Organizational and individual perspectives on caring in hospitals.
Abstract: aring and humanism in hospitals exist on both the organizational and the individual levels. This paper identifies key organizations and foundations that have succeeded in promoting or fostering caring environments in hospitals. These include the Picker Institute, the Baptist Healing Trust, Sage Consulting, and the Caritas Consortium. Exemplary, caring clinicians in hospitals are also described. These clinicians developed positive relationships with patients and in interviews communicated a number of approaches to express caring to patients. Health and human services managers can take a number of steps to promote caring among their clinicians. However, they must implement a culture and a reward system that encourages humanism.
Subject: Hospitals (United States)
Hospitals (Technology application)
Hospitals (Quality management)
Hospitals (Services)
Author: Graber, David R.
Pub Date: 03/22/2009
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2009 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2009 Source Volume: 31 Source Issue: 4
Topic: Event Code: 353 Product quality; 360 Services information Computer Subject: Technology application
Product: Product Code: 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033749
Full Text: Hospitals have long been the technological and cultural centers of American healthcare. Certainly, when compared to other countries, American hospitals are unsurpassed at providing care for many diseases and disabilities, especially life-threatening, acute episodes. The crowning achievement of U.S. hospitals is their excellence in the advanced modes of diagnosis, treatments, and operations that have saved many lives--ones that would have been lost in earlier times.

Modern hospitals are typically large organizations or members of corporations, with a management that is focused on efficiency, productivity, and profit. A "high tech" workplace, overseen with a corporate, business centered concept of management are key elements in the culture of today's hospitals. Such a culture is not necessarily deficient or dysfunctional, unless it has supplanted and eliminated the value or ethos of humanistic, compassionate care. In that event, high proportions of patients will experience neglect, be ignored, and not feel respected or satisfied during their visit.

In recent years, hospitals have finally begun to acknowledge a link between caring and concern, and patient satisfaction. 2001 Press Ganey National Inpatient Data showed a high correlation (r=.75) between "the degree to which staff address emotional/spiritual needs" and overall patient satisfaction (Clark, Drain, & Malone, 2003). Similarly, a McKinsey survey asked participants to allocate 100 points among different factors that influenced their choice of a hospital. On average, 20 percent of a patient's choice was based on clinical reputation; however, 41% of their choice was based on nonclinical factors, such as provision of information, having appointments on time, room appearance and functioning, and a supportive environment (Grote, Newman, & Sutaria, 2007).

For some time, a plethora of articles, books, and various publications have been highly critical of a lack of caring and empathy in the hospital experience of patients. What are the elements of a caring, humanistic hospital experience? Christianson et al. (2007) describe environmental design, complementary therapies, spiritual support, and a more personalized relationship between nurses and patients as components of a strategy employed by hospitals to reinvent the patient experience. Others have focused on the caring, compassionate element of hospital care as the most essential element--one critical for changing and improving the hospital experience (Chapman, 2006). This article will focus primarily on this dimension of care: on hospitals and clinicians in hospitals that consider positive patient relationships, effective communication, and interpersonal support to be of paramount importance. Thus, this paper considers the macro, or organizational level, and the micro, or individual level, as two distinct, yet essential and complementary aspects of caring in hospital settings.

CALLS FOR HOSPITAL REFORM

In the last forty years, numerous foundations, commissions, and conferences recommended greater caring and humanism among healthcare professionals and hospitals. The perceived need for a less detached and formal relationship between the caregiver and the patient was at the root of two new terms--patient-centered care and relationship-centered care.

