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Relationship-based care: implementing a caring, healing environment.

Relationship-based care is focused on a caring and healing environment which is vital to the quality of patient care. By using the six key dimensions of the model, health care organizations are able to focus their relationships with those they encounter and thus create a caring, healing environment. The Relationship-Based Care Model is patient- and family-centered, surrounded by a framework of leadership, teamwork, professional nursing practice, patient care delivery, resource-driven practice, and outcomes measurement (Koloroutis, 2004). This model comprises three crucial relationships: the relationship with the patient and family, the relationship with self, and the relationship with co-workers. This framework is essential for a successful implementation of relationship-based care. Koloroutis encouraged organizations to inspire staff, establish practices and processes, educate all members of the organization, and examine practice results after implementing this transformation to relationship-based care.

The Surgical Medical Care Center (SMCC), located in a mid-western hospital, houses 61 beds with a patient population consisting largely of postoperative patients. In April 2008, SMCC was invited to participate in a Voluntary Hospitals of America (VHA) initiative based on the Relationship-Based Care Model. This initiative, RetuRN to Care[TM], focused on involving staff nurses in decision making, improving work environment, implementing evidence-based changes to improve patient care, and improving job satisfaction (Kirsch, 2008a, 2008b).

Literature Review

A literature search using Medline and Academic Search Premier, focusing on articles from 2006-2010, was conducted to explore whether hourly rounding on inpatient nursing units was beneficial. The literature described different ways of implementing purposeful hourly rounding: offering restroom assistance, providing for patient comfort in bed or turning patients, putting phones/call lights within reach, and assessing pain intensity (Ford, 2010). Ford found hourly rounding resulted in a 52% reduction in call light use, giving nurses more time to provide patient care and prevent patient falls. In a study conducted in 2006, expected outcomes of hourly rounding included increased patient safety through decreased falls and skin breakdown, increased patient satisfaction and comfort, and decreased call light use (Bourgault et al., 2008). During this study, a survey was given to patients before and after the implementation of hourly rounding; while there was an increase in patient satisfaction, falls were not decreased significantly (Bourgault et al., 2008). In a study by Leighty (2006), a 20% decrease was reported in steps taken by nurses during their shift after implementing hourly rounding with a proactive approach. Staff nurses were asked to wear pedometers and found they walked 4.3 miles a shift in comparison to the 5.3 miles they walked prior to the implementation, thus giving nurses more time and improving their efficiency.

In a call light study over a 6-week period, a decrease was noted in call lights from 13,216 in the 2-week period prior to initiating hourly rounding, to 9,316 in the 2 weeks after hourly rounding was initiated (Meade, Bursell, & Kelelsen, 2006). The call lights continued to decrease to 8,315 through the remainder of the study. Patient satisfaction scores and fall rates were also monitored during this time. The study showed an improvement in patient satisfaction from 79.9 to 91.9 on a 100-point scale after hourly rounding was initiated. Falls decreased from 25 in the 4-week period prior to initiating hourly rounding, to 17. Patients reported their pain was better managed, and nurses reported being less stressed and having more time for documentation and patient education.

Getting Started

The SMCC RetuRN to Care team attended three face-to-face meetings conducted by VHA over the course of the first year. The meetings began by discussing ways to implement a change at the bedside, the challenges involved, how to coach staff, and manager behaviors associated with a successful outcome. Hospital nursing administrators agreed the project would benefit the hospital and the patients, and supported the team organizationally and financially.

In getting started, VHA challenged all hospitals involved to develop a vision statement, complete a Clinical and Operation Time Survey (COTS), submit Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and complete a gap analysis to compare their facility to two other facilities identified by VHA to have demonstrated best practices. The vision statement was developed by the RetuRN to Care team with input from the entire SMCC staff. The final version of the vision statement is as follows: "Our Vision is for all Surgical-Medical Care Center patients and families to receive safe, reliable, competent, and compassionate nursing care in a caring environment."

Once the vision statement was developed, the COTS was conducted. This survey was one of the requirements of VHA to assist in assessment, change strategies, and implementation of relationship-based care. The SMCC RetuRN to Care team requested staff input on perceptions of the amount of time the RN was engaged in clinical and non-clinical duties. The COTS revealed nurses spend 40% of their time delivering patient care, 10% of their time delivering patient care support, 26% of their time engaged in clinical documentation, and 11% of their time performing administrative and clerical duties; 14% of nurses' time was impacted negatively by various barriers (e.g., equipment breakdowns, unavailable supplies, phone interruptions, and tracking down personnel, etc.).

Nursing-specific HCAHPS scores were submitted to VHA to demonstrate how the patients perceived the quality of care delivered. At the initiation of RetuRN to Care in April 2008, HCAHPS scores were mixed. Patients indicated 75% of the time "nurses treated me with courtesy and respect," and 50% of the time patients agreed "nurses listened to me carefully." In addition, 50% of the time "nurses explained in way you understand," and 58% of the time "communication with nurses" was good.

