Consumer Relationships

This chapter explores the changes that have altered consumer relationships with healthcare providers and looks specifically at nurses’ responsibilities to the consumer. Nurses set the tone for effective staff-patient interaction. Because nurses are the healthcare providers who spend the most time with the consumer, this chapter provides concepts and strategies to assist in developing effective nurse-consumer relationships.

Objectives

• Categorize health consumers’ interactions into three relationship structures.

• Interpret the results of selected changes that have influenced consumer relationships in health care.

• Examine the importance of a service-oriented philosophy to the quality of the nurse-consumer relationship.

• Apply the four major responsibilities of nursing—service, advocacy, teaching, and leadership—to the promotion of successful nurse-consumer relationships.

The Challenge

Suzanne Freeman RN, MBA President of Carolinas Medical Center, Charlotte, North Carolina

Customer satisfaction is the number-one goal in our healthcare facilities. The hospital board officially acknowledged this goal, and systems were set in place to measure, monitor, and improve customer satisfaction. The staff ultimately defined principles to illustrate their commitment to this goal: teamwork, integrity, caring, commitment, and communication. Each individual would be treated with dignity and as a valued member of a “family.”

The husband of a patient seen in the emergency department (ED) some time ago called the nurse manager a few days after his wife’s visit. When she arrived at the ED, her chief complaint was intermittent chest pain for 2 days. She had indicated that she did not have pain upon arrival to the ED and was ultimately admitted to the hospital with the diagnosis statement “Chest pain, rule out MI [myocardial infarction].”

The husband complained that his wife had been required to “sign herself in,” even though he had asked the nurse to have his wife seen immediately. He thought that the nurse had not taken his wife’s complaints seriously and that the resulting delay had caused her condition to worsen. He attributed this issue to the fact that his wife required coronary artery bypass surgery the following day.

The nurse manager immediately met with the triage nurse involved. They talked through the encounter and examined the documentation. The triage nurse thought that her assessment of “nonemergent” was valid. She noted that the patient was registered by the patient registration personnel and that the physician saw her within 30 minutes of her arrival. The triage nurse’s assessment indicated “Vital signs stable, no history of heart disease, right-sided chest pain × 2 days.” The pain scale records indicated “No pain now.” The assessment made by the triage nurse appeared valid to the nurse manager. The nurse manager also noted that the nurse’s competency in assessing patients for triage was historically reliable. The triage nurse did not recall the husband asking for his wife to be seen immediately.

The nurse manager visited the patient and her spouse in the coronary care unit. She apologized for their expectations not being met during the triage process. She assured the couple that their concerns were taken seriously and offered her sincerest apologies. Her words seemed to be well received by the couple. Each thanked her for her concern and visit.

Apparently, the couple was not satisfied, however, because the husband called the vice president for patient services that same day. He related the story, including the nurse manager’s visit. He added that he had recently viewed a news report about how women were undertreated and misdiagnosed with regard to chest pain. The vice president listened carefully and promised to follow up quickly with a response.

What do you think you would do if you were this nurse? The staff nurse? The nurse manager? The vice president?

Introduction

Consumer relationships in healthcare delivery refers to the multitude of encounters between the consumer (client, patient, or customer) and healthcare system representatives. Who are the consumers of health care, and what do they expect from providers? What are their likes and dislikes, and how do they evaluate their health care?

Today, hospitals and other healthcare organizations are concerned with protecting consumer rights and are actively engaged in assessing patient/consumer satisfaction as a strategy to improve quality, enhance market share, and meet regulatory and/or accreditation requirements. The role of nurses as trusted professionals in the development of consumer relationships in healthcare organizations is increasingly recognized for its importance.

Consumers hold nurses in high regard. They view nurses as knowledgeable, worthy of respect, concerned for others, honest, caring, confidential, friendly, hardworking, and especially trustworthy. Nurses are perceived by 52% of Americans as having very great prestige (Harris Interactive, Inc., 2008). Nurses top the list in the 2009 Gallup poll of the public’s ratings of honesty and ethical standards of various professions with 83% of Americans believing nurses’ honesty and ethical standards are “high” or “very high” (American Nurses Association [ANA], 2009). Nurses have been at the top of the list in all but one year since they were added to the annual survey in 1999. Nurses, by virtue of this favorable status with the public, occupy positions of influence and can foster and promote successful consumer relationships across healthcare settings.