The Picker Institute, which is discussed later in this paper, is generally credited with having coined the term patient-centered care. According to the Picker Institute, patient-centered care involves eight principles. Four of the principles clearly relate to humanism in care: involvement in decisions and respect for patients' preferences; clear, comprehensible information and support for self-care; empathy and emotional support; and involvement of family and friends (Picker Institute, 2008). Similarly, the key elements of the Planetree model, also described below, are denoted as representing patient-centered care (Frampton, 2003). One definition was developed by the Institute of Medicine (20001, p.6), which stated that patient-centered care involved, "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring the patient values guide all clinical decisions." Clearly, the key elements of patient-centered care, when actualized, represent a greater value and respect by the caregiver for the patient and a recognition of the patient's autonomy. These may make a critical contribution to all aspects of his or her treatment. Thus, the adoption of this approach could be said to be a voluntary mitigation of the control, paternalism, and interpersonal detachment that have been assumed by caregivers and hospital clinicians, particularly physicians, in the 20th century.

Another expression, relationship-centered care, also indicated a new focus or orientation in patient relations. This term appears to have its genesis in joint effort between the Fetzer Institute and the Pew Health Professions Commission. In 1992, a Pew Health Professions Commission--Fetzer Institute Task Force recommended the adoption of "relationship-centered care", which involves communicating openly with patients, and practicing with a healing and caring ethic (Tresolini, 1994).

PIONEERS OF HUMANISTIC HOSPITAL CARE

A wide variety of initiatives have also been implemented over the past four decades to improve caring in hospitals and to develop alternative models to transform the hospital experience. These initiatives have been spearheaded by foundations, alliances of hospitals, organizational consultants, and other groups. There are and have been many innovative and visionary hospitals that have implemented caring and humanistic programs. This paper does not purport to describe each initiative, but to describe a few organizations and individuals that have had widespread influence on hospitals.

Planetree Alliance

In 1978, a community activist, Angelica Thieriot was hospitalized at a San Francisco hospital with a life-threatening condition. Within a year, both her son and father-in-law were also hospitalized. Thieriot was so appalled and distressed by her experiences, she was motivated to try to foster more healing, caring hospital experiences for patients and families (Frampton, 2003). Her efforts ultimately led to the dissemination of the Planetree model of hospital care. The first site, a 13-bed medical-surgical unit in San Francisco fostered open communication between physicians and patients--patients were encouraged to participate in their care and treatment decisions. One person, typically a family member, became a care partner, who worked closely with nurses to learn the skills that might be necessary once the patient was discharged. The unit contained many architectural changes: open and airy work spaces, a kitchenette stocked with healthy snack foods, and a patient lounge that served as a medical and health information resource. On the unit, there were unrestricted visiting hours, and family members were encouraged to stay overnight.

Today, the key elements of the Planetree model are:

* Caring human interactions and human touch, and recognizing the importance of family, friends, and social support

* Architectural design conducive to healing

* Empowering patients through information and education

* Good nutrition and tasteful foods

* Complementary therapies

* Spirituality

* Promoting healthy communities (Planetree Incorporated, 2008).

Planetree has spread across the country and as of May, 2008 about 100 acute care hospitals were participating in the Planetree model in the United States (Planetree Incorporated, 2008).

Picker Institute

In 1986, Harvey and Jean Picker founded the Picker Institute, which at that time was merged with the Commonwealth Fund. Similar to the genesis of the Planetree model by Angelica Thieriot, after an acute episode resulting in the hospitalization of Jean Picker, the Pickers decided to dedicate their efforts to improving the response of the American healthcare system to the needs of the patient.

In the early 1990s, the institute's major focus was on determining how to evaluate the quality of patient-centeredness in the healthcare environment. The institute initiated a research project with Harvard University, and Dr. Paul Cleary as the principal investigator. After deciding that the optimum way of determining patient satisfaction was by asking the patient directly, the Picker Institute designed surveys to measure the patient's healthcare experience. The surveys, in widespread use today in many American hospitals, measure patient satisfaction in the various domains of patient-centered care.

Initially the project was rejected by hospitals nationwide, but eventually the group gathered a small number of hospitals and administered the surveys. The results were reported confidentially to each hospital, along with an indication of where each hospital ranked with regard to its colleagues in size, ownership, and other features (personal communication, C. Marsh, April 30, 2008).

Since the mid-1990s, the Institute's focus has been on education and research in an effort to integrate patient-centered care into the medical education curriculum, and to recognize organizations and individuals who have shown commitment to and success in promoting and achieving patient-centered care (Picker Institute--Our Values, para.3, 2008).

