IMAGINE WALKING into a room and overhearing one of your peers telling a patient, “Quit calling me, I have other people to take care of besides you. You're doing fine and don't need me to be in here every minute of the day.” We've all cared for challenging patients in our careers, but as professionals we should never speak disrespectfully or express negative sentiments to our patients. After observing that incident, one author (Mickey Bladh) began to notice other interactions that demonstrated a lack of professional nurse-to-patient etiquette.
The public views nursing as one of America's most prestigious, trusted, and ethical professions. This is documented in more than a decade of national public opinion surveys conducted by the Gallup and Harris polling organizations.1,2 Poor nurse-to-patient etiquette undermines the public's trust in the nursing profession.
This article reviews basic guidelines for professional nurses as illustrated by some commonplace vignettes witnessed by Ms. Bladh that demonstrate the artful application of nurse-to-patient etiquette. It also discusses how nurses can guard against lapses in professionalism.
Is professionalism in decline?
The characteristics of professionalism in nursing are consistently described across time, geographic locations, workplace settings, academic institutions, and professional organizations. Yet some see evidence that professionalism is declining, perhaps even disappearing from view in day-to-day practice.3-5
Etiquette is simply a socially acceptable way of interacting in a manner that conveys respect and makes others feel comfortable. Rules of etiquette govern both formal and informal settings, and each situation has spoken and unspoken rules. Cultural differences may alter these guidelines somewhat, but most that apply to common behaviors are widely accepted. Some familiar guidelines include saying please and thank you, not interrupting others when they're speaking, cleaning up your own mess, dressing to impress, being on time, and being respectful of others' belongings and personal space. Adherence to these simple rules of conduct influence whether or not a nurse is viewed as trustworthy by others.3
Professional nurse-to-patient etiquette combines concepts learned in family and social settings with nursing standards of care. How then should a highly trusted, honest, and ethical nursing professional behave? The following points provide a solid framework for nurse-to-patient etiquette.
Make a positive first impression. First impressions matter; poor first impressions are very difficult to alter. Think of someone who didn't make a good first impression. Wasn't it only after getting to know this person that your impression changed? Nurses generally don't have the luxury of time to correct erroneous first impressions. The trust engendered by professional appearance and behavior creates an emotional connection between the patient and nurse for the duration of the relationship and shouldn't be taken lightly.6
Good personal hygiene is an important aspect of creating a positive impression. Frequent hand hygiene and good grooming show that you value being healthy and clean.
Dress to impress. Your patient's impression of you is formed as soon as you walk into the room, even before you've spoken. A professional appearance projects confidence and encourages the patient to trust in your ability to provide safe and effective care. Shoes, clothing, and other apparel should be neat, clean, appropriately fitted, and in good repair.
What constitutes a professional appearance? From starched white uniforms and caps to the color and style of scrubs, this has been a “hot button” topic for years. However, most healthcare organizations have policies that provide specific expectations regarding personal appearance. Be aware of the organizational dress code and of differences in the patient population when considering how personal choices in appearance may be viewed. For example, a pediatric nurse might wear “kids-friendly” scrubs designed to put children at ease. Nurses on an adult unit might wear color-coded scrubs to differentiate themselves from other healthcare providers, such as unlicensed assistive personnel, radiology technicians, respiratory therapy technicians, or phlebotomists.7,8
Talk with your patient. Clear, easily understood communication is best, especially considering the diversity of the patient population. Ideally, the nurse-patient relationship begins when you introduce yourself and identify your role in the patient's care. When my mother was in the hospital, a healthcare provider walked into the room, checked the I.V. infusion, and documented a set of vital signs all without saying one word to my mother or me. There was no introduction or discussion of my mother's care. I found this impersonal interaction very disturbing. I followed the healthcare provider out of the room and introduced myself; in reply she told me she was covering for the primary caregiver who was on break. I explained that it was of significant concern to me that she had provided care to my mother without any introduction or explanation. She listened and then sincerely apologized for her lapse.
So, talk to your patients. Tell them who you are, and keep it simple; for example, “My name is Nancy and I'll be the registered nurse caring for you today.” Share information appropriately with the patient and family. Keep the patient and family in the communication loop, even if you have no news to report. If you need to have the same conversation multiple times, do it with a smile.
Consider the average literacy level of the lay public, which is currently between 7th and 8th grade level; health literacy is a concern for all racial and ethnic groups.9,10 Adjust your phrasing to ensure that you can be easily understood and avoid using medical jargon or acronyms. Speak slowly and clearly, using your normal tone of voice.
Besides being a breach of etiquette, poor communication undermines patient safety. The result may be confusion and a waste of resources at best, a fatal medical error at worst. Make sure your patients understand what's happening, when it will happen, and why. Empower patients and their families by telling them to immediately call you if something doesn't sound or look right. When the plan of the day is communicated to patients and family, they're more likely to ask questions if something goes wrong.
