A trusting nurse-patient relationship in which there's an open and honest line of communication between the two parties is necessary to identify our patients' psychosocial needs. Good communication between clinicians and patients is fundamental to build trust and develop a therapeutic relationship, which can influence patients' well-being.1,2 The quality of time spent communicating with patients can result in the delivery of meaningful nursing care and yield positive patient outcomes, particularly in the areas of health self-management, adherence, and satisfaction.
Although face-to-face interaction with patients is important, effective communication has decreased due to other competing nursing responsibilities, such as the demand for real-time documentation in the electronic health record (EHR), shorter lengths of stay (LOS), the push to discharge patients before noon, and the onboarding of novice nurses. Literature shows that EHR use may reduce the time that healthcare providers spend with patients.3 Bedside communication is often perceived as quick, task-oriented, and unidirectional due to time constraints. In addition, new graduate nurses often lack confidence in their nursing skills and developing bedside nurse-patient relationships.4
As part of the New York University Langone Medical Center's initiative to improve patient satisfaction and assess bedside care quality, leadership rounds are completed daily on each unit. During these rounds on an acute medical-surgical unit, it was observed that the interaction between nurses and patients appeared to be automated, hurried, and disjointed. This was evidenced by erratic Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, which were discussed during staff meetings. With the recognition of these issues, the nurse manager, together with the nursing staff, formulated an action plan—dubbed “Social 10”—to improve nurse-patient relationships by encouraging nurses to spend more time with their patients at the bedside.
Getting to know you
Social 10 is an allotment of 10 minutes for the nurse and patient to have uninterrupted time to talk and get to know each other on a more personal level. During this time, nurses are encouraged to refrain from performing clinical tasks, particularly documentation. The intent of this conversation is for patients to talk about themselves, their family, their likes and dislikes, their hobbies, their work, or any other topic of interest. The benefit of this communication is multifaceted. It allows nurses to slow down, center themselves, and be in the present with their patients. The time spent at the bedside actively listening and speaking with patients gives nurses an opportunity to build rapport and form a more personal relationship, gaining knowledge about their patients that may be useful in formulating a comprehensive, individualized care plan.
An education task force was formed to review the literature on communication and the nurse-patient relationship. The literature review focused on three core components for staff education: interpersonal communication, characteristics of a good conversationalist, and the nurse-patient relationship. The task force identified that patient-centered communication actively encourages patients to participate in a conversation.5 Clinicians' readiness to listen, friendliness, and ability to give time and be present at the bedside are what patients perceive to be the components of effective verbal and nonverbal communication.6
Findings from the literature were shared and discussed by task force members. An educational plan was developed to train staff in interpersonal communication. The content of the education material consisted of an introduction to Social 10, the rationale for implementing it, evidence derived from research, characteristics of a good conversationalist (actively listen, maintain eye contact, and be mindful of body language), guidelines for executing Social 10 (time spent may vary; don't perform clinical tasks during these conversations; eliminate physical barriers, such as papers, clipboards, and work phones; sit down if possible; and be at eye level with the patient), and tips on how to start a conversation. Role-playing was also incorporated to model the proper execution of Social 10 at the bedside. Ten 1-hour educational sessions were scheduled so that clinical nursing staff members from all shifts were able to attend the in-service.
Social 10 was implemented on August 2014 on a 31-bed acute medical-surgical unit with three levels of care: 17 regular telemetry beds, 8 stepdown beds, and 6 transplant intensive care beds. The patient population is diverse, ranging from young to older adults, with a focus on gastrointestinal medicine, liver and kidney transplant, head and neck surgery, general surgery, vascular surgery, orthopedic surgery, and inpatient hospice and palliative care. These patient populations have varying LOS and pose different complex care needs. During the implementation phase, charge nurses and task force members shadowed and guided the nursing staff to integrate Social 10 into practice through direct observation. Immediate feedback and coaching were given to the nurses to enhance their proficiency with patient engagement.
To evaluate the sustainability of Social 10 on the unit, task force members conducted follow-up interviews with nurses about their experiences using it on a daily basis for a month. Charge nurses also gathered feedback from patients and families selected randomly during rounds. To measure the impact of Social 10 on patient satisfaction, both qualitative and quantitative data associated with patients' perceptions of nursing interaction and communication at the bedside were explored and compared with preimplementation data. Quarterly data were then plotted and trended to evaluate efficacy and sustainability.
