The key to the optimal patient experience is sustainably grounded in the ethos and practice of nursing.
From Florence Nightingale: “I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet -- all at the least expense of vital power to the patient.”
To nurse someone to health makes us think of specifics images of caring, as well as any number of tasks and responsibilities. The professional nurse, however, does so much more with skill, knowledge, and in-depth commitment.
When Nightingale wrote this, she was writing a job description of one person. However, in current healthcare organizations many of these tasks wind up being handed to environmental services, housekeeping, and dietary services. Further, a nurse aid or CNA might also take over bathing patients and providing blankets.
Yet, there is higher risk with the nurse not doing the bathing and not observing patients except at medication time. Nightingale often wrote about how a patient would perk up when the nurse walked into the room, but such a burst of energy was for performance or out of pride. A skilled and trained nurse would see past this to actually understand what was happening with the patient.
The result is that, for patients, many people are involved in their care, with the nurse administering medications and performing a variety of clinical tasks. What’s more, nurses do all the work of tending to medical needs according to what physicians request and, as well, what they see.
For patients, each person that enters their room performing any of these roles carries the mantel of nursing. Because of this, it is common for patients or family members to ask whichever staff person is in the room about the next pain medication, meal, or any number of other things.
If you ask patients who is the most important to their recovery, they will tell you it’s the physician and the nurse. They tolerate the system that sends in surrogates, but become frustrated with the inconsistency in quality and authority.
Where is Nursing Located in the Patient Experience?
Nurses have not yet been called to, called for, referenced, or sought out to lead us into a more humane model of care that has been codified in each nurse from the day they decided to go to nursing school. The patient experience is a nursing tradition of compassion and respect for the personhood of the patient. It is inseparable from what nursing is.
Further, a subculture of nursing has formed without acknowledging its dilution of the patient experience/caregiver relationship. Patients now have one person to tend to taking their vital signs, another to respond to all their non-clinical needs, another to feed them, another to bathe them, and still another to get the “real” nurse.
Each one of these individuals knows a piece of the patient only to the degree their position allows. The rigorous call to service that is the nurse, the attention to every detail that holds the clue to the patient’s pain and suffering is not part of this subculture. In fact, the tasks that a CNA or nurse aide performs are done with minimal understanding of what human caring is. While they are considered non-professional assistants, to patients these individuals are in their room to care for them. And to do so with the highest regard for the patient and family.
In service to patients, the cohesive practice of caring should be consistent in all those who take on even a small piece of the total responsibility. Everyone, then, who enters into the domain of the patient is a nurse in the sense, as Nightingale expressed, that the health of the patient has been entrusted to them. Anything less is unsafe and inappropriate to the healing relationship and integrity of care.
Nightingale wrote that the task of the nurse is to make sure that her patient is cared for exactly as she would if she is not there, for any reason at all.
She wrote, “Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”
And Then Came HCAHPS
The HCAHPS survey makes visible what Nightingale acknowledged 150 years ago and is the mandate of Watson’s Theory of Human Caring.
HCAHPS surveys begin with questions about physicians and nurses speaking to the patient with respect. Nightingale wrote this about how to speak to a patient:
“Always sit within the patient's view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person speaking. If you make this act a wearisome one on the part of the patient you are doing him harm. So also if by continuing to stand you make him continuously raise his eyes to see you. Be as motionless as possible, and never gesticulate in speaking to the sick.”
Respect has many meanings, each unique to the individual and the situation. However, holding the patient in the highest regard was a founding tenet for the Nightingale nurse. She wrote about how not to strain the patient, how to acknowledge by one’s actions that the patient’s comfort was primary to the conversation. At that time, and even today, this is a demonstration of respect.
Many nurses have no idea what HCAHPS is other than memorandums coming from others. They are removed from the other side of HCAHPS because the ethos of their practice disavows disrespect for the patient, for the family, and for each other. And, what HCAHPS measures is already within their professional mission and practice.
As we continue to move into greater depth of our understanding what the patient experience is for the patient, those who care at the bedside must be acknowledged and supported. The key to the optimal patient experience is, again, in the ethos and practice of nursing. It is in the mission of caring merged with skill and knowledge that is in the core of each nurse that we will find answers to how to respect and heal patients into wholeness.
Susan E. Mazer, Ph.D. is the President and CEO of Healing HealthCare Systems®, Inc., which produces The C.A.R.E. Channel. In her work in healthcare, she has authored and facilitated educational training for nurses and physicians. Dr. Mazer has published articles in numerous national publications and is a frequent speaker at healthcare industry conferences. She writes about the patient experience in her weekly blog and is also a contributing blogger to the Huffington Post’s "Power of Humanity" editorial platform, dedicated to infusing more compassion into healthcare and our daily lives.