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The Healing Power of Relationship-Based Care for the Elderly

This nursing protocol is aimed at helping older patients have a better hospital outcome and empowering nurses to take a more pro-active role. 

By Margaret Jaworski

There were tears, cheers and a standing ovation when Dr. Marie Manthey, MNA, FAAN, FRCN, President Emeritus, Creative Healthcare Management, finished her keynote speech, the opening address of the 2011 NICHE Conference held last month in Las Vegas, Nevada.  The annual conference of Nurses Improving Health Care for Hospitalized Elders (NICHE) brought together hundreds of nurses, nurse leaders, educators and other healthcare professionals whose shared passion and purpose is to improve the quality of care for hospitalized older adults.

In her 40 plus year nursing career, Dr. Manthey has, as she succinctly puts it, “seen it all and done it all.” Through her experience —from stints as a staff nurse to VP of patient services and everything in between— Dr. Manthey helped develop and codify the concept of Primary Nursing, which she describes as “a delivery system in hospital nursing that created a professional role and autonomy for the bedside RN.”  Her classic text, The Practice of Primary Nursing, first published in 1980, was updated in 2002. She also contributed to Relationship Based Care: A Model for Transforming Practice. In 1979, Dr. Manthey founded Creative Health Care Management as a one-woman health care consulting service. Since then the company has gone international bringing the concept, practice and importance of “Relationship-Based Care” to not only US hospitals, but also a dozen countries throughout Europe, Asia and the Middle East.

Relationship-Based Care is a “customization” of primary care, explains Dr. Manthey. At the core of these care systems is the recognition that best nursing practices allow and encourage “nurses and patients to connect in a therapeutic relationship that facilitates healing,” she says.

To illustrate her point, Dr. Manthey recounted a personal story. At the age of five, she was taken to the hospital with a serious medical condition that required painful treatments. Her parents were unable to stay with her. Even now, more than a half century later, Dr. Manthey remembers the overwhelming fear and confusion, the vulnerability and loneliness she felt. And then Nurse Florence Marie Fischer arrived. “Nurse Fischer took the time to sit with me and console me. She colored in my coloring book,” Dr. Manthey recalled.  “And at that moment, I felt a connection. I felt healing.”  That day a frightened child felt comforted and a compassionate nurse was born.

“Every day nurses have the opportunity to connect with vulnerable patients who need comfort and reassurance,” says Dr. Manthey. “Every day, nurses have the opportunity to better a patient’s hospital experience.”

Dr. Manthey is a strong advocate of NICHE and its focus on evidence-based protocols and models of care that aim to treat the whole person. “And that’s why the program is invaluable in helping hospitals advance the quality of care for older Americans, in developing nursing leaders and encouraging nurses to find creative, caring solutions to problems faced by elders in an acute setting.”

In the speech and during a follow up interview, Dr. Manthey elaborated on the fundamentals of Relationship-Based Care in today’s healthcare culture and the importance of quality care for hospitalized older adults.

Staff nurses have a multitude of demands on their time. How can they incorporate one-on-one time with patients into their schedules?
Relationship-Based Care isn’t necessarily a time hog. Taking a few minutes out of the day to introduce yourself to a patient, sit by the bedside and connect with that patient often takes less time than you’d think. Sometimes it’s a minute; sometimes a few seconds and that connection can be made in the context of other tasks. The key is to be mindful, to have the intention to connect.  Presence is a state of being.

In your opinion what is the most challenging issue facing nurses today?
Acceptance of responsibility. The role of a primary nurse is to take responsibility for managing the care of a small group of patients. If nurses aren’t willing to stand up, claim responsibility for a patient, and be accountable for that person’s care, they end up sacrificing their authority. Primary nursing and relationship-based nursing is all about accepting responsibility.

Can you give an example of how nurses can claim the role?
What I encourage people to do is to go on rounds with physicians and to participate in decision making with physicians, to never let there be a conference on a patient that isn’t attended by a nurse.

What is the role of nurse managers and leaders in empowering nurses?
One of the most important roles of a leader is to encourage positive change, to paint a picture of the future that is more desirable than the present and to convey this vision in language that inspires others to follow. A good leader will base this vision on positive universal human values. A good leader stresses accountability and responsibility.

Talk about the importance of leadership and empowerment.
This is the biggest bugaboo we face. We are not deliberately empowering hospital employees. Instead, we’re controlling them, and that’s the stupidest thing we could possibly do. It’s counterproductive because when you empower people, you expand capacity and create energy. You have more resources so you don’t need as much staff. When you have people who are truly empowered and who are in good professional relationships based on mutual trust, costs go down. Where there is trust, it cuts time in half.

Why is there so much resistance to this?
We’re a fear-based country and a fear based society. And when people are consumed by fear, they inevitably try to impose more control. Financial fears, insecurity we experienced in the ’90s with all the mergers and acquisitions and the changing roles of nurses, all of these things contributed to this environment. I’m not a doom and gloom person. The antidote is for us to evolve personally in our profession so that we have personal security and develop a sense of self rather than identifying only with job security. Insecurity generates fear. I don’t have any formula for accomplishing this but I know this is the direction we must take.

One of the pillars of relationship-based care is caring for oneself. Why is that so important?
As nurses, we have to recognize that if we are not taking good care or ourselves, not taking stock of our own emotional and spiritual well being, it is difficult if not downright impossible to take care of others.  This awareness of self is critically important and it’s a huge challenge for many nurses as well as non-nurses.

What changes in hospital culture has Relationship-Based Nursing brought about?
In my speech, I talked about an experience that illustrates the impact relationship based nursing has not just on the nurses but also on the entire hospital. At one of the hospitals, one of the laundry staff said, “I now understand that I’m washing the sheets that touch the skin of a sick person.” That staffer had become part of the care team. That’s the best example of how relationship-based care spreads throughout a hospital and it proves that we can change hospital culture. We’re bringing nurses back to the essence of nursing, to holistic healing, to treating the whole person.

What’s the first thing you would do to change the present healthcare system?
That’s a big question. We need to shift from paying for procedures to paying for health. We need to focus on successful prevention of illness rather than financial success based on the number of procedures performed and billed. We need to initiate discussions all over the country about quality of life and end of life issues.

How can nurses help initiate this discussion? 
I think nursing unions could sponsor those discussions and it would be a real proactive and constructive way for the unions to participate in something that is instructive and meaningful. And nurses could speak to these things and people could get into discussions about it. We’re uniquely positioned to help advance this conversation. After all, we’re the ones who are there at the bedside. We’re the ones who know what’s going on.

You’re a big believer in the value of conversation, aren’t you?
Very much so. I’ve hosted nursing salons at my house and now there are nursing salons around the country where seasoned nurses, student nurses, educators and others gather to have a meaningful conversation. I truly believe that conversations can help turn passion into power.

Note: To read more about the nursing salons, go to mariesnursingsalon.wordpress.com/

A future article will highlight how Hartford Hospital in Connecticut adopted the NICHE protocol to the benefit of staff and patients.