We are all consumers of health care—friends, neighbors, families, people like us, and people very different from us. Consumers are diverse culturally, ethnically, socially, physically, and psychologically. Consumers are indeed becoming better connoisseurs of health care than they were in the past. One sure sign of the healthcare industry’s response to that fact is direct marketing of pharmaceuticals and other health-related products. Between 1996 and 2005, the annual spending on direct-to-consumer advertising for prescription drugs in the United States grew from $11.2 billion to $29.9 billion (Donohue, Cevasco, & Rosenthal, 2007). Chronic health conditions require that consumers take an active role in managing their health. Chronic illnesses account for 60% of global mortality and one third of the world’s disease burden, with 80% of chronic disease deaths occurring in low-income and middle-income countries (World Health Organization, 2008). Employers view consumerism as a vehicle for reducing healthcare costs and for improving quality by empowering employees to make more appropriate choices about healthcare services while improving health care. The Leapfrog Group, a consortium of more than 160 employers and organizations that buys health care, is working to prevent mistakes in health care and improve the quality and affordability of health care. Its focus is on making leaps in hospital quality, safety, and affordability by implementing computerized physician order entry, referring patients to appropriate facilities for high-risk surgeries and conditions, staffing intensive care units with intensivists, and implementing practices to improve safety (Leapfrog Group, 2009). According to a survey conducted by Parks Associates, 20 million U.S. households do not have Web access, half of the people who do not use the Web are older than 65 years, and 56% of those without Web access do not have education beyond high school (Smith, 2008). Despite this digital divide, individuals with chronic conditions are more likely to use the Web for health information than those without a chronic condition, and the uninsured, particularly those with chronic conditions, are more likely to use the Web to search for health-related information (Bundorf, Wagner, Singer, & Baker, 2006). Although these data have implications for access to healthcare information, they also reflect changes that affect the nature of the relationship between consumers and nurses, consumers and other healthcare providers, and consumers and healthcare organizations.

Consumers have access to limitless amounts of information about health; however, such access may vary to some degree by ethnicity and socioeconomic status. Although some information that is available from the Internet and other resources might not be valid, healthcare consumers tend to be better informed now more than they ever have been. Numerous government agencies and voluntary organizations provide consumers with guidance in managing chronic conditions, making decisions about health, and preventing harm from lapses in patient safety. Publicity about medical errors and the nursing shortage and information campaigns directed toward consumers to promote safety have heightened consumer awareness being involved in all aspects of one’s health care. Consumers question providers regarding the care they receive or do not receive, and they ask, “Why are you doing that?” “Where can I get the best care?” “Why did my nurse do that differently yesterday?” and “How do I know what is the best decision for me?”

Relationships

The Consumer Focus

Consumer relationships are constantly changing and thus affect the providers of health services: primary care and public health services, managed care organizations, hospitals, home health agencies, and long-term care facilities, as well as individual providers such as nurses and physicians. As inpatient services have become more complex and outpatient services have grown, competition for patients becomes fiercer. This has resulted in a shift in focus from healthcare providers to healthcare consumers. As noted in “The Challenge” at the beginning of the chapter, consumers drive what happens in our healthcare settings. Healthcare processes are being redefined with the consumer as the center. How consumers view and value their care is important data. Consumers enter into distinct relationships to meet their healthcare needs, including relationships with healthcare agencies, insurers or payers, nurses, physicians, and allied health providers. Changes in access, insurance coverage, nurses’ roles and responsibilities, physician services, communication technology, pay-for-performance, and globalization are just a few factors influencing these relationships.

Health Literacy

Consumers rely on information from a variety of sources to make healthcare decisions. The relationships that consumers develop with their healthcare providers, including nurses, are important in helping them navigate the healthcare system. However, nearly half of America’s adults—that is, 90 million people—have difficulty understanding and using health information (Nielson-Bohlman, Panzer, & Kindig, 2004). The definition of health literacy used by the federal government is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (U.S. Department of Health and Human Services, 2008).

Understanding consumers’ health-literacy needs goes beyond examining reading ability. The first component of its definition is the capacity to obtain. This accessibility is also influenced by global aging, climate change, war and terrorism, and life-extending medical and technologic advances (Perlow, 2010). Health literacy is important because research has demonstrated that people with low health literacy do not understand health information very well and tend to get less preventive health care, which in turn may affect their health (Nielson-Bohlman et al., 2004). Promoting health literacy involves education, consideration of the context, and sociocultural factors. For example, a nurse who is an expert clinician in a specialty practice area, when diagnosed with a serious chronic illness, may not have the appropriate background to make informed healthcare decisions. Promoting health literacy is an important component of health care because individuals with limited literacy are vulnerable. They are more likely to be sicker when they enter into the healthcare system and are more likely to use more healthcare services.

