A Therapeutic Sighting: The Power of Seeing Eye-to-Eye

We recently received a story highlighting what happens when a caregiver does what it takes to really “hold” someone in her care. At Covenant HealthCare in Saginaw, Michigan, a recent rise in teen suicide attempts has been met with a new kind of curiosity—one that has been actively cultivated in the staff. This story comes from an ER nurse:

Young woman suffering from a severe depression (very harsh lightI recently had a teenage child admitted with a drug overdose after attempting suicide. It seems like we have had an epidemic of these patients, every week admitting 1 or 2 children with this diagnosis. Some staff members seem to become resentful to these kids, assuming that they are over dramatic and making stupid decisions. (There may be some truth in that, but there is always a whole lot more to the story than what you see in front of you!)

This particular girl arrived to the unit acting out—belligerent in her behavior and language. She was placed in 4 point restraints while in the ECC for fear that she might harm herself or others.

After attending a recent See Me as a Person Workshop, I decided to wonder about this young girl: What was happening, and why was she behaving the way she was? I sat with her and spoke directly to her, allowing her the opportunity to yell and swear while I maintained my composure and just listened.

After a short time, and once she realized that I was no threat to her, she calmed down, and we were capable of having a real conversation. I was able to remove the four restraints with a mutual understanding that she would cooperate with the care we were providing.

Before attending the workshop, I would likely have left her in restraints and wanted to “get in her face” to redirect her behavior. I really see the benefit of taking the time to understand the patient and to gain their confidence and respect to help manage her care. What I learned in the workshop sure made life easier in the long run that night!

While this nurse doesn’t talk directly about a change in her “default” behaviors, that is in effect what she’s talking about. Her old default would have been to “get in her face,” and thanks to the time she had spent learning about, discussing, and reflecting on the See Me as a Person practices of attuning, wondering, following, and holding, she has found herself with a new default: she is now fascinated by the people in her care. She is curious. She knows that there is a backstory, and that whether she learns it or not, there is a reason for the person’s behavior. She also understands that part of that person’s healing is likely to be that she is seen, heard, and received without judgment by another human being.

When you know and are committed to using the See Me as a Person practices, you have the ability to receive the person you’re caring for without judgment. In the instance of a suicide attempt, medical treatment can address the physical ramifications of the attempt, but the physical ramifications are typically only a small fraction of the problem.  Because the person is probably also suffering from a sense of isolation and hopelessness (and/or a host of other mental/emotional/spiritual woes), it is largely in the relational care of the patient that some healing of the root cause could take place.

For years, the experience of receiving good relational care was left to the luck-of-the-draw. You might, if you’re lucky, get a caregiver who is willing to connect and knows how to do it. In cultures like the one at Covenant HealthCare, the odds are much better, however, that everyone walking through their doors will receive good relational care. For the past two years, Covenant has embraced the See Me as a Person practices. They have offered the workshop to their staff in all disciplines, and they have transformed their culture to one in which curiosity replaces assumptions, people are seen, people are heard, and people feel held.

We are always gratified to hear stories like the one sent to us by this devoted ER nurse. It is an honor to help caregivers in all disciplines to provide superior relational care, with greater consistency and mindfulness, to the patients and families they serve.

Q & A: What was the Inspiration for the RBC Model?

QUESTION:
Hello! I am in graduate school at Kent State University working to become a nurse practitioner. My group chose your nursing theory to present for our peers. We would like to know what was your motivation for developing the Relationship Based Care theory? What was your process used for developing this theory? Also if there is any information that you would like to add regarding the theory? I have recently purchased a couple of your books and your CD, and I love your theory!! I have practiced as a bedside nurse for fourteen years and have been inspired by your writing and stories! I am excited to present your theory to my classmates and also to my coworkers. Thank you in advance for your guidance, and I look forward to hearing from you!

Sincerely,
Lisa Meek, BSN, CMSRN

ANSWER:
Mary-Koloroutis-150x150Hello, Lisa! It is rewarding to know that Relationship-Based Care resonates with you and is helping to inform your practice. Relationship-Based Care has evolved over the past 25 years beginning with the seminal work of Marie Manthey on primary nursing—a care delivery system that puts the patient-nurse relationship central. My motivation for contributing to the development of the RBC Model is very simple, actually. When I entered nursing practice, it was clear to me that safeguarding the humanity of those in our care as well as the humanity of those of us providing care would take intention and awareness as well as leadership (whether at the point of care or leading in a role within the organization). Institutions are where most care is provided and they are, by nature and design, prone to dehumanizing processes. The volume of patients served, the complexity of human caring and the complexity and escalating development in the sciences and technology all take attention and can undermine our core purpose. Holding the person central takes mindfulness, teamwork, and perseverance, along with an established way of doing/way of being within an organization that supports caregivers in keeping patients and families central at all times.

