they respected
• did they feel safe in the environment to be able to state their priorities
• active participant and ongoing throughout the whole corse
• were all options provided based on evidence based and informed care
• surveys are hospital or unit based; handed out or filled out upon discharge

Question 21

BPG - Organizational recommendations

Answer 21

• Create an organizational culture that exemplifies its commitment to person-and family centred care.
• Design an environment that demonstrably improves the person’s experience of health care.
• Collect continuous feedback from the person to determine whether their experience with health care and services was person- and family- centred, and utilize this feedback to make improvements at all levels of the health system.
• beyond you; more about agency
• important to note; this importance has to be within the agency you work in
• important to think about when considering job opportunities
• will be in their vision mission statement - is family centred care there?
• improving person’s experience: unit specific; is the staff and healthcare team model the behaviour you want? are they collaborative with each other, are they respective to one another, do they model the statement?
• feedback is important because you want to know how the pt is feeling and their family

organization in a higher level needs to recognize this and understand
- as much as the healthcare team makes the pt a partner; the staff needs to feel valued and that their opinion matters

• staff appreciation days; staff surveys and feedback; are they involved in decision making at a higher level; opportunities in QA; do they feel respected and safe enough to get input about what working and not working
• ask for pt input; pt representation on the committee
• being pt and family centred takes flexibility with regards to schedule; is the organization (unit based) allowing you the flexibility in making these decisions
• i.e. use of pet therapy (RNAO document); are they allowed onto the unit; even if they’re worried about IPAC; how open are they to these different strategies in order to provide pt and family centred care
• while we want this to be a part of identity; it is not easy
• need to learn how to deal with the challenges of things; want to align values of organization with your personal values

Question 22

Role Formation - Ostogosky et al (2015)

Answer 22

• Study of accelerated baccalaureate students over their 15-month program
• Evolving role perception

1) Narrow understanding of role
– fake it until you make it

2) Increasing confidence in technical skills
- More comfortable “talking the talk” of nurses

3) Developing sense of empowerment and greater understanding of the importance of advocacy

4) Developing a sense of moral agency and expressed recognition of nurses privileged roles
- Internalize being a nurse instead of just doing nurse work

5) Refocus on skill mastery with the context of increased complexity
– “doing it all”

Question 23

Colleen’s story: what it patient and family centre care

Answer 23

• Patient and family centred care as decisions and actions that have, at their heart, the welfare of patient and their families
• Need to being with understanding that illness is a family affair; when one person get sick, it affect everyone in the family to some degree
• Effect is multiplied if illness of serious or chronic
• Families are often invaluable aid to healing through the emotional and practical support they provide to the patient
• Important to include them as highly regarded members of the care team
• Health care professionals make thousands of decisions leading to actions that affect outcomes
• Term “heart” suggest both centrality and compassion that goes beyond basic job description

Question 24

Colleen’s story: family as care recipients

Answer 24

• Family forms a crucible that contains most of our hopes, dreams, ambitions, insecurities, fears and so on
• Physical pain can, and often does, touch upon emotional pain – it puts us in touch with long-bruised psychological injuries, many of which happen within the context of family
• In addition to dealing with this physical distress, patient and family are often struggling with these issues as well
• One needs to consider how best to support the whole family lest we end up with more than one patient

Question 25

Colleen’s story: family as caregivers

Answer 25

• While family members are care recipients, they are also an important asset insofar as they provide invaluable service through their loving care
• The concepts of family as care recipients and valuable members of the care team is well understood in some areas of medicine: mainly child health and maternity
• Natural protectiveness about babies and children; understanding that they are dependent on family and that supporting the family is the right thing to do

Question 26

Colleen’s story: hits and misses

Answer 26

• Patient and family centred care is not always easily accomplished
• There are inevitably competing needs amongst players in a system as complex as healthcare
• Fine to say that patients and families need to be at the centre of all decisions; but the reality is that everybody has needs and there will always be practical restraints
• There is a power imbalance that exists in the patient-healthcare worker relationship; scared that if you push too hard there might be some consequences that will affect care
• There are “inconsistencies” in policy and procedure that are not satisfactory for either the patient or the healthcare workers
• At the very least the system lacks fairness when there is on option for negotiation
• Confusion regarding process leads to miscommunication, misunderstanding, and possible resentment; this only adds to everyone’s stress level
• Another constraint of the healthcare system is that most providers are focused almost exclusively on the physical aspect of the patient’s problem and do not ask about mood or whether the situation is difficult for the family
• Powerful when healthcare provider acknowledges their limitations
• In so many medical setting the way it works serves to compound and complicate whatever physical ailment the patient may be suffering by increasing distress
• Lack of awareness when talking to other staff in front of a patient (blatant lack of awareness of the patient’s presence)
• Healthcare providers need to understand that many of these procedures are not routine for patients are they are often fraught with anxiety
• Need to talk to the patient and tell them what is happening and ask for their understanding
• Think about what your waiting area looks like, what the privacy is like, signs being displayed, organization, explanations (pamphlets), encouraged to ask questions, current magazines, etc.

Question 27

Colleen’s story: ways to make the healthcare system better

Answer 27

• Our healthcare system gets its top marks for its handling of medical matters
• Care is not always very patient-and family centred
• Most HCP appear to be poorly trained on how to act or what to recommend when it comes to the psychological that arise for the patient and their family members
• The competing needs of others in the system often override the needs of the patients and their families
• Factors such as workload, bureaucracy, information that don’t mesh, lack of cohesion and consistency between work units, poor communication, lack of feedback, and desensitization of health care workers seem to compete with the ability to provide patient and family centred care
• Some changes may take years to implement while other can be altered by shifts in attitudes

Question 28

Colleen’s story: changes that can be done today

Answer 28

• Welcome families and acknowledge their roles as both recipient and caregiver
• Educate yourself about resources that exist to support patient and their families emotional, psychological and spiritual needs
• Recognized the inherent power imbalance that exists in healthcare and consciously work to overcome it by treating patients as partners
• Adopt a service attitude: explanations, understanding, apologies
• See patients as individuals; remain attentive to their presence and needs; make eye contact and actively listen
• Understand that ill health takes away ones sense of control and makes people vulnerable; help by keeping patients informed, providing information and empowering them to make choices
• Confirm and follow through on agreements
• Protect patients dignity and privacy
• Provide simple comforts
• Remember that your interaction with the patient and their family member is likely only one stop along the path that may be long, circuitous, disjointed and full of emotions
• The decisions you make on how to act have a profound effect on this journey
• Interconnectivity of the patient and family; work with them as partners
• This is how patents and family remain at the heart of healthcare