It was one of those spring days that is, in and of itself, an inspiration. Roger Ebert was in town, and we were joining with many other film buffs for a three-day festival to view his picks for first-rate but unheralded movies. We went for a long walk between films, and that’s where the idea for this book was born.
Mary had written and taught for years about Relationship-Based Care, the notion that health care could be markedly improved by attending to the connection between the clinician and patient, and that organizations can transform their cultures to surround, support, and make time for that connection.
Michael had written and taught for years about the nuances of the infant-parent relationship, that often-taken-for-granted and sometimes elusive attachment between baby and parent upon which much of the baby’s development (sense of self, sense of self-with-others, capacity to trust) depends.
As a nurse, Mary knew a great deal about the practicalities of health care, and the enormous challenges faced by caregivers (particularly those in hospitals) who are trying to carve out time to connect with their patients, often with limited success.
As a counselor in private practice, Michael knew some things about the processes by which humans connect with each other both in therapy and in real life.
Both of us understood that the efficacy of care—and perhaps just as importantly, the patient’s experience of care—depends heavily on authentic human connection. Patients in Michael’s practice didn’t get better because he was clever or used good tactics or strategies. They got better when they experienced his empathy, his earnest efforts to understand them by hearing their stories, and when they re-experienced old hurts in this new relationship with someone who, this time around, wouldn’t hurt them.
Stirred by portrayals of anger and violence in some of the films we’d seen at the festival, we began exchanging stories about patients’ anger and soon realized that we shared a perspective: anger was not “bad behavior”; anger was meaningful, a signal that the angry person was terrified and needed to sound the alarm that he was feeling powerless and without other more rational resources. Could the same be true about other difficult patient behaviors or patient family behaviors: resistance to procedures, excessive dependence, or demandingness, for example? Could many of these behaviors, which so complicate the already-difficult day of many clinicians, be dealt with more easily if they were understood and responded to as actual communications, and could such an approach save time in the long run?
Still reveling in the early spring sun and kicking leaves left over from the previous fall, we stepped into the most uplifting possibility of all: Could it be that health care providers already have knowledge and skills which, if only used with intention, could dramatically increase the speed of recovery, could improve the patient’s experience in the hospital, could calm the units, and could increase the caregiver’s sense of meaning and purpose?
A model became apparent to us for describing exactly what comprises the experience of authentic human connection. We thought we could describe what happens between patient and caregiver in terms that would have immediate meaning and applicability to clinicians in any health care discipline. We saw the possibility for a book that presented three highly effective therapeutic practices and actually helped clinicians from all disciplines understand how to integrate them into their own daily practice.
We have observed that many books that presume to be how-to books actually end up being why-to books. They make the case for a way of being or a way of doing and they don’t actually tell you how to do anything. A book about relationships is an especially thorny endeavor from this perspective. Relationships are based on authenticity, so how can it be that anyone could write a book that “taught” people how to be in authentic relationship with each other? As we talked, three practices emerged fairly quickly and came to the forefront. We decided that these three practices could not only be taught, but they were already happening in satisfying patient experiences. We tested them in conversations with peers and then with groups in our seminars, and we saw that people were responding. It was clear that they were hungry for practical and accessible ways to be authentically present to the people they cared for, even as they also felt discouraged by the complexities and pressures of the health care world.
We offer to you, herein, a clear, practical encapsulation of the elements of human connection as they are expressed in the health care setting. We bring to you three therapeutic practices that we call wondering, following, and holding. They are practices which create authentic connection when clinicians are present and attuned to their patients.
We first explore our natural capacity to attune and how it can help us to be more present and accessible to the people in our care. Within that overall mindset of attunement, we hope that you will find wondering about your patients to be as uplifting for both you and the patient as we propose it can be. We will suggest what it means to follow your patient, and the implications of such an uncommon (but we think, intuitive) behavior for getting an accurate health history, getting a true response to daily inquiries, getting an understanding of why this patient’s brother is so burdensome to the staff, or why the patient presses the call button so often. We will consider with you what it is like to hold a patient in every sense of the word and what it is like for the patient and family to truly feel held in our care.
