Using H.E.A.R.T. to Address Patient Issues

If nurses would only show a little heart when dealing with difficult situations involving patients and families, it is likely that ruffled feathers could quickly be smoothed. The heart to which I’m referring is Respond with H.E.A.R.T., a practical, common sense approach for addressing patients’ frustrations and complaints that is being used at the Cleveland Clinic (the Clinic) in Cleveland, Ohio.

The program, an extension of the Clinic’s commitment to put patients first, is designed for use by any employee at the Clinic, not only nurses. It is quite a basic premise and one that would work in any interpersonal situation: nurse to patient, nurse to coworker, husband to wife, friend to friend.

The beauty of H.E.A.R.T. is that the booklet that outlines the steps involved also offers suggestions for dialogue to be used in a variety of scenarios. The five steps of H.E.A.R.T. are:

Hear: When someone is upset, stop what you are doing, focus on him or her and truly hear their complaint. Don’t interrupt, just listen.

Empathize: Think about the emotions he or she might be feeling, and verbalize that you can relate. “I can imagine how upsetting this must be for you.”

Apologize: A sincere apology can be powerfully effective in defusing a contentious situation. “I’m sorry that you are so frustrated,” or “I’m sorry that we did not meet your expectations.”

Respond: This is where you solve the problem. Say what you are going to do and what he or she can expect. “I’m going to call your doctor and I’ll be back in 10 minutes to give you an update,” or get the person’s input—“How can I make this better?”

Thank: Dealing with an upset person can be a challenge but be mindful that you are being given an important opportunity to rectify a negative impression. “Thank you for sharing your concerns with me,” or “Thank you for taking the time to make me aware of this.”

These steps can be used in myriad situations, from complaints about waiting for call lights to be answered to delays in meals being delivered, from questioning the need for a procedure to complaints about the attitudes of staff members.

I’m not always a fan of role playing, but in this case I think it would be beneficial. Practicing what to say in given situations puts the appropriate words closer to the tip of the tongue when those situations arise, rather than the easier-to-come-by defensive response.

Five simple steps. Worth a try, don’t you agree?

Protecting Privacy Involves More than Safegurading Information

Nurses and physicians have been charged with the nearly sacred duty of protecting patient privacy for as long as I’ve been a nurse and for decades before that. For the past several years, the importance of privacy has been elevated to a very serious, protect-it-at-all-costs-or-you-could-be-dragged-into-court status. In the role of patient, we’re signing papers right and left every time we visit a physician’s office or are admitted to a hospital. Nurses in those settings are making sure those papers get signed. We are all toeing a fragile line to keep names, medical histories, diagnoses and treatments tightly under wraps, which is as it should be. But, we need to remember that there are other kinds of privacy and they, too, need protection.

On a recent evening a friend took her elderly father to the local emergency room, soon after the father mentioned to her that he hadn’t urinated for two days. Without revealing everything that took place, I will just say that the nurse (male) shared explanations and asked questions regarding extremely personal activity. Necessary conversation? Yes (I guess). In the presence of the patient’s daughter and granddaughter? I think not.

I had a similar experience, coincidentally in the same emergency department, several years ago. I’d accompanied a male high school-aged exchange student there for treatment of a dramatically swollen ankle and red streaks up his lower leg. With no warning the physician began asking about the young man’s sexual activity. I was so taken by surprise that I did nothing to protest, but I felt then and still feel that the physician’s behavior was inappropriate.

Asking family or friends to step out of the room momentarily is perfectly acceptable and should be done (gracefully) more often. In the recent case, the patient is quite hard of hearing so the daughter thinks it’s possible that her father didn’t catch enough of what was said to be mortified, but the two females in the room report being uncomfortable. In fact, the granddaughter did leave the room during the conversation and, later, the nurse did offer an apology. I am not a prude—far from it, in fact. But, isn’t this a matter of courtesy and respect for both the patient and the family?

Privacy involves more that medical records and indiscriminate gossip. We need to pay attention to what we say, and in front of whom, just as we need to ensure our patients are modestly draped during exams and procedures—which, now that I think of it, we could also do a better job of.

How do you handle similar situations?

Medical Quizzes Help Sharpen Skills

Are there other nurses out there who enjoy the challenge of making diagnoses? It seems I can’t pass up an opportunity to attempt solutions to medical puzzles. A few seasons back, a news magazine show on TV (Dateline, I think) ran a series of episodes in which three case studies were presented each week.

The cases weren’t presented in sequence, as in case #1 in its entirety, then case #2, followed by case #3. Instead, there was a brief lead-in to case #1, after which four choices of diagnoses were flashed on the screen and the viewer was asked to select one. Then, the show moved on in the same fashion to case #2 and, finally, to case #3. During the course of the hour-long show, each case was revisited twice more, with further details of the case presented each time. Again, at the end of each short segment, the four choices of diagnoses were displayed onscreen and the viewer was asked, again, to choose a diagnosis. So, I, the viewer was given the opportunity, based on the additional information presented, to have a change of mind or stick with my original assessment. I really got into that show and had a surprising record of accuracy.

