Karim Bauza
First, in providing care to Mexican patients, one must understand the absolute importance of family. Culturally, in Mexico and other Latin American countries, family holds things together. From the perspective of my culture and Mexican/
Latina heritage, I know that if something happens to me, I have a strong family support system to rely on. The importance of family extends to medical care contexts. Some nurses would like to care for patients without family present;
working with family members in difficult healthcare contexts can be frustrating.
Having family in the room or answering their questions may be difficult, but family have expectations and responsibilities to be on top of the care and to help in making decisions for their family member. If I were injured and hospi- talized, my whole family would be in the room. Someone would be with me (or desire to be) 100% of the time.
Listening to the family in the hospital is important. If a family member were to be intubated, you would be able to get significant information from family (e.g., patient allergies and personal preferences). In Latina cultures, family is a resource. It would be unusual for family not to be present or not to visit regu- larly when a family member is hospitalized. Coming from this family-centered culture, it is shocking when I care for non-Latino patients and sometimes family may not be there or visit for days at a time. Family is a great resource that is often underutilized. If I had a family member who was hospitalized, I would want the nurse to make me feel included. I would be listening to how my fam- ily member will get better. How could my loved one be more comfortable?
How are their holistic needs being met?
42 I. FOUNDATIONS FOR USE OF COMPLEMENTARY THERAPIES
The difference in knowledge and practice between the large urban tertiary care centers and what is available in small towns or locations in Mexico is signif- icant. There are “medical deserts” in Mexico. There are cultural differences that should be considered. For example, in the Mexican culture, someone with sniffles may take penicillin—penicillin for everything. It is available without prescription.
If a patient arrives in the United States from Mexico requiring healthcare, they would have many questions, which may go unasked and unanswered if a ther- apeutic relationship is not developed through mutual listening. In this process, nurses should try their best to include the family. We learned this in our basic education, but its importance cannot be overemphasized.
So, what would I recommend a nurse do? Listen. Many Mexican or Latina patients may not know why they are taking their prescribed medications; listen to what they think is the purpose of the treatment or medication. Use thera- peutic listening skills to build the bridge to get closer to them in a therapeutic relationship to close the gap between what they are thinking about their care and health and what they may need to know to ensure desired therapeutic outcomes. Use listening skills to gather important information about Latina patients’ medical and cultural background and understanding of their health or illness. As a nurse, a priority is to understand their expectations of treatment outcomes. To achieve positive healthcare outcomes, it is important to reach common understandings with the patient and family members who may sup- port the patients or provide care. Otherwise, problems with medical adherence to the prescribed drugs, medical treatments, or therapies are likely. Without careful listening for understanding and reaching mutual expectations and goals for care, medical therapies may be doomed to fail. For example, in the case of wound care, it is important that the patient and family have the supplies and understanding of the timing and techniques of dressing changes—other- wise, the wound won’t be properly dressed and the patient is likely to return with infection.
Listening needs to occur on both sides in a relationship. It should not only be the nurse or provider saying, “This is my expectation for your treatment and outcome.” The nurse may need to be the one who listens first; nurses can model listening and respect. Two-sided listening has an important role in the caregiving relationship. Nurses can listen to hear what the patient and family understands and what they are seeking from care. Only through listening and truly hearing can the nurse know and understand patient and family prefer- ences and demonstrate caring. In this manner, trust is developed, and patients and families can be confident that the nurse and providers have their best interest at heart.
Language Challenges
Interpreter-mediated healthcare encounters can be a challenge for therapeutic interchange. The issue of translation and interpretation in healthcare includes more than the differences in language use. Interpretation should be founded on a word-for-word translation while incorporating nuances and maintaining seman- tic equivalency of communication. Difficulties in translation and interpretation
3. THErApEuTIC LISTENING 43 in healthcare encounters are illustrated, for example, in a study by Flores et al.
(2003) of Spanish–English interpretations in pediatric encounters. The study found that there were, on average, 31 errors in medical interpretation per clinical encounter. Most errors were categorized as “omissions” of important information and had potential clinical consequences. Those serious errors were more likely to be committed by nonprofessional interpreters—including nurses, social workers, and siblings—as compared with those committed by hospital interpreters. use of appropriately trained and experienced interpreters is a necessity for clients who have language barriers.