Paradoxically, although it’s likely that you’ll learn many new things in this book, it’s far from true that this book will burden you with more things to remember.
Wondering, following, and holding actually represent a return to a level of deep human connection that is likely written quite strongly into your professional “muscle memory” already. It’s likely that in the time it takes for you to read this book, its concepts will begin to integrate themselves into your work and even into your personal life. Ultimately, this is a book about relationships, so it seems more than conceivable that you’ll feel the truth of it in your bones. You may even recognize it as a return to your own deepest truth. Perhaps it represents a new way for you to understand that thing you could never quite put your finger on that describes why you went into health care in the first place.
We think you’ll discover that you already practice wondering, following, and holding in your peak patient encounters. But sometimes, unless those peak experiences are deconstructed for us, we’re not entirely certain of what comprises them. We may even refer to them as “magic moments,” placing them well outside of the realm of the replicable. We may look at the work of a colleague and determine that she just “has it,”…and that, perhaps, we don’t.
But you do have it. In your best moments you’re doing all or most of these four things:
1) You’re being fully present with “this person right now,” attuning to who he or she is as a human being.
2) You’re suspending your conclusions as you ask questions and listen carefully for answers that make wonder an integral part of the relationships you build.
3) You’re following the cues you’re getting from the person in front of you, venturing into new inquiries based directly on both the verbal and nonverbal answers you’re receiving.
4) You’re metaphorically (and sometimes literally) holding the person in a way that demonstrates that you will do what it takes to safeguard the other from physical, mental, and emotional harm no matter what might threaten to interfere with your connection.
It sounds familiar, doesn’t it? If you are a clinician within any discipline in the world of health care, we’re certain that you’ve experienced every one of these four things.
Authentic Connection and Patient Satisfaction
Michael offers this remembrance of an experience of authentic connection that has stayed with him for more than half a lifetime:
|I vividly remember what it was like to walk into the old, downtown diner in Traverse City, Michigan, 35 years ago. I never knew the waitress’s name, though I call her “Ruby” in my mind; somehow that appellation captures her warmth, her age (advanced), and her no-nonsense sweetness.|
|She never wrote anything down. She just listened with such care that she could easily walk back to the cook’s window and repeat the order perfectly. This was only the first sign of her astounding efficiency. Every move she made had the mark of a pro. It didn’t stress her a bit that she was often in charge of the whole joint on her own, such was her professionalism, her dignity, her speed, her capacity to take care of business with zero wasted effort. How was she able to simultaneously carry on the way she did with her customers and get everything to every table without missing a beat?|
|If you had been there more than twice she knew your name and she used it to address you. If you didn’t eat your carrots she would needle you until you did (or until you erupted with such laughter that you could scarcely eat anything). She would remember that you liked your hash browns crispy and would sometimes take the plate back to have the cook make it right before you could even think to complain. When she asked about how the breakfast suited you, she asked in such a way that you imagined she was really looking out for your satisfaction, your health, your nurturance.|
|Ruby may have honed her talents on the discharged or day-pass patients from the huge mental hospital nearby. She fussed over them in a way that likely contributed to their success in the outside world. However she came by her abilities, Ruby was a professional, and no program or system was ever needed to motivate her to be interested in “the customer experience.” And I suspect there was never an argument in her mind about whether she had time to look after her relationships with her customers.|
|Ruby was not there to serve up meals; she was there to feed her people.|
|Her incredible efficiency allowed her to do exactly that, in less time than it would take many waitresses to stumble through a shift while barely noticing their customers as individual people at all. The well-done burger with no pickles never went to “table four.” It went to Jack.Unbeknownst to Ruby, she had a profound impact on how I would practice psychotherapy for the next several decades. She listened. She watched out for people. Her interest in people was sincere and unshakeable. She was infinitely kind and she brought an authentic, well-timed playfulness that lifted people. In my best moments, I can only hope that I connect with the true purpose of my work and the people in my care as Ruby did.|
Some institutions, despairing of the possibility of clinicians ever being able to build authentic relationships with patients, will set out to mimic the rudiments of relatedness. If we say the words that people might say if they were in a relationship, maybe we can get away with not actually having one.
