Welcome to The Therapeutic Relationship

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The See Me as a Person Web site exists to provide guidance to clinicians in all disciplines in creating, nurturing, and deepening their therapeutic relationships. Mary Koloroutis and Michael Trout, authors of the book See Me as a Person, mentor site visitors in the practical therapeutic arts of wondering, following, and holding on behalf of patients and their families—all within a container of presence and attunement.

We invite you to share your questions and challenges with us as you strive daily to bring authenticity and deep connection to the relationships you create with the patients and families you serve, even within today’s highly technical, fast-paced, time-constrained, and frequently chaotic health care environments.

 

“May I see in all who suffer only the fellow human being.” Oath of Maimonides

A Relationship-Based Way of Being

Who is the most relationally proficient person you know?

You may not have heard the term relationally proficient before, but we’re confident that you understand the question. Who do you know who makes a practice of really tuning in to people? Who do you know who is genuinely curious about people? Who is strangely adept at focusing on what a person says and asking questions that help that person get to the core of it? Who do you know who feels, to you and others, like a living, breathing safe haven?

Nearly everyone danna_godeassi_repubblica_conversationdemonstrates a high level of relational proficiency at least some of the time.

There are people with whom nearly all of us just find it easy to connect. The difference is that for the truly relationally proficient among us, there’s nothing conditional about the willingness to connect; it’s not dependent on how much we like the other person. Being relationally proficient becomes part of who we are. While it may be true that a few of us are born with such capacity, or are nurtured in our families of origin such that relational proficiency is second nature to us, it is also true that it can be learned.

Take a look at the practices mentioned in that first paragraph: tuning in, being curious, engaging with what the person says, being a safe haven. These are relational practices, and they are learnable skills.

But are these practices necessary components of exceptional care? We have come to understand that they are necessary if care is to even be called adequate.

More than tools

While these relational practices are more than mere tools, they are in fact tools, and when used properly they’re tools that make some very important things happen. If we use the tool of tuning in—or attuning—to someone, the person feels seen because she is seen. She feels as though she matters, and, interestingly, the more attuned attention you pay to the person, the more you will come to care about the person (Goleman, 2013). If you use the tool of genuine curiosity—if you wonder with and about a person—the person feels as though he is worthy of your interest and, again, he feels as though he matters to you. If you use the tool of hooking in with genuine interest to what the person says or does—the tool called following—the person experiences that you are not only working for him, but that you are working with him to find a solution or to get him some relief. If you use the tool of creating a safe haven—the tool of mentally and emotionally (and sometimes physically) holding the person—the person will feel safe with you (Koloroutis & Trout, 2012).

The practices that create and nurture relationships with patients and families are attuning, wondering, following, and holding. As we teach these practices, we have noticed that there seem to be few if any people who have adopted the therapeutic practices of attuning, wondering, following, and holding in their work with patients and families who have not also embraced them in their relationships with their own families, significant others, friends, and co-workers. They are not merely “therapeutic practices;” they’re the four practices that create, nurture, deepen, and improve all relationships.

Trout, M., & Koloroutis, M. (2017). A relationship-based way of being. In M. Koloroutis & D. Abelson (Eds.), Advancing relationship-based cultures. Minneapolis, MN: Creative Health Care Management. Manuscript submitted for publication.

Build a Judgement-Free Environment

As a See Me as a Person facilitator and leader, Tina Martin, MSN, RN, NE-BC, Magnet Program Coordinator Lancasterjudgement-free-zone General Health/Penn Medicine sends out weekly thoughts for sharing in huddles or email communications.  We wanted to share this “thought for the week.”  It is a wonderful example of how leaders can re-mind us to step out of auto-pilot reactive thinking/behavior and be intentionally non-judging. 

We all deserve a “judgment free environment.” A fitness chain even advertises that they have a “judgement-free zone” so people feel comfortable exercising without being labeled. It can be easy to fall into the labeling trap. We know “we can’t judge a book by its cover” but we often do. We judge people by their appearance, by the way they talk, by their behavior. We develop preconceived notions before we really get to know a person.

