Patient satisfaction scores in hospitals have steadily decreased in the United States. According to Zwillich (2007), “Americans are more dissatisfied than citizens of other nations with their basic health care, even while paying more of their own money for treatment”. Research has shown that the nursing shortage that has plagued the United States has played a large role in the downward trend of patient satisfaction. Citing a report by Press Ganey Associates, Inc., Sara Nemeth (2007) reports that the higher the ratio between working Registered Nurses in any given state, the higher the patient satisfaction scores will be. From this data, it can be surmised that patient satisfaction will increase as the number of nursing staff increases. These results demand a call to action, and patient satisfaction depends upon it.
A study published by the American Association of Colleges of Nursing states that the shortage of nurses may be affecting health care quality and patient outcomes, quoting the New England Journal of Medine as reporting that 53% of physicians and 65% of the public cited the nursing shortage as a leading cause of medical errors. The same study also states, according to Joint Commission for Accreditation of Healthcare Organizations (2007), that the shortage of nurses in America is, “putting patients’ lives in danger”, and found that since 1996, low nursing staff levels were contributing factors in 24% of patient deaths and injuries.
The nursing shortage is not going away any time soon. In the same article by the American Association of Colleges of Nurses, it is estimated that 30 states had shortages in the year 2000, and this projection is expected to intensify to where 44 states, plus the District of Columbia will have nursing shortages by the year 2020. In addition, according to the National Council of State Boards of Nursing, the number of nurses taking state boards for the first time decreased by 20% between 1995 and 2003.
Finally, Dr. Amy Tuteur quotes results Press Ganey President and CEO, Melvin Hall (2007) as saying, “The American Consumer Satisfaction Index (ASCI) from the University of Michigan has shown that customers’ satisfaction with healthcare has decreased significantly over the past several years”. Her statement is reflective of the majority of research being done in this area.
According to the ECRA group (2007), healthcare leaders must be held accountable for the quality of care they provide. Patient satisfaction is increasingly being looked at as an indicator of positive patient outcomes, and a better quality of life. ECRA states that the patients’ perceptions of the quality of care they receive, and the attention that is paid to them can be as important as clinical health measures when patients are viewing their clinical outcomes.
With the research showing that the nursing shortage is going to be here for quite some time, health care professionals must find a way to effectively deliver care, and bring patient satisfaction scores back to baseline, and above. Communicating with patients is key. Levinson (2007) states that poor communication often leads to patient dissatisfaction, whereas, “Effective communication enhances patient satisfaction and health outcomes.” Levinson also stated that the combination of a bad outcome and patient dissatisfaction, “Is a recipe for litigation”. In a similar article, J.W. Pichert (2007) stated that healthcare professionals must understand patients’ specific dissatisfactions and prevent them in the first place, thereby rectifying patients’ concerns. These findings suggest that nurses must find a way to enhance their communication with patients, reverse the trend of dissatisfied patients, and change the culture of patient care in a positive way.
In 2005, the Studer Group (2006) introduced a strategy into the healthcare market, called, “The Nursing Bundle”. It has been adopted by multiple hospitals across the United States, and has provided the tools for hospitals to significantly increase their patient satisfaction scores, and increase patient safety.
The Nursing Bundle is comprised of five key strategies, all aimed at promoting excellent patient care, proactively meeting the needs of patients, and increasing the level of patient satisfaction. Each component of the Nursing Bundle raises the standard of care on it’s own merit, but together, the five components tie into each other and have had a profound effect on the care delivery system.
The first component is Individualized Patient Care. This refers to identifying key priorities to the patient upon admission to the nursing unit. The nurse asks the patient what the two most important needs he or she has that if met, would allow them to feel as though they have received excellent care. This information is written on a dry erase board in the patient’s room, and alerts all staff to the patient’s individual needs. The patient’s individual pain scale is also assessed, and written on the board. The patient will see that the staff is concerned about them as individuals, and that they don’t treat everybody the same. The patient’s perspective is valued as being the most important, and they will be reassured that everybody is aware of what their specific needs are, thereby making them less anxious and more compliant with their care and treatments.