For subjective qualitative data, the inpatient weekly comments report (IWCR), which is collected and compiled by the patient experience department, was reviewed for any improvement in the number of patients positively commenting on facets of effective communication, such as attentiveness, sensitivity to needs, caring, professionalism, friendliness, and courtesy. The following HCAHPS domains were used for quantitative data: “likelihood to recommend the hospital,” “communication with nurses,” and “nurses listen carefully to you.” The pain management domain, including “pain well-controlled,” was also examined because nurses' sensitivity and response to patients' needs can have a positive or negative impact on pain management.
Since the initiation of Social 10, more patients have reported satisfaction with nursing care. Exploring the IWCR showed that courtesy, authenticity, compassion, professionalism, and attentiveness were recurring descriptions used by patients to express their relationship with nursing staff. For example, one patient wrote that their nurses' “authentic and real concern for my well-being before and after surgery was outstanding and superb...they have made me feel welcomed, the atmosphere was always courteous, friendly, [and] respectful. I felt like a person, never once [did I feel] like I was just a Medicaid number [or] paycheck.” Another patient with chronic pain reported, “he [the nurse] recognized that I was distressed and listened carefully to understand why, [he had] great nursing skill.” Other descriptions frequently used by patients included “caring and compassionate,” “listened and remedied problems,” and “given undivided attention,” all of which are components of effective communication.
There's also been an overall increase in the unit's percentile ranking for all of the HCAHPS domains being followed. Social 10 was introduced in the third quarter of 2014; HCAHPS scores for the first and second quarter of 2015 were evaluated. Patients highly recommending the hospital and reporting that staff members took their preference into account increased 6.1 and 7.9 points, respectively. Pain management saw a top box point increase of 6.8 for the second quarter of 2015; within this domain, “pain well-controlled” increased 10.1 points.
Previous scores for “communication with nurses” and “nurses listen carefully to you” had been unsteady, with no consistent trend. However, since the implementation of Social 10, these two domains have seen a gradual upward trend, with a top box increase of 2.7 and 4.5, respectively, for the second quarter of 2015. Slow improvement in the “communication with nurses” and “nurses listen carefully to you” domains can be explained by the nursing staff changes we experienced between September 2014 and June 2015.
Effective communication requires specific interpersonal skills that need guidance and time to master, such as active listening, therapeutic presence, and time management. Since Social 10 was initiated, there was a 10% RN turnover due to nurses graduating with advanced degrees, returning to school full time, switching to part time to concentrate on graduate studies, and relocations/transfers to another unit. To sustain the unit's staffing pattern requirements, new graduates were hired and the focus was on onboarding. A period of learning and adjustment for the new graduates must be taken into consideration.
Based on the qualitative IWCR and quantitative HCAHPS data comparison, we found that spending quality time talking with patients can enhance the nurse-patient relationship. Although it can be argued that improvements in the “likelihood to recommend the hospital” and “pain management” domains are the result of many variables that influence the patient experience, such as interactions with the interdisciplinary team and overall hospital stay, it should be emphasized that nurses play the most prominent role in patient satisfaction because they're at the forefront of patient care at all times. Once a nurse-patient relationship is established, the nurse has the opportunity at any point during the patient's hospitalization to ensure that he or she has a positive experience. Therapeutic relationships and effective communication allow patients to express their concerns openly and honestly.
A perfect 10!
Social 10 has been successful in improving bedside communication and enhancing the therapeutic nurse-patient relationship. The initiative has strengthened the trust that patients have for their clinicians and allowed nurses to gain information about their patients. With the utilization of information gathered during Social 10, nurses can formulate an individualized care plan that incorporates patient preferences and psychosocial and learning needs, improving adherence and clinical outcomes.
Partnership with the nursing education department to integrate Social 10 as part of the orientation curriculum for newly hired nurses will be beneficial to ensure sustainability and continuity of therapeutic communication. Further studies on Social 10 conducted in different healthcare settings are recommended to confirm its positive impact on communication, patient satisfaction, and the therapeutic nurse-patient relationship.