The work I did with Michael Trout on the book and workshop See Me as a Person was motivated by recognizing that while we talked about the nurse-patient therapeutic relationship as the center piece of care in RBC, it was an elusive concept to many in practice.  The “how” of therapeutic relationships had not been fully addressed. Those who excel at establishing and nurturing therapeutic relationships were seen as “simply knowing how to relate” and thus, the knowledge and discipline behind therapeutic relationships and the fact that relational practices can and should be taught was missed. We deconstructed what it looks like when we as caregivers are at our best and in a therapeutic interaction with a person. When authentic connection was established, four things were nearly always happening: We are present and attuned (focused on the person); we are wondering (genuinely interested in the person and what the person has to teach us, so we can provide the best possible care); we are “following,” (remembering and acting on what we have been taught); and we are holding (creating a safe haven for healing by doing what we say we will do; safeguarding the dignity of the people in our care; watching over them, keeping them informed, etc.

I am so pleased that Kent State is integrating this into practice. I remain

Respectfully yours,
Mary Koloroutis

The Practice of Wondering

Friend, colleague, and See Me as a Person workshop facilitator, Dan Kopp, M.D., shares a recent experience of rapturous wonder. We are moved by this beautiful expression of deep curiosity about a fellow human being and think this post stands as an example of how, over time and with intention, one’s propensity for wonder can become second nature.

~ Mary and Michael

farmer hands (2)I first noticed his gnarled right hand as he slid into the seat across the aisle of the 737 to Seattle. Tall and thin, he appeared to be in his mid-eighties. Sparse white hair and a bushy gray mustache framed a gaunt face that held a somewhat confused expression. A short and stout fifty-something woman was already settled into the middle seat beside him. She was obviously his daughter by the bits of conversation I overheard. Their exchanges suggested he most likely suffered from some type of dementia. She reminded him to put the ticket stub for the jet-way-checked bag into his wallet so he wouldn’t lose it. As he stood to comply, he removed a dark, slightly stained tweed jacket, revealing a well-worn plaid long-sleeved shirt. He sported camouflaged suspenders over stooped shoulders that apparently helped a wide brown belt secure his faded jeans.

It was his hands, though, that were mesmerizing. There was all the evidence of the countless tasks I imagined they’d performed over eight decades. Though there was little meat in or around the long, slender fingers, prominent purple veins tented his thin skin. Nicotine had stained the tips of the first two fingers of that right hand, as it did the lower edge of his mustache, correlating with the pungent odor of tobacco clinging to his clothes.

The woman continued to attend and speak with him more as a grandchild than the man she called Dad. I further imagined how those hands might have held her a half century ago, soothing her when she cried. I suspected he was a farmer and had worked long and physically demanding years in his fields, though there were no certain clues for that. My hunch was he’d been a good provider for his family, but don’t ask me why. Perhaps it was the soft expression of love I saw in his daughter’s eyes as she held a cell phone at arm’s length announcing she wanted a “selfie” of just the two of them.

He seemed oddly curious at seeing their faces together on the device. She was obviously pleased to have captured the moment. I smiled when he then interrupted the young flight attendant on seat belt patrol. She seemed confused to observe him holding his right hand up in the air until he moved it back and forth. He apparently wanted to “high five” her, something he undoubtedly did often with his children and grandchildren over the years, and she finally graciously obliged.

I saw worry lines deepen on his daughter’s face and wondered if she was dreading this long flight to the northwest coast. I suspected she was considering how many times he might need to use the bathroom, or what he might say that could offend another passenger who didn’t understand how polite and appropriate he had always been before those hands grew gnarled. I continued to wonder about the many tasks they had performed. How often had they swung a hammer, guided a rip saw, or caressed his wife’s face? Had they aimed a rifle in combat? Was the slight tremble from some physical or emotional scar of war?

So many questions flooded over me as I now studied not only his hands but his brown and weathered face in profile. He smiled occasionally, but it never seemed to correlate with anything. I found myself deeply engrossed in this gentleman and really curious about his back-story. I wanted to hear some of his life experiences and understand his relationships with those about whom he cared.

Common decency, however, and respect for both him and his daughter prevented me from intruding more visibly. Later, in the airport, I saw them again, this time walking together quite slowly, hand-in-hand and seemingly lost in their own connection. Even slightly bent at the waist, he still towered over her as she clung tightly to his much larger hand. I thought from a distance it just might have looked as it did when she was seven.

 

How Listening to the Family Can Make or Break a Therapeutic Encounter

This week I witnessed an interaction between a hospice nurse and a family who is coping with their loved one being newly admitted to hospice.

The nurse is devoted to her work and to the care of the patient and family.  Of that, I have no doubt. 

She is knowledgeable about the medications and the way to coordinate resources.  I know she will excel at holding the patient and family in her care through being highly responsive and highly proactive.  She went to extraordinary trouble to dress a wound that the patient had sustained from a fall.  She needed to go to her car, adapt the bandages to fit the area, cleanse, and teach.  She was careful with the patient’s fragile skin and gentle in her touch and care.

