HSE plans to build patient relationships all well and good but essentials of respectful care never change

Much nonsense has been talked about the HSE forbidding staff to call patients “love”, writes Terry Prone

THE minute they mention the new arrival in ward six, they cast their eyes upward. This one will be tough-going, is the unspoken prophecy. She’s close to 80 and was admitted after a hip-breaking fall complicated by a leg ulcer that’s not going away, although, give her her due, she’s been taking care of the ulcer herself with some efficiency. How did she fall? Mis-step when she was putting out the milk bottles.

Once the milk bottles get mentioned, it’s clear that this oul’ wan didn’t land in hospital today or yesterday. It was probably 30 years ago, and she was fictional, was the broken hip in ward six.

The nursing board at the time — An Bord Altranais — commissioned me to write a video which would incorporate all the things that could go wrong in the crucial opening to the relationship between the attending nurse and a new patient.

The little playlet, which may have run for no longer than five minutes, was to spark a workshop among nurses, facilitated by an expert.

It was the best fun in the world, creating the oul’ wan, who was played by a great actress named Marie Keane. It was fun because the character was such a pain in the arse while being vividly lucid at the same time.

No whinge was left unexpressed. She gave out about everything, starting with the fact that the nurse was asking her the same goddam (her word) questions she had been asked by three separate other people since she had landed in the hospital.

Why, she asked, did all these people working for the same institution within the same health service not share the information and not put the patient through the misery of having to constantly repeat themselves when they were already exhausted and sick? Why did the staff not pay attention, first time around? The young nurse, who wasn’t a bad nurse, shrugged and smiled; rules are rules, you know yourself.

The oul’ wan clearly didn’t know or accept this, but eventually submitted to answering the same questions all over again, as a result of which it became clear that she was a widow with one daughter who by any measure was a decent caring daughter, but who, in the patient’s portrayal, was interfering, pious, humorless and ostentatiously dutiful.

The patient also announced that she liked highly spiced foods, grimly adding that she knew she was stuck, for the next while, with the blandest of bland hospital food. Things like blancmange, she added. The nurse evidently didn’t have a clue what that was, and had even less interest in finding out. All of the little trailing wires providing clues to the difficult old woman’s personality, background, loves, hates and realities were missed, one by one, as she was reduced, on paper, to a neatly-written compendium of data the hospital deemed relevant, right down to her having the most expensive form of VHI cover, because her late husband was obsessed by not being subject to the public system. “Mmmm?” was the nurse’s response to this particular statement.

Marie Keane didn’t need a scripted line to show how demeaning was this lack of interest.

She just sat there, expressionless, against the A-shaped pile of pillows propped against the metal support frame, and shriveled into defeated acceptance of her new status. Her new diminished, demeaned status.

Add up all the clues in the playlet and a complete profile of the patient emerged, one aspect of which was that she was not the kind of woman who would respond well to being first-named. She was the kind of woman who would describe that as “over-familiarity” on the part of the nurse. Who promptly used the patient’s first name and departed, happy that she had managed a difficult patient well.

In workshops after the video was shown, some nurses were baffled as to why they were watching it at all: the nurse onscreen, they maintained, had done what nurses were supposed to do, competently and civilly. Going further, one participant would assert the nurse was a saint in the face of a profoundly difficult patient. Someone else would ask what was meant by “difficult” and several voices would offer examples of just how obnoxious the old lady had been.

At this point, the discussion tended to move into the hot-and-heavy department, with, on one occasion, a nurse stopping everyone in their tracks by saying quietly that it was dead easy to take care of the likable, but that everybody present had signed up to take care of likable and dislikable alike.

It wasn’t lifelike

SOMETIMES, nurses would claim that it wasn’t lifelike — only to be challenged by others in the group who claimed to have witnessed behaviours and responses portrayed.

The argument would on occasion be made that nurses are all under such fierce pressure, they can’t find time to be coddling individual patients, with other nurses pointing out that it doesn’t take much time to register and use a patient’s name, and was the nurse in the video dumb, or what, that she couldn’t see the old woman bristling at the use of her first name?

The end of the session invariably created two outcomes, as revealed by subsequent measurement. The first outcome was that every nurse who took part subsequently approached that initial interrogation, not primarily as a fact-finding activity but as the introduction to a therapeutic relationship.

The second outcome was that each group developed their own set of agreed rules for such encounters in future.

The wording of the rules varied between groups, but the 10 key self-directed strictures matched almost completely from group to group: 

1) Learn and use the patient’s name, having first found out how they like to be addressed; 2) Learn the patient: make eye contact; 

3) Don’t disrespect them by writing down what the system wants to know about them, but NOT writing down what they want the system to know about them; 

4) Probe; no information shared should be noted without context; 

5) Don’t patronise; 

6) Don’t bristle if criticised or if the patient goes on about some previous bad experience; 

7) Don’t look at your watch — nothing is more important than the human being in front of you; 

8) If in a shared ward, don’t repeat confidential information provided at the top of your voice; 

9) Don’t ever, subsequently, refer to the patient pejoratively (“that oul’ cow in bed eight”) or permit colleagues or consultants to refer to the patient by ailment (“the broken hip on the third floor”); 

10) If you promise to find something out for the patient, make sure you deliver on that promise.

Much nonsense has been talked about the HSE forbidding staff to call patients “love”.

In fact, it’s fair to assume that the 120 page document backing their new plans to build relationships with patients follow the principles adduced in the workshops of three decades back. Because the essentials of respectful care never change.

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