Healthcare Provider–Consumer Relationships

Healthcare provider–consumer relationships have changed as physicians’ typical mode of practice moved from a single, private enterprise to multigroup practices that also include nurse practitioners, certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, registered nurse first assistants, physician assistants, and other healthcare professionals. Some group practices are incorporated into health maintenance organizations (HMOs), managed care programs, physician-hospital organizations or the emerging accountable care organizations. When consumers visit a group practice, they might not have the option of selecting a specific healthcare provider. Patients no longer know their healthcare providers as they did in the past, and providers may be less familiar with their patients, resulting in decreased opportunity for the development of mutual respect and trust. Furthermore, many hospitals now use hospitalists and there is some evidence that the coordination of care and accountability for the quality of care after discharge are more challenging (Pham, Grossman, Cohen, & Bodenheimer, 2008). However, trust still is an important component of consumer relationships. Trust is influenced by the healthcare provider’s competence but also is linked to interpersonal caring attributes (Hupcey & Miller, 2006). Older adults are interested in caring, respectful, and educational relationships with their healthcare providers and perceive nurses as authority figures who provide reliable information to help them with treatment decisions (Calvin, Frazier, & Cohen, 2007). Patients want and expect attentiveness to their concerns and respectful treatment.

Rural healthcare consumers have seen local hospitals close, and therefore they need to seek care in regional health centers. They may not have relationships with their new healthcare providers. This often leads consumers to be more critical and less accepting of their care. They may feel alienated and insecure in unfamiliar circumstances, even if they are receiving the best care. Patients’ perceptions are an increasingly valued outcome of care. Consumers may be caught in the middle without a healthcare provider when physicians leave communities because of malpractice premiums, when insurance companies limit access to certain types of healthcare providers, or when the providers change their healthcare facility affiliations. Furthermore, sicker patients are less satisfied with the quality of health care they receive than are their healthier counterparts (Wolff & Roter, 2008). It is incumbent upon healthcare practitioners to be sensitive to the needs of patients with complex conditions requiring expert intervention.

Agency-Consumer Relationships

Healthcare consumers may have been accustomed to receiving acute care in an inpatient setting. This option is no longer available for many. Patients may be angry and frightened at the thought of being on their own or receiving very limited services from home health agencies. The type of insurance coverage and the insurance carrier will probably dictate the specific hospital or healthcare agency used. Managed care options require that the consumer use particular and specific healthcare facilities or be responsible for all or a larger portion of the bill.

Patients discharged from emergency departments are often ill-prepared to manage their care at home because they do not understand discharge instructions (Engel et al., 2008). Nurses in acute care settings have limited time to provide complex discharge instructions. Home health nurses may not be able to make a sufficient number of visits to enable patients to successfully manage a chronic illness. Care options are decreasing, and costs are increasing. Most insurance plans have included a copayment or a deductible clause requiring the consumer to meet a certain dollar amount before the insurance companies will pay their 60% to 90% of the bill. In some instances, workers with entry-level jobs have had health plans requiring deductibles of $2000 to $5000, making preventive health services largely prohibitive. Medicare and Medicaid recipients also find themselves in the midst of changes in terms of how healthcare costs are managed. Understanding the Medicare prescription drug benefit is a daunting task for many seniors. As the 2010 Health Care Reform laws unfold, some of these challenges may be minimized.

Consumer-directed healthcare plans generally have had high deductibles with the goal of reducing healthcare costs by providing consumers with information about choices, risks, benefits, and costs. The goal has been to have greater emphasis on case management, disease management, and patient education. These plans use report cards, risk assessments, nurse-help telephone lines, websites, and an array of other consumer education materials. Consumers will be comparison-shopping for healthcare services just as they might comparison-shop for prescription drugs. Despite this growth in consumer awareness, the impact of consumer-directed healthcare plans on patient satisfaction and healthcare costs is unknown. Critics of consumer-directed healthcare plans indicate that these plans shift costs to consumers without any true reductions in healthcare spending. People enrolled in a high-deductible health plan were more likely to start forgoing medical care to save money (Dixon, Greene, & Hibbard, 2008). Furthermore, as the number of chronic illnesses among family members increases, the more likely they are to switch to using a high-deductible healthcare plan (Naessens et al., 2008).

