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Changing Practice

Everybody matters 2: promoting dignity in acute care through effective communication

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Good communication is vital to dignified care. This project explored the ways in which nurses could improve their relationships with both patients and colleagues

Authors

Caroline Nicholson, PhD, MSc, BSc, HV/DNCerts, RGN, is dignity development nurse; Mary Flatley, PhD, BSc, RGN, is lead research and development nurse; both at Royal Free Hampstead Trust and City University; Charlotte Wilkinson, DH, MA, MSc, RGN, is lead research and development nurse, Barnet and Chase Farm Hospitals Trust and City University; Julienne Meyer, PhD, MSc, BSc, CertEd (FE), RNT, RN, is professor of nursing/project lead, School of Community and Health Sciences, City University; Patricia Dale, RGN, is dignity development nurse, Royal Free Hampstead Trust and City University; Lucinda Wessel, RGN, is dignity development nurse, Barnet and Chase Farm Hospitals Trust and City University.

Abstract

Nicholson C et al (2010) Everybody matters 2: promoting dignity in acute care through effective communication.  Nursing Times; 106: 21, early online publication.

The Dignity in Care Project (DCP) aims to deepen understanding and develop practical interventions to promote dignified care in hospitals. A key feature is that “everybody matters” (a project slogan) and that promoting and sustaining dignity in acute care requires recognition and support for staff as well as for patients and their families.

DCP is a nurse led research collaboration with Royal Free Hampstead Trust, Barnet and Chase Farm Hospitals Trust and City University. Practical interventions devised by the project are presented around three key themes. Part 1 of this series explored the first theme, “maintaining identity: see who
I am”, and this second part examines the second theme, “creating community: connect with me”. This recognises that in the act of caring, nurses receive as well as give. Dignified care has a reciprocity where both carer and patient/family give and receive, rather than simply involving a list of practical tasks done to someone. The third and final part looks at “shared decision making: involve me” (Bridges et al, 2009).

Keywords Dignity, Communication, Connection, Dignified care

  • This article has been double-blind peer reviewed 

“Connect with me”

Creating community may not be nurses’ first thought when thinking about dignity. However, to move beyond just doing things to people, the idea of a two way relationship is important. To be human we all need connection and communication, particularly in times of uncertainty and vulnerability. Although it varies between individuals, being a hospital patient creates an unbalancing of the emotional, spiritual and social aspects of every person, as well as a physical difficulty. To deliver dignified care, it is essential that nurses recognise and connect with patients who are in this position.

Defining “caring” is not easy and there are many models and theories. Iles (2006) defined healthcare as “acts of work and/or courage undertaken with the intention of enabling the potential of patients”. This potential varies according to patient circumstances but always involves an intention of will, what Iles calls “courage”, by the healthcare professional to risk connection with, and on behalf of, the people they are caring for. In this project we talk about the possibilities within a patient-staff connection, when we choose to see a patient as a person to be engaged with rather than a body to do things to.

The quote from a student nurse interviewed by the project exemplifies this connection (Box 1). This quote exemplifies something extremely important that is often missed about caring: the connections made with patients and their families can be good and are, in part, the reason why we became nurses; in the process of caring, we receive as well as give (Beeby, 2000). One man (interviewed during the project), who had been in and out of hospital over many years, noted:

“You look out for them [the nurses], they have a hard job and it’s the patient not just the nurses who need to think, you know, [you need to] be thinking about them too, after all they’re only human.”

Box 1.  Student nurse comment on connection

“I have learnt [from the project] to talk to patients; even though they’re not in a state of understanding or they’re confused, or as you would label them [have] dementia, it doesn’t mean that they don’t understand. We still treat them the same as any other patient who is less confused. Ask them, gain consent from them before we do anything, bathing them, like Lily,* she stops screaming, you know, when you ask her and explain about washing instead of just doing it to her. Yesterday we did that and she laughed with us, it’s not always like that but sometimes [it is].”

*Names have been changed.

It is interesting to turn things on their head and think about what you as a nurse receive from the people for whom you care. Appreciating what people give you may be as simple as recognising a thank you or a patient’s smile; it may be a mutual interest that you share with patients or something they give you through their stories and conversation. Finding your way to those connections is the focus of this article.      