Erie Chapman and the Baptist Healing Trust

With virtually no healthcare experience, Erie Chapman became a hospital CEO at the age of 33, in Toledo, Ohio. Over a period of 25 years, he was the CEO of several large community hospitals and healthcare systems. In spite of initially lacking healthcare experience, or perhaps because of it, he was successful in changing the culture and focus of these organizations to provide "radical loving care (Baptist Healing Trust -Staff: Erie Chapman, para. 1; Chapman, 2003)." Some of the key principles that Chapman advocates for caring hospitals are that:

* Every single employee partner treats patients with loving care: a continuous train of caring. No unit or department is excluded from this expectation and organizational value.

* Every single leader treats staff with love and respect. The CEO's job is to take care of the people who take care of people.

* All hiring is done with a focus on finding people who have a servant's heart. Hiring is behavior-based, and review processes reinforce both results and loving care.

Chapman's principal focus has been on changing the culture of hospitals, and of evoking the feeling among staff that their work is a calling or sacred work, and emphasizing the values of caring and service. He is less focused on customer relations programs or prescriptive behavioral programs for staff, stating that such programs may seek to create "Stepford Caregivers"--individuals who mechanically repeat scripted language and adopt plastic smiles," and involve "...customer-service tricks, not loving-service skill and compassion (Chapman, 2006, p.6)."

Currently, Erie Chapman is the President of Baptist Healing Trust, which is committed to supporting caring cultures hospitals and charities nationwide, and locally at Baptist Hospital (Nashville, Tennessee), which is owned by Ascension Health. Baptist Healing Trust also supports charitable organizations in middle Tennessee that provide loving healthcare and provides consultant services to healthcare organizations that are interested in developing caring, humanistic cultures.

Sage Consulting

Sage Consulting in Novato, California works with hospitals to improve their organizational effectiveness. A primary, philosophical foundation of Sage Consulting is for caregivers to establish meaningful and supportive caregiver/patient/family relationships so that patients are less anxious and feel more at ease, while in the hospital. A program called First Touch[R]: Building Connections, supports non-clinical, personal contact between caregivers and patients and their families (Inderwiesen, Hiegel, Manney, & Olson, 2003). Nurses (when beginning their shift) enter the room without any equipment or supplies and, before starting their clinical or task oriented activities, stay "present" for the patient while developing a brief, personal relationship. Near the end of the shift, caregivers let the patient and family know that they are leaving, and talk about their time with the patient. They also inform patients of who the next nurse will be, and "transfer trust", by saying positive things about the next caregiver. Nurses, at some participating hospitals, were initially concerned that this process would add to an already busy schedule. However, Lolma Olson, president of Sage Consulting, states that First Touch[R] actually saves time and has reduced call light use. (Larson, 2004).

Olson believes that when caregivers are not motivated by their hearts they do not embrace the idea of customer service; consequently, they will not be effective in their relationship practice. (Batstone, 2008, para 8). Ms. Olson says that caregivers want to be motivated by more than tasks; however, they may feel that they don't have permission to interact and establish meaningful relationships with their patients.

Sage Consulting encourages caregivers, who might not be comfortable with "establishing a personal (yet still professional) relationship" with the patient to try out some "conversation starters". These help caregivers who might not have the social skills to interact easily with their patients and patients' families. Sage Consulting has found that caregivers and organizational leaders often believe that staff should already know how to interact easily with patients. However, in the initial practice with the First Touch[R] philosophy and process, they generally find that there is room for improvement and everyone can strive for more meaningful patient interactions.

Sage Consulting supports or advocates using appropriate or caring touch, and counsels caregivers to suspend their judgments of patients and their families. Another approach that helps foster a caring environment is through workshops and meetings where staff engage in "storytelling", sharing positive, learning encounters with patients and families (L. Olson, Personal Communication, May 19, 2008). A similar approach is advocated by Chapman (2006), who notes that staff can help train other staff by sharing their experiences in caring for patients.