Many healthcare organizations are still operating under an outmoded paradigm with only the needs of physicians and third-party payers driving the agency’s priorities. In increasingly competitive healthcare markets, there is greater application of information-sharing services known as Web 2.0 (allowing users to interact with and alter content), the potential for open-source electronic health records, and the use of digital media and mobile computing (Gardiner, 2008). New services include self-monitoring with technology in the home, videoconferencing, text messaging and instant messaging with healthcare providers, and clinics staffed by nurse practitioners in grocery stores. These changes will require that healthcare organization leaders focus efforts on relationships with patients who are more knowledgeable and demanding.

Nurse-Consumer Relationships

Nurses spend a lot of time with the consumer, and these encounters are generally personal and intensely meaningful. Nurses are in a distinct position to influence and promote positive consumer relationships. The nurse manager sets the tone for effective staff-patient interactions centered on the patient.

Changes from hospital or nursing home care to outpatient and in-home care have particularly altered the nurse-consumer relationship. Nurses are taking leadership roles as primary care providers (e.g., nurse practitioners, midwives), teachers and educators, and home healthcare managers and advocates, particularly in compensation and insurance areas. Nurses are emerging as the gatekeepers of the healthcare system, the liaisons between the consumer and a complex healthcare market. Ensuring that patients receive well-coordinated care across all providers, settings, and levels of care has been recognized as integral to the quality of care by the National Priorities Partnership (2008), a coalition of 28 major healthcare organizations including the American Nurses Association (ANA). The nurse manager is a key position to facilitate care coordination by working with case managers and members of the interdisciplinary healthcare team. The nurse in the gatekeeper or care coordinator role can be an influential advocate for consumers who could receive less-than-desired care in a complicated healthcare system. This group typically has included those who receive no care and need it most, such as those who are homeless, uninsured, or underinsured persons, persons who abuse drugs or alcohol, children of poverty, migrant workers, and people with acquired immunodeficiency syndrome (AIDS). Some institutions and private corporations capitalize on the case-management skills of nurses by developing the “nurse navigator” or “patient navigator” roles, which are designed to assist patients through a complex healthcare system or with healthcare decisions. Policymakers are examining the role of “medical homes” in facilitating the integration of care across systems. A medical home is a patient-centered, multifaceted source of personal primary health care (Rosenthal, 2008). The concept was originally focused on children and adolescents and includes having a usual source of health care. People with a usual source of health care are more likely to get health care (Robert Graham Center, 2007). Although discussions have focused on physician-directed care, advanced practice nurses provide an integral safety net for patients who are uninsured or underinsured or who have chronic health conditions and need to be included in policy decisions about medical homes.

Nursing has long recognized the value of the integral nature of the nurse-patient relationship and the value of caring as an element of that relationship. The Code of Ethics for Nurses holds that the “nurse’s primary commitment is to the patient” with an expectation that the nurse involves patients in planning for care (ANA, 2001, pp. 9-10). Patient-centered care includes alleviating vulnerabilities, both physiologic and interpersonal; it also includes therapeutic engagement and developing a relationship in a manner that is reinforced by the information practices of a particular setting (Hobbs, 2009). Wylie and Wagenfeld-Heintz (2004) describe the evidence for nurses’ receptiveness to mutuality and reciprocity in relationships that honor all persons. Mutuality balances power and respect and promotes productive communication.

Nurses have four major responsibilities in promoting successful consumer relationships, as follows:

Exercise 22-1

List as many clinical situations as you can think of in which the nurse might carry out the four aforementioned responsibilities. Compare your list with those of your peers.

Service

A service orientation responds to the needs of the customer. In “The Challenge” at the beginning of the chapter, activities centered on the patient and family, including how nursing care and all other services are delivered so that patient care is holistic. The National Priorities Partnership’s goals (2008), in addition to the previously mentioned care coordination, include engaging patients and their families in managing their health and making decisions about their care, improving the health of the population, improving the safety and reliability of America’s healthcare system, guaranteeing appropriate and compassionate care for patients with life-limiting illnesses, and eliminating overuse.

The patient must be at the center of care to achieve these goals. Healthcare professionals, including nurses, want to deliver patient-centered care. However, assessing how well that is accomplished in an organization is challenging. The Picker Institute, a nonprofit organization, has done extensive research on the evaluation of care from the patient’s perspective. Its model of patient-centered care, no matter where the services are delivered, focuses on the consumer’s perspective, as illustrated in Box 22-1. Each dimension is an important part of the consumer’s interaction with the healthcare system and provides guidance in promoting consumer relationships.