Respect personal space. Nurses work in a unique environment and must acknowledge the challenges an individual and family face with respect to personal space. Ask for permission to touch someone before you do so. I once observed a nurse, at the beginning of the shift, go into the room of a patient she'd never seen before and lift the patient's gown to check an abdominal dressing without saying a word. The look I saw in the patient's eyes was pure panic.
Knock and announce yourself before entering a room. Give the patient a chance to attain a modest appearance, if necessary, before you begin communicating. Gender issues need to be respected, especially when the patient and nurse are of the opposite gender.11
Be in the moment. Have you ever realized that the person you were talking to wasn't listening? How did that make you feel? Show that you're present. Use eye contact to communicate your care and concern. Remember to smile and avoid body language that conveys impatience, boredom, or annoyance.6
Nurses must have the highest set of professional standards regarding interactions with the sick and injured. Being present is more than concentrating on a task such as starting an I.V. or administering medication. It means sharing the moment with the patient and taking the time to listen while giving care.
Time is a valuable commodity for every nurse and giving patients the personal attention they deserve in our dynamic, fast-paced environment can be a challenge. But if you can find time to sit with a patient or family and be in the moment with them, do it. This simple act bolsters the confidence and trust at the core of a therapeutic nurse-patient relationship.
Don't allow technology to get in the way of personal interactions. While performing documentation in the room, for example, look at patients when you speak to them, sit at eye level when appropriate, give them time to process information, wait for their response, clarify their response, and give them time to ask questions. Summarize the discussion by confirming what you both understood from the conversation. You may be surprised to find that some information was misheard or processed incorrectly; this is your chance to clarify any misunderstandings.
Keep your promises. Every nurse must convey a sense of courtesy, care, concern, and confidence when providing nursing care. One way to do that is to keep promises. If you tell patients or family members that you'll be back at a specific time to check on them, do it. Of course, unexpected circumstances sometimes prevent nurses from keeping promises. Restore faith using these three components:
- Touch base with the patient as soon as possible.
- Acknowledge that the promise couldn't be delivered as intended and why, offering a brief explanation.
- Move forward with the follow up.
Also recognize that if the patient is emotionally distressed, these feelings may reflect concern about his or her situation, not you. Don't take it personally. However, if your efforts to reassure the patient are unsuccessful, enlist the participation of a manager, chaplain, social services representative, or other appropriate resource to mitigate the situation.
Be a gatekeeper of information. Think about a time when you, a family member, or friend was admitted to the hospital. Did you experience a multitude of people telling you different things to the point that you wondered if anyone knew what was going on? The nurse is gatekeeper and patient advocate. If you sense that the patient is troubled or anxious, don't ignore your nursing intuition. Help the patient sort through information overload. When patients consider information provided to them to be unreliable or overwhelming, they may eventually distrust the nurse as well.11
Recognize cultural differences. Be aware of differing cultures in your patient population and approach patient care with cultural competence. Especially important, avoid stereotyping. Don't assume that patients with a particular ancestry incorporate the beliefs and values of that heritage in every aspect of their lives. For example, a generalization of Asian culture is that the man in the home makes all decisions. It's been my experience that in the Americanization of Asian and other cultures, shared decision making is becoming more common.
Follow the Golden Rule. Treat others as you would want to be treated. This approach shows that you value the human condition and that you have compassion for others.
Conduct yourself with integrity. Someday you'll make a mistake; we all have. Own up to it. I knew a nurse who administered I.V. penicillin to a patient who was allergic to the medication. She recognized and corrected her mistake almost immediately and the patient wasn't harmed. She could have easily gone on with her day without anyone being the wiser. Instead, following facility policy and procedure, she told the patient, family, physician, and manager what had occurred and filed an event report. She believed it was the right thing to do and that if she were in a similar situation she'd want her nurse to act with integrity. The outcome wasn't what she expected—instead of being disciplined, she was held up as an example of nursing excellence.
Think before you speak. Disasters can occur when talking about patients in the room while assuming they can't hear or understand. Patients, families, or visitors may not choose to speak English, but this doesn't mean they don't understand English. Remember to share patient-care information only with colleagues who need to know, as required by the privacy provisions in the Health Insurance Portability and Accountability Act.12 Conversations in public areas should remain professional at all times. I remember a nurse telling me that she was very embarrassed after sharing at lunch what she thought was a funny story about a patient. She didn't reveal the patient's name or room number, so she felt she was being discreet. Unfortunately for her, the patient's family was sitting close by, heard what she was saying, and realized she was talking about their relative. They were not amused.
Etiquette equals kindness and common sense
It's not complicated. In nursing as in life, building relationships with kindness and caring matters. In the words of the poet Maya Angelou, “At the end of the day, people won't remember what you said or did, they will remember how you made them feel.”