The Watson Caring Science Institute and the International Caritas Consortium

The Watson Caring Science Institute (WCSI) is an international foundation created to restore the deeper nature of caring and healing. The WCSI and International Caritas Consortium (ICC) have jointly created an emerging network of clinical systems and formal programs and services for clinicians, educators, administrators, and leaders in nursing practice and education. However, hospitals, have been the primary, but not sole, organizational setting for the concepts and programs emerging from these organizations.

This network originally developed for the nursing sector and was designed to positively influence professional nursing, and caring-theory-guided relationship practices and research. However, the broader model of Caring Science and Philosophy of Caring-Healing is being increasingly used as a philosophical and ethical guide for all healthcare professionals and staff. This approach to nursing is grounded in Dr. Jean Watson's Theory of Human Caring (Watson 2005; 2008). More recently, the word "caritas" has been adopted to denote practices that unite human caring and love as the foundation for authentic human caring-healing relationships. Caritas is a Latin word that combines caring or charity with love or affection.

Nursing leaders and professionals initiated the Caritas Consortium in 2004, with a group of committed professional nursing leaders meeting informally to share experiences and successes in using Watson's Caring Theory as guide for professional nursing practice reform and also for personal/professional renewal and reengagement. By 2008, nurses at dozens of hospitals and other continents were engaged in this experience and participating in meetings taking place twice each year. Some of the principles embraced in the Caritas movement are:

1) Hospitals and other healthcare organizations must evolve from dominant techno-cure systems, which have become depersonalized, essentially dysfunctional and unhealthy (biocidic), into heart-centered, humanistic, caring-healing (biogenic) systems for staff , healthcare practitioners, and patients and their families.

2) Authentic caring involves the caregiver being increasingly aware of her or his intentionality, caring consciousness, and heart-centered human presence. This contributes to caring or healing moments with patients that transcend the 'required professional courtesy models' involving detachment and distance.

3) The person served is viewed as whole and complete --not simply someone with a disease condition; caring seeks to sustain human dignity, and sustain caring in instances where human caring is threatened.

4) As the caregiver or nurse grows professionally and spiritually, she/he develops greater competency for caring literacy, able to be present in the moment for compassionate caring, and more able to connect with and better serve the other.

5) The Caritas Nurse has a greater capacity for oneness and authentic connection with the individuals served. In this sense, nursing can be a path not only to personal and professional development, but also to spiritual growth.

6) Caritas nursing helps develop the wisdom for self-realization and authentic use of self as the ultimate instrument for human caring.

In October, 2008 the WCSI launched a new educational program: Caritas Coach Educational Program to prepare leaders and clinicians in translating and living out the Caritas practices within their systems. The program seeks to sustain informed professional heart-centered compassionate caring practices and thereby influence other staff and systems.

Recently, interest has developed among healthcare and nursing executives in formalizing the Caritas model and applying it throughout healthcare organizations or systems. Systems are being designated as Affiliate Partner Caring Science Hospitals and Charter WCSI sponsors to recognize their authentic commitment to extend, sustain, and support this work.

Clearly, the Caritas model is one that involves extensive personal growth and development that undergirds and supports professional behaviors and positive patient relationships, which may be considered essential to humanism in healthcare. As such, it is fundamentally distinct from management programs that prescribe behaviors and scripts to healthcare professionals with little or no emphasis on evoking values, attitudes, and caring behaviors that are individual and a natural expression of the caring and the wisdom of the healthcare professional. For a further exposition of the Caritas model, refer to Jean Watson's article in this symposium, Caring Science and Human Caring Theory: Transforming Personal/Professional Practices of Nursing and Health Care.