A comparison was completed to determine SMCC's clinical quality and safety measures with two hospitals identified by VHA to have demonstrated best practice. The overall scores were 53% from one hospital and 49% from the other hospital, which indicated the following challenge areas: leadership, systems and processes, tools, technology, and supplies (Kirsch, 2008a). From these specific areas, detailed criteria were extracted to give the team ideas for improvement. Possible actions included implementing hourly rounding; initiating the use of white boards; coaching staff; and building relationships with patients, co-workers, self, and physicians. This comparison assisted the team in identifying areas for improvement and was used in the development of an action plan.

Implementation of Relationship-Based Care

The team attended a VHA Conference in September 2008. They received multiple educational resources from VHA, as well as from other hospitals that attended the conference. These resources became useful tools in creating SMCC's action plan for implementing the RetuRN to Care initiative.

In an attempt to maintain momentum from the VHA Conference, the team conducted weekly meetings. During these meetings, team members read all conference materials and created an action plan. The most important planned initiatives were the installation of white boards in each patient room and the approach to hourly rounding. The focus then moved to coaching and building the relationship with self, co-workers, and patients and their family members.

The facility's standard for each patient room includes a white communication board. The standard boards include the room number and phone number. The team modified the content of the boards to include the nurse and patient care associate names, the patient's preferred name, diet, activity, and daily goals developed in collaboration with the patient.

The next step was to identify the most common patient needs when answering the call bells. A call bell log was kept at the information center and reviewed for the most common needs of the patients on the unit. These needs included pain medicine, bathroom assistance, drinks, repositioning, pump alarms, and room tidiness. These most common needs became the focus of hourly rounding and the development of the 6 Ps: pain, potty, PO, position, pump, and pickup.

The team needed a way to track staff adherence to hourly rounding and documentation on the white boards, as well as a way to inform patients and families of the efforts to accommodate their needs through hourly rounding. A document from VHA was modified for use on the unit as the green sheet. This sheet included a description of the rounding process, use of the white board, and other general information for the patient. It also included a section for the staff to document hourly rounding. The informational portion of the green sheet was reformatted as a tool to communicate the hourly rounding process to patients and families, and was placed in patients' admission packets.

In addition to documenting on the green sheets, the SMCC staff documented their hourly rounds in the patient chart. Charts were audited to verify consistent documentation of addressing the 6 Ps. The team recognized staff who demonstrated the greatest adherence to documentation requirements with customized scrub tops.

After approximately 6 months, the team noticed a decline in adherence to hourly rounding, so staff members were asked to re-commit to the SMCC vision (Koloroutis, 2004). By signing the agreement, the SMCC staff acknowledged the rounding standards and required documentation on the white boards in each room. As the next step, the team continued to evaluate progress with a "Commitment to my Co-worker, Healthy Team Assessment Survey" (Koloroutis, 2004). The results from this survey provided insight into the need to educate staff on team building and building a positive environment for confronting peers and addressing problems.



The team also invited the human resources manager to a meeting, where mandatory team-building inservices were identified as an intervention. Through the inservices, SMCC staff would discuss different ways to address situations with peers and to continue working well together as a team. The goal was to create a safe and healthy environment where staff could continue to work as a team and hold each other accountable for doing what is required.


Implementation of relationship-based care has required continuous education, and reinforcement of the vision and goals of the RetuRN to Care team. The initial education was focused on coaching current staff on relationship-based care, which included hourly rounding and updated white communication boards. To ensure new employees received the same information on relationship-based care, the team revised the orientation packets to include a description of expectations as well as standards for completing the white communication boards and hourly rounding. The vision statement created by the team also was included in the orientation packets.

In addition to the orientation packets, new and current employees were required to view an educational video created by the RetuRN to Care team. The video describes relationship-based care and highlights the six dimensions identified by Koloroutis (2004). The team customized these six dimensions to fit into the hospital's culture. One of the key components in the video is describing the old way of providing care compared to the new way. For example, the old mindset was, "I need more time to meet all my patients' needs." The new mindset is, "I will identify what needs are essential to be met today." This video gave the SMCC staff concrete direction in how they can incorporate relationship-based care in their daily work.

Ongoing education continues to be a significant factor in the implementation of relationship-based care. The team hosts P parties on a regular basis, reviewing information on focused hourly rounding and the importance of the 6 Ps. The team chooses a different theme for each party, such as Valentine's Day, 4th of July, and tailgating, and provides snacks associated with the letter P (e.g., popcorn, pretzels, punch). For staff members unable to attend the parties, RetuRN to Care team members provided one-on-one education and coaching on focused hourly rounding. Staff also received copies of current literature on relationship-based care.


The RetuRN to Care team's goal of providing patients with the ideal experience was evaluated through review of multiple clinical outcomes and quality indicators. To provide the ideal experience, the team implemented changes which impacted patient safety, quality of nursing care, clinical competence, and the relationships with others. Monitored scores included HCAHPS results, clinical outcomes, and a follow-up COTS.