Think of all the labels we place on our patients. We judge them by the amount of times they use their call bell, by the frequency of their hospital admissions, by their addiction disease. Sometimes these labels can create an unsafe environment for our patient, especially when we label our patient by their room number or a diagnosis, without using their name. What about labels we place on our colleagues? We sometimes label an entire department because of the actions of one person.

We all deserve to work and receive care in a “judgement-free environment.”  For today, stop using labels to refer to other people and encourage your colleagues to do the same. You will be amazed at how this change in behavior will leave your mind open to wondering about your colleagues and your patients…and seeing them as a person.

 

Honoring Relationship

Relationship. Human connection. In diverse settings from hospitals to clinics, caregivers are honoring the importance of the relational part of their professional role. A beautiful example is this reflection from Tina Martin, MSN, RN, NE-BC, Magnet Program Coordinator and facilitator of See Me as a Person   Thank you Tina and all caregivers everywhere for your care and compassion.

Week of July 25, 2016 – Relationship Based Care SMAAP Thought for the Week Lancaster General Health/Penn Medicine

Have you ever considered illAlthough the world is full of SufferingIt is Full Also of the overcoming of it (1)ness as a “non-ordinary state?” And as with many other things, illness and a “non-ordinary” state can take on many degrees of severity. It can be a minor illness, such as a headache. It can be a chronic illness that never can be cured. Or it can be a devastating, life-ending illness. Being in a “non-ordinary” state causes us to behave and act in “non-ordinary” ways (Koloroutis and Trout, n.d.).  Being in this “non-ordinary state” creates in us a feeling of vulnerability, helplessness, fear, sometimes anger. It also creates a need for human connection. Being aware of this “non-ordinary state” and being attuned to your patient enhances the connection you will have with your patient. That connection….that therapeutic relationship…is what is needed to help your patient and their family feel safe and held in your care.

The following note was left on the door of a patient who was dying in an ICU (Koloroutis & Trout, 2016)

“This may be a typical stressed out day for you…

But our lives have been turned upside down.

Please take a breath.

With deep appreciation, Carol’s Family”

References
Koloroutis, M. & Trout, M. (unpublished). Attunement as the doorway to human connection. In M. Koloroutis & D. Abelson (Eds.), Creating Relationship-Based Cultures.
Koloroutis, M. & Trout, M. (2016) See Me as a Person Facilitator Manual (3rd ed).  Minneapolis, MN: CHCM.

 

 

 

Attuned Care = Safer Care

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Each one-point increase on a scale that measured depersonalization — a feeling of withdrawal or of treating patients as objects rather than as human beings — was associated with an 11 percent increase in the likelihood of reporting an error. Each one-point increase on a scale measuring emotional exhaustion was associated with a 5 percent increase.

Annals of Surgery

You probably know death certificates don’t record when a person dies from a medical error.  Still, with surprising frequency, medical errors in various forms including communication break-downs lead to death, near misses and complications, not to mention human suffering.

Patient harm from medical error can occur at the individual or system level

Significantly, we in healthcare are getting better at understanding how communication breakdowns, and misattunement can directly result in patient harm and death. Nonetheless, we spend just a fraction of our healthcare budgets on building skills and accountability to eliminate ineffective human interactions which lead to medical error.

Imagine…

We imagine a day when highly attuned relationships will be an expected part of high quality medical care. Picture this: relationship-based cultures which honor the human dignity of each person. Clinicians meet and connect intentionally with teammates, patients and families. Partnership replaces hierarchy.

Some people criticize relational aspects of medical care as a “needless luxury”.  We teach people how to attune. It is remarkable how quickly people learn this skill when we de-mystify it. Moreover, the learning spreads.  Very quickly we see people model the behaviors, thus, creating a culture in which attuned and caring communication is an expected norm.

Build Your Compassion Muscle

Compassion muscleThe Greater Good Science Center partnered with Compassion Lab and the University of Michigan’s Center for Positive Organizational Scholarship to develop a Compassionate Organizations Quiz.  They asked readers about their experiences of organizational compassion. You’d think compassion in healthcare would be widely practiced, surprisingly, it isn’t. In fact, other industries including criminal justice, are more compassionate than healthcare.