Another study showed that non–English-speaking family members are at increased risk of receiving less information about the patient’s condition, as evidenced by less family conference time and shorter duration and less pro- portion of clinician speech during a conference (Thornton, pham, Engelberg, Jackson, & Curtis, 2009). This study also showed that non–English-speaking families receive less reported emotional support from their healthcare providers, including valuing families’ input, easing emotional burdens, and actively listen- ing (Thornton et al., 2009). Healthcare professionals’ cultural sensitivity and considerations are vital to promoting quality of care for patients/families with language barriers.
FUTURE RESEARCH
Many research questions have potential for exploration in the area of therapeutic listening. Systematic studies are needed to develop a body of knowledge. The study designs will require new paradigms beyond traditional randomized controlled trials for, among other things, ethical and feasibility reasons. Qualitative studies, case reports, or mixed-method designs may be better options for understanding the nature and effects of therapeutic listening. Some potential questions for future research are:
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● Can therapeutic listening via telephone or other interactive technology (syn- chronous or asynchronous) be effective at a distance?
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● What are the effects of listening by healthcare providers on patient satisfac- tion and other outcomes of care?
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● Are interventions to enhance listening on the part of healthcare providers cost-effective and legitimate areas on which to focus continuous quality improvement to increase patient safety and quality of care?
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● How do multicultural differences manifest in the processes and effectiveness of therapeutic listening?
WEBSITES
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● International Communication Association (www.icahdq.org)
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● International Listening Association (www.listen.org)
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● Communication Institute for Online Scholarship (www.cios.org)
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● EACH: International Association for Communication in Health Care (www .each.eu)
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● AACH: Academy on Communication in Healthcare (www.achonline.org)
44 I. FOUNDATIONS FOR USE OF COMPLEMENTARY THERAPIES
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4
Creating Optimal Healing Environments
Mary Jo Kreitzer and Terri Zborowsky
nurses have long been leaders in creating optimal healing environments ( OHE s).
Florence nightingale, the founder of modern nursing, described the role of the nurse as helping the patient attain the best possible condition so that nature can act and self-healing occur ( Dossey, 2000 ). nightingale recognized the nurse’s role in both caring for the patient and managing the physical environment. she wrote about the importance of natural light, fresh air, noise reduction, and infection con- trol, as well as spirituality, presence, and caring. Her philosophy embodied the notion that people have the innate capacity to heal and as nurses, we create the conditions that support healing within a person. increasingly, a base of evidence about the creation of OHEs is emerging from many disciplines, including nursing, interior design, architecture, neuroscience, psychoneuroimmunology, and environ- mental psychology, among others. Just as evidence-based practice informs clinical decision making, evidence-based design impacts the planning and construction of healthcare facilities. nurses need to be informed about the ways in which the phys- ical environment affects health outcomes so that they can contribute to the design of patient care units and other healthcare facilities that will optimize the health and well-being of patients, their families, and the staff. nurses are also in a unique position to carry out needed research on the impact of specific design interventions on intended outcomes.
DEFINITION
The word healing comes from the Anglo-saxon word haelen , which means “to make whole.” Healing environments are designed to promote harmony or balance of mind, body, and spirit; to reduce anxiety and stress; and to be restorative. An OHE model developed by Zborowsky & Kreitzer (2009) and depicted in Figure 4.1 illustrates that an OHE is created through a deep and dynamic interplay among people, place, and process . in this model, “people” includes the caregivers and sup- port team that surround the patient. The characteristics and competencies of the
47
48 I. FOUNDATIONS FOR USE OF COMPLEMENTARY THERAPIES
staff and the knowledge, skills, and attitudes that they embody are some of the most critical elements of an OHE. The “place” element focuses on the physical space where care is provided and the geography that surrounds the patient, family, and caregiver. “Place” elements include meeting functional requirements or pro- gram needs, access to nature, positive distractions, design elements that help create aesthetics, ambient environment, and ecosystem sustainability (see Exhibit 4.1 for definitions). The “process” element refers to the care processes as well as the leader- ship processes that support a culture aligned with creating an OHE. Care processes include conventional, integrative, and behavioral interventions.
