Tell Me More^® As A Tool for Provider Connectedness With Hospitalized Patients: A Mixed-Methods Study

Abstract

Rates of burnout and compassion fatigue in healthcare professionals have remained high since the beginning of the pandemic with adverse implications for patient care. Tell Me More^® (TMM) is a tool licensed by the Gold Foundation, which was created with the purpose of helping patients, caregivers, and hospital staff to connect with each other on a humanistic level. Research has shown the benefits of the TMM with students and anecdotally with patients. This mixed-method study, which consisted of surveys and semistructured interviews with healthcare professionals (n = 72), sought out to understand the impact of implementation of TMM on a hospital floor. Surveys were distributed before and after the occurrence of TMM with interviews only occurring afterward. Three out of 8 survey items were found to be significant. Content analysis from interviews generated 4 themes from participants which included “Connectedness to Patient,” “Separation of Person and Illness,” “Communication with Patient's Support Network,” and “Connectedness with Non-Verbal Patients.” TMM is a useful tool for strengthening provider–patient relationships in hospital settings and may therefore lessen compassion fatigue and burnout.

Introduction

Compassion fatigue is the experience of emotional withdrawal, in combination with physical and mental exhaustion, that can be experienced by those in an extended caretaking role.^1,2 Since the COVID-19 pandemic providers have dealt with an increased demand for care, often with inadequate resources, leading to secondary traumatic stress and burnout.^3,4 A meta-analysis by Lluch et al found that compared to before the pandemic healthcare professionals had higher levels of compassion fatigue. This was reported in tandem with higher rates of emotional exhaustion and depersonalization. ⁵ This is a troubling statistic, as burnout is correlated with increased medical error and lower patient satisfaction.^6–8

Many studies focus on ways to improve provider well-being while decreasing compassion fatigue and burnout.^9–11 One such wellness practice is finding renewed motivation for work, which can come from spending more time with patients. ¹² A 2018 study showed that nurses spent 33% of their time in patients’ rooms, and that, from a patient perspective, 88% of patient interactions with healthcare workers during their stay were with nurses. ¹³ Therefore, as nurse burnout, unsustainable workloads, and patient depersonalization increase,^14,15 care will be inversely affected. Conversely, strong nurse–patient relationships reduce the length of hospital stays and improve patient outcomes.^16–18 As such, the negative correlation between high burnout rates and patient-centered outcomes demonstrates the importance of identifying and implementing measures to increase providers’ sense of connection to patients.

Patient-centered care is central to the ethos of many healthcare professionals, and there has been extensive research on its importance to the practice of nursing.^19,20 Much of this research focuses on “knowing the patient,” or having awareness of a patient's clinical and personal information in order to provide individualized patient care, rather than broadly treating a diagnosis. ²¹ This type of care increases trust between patient and provider ²² and improves patient satisfaction, while increasing work engagement. ²³ This research suggests that any tool providers can use to connect with their patients, while managing their clinical responsibilities, may play a role in improving their work satisfaction.

The Arnold P. Gold Foundation's Tell Me More^® program (TMM) was introduced in 2014 to foster empathy and humanism in healthcare to facilitate humanistic patient–provider interactions. Tell Me More^® is a medical student driven program that facilitates meaningful dialogue between students and patients regarding their personalities, family, friends, aspirations, hobbies, and life lessons. Most importantly, it allows students to gather an expanded social history to understand who the patient is as a person before and beyond their current illness. These conversations are then summarized visually on an eye-catching poster highlighting the patient's personal narrative. The poster is displayed in the patient's room with the intention to introduce all members of the healthcare team to important aspects about the patient beyond their diagnosis and illness journey (Supplemental Figure 1). Previous studies have shown that TMM has numerous benefits to medical students as well as preliminary data showing a positive impact on patients’ and their stay.^24–26 This study aims to measure the impact of the TMM program on hospital staff's connectedness with their patients. We hypothesize that TMM will improve staff–patient connectedness by increasing staff knowledge of patients, patient knowledge of staff, staff memory of patients, and staff's perception of their relationship with patients.