While there may be numerous reasons for healthcare to lag in compassion, there are provoking reasons to bring compassion-building practices back to the heart of healthcare.  Compassionate care is defined as care that notices, feels and responds to the suffering of others (Von Dietz, 2000, M; Lown, B.A.J.Rosen, J.Martilla 2011) – representing a specific kind caring. We are beginning to understand how and why organizational compassion is vital to all of us in healthcare – whether patient or professional. It positively influences pretty much every critical measure including HCAHPS and employee engagement. For example, in a study of over 260 hospitals, investigators discovered that practices including compassionate employee awards, and pastoral care support for staff strongly positively correlated to patients’ “likelihood to recommend” the hospital.  (Click here to download Compassion Practices and HCAHPS)

One notable example of meaningful employee recognition which cultivates organizational compassion is The Daisy Award.  This award recognizes extraordinary nursing care. A large multi-site study analyzed the results of over 2000 nominations from patients, families and colleagues and identified several behavioral themes common to Daisy Award winners. “Genuine compassion and caring” ranked first out of 22 extraordinary nursing behaviors. (To learn more check out these resources: Strengthening the Workforce Through Meaningful Recognition and CHCM Daisy Foundation White Paper).  Perhaps most important is the sense of accomplishment and pride such awards provide caregivers.  We encourage you to take action in your organization to consciously build a culture of compassion.

Check out our downloadable infographic: Build Your Compassion Muscle 

Room 372

Agnes Toth
Written and shared with permission by David Abelson, MD, Former Park Nicollet CEO and Health Partners’ Senior Executive
My daughter recently acted in The Hour We Knew Nothing of Each Other, a one act play by Peter Handke. The play depicts a town square with hundreds of characters including old ladies, lovers, children, joggers, mothers, fathers, brides, musicians, clowns, workmen all wordlessly crossing the stage. We glimpse moments in their lives leaving us to wonder about their past and future stories.

The play reminded me of a hospital. Consider the story told to me by a colleague about the patient in room 372. Some people may perceive “bed 372” as a cranky lady who complains excessively about not getting a warm blanket on demand. After all, why should she make such a “big deal” about not immediately getting a warm blanket?

Her name is Shirley. She is 74 years old, a “warrior” who has survived two open heart surgeries, a stroke and several cardioversions for atrial fibrillation. Following each setback or surgery, she fought her way back. She worked hard in rehab five days per week to stay in shape and subsequently befriended the other phase-three rehab patients and staff.

In March, 2007, her husband died, and one month later, so did her son. Caring for her husband toward the end of his life challenged her as she felt powerless and demoralized. One day while talking with her physician, she broke down and cried, recalling a terrifying incident when she was about 10 years old. She and her family were living on a farm in southern Minnesota. Her grandfather was very ill, and staying with the family. The rest of the family left to work the fields, leaving Shirley alone in the house to care for her grandfather. Her grandfather took a rapid turn for the worse, dying while she was alone with him. She felt helpless about getting the help needed to save him.

After her husband and son died, Shirley fought serious loneliness and depression for a year. About six months ago she met John. A couple of weeks ago she and John were about to go out to dinner, when she collapsed in cardiac arrest. John called 911 and performed CPR. The ambulance brought her to Methodist Hospital where she underwent acute re­opening of a blocked circumflex coronary artery. She was placed on the hypothermia protocol (chilled, sedated, and paralyzed) for the first 24 hours to minimize damage to vital organs. Imagine her with suboptimal sedation, unable to move, feeling powerless, and absolutely freezing.

After being in the ICU on a ventilator for two weeks she graduated to room 372. She lost some of her short term memory as a result of the arrest and appears more impatient than before. She finds swallowing difficult and dislikes the soft diet. She’s slowly increased her capability to exercise, but struggles with the amount of muscle strength she’s lost. Some days she gets kind of “cranky.”

And she sometimes gets cold. When she gets chilly, she becomes terrified by an ill-defined recollection of feeling absolutely freezing, unable to move, and powerless to do anything. She feels desperate for a caring person to bring her a warm blanket, to comfort her, ease the cold, and eradicate her sense of powerlessness. Sometimes she must wait for over an hour and gets really “cranky.”

