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Back to the Bedside with Relationship-based Care

E’Louise Ondash, RN, contributor

About three years ago, the nurses at Barnes-Jewish St. Peters Hospital, northwest of St. Louis, Missouri, had about reached the limits of their patience. They were spending far too much time with paperwork and other tasks that kept them away from their patients’ bedsides.

Barnes-Jewish St. Peters Hospital implemented a Return to Care program to bring nursing back to the bedside.

So they decided to do something about it.

“The patients were not getting the care,” explained Jill Skyles, RN, BSN, MBA, vice president of patient care services and chief nursing officer. “The patient satisfaction scores were the lowest and nurses were eager to try something different. They felt they were not maximizing their abilities as professional nurses. We felt there had to be a better way.”

They began searching for that better way and Skyles soon discovered Relationship-Based Care (RBC). This philosophy of nursing was founded by former nurse Marie Manthey, MS, Ph.D.

“Nursing isn’t about doing tasks,” explained Manthey at a March leadership conference sponsored by VHA, a nationwide alliance of not-for-profit hospitals and non-acute health care organizations of which Barnes-Jewish St. Peters is a member.

“Nurses go into nursing not to become technicians, but to have a meaningful career interacting with other human beings in a way that is helpful,” Manthey continued. “In the absence of a nurse-patient relationship, tasks are just tasks. They aren’t nursing,”

Skyles liked what she heard and brought the information on RBC back to St. Peters. She found that other nurses were just as enthusiastic; they liked the emphasis on the importance of relationships in the nursing profession.

“There are three relationships in nursing that are important,” Skyles explained. “The one with the patient and the family, the one with our colleagues and the one with ourselves. And if we don’t take care of self, we can’t take care of anyone else.”

The RBC philosophy incorporates two models in its patient-care program: shared governance, which brings multiple disciplines to the table when planning patient care, and primary nursing, which designates one nurse responsible for a patient’s care throughout the hospital stay.

“You write the care plan, develop a relationship with the family, and the next nurse follows that plan of care, unless there’s a change of condition,” Skyles explained.

Relationship-Based Care also promotes nurse autonomy.

“Marie [Manthey] says we need to allow nurses to prioritize,” Skyles said. “For instance, what can be skipped during the shift? The patient may not have to be ambulated at a certain time or have a bath at certain time. RBC allows a nurse to use judgment.”

Barnes-Jewish St. Peters, with 111 beds with 64 under construction, has worked with VHA to develop a program that works for them. It is just one model for other hospitals who want to embark on a “Return to Care” program.

“You’ve got to ask yourself why nurses are leaving the profession,” said Lillee Gelinas, RN, MSN, FAAN, vice president and chief nursing officer at VHA. “Well, we’ve spent the last 10 to 15 years reducing full-time employees and putting the burden on nurses. We did a study of 22,000 nursing hours in 15 states and found that the average time spent at the bedside is between 21and 31 percent of the time. In our system, it’s about 30 percent.”

Return to Care, which is now part of VHA’s clinical education series, has identified four areas of greatest concern for nurses that should be evaluated if the goal is to create more time for direct patient care:
* Documentation—electronic records are cumbersome and time-consuming and must be streamlined.
* Medication administration—interruption and shortage of Pyxis machines are a problem.
* Hunting and gathering—too much time is spent searching for wheelchairs, stretchers and IV pumps.
* Communication—too much time is spent calling doctors, lab, X-ray, dietary, etc.

“Return to Care is a program for all of our hospitals nationwide,” said Patricia Tyler, RN, CCRN, director of performance improvement at VHA West Coast. “We’re gathering all of the leading practices and sharing them. We’re asking what were the key strategies, tools and templates—the things used to change culture? What did leadership do?”

The Return to Care program officially launched on March 19, 2008, when 620 health care professionals from 124 hospitals participated in the first conference. The idea has taken off, Tyler said, and evaluation scores of the program are high.

“We’ve focused on [Barnes-Jewish] St. Peters because they have done outstanding work in retention of nurses, decreased complications of care and increased time at the bedside,” Tyler reported. “Patient and nurse satisfaction is going up, and there has been improvement in quality and patient safety outcomes.”

Find out more about VHA and their Return to Care program on their Web site, www.vha.com.