Nursing Communication Bundle: Behavior Standards Review Article Series: 1

Glenn D. Pascual*

DHSc, DNP, MSN, RN, MBA, EMHL, FACHE, CPXP, OCN

*Corresponding author: Glenn D. Pascual, DHSc, DNP, MSN, RN, MBA, EMHL, FACHE, CPXP, OCN. 14060 Marquesas Way Apt. 2517 Marina del Rey, California 90292, USA, Email: Gdpascual1@hotmail.com

Citation: Pascual GD. Nursing Communication Bundle: Behavior Standards - Review Article Series: 1. Int J Nursing Sci Clinical Practices. 2021;1(2):1-6.

Received Date: October 08, 2021; Accepted Date: November 01, 2021; Published Date: November 11, 2021

Changing healthcare delivery systems demand greater accountability from hospital organizations and healthcare providers (Briggs et al., 2018). The radical restructuring of the healthcare system that is required to reduce spiraling healthcare costs and make healthcare accessible to all citizens will necessitate ongoing changes in healthcare organizations. The challenge for hospital organizations is to improve quality and service delivery through an ongoing process of innovation, restructuring of systems and processes, and implementation of aligned service behaviors to increase patient satisfaction and enhance clinical outcomes (Figure 1.0). Patient satisfaction scores serve as system indicators for financial reimbursement from government and private insurance agencies and as impetus for hospital organizations to choose the functional system of delivering care to improve quality, achieve desired outcomes, and enhance the patient care experience.

Given the macroeconomic nature of the impact of patient satisfaction scores on hospital reimbursement, the challenge for healthcare organizations is to improve quality and service delivery through an ongoing process of innovation, restructuring systems and processes, and implementation of aligned standardized service behaviors to increase patient satisfaction and enhance clinical outcomes. Hospitals under the current healthcare landscape are rewarded for the quality of care provided; thus, better outcomes indicate hospitals’ financial viability (Centers for Medicare and Medicaid Services, 2018).Managing service delivery across a highly divergent and fast-paced healthcare system requires sharp focus on execution and standardized operational excellence. Continuous quality improvement (CQI) has been shown to be a powerful tool to help make health care organizations more effective. CQI is a structured system for creating organization-wide participation and partnership in planning and implementing continuous improvement methods to understand, meet, or exceed patient needs and expectations.Developing a culture of excellence and quality in care can create an enthusiasm for change, passion for results, and drive for innovation equating to better service to healthcare consumers and better patient satisfaction scores.

As stated in the article, “Supporting caring efficacy in nurses through standardization of communication”, the science of communication is a predictor of quality, safety, and experience (Pascual, 2021). Communication with nurses is a critical element of patient satisfaction. More so, the evidence-based issues surrounding nursing communication have revolved around the following: structure, standards, support, spread, and sustainability (Herman et al., 2019). Structure means no fragmenting of the evidence-based interventions. The implementation of the interventions should be systematic, organized, patient-centered, and establish a flow with less variability along the care experience journey (Lin et al., 2015). The standard of execution should be consistent and have a strong association between the elemental components of nursing communication (Stimpfel et al., 2016). All stakeholders should support the initiative by taking ownership from the inception of the program until positive outcomes are achieved (Daniels, 2016). The spread should correspond with the capacity of the evidence-based interventions to be generalizable in any setting or location, practice, and population (Bansal et al., 2016). Sustainability means delivering great results at a certain rate or level in the context of reliability and transformation (Manss, 2017).

Figure 1.0: Value Chain of the Health Care Industry

Nursing Communication Bundle Elements: Behavior Standards

Meaningful nurse-patient communication is pivotal to building trust, alleviating uncertainty, developing mutual relationships, and creating a purposeful connection to enhance the current situation surrounding the care journey (Bumpers et al., 2019). Nursing communication is a linchpin to high reliable systems and processes, patient satisfaction and safety, and an engaged, high-performing workforce (Allenbaugh et al., 2019). Hospital organizations have focused on different strategies to improve the scores. Some initially implemented training focused on communication whereas others have focused on building a culture and reputation (Lofti et al., 2019; Owens et al., 2017). Although there are worthwhile strategies, the CMS objectified that nursing communication has the strongest correlation with most of the HCAHPS domains particularly with the overall rate of hospital care as evidence by the synthesis of 3.1million HCAHPS surveys in its 2014 HCAHPS PatientLevel Correlations (Briggs et al., 2018).