The hospital, viewed as a set in the play, The Hour We Knew Nothing of Each Other, ­presents a stage on which people cross in an average of 4 days. As a snapshot, we see only a “cranky” lady in room 372, unreasonably demanding blankets. Alternatively, consider the intricate back story preceding the snapshot and our privileged position to create a memorable hospital stay adding to the life narrative of the patient and family.

What’s the value for a patient of a good night’s rest?

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Safe Haven, Holding…

Holding is lifting up, affirming, protecting and dignifying the person

I watch over and create a safe haven for those patients and families in my care – See Me as a Person

 “How was your night?” This is one of the most often heard inquiries each morning when staff come into the patient room first thing in the morning.  Responses range from “terrible to OK”.  We rarely hear “I rested well”. However, consider this brilliant idea: creating a “Therapeutic Night” for patients. This practice, shared with us by, by Mary Del Guidice MSN, BS, RN, CENP, CNO of Penn Hospital, is a beautiful example of integrating therapeutic relational practices with clinical care priorities and patient-centered care. The result is an important intervention which is aiding patients in getting a restful night’s sleep.

The theory behind the “Therapeutic Night” Mary says, is a response to a thorny challenge – helping patients be less anxious at night.  She says, “every patient that enters the threshold of our doors into our care is afraid…. afraid of something.  This fear is most profound at night. The ‘Therapeutic Night’ is meant to communicate through caring (therapeutic practices) that the health care team is there through the wee hours watching over and keeping patients safe”. She has partnered with the Patient Experience Team to embed this practice into their H.E.A.R.T Bundle of patient-centered care practices at Penn.  Thank you Mary Del Guidice for allowing us to share your practice. We hope it spurs others to consider implementing this brilliant idea.

 

 

Defining the “Relational Aspects” of Award Winning Care

DAISY paper coverI recently had the honor of collaborating with DAISY co-founder Bonnie Barnes and DAISY Executive Director, Cynthia Sweeney to create a resource designed to help clinicians recognize their use of the therapeutic practices of attuning, wondering, following, and holding in their daily work.

Our hope for this paper is two-fold:

1)  That nurses in DAISY organization will use this resource to write DAISY nominations that overtly articulate the high degree of relational proficiency of each nurse nominated, and

2)  That caregivers in all organizations will use this resource as a basis for demystifying and better understanding the practices that comprise therapeutic relationships.

We believe that culture is created, in part, by language. Once the language of attuning, wondering, following, and holding becomes a part of the culture, relationship throughout the organization are positively affected!

Click here to read the white paper, “Inspiring Nurses to See the Extraordinary in their Ordinary.”

Mary Koloroutis

A Therapeutic Sighting: The Power of Seeing Eye-to-Eye

We recently received a story highlighting what happens when a caregiver does what it takes to really “hold” someone in her care. At Covenant HealthCare in Saginaw, Michigan, a recent rise in teen suicide attempts has been met with a new kind of curiosity—one that has been actively cultivated in the staff. This story comes from an ER nurse:

Young woman suffering from a severe depression (very harsh lightI recently had a teenage child admitted with a drug overdose after attempting suicide. It seems like we have had an epidemic of these patients, every week admitting 1 or 2 children with this diagnosis. Some staff members seem to become resentful to these kids, assuming that they are over dramatic and making stupid decisions. (There may be some truth in that, but there is always a whole lot more to the story than what you see in front of you!)

This particular girl arrived to the unit acting out—belligerent in her behavior and language. She was placed in 4 point restraints while in the ECC for fear that she might harm herself or others.

After attending a recent See Me as a Person Workshop, I decided to wonder about this young girl: What was happening, and why was she behaving the way she was? I sat with her and spoke directly to her, allowing her the opportunity to yell and swear while I maintained my composure and just listened.

After a short time, and once she realized that I was no threat to her, she calmed down, and we were capable of having a real conversation. I was able to remove the four restraints with a mutual understanding that she would cooperate with the care we were providing.

Before attending the workshop, I would likely have left her in restraints and wanted to “get in her face” to redirect her behavior. I really see the benefit of taking the time to understand the patient and to gain their confidence and respect to help manage her care. What I learned in the workshop sure made life easier in the long run that night!

