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38 American Nurse Today Volume 14, Number 2 AmericanNurseToday.com“I FELT INVISIBLE,”responded a patient when askedabout her recent experience with a new healthcareprovider. When questioned further, she vividly recalledthe absolute worst part of this recent medical experi-ence: It’s abrupt and unfortunate ending. The patientfelt that the provider was in a hurry to move on to thenext patient. How do these types of experiences affecthuman health? Research shows that people tend to re-call the most unpleasant portion of an experience andhow it ended with greater detail than a cumulativeevent as a whole. In other words, a patient’s percep-tion of the end of an encounter can create lasting im-pressions. In this era of value-based care, an organization’ssuccess hinges on patients’ perceived quality of theirexperience and care. Nurses are highly educated in thewhys, whats, and how-tos of task completion, but wereceive little guidance in the crucial impact of timing inthe successful completion of patient encounters. End-ings hold the power to change thinking and redirectactions. They should guide what we do and how wedo it. The peak end rule In the early 1990s, Dr. Daniel Kahneman and his col-leagues completed studies of various patient experi-ences during colonoscopies and other painful or un-pleasant procedures. From these studies, the “peak endrule” was discovered: a person’s remembered experi-ence is primarily determined by the moment of greatestintensity (the peak) and how the experience culminat-ed (the end). The researchers found that shorter col on -oscopies with more painful endings were recalled asbeing worse than longer colonoscopies that ended withless unpleasantness (even if substantially more painwas delivered throughout the entire experience).Another experiment had participants submerge theirhands into frigid water for set amounts of time. Al-though both trials featured 60 seconds of identicalpain, the second trial added 30 seconds of reducedpain at the end (the water warmed slightly between 60and 90 seconds). Despite similar peak pain moments(at around 60 seconds), most participants, when askedwhich trial to repeat, chose the longer one. Increaseddurations of pain were preferred when the end wasmore comfortable. Patients and endingsThe tendency of people to evaluate the quality of ex-periences by certain moments (especially the end) ratherthan by the full experience continues to be supportedin our current healthcare climate. For example, whenpatients evaluate a hospital or clinic experience, ratingsare likely to correlate with perceptions of treatment andcare occurring at the event’s conclusion. Nurses must be aware of the powerful impact thatendings—whether physical, psychological, or both—have on human opinion and subsequent decisions. Con-sider this scenario: A nurse caring for a pediatric pa-tient undergoing a painful procedure helps to ensurereduced pain to the greatest extent possible throughoutthe procedure and at the end. Could these actions pos-The extraordinary impact ofendings Why wrapping up well is essential for nurses and beneficial to patients.By Jayne Jennings Dunlap, DNP, APRN, FNP-CHEALTHYNURSE

AmericanNurseToday.comFebruary 2019American Nurse Today39itively affect patient and family adherence to futurehealthcare treatments and recommendations and influ-ence health trajectories? Consider also the impact thatappropriate nursing follow-up procedures (via tele-phone, secure healthcare portal, or home visits) mayhave on a patient discharged from the hospital or clinicafter a bad experience. These strategies can ensure thatpatients who left the hospital unclear about next stepsstill have a positive ending experience related to theirhospital stay. (See Practical tips for a positive ending.)Good news or bad news?When given a choice between receiving good or badnews first, most patients choose bad news, even thoughthose delivering the news typically want to start withthe good. In other words, patients prefer happy end-ings. They want the sequence of events to rise ratherthan fall. Use this knowledge to help you understandhuman behavior and improve patient interactions. Con-sider starting with the negative aspects of a procedureor intervention and then share the benefits, or at leastbe sure to end with some benefits. The power of poignancyEndings help people rate and recall experiences. Al-though most people prefer to save the good news forlast, they long for something more complex than hap-To e n s u re a p o s i t i ve e n d i n g t o a p a t i e n t e n c o u n t e r, c o n s i d e rthese suggestions:•Use evidence-based interventions to avoid painful end-ings to unpleasant procedures.•Personalize the ending of a patient encounter by recall-ing notable information he or she shared. •Recall any previous positive progress the patient hasmade. •Provide closure and encouragement for health goalsthat have already been achieved. •Challenge patients to overcome current barriers tohealth. •Review motivators the patient has disclosed that couldhelp improve overall health. •Educate patients about why their health plans are intheir own best interest. •Connect patients with necessary resources and support. •Highlight the importance of care partnerships. •Make eye contact with patients at the conclusion of ap-pointments (avoid looking at health information tech-nology). •Escort patients to the check-out area, if time permits. Practical tips for a positiveendingA nurse practitioner student,near the end of her clinicalexperience, wrote about thepoignancy of nursing.“I no longer want to justrush through and get myprogram completed so that I may move on to the nextchapter of my life. Now, I longto soak up each class andevery bit of information—be-cause when I finish, I will bethe one making the diagnos-tic and management deci-sions. I will be the one takingthe lives of patients into myhands and I pray that I amready! This program is teach-ing me more than how to bea great nurse practitioner, it isteaching me how to use mygift and passion for helpingpeople. “I have had a colossal par-adigm shift. The things I havelearned thus far in familymedicine are invaluable. Ihave learned humility fromthe 50-year-old man whohugged me after we just di-agnosed him with diabetes. Ihave learned about the pow-er of love from an 80-year-oldwoman who just lost the loveof her life and was complete-ly devastated. I have learnedabout the unpredictability oflife from the stressed-out andhighly anxious army wifewhose husband is about todeploy, leaving her alonewith four children. I havelearned about the impor-tance of touch from a womanwith neurofibromatosis thatcovers every inch of herbody. She needed help wash-ing her back because shecan’t reach it and lives alone. “My preceptor remindsme every day that we don’twork at a factory where wecan just rush from patient topatient. These patients arereal people with real prob-lems who need help. Primarycare is so much more thanmanaging acute and chronicillnesses and writing pre-scriptions. It is about provid-ing excellent care for yourcommunity, which trusts youwith its collective health andwellness.”Poignant care