BEHAVIORS, ACTIONS, AND ROLES FOR CARING CLINICIANS IN HOSPITALS

Most hospitals assert a commitment to empathy and patient dignity in their mission or vision statements, yet do little to support these among their staff and in the organizational environment. This may be a reflection of the interests of organizational leaders, typically managers and physicians, who are often more focused on the technical and clinical aspects of care than on the interpersonal dimensions of care. Perhaps the myriad job responsibilities and pressing time demands of work in hospitals may capture the attention of caregivers, and leave them little time or energy to devote to humanistic care of their patients. On the other hand, there are a few hospitals that have succeeded in establishing caring cultures. In virtually every hospital, some individuals stand out and are noted by their coworkers and by patients as being consistently caring and compassionate. These caring actions usually are not carried out at the convenience of the clinicians or when they have nothing else to do. As their work is generally quite demanding, their ability to provide exemplary patient care is all the more exceptional.

This paper has described some of the organizations that have influenced hospitals to move toward a more humanistic model of care and provided a brief or general description of their interventions with staff to inculcate humanism and caring in their relationships with patients.

Another relevant perspective is from the individual level: the thoughts, feelings, actions, and self-concept of hospital clinicians who provide compassionate, humanistic care in difficult circumstances. Graber and Mitcham (2004) conducted a qualitative study of exemplary, caring clinicians at two large Southern hospitals. The study had several aims, but perhaps the most important one was to find out what the most caring and compassionate nurses and other clinicians do when caring for patients.

Twenty four nurses, therapists, and physicians were interviewed. These clinicians had been identified by other staff and clinical managers as being highly caring and compassionate. Some of the most interesting and useful findings related to these hospital clinicians -- establishing relationships with patients and expressing caring to patients (Graber & Mitcham, 2004).

Establishing Relationships

Virtually all of the clinicians experienced and generally enjoyed close relationships with their patients (note that the clinicians were identified as exemplary, caring clinicians). Several of the clinicians distinguished between emotional involvement and empathic support, indicating that emotionalism should be avoided. The clinicians did not assume a posture of distancing or "detached concern" as their predominant style: many stated that a detached and formal professional personality was incompatible with their nature.

The description of relationships varied among the clinicians based on their work responsibilities and patient interactions. For example, an emergency room nurse had shorter patient relationships than the therapists we interviewed. However, most of these clinicians described conversations with patients that were not limited to discussions about care and treatment, but involved a sharing of personal information. A number of clinicians also cited times they were remembered by patients and received phone calls, letters, cards, or photographs from them. In some cases, continuing communication extended over a number of years.

Clinician Expression of Caring

The clinicians that were interviewed appeared to be good communicators and described a number of actions or approaches to expressing caring and compassion to patients. For example, several nurses stated that they always introduce themselves to patients, let them know they will be taking care of them that day, and often ask if there's anything they can do to help them (note: this is similar to the First Touch program used by Sage Consulting). A number of clinicians stated that caring is often shown in little things, such as a smile or pat on the back, or using a friendly tone of voice.

The clinicians made an effort to get to know new patients. One told us, "If you go in and make eye contact with them and say, 'How many kids do you have? Oh, look at these pictures up here ...' and you humanize them, you get a much better response when you deal with the medical issues (Graber & Mitcham, 2004, p. 89)." In addition to establishing rapport and relationships with hospital patients, the clinicians noted that educating patients and advocating for patients' needs were often important and necessary.

MANAGEMENT PROMOTION OF CARING AMONG CLINICIANS

This study has indicated that caring, healthcare clinicians can have fulfilling professional lives in hospitals. The study also indicated that such caring is not necessarily overly demanding or draining -the clinicians in our study showed high levels of satisfaction with their positions and their responsibilities. A converse finding was noted by Carmel and Glick (1996), who used a sociometric questionnaire to explore physicians' compassionate-empathic behavior and determine how organizational factors might affect such behavior. They found that those with fewer years in medical practice scored higher on "prosocial, non-stereotypic attitudes toward patients and on empathy measures . but report higher emotional exhaustion (defined as burnout) than other physicians" (p. 1253). A more telling finding in the 1996 study is reflected in the ranking of empathy as least important for getting promoted within the hospital, thereby highlighting the culture clash between what is desired by patients and what is rewarded by health care organizations.

