1. Kennedy, Maureen Shawn MA, RN


The transformative power of relationship building.


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At its core, nursing depends on strong relationships. Success, whether in helping patients make changes that will lead to better outcomes or in working with colleagues to improve delivery of care, largely hinges on how well we establish meaningful connections with others. When nurses, physicians, other health care personnel, patients, and family members can agree on the goals and the best way to achieve them, patients get optimal care. Two articles this month particularly speak to this.

Figure. Maureen Shaw... - Click to enlarge in new windowFigure. Maureen Shawn Kennedy

In "Strengths-Based Nursing," Canadian scholar Laurie N. Gottlieb puts forth a holistic approach to care that flips the way we've traditionally viewed patients. For many years, nursing's approach to patient care involved assessing patients to determine what their problems were and developing a treatment plan to "fix" those problems. We expected patients to follow the plan; when they didn't, they were sometimes labeled noncompliant. More recently, health care professionals have recognized the need to move away from that simplistic, authoritarian model. For example, the concept of compliance has been replaced by that of adherence, an acknowledgment that there can be good reasons why a patient isn't following the treatment plan. But that's just one small, albeit positive, change in our thinking. Even in today's patient-centered approach to care, we still view patients through the lens of their health problems.


Strengths-based nursing offers a striking shift in perspective: it asks us to focus on our patients' strengths. It's an approach in keeping with Nightingale's vision, which called for nurses to create environments conducive to healing. Strengths-based nursing invokes eight core values that, taken together, further that vision by seeking "to discern a person's strengths and use them to deal with problems, compensate for deficits, and overcome limitations." This approach requires an investment in the nurse-patient relationship, and Gottlieb argues that this is what differentiates nursing from medicine. Too often, the fundamentals of nursing care (such as comfort, nutrition, rest, and positioning)-which are essential to facilitate healing and prevent complications-get short shrift, because nurses are too busy fulfilling medical tasks directed at solving the patient's health problems. Gottlieb stresses the point that nurses need adequate time to devote to nursing care, a point that's especially relevant now, as we seek ways to restructure our current health care system. And good nursing care requires establishing real relationships with patients.


In another feature article, "Sustaining Pressure Ulcer Best Practices in a High-Volume Cardiac Care Environment," Rohini Paul and colleagues describe how staff at Narayana Hrudayalaya Cardiac Hospital in Bangalore, India, united to address the facility's rising rate of pressure ulcers. An investigation determined that, to lower the rate, surgeons and anesthesiologists would have to change their procedures; nurses, no matter how committed, couldn't have solved the problem by themselves. Success would require relationship building and leadership. The hospital's nursing superintendent (Paul) was tasked with creating a plan to reduce the pressure ulcer rate. Then, with the hospital director's support, the nursing team worked to get the entire hospital staff on board with the proposed changes. The quality improvement program required no investments in technology, equipment, or additional staff. Rather, it involved further educating staff members about ulcer prevention and fostering and maintaining in them a sense of personal accountability. The intervention itself involved modifications to basic nursing tasks, particularly repositioning and skin care. The results: the pressure ulcer rate declined from a baseline average of 6% between August and December 2009, to just over 3% within a month of implementation. By July 2010, the rate was zero-a rate that, as of the article's editing in April, has been sustained.


Both articles serve as reminders of the critically important role that nursing plays-or can play-in the provision of high-quality health care. We have an opportunity today, as hospitals revisit their practices and processes in transforming their systems to align with new models of care and financing, to reconsider how to best strengthen nursing's role. Just as we have supported advanced practice nurses in practicing to the full extent of their education and training, so too must we remove the barriers that prevent nurses in hospitals, nursing homes, and community health care settings from doing the same. That might sound like a tall order. But then again, we nurses know how to forge strong relationships in the service of a common goal.