The Institute of Healthcare Improvement (IHI) developed the concepts of bundles to assist in reliably delivering the best evidence to care for patients (Riebling et al., 2019). A bundle is a straightforward set of single evidence-based practice interventions links together into a package of associated tactical elements. It is designed to make the process more reliable for care providers to apply. The standard bundle elements, when executed collectively and reliably, have been proven to improve patient satisfaction scores (Riebling et al., 2019). The standardized nursing communication bundles include behavior standards (Huron Consulting Group Incorporation, 2019; La Chapelle, 2018), patient-focused handover (Shimp & Sims, 2016), intentional rounding (Bansal et al., 2016), and discharge practice (Chan et al., 2015) (Figure 2).

Behavior Standards

Behavior standards allow providers of care to learn the structure and accountability that are necessary to foster a trusting relationship (La Chapelle, 2018). Scripting, using key words at key times technique, and communication skills training has been advocated to be the solution in promoting behavior standards necessary to increase nursing communication scores. Studer Group promoted using key words at key times with key behaviors strategy to guide healthcare staff in a positive direction (Huron Consulting Group Incorporation, 2019). Relatedly, Studer Group emphasized finding the right words at the right time builds a culture of operational excellence in care experience (Huron Consulting Group Incorporation, 2019). While keywords are important, these communication behaviors are not a script. The keywords framed a simple, consistent way to integrate fundamental patient communication elements into every patient encounter (La Chapelle, 2018).

On the other hand, Brewer and Watson (2015) identified scripting as an intervention to demonstrate caring with an authentic presence being part of the human caring professional practices. Scripting as a structured approach undermined the possibility of true caring connections. Contrariwise, Townsend-Gervis et al., (2014) gave the substance of delivering uniformity, framework, repeatability, and reliability of communication as essential and vital to improving quality indicators (e.g., readmission rates, catheter compliance) and patient outcomes and satisfaction. Establishing clearly defined parameters of acceptable behaviors served as a commitment to how nurses interact and treat others. The behavior standards are a model of care that illuminates organizational values and builds a common thread expected in every patient encounter.

Hospital organizations developed curriculums and training for staff to set the tone of improvement in nursing communication.

Figure 2.0: Standardized Nursing Communication Bundle

Allenbaugh et al. (2019) initiated and validated a curriculum for the providers of care that significantly improved clinical communication skills and some communication specific HCAHPS composite scores. Compton et al. (2018) created service standards that guide nursing practice. A recurrent curriculum is imperative to establish a measure for monitoring compliance with these behaviors, so care experience structures and initiatives can be adjusted accordingly.

Narrating of care involves a nurse explaining the what and the why to patient and/or family for all clinical care activities (Kaiser Permanente National Service and Quality, 2017). Narrating of care supports the value and uniqueness of every patient through information sharing and participative decision-making. Explaining the what rationalizes the intent and clearly articulates the care process. Explaining the why frames a reflective mechanism emphasizing the background and connects the desired outcome with the purpose (Lin et al., 2016). Pascual (2021) found that following the pathway of navigating the why and the what fosters respect and buy-in from the staff. A key behavior like the “First Seven Second Impression” is used to set the tone of care/ culture upon the patient’s arrival in the unit (Pascual, 2019). In every patient encounter, a nurse knocks on the door, smiles, and washes their hands before and after entering the room. It establishes the ability to make a good first impression (Lau, 2019). Using the process comes the provision of respectful and compassionate value-based care. Providing respectful care fosters nurse-patient relationship building and has been shown to build positive outcomes and promote faster healing (La Chapelle, 2018).