Individualized patient care also allows staff the opportunity to ask about the patient’s individual needs when rounding, eliminating call lights for unmet needs. The nurse will be alerted to the patient’s pain needs, and the physician will be alerted to the patient’s desired pain level. Ultimately, the patients will be more satisfied that their individual needs are being met.
The second component is Bedside Shift Report. Prior to the end of the shift, the nurse informs the patient that they will be doing bedside shift report very soon. The nurse tells the patient that their privacy is important, and asks if they would like the nurse to ask visitors to leave, should visitors be there at the time of shift report. This shows the patient that the nurse recognizes and facilitates their need for privacy.
During the shift report, the nurse introduces the oncoming nurse to the patient. The patient’s condition, tests, and procedures are reported to the oncoming nurse, and any needed clarifications are made for the patient at this time. This serves to show the patient that the oncoming nurse is aware of their needs, and reduces anxiety that perhaps the next nurse does not know their case. They will be more satisfied because they know who their nurse is, and that things are being done and monitored throughout the shift. Finally, the process will aid in increasing communication. Studer has determined that communication issues are the root cause of about 30% of patient safety events, and improved communication between caregivers positively impacts patient care and outcomes.
For the nurse, bedside shift report improves the sharing of information between healthcare providers by utilizing a standardized method of communicating. If asked questions, the nurse won’t have to say, “I haven’t seen my patients yet”, and will be more prepared. The off-going nurse can also use this time to use “hands-on” to show the oncoming nurse how to operate special equipment, or how special orders are being handled. Accountability will increase, since each nurse will know his or her patients’ condition at the beginning of the shift. Finally, bedside report improves the nurse’s understanding of the patient’s condition, as he or she is able to visualize the patient. With the nurse is better prepared and more comprehensively informed, the patient will have an increased sense of well being, and will ultimately be more satisfied.
The third element of the nursing bundle, and the most important, is hourly rounding. In a study done by C.M. Meade (2007), “Specific nursing actions performed at set intervals were associated with statistically significant reduced patient use of the call light overall, as well as a reduction of patient falls, and increased patient satisfaction”.
Hourly rounding has eight components that integrate to ensure that the patient is receiving the care that they need, and most important, the care they feel that they deserve. First, the nurse uses key words and/or actions to introduce themselves, their skill set, and their experience. The word “round” is used, because this is a word that is familiar to most people, and will help frame the context of the interaction. The patient is told when the nurse will round again, thereby decreasing anxiety and building trust.
Second, the nurse performs any scheduled tasks during the hourly round. Performing tasks while rounding allows the nurse to include scheduled work into the rounds, thereby accomplishing everything in one trip to the patient’s room. If there is not a scheduled task, the patient still has the reassurance that the nurse is coming to the room, and has the opportunity to voice an unanticipated need.
Third, the nurse addresses the “3 P’s” that Studer has identified as being the most common reasons patient use their call bells. These are pain, potty and position. Proactively assessing and treating pain keeps pain from becoming severe, and increases satisfaction as a result. Scheduling patients to use the bathroom on rounds avoids unassisted walks to the bathroom, which can lead to falls. Helping the patient change positions also helps to keep them comfortable, and reduces the chance of a pressure ulcer, especially in the elderly.
Fourth, the nurse performs comfort measures, such as fluffing pillows, straightening sheets, filling water pitchers, and offering something to drink. These are basic nursing functions that often get left undone if not intentionally scheduled, and lead to additional call light requests, and ultimately result in patient dissatisfaction.
Fifth, the nurse conducts an environmental assessment of the room. This allows the nurse to determine whether there are any needs the patient has not identified that could raise the potential for the patient needing the nurse to return before the next scheduled hourly round. These needs include making sure the call light and telephone are within reach, the garbage can is next to the bed, and the patient looks comfortable.
Sixth, closing key words are used before the nurse leaves the room. These are words such as, “Is there anything else I can do for you before I leave?” I have time”. This will not only decrease the need for the patient to ring the call light, but will allow the nurse to accomplish any other task while he or she is still in the room. It also tells the patient that all needs, no matter how small, are being addressed. The patient will be more satisfied with the nursing care if he or she knows the nurse has time to meet their needs.
