What does an iceberg have to do with patient and family care?

By Lori C. Marshall | 08/15/2016

Hint: Effective communication involves more than just cold, hard facts.

Image of iceberg

The editor of Reflections on Nursing Leadership (RNL) interviews Lori Marshall, author of Mastering Patient & Family Education: A Healthcare Handbook for Success.
RNL: You developed the Marshall Personalized Patient-Family Education Model (PPFEM) to address certain deficiencies that can negatively affect healthcare outcomes. What are they, and how does your model address them?
Lori MarshallLori Marshall: The model addresses two kinds of deficiencies. The first is failure to recognize that patient-family education requires specialized knowledge. While nurses—as well as professionals in other healthcare disciplines—are aware that education of patients and families is part of their scopes of practice, expertise in providing this education is not universal. In other words, it changes from person to person.
It is not uncommon for a nurse to approach patient education without a plan or forethought about what the patient needs to know in preparation for the next part of his or her healthcare journey— whether it be, for example, transferring to another unit in the same health system or to a different type of care setting, such as a skilled-nursing facility, or to return home. As the largest group of healthcare professionals, nurses play an important role in achieving positive outcomes by anticipating and providing for educational needs of patients and their families.
The second deficiency is models of care that fail to equip nurses and other healthcare providers with sufficient information, based on inclusive caregiving principles, to properly focus their educational efforts. Many models don’t provide needed details. The PPFEM is a shared, easy-to-remember mental model that helps nurses address learning needs of patients and families in four stages: 1) negotiate, 2) navigate, 3) manage, and 4) maintain. Each of these stages has a set of goals that support the learning needs of the other three stages.
By grouping relevant learning needs in this way, my model promotes common understanding and purpose, thereby yielding more consistent and reliable results. To identify learning needs, a nurse first learns the patient’s story. Once learning needs are identified, the nurse, working with the patient and perhaps his or her family, suggests actions that lead to desirable goals, including a way to track progress.
Above all, by acknowledging the interdependence of nurses and healthcare consumers and by responding effectively to the needs of healthcare consumers who are self-directed learners, the PPFEM builds bridges between health systems. Working with this model, nurses who have not previously acquired the ability to simultaneously see both “the forest” and “the trees” will develop a new paradigm. No longer will they be concerned only with getting through to the end of a shift, completing a list of tasks, or addressing a patient’s immediate learning needs. Instead, while performing what must be done at the moment, they will also learn to concurrently look at the road that lies ahead on a patient’s healthcare journey and begin paving the way for additional steps on that journey.
RNL: As you point out in Mastering Patient & Family Education, patients and families have “stories” (information, history, and perspectives) that they bring to their healthcare experiences. You also observe that communication of a patient’s story is either strengthened or weakened by the story that the healthcare provider—a nurse, perhaps—brings to the patient encounter. The objective, I assume, is to help both parties learn how not to talk past each other. How does your model help patients “tell” their stories more effectively? How does it help nurses “hear” patient stories more accurately?
Marshall: One of a nurse’s most significant roles and one that greatly impacts healthcare outcomes is that of patient/family educator. Successful patient/family education is achieved only when all relevant learner characteristics and experiences have been considered in formulating a plan that addresses learning goals. I call this the learning exchange, and it begins by understanding what led up to the patient’s current health status.
The metaphor “tip of the iceberg” is helpful for showing why a comprehensive approach is needed. When we look at icebergs, we see what is visible above the water but are unable to see the much larger portion that lies beneath the surface. The same is true when it comes to understanding various influences on a patient’s healthcare journey. Not until we look below the surface and see the size, shape, and interconnectedness of those influences will we have any idea of what we’re dealing with.
Everyone has a story. I have one. You have one. Every nurse brings a personal story into his or her care-delivery practice. A nurse’s story can help him or her be more sensitive and receptive to issues, or it can desensitize that person to the point where he or she is blind to an issue. Past experiences can affect—positively or negatively—our comfort level with health systems, providers, or others who play key roles in our healthcare journeys. In adult care, most of the emphasis is on the patient. In pediatrics, it’s primarily on the family. But the caregiver may wonder, “Who is family?,” and the patient may wonder, “Why is it that the stories of my doctors, nurses, and other providers don’t play a role in my health outcome?” Knowing that everyone has a story and recognizing that everyone involved in a patient’s healthcare journey brings a different perspective help highlight the interplay and complexity of that journey.
