Implementing Compassionate Care Interventions in an Urban Primary Care Setting

The development of Compassionate Care interventions for primary care is an overarching series of interventions and education aimed at enhancing culturally appropriate care to an underserved population.  These interventions also address a number of priorities within the Patient Protection and Affordable Care Act of 2010, specifically in the area of quality improvement. The ACA’s first priority is identified within the category of improvement of quality and health system performance. This section addresses national priorities that include the improved delivery of health care services, patient health outcomes and population health (ACA, 2013).  Further, in the Institute of Medicine’s Priority Areas for National Action: Transforming Health Care Quality (2014), an overarching priority in the improvement of quality is to provide the patient with an enhanced care experience. They evaluated and chose priorities according to the degree in which changes in the system can improve day to day care and quality of life for the patients (Institute of Medicine, 2014). The priorities include the six quality aims of safety, timeliness, efficiency but also of patient-centeredness and equity. Efforts for improvement may include reorganization at a micro, organizational or environmental level but should be focused on and evaluated by their ability to improve the overall patient experience. We have developed interventions that will focus on several of these areas to improve quality with and through the staff and ultimately affect the quality of health care delivery. 

            In a successful systems environment, workers move beyond their small focus to understand how their role is intricately woven into the successful operations of the whole. They become a learning organization that continually strives to expand their knowledge and capacity and move towards common goals (Peterson, 2014). Instilling ideas and positive ways to improve quality can serve as a basis for the development for an open environment, shared visions and ideas and ultimately, a more effective environment for change (Peterson, 2014).

The Compassionate Care Interventions developed for the urban primary care setting have an approximate 24 month timeline. The individual interventions will include: (a) training for all staff in the utilization of a mindfulness app on phone or computer; (b) a presentation to all staff on the negative effects of lateral violence to increase staff awareness; (c) a Mindfulness-Based Intervention (MBI) with the clinical staff as participants; (d) motivational interviewing training for all clinical staff, and (e) intercultural communication/culturally appropriate care training (Spanish, Burmese, Somalian, HIV +, Transgender) to all staff with patient contact.

When discussing mindfulness or meditation, the words conjure images of a quiet, private time of tranquility and peace. Traditionally, hospitals and primary care practices don’t seem like a location where mindfulness has a place as a therapeutic option. There is, in fact, evidence that mindfulness is profoundly healing, and can be utilized in the health care system, from prevention, diagnosis, and treatment, through cure, palliative care, and even health administration and medical training. There are multiple practices that can be called mindfulness tools. Mindfulness  attitudes include; (a) non-judging, (b) patience, (c) “beginner’s mind”, (d) trust, (e) non-striving, (f) acceptance, and (g) letting go (Kabat-Zinn, 2009). Three critical elements of mindfulness include; (a) attention, (b) attitude, which incorporates wisdom, spirituality, compassion, peace of mind, and (c) intention, which has to do with self-regulation, self-exploration, and self-liberation.

Mindfulness practices are useful for the staff and health care provider in providing enhanced care by both self-disciplined practice of present-centered awareness, as well as a treatment modality that could enhance patient/client well-being. Two different training will be offered to the organization in mindfulness. The first will be to all staff in the use of a mindfulness app, with buy in from the organization to allow staff to utilize app when feeling stressed in the workplace. The Mindful Attention Awareness Scale (MAAS) will be completed prior to, and eight weeks after training. Additionally, the  4 week, 1 ½ hour weekly MBI will be offered to the health care providers in the facility after completion of the app training.

Motivational interviewing (MI) is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change (MINT, 2014). MI is based on the assumption that ambivalence to change is normal and can be addressed by assess the patient’s motivations and stage of readiness. The collaborative partnership between provider and patient is an alliance that takes into account both participants expertise. The intervention in the primary care clinic would consist of 4- two hour weekly training sessions that would include both didactic, as well as experiential content. The Organizational Readiness to Change Assessment (ORCA) will be administered on completion of training to all participants.

Lateral Violence (LV) has been documented in the Nursing literature for over 25 years (Sheridan-Leos, 2008).  Some of the direct effects of lateral violence include increased stress, poor morale, physical symptoms and feelings of isolation from other staff members (Sheridan-Leos, 2008).  Although the literature identifies Nursing as a primary population affected, the ANA (2014) reports that other professions to include pharmacists can also be affected.  One of the first interventions in addressing lateral violence is for staff to make an effort to care for one another, engage in self-awareness and name LV for what it is (Longo & Sherman, 2007; Sheridan-Leos, 2008). The program will address concepts in LV as well as define both overt and covert behaviors in LV as well as discuss interventions to combat LV in the workplace.  We are also planning skits to demonstrate positive behaviors, conflict management and proper feedback techniques. 

Cultural competence is often encountered in the primary care areas in an urban center, yet, literature reports gaps in provider knowledge in intercultural communication (Rosenburg, Richard, Lussier & Abdool, 2006). The program focuses on a series of monthly lectures and discussions focusing on the most common cultural groups to include Spanish, Burmese, Somalian, HIV + and transgender considerations. The lectures will include aspects of the cultural norms and beliefs as they pertain to medical care. They will be followed by staff discussion in an effort to discuss ways to improve care that is culturally sensitive. 

Outcomes measures for the intervention will include both staff and patient satisfaction surveys. The patient survey would include looking at what data is already available on patient satisfaction and adding phone surveys at a determined time after the last intervention. The phone survey in the patient’s native language would include:

• Provider/nurse listen to concerns
• Satisfied with patient education
• Confidence in treatment
• Treated respectfully
• Timely care/wait period
• Environment
• Parking
• Ease of scheduling, telephone access etc.

Focus groups may be utilized with staff and results of the intervention should include overall job satisfaction score, increased confidence, increased listening, increased respect, and less staff turnover.