It was 7 o'clock in the morning back in May 2013 as I began my leader rounds on the oncology unit I supervise. Patients were just stirring. You could hear the rustle of activity as morning care was given and patients were being readied for breakfast, labs, and therapy. As I came to Room 243, I heard the two young nurses in the room in the middle of bedside report:
“The patient received pain medication twice on my shift. According to the computer, her pain level is averaging around a 5 on a 10-point scale. Telemetry tells me her strips were stable all night. Her pulse ox was also in the mid-90s overnight with no apnea noticed on her monitoring.”
At this point, the nurses moved to the next room.
My “old school nursing” brain was processing all this information and came to a realization: Not once had these two nurses spoken to the patient or asked her how she was feeling. Everything they shared and everything they were basing their plan of care on was the product of electronic monitoring. Even the process of bedside charting in an electronic medical record has become impersonal.
The reality is that technology is quickly replacing the soft skills of nursing assessment in the care of our cancer patients. Assessment information has been drilled down to a series of check boxes with very little opportunity to enter free data into a narrative field. It does represent progress, but at what cost?
It became clear at our institution that before we became as impersonal as Dr. McCoy's scanner on Star Trek, we needed to revisit the fundamentals of oncology nursing, and we needed to learn to put a bit more humanity into our care.
Here are some pointers our team developed to move the “Soft Skills” back into nursing.
1. Focus on the Patient: Focus on the patient, not the computer. Oncology nurses are encouraged to lower the computer cart to seated level and pull a chair up next to the patient's bedside for the assessment documentation. By having to look at the patient and then back to the computer screen, the patient gets a sense that he or she is the focus of the nurse's attention.
2. Talk to the Patient: Include the patient in the rounding conversations. Open-ended statements like “Please describe the pain you had overnight” followed by a request to assign a pain scale number, is much more valuable information. It also lets the patient weigh in on pain control—what worked, and what didn't. It makes patients feel that you care about their pain, not just the number.
3. Treat the Patient: Treat the patient, not the technology. More and more we are seeing medical errors related to physicians and nurses responding to changes on a monitor or other technology readings, instead of assessing the actual patient. There is nothing more embarrassing for a nurse than to call a code from a telemetry station only to discover a lead had come off the patient.
4. Touch the Patient: Touch is as important (if not more so) than tech. One bit of feedback I hear repeated over and over again in patient focus groups is “The nurse never touched me, unless it was to do something to me.” The simple, comforting acts like holding a hand or stroking a shoulder have largely disappeared from nursing, only to be replaced by the application of leads and probes.
5. Respond to the Patient: Never respond to an alarm or alert without looking at, and talking to, the patient first. Going right for the button to silence the noise is an instinct. Our nurses are replacing that instinct with the act of greeting the patient and noting that there is an alarm going off. If it is nothing significant, reassure the patient before leaving the room, and always ask if there is anything he or she needs while you are there. Just silencing the alarm and then leaving the room causes the patient to fret as to ”What just happened? Am I OK?”—and sends the message that restoring quiet was more important to the nurses than identifying the cause.
The ‘Believe’ Care Model
Our nurses established what they call the “Believe” model of care: Believe you can do your best for every patient with every contact. We are now including patients in the bedside report conversation, almost to the same extent as we include the nurse going off duty.
The patient becomes the continuity-of-care feature, providing each successive shift with important information regarding his or her care needs. Even for patients, who are not physically or cognitively able to participate, the use of white boards to communicate important care items, shared during lucid moments or from family caregivers, has helped us to better personalize care.
Fast forward to (as I write this) January 2014 and that aforementioned bedside report goes:
“Good morning, Mrs. S. How was your night? I see you had some pain at bedtime. Can you describe your pain for us? Did the medication you received give you relief? How long did that take? What would you say your pain level is this morning? I am going to listen to your heart and lungs right now, and then I will get some data from those monitors to include in my notes. In a little bit after Nurse Jane and I finish rounding, I will be back and do a more complete assessment. Is there anything you need until then? [Nurse takes patient's hand in hers] We are here to take care of you, so please make sure you tell us if you need something—no matter how small—because taking care of you is the reason we are here.”
Why are we doing this? Well, the primary reason is because it makes us better oncology nurses, but it also had an unanticipated secondary gain. As we moved away from the technology and put the focus back on the patient where it belongs, our patient satisfaction ratings (as measure by Press-Ganey) soared from 81 percent to a consistent 94 percent for the past two quarters.
In the new valued-based world of health care, it is nice to find that doing the right thing pays off in the end.
GEORGIA J. SMITH, RN, OCN, is Director of Cancer Services for Sacred Heart Hospital in Eau Claire, Wis., where she has led numerous quality and patient-focused initiatives. The hospital currently holds a top decile ranking in patient satisfaction for its oncology service line.