Improving patient care experience requires supporting caring efficacy through the standardization of nursing communication. A correlational study was designed to test a quantitative method of measuring caring in the simulated environment (Eggenberger et al., 2012). A purposive sample of 57 accelerated baccalaureate nursing students participated in the study whose curriculum structure was grounded in caring theory. The study compared student self-ratings with faculty ratings on caring efficacy during a simulation experience using the Caring Efficacy Scale (CES) tool. Independent t-test indicated students’ self-ratings were significantly correlated to the faculty ratings. The Coates’ CES tool used in the simulation environment shown both statistically significant measurement strength and conceptual linkages to caring behaviors (Eggenberger et al., 2012).

Implementation of Intervention

Behavior Standard 1- Service Standards: During the lecture, the project lead introduced the service standards to set a code of conduct, whereby nurses signed an agreement/attestation to clarify purpose and accountability. Behavior Standard 2- First Seven Second: The project lead emphasized the importance of knocking (three times), smiling, and washing of hands before and after entering the room. It is expected that the nurses purposely verbalized the act (Script: Preferred Name, I’m washing my hands).

Behavior Standard 3-Key Words at Key Times: The project lead highlighted the three nursing communication domain questions (treating with courtesy and respect, listening carefully, and explaining things clearly) using buzz words. The buzz words were intended to create a recall effect with patients. The project lead used a poster that was affixed in every patients’ rooms. The expectation was for nurses to read the items in the poster slowly and clearly while their hands are pointing on the buzz words during the middle and last hour of the shift (twice-a-day). In addition, the nurses thanked the patient for being able to care for them.

Behavior Standard 4-Narrating of Care: The nurses were expected to announce the words what and why when doing a procedure or when educating patients. The verification of understanding will follow by asking the patient (Script: “Am I clear?” or “Is there anything you need further explanation?”). If the patient expressed understanding, the nurses asked the patient to repeat important information as part of the teachback protocol. The nurses again thanked the patient for being able to care for them.

Figure 3.0: Behavior Standards

Implication of Behavior Standards to Quality, Safety, and Experience: Conclusion

Commitment to quality care entailed accountability in putting the systems and processes in place to measure standards through performance measures and service behavior indicators. Meaningful nurse-patient communication is pivotal to building trust, alleviating uncertainty, developing mutual relationships, and creating a purposeful connection to enhance the current situation surrounding the care journey (Bumpers, et al., 2019). Nursing communication is a linchpin to high reliable systems and processes, patient satisfaction and safety, and an engaged, high-performing workforce (Allenbaugh, Corbelli, Rack, Rubio, & Spagnoletti, 2019). Hospital organizations have focused on different strategies to improve the scores. Some initially implemented trainings focused on communication efforts, whereas others have focused on building a culture and reputation (Stimpfel et al., 2016). Although there are worthwhile strategies, the CMS objectified that nursing communication have the strongest correlation with most of the HCAHPS domains particularly the overall rate of hospital care after synthesizing 3.1million HCAHPS surveys in its 2014 HCAHPS Patient Level Correlations (Briggs et al., 2018).

The Institute of Healthcare Improvement (IHI) developed the concepts of ‘bundles’ to assist in reliably delivering the best evidence to care for patients (Riebling et al., 2019). A bundle links single interventions together into a package of associated tactical elements that providers of care must follow every patient every time. It is a straightforward set of evidence-based practice designed to make process more reliable. The standard bundle elements e.g., behavior standards, when executed collectively and reliably, have been proven to improve outcomes (Riebling et al., 2019). Analyzing this concept led to the formation of a standard bundle of elements which could potentially lead to an improved nursing communication composites score.

Nursing communication is elusive because of the inherent barrier between a nurse and a lay patient. Each are in stark contrast with each other from skillset to mindset. The nurse vantage point to communicating with a patient is clinically based while the patient has an expectation of relational-based communication (La Chapelle, 2018). Accordingly, the stressors that are in place for the nurses, and stressors in place for being hospitalized also cause this communication to be allusive. The flow of information between care providers in a medical setting can be thought of as the basic unit of nearly every important aspect of what happens in nursing. Communication makes up a culture in a unit, the leadership style of a leader, the collaborative or toxic way members of a team coordinate their efforts. As such, communication issues can be understood as the root of the most important problems we face in the nursing profession. Research on solutions to the challenges, therefore, must focus on communication if we hope to find real solutions that get at the source of our problems in nearly every aspect of what we do.

Behavior standards are the blueprint of the patient’s care experience journey. They play an important part in high performance work environments. The context and brevity of the care provider’s behavior dictates alignment to the organization’s values. Behavior standards are foundational and equivocally ensembles the tone and culture of the unit, department, or the entire organization. Adherence to the use of behavior standards improve the quality of one’s communications and interactions by weaving together information and allows patterns to emerge, define and agree on expectations, encourages communication through relationship-based care, and validates valuebased impressions using the domain of perception checking. As health care leaders, care providers, and stakeholders we live and work in a service-based economy that is continually laced with the winds of change. This places a great premium on “behaviors and care standards” by the organizations as well as individuals. Only the early adopters, so to speak, will be able to maintain the pace and succeed in a constantly changing healthcare environment.

About the Author

Dr. Glenn D. Pascual is a healthcare leader of 22 years. A combination of strong Ivy League education, outstanding work experience, awardwinning performance, and the right leadership/soft skills make an outstanding and highly desirable leader, innovator, motivator, and change agent. In November 2020, he was named as Gawad Amerika’s “Hero Front liner Excellence in the field of Hospital Administration and Management.” This most recent honor brings to 61 the total number of states, regional, national, and international awards bestowed on Glenn in the past 12 years. He completed his second doctoral degree in Nursing Practice in the prestigious Pennsylvania State University. To date, this well-known leader has earned two doctorate degree, three executive master’s degree, and three board certifications including a Fellow in the American College of Healthcare Executives. His best practice innovation awards highlighted his passion for patient care and care experience delivery. Dr. G as everyone calls him believes: “Leaders do not decide their futures; they decide their behaviors and their behaviors decide their futures.”

References

  1. Allenbaugh J, Corbelli J, Rack L, Rubio D, Spagnoletti C. A brief communication curriculum improves resident and nurse communication skills and patient satisfaction. Journal of General Internal Medicine. 2019;34(7):1167-1173. doi. org/10.1007/s11606-019-04951-6 

  2. Bansal M, Abdallah A, Pennisi A, Arnaoutakis K, Makhoul I, Mehta P. Improving communication on intent of chemotherapy using QOPI scores and PDSA cycles. Journal of Cancer Education. 2016;31(4):736-741. doi.org/10.1007/s13187-015-0897-x 

  3. Brewer BB, Watson J. Evaluation of authentic human caring professional practices. JONA: The Journal of Nursing Administration. 2015;45(12):622-627. doi.org/10.1097/NNA.0000000000000275 

  4. Briggs K, Sharma L, Chandrasekaran A, Douglas C, Aroh D, Finefrock D. The effect of a hybrid training program: Improving nursing communication skills and HCAHPS scores. Nursing Management (Springhouse). 2018;49(2):51-53. doi. org/10.1097/01.NUMA.0000529931.81622.66

  5. Bumpers B, Dearmon V, Dycus P. Impacting the patient’s experience in a children’s hospital using a communication bundle strategy. Journal of Nursing Care Quality. 2019;34(1):86-90. doi.org/10.1097/NCQ.0000000000000336 

  6. Centers for Medicare and Medicaid Services. Hospital Value-Based Purchasing: CMS. Gov. 2018. 

  7. www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMNL/MNLProducts/downloads/Hospital_VBPurchasing_Fact-Sheet_ICN907664.pdf.