While this nurse doesn’t talk directly about a change in her “default” behaviors, that is in effect what she’s talking about. Her old default would have been to “get in her face,” and thanks to the time she had spent learning about, discussing, and reflecting on the See Me as a Person practices of attuning, wondering, following, and holding, she has found herself with a new default: she is now fascinated by the people in her care. She is curious. She knows that there is a backstory, and that whether she learns it or not, there is a reason for the person’s behavior. She also understands that part of that person’s healing is likely to be that she is seen, heard, and received without judgment by another human being.

When you know and are committed to using the See Me as a Person practices, you have the ability to receive the person you’re caring for without judgment. In the instance of a suicide attempt, medical treatment can address the physical ramifications of the attempt, but the physical ramifications are typically only a small fraction of the problem.  Because the person is probably also suffering from a sense of isolation and hopelessness (and/or a host of other mental/emotional/spiritual woes), it is largely in the relational care of the patient that some healing of the root cause could take place.

For years, the experience of receiving good relational care was left to the luck-of-the-draw. You might, if you’re lucky, get a caregiver who is willing to connect and knows how to do it. In cultures like the one at Covenant HealthCare, the odds are much better, however, that everyone walking through their doors will receive good relational care. For the past two years, Covenant has embraced the See Me as a Person practices. They have offered the workshop to their staff in all disciplines, and they have transformed their culture to one in which curiosity replaces assumptions, people are seen, people are heard, and people feel held.

We are always gratified to hear stories like the one sent to us by this devoted ER nurse. It is an honor to help caregivers in all disciplines to provide superior relational care, with greater consistency and mindfulness, to the patients and families they serve.

Q & A: What was the Inspiration for the RBC Model?

QUESTION:
Hello! I am in graduate school at Kent State University working to become a nurse practitioner. My group chose your nursing theory to present for our peers. We would like to know what was your motivation for developing the Relationship Based Care theory? What was your process used for developing this theory? Also if there is any information that you would like to add regarding the theory? I have recently purchased a couple of your books and your CD, and I love your theory!! I have practiced as a bedside nurse for fourteen years and have been inspired by your writing and stories! I am excited to present your theory to my classmates and also to my coworkers. Thank you in advance for your guidance, and I look forward to hearing from you!

Sincerely,
Lisa Meek, BSN, CMSRN

ANSWER:
Mary-Koloroutis-150x150Hello, Lisa! It is rewarding to know that Relationship-Based Care resonates with you and is helping to inform your practice. Relationship-Based Care has evolved over the past 25 years beginning with the seminal work of Marie Manthey on primary nursing—a care delivery system that puts the patient-nurse relationship central. My motivation for contributing to the development of the RBC Model is very simple, actually. When I entered nursing practice, it was clear to me that safeguarding the humanity of those in our care as well as the humanity of those of us providing care would take intention and awareness as well as leadership (whether at the point of care or leading in a role within the organization). Institutions are where most care is provided and they are, by nature and design, prone to dehumanizing processes. The volume of patients served, the complexity of human caring and the complexity and escalating development in the sciences and technology all take attention and can undermine our core purpose. Holding the person central takes mindfulness, teamwork, and perseverance, along with an established way of doing/way of being within an organization that supports caregivers in keeping patients and families central at all times.

The work I did with Michael Trout on the book and workshop See Me as a Person was motivated by recognizing that while we talked about the nurse-patient therapeutic relationship as the center piece of care in RBC, it was an elusive concept to many in practice.  The “how” of therapeutic relationships had not been fully addressed. Those who excel at establishing and nurturing therapeutic relationships were seen as “simply knowing how to relate” and thus, the knowledge and discipline behind therapeutic relationships and the fact that relational practices can and should be taught was missed. We deconstructed what it looks like when we as caregivers are at our best and in a therapeutic interaction with a person. When authentic connection was established, four things were nearly always happening: We are present and attuned (focused on the person); we are wondering (genuinely interested in the person and what the person has to teach us, so we can provide the best possible care); we are “following,” (remembering and acting on what we have been taught); and we are holding (creating a safe haven for healing by doing what we say we will do; safeguarding the dignity of the people in our care; watching over them, keeping them informed, etc.

I am so pleased that Kent State is integrating this into practice. I remain

Respectfully yours,
Mary Koloroutis