Seventh, the nurse explains to the patient when he or she will be back. When the patients know the nurse will be back hourly, they will cluster their requests in the context of the nurses rounds, rather than relying on using the call bell, as long as they know the nurse will be back in an hour, and their request is not urgent.
Finally, prior to leaving the room, the nurse documents the rounds on a hourly checklist inside the patient’s room. This allows the patient to visibly see that it’s been only an hour between rounds, it allows the family to see that their loved one is being attended to frequently, and it allows the nurse manager to ensure that rounds are being done appropriately.
Hourly rounding not only has the benefit of proactively meeting the needs of the patient, but by decreasing the call lights, the nurse is able to stay focused and round on a schedule. According to Carla Cox, Administrative Director for Cardinal Health (2007), “A patient who is confident a nurse is checking on them regularly is more likely to wait for the nurse to stop in, rather than hit a call light”.
In addition to the research performed by the Studer Group, a study by Christine Mead, PhD, Executive Director of the Alliance for Health Care Research ((2007), had similar findings in regard to rounding. She stated, “Nurses’ rounds conducted regularly, every 1 or 2 hours, may help decrease patients’ use of call lights, as well as increasing patient safety and level of patient satisfaction”. In another article, Mary Shepherd, RN, Nursing Project Manager at Methodist Hospital in Houston, TX (2007) perhaps brought it together when she said, “Too many times we take for granted that the patient knows what we are doing when we enter their room. But these are non-clinical people who have no idea why we are asking them their name and birth date 30 times a day. One concept of the hourly rounding program is to take the time to verbalize everything that we are doing, letting them know it is for their safety, for their benefit”.
The fourth element of the nursing bundle is Manager Rounds on Patient. The unit manager visits every patient on his or her unit at least once per day, and validates that the elements of the nursing bundle are being accomplished. He or she asks the patient if they have had any difficulty accessing their nurse, if the nurse has been in to see them frequently, and if their pain has been adequately controlled. They also ask if the individual need listed on the board has been consistently met, and if they have had any difficulty accessing the bathroom. The patient has an increased sense of well being, not only knowing that they have been receiving individualized care, but also knowing that the unit manager is rounding daily to ensure that it is being provided.
The fifth, and last element of the nursing bundle is Discharge Telephone Calls. Patient’s perspective is valued as being most important. Discharge telephone calls make the patients feel cared about as a person, they decrease patient anxiety, provide an opportunity to evaluate patient education, to determine patients’ compliance with discharge instructions, to assess the overall impressions of the hospital’s performance, and to reinforce the patient’s perception that excellent care has been provided. For the staff, they provide a positive experience for staff, since most discharge calls are positive, they provide an opportunity for service recovery, and they provide an opportunity to identify trends that may require improvement in practice.
The discharge telephone call is also the last opportunity the nurse has to be sure the patient was satisfied. The nurse has a scripted dialogue, and begins by identifying him/herself, and asking if it is a good time for the patient to talk. This shows that the nurse respects and values their time. The patient is asked if they understood their discharge instructions, and if any questions have surfaced since their discharge. This shows the patient that even though he or she has been discharged, the staff of the hospital still has their well being in mind. The nurse then states that the hospital always likes to make sure their patients were very happy with their care, and states it just that way, following with, “How was your care?”. Next, the nurse thanks the patient for allowing the hospital to care for them, and makes sure they have a telephone number to call if they have any other questions. The discharge telephone call gives closure in a positive way to the patient, and brings their care into their home setting. When they receive their satisfaction survey in the mail, they are more likely to remember the care they received having received the discharge call as well.
With no end in sight to the nursing shortage, and the grim ramifications research has shown as a result, healthcare providers need to find ways to get back to the basics of nursing to improve the care delivery system, without waiting for the tide to turn again. The Studer Group (2006) has put together an excellent program to raise the bar back to where it needs to be.
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