SF General talks to patients using everyday language to better coach them and develop a therapeutic alliance.
Collaborator (Non-Members)Larissa Thomas, Michelle Schneidermann
As nurses, our goal has always been to fix patients. They come in sick and we give them pills to make them better. But now, our focus has shifted to giving patients tools to empower themselves. The challenge is that many of our patients have very low health literacy and some aren’t even literate. Many of our patients also don’t speak English, so we’re really teaching their 13-year-old daughter who then needs to translate for her parents. I met with one patient who had CHF for 10 years, but never knew what it meant. I went in and started talking about his heart failure and he said, “I don’t have that, I have CHF.”
San Francisco General is a non-profit hospital and level 1 trauma center in San Francisco, CA. It has 598 beds and serves a diverse population, the majority of whom are lower income and do not speak English as their first language. Many are also illiterate in English as well as their preferred language. The hospital also serves individuals who may not have health coverage, housing or access to food. They enroll the most difficult to engage patients who have a history of substance abuse and poor health outcomes. Their transitions program began in 2009 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We try to meet patients where they are and speak in their language. Medical terminology is good for clarity when we’re speaking with peers, but the goal of conversations with patients is to help them understand their condition, not teach them terms we learned in nursing or medical school. So when we talk to doctors we may say, “The patient has edema because they’re not taking their Lasix,” but when we turn to the patient, we say, “The reason your legs are puffy is because you’re not peeing. You’re not peeing because you’re not taking your water pill.” That’s much easier for them to understand and also easier for their child to translate for them.
Besides using everyday language, we also use images as much as possible. Rather than telling patients what a low sodium diet is, we show them a picture of lots of foods, ask them which ones they eat, and make suggestions on the better options for them.
We also tell patients that they deserve to understand what’s going on with their body and should feel comfortable asking doctors or nurses to slow down and explain things again. It’s like when you get work done on your car or your home—you’re paying for the service so you make sure to ask what they’re doing and why they’re doing it.
The patients understand a lot more of what we’re teaching them. Patients who are readmitted aren’t being readmitted for the same reasons. They’ve learned some of what we taught them and used it to manage their diseases. They also feel more empowered to take care of themselves and are more confident about asking questions.
All of this isn’t about dumbing material down for patients. It’s about making it clearer by using language that they understand.
Speaking to patients using language they understand helps us develop therapeutic alliances quicker. They sense that we understand and respect them (and they understand us better), so it sets a good foundation for a relationship.
It was important for us to reframe these conversations from teaching to coaching. Nurses are used to teaching—it’s very one-way and about passing knowledge down. With coaching, you’re all on the same team and it’s about helping each other succeed.