Methods

Participants

Healthcare professionals who worked for the Northwell Health^® tertiary care hospital system between June and August 2022 were recruited to participate in the study. The Northwell Health^® system consists of 23 hospitals, 12 000 credentialed physicians, and 19 000 nurses. Our participants represented 5 distinct Northwell sites. The Northwell Health^® Institutional Review Board (IRB: 22-0335) approved the study as exempt. All the healthcare professionals participating in the study signed an informed consent form.

Data Collection

Medical students collected data from a self-completed, anonymous modified Nijmegen Continuity Questionnaire. This survey was adapted by the researchers after a review of the literature on provider–patient connectedness.^27–29 The survey had 8 questions regarding the patient–provider relationship scored on a 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”) (Supplemental Figure 2).

For the qualitative portion, researchers chose a descriptive design for this study. Data were sourced from semistructured interviews, wherein the interviewers had a list of preprepared open-ended questions, allowing for flexibility and increased responsiveness of the interviewees to elaborate on their experiences with TMM^30,31 (Supplemental Figure 3).

Procedure

Medical student researchers implemented the TMM program at 5 Northwell hospitals. The TMM program was conducted for duration of 1-to-2 weeks on each given floor, as detailed in Qinq et al ²⁶ and Bhuiya et al. ²⁴

One week prior to beginning the TMM program, researchers administered the modified Nijmegen Continuity Questionnaire to staff on the unit. On the final day of the TMM program, researchers readministered the same questionnaire to the unit staff. Anyone who received the survey was then asked if they were willing to participate in an optional brief interview about their perceptions of the program and its impact. The content of these interviews followed a semistructured protocol and was completed by one of the researchers.

Data Analysis

Researchers used IBM SPSS Statistics (SPSS Inc., Version 28.0) to analyze the quantitative data. Descriptive statistics were reported as means and standard deviations for continuous variables and frequencies and percent for ordinal data. The Mann-Whitney U test was used to examine changes in the questionnaire responses before and after the TMM program was implemented. Statistically significant levels were set at a P value of less than .05.

Researchers compiled deidentified interviews from providers into one document. These interviews were analyzed using a content analysis approach, specifically editing analysis, which involves interpreting data through meaningful segments and units. Previous research applied content analysis ²⁴ to qualitative data. The culmination of this analysis produces key themes from the interviews. Researchers conducted and reported qualitative analysis following the recommended consolidated criteria for reporting qualitative research (COREQ) ³² .

Results

Demographics

The sample for this study consisted of 72 healthcare professionals who worked at the Northwell Health^® hospital system (Table 1). The occupation held by most of the participants fell in the nursing category (n = 50, 69%). The largest group of participants had worked for the health system from 0 to 5 years (n = 27, 37%). Prior to the implementation of the TMM program on each floor, 45% of participants were familiar with the program. At the conclusion of the TMM program that value increased to 92% of participants.

Table 1.

Demographic Characteristics of the 72 Participants Who Responded to the Survey.

Characteristic	n (%)
Occupation
Registered nurses, nurse practitioners, and nurse managers	50 (69)
Physicians	2 (3)
Social workers	2 (3)
Support staff	18 (25)
Length of time working
0-5 years	27 (37)
5-10 years	11 (15)
10-15 years	9 (12)
15-20 years	9 (12)
20+ years	16 (22)
Size of hospital
0-200 beds	24 (33)
200-500 beds	4 (18)
500+ beds	44 (61)
Familiarity with TMM
Before TMM	21 (45)
After TMM	23 (92)

Abbreviation: TMM, Tell Me More^®.

Out of the 72 healthcare professionals who participated in the study, only 8, all of whom held positions in the nursing category, agreed to participate in the qualitative interviews.

Findings

After the conclusion of TMM, when looking at aggregated data from all healthcare professionals who participated, 3 out of 8 statements showed a statistical difference between pre- and post-TMM questionnaires (Table 2). Those statements were: “I know my patients very well” (U = 749.5, P < .034), “My patients know me very well” (U = 788.0, P < .013), and “I remember my patient very well when I see them” (U = 844.0, P < .001). Specifically for the statements, “I know my patients very well” and “My patients know me very well,” using a Likert scale with values 1 to 5, there was a positive shift after the completion of TMM where participants did not select “strongly disagree” or “disagree” (Figure 1).

Table 2.

