Patient Centricity - Joy Chin, BSN, RN

"Patient centered care is achievable; it might be difficult but it is attainable. Nurses have to go in and say, this is the reason I came into this business, to make a difference in my patients lives" Joy Chin, BSN, RN.  


I’ve been a nurse for 27 years, I have graduated from Loyola University in Chicago. I’ve worked on med-surgical floors- special procedures, which is for arteriograms. I’ve gone into pre-op, where I’ve worked with getting patients ready for surgery in the perioperative area which I’m currently in the pre-admission testing.

A Day in the Life of Nurse Joy

I make sure patients paperwork are in order, ensuring patient don't cancel on the day of surgery, so if they need any kind of clearance i.e cardiac clearance that's where I come in and make sure all of that is taken care of. Now usually when my patients come in, we have a little office which is kind of nice that because you get to sit down with a patient face to face. When patients come in to who are having their procedure, firstly, you want to make sure that patients know why their there. Question; Why are you having this surgery? Did you have a second opinion? Did your doctor explain the procedure to you when you first met him or her?

It's important to make sure that the doctor is talking to the patient not a medical assistant, or event a nurse practitioner or a physician assistant should not be explaining the procedure to the patient the first time. The surgeon should be the one talking to the patent because they are the ones performing the procedures. I ensure that the patient is aware of what's going on, we ask questions about after surgery.

Where are your recovering? If the individual is having a joint replacement; Are you going to have rehabilitation? Are you going to have someone coming to your home for rehab? That's important, you want to find out if the patient lives alone. If the patient lives alone and their going home that same day, they can't go home by themselves. That needs to be told to the doctor. Questioning, did you arrange for the patient to have a 23 hour observation? Is the patient going to have a family member coming in from out of state etc.

Most of the time patients are not prepared due to time restraint when their in the doctor’s office. Patients are and I’m sorry to say this but they are kind of (treated) like an assembly line. Basically in the office a medical assistant might come in and talk to the patient, here's your PAT pre-admission testing appointment and they will fill you in. When the patient arrives they are like “can you explain this procedure to me” at which point we’re like no, the surgeon is the one doing the cutting.

We’re not doing a procedure. We’re just making sure, that you’re cleared and that no hiccups will occur on the day of surgery. Usually the patient has to be redirected back to the surgeon’s office or we’re actually being advocate for the patient doctor, and saying “Ms. Smith is still not sure why she's having this procedure, she don't know what type of procedure it will be. Are you going to make an incision, or is it going to be laparoscopic, what are you doing? This patient needs additional teaching. We then have to send the patient back to the office, mostly, their very close. Sometimes, we call a shuttle for the patient to be transported from the hospital back to the doctor’s office.

It's always about getting to the core; Do you know what you’re having? Do you know what’s happening? The patient will then respond “Well the doctor says that I need this surgery”. To which we respond, we need to know what do you think, do you think you need this surgery, do you, did you get a second opinion. We have talk to our patients, we have to build a rapport. We have to make sure the patient feels comfortable, provide a safe and secure, non-judgmental environment for the patient.

When you do that, you'll hear a lot of stuff that you didn't even ask but you’ll find out. You’ll find out that M.s Smith lost her husband a month ago, but no one knew. Then she lost her insurance, and now she's not even taking her medication because she doesn't have insurance to pay for it. Therefore, its not that the patient is being non compliant on purpose, the patient is just not being helped. Finding out, get to the core, listen to the patient.

Realism Vs. Idealism in Clinician’s Workflow.

The majority of nurses, when we come into our profession. We’re coming into our profession with this positive idealistic mindset. Saying we’re going to do good for our patients, we will make an positive impact, and make a difference in their lives. You get on the unit you have barriers. Barriers such as time restraint, we’re always pressed for time.

The nurse to patient ratio is very high, you have six patient to a nurse etc. Clinician face situations with excessive charting, double charting, you’re putting the same information in different places. They do say if it's not documented it didn't happen, however, if its documented once why do we need to have it in three different places? Documentation, high patient ratio, press for time are some of the barriers that I can think of and I’m sure they are more.

Patient Centrism

Patient centered care is achievable, it might be difficult but it is attainable. Nurses have to go in and say “this is the reason I came into this business, to make a difference in my patients lives. Therefore I’m going to set goals; even If I set goals to meet two patients needs that day. It's better than meeting non. If I go on and make small changes like make eye contact.

For example, I will touch my patient, I’m NOT going in with the computer and talk to the computer while I’m talking to my patient. I’m going to listen to what my patient is saying. I’m going to turn and then and say I hear you I feel your pain, how are you feeling this morning, how are you coping? Is there anything I can do to make your visit much more pleasant? Its about how we attack our day, When we come in and say, I know all of this is happening around me but this is what I’m going to for my patient.

Social Determinants of Health

There are different ways of inquiring about social determinants of health. Finding out where the patient lives, how is the patient living condition at home, is the patient having difficulty providing, funds to obtain their medication? How about food, are they able to provide for themselves? Will they have to use the money that they will be buying their medication to buy food and pay their rent? This is how you find out these things, by communicating with your patient and inquiring about where, the need is lacking.