Because you are holding this book in your capable and curious hands, we suspect that you might be thinking a little more deeply about patient satisfaction. We suspect you might be wondering how to build a culture that makes possible the sort of patient experience that shows up in elevated HCAHPS scores.
We are entering a time in health care which is challenging for many reasons, not the least of which is that attending to the patient experience now has dollars attached to it. This will be a headache for some and an opportunity for others. How we interpret patient satisfaction and how we go about the job of improving our HCAHPS scores will reflect the values and beliefs of the cultures in which we practice.
Standardizing a culture of therapeutic relationships is tough. We will stumble. But if we remember why we’re interested in the patient experience, we may be able to improve it. At Carolinas HealthCare System, employees were trained to use a variety of “tactics,” including listening to patients for two minutes without interruption and regularly using expressions such as, “I want to make sure I understood you correctly” (Bush, 2011, p. 24). Admittedly, this could come out all wrong, with staff using the tactic but forgetting the actual experience of relating. On the other hand, it could be brilliant. If staff actually committed to the spirit as well as the letter of the tactic, they could find themselves becoming genuinely interested in the patient during that sacred two minutes of uninterrupted listening. Any follow-up questions might become meaningful to the clinician who really does become invested in whether or not she has understood correctly.
The Chief Patient Experience Officer at the Cleveland Clinic has taken note that patients perceive their doctor to have spent much more time with them in the room if the doctor happens to have been sitting down during the exchange (Bush, 2011). So do we standardize sitting down as a key strategy for improving patient satisfaction? It might work quite well if we did. Mandating something as innocuous yet effective as sitting is not likely to interfere with the clinician’s authenticity; in fact it could serve as a practical cue for becoming more attuned and present.
Scripting, however, is another matter.
“Hi, my name is Sandy, and I’ll be your waitress this evening.” Why is it that this scripted introduction—now in wide use in restaurants around the country, evidently because someone thought it would be an effective way to upgrade the customer experience—comes off as so empty?
Perhaps it’s because it is empty. Can you imagine Ruby, the magnificently attuned server in Michael’s memory, saying exactly the same thing to each unique person she encountered?
The Chief Medical Officer at Parkview Health System in Fort Wayne, Indiana has concluded that scripting will not get the job done and that improvements due to scripting are not sustainable (Bush, 2011). He teaches instead the value of curiosity as one of the core elements in creating a therapeutic relationship. This is the direction of our thinking as well. The therapeutic practices of wondering, following, and holding take us out of the world of scripting and give us a framework, principles, and language to authentically engage with this person, right now.
We’re a sophisticated society. There are customer service initiatives in action everywhere, and we can feel the difference between what’s sincere and what’s not. It’s nice that a bank has great customer service. We love that when we walk into our bank someone greets us and helps us to get into the right line or to have a seat with the assurance that our banker is being notified immediately of our arrival. There is no question that these practices have as their primary aim helping the customer feel oriented and well-taken care of and that they help customers feel as though the bank is not in the business of ignoring them or wasting their time.
But it’s what happens next that determines whether those systems will leave us feeling held or dropped by those who appear to be taking such good care of us.
If the next person who speaks to us uses the exact same greeting as the first person did, the authenticity of both greetings is suddenly questioned. We perceive at that point that we’re being “handled.” Rather than allow ourselves to be fooled into thinking that anybody is interested in building a relationship with us, we see that they’re doing only what they’ve been mandated by policy to do. If one person tells us to have an “outstanding” day we may think it a little extreme, though possibly charming in its oddity. But if we hear it twice in three minutes, it feels more like an insult to our intelligence than a sincere wish for our happiness.