BOX 22-1

Seven Primary Dimensions of Patient-Centered Care

• Respect for patient’s values, preferences, and expressed needs: includes attention to quality of life, involvement in decision making, preservation of patient’s dignity, and recognition of patient’s needs and autonomy

• Coordination and integration of care: involves clinical care, ancillary and support services, and “front-line” patient care

• Information, communication, and education: includes information on clinical status, progress, and prognosis; information on processes of care; and information and education to facilitate autonomy, self-care, and health promotion

• Physical comfort: considers pain management, help with activities of daily living, and hospital environment

• Emotional support and alleviation of fear and anxiety: demands attention to anxiety over clinical status, treatment, and prognosis; anxiety over the effect of the illness on self and family; and anxiety over the financial impact of the illness

• Involvement of family and friends: recognizes the need to accommodate family and friends and involve family in decision making; to support the family as caregiver; and to recognize family needs

• Transition and continuity: addresses patient anxieties and concerns about information on medication, treatment regimens, follow-up, danger signals after leaving the hospital, recovery, health promotion, and prevention of recurrence; coordination and planning for continuing care and treatment; and access to continuity of care and assistance

From Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T.L. (2002). Through the patient’s eyes: Understanding and promoting patient-centered care. San Francisco: Jossey-Bass.

Even with an increasing emphasis on customer service, most healthcare facilities are not as “customer-friendly” as they might be; that is, they are built and organized in a manner that best serves the organization, not the consumer. They are compartmentalized, with each department having specialized functions. Patients are transported to departments to receive services. They risk loss of privacy, excessive exposure, and increased discomfort and fatigue during the transfer and waiting episodes. On an average day, a seriously ill hospitalized patient may have encounters with 50 or more personnel in the course of receiving care and treatment. This approach is not “service-oriented.” A service orientation means delivering services in a manner that is least disruptive. When possible, services should come to the patient and should be as easy, comfortable, pleasant, and effective as possible. Meeting the emotional, psychosocial, and spiritual needs of the patient is important. The consumer is interested in high-quality care that is technologically advanced and compassionate (Doucette, 2003). The quality of care refers to the outcomes of care in relation to a standard, whereas the service is a measure of perception of what matters to the patient (Doucette, 2003).

Exercise 22-2

List five examples of what you think are not consumer-friendly practices or situations in your nursing setting. (Example: Patients being asked to repeat information several times to different staff members such as admissions clerks, nurses, and radiograph technicians.) Identify at least two strategies to help address each problem.

Providing satisfying and meaningful service is not easy. Every consumer is different, and every situation is different. How things are done and how needs are met vary. Service is not a prescribed set of rules and regulations. Service is a multidimensional concept and means placing a premium on the design, development, and delivery of care. For example, a home care patient needs intravenous (IV) antibiotic therapy. Inserting the IV catheter is the task-oriented, production part of the care. The service aspect involves considering the patient’s specialized needs, such as placing the needle in the left arm so that he can continue to use a cane with his right arm or using a local anesthetic before inserting the needle to reduce discomfort.

Delivering nursing care includes both service and product characteristics. In the context of health care, a service involves interaction between a consumer and the healthcare system related to the provision of needs, whereas a product is a tangible item with physical characteristics. Some nursing actions require clearly prescribed rituals—the actual physical act of production, such as insertion of a Foley catheter. In performing this act, certain physical characteristics are apparent and the outcome is predictable. At the same time, no two patients are alike; human interaction alters the situation, and unforeseen variables demand spontaneity. Caring, concern, and respect for the individual are intangible characteristics that affect the ultimate success or failure of the nursing action. Quality nursing care must be both clinically correct and satisfying to the customer. “Clinically correct” is the product aspect, and “satisfying to the consumer” is the service orientation. Each individual nurse is responsible for being competent and providing quality patient care that is clinically correct and satisfying. The nurse manager is accountable for the overall quality of care delivered to patients.

Healthcare agencies must be sensitive to whether the agency milieu is indeed a healing environment that supports and reinforces the actual quality of clinical care. The challenge in the busy, unpredictable, cost-constrained healthcare environment is to provide care that has a consumer focus by meeting or exceeding customer expectations. Nurses, as leaders, need to recognize the economic value of their services as well as the economic value of improving the quality of the patient experience. Linking a satisfactory patient experience with positive outcomes depends on identifying patient preferences (Ervin, 2006). This is illustrated in the Literature Perspective below in Kerfoot’s description of the signature experience.

Literature Perspective

Resource: Kerfoot, K. (2007). Patient satisfaction and high reliability organizations: What’s the connection? Nursing Economic$, 25, 119-120.

Organizations desiring to have a competitive edge strive for a standardized signature experience, the ideal experