What a Nurse Taught Me about Checklists and the Doctor-Patient Relationship

Screen Shot 2014-06-02 at 6.14.14 PMShe hugged one daughter who was “a hugger” and avoided embracing the other daughter who wasn’t. She sat with the family, listened and supported them in their anguish.

Schwartz gave comfort to the family because she cares and has true empathy.

There’s no way that we could train her to care more. Yet too often, efforts by hospitals to improve the patient and family experience approach it purely as a technical challenge.

For instance, we provide scripts to health care professionals to help them navigate various situations, from what to say when walking into a patient’s room to service recovery when things haven’t gone as they wished.

We try to identify and broadly implement the practices that will best enhance patient experiences, such as rounding hourly in patient rooms to address pain management, bathroom visits and other needs.

These are well-intentioned and needed efforts to improve the patient experience. But they could very well backfire if we don’t simultaneously embrace the human element and tap into clinicians’ desire to be empathic healers and comforters.

I fear that we send the wrong message, for instance, when we simply hand detailed scripts to staff in low-performing units or hospitals. Subtly, we’re labeling them as someone who does not care adequately for patients, and that they need to be taught how to do better.

Here, we say, mouth these words and the patient and loved ones will believe that you care. Likewise, hourly rounding and other interventions will not be effective if we simply treat them as a box to be checked off.

Words are important, of course. And caregivers can certainly learn how to insert key words and phrases into their conversations with patients to show they care and open the door to more meaningful dialogue. However, health care is too complex and nuanced for a lengthy script to be useful.

Clinicians witness the extreme highs and lows of other people’s lives, yet like any job this becomes our everyday reality, with mundane documentation, meetings and bureaucracy. It’s easy to forget that “just like me” someone may be in the hospital for the first time, that their family members must take off work for an extended period of time to be with them, or that the outcome of their stay is a turning point in their family’s future.

When we lose sight of the connection with our common humanity, with our patients’ suffering, we can fail to connect with our patients’ needs for empathy as well as healing.  We can get so caught up in the tasks that we need to do that we don’t stop to care. While we think we are still delivering good care, patients perceive our frenzied state and decide it’s wiser not to raise valid concerns.

What can help us to reverse this?

There’s more than a single thing, but one powerful approach involves coaching caregivers on their interactions with patients and loved ones. On a surgical unit in The Johns Hopkins Hospital, scores on HCAHPS—the national post-discharge survey sent to patients after discharge—were far below national averages. In their written responses, some patients said that they felt unwelcome to raise concerns, or that staff made them feel like a burden.

The low scores understandably got the hospital’s attention, leading to a partnership between the unit and Service Excellence department. As part of their response, Debbie Miller, project administrator in Service Excellence, began to listen in on their conversations with patients from outside of the patient rooms. When these caregivers emerged, Miller would coach them, providing feedback and suggesting what they might have done to improve the patient experience.

At times, Miller would guide them on how to rephrase what they had said so that patients felt better about their experience and more welcome to share concerns. She showed them how they could incorporate key phrases into their discussions (such as What is your goal today? or I’m listening to what you’re telling me…) to reinforce their concern for the patient as a person.

She also put together a list of 12 key (and simple) behaviors  to be incorporated into every encounter, such as introducing themselves by name, asking the patients how they want to be addressed and use that name, making frequent eye contact, and allowing patients to tell stories without interruption.

At its heart, she says, her approach was about getting caregivers to shift their focus when interacting with patients, from completing tasks to having meaningful conversations that forge a personal connection and build trust. And it doesn’t have to take long, she says. The little things, such as taking time to ask if a patient needs a bed bath or teeth brushed, can have a big impact.

The unit’s scores on HCAHPS grew quickly, and impressively. Within several months, scores typically ranked well above the 90th percentile. In April 2014, they were in the 97th. “My admission was the best experience ever,” write one patient in the survey. “My visitors and family enjoyed the helpfulness of the employees,” wrote another.

Clinicians sometimes need a reminder of our common humanity with patients, allowing us to realize that “just like me” they might be worried, scared or suffering. If we see the connections to patients and find a way to tap into our inner strength as caregivers, empathy will flourish and we can figure out the best way to respond, as Schwartz did.

We will know that we should introduce ourselves by name, smile, ask the patient what name they like to be called, look them in the eye, and ask them if there’s anything we can do for them. Hourly rounding will not seem a burden, but rather a blessing.

Clinicians will make rounds in patient’s rooms and conduct shift reports at the bedside, to make sure that patients and family members are involved in the care plan, know what’s going on and are able to ask questions. We will recognize the nuances of a patient’s situation that no script could prepare us for.

Peter Pronovost, MD, PhD is director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and a practicing anesthesiologist and critical care physician dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts appear occasionally on THCB and on his own blog, Points from Pronovost.

8 replies »

  1. Alex, I agree this is a great idea for every medical center. Empathy is something that cannot be taught in nursing or medical school. For instance, I am a nurse that works with several nursing students. One particular experience that I recall was when a patient passed away and the family was very upset. I comforted the family by spending time with them listening to their stories about their loved one and providing emotional & spiritual support. After the family had left the nursing student told me “Wow…I am impressed! How did you do that and how do I learn to do just what you did when I have a patient pass away?” I believe it is a learned behavior but some may never completely learn how to be empathetic.

  2. Great topic! As healthcare providers we sometimes forget what it would be like to be “on the other side” as a patient. It is easy to get caught up in the daily tasks and forget that our patients is someone’s mother, father, sister, brother, etc. As a nurse I always try to place myself in my patients shoes and/or the families shoes when caring for them. This helps with connecting with my patients/families and building trusting relationships.

  3. as a recent patient, admitted due to chest pain, I can say that had the above protocol been followed, I would have not gone through the 24 hour panic, yes panic, attack. No one above the lovely CNA’s cared one way or another about any history I could have shared with them. The attitude was shut up, we have to do this. I tried to tell them that when in anxiety, my veins constrict, so they needed to get me calm first. They thought that idea was hysterical, and kept digging into my arms and veins, chasing rolling collapsed veins around undaer my skin. They had no luck, and finally had to call the “IV team”, who knew the problem well, found a vein in mid arm.mthen, I got a hospitalist. Never again. Can you say, cold, stranger, disinterested in patient, only interested in data. My doctor then revealed she was unaffiliated. I left there at 7 am the next morning, before the nuclear stress test, because the fear of more dictatorial nurses, a third hospitalist, no friendly face, no familiarity, being a data dot, more pain, anxiety, fear, .was greater than the fear of dropping dead. Still alive and in my bunker. Anxiety from that experience is still my companion. Medical care, is now medical data analysis, there is no Care in the mix anywhere. And, whoever thought up hospitalists should be shot.

  4. Who is the person named Schwartz as the start of this piece?

    This is an important program that others should consider. Thank you for sharing your experiences.

  5. The EHR with its meaningfully useless tasks and grids has become the patient, while the real patient is starved for attention.

    What you describe is an unintended consequence of going paperless. I think that the patients would agree, as they die emotionally and physiologically from the neglect you seem to know.

  6. Many thanks! The only thing I would add is that increased compassion not only improves what patients report in their surveys but also their health – mental and physical. Good for you for encouraging doctors to tap into this oft-neglected element of good health care.