“They made me feel genuinely cared for. They listened, made eye contact with me, conveyed warmth and understanding in their voice and repeated back to me what I was saying.” — Sophia, about her visit to a chronic pain clinic, from a “care moment” prepared by the Patient Experience department of Alberta Health Services.
Mounting concern that health professional/patient interactions are often less than therapeutic has led to many initiatives aimed at finding ways to put the care back into the health care system.
In Canada, one such initiative is the creation of the Patient Experience department of Alberta Health Services.
Established in 2009 as part of AHS’s health care quality and improvement division, it produces easy-to-use tools and conducts workshops across the spectrum—from hospitals to long term care facilities, home care organizations and emergency medical services—aimed at improving patients’ experiences in the system.
A key way to do this (and one focus of the department’s work) is to better provide emotional support to patients. The current international push for more patient engagement and for patient-centred care generally acknowledges the importance of patient emotional support.
Ways to improve provider/patient relationships
The tools are two-pagers. Staff boil down extensive research into easy-to-understand guidelines about ways to improve patients’ experiences. These include actions such as introducing yourself, practising active listening, sitting or standing by the patient’s side.
“Health care professionals at the front line have been so busy for so long,” says Willow Brocke, the department’s director of the patient engagement.
Providers say they feel like an extension of technology
“The volume of work, the speed, the expectations, and the increase in what’s possible with life saving technologies—it’s a pressure cooker. People tell us they’re feeling like an extension of technology. At a humanistic level, there is a sense of lost meaning.”
Sholom Glouberman, president of the Patients Association of Canada, calls this instrumentalism. “The instruments have got so powerful that doctors don’t talk to patients, they order tests.”
A recent blog post in the New York Times (titled For New Doctors, 8 Minutes Per Patient) described how, increasingly, doctors cull electronic medical records for information about a patient: “When finally in a room with patients, they try to speed up their work again, but by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.”
Relationships with patients are vulnerable “in profound ways”
Dr. Jim Kitchens, a clinician-teacher at St. Michael’s Hospital in Toronto, says the increasingly fast pace of health care means that the doctor/patient relationship is vulnerable “in profound ways that are hard to articulate.”
He adds that although it’s accepted that listening to a patients’ medical history story is important for the purpose of making a diagnosis, “we may not fully appreciate the importance to patients of having been heard . . . real healing may be delayed or denied until that happens.”
Importantly, patient emotional support—and hence patient satisfaction—is linked to better clinical outcomes, note the Canadian authors of the recent Health Quarterly article, Understanding the Patients’ Perspective of Emotional Support to Significantly Improve Overall Patient Satisfaction.
The task: to maintain a caring disposition while working with new technologies
“We need to teach providers how to maintain a caring disposition amongst all this new technology,” says Keith Adamson, lead author of the Health Quarterly article.
Care delivery is often focused on the what, and not the how, the article argues. “But the provider patient transaction is still fundamentally one between human beings,” he adds.
To try to understand what constitutes emotional support from the patient point of view, Adamson and co-authors conducted lengthy interviews with a random selection of 25 patients who were being discharged from a large community hospital in Toronto.
In the hospital’s regular key indicator reports, overall patient satisfaction scores were quite static. “We wanted to dig deeper, to see what we could do to improve scores—to be aspirational, not just content with static numbers.”
Co-author Jatinder Bains notes there was some concern that “the patients would be afraid to talk about the experiences, that they would think it would jeopardize their future care. But most were quite willing.”
Ways to provide emotional support: from basic to advanced levels
Their findings led them to construct, for health care practitioners, a template of “key actions related to the different levels of emotional support”—actions that are very similar to those outlined in several of the two-pagers from the Alberta group.
The basic level includes practices such as introducing yourself, showing “manners and politeness to create a friendly environment,” maintaining eye contact, and ensuring a clean physical environment.
Advanced levels of emotional support include sitting with patients and “providing opportunities for them to feel accompanied in their struggles,” directly answering questions, making the patient feel special, and making supportive gestures such as, when appropriate, holding the patient’s hand.
Not everyone will be capable or interested in providing support at the advanced level, but everyone in health care should practice basic level skills, Adamson says.
In the 2012 Health Affairs article, Developing Physician Communication Skills for Patient-Centered Care, lead author Wendy Levinson notes that the US Institute of Medicine noted that patient centred care is characterized by (among other attributes) emotional support for patients.
“We end up seeing things only through our own eyes”
“We get so good at the task,” Carol Manson-McLeod, a nurse and head of emergency services for the Edmonton Zone of Alberta Health Services said, “that we end up seeing things only through our own eyes.”
Manson-McLeod said her staff had a wake up call last summer after a physician arranged for a former patient to tell her story. The patient had spent two nights in an emergency ward and was subsequently shunted around several different hospital departments.
“The care tasks were carried out, but compassion and caring was completely lacking. We listened to her story and it was quite distressing.”
The patient experience department was subsequently invited to hold a series of eight workshops for emergency ward staff at two large Edmonton area hospitals. Staff were paid for their time attending the workshops, which each had between 30 and 40 participants.
The importance of hearing positive stories from patients
The workshops always feature patients. “It’s most powerful when we have patients come and present in person, but we also have videos, and one paragraph stories that illustrate a time when we got it right,” says Jennifer Rees, executive director of the AHS Patient Experience department
Because health care workers hear enough stories about inadequate care, the patient stories presented in workshops always concern positive interactions with hospital staff—what worked well, what made a difference.
For example, a woman whose husband died in the emergency department “told the workshop how cared for she felt” by the social worker who met with her after her husband’s death, Manson-McLeod said.
The workshops, which staff reported were the “best ever”, led to tangible changes, she says. “For example, one of the triage nurses was just complaining to me about patients, how they butt in, and then one of the other nurses interrupted to say, “you have to look at it from the patient’s point of view.””
Manson-McLeod says that some people fear that taking time to interact with patients will add to their workload.
“It doesn’t add to the work flow. In my experience, it enhances my work. It makes me feels more valued as a health care provider.”