This model of OHE illustrates that optimally, there is coherence and alignment between the “people—nurses, patients and families,” the “processes—caregiving in the context of patient centered care,” and in a “place—physical environment” that is designed to maximize positive outcomes for patients, their family, and staff. The reality is that much of care occurs in old, dysfunctional facilities. Even healthcare facilities built 20 years ago lack the available space and mechanical systems to func- tion well today due to changes in building codes, guidelines, and best practice in care models. An inadequate space makes it more difficult to attain a truly healing environment, although the elements of the caregiver and the care provided are even more critical than the physical place or space. Today, there is a better understanding of, and rigorous research that describes ways of choosing, elements of “place” that support and enable an OHE.
The primary emphasis of this volume is on the evidence and clinical applica- tions of complementary and alternative therapies that nurses can use to enhance their practice. This chapter focuses on the physical environment in which care is provided and the ways in which evidence can be used to create environments that contribute to positive health outcomes.
Figure 4.1 People, place, and process: The role of place in creating OHEs.
OHEs, optimal healing environments.
Source: Reprinted from Zborowsky, T., & Kreitzer, M. J. (2009). People, place, and process:
The role of place in creating optimal healing environments. Creative Nursing, 15(4), 186–190.
4. CREATing OPTiMAl HEAling EnviROnMEnTs 49
SCIENTIFIC BASIS
A growing body of evidence links the physical environment to health outcomes.
According to a review of the research literature on evidence-based healthcare design (Ulrich et al., 2008), over 1,000 rigorous empirical studies link the design of a hospital’s physical environment with healthcare outcomes. The studies cover a broad scope, with evidence linking:
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● Single-bed rooms with reduced hospital-acquired infections, reduced medical errors, reduced patient falls, improved patient sleep, and increased patient satisfaction
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● Decentralized supplies with increased staff effectiveness
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● Appropriate lighting with decreased medical errors and decreased staff stress
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● Ceiling lifts with decreased staff injuries
Although many of the studies focus on topics such as infection control, patient falls, staff productivity, and staff injuries, a growing number of studies focus on other aspects of the environment that contribute to healing.
As described by Malkin (2008), design strategies that focus on creating healing environments have in common the goal of reducing stress and include:
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● Connections to nature (e.g., artwork with a nature theme, views to the out- side, interior gardens, plants)
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● Options that give patients choices and control (e.g., room service menu, choice of music and art, ability to control lighting and temperature)
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● spaces that provide access to social support (e.g., family zones within patient rooms that offer sleeping space, storage, and adequate seating)
Exhibit 4.1. OHE “Place” Element Definitions
Meets Functional Requirements: Functional requirements are identified during the programming phase of the design process (see Facility guidelines institute [Fgi] guidelines for more information: https://www.fgiguidelines.org/wp-content/
uploads/2015/08/2001guidelines.pdf). These requirements include patient and staff safety, space for social support, and staff work areas, among others.
Access to Nature: includes actual or visual access to natural settings or designed nature settings. Access to daylight.
Positive Distractions: includes elements of the design environment that are of a two- or three-dimensional nature (e.g., artwork, water features, fire places).
Design Elements: includes the design elements—color, texture, shape, form, and volume—that contribute to the creation of furniture, fabric, and room layout, among other design artifacts.
Ambient Environment: includes the design elements of artificial light, sound, odor, and heating, ventilation, and air conditioning (HvAC).
Supports a Sustainable Ecosystem: includes the economic, social, and ecolog- ical impact of the design elements of the building and impact of any construction.
OHEs, optimal healing environments.