However, not all patients are easy to care for and working in hospitals inevitably involves exposure to highly stressful and emotional situations at times. Cornwell (2009) noted that staff experiences are “likely to be affected not only by the quality of their interactions with patients but also by the quality of those with colleagues from the same team, unit and department”. It is clear from our work and others’ – such as Crow et al (2009) – that sustaining dignity in care requires attention to the connections between staff as well as between staff and patients or their carers.

In a listening exercise we asked staff in both trusts what made them feel valued at work. Feeling appreciated was the biggest theme and 42% of all responses related this to being appreciated by colleagues and managers. One nurse wrote:

“I feel valued when I am consulted and asked rather than told to do something. It’s about working as a team and understanding that we are all human!”

Part of “connecting with” is acknowledging the reality of working in hospitals. Connecting with the humanity of patients and that of other staff is an essential part of giving and sustaining dignity.

Below are some practical suggestions that have emerged from talking to and working with nurses on the wards. Their aim is to help other nurses both reflect on and develop everyday practice to connect with the people being cared for and the staff they are caring with. For ease these are considered under the following headings and summarised in Table 1.

  • Connecting with and creating values around caring;
  • Putting yourself in another’s shoes;
  • Promoting communication that connects with the person.

Connecting with and creating values around caring

The culture of the unit, that is, the way we work with others and our shared understandings about the jobs we do, is vital in shaping the type of care we give (Baillie, 2009). Yet often our values on care are individual and unspoken.

Relationships with patients are not a matter of individual commitment but a vital component of professional accountability that can be linked to better quality care (Weinberg, 2006). As such, articulating the relational aspect of nursing work, where time is taken to know the individual and their unique perspective and history, is important.

What do you believe in? In this project we used a modified beliefs and values questionnaire (Manley, 1997) to help different staff groups to consider and develop a shared understanding of care. We asked ward staff to complete three sentences:

  • If I were a patient on this ward/department I would like…
  • If I were a relative/significant other of a patient I would like…
  • As a member of staff on this ward/department I would like…

The nurses who asked the questions found the process of carrying out the questionnaire helpful. New ways of relating as colleagues emerged as staff exchanged ideas and experiences around giving and receiving care. In bringing the answers together and identifying themes, some ward leaders were struck by the similarity of the professionals’ answers. The questionnaire helped to identify the strengths they already had as a team and identified areas of development.

Connecting with colleagues: finding ways of hearing what it is like for nurses to do their job is an important aspect of creating connections. The Assessment of Work Environment Schedule (AWES) tool (Nolan et al, 1998) is a structured tool to measure nurses’ work environment. It has 34 questions, which are clustered around
six themes:

  • Recognition and regard;
  • Workload;
  • Continuing professional development;
  • Quality of care;
  • Working relationships;
  • Autonomy/decision making.

We used AWES primarily as a way to begin conversations about the importance of ward culture to the practice of giving and sustaining dignified care. Ward staff found the tool easy to fill in and it created a space to discuss the work environment and the challenges and possibilities of ward culture in giving care.

Putting yourself in another’s shoes

The act of empathy – seeing and feeling the situation from the other’s unique perspective – is a key part of giving dignified care. What did become clear from project interviews was the impact on nurses and their care as a result of being on the other side, as a patient or relative:

“Since my mum was ill it is different, I see her in other patients, I want to check out that they are OK, that’s what I wanted for her.”

Although it is necessary to step back into professional roles in order to care well, keeping connected to others’ perspectives and their individual experience is important.

Connecting with patients/carers: in the project we use a variety of creative techniques to think about the experiences of others. One example is the use of drawing to help nurses explore their own feelings and expectations about older age. A group of nurses were asked to think about and then draw themselves aged 80 (Roberts et al, 2003). They were invited to explain any aspects of their picture to their colleagues. The physical characteristics of ageing were an obvious focus of many pictures and led to discussions around nurse attitudes and how this may affect the connections people made. One nurse commented on the exercise:

“It was good fun and interesting, it’s good to remember not to assume, if you don’t ask you don’t know.”  

