Sometimes I think ‘we’ promote patients’ dependence on ‘us’ and this has an insidious and counterproductive affect on patient empowerment and patient-centered care! A very complicated and complex topic that is worth reflecting on and discussing and will be helpful in personal growth and shifting our systems in this direction. So here’s the challenge:
When are we promoting dependence and when are we promoting independence?
Any time that healthcare professionals get secondary gains from helping others we may be contributing to patients being dependent on us. This is a red flag that we should all be aware of! I’m not talking about feeling good about being helpful to others, but I am talking about getting our needs met such as a sense of love and belonging in the course of providing care. For instance, what about when a patient has a preference for a particular nurse or doctor? Patients may have very good reasons for such a preference and I totally believe that therapeutic relationships and continuity of care are vitally important to outcomes, but if we ever catch ourselves going down a path where WE feel good about that preference, we need to be very careful! Here’s an example that is oversimplified, but will help bring this point home.
The situation: Mrs. Jones is an 84 year old widow who has been discharged from the hospital with a new diagnosis of insulin dependent type 2 Diabetes. She is a retired teacher who has lived alone since her husband died 6 months earlier. She has been assigned a home health RN, Nurse Smith to monitor her blood glucose and continue patient education regarding her dietary changes and insulin administration. Nurse Smith is explaining that she is going on vacation the following week and the next home visit will be made by her colleague Nurse Brown when Mrs. Jones gets teary. “You’re the only nurse that I want to come here. You’ve been such a good teacher with all of this confusing information.”
The nurse who may be seeking some secondary gains:
This nurse listens to Mrs. Jones and provides a light touch to her arm with one hand and a tissue with the other. She feels good that Mrs. Jones only wants to have her come to her house and it affirms that she is a good nurse and person. She wonders how she can address this patient’s concern and remembers that her vacation plans involve a late-in-the-day flight the following Monday and offers to make the next visit early in the morning before leaving.
The nurse with healthy professional boundaries:
This nurse also listens to Mrs. Jones and provides a light touch to her arm with one hand and a tissue with the other. She feels good that her expertise is helping Mrs. Jones make progress in managing her diabetes and recognizes that the patient is vulnerable re: a new diagnosis as well as the recent loss of her spouse. She also knows that Nurse Brown is very capable of providing effective care and they will need some time and opportunity to build their therapeutic relationship. She wants to honor the patient’s feelings, facilitate a positive relationship with Nurse Brown, and preserve her vacation plans. She shares that she is glad her interventions are helpful and that they have a nice rapport and offers that Nurse Brown has taken a recent workshop on the latest treatments for Diabetes and may have some additional insights to offer.
In the first scenario, the nurse may appear to be providing patient-centered care because she is doing what the patient wants. In reality the nurse is encouraging the patient to be dependent on her for friendship or social support and lacks faith in both the patient and her colleague. Care decisions become enmeshed with the nurse’s need for approval or belonging.
In the second scenario, the nurse subtly empowers the patient to engage in a successful therapeutic relationship with another nurse in order to promote her independence with her care. Care decisions stay focused on the clinical needs of the patient and her therapeutic goals.
I think our ability to recognize our own needs and wants will help us to steer clear of expecting patients to meet them and seek other support, i.e. the needs and wants are totally fine, but inappropriate to seek them from our patients. In order to do this we must be willing to reflect on our own behaviors and motivation. As we do this, we’ll have a clearer path towards helping patients identify their own needs, being more receptive to patients challenging our expertise, and using our expertise to ensure optimal outcomes that are in sync with what patients want. In other words, by getting our egos out of the picture of clinical decision-making we’ll have a cleaner field from which to meet patients where they are at in ways that will be helpful to them.
Ultimately there are many ways that our healthcare professionals and our systems promote dependency and I suspect we could have some interesting conversations about healthy versus unhealthy dependency affecting individuals and systems. Consider how doctors are often referred to as “Gods” and nurses as “Angels”. Do these labels fuel our secondary gains? Do they keep us in ‘Us’ versus ‘Them’ mindsets? And how about these common phrases:
- If you are sick for more than three days you must have a doctor’s note to come back to work.
- Make sure to talk with your healthcare professional if you are going to try this exercise program.
- You must have a referral from your primary care physician if your insurance is going to cover your visit to the specialist.
Don’t they all have elements of dependency that may be misplaced? What are your thoughts?
This post was written as part of the Nurse Blog Carnival.