I say surprising because I haven’t worked in a clinical setting for many years and don’t take official continuing education courses. I do read a number of publications and gather quite a lot of information online but I know my skills are rusty since I don’t have the benefit of constant immersion and reinforcement.

One trick I used when watching the TV show was to state a diagnosis even before the choices were flashed on the screen. If my preliminary diagnosis showed up as one of the four choices offered, I most often stuck with it—successfully. You know that old saw: go with your first instinct.

I receive regular e-mails from Medscape CME and last week’s mailing offered the opportunity to make diagnoses of five case studies. I made correct diagnoses of four of the five cases, three of which were somewhat obscure conditions. The answer in the fifth case involved reading a CT scan, something at which I am not adept.

I see value in taking the time to give thought to these medical mysteries for a few reasons. One, these exercises just plain get the old cranial wheels turning. Then, I am forced to consider the evidence: symptoms, treatments that haven’t solved the problem and diagnostic tests. I always learn something and a lot of it actually sticks with me.

I recommend that even nurses who are in a clinical setting every workday take a stab at responding to these little quizzes. They are fun, it doesn’t take long, doing so will take you outside your medical specialty box and no one will know if you answer incorrectly.

Who enjoys these tests the way I do? Don’t you, too, find them beneficial?

The Truth About Nursing: Changing How the World Thinks About Nursing

The Truth About Nursing (TTAN) is a new, Maryland-based non-profit organization that promotes nursing by insisting on accurate portrayals of the profession by all media, be it television, movies or print. TTAN is a tough taskmaster, keeping a close eye on the media and raising a ruckus when they get it wrong.

I’ll bet most of us watch an episode of “Grey’s Anatomy” or “House” and say, ‘That would never happen,’ or ‘What really goes on in the hospital is nothing like that,” and let it go at that. Thank goodness TTAN is on the ball, watching out for the rest of us who, for whatever reason, rarely, if ever, take action.

It’s easy to say, “Oh, it’s just TV—what’s the big deal?” But TTAN says it is a very big deal indeed. Just two examples: The media continue to diminish the value of nurses and the major contribution they make in managing the world’s health. The media allow major physician characters in TV medical dramas to demean and disparage nurses. In so doing, media is also adding to the problem of the world’s nursing shortage and, ultimately, untold unnecessary deaths across the globe. When a profession is depicted as lacking esteem and respect, or represented as performing unimportant tasks, it is difficult for that profession to attract the numbers of quality practitioners necessary to do its job well.

TTAN wants the world to know exactly what it is nurses do—and, we do plenty. But, the majority of the populace has no idea regarding the level of education and skill that nurses bring to their work or the magnitude of the responsibility we carry.

A major complaint of TTAN is that TV medical dramas most often show physicians doing the work that is done almost exclusively by nurses. Wouldn’t we all love to see a real life situation where the physicians really were left to do it all with no help whatsoever from nurses? What a chaotic scene that would be!

We all need to get involved in helping set the record straight and TTAN has simplified the process for us. Go to www.truthaboutnursing.org and click on campaigns, take action or contact us. There is great information on all three pages.

TTAN’s executive director, Sandy Summers, has written a new book, "Saving Lives" with co-author Harry Summers. Two chapters of the book are devoted to a plan that tells in simple terms how each of us can help change how the world thinks about us. I haven’t yet had a chance to read and review the book or to get a good look at the plan but I’ll be writing more about all of it in the near future.

Come on nurses, get on board. We have important work to do.

Try a Touch of Levity to Put Patients at Ease

I’ve been known to remark, “I’d do anything for a good laugh,” which is, of course, a broad generalization. While I do enjoy a good laugh and a lighthearted (not silly—well, okay, sometimes silly) approach to life, it goes without saying that I wouldn’t do just anything to bring about a chuckle or two.

The American Journal of Nursing arrived in my mailbox a couple days ago. Within the pages of the esteemed Journal is an article, authored by a student nurse, that advocates humor as a means of breaking the ice and helping the patient relax.

Her suggestions are simple and not remotely in the category of knee slappers, but they have worked for her. Often just a short, “How’s it going?” or, “How about those Mets,” spoken directly to the patient who is about to have a bedside procedure, can produce a little smile and maybe some conversation.

I don’t remember, in my student days, being specifically instructed to avoid humor. I do, however, recall quite clearly that we were to present ourselves in a strictly professional manner, so it seems that even a hint of funny business would’ve been frowned upon.

Humor definitely has its place in medical circumstances and can effectively defuse tense situations. I recall a doctor’s use of humor that nearly 25 years later still makes me smile. My mother was suddenly struck by what was later diagnosed as rheumatoid arthritis. Almost overnight she went from being asymptomatic to having total large joint involvement. Both knees were swollen to the size of softballs. Her hip and shoulder joints were so painful that she couldn’t bend into a sitting position or raise her arms to brush her hair. In a word, she was miserable.