Survey Questions Asked of Our 72 Participants Before and After Tell Me More^® Including the Percentage of Combined Strongly Agree and Agree Responses.

Question	Strongly agree + Agree (%)		Strongly agree + Agree (%)
	Pre	Post
I know my patients very well	81	96	U = 749.5, P < .034
My patients know me very well	37	72	U = 788.0, P < .013
I remember my patient very well when I see them	73	96	U = 844.0, P < .001
I have a very good relationship with my patient	87	92	U = 700.0, P < .142
I know my patient's familial circumstances very well	49	64	U = 686.0, P < .217
I know my patient's daily activities very well	62	72	U = 636.5, P < .536
I tend to forget what my patient has told me before	76 a	80 a	U = 533.0, P < .492
I know very well what my patient believes is important in their care	66	80	U = 718.0, P < .103

^a Percentage for strongly disagree/disagree.

Figure 1.

Frequency distribution visual—3 statements that showed significant differences before and after the implementation of Tell Me More^® (TMM) across all healthcare professionals.

Findings from the interviews revealed 4 themes which provide insight into how TMM had a positive impact on the healthcare team: (1) connectedness to patient, (2) separation of person and illness, (3) communication with patient's support network, and (4) connectedness with nonverbal patients. The interviews also revealed a theme related to the improvement of TMM: (5) expansion of the program.

Theme 1: Connectedness to Patient

Participants found that implementation of TMM on their units allowed them to connect better with their patients and patients’ loved ones, regardless of the reason the patient was hospitalized. One interviewee found that TMM had the ability to jumpstart provider–patient relationships:

“It's a way of enabling or starting a conversation with the patient and the patient feels that relationship right away, like we know them already”

Another interviewee found that she was able to have conversations with a patient that she didn’t think would have been possible without the help of TMM:

“She happened to come from Jamaica and put a lot of, like, her information on the [poster], and it was cool for me to go in and go over everything with her, and it made her so excited to talk about herself and to involve us with the things that she likes”

Theme 2: Separation of Person and Illness

Many participants shared how important it is, for themselves as well as for their patients, to separate the patient from their illness. They found that the conversations facilitated after the creation of the TMM poster made it much easier to accomplish that goal. One interviewee who worked in an oncology unit believed that TMM could help with patient anxiety:

“I think the TMM project is very good. It's very important for patients, especially our patients in the oncology department because they're undergoing a life altering event–their anxiety is very high–so connecting with them on a personal level makes them feel like humans rather than just a diagnosis”

TMM also helped participants remember their patients during rounds and shift changes. What normally may have been strictly clinical interactions transformed to conversation including personal details, with one nurse noting:

“I actually looked at [the poster] in somebody's room and read something on it and talked [with colleagues]—the electrician—Yeah, he is an electrician”

Theme 3: Communication With Patient's Support Network

Interviewees found that TMM had this ability, depending on the content of a patient's poster, to connect patients to their families and give providers insight into family dynamics:

“There's a period of time where the families don't communicate for whatever reason and [TMM] allows them to get back in it to be almost like a conversation starter. And they can say ‘oh, I don't remember that dad or mom did that’, you know, ‘I didn't know that’. And it's nice.”

Others commented on how TMM can help create an expanded social history detailing parts of a patient's support network:

“I think it gives a quick snapshot of what the families … been through–their history, [the patient's] involvement with their families and what they've done in their lives”

Theme 4: Connectedness With Nonverbal Patients

Although most of the participants worked with patients who are verbal, there were some interviewees who worked exclusively in a hospice setting, sometimes with patients who were no longer able to speak. In these cases, the poster was made by speaking with family members in person or over the phone. One interviewee commented on how TMM was able to humanize their patients for them:

“Sometimes the patients are nonverbal so you really can't communicate [with them]. You can, if you walk in the room and you can maybe see–take a look at the poster and just say, oh you used to be a pilot”

Overall, interviewees found TMM to be a useful connection tool for a variety of patients:

“I do [it] for the patients that are alert and somewhat oriented and verbal. But then for the patients that are not, again it does allow us to connect”

Theme 5: Expansion of the Program

The interviews also highlighted the unexpected outcome of desire from staff to expand the program. One interviewee suggested, “having the medical students present on the patients who participated in TMM [during] rounds.” They suggested that sharing TMM posters and interview information would humanize the patients to the whole clinical team, jumpstarting rapport-building. Another suggested, “starting this process early on during the admission [process].” They believed that integrating TMM throughout patients’ stays would help staff connect with the patients, “letting them know that [the staff] really cares about them personally.”