We know the difference between people who are trying to build authentic relationships with us and people who have said nice things to us because they are directed to do so.
And this is just a bank. Most of the people walking into a bank are not sick or injured; however, in a health care setting nearly everyone is vulnerable due to illness, injury, or deep concern for the well-being of a loved one. We have experienced that people’s sensitivity to insincerity and disconnection gets stronger when they’re vulnerable. Patients and families are hyper alert. They’re the reason that the following Maya Angelou quote gets so much play: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” We repeat it often, not just because it describes the truth of our past experience, but because it has the power to inform everything we do for our patients and their families from here on out. When we create a practice built on tactics, techniques, and prescribed behaviors, we risk limiting the ability of clinicians to connect as human beings, making them feel vigilant about what to say rather than how to be with their patients.
The ultra-efficient customer-centered approach that the bank has for making sure that customers are greeted, oriented, and shepherded through their visits is essential to customer satisfaction, yet it is in no way a substitute for authentic, responsive relationships. Efficient systems are what make time for authentic relationships to happen. Good systems and good relationships are interdependent.
Why Human Connection is as Essential for Clinicians as it is for Patients and their Families
What do you suppose ever became of Ruby? Do you suppose she quit, certain that she could do better financially or perhaps find work a little closer to home? Do you suppose—well, can you even fathom the possibility—that she burned out?
Given what you know about how much of herself Ruby put into her work and how much nourishment she received from the people she so attentively fed, it seems likely that Ruby found a way of being in her work that was 100% sustainable. She fed others (literally and metaphorically) and she allowed herself to be in relationship with those she fed in a way that kept her energized. It could be said that she found meaning in her work, but it’s far more accurate to say that she put meaning into her work through her decision to be in authentic, spontaneous relationship, if only for a short time, with everyone who came into “her” restaurant.
There is no question that some of Ruby’s customers were more challenging than others. Some came in with chips on their shoulders and perhaps even with grudges against waitresses and restaurants in particular; others found fault with anything she brought them. But Ruby knew that her job was to take care of people, and she also knew that people with chips on their shoulders and those who complained about everything were starved for something. She may or may not have been able to put her finger on the idea that what these people were starved for was human connection, but since that’s what she so skillfully administered in these instances, she obviously knew it.
There are boundaries within the therapeutic relationship that might lead us to starve ourselves as caregivers from the very thing that keeps us going: “Don’t get too involved with any one patient”… “Let it go, and go on to the next person”… “There’s only so much you can do.”
All of these admonishments have merit and all are meant to protect the caregiver from pain, vulnerability, and even burnout and compassion fatigue. But if we take them too far and shut ourselves off from human connection with our patients, our empathy will shut down. Before too long, we’ll find ourselves walking through our day more focused on getting to the end of it than we are on connecting with our patients, their families, or our team members. (For a tool to reflection on therapeutic boundaries, see Appendix A on page 243.)
It’s one of those things that Ruby knew, or perhaps that she just intuitively did. She connected, and from that continual movement toward connection she got what she herself needed to keep going: she got human connection.
The therapeutic relationship is defined by some as a completely unselfish relationship. The needs of the caregiver are not supposed to be met in the therapeutic relationship. But while we believe that this is a boundary that must continually be tended to and reflected upon, the caregiver, being human, also has a need for human connection.
It is too easy in our chaotic, time-constrained health care environments to substitute niceties for connection, and it is very difficult to understand the level to which you may be doing so yourself without some reflection on that subject. We invite you to ask yourself these questions:
- Do I ever use niceness to mask my true feelings? Is this sometimes necessary? Is this sometimes appropriate? What effect does it have on my relationships?
- How often, if ever, do I enter a patient’s room or invite a patient in for an appointment before I’m mentally or emotionally ready to focus, listen, and connect?
- What do I “get” in my best patient encounters? How do I feel about “getting something” within the therapeutic relationship?