Being visibly appreciative: it is not always easy to keep connected to others, particularly in times of stress, and the role of the ward leader is pivotal (Royal College of Nursing, 2009). It is helpful to create routine practices that keep nursing leadership connected to staff, patients and the realities of clinical practice. Examples of this include the charge nurse who goes round his ward daily, checking with each patient to see how they are and if they have any immediate concerns. Appreciation can get lost in the busy ward culture. Yet being thankful is a skill and needs to be practised like any other. Some ward leaders intentionally end the shift by thanking their staff, while others highlight to their ward team the letters of thanks from patients and family. Focusing on what the ward is doing well is a powerful tool in keeping people connected to each other and to their jobs.

Promoting communication that connects with the person

Communicating well is complex and involves aspects of ourselves, the other person and the context in which communication occurs. Promoting communication may involve learning skills, recognising attitudes and changing the environment in which care is given. We used the Shortened Quality of Interaction Schedule (SQUIS) (Dean et al, 1993) to help nurses to value existing good communication in their unit and identify areas to develop.     

Valuing and enhancing good communication: SQUIS is a simple observation tool to allow staff to stop, look, listen and appreciate the quality of communication where they work (Ashburner et al, 2004). We used two people, one project nurse and a senior clinician from the unit, to record interactions between staff, patients and relatives/visitors. This was done for up to 20 minutes in communal areas of the ward/department.

The interactions are coded into four categories:

  • Positive social interaction (PS) denotes empathy, connecting with the person;
  • Basic care interaction (BC) records communication around getting a task done;
  • Neutral interaction (N) is a brief, indifferent interaction;
  • Negative interaction (N-) records communication that ignores, patronises or is rude.

The ward team then discuss the exercise together, focusing on recognising good practice in their area and looking at how compassionate communication can be promoted. They can then consider what specific processes or behaviours in the ward may diminish this.

The wards in our project found SQUIS extremely helpful in providing a structured way to stop and observe their everyday environment. The observers commented on the power of positive social interactions, such as: the importance of touch with a person who is confused; nurses staying with someone in distress; and ensuring being at eye level when communicating with a patient in a chair.

The observation was a powerful reminder of communication habits that can get in the way of connecting with patients and colleagues. Examples might include talking through closed curtains, conversations about “doing” tasks to bed numbers while with patients, and the noise of staff calling out across the ward to each other for keys.

Nurses responded well to the tangible and structured feedback that SQUIS provided and were able to make and then see the difference in the quality of communications. The following extract from project interview data shows the lasting impact on connecting with people through taking time to stop, look and listen: 

“As the matron, I managed a housekeeper for about two years and, while we had a fairly amicable relationship, it was not particularly friendly. Following a SQUIS session a few weeks ago we observed that her interaction with the patients when giving out tea and coffee was extremely good. Following that observation I fed back to her on how well both the sister and I felt she had done. She was very pleased at the time. However, what I think is more interesting is her change in attitude toward myself, she is now very friendly and happy to see me” (Interview after SQUIS).

Conclusion

The phrase “walk a mile in another man’s shoes” suggests it is not really possible to  connect with someone unless you spend some time thinking about their situation or life – metaphorically, putting on their shoes. The challenge in “connect with me” is to move beyond clinical-patient contact to human-human contact. This article provides practical examples to help nurses connect with the people they are caring for and working with. This is rewarding but can be difficult work and the complexities of busy hospitals, with many different people providing care, can challenge sustained human connection.

The third article in this series explores further the importance of trusts in supporting staff to remain connected and involved with the people they care for and work with. For staff to “connect with me” they need to be supported by the organisation and fellow workers as well as by wider policy decisions. Although acknowledging the impact this can have on giving dignified care, this project highlights the power of kindness, mutual respect and appreciative relationships even in the most pressing times.

Acknowledgement

We would like to thank all patients, family and staff who took part in the project. 

  • 1 Comment

Readers' comments (1)

  • Peter Goble

    I like this article, and especially the idea of reciprocity in human relationships.

    Do the authors have any idea of what might be the minimum time required for any kind of reciprocal relationship to emerge, allowing for significant 'connection'?

    My own unresearched but intuitive experience over a lifetime (50+ years) of nursing suggests that it must be based on a number of serial interactions over a significant, but not necessarily lengthy period of time.

    My experience as a patient suggests that serial interaction over time with the same nurse is highly problematic, except under exceptional circumstances, making for not much, or no real connection. My experience as a patient has suggested that it is I, the patient, who has to take the initiative in this respect, usually against the odds.

    Perhaps some research could address this question?

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