  8. Chan B, Goldman LE, Sarkar U, Schneidermann M, Kessell E, Guzam D, Crutchfield J, Kushel M. The effect of a care transition intervention on the patient experience of older multi-lingual adults in the safety net: Results of a randomized controlled trial. Journal of General Internal Medicine. 2015;30(12):1788-1794. doi.org/10.1007/s11606-015-3362-y 

  9. Compton EK, Gildemeyer K, Mason TM, Hartranft SR, Sutton SK. Nurses’ caring behaviors. Clinical Journal of Oncology Nursing. 2018;22(2):169-174. doi.org/10.1188/18. CJON.169-174 

  10. Daniels JF. Purposeful and timely nursing rounds: A best practice implementation project. Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports. 2016;14(1):248-267. doi.org/10.11124/jbisrir-2016-2537 

  11. Eggenberger TL, Keller KB, Chase SK, Payne L. A quantitative approach to evaluating caring in nursing simulation. Nursing Education Perspectives. 2012;33(6):406-409. doi: 10.5480/1536-5026-33.6.406

  12. Hermann RM, Long E, Trotta RL. Improving patients’ experiences communicating with nurses and providers in the emergency department. Journal of Emergency Nursing. 2019;45(5):523-530. doi.org/10.1016/j.jen.2018.12.001 

  13. Huron Consulting Group Incorporation. “Always behavior”- Behavior 4: Using key words at key times. Studer Group. 2019. 

  14. Kaiser Permanente National Service and Quality. National Care Experience (NCE): RN communication regional current state assessment. 2018.

  15. La Chapelle KM. 21st century leadership. Power Mentor. 2019. 

  16. Lin M, Heisler S, Fahey L, McGinnis J, Whiffen TL. Nurse knowledge exchange plus: Human-centered implementation for spread and sustainability. Joint Commission Journal on Quality and Patient Safety. 2015;41(7):303-312. doi. org/10.1016/s1553-7250(15)41040-2 

  17. Lotfi M, Zamanzadeh V, Valizadeh L, Khajehgoodari M. Assessment of nurse–patient communication and patient satisfaction from nursing care. Nursing Open. 2019;6(3):1189-1196. doi.org/10.1002/nop2.316 

  18. Manss G. Implementation of daily senior leader rounds using a transformational leadership approach. Nurse Leader. 2017;15(1):65-69. doi.org/10.1016/j.mnl.2016.08.012 24. National Research Corporation. HCAHPS scores. NRC Health. 2019. 

  19. Owens K, Eggers J, Keller S, McDonald A. The imperative of culture: A quantitative analysis of the impact of culture on workforce engagement, patient experience, physician engagement, value-based purchasing, and turnover. Journal of Healthcare Leadership. 2017;9:25-31. doi.org/10.2147/ JHL.S126381 

  20. Pascual G. Supporting caring efficacy in nurses through standardization of communication. International Journal of Nursing Sciences and Clinical Practice. 2021;1(1):26-36. 

  21. Riebling NB, Norouzzadeh S, Reeder G, Mouradian C, Hillier A, Cowan R, Doerfler M. Quantifying patient satisfaction with process metrics using a weighted bundle approach. British Medical Journal: Open Quality. 2019;8(1):e000458-e000458. doi.org/10.1136/bmjoq-2018-000458 

  22. Shimp K, Sims A. Photo identification on a medical-surgical unit improves communication resulting in positive patient outcomes. Nursing Economic. 2016;34(6):309-311. 

  23. Stimpfel AW, Sloane DM, McHugh MD, Aiken LH. Hospitals known for nursing excellence associated with better hospital experience for patients. Health Services Research. 2016;51(3):1120-1134. doi.org/10.1111/1475-6773.12357 

  24. Townsend-Gervis M, Cornell P, Vardaman JM. Interdisciplinary rounds, and structured communication reduce readmissions and improve some patient outcomes. Western Journal of Nursing Research. 2014;36(7):917-928. doi. org/10.1177/0193945914527521