The patient’s story is what drives the journey. It provides the foundation for effective communication, and if a nurse has not reflected sufficiently on his or her own story (perspectives and history, in particular), he or she could unknowingly and negatively influence communication. Stories connect people; they’re relational. Telling someone “I have walked this pathway and had to do this, too” creates a common bond. Bridging that connection by humanizing the experience and without communicating a negative bias, judgment, or one-size-fits-all mentality is the delicate balance we seek in the practice of nursing.
RNL: As you discuss in your book, global patient and family education partnerships are mutually beneficial collaborations in which entities from developed and developing countries benefit from each other. What are some of the skills healthcare providers in developed countries learn from their counterparts in developing countries and vice versa?
Marshall: There are several skills and insights healthcare providers can learn when traveling from a developed country to a developing one. Perhaps one of the most important is the ability to find simple, cost-effective solutions. It’s a lesson in reducing complexity and drawing upon available resources. It requires far more innovation and creativity to develop uncomplicated but effective solutions on a large scale than to come up with intricate solutions that depend upon a wide variety of conditions and that, because of their complexity, achieve minimal success or end in failure. Finding simpler but effective approaches is something developing countries need far more than developed ones.
One of my favorite articles that highlights the benefits of “reverse innovation” comes from Syed et al. (2012). The authors provide examples of how developed countries can help developing ones respond to crisis, handle staffing shortages and better utilize human resources, employ mobile technology for national communication systems, and develop programs that improve access to medicines. Reverse innovation provides a wonderful lens for amplifying the bidirectional nature of a global partnership. It is very important to not enter into these relationships with a superior attitude or try to make “them” like “us.”
Mastering Patient & Family Education bookAdditionally, care delivery models used in developing countries can show developed ones how to better utilize patient and family roles in the healthcare experience, including sharing physical space. I have travelled to various European countries, Australia, New Zealand, Japan, and, recently, China. Seeing laundry hanging from a window or balcony of a hospital reminds us of the impact long-term hospitalization has on a family and the need to share space with those we care for, especially during long-term care situations. The idea of this taking place in a U.S. hospital is unheard of, but isn’t that part of promoting family-centered care? Are we as welcoming and open as we think we are?
When nurses from developing countries travel to developed ones, they focus primarily on relationships and partnerships, especially those between nurses and physicians. This is especially true with regard to nursing’s more autonomous role in developed countries and the flattened hierarchy in which a nurse is co-responsible for voicing as well as stopping harmful events. Of course, nurses from developing countries are also aware that hospitals in developed nations have more facility space, greater resources, and smaller nurse-to-patient ratios. They also show interest, almost universally, in patient education structures and process, especially use of simulation and complex-care curricula.
Another benefit of global partnership, one highly valued by healthcare providers in developing countries, is leveraging for their use the clinical expertise they find in developed countries. This leveraging may come in the form of emulating specific clinical practices or acquiring clinical knowledge and skills they don’t currently have. The challenge is how to effectively apply this knowledge to a specific patient population or health issue or how to transfer a particular practice to one’s own country. For example, in the inpatient setting, it could be inaugurating the use of an ostomy nurse or borrowing a specific approach in caring for a child with a gastrostomy tube, including policies and procedures. Other well-known, community-based partnerships seek to prevent disease or promote health and may include immunizations, teaching about food and nutrition, providing primary care, or avoiding waterborne illnesses.
What I’ve come to understand and embrace is that every country has something to offer. What is one country’s weakness or limitation is another country’s strength. Global partnerships are relationships built on trust, respect, and valuing one’s global partner. Ultimately, successful partnerships adopt the best each partner has to offer for the sake of improving the health and well-being of people around the world. RNL
Lori C. Marshall, PhD, MSN, RN, administrator of Patient Family Education and Resources at Children’s Hospital Los Angeles, is the author of Mastering Patient & Family Education: A Healthcare Handbook for Success.

Syed, S. B., Dadwal, V., Rutter, P., Storr, J., Hightower, J. D., Gooden, R., … Pittet, D. (2012) Developed-developing country partnerships: Benefits to developed countries? Globalization and Health, 8(17). doi: 10.1186/1744-8603-8-17
Mastering Patient & Family Education: A Healthcare Handbook for Success, by Lori C. Marshall
ISBN-13: 9781940446301. Published by STTI, 2015
Price: US $59.95. Soft cover, 456 pages. Trim size: 7⅜ x 9⅛
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