Discussion

This study measures the impact of the TMM program on connectedness between healthcare professionals and their patients. Both the quantitative and qualitative data support the hypothesis that TMM improves provider feelings of closeness to patients across the spectrum of healthcare professionals, the majority of whom in this study's sample were nurses. After 1 to 2 weeks of TMM as a patient-focused intervention on a clinical floor, researchers found that this tool increased staff knowledge of patients, staff memory of patients, and even the staff perception of how much patients knew about them.

Our data indicate that TMM helps healthcare professionals humanize patients beyond their diagnoses, attending to both their physical and emotional needs. Based on this improved provider–patient relationship, the TMM program has the potential to lessen the impact of provider burnout on patient care, and perhaps lessen the rate of burnout itself ¹⁶ .

Furthermore, it is known that good provider–patient relationships reduce the length of hospital stays and improve patient outcomes^22,23,33. Even amid provider personnel shortages, decreased lengths of rapport-building time with patients^13,15 and, specifically, decreasing nurse-to-patient ratios ¹⁵ , TMM as it functions now can help nurses and other healthcare professionals connect with patients and patient support networks.

Prior research on this subject has shown that TMM can be adapted successfully with a medical interpreter phone to work for patients with limited English proficiency and may serve as a nonverbal form of communication between patients and their providers ²⁵ . Our data reaffirm the usefulness of TMM as a tool to improve provider connectedness to nonverbal patients; interviewees shared that medical students who worked with families of the patients due to the patients’ inability to communicate with the students themselves were still able to create representative posters of who the patients were, ultimately having a positive effect on both the healthcare team and the families. The nurse–patient relationship can be viewed as inclusive of nurse relationship with family members in some cases, and these extended relationships can help humanize the hospital experience^16,23,24. With this in mind, our findings suggest that TMM could play a role in decreasing provider depersonalization of hospitalized patients, improving patient and family satisfaction^7,8,14–19.

Limitations

An unexpected finding from our study, evident in qualitative interview themes, was that TMM does seem to increase staff knowledge of patients’ familial circumstances, improving patient-family–provider relationships although there was no statistical significance found between TMM and perceived staff relationship with patients or staff knowledge of patient's familial circumstances. We attribute this dissonance between quantitative and qualitative results to the fact that the pre- and post-TMM surveys were not matched to participants. This limitation is partially due to anonymity of participants throughout the process prohibiting pre- and post-survey matching, and partially due to staff's unpredictable work schedules. In addition, different employees were on a shift at the times of pre- and postsurvey distribution so participants may have completed a presurvey but not a postsurvey, and vice versa. Despite this limitation we feel confident in our data, as 92% of post-TMM participants were aware of the program.

Further research is needed on TMM and its long-term impact on both patients and providers. In this study, students conducted TMM for 1-to-2-week periods, throughout which time there was also high patient turnover. Studying the impact of TMM on patient–provider relationships over a longer period or implementing it on floors where there is slower patient turnover could demonstrate TMM's potentially varied usefulness in different settings. Many participants also found that having an in-service on TMM would be beneficial to the entire clinical team, so that everyone could take more of an active role in helping TMM succeed. Another recommended avenue of study is collecting and analyzing direct patient feedback. Many hospitals use surveys to measure patient healthcare experience ³⁴ ; depending on feasibility of adding questions to these surveys, collecting unbiased feedback on the program through additional survey questions could help shape TMM's future and widespread use.

Conclusion

The results from this study show that Tell Me More^® can function to improve provider–patient connectedness. TMM offers a holistic picture of patients to healthcare providers, who subsequently build trust by seeing the patient as a person apart from their diagnosis. TMM also gives space for healthcare professionals to share and find commonalities with their patients, improving reciprocity in provider–patient relationships. Theimplementation of TMM in the hospital setting has shown to have a positive effect on participating medical students; this work demonstrates a similar effect on other healthcare professionals cultivating important connections between providers and patients and potentially another pathway to reduce compassion fatigue.