I could not help but notice, however, that when it came to her interaction with the patient’s wife, she seemed most comfortable when teaching, guiding, informing, and advising.  The wife of the patient has been caring for him for over two years and yet a conversation about what those two years have been like—what the wife is confident about, knowledgeable about, and struggling with—did not happen.

I witnessed the wife being agitated and responding in clipped words and saying “Yes, I know…” as the nurse instructed her in great detail, never asking any questions to learn more about what the wife already knew.  If the nurse noticed the wife’s tone, she did not indicate so, and continued with teaching about a particular medication that the wife said several times that she did not want to give her husband because of the unwanted side effects and her own assessment (informed by two years as his primary caregiver) of his current status.

The nurse stated her goal for the day’s encounter as getting to know them and building trust. My hunch is the nurse was pleased with the interaction and felt like she had thoroughly done her job.

Some hours after the nurse departed, the wife expressed concern about the nurse and asked my opinion about whether they would be able to work together.  I could honestly answer Yes, as my assessment was that they would find their rhythm together over time.  I guided the wife to simply say to the nurse, “I want you to please pause and listen to what I’m saying to you.”  If she does this in the future, an exchange can take place that makes a relationship possible. As it was, there was a sender of information (the nurse) and a receiver of information (the wife). But that sort of one-way transaction does not create a relationship; in order for trust to be built between the nurse and the patients wife, the wife must feel seen and heard.

The problem here may come partly from how this nurse’s role was defined for her. Her title—Case Manager—suggests to her that she is to be a “manager” of care, and that’s what she did. But people know the difference between being managed and being cared for. Is it possible that her perception of her the role as manager interfered with her ability to simply quiet down and be interested in learning about the wife?

When the stakes are so high, as they are in this sort of high acuity and/or end-of-life setting, the patient and family are exquisitely attuned, but in a very specific way: They are vigilantly looking for the attunement of the people caring for them. The way to make an encounter of this sort go well is to quiet yourself and listen.

*****

Rea GinsbergI happened upon this beautiful blog post by Rea Ginsberg shortly after this experience, and it really stirred my thinking. It speaks to how difficult and somewhat unnatural it is to simply quiet ourselves and listen. It is, however, essential.

To read the post, “Can You Hear Me Now? Listening to Grief, Notes from a Perpetual Student,” click here.

 

~ Mary Koloroutis

A Therapeutic Sighting: It’s a Wonderful World

Dr. Andrew-Jaya. MDThis is love in action!

Dr. Carey D. Andrew-Jaja of Magee Womens Hospital in Pittsburgh, PA shows us what it’s like to be seen as a unique and special person by the physician helping you enter this wonderful world.  Watch how the physician (and the baby’s parents) attunes, wonders, follows, and holds.  Magnificent!

~ Mary            Click here to watch the video!

A Therapeutic Sighting: A Charge Nurse Attunes, Follows…Connects

We are warmed by this beautiful nurse’s way of being. She is seeing every patient as a person.

HNH News logo“You just go along with the patient,” Cheung says. “If they’re in pain, I try to see if I can address that problem. Then I keep going back to the patient. When I say I’m coming back in an hour, I will come back in an hour. And they expect to see me.” That builds respect and trust, she says. “If a patient trusts you, you can help them solve some of their problems.”

To read this inspiring article, click here.

I Am Your Patient

I am your patient. I am a person with family, friends, faith, hope, longings, and plans for the future.
Everything you do or say that helps me feel seen as a person, moves me one step closer to healing.
When you do the things I’d do for myself if I could, I feel like you’ve got my back.
Every time you help my family, you help me. Every time you hold my hand, I’m comforted.
Every time you are in my room and you see me –
not as a diagnosis or series of tasks – but for who I really am – I feel safe.

Marcus with dog

 

~Marcus Engel (as a patient, “The Other End of the Stethoscope”)

To learn more about Marcus Engel, visit www.MarcusEngel.com.

How Compassionate is Your Organization?

306648_430031007052972_255367038_nTake this short survey from Hearts in Healthcare to learn something about how compassionate your organization is. We invite you to use your findings as a springboard for discussion with your peers. Making compassion a topic of discussion in your organization helps clinicians in all disciplines to be more mindfully compassionate in their interactions with patients, families, and each other.

To take Hearts in Healthcare’s brief, but revealing survey, click here.

A Therapeutic Sighting: Making a Human Connection in No Time

306648_430031007052972_255367038_nThis is a beautiful response to all who say, “But we already do this” or “I don’t have time.” Thank you, each one of you, who see your patient not as a broken body but as a full human being who needs you. Thank you for your knowledge and understanding about what it means to be wounded on the inside as well as the outside. Thank you, all of you, who are the nurse in this story.

With appreciation to Hearts in Healthcare for sharing this clip.