The aim of this book is not to shatter current conventions in health care. Indeed it does far more to refine them than it does to revolutionize them. We have discovered that there are subtleties in practice that merit close reflection, peer discussion, and in some cases, an upgrade. As you’ll see, reflection plays a very important role in this book. We are far less interested in telling anyone how to practice differently than we are in helping clinicians to look more closely at their practice and to make more conscious decisions about how they will show up in their relationships with the people in their care, as well as with their team members.
Who is This Book For?
This is a book for clinicians, decision makers, and all stakeholders in the world of health care who are inspired by the constant, challenging reminder that illness and injury are complicated and that while all of our technology is wondrous, it’s not the totality of health care; it’s just a part of it.
When we’ve written about relationships so far, it has been to point out the vital importance of establishing an authentic human connection between patients, patients’ families, and the clinicians who care for them. But the truth is that those relationships happen most frequently and most easily when other relationships within health care settings are designed to support the clinician-patient relationship. We are not naïve about the time constraints and chaotic environments in which nearly all clinicians work. We know that most clinicians are not given (at least not in any recognizable way) ample time to spend with their patients. But we also know that human connection can happen in a moment and that ample time is not a prerequisite for connection. One moment of true presence with another—the turning of one’s full attention to another human being in order to receive without judgment, his concerns, his worries, perhaps the new and terrifying experience of vulnerability that threatens to crush him—has the power to uplift the other and sometimes even to transform his experience.
This is a book for people who are not afraid to remember how much we human beings need each other.
There are no disciplines within health care in which the human beings who come to us are not experiencing vulnerability. It’s the nature of the beast; we help people who are hurting. It’s reasonable, then, that we might want to distance ourselves from that hurt. If we keep busy we can distract ourselves from the pain of others. We’re taught to keep an emotional distance from our patients, and it is true that if we were to bring a completely naked empathy to all of our encounters with all of our patients we might risk drowning in their seemingly infinite sorrows. But we believe that there is a middle ground that has been lost. Technology has increased at a rate that has challenged us to keep a balance between the technical and human aspects of our care. When we lose the balance between the technical and human aspects of our care, our patients and their families suffer and so do we. The Schwartz Center for Compassionate Health Care (2012) has gathered and interpreted research on the value of compassionate connections between health care clinicians and patients and their families. According to the Schwartz Center research, effective patient-caregiver communication and relationships are associated with the following measurable outcomes:
1) Enhanced patient satisfaction
2) Informed, shared decision-making
3) Increased adherence to recommended treatments
4) Improved health outcomes
5) Reduced malpractice claims
While it certainly helps that we have credible research that demonstrates the cause-and-effect connection between compassionate care and better clinical and business outcomes, research alone doesn’t make change happen. Connection cannot be mandated, and it would be ridiculous to think that anyone can be chastened into creating authentic human connections with patients, families, and team members. Instead, authentic human connection must be demonstrated continually and courageously by those to whom it comes easily, and it must be actively, compassionately cultivated in those to whom it does not.
Therapeutic care requires that clinical professionals do all of the following:
1) Practice with competence, both technically and relationally.
2) Establish authentic connections.
3) Convey compassion, empathy, and an understanding of the meaning and magnitude of the patient’s illness or injury to the patient and family.
Unless these things occur people do not feel seen or safe, and their prospect for long-term healing may be compromised. We are thus called to create cultures of excellence that result in a focus on healing and wholeness through authentic human interactions at every level and in every relationship.
This book is first and foremost for individual clinicians who are willing to do what it takes to create authentic relationships with the people in their care. It is next for health care teams who recognize the importance of the therapeutic relationship and come together to support each other to assure that each clinician-patient relationship is supported and protected. It’s for health care leaders who have the moral obligation to build and sustain the organizational conditions in which humane and compassionate care can thrive.
We have chosen the word clinician as the term to refer to professional health care providers from many disciplines: physicians, nurses, physical therapists, social workers, chaplains, speech therapists, occupational therapists, case managers, psychologists and more.
This book is for all of us. Today we may call ourselves clinician, team member, or health care leader; tomorrow we may be calling ourselves patient.