The HCAHPS scores have demonstrated a steady upward trend. Continuous monitoring began in April 2008, when the RetuRN to Care team was formed. Over a 2-year period, HCAHPS scores increased to 100% of the time "nurses treated me with courtesy and respect;" 86% of the time "nurses listened to me carefully;" 86% of the time "nurses explained in way you understand;" and 90% of the time "communication with nurses" was good.

Properly completing hourly rounding results in the implementation of preventive measures, such as turning the patient to decrease risk of pressure ulcer development and offering bathroom assistance for a patient at risk for falls. The hospital participates in the National Database of Nursing Quality Indicators (NDNQI) data collection, which provides comparative data for falls and pressure ulcers in hospitalized patients. The overall trend in SMCC's NDNQI data demonstrated a reduction in total falls, falls with injury, and hospital-acquired pressure ulcers. The data collected from the first quarter of 2008 to the first quarter of 2010 are shown in Figures 1 and 2.

Since the RetuRN to Care team began its initiative, patient satisfaction scores have improved. After the initiation of the white communication boards, hourly rounding, and relationship-based care, the unit received the facility's Most Improved award for patient satisfaction during the second quarter of 2009. Patient satisfaction scores had improved from 83.3 in the first quarter to 85.0 in the second quarter; this represented the highest increase for inpatient units within the hospital.

Results of the follow-up COTS demonstrated an increase of 3% in nurses spending more time at the bedside delivering patient care in comparison to the 2008 survey. Other results of the COTS survey also showed positive feedback: a 3% increase in time nurses spent delivering patient cares support, a 3% decrease in the amount of time nurses spent engaged in clinical documentation, and a 4% decrease in administrative and clerical duties. Outcomes clearly indicated SMCC was meeting the identified goals and, in turn, providing its patients with a caring, healing environment.

In conclusion, relationship-based care was implemented successfully by educating new staff, providing continuing education to current staff, rewarding those who showed the greatest adherence during implementation, and providing the necessary tools. The RetuRN to Care team customized several different tools, including the white boards, green sheets, and purposeful hourly rounding to fit the needs of the unit. In turn, the unit experienced positive results, including an increase in patient satisfaction, a reduction in patient falls, fewer hospital-acquired pressure ulcers, as well as decreasing call light use which could improve staff efficiency and give the nurses more time at the bedside.


Bourgault, A., King, M., Hart, P., Campbell, M., Swartz, S., & Leu, M. (2008). Circle of excellence: Does regular rounding by nursing associates boost patient satisfaction? Nursing Management, 39(11), 18-24.

Ford, B. (2010). Hourly rounding: A strategy to improve patient satisfaction scores. MEDSURG Nursing, 19(3), 188-191.

Kirsch, J. (2008a, May). Workshop #1. In VHA central: Return to care rapid adoption network. Symposium conducted at the meeting of the Voluntary Hospitals of America, Indianapolis, IN.

Kirsch, J. (2008b, September). Workshop #2. In VHA central: Return to care rapid adoption network. Symposium conducted at the meeting of the Voluntary Hospitals of America, Indianapolis, IN.

Koloroutis, M. (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Healthcare Management.

Leighty, J. (2006). You called? Hourly rounding cuts call lights. Nursing Spectrum. Retrieved from CMS/knowledgeAssetDetail?inode=323256

Meade, C., Bursell, A., & Kelelsen, L. (2006). Effects of nursing rounds on patients' call light use, satisfaction and safety. American Journal of Nursing, 106(9), 58-70.


Kirsch, J. (2009, April). Workshop #3. In VHA central: Return to care rapid adoption network. Symposium conducted at the meeting of the Voluntary Hospitals of America, Indianapolis, IN.

Jennifer Woolley, BS, is Patient Care Associate, Deaconess Hospital, Evansville, IN.

Robin Perkins, RN, CMSRN, is Staff Nurse, Deaconess Hospital, Evansville, IN.

Patty Laird, MSN, RN, NE-BC, OCN, is Department Manager, Deaconess Hospital, Evansville, IN.

Jennifer Palmer, BSN, RN, CMSRN, is Staff Development Specialist, Deaconess Hospital, Evansville, IN.

Mary Beth Schitter, BSN, RN, CMSRN, is Team Leader, Deaconess Hospital, Evansville, IN.

Kelsie Tarter, BSN, RN, CMSRN, is Staff Nurse, Deaconess Hospital, Evansville, IN.

Mindy George, is Quality Improvement Data Specialist, Deaconess Hospital, Evansville, IN.

Grace Atkinson, BSN, RN, is Staff Nurse, Deaconess Hospital, Evansville, IN.

Katie McKinney, BSN, RN, is Staff Nurse, Deaconess Hospital, Evansville, IN.

McKenzie Woolsey, BSN, RN, is Staff Nurse, Deaconess Hospital, Evansville, IN.
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Title Annotation:Professional Issues
Author:Woolley, Jennifer; Perkins, Robin; Laird, Patty; Palmer, Jennifer; Schitter, Mary Beth; Tarter, Kels
Publication:MedSurg Nursing
Date:May 1, 2012
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