Although the studies by Graber and Mitcham (2004) and Carmel and Glick (1996) revealed somewhat different findings, they both suggest that the organizational culture may be the key element in promoting individual caring among hospital clinicians. The Graber and Mitcham study was conducted at 2 nonprofit hospitals in the southeastern United States where the clinicians largely felt supported by their organization in being caring and empathic to patients. Carmel and Glick (1996, p.1260) note that ".introducing into medical systems formal recognition and professional rewards for compassionate-empathic behavior toward patients might enhance this pattern of behavior among physicians as well as other helping professionals." Thus, formal programs to promote humanism and empathy among clinicians and to reward clinicians for these behaviors are the task of managers and clinical leaders in healthcare organizations. Fortunately, many healthcare organizations are enriched by a few caring, humanistic professionals. However, to spread caring and humanism and institutionalize it, management must become actively involved and transform the organizational culture in part through the reward system.

One objection to inculcating and spreading caring across hospitals and other healthcare organizations is reflected in the term "compassion fatigue". Pfifferling and Gilley (2000, p.39) state that compassion fatigue is, " a deep physical, emotional, and spiritual exhaustion accompanied by acute emotional pain." The writings on compassion fatigue focus on overwork, and on clinicians assuming too many duties and responsibilities as the main contributors to this condition. In the view and experience of the author, the expression of caring and compassion typically does not deplete or emotionally drain clinicians.

As mentioned previously, several of the caring clinicians interviewed by Graber and Mitcham (2004) noted that emotionalism should be avoided; however, caring and empathic support were fulfilling and fostered a healthy, reciprocal exchange between the caregiver and the patient. Nevertheless, some clinicians do take on too many duties and over-extend themselves in trying to serve their patients. Managers in healthcare organizations have the responsibility of recognizing, assisting, and perhaps counseling these clinicians. They may be valuable organizational members, but over time may burn out and become ineffective. Some programs that may assist healthcare organizations in retaining such clinicians are caregiver support groups, exercise programs, job redesign, and establishing support staff who are available when needed to assist patients and family members.

CONCLUSION

This paper has described a few of the pioneering efforts by a few, visionary organizations to transform the nature of care delivery in hospitals. It has also provided information on what exemplary clinicians actually do in providing humanistic care and the nature of their relationships with patients. These two foci of this paper should provide healthcare leaders with practical information about what steps they can take to remold their organization, and also what type of clinicians they should seek to hire and develop. Thus, micro (clinician-level) and the macro (organization-level) considerations are essential for health care managers that seek to develop new models of caring hospitals.

Hospital managers in both proprietary and nonprofit hospitals can adopt a multitude of approaches to foster a caring, clinical environment. However, creating a creating and sustaining this environment is much more than a program or project. Essentially it involves a radical and permanent new culture for the hospital: one that is expected to be enduring and firmly entrenched in the consciousness of organizational members and stakeholders. For those who would seek to transform their hospitals, there are a number of organizations and hospitals who have experience and success in creating caring cultures. These organizations can serve as models and also provide expertise about the practical steps needed to succeed. Hospital leaders need not look far to find the exemplary clinicians who can act as role models--they exist in every organization, and unit and department managers know who they are.

American hospital leaders should consider devoting the same level of energy and attention to assuring that compassionate care is provided, as they have to programs such as quality management, evidence-based practice, and hospital restructuring. They may find that a caring environment makes a significant contribution to patient satisfaction, employee morale, and even patient outcomes. Although compassion and caring are ultimately beyond valuation and rationalization, they provide meaning in life to caring clinicians, and comfort and hope to patients.

Hospitals are not the only healthcare organizations that need to apply humanism and compassionate care. All organizations that are involved in caring for people should be providing caring relationships between providers and patients and their caregivers. Caring relationships are important in health and human services organizations, and in such settings as nursing homes, psychiatric facilities, and aging/childcare environments. Hospital and other healthcare managers should begin to embrace an ethos and culture of caring and realize this is a path to achieve professional and organizational success in its deepest sense.

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DAVID R. GRABER

Medical University of South Carolina
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