Quite uncharacteristically, Miss Colorado, Kelley Johnson walked to her mark on the stage of the Miss America Pageant the evening of September 13th and the audience fell silent. There was no musical fanfare, no dancing shoes or instruments in her hands. A quick look around the stage revealed no Steinway grand piano waiting for fingers with a thousand hours of practice to rattle the keys. The only music to be heard had already passed through the tubing of the white stethoscope hanging around her neck. The rhythmic “lub-dup, lub-dup” of countless hearts. Her outfit was far from the one-of-a-kind evening gown, but was the daily evening wear of the 3.2 million nurses who pull on scrubs of every hue and shade. With no hesitation, she walked to her spot, paused briefly, reflected on her first words, and started.“Every nurse has a patient that reminds them why they became a nurse in the first place.” That was the one and only time in her almost two minute monologue that she used the word “patient.” As Miss Johnson was reaching the end of her reflection, “you are a person … first.” There is nothing magical about the term patient. It is a label and little more. Each was a person before they entered our clinical world and each is a person when they leave. We may heal their bodies, save their lives, and return to them the precious gift of time. We also need to change some of their habits or the efforts may be somewhat in vain.She spoke about Joe and her words fell on millions of ears around the world. Several times she repeated the phrase, “I am just a nurse.” Speaking for Joe, Kelley went on, “Although you say it all the time, you are not just a nurse, you are my nurse and you have changed my life because you have cared about me.”
“Can’t do versus won’t do”
Each year 125,000 hearts in the US cease to beat because people failed to follow their plan of care after discharge. Each will have died from any number of common diseases and disorders, but the death certificate will never state “non-adherence” as the cause of death. When questioned as to why they failed to follow their provider’s plan of care, there will be as many excuses or reasons as there are stars in the night sky. Who cares about the Joe’s, when they go home? Who does the follow-up after discharge that will maintain the fixes that were started in the hospital by a million Kelley Johnsons?The patient-centered world of nursing wraps around the patient during the average 4.8 day hospital stay. We have 115 hours with the person assigned to us to learn about his or her disease, complete the ever important nursing assessment, review and implement the doctor’s orders, and hustle them off to this test or that therapy.If the environment is quiet at night, we lose 38 hours as the patients sleep. We now have 77 hours to learn more about Joe and to begin to see what new skills and habits are required to change his life. Who makes the decision with the patient and their family whether the patient can’t do or won’t do the necessary behaviors to sustain a recovery effort? “Can’t do” is a training issue. “Won’t do” is a motivational issue. Both require behavior based interventions.
Nothing so needs reforming as other People’s habits – Mark Twain
Habits are stubborn things and replacing “old bad” with “new better” is well within the professional domain of nurses. Far too often, patient education is relegated to the last few hours on the final day of discharge. The tools of Teachback and Motivational Interviewing are pulled out by staff nurses and patient educators and while well-intended, the information is pretty much forgotten by the time the patient becomes a person and that means when they depart through the front door of the hospital. People trust the information provided by their nurse, but it becomes a sideshow to the main event of being discharged. In many instances, patient education is a book or pamphlet that is hastily reviewed as the transportation tech is standing in the door with a wheelchair. People return to the environment that contributed to their illness.The average face time with a primary care physician during an appointment is 8 to 10 minutes. It has been reported that the average time to smoke a cigarette is 7 minutes. A pack-a-day smoker will spend 140 minutes a day getting reinforced from their habit and less than 30 minutes a year with their physician getting negative reinforcement (e.g., “if you don’t quit smoking you are going to die).
Home is where the habit is
The familiar habits and reinforcers surround their very being and the 2 hours of patient education are overcome by 1,960 hours of counter teaching and reinforcement by colleagues at work. Add to that an additional 3,880 annual hours of time with family and friends and internet based second opinions. My father was a very young 2nd lieutenant at the conclusion of World War II. In fact, he was commissioned in the Quartermaster Corps at the age of 19. Barely a man and needing to look more mature, he took up smoking. I cannot remember a time in the 50s, 60s, and 70s that he did not have a cigarette in his hand. His nails were clubbed and yellowed from years of smoking. We all knew the cues for him to light up. A cup of coffee in the morning and a newspaper; a beer in the afternoon or early evening; walking outside; walking inside; sitting at his easel with a paintbrush or palate knife in one hand. The list was endless and the reinforcers; time with friends, time outside, time reflecting on his art, the nicotine fix, the local watering hole, and dozens of other reinforcers far too numerous to list. Dad was non-adherent to his plan of care and there was no one to advocate for a lifestyle change or someone to be “just a nurse” for his behavior change. In 1992, Dad died of emphysema at the age of 65.
Plan of Care Adherence – Another Challenge for Nurses
When it comes to trust, there is no other profession that tops nursing, according to a January 2015 Gallup poll. Since 1999, when nurses were first added to the survey, they have consistently held the top spot for honesty and ethical standards. In 2001, firefighters moved to the top spot but it took an act of war to make that shift.Medication non-adherence is the 4th leading cause of death in the US each year overall and is the leading cause of death if it is characterized as “accidental death.” If the health services industry is serious about changing “patient” behavior, then now is the time to be serious about teaching nurses how to be better educators through understanding and practicing the science of behavior. Adherence Management (AdM (pronounced ‘Adam’)) Coaching provides nurses, pharmacists, and therapists with a practical set of tools that will allow them to work individually and together as a combined services team to improve medication and plan of care adherence. Home health nurses and nurse advocates spend a great deal of time with their patients. AdM Coaching skills also provide these health services professionals with a much needed tool kit to determine the functions of behavior, identify reinforcers, evaluate and understand the consequences of behavior from the patient’s perspective, and establish a viable nursing care plan.
You will never be ‘just a nurse’
There is probably not a nurse in practice today who has not said, “I am just a nurse.” You can be an AdM Nurse and you can help save many of the 125,000 people who die each year because “you cared about” the thousands of Joes and Josephine’s who come into your world every day. AdM Nursing requires more time with patients, former patients and their families.