Social service, case management at work I usually try to always get a consult. Not by discharge, but try to get that ahead of time. By the time of the hospitalization so that they can figure out where the patient will need help. Inquiring about basic needs, family member, neighbors that can help. We just need to facilitate the line between where this patient is coming from and meet this patient at their level, at their preference.

We need to treat the patient to how they can adopt to the healthcare. Not like, okay you’re supposed to be meeting us at this level, so I’m sorry. No, that's not what we’re supposed to be helping patients by asking them how we can be beneficial to them. Getting the patient involved in their decision making, can you share how you would like us to take care of you? What will help in your condition. Finding out where the patient is at.

When the patient comes in and they have a wall up, almost saying, you’re the nurse I’m the patient, and you think I don't know about myself but I do. You a s a nurse is basically going to say, Ms. Smith tell me about yourself. Patients do not want you in their face telling them, this is what you need to do, this is how it's going to be. Instead, do you prefer to have your treatment, in the middle because you tend to be up in the middle of the day?

How can we work around that to make everything goes smoothly for you”? Do to prefer to go to physical therapy, mid day because your arthritis acts up in the morning?” Or the nurse should be talking to the physical therapist, asking what time they will arrive to tend to Ms. smith. Should we medicate her 30-45 minutes before she goes to physical therapy?

For Patients

If the patient knows that you’re willing to work with them and meet them at their level. i/e non-judgmental environment, you have to be able to provide that for them. I try to encourage my patients to ask a lot of questions. The department that I’m in, I encourage a lot of questions, because patients tend to say “the doctor said this is how it's supposed to be so that's it.I say question the doctor, don't be afraid to question the doctor, If you don't feel comfortable within yourself ask is this the only choice that I have or do I have a second choice? Do I have to have this surgery now? Can it be delayed, can I have conservative therapy, before actually going into surgery. They will meet you at your level. Have your list, bring it with you to the doctor’s office, and check off questions as they are answered.Don't leave that office, do not leave that office, do not get up out that chair until all of your questions are answered. I try to empower my patients, exposing, we're not trying to cripple you, when you leave and go back to your pre-existing hospitalization state, we're not going to be there with you. I want you to be equipped with this tool. So that when you encourage additional healthcare services you are able to interact and feel at ease with what you have on board.

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Danny van Leeuwen | E-patient | Caregiver | Nurse | Informaticist | Leader

"The cost of care needs to me more transparent, more predictable and more reasonable. There is nothing like the fear of not being able to afford what you need, or going bankrupted" Danny van Leeuwen, RN, MPH, CPHQ. 

 


How does an individual figure out what works for them?

"I think you learn what works by trying things. The life journey for an individual, for me, for you, is an experiment. The way I look at it is, that I'm trying to accomplish something with my health journey. I have multiple sclerosis, its a progressive disease and I want to progress as slowly as possible.

I'm also a person that's pathologically optimistic, and I don't want to mess with that. Its a real strength to be optimistic, I feel better having a positive attitude. I also play the baritone saxophone, and I don't want to mess with that. Those are the three things that I want to accomplish, so I need to experiment with the things that are going to help me accomplish those health goals.

I can and I do go to research and try to learn what works for populations, or groups of people. Just because something works for groups of people or is likely to work for groups of people doesn't mean it will work for me so I feel like I need to try stuff. If it doesn't work then I need to adjust and try something else, so I think its experimentation".

Suggestions for improving empathy in health service delivery?

"You don't create empathy. There are people who have no empathy, there are people who have lots of empathy and then there are people in between. I think what you can do is foster the situation where empathy can exist and grow. Its very challenging to be empathetic when you have 8 minutes as a clinician, to spend with someone when theres this whole list of things to do.

You're consumed with checkin all the boxes and its hard because empathy requires listening and reflexion, which means you have to pause and think about; what do I see here in-front of me, whats the story I'm hearing, whats behind what their saying. That takes a moment, and when you're really rushed its really hard to do that".

Appeal to policy makers?

"The cost of care needs to me more transparent, more predictable and more reasonable. There is nothing like the fear of not being able to afford what you need, or going bankrupted. The next thing is the availability of information. My information about me, is mine. Right now information is so silo, its so dependent on the platform, i.e electronic record, the setting. Its very difficult to share that information amongst settings.

As a patient I want to have access to all the information there is about me, I'll pick and choose whats important and whats not. But, I want to be able to have access. I also think that the way healthcare is setup is by episode and diagnosis. An episode is a snapshot, its a moment in time. A diagnosis is a label about some aspect of my dis-health. I think policy makers should focus on longitudinal care over time, thinking about me a person, rather than a diagnosis".

Advice to clinicians that are new to healthcare environment?

"It would be good for people who go into the healthcare profession to spend a day in the shoes of people who are living in the setting their in. If their a patient, spend the day in the bed. When I was a young nurse I went to the Rusk Institute in New York City to learn about physical rehabilitation; I spent the day in a wheelchair.

That was a transformative experience, gaining some lived experience, I think that would be one thing. I would encourage networking as a young clinician. Finding people who care about the patients in this manner. Finding out who they are and then meeting with them regularly to share what works and what doesn't. Having that support system outside of the work environment I think is really important".

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