The scheduler for a rhuematologist in a large multi-specialty clinic took pity on us and squeezed Mother into his jam-packed schedule. After checking in, we were soon taken into an exam room where we waited and waited and waited for more than 45 minutes, with Mother unable to sit because it was too painful for her.

We didn’t fault the physician. We knew the office was doing us a favor and we were grateful to be there but that did nothing to relieve the discomfort Mother was enduring. Suddenly the door swung open, the doctor stepped in, put a hand on his hip and said in an incredulous tone, “Erma! Where have you been? I’ve been waiting on you for hours.”

All three of us laughed. The doctor knew how patients often become testy when they have to wait and he wisely used humor to soften any irritation he might encounter when he entered that exam room. It worked. Our wait instantly became a non-issue and we got on with the task at hand.

Medicine is serious business, no question about it, but a small infusion of real-people speak can go a long way toward lightening the mood and easing anxiety. Give it a try and tell me the story about how it worked.

The Dilemma of Long Term Care for the Elderly Deaf

I don’t like to think of myself as living in a bubble, unaware of the plight of others, but sometimes an issue is brought to my attention and I am dismayed to realize that I’ve never given a thought to something that is so monumental to someone else.

That happened today. I had a few back and forth e-mail exchanges with a woman I have never met. I will call her Mary. In the course of telling one another our respective stories, she mentioned that her father has been deaf all of his life. In his youth he attended schools for the deaf and communicates using American Sign Language. For most of his working years he lived in California, worked in the airline industry and had many friends in the deaf community there.

Life was good for many years but, then, as he aged his health became more fragile. He suffered several strokes and was unable to care for himself. Mary, who has lived in Arkansas with her family for the past 18 years, moved him there. Initially, he was placed in a nursing home but it was impossible for him to communicate with his caregivers and vice versa. Mary quit her job as a teacher’s aide in special education and is now caring for her father in her home.

Mary’s aunt, who lost her hearing at the age of nine, is one of the founders of an assisted living facility and nursing home, expressly for the deaf, that is being built in Phoenix. Other such facilities exist in Massachusetts, Ohio and Texas. None of the three existing facilities is located near Mary, however, and don’t provide a solution to her and her father’s problems.

Mary commented that she has been unable to find another deaf person in a nursing home anywhere in the entire state of Arkansas. It seems the elderly deaf in Arkansas are cared for in the homes of family members. But, Mary pointed out, not all deaf have kids who can care for them and the challenges for the deaf in the medical world are immense. Even if Mary’s father were living in a deaf community, the strokes he has suffered have affected his ability to sign, complicating his ability to communicate with others who sign.

I had never considered the difficulties and isolation faced by the elderly deaf when they are cared for in a strictly hearing environment where no one is trained in sign language. The very idea of such a lonely existence is heartbreaking. Under the best of circumstances patients struggle with adjusting to long-term care facilities. Imagine being in unfamiliar surroundings, unable to communicate pain and discomfort to your caregivers or being unable to understand instructions and explanations from them. Imagine having limited, if any, means to socialize with hearing residents. It is a disheartening picture.

Please share any experiences you have had caring for the deaf, particularly the elderly deaf.

Bedside Manner: Can it be Taught?

Bedside manner is a term usually associated with physicians, not nurses. Is that because the Angel of Mercy stereotype expects that nurses are innately equipped with ideal skills for interacting on all levels with patients and their families, relegating bedside manner to a non-issue status? Not necessarily so.

I mention the topic because I was reading an article about the bedside manner of physicians and how it is addressed (or not) as part of the medical school curriculum. One faculty member stated that bedside manner cannot be taught—you either have it or you don’t.

Oh, my! I certainly disagree with that statement. Of course, bedside manner can be taught. To say it can’t be done is to excuse the behavior of those who aren’t willing to learn.

There are many facets involved in getting the message across to medical students and residents, but perhaps the most important one, according to a recent study, is the modeling of what constitutes good bedside manner by faculty and attending physicians.

The study took place at five major medical centers and involved a cadre of physicians who met weekly for behavior exercises and discussions to improve their interactions with patients. The idea was that when they put their newfound skills to use, the students and residents would learn by observation. Using a control group for comparison, the results of the study proved modeling to be highly effective.

It was the modeling aspect that caught my attention because of a foolish and imprudent willingness to model my behavior after a nurse who was not the best example. The emergency room was my nursing milieu of choice and the head nurse of the department was highly skilled and capable. She was also tough and crusty, as opposed to warm and fuzzy, and sharp-tongued remarks by her to staff and patients alike were the norm.

It is embarrassing to think about now (and has been for many, many years), but for much too long I imitated her behavior, that bordered on rude, if not crude. It seemed to be the ER culture and I allowed myself to fall right into it. Those who know me now would have a hard time believing that conformity was ever important to me but I think wanting to fit in had something to do with my less than ideal behavior.

My message to nurses is that bedside manner is important, especially in the presence of young or new nurses. The main benefit, of course, is to the patient but being a good example to other nurses ultimately benefits greater numbers of patients. It is a simple, but sometimes overlooked, premise that the most effective teaching is often done by example.

Any thoughts on this subject are welcomed.