Q & A: Engaging the Family: An Inquiry from Brazil

QUESTION:

I am a nurse, and I coordinate the care team of a hospital in the city of São Paulo, Brazil. Last year we had wonderful experiences when you provided the Therapeutic Relationship workshop at our organization. After that we started to hold organized meetings with the families of the patients who were hospitalized in the Intensive Care Unit and clinical/ surgical units. The purpose of these meetings has been to bring these families together with the caregivers in order to take care not only of their health but also to meet their needs and build better relationships. Although it’s not a common practice in our hospitals in Brazil, the results have been excellent, bringing many opportunities, but it is not always so easy to make the families understand our purpose or to get at the point we want. Sometimes the conversations are more superficial.

What could we do to help these families feel safe enough to engage therapeutically?

ANSWER:

Mary-Koloroutis-150x150We’re very excited about the work you’re doing, and we look forward to hearing more about how your meetings with families are impacting care and the overall patient and family experience. Partnering with the family during the rush of daily care can be challenging (though very rewarding). Finding a way to intentionally partner with families in a planned meeting for the purpose of engaging them in a dialogue about what matters most is a brilliant and proactive intervention. We offer the following thoughts and tips in the hopes that they will be useful. Let’s begin by remembering that every therapeutic encounter has a beginning, middle, and end.

The Beginning: Meeting

Paying attention to the beginning is important to set the stage, clarify the purpose, and establish a sense of safety. Some beginning tips include the obvious such as having every member of the team and the family members introduce themselves. You may also want to establish “agreements” that may be helpful to assure safety and freedom of expression. Some examples of agreements are: begin and end on time; protect privacy; honor confidentiality; and prevent unnecessary interruptions. Prepare yourselves to be fully present and attuned. Prepare to listen, see, and give your undivided attention. Remember that for many people, the hospital setting is foreign and even intimidating. Tending to their safety and comfort will facilitate trust and more open expression.

Clarifying your purpose is important to engage the family and to ease any anxiety. If the goal of the interaction is to better meet their needs, you might state it as, “We’re here to learn more from you about how we can support you during this difficult time.” Then express your sincere interest in what they’re going through.

The Middle: Connecting

The conversation with the family is facilitated by wondering through open-ended questions:

• What has your experience here been like so far?
• What worries you most about your loved one’s condition?
• What is on your mind right now about your loved one’s care?
• In what way has your loved one’s illness affected your life?

You want to convey the message: “We want to understand your experience better so that together we can partner to be as proactive as possible.” However, this message is best conveyed by demonstrating genuine interest rather than stating it as an objective.

Once the answers start flowing (even if the flow is more like a trickle) your job is to follow what you are being told. Following is the act of hooking into the last thing the person says (or sometimes doesn’t say) and making your next question or comment follow what the family member is teaching you about his or her experience. When following, you find yourself interested in learning all you can about the other’s experience. Your focus is on the person, and your curiosity and openness encourage the family to let you know honestly what is on their minds. In this way, we honor and respect what the family is teaching us by making it quite literally the most important information that anyone in the room is able to provide. This therapeutic focus empowers the family to truly make a difference in the patient’s experience and in their own. It is a contrast to the very normal feelings of helplessness that are a common human response for the family members of people facing illness and injury.

Following can be verbal or non-verbal. Sometimes the best following is the act of letting the emotion expressed by the other register on your own face, or uttering an empathetic sound, or simply offering your quiet, attuned presence as you wait and listen for the person to continue. Here is some language that may help you follow:

• Tell me more about…
• When you said…, I wondered…
• What else will help us understand how your loved one cope’s with …
• Is there more about…that you’d like us to know?
• OR simply convey nonverbally and by quiet waiting that you are here to listen further

The End: Transitioning

The ending provides a structured way to clarify understanding, receive feedback, identify any next steps, and determine if there is anything further required before ending the encounter. An effective way to close the time is to ask everyone present, “What one or two things have you learned or are you taking away as a result of our time together?” “Checking out” in this way assures that every voice is heard, and in particular, that the family members know they have been heard and that any necessary actions are clearly articulated and implemented.

If you create a structure (beginning, middle, and end), stay attuned and present, and consciously practice wondering and following, the family members will feel respected, safe, and held in your care. When your deepest intention is to build relationships with family members and to learn from them so that you can provide better care for their loved one, your deep intention creates the space for true partnership. This kind of relationship, one built on respect and proactive engagement, will assure that the patient and the family receive extraordinary and compassionate care.

~ Mary Koloroutis

Commentary on “A Flight Tested Solution to Patient Safety”

Beyond ChecklistsThis was brought to my attention in a LinkedIn conversation of the Sigma Theta Tau International discussion group. A participant posted this article, which mentions the book Beyond the Checklist, by Suzanne Gordon, Patrick Mendenhall, and Bonnie Blair O’Connor.

I highly recommend you read this article, and here’s why:

Despite widespread research proving that human relationships are critical to safe, quality patient care, there continues to be greater emphasis on checklists and mandates and less on investing and committing fully to the development of relational skills in individuals and teams. Safety requires connected teams who talk to each other regardless of role or position. Healthy, high functioning teams are built on trust, mutual respect, open and honest communication, and consistent and visible support for each other and from their organization’s top leaders. Clearly articulated expectations for civil and intelligent team relationships are vital for creating a healthy work culture, which is foundational to safety and quality, and for recruiting and retaining the most talented and committed individuals. It is time to invest in the systematic development of relationship-based, healthy work cultures in which the provision of care to patients and their loved ones drives everything and their safety is our moral obligation and a sacred trust.

~ Mary Koloroutis

To purchase Beyond the Checklist, click here.
To purchase See Me as a Person, click here.

Q & A: Nurse Sometimes Feels Like He’s Acting

QUESTION:

We’re working on creating therapeutic relationships with each patient. One nurse noted that he feels like he’s “acting” with some patients, so that he can best communicate with them. This is a problem when he has two patients in the same room, because he’s afraid that they will sense his different behaviors with them. How do you develop authentic relationships in this circumstance?

ANSWER:
Michael-Trout-150x150We love this question! I surmise several things about the nurse on the floor, as well as the person who poses the question, all of them noble (so disabuse me of my fantasies, if I’m wrong!):

• If this nurse is worried about “acting,” then it must matter to him to not appear so. This suggests to me that authenticity is important to him. He must be highly sensitive to his patients’ perceptions, since he wouldn’t know the difference, if he were not.

• If you and the nurse you describe are concerned about two patients who are sharing a room noticing different interactive behavior between him and each of them, this suggests that his behavior is different with each, which implies that this nurse’s behavior is actually being guided by each individual patient. Hurrah! This is the natural result of attunement and following which are, by definition, highly individualized acts.

I wonder if the nurse’s worries about “acting” arise in part from inexperience with such intensely individual interactions that are based exclusively on the needs of the other. In a sense, the sort of interactions that characterize a therapeutic relationship are unnatural. They are not social, so they don’t feel like how we talk to a friend or someone at church. The therapeutic relationship is like no other. It serves only the other person. The words out of the clinician’s mouth are guided by—indeed, formed in response to—the last thing the patient did or said. Such a relationship is intense, but not intimate in ways already known to us. Where else in life do we get to practice this unusual way of connecting with another human being?

I wonder if an exercise would clarify things a bit. What if you asked him to make note of two things about each of his patients (just for a few days) that he has noticed and to which he is responding when he cares for them? These two things, in his mind, may be helping him to distinguish his patients, one from another, but he may not have thought about what they are exactly, and how they might be shaping his behavior with each patient. Then ask him to verbalize in two sentences about how he interacts uniquely with each of those patients based on their distinguishing characteristics.

This exercise might offer him much greater clarity about how his interactions came to be, and why his own behavior with each patient is what it is. What may have felt like “acting” may actually be his sensitive following, which is guiding him to behave in specific, nuanced ways that, of course, don’t feel exactly “natural.” The patient in the other bed, listening to such personal, nuanced interchanges may indeed wonder why the nurse didn’t say the same things to her, but I don’t think this feeling will last. (Just such an experience will, by the way, inevitably evoke old feelings in our patients about fairness in the patient’s family of origin, as well as her perceived position in the family, whether there were obvious favorites, how attention was acquired, etc.) A sibling may have an initial reaction (“That’s unfair!”) when he hears Mom saying/doing/giving something to a brother or sister, only to be most surprised and pleased when Mom says/does/gives something to him that’s not the same, but is better, because it’s personal. Mom thought about him. Her gift was to know him.

My guess is that this earnest nurse is tapping right into the spirit of attunement and the mysteries of following. He just needs a little more experience in getting comfortable with a non-scripted, highly-personal, nuanced mode of interacting with his patients. It’s quite possible that he’s heading in exactly the right direction.

~Michael Trout

Q & A: How Can I Have Better Relationships with the Techs on my Unit?

QUESTION:

When RN’s and techs work together, the tech inevitably feels indignant no matter how you treat them. Can you think of anything I can do to make these relationships better?

ANSWER:

Michael-Trout-150x150We have a notion that the indignation about which you speak is a direct reflection of the tech’s response to the perceived hierarchy. This doesn’t mean the RNs are doing anything wrong. It may be that the techs in your organization believe themselves to be undervalued—perhaps because of the pay structure, the way hours are set, who gets invited to certain meetings, or old (deeply-rooted, historical) traditions or attitudes about techs in your community or in your organization. It may mean only that you happen to have a couple of techs with anger about what they perceive as class privilege or about opportunities they didn’t have (or didn’t take). As you wonder about these possibilities, remember that the circumstances in your culture to which they are reacting with indignation do not have to be apparent to you—indeed, they don’t even have to be real—in order for some of your techs to feel them, to perceive them.

It may, however, be none of these. The simple fact is that people usually behave indignantly when they feel unseen. This is an irony, as indignant people often appear as if they already know everything, which could lead one to assume that such people have too much self-esteem—that they are, if anything, overly cocky and resistant to cooperation.

But appearances may be deceiving.

If a patient or family member behaved indignantly (pretending he/she was superior to you, needed to learn nothing from you, etc.), you would quickly know the reason: The patient was likely feeling vulnerable and afraid and was covering both troublesome feelings by behaving conversely. You would not react to the indignant behavior, and you would not arm-wrestle the patient for control and authority. You would bring your calm presence to the bedside and quietly wrap your caregiving arms around the frightened and vulnerable person. And you would do whatever you could to increase the patient’s (or family member’s) felt sense of authority over whatever was happening. For example, you might ask the patient or family member for information about what their experience had been with the situation at hand, and then remark on how helpful whatever they contributed will be to their care.

Ditto with the indignant techs.

You might wonder on their behalf as to whether they are frightened about making a mistake, worried about being up to the task, jittery about taking on responsibility. You might wonder whether they have gotten an earful from a demanding parent or an unsupportive teacher and are steeling themselves against getting the same from you. Surprise them with your inquiry about what their experience has been with a particular issue (or a particular type of patient), and then find something in their response you can compliment. Let them know you will be working together and that you are grateful for their partnership. In other words, let them know what you want your patients to know: that you consider their welfare essential—never secondary—to the operation of the unit, and you have their back.

Write us back about what you discover really was the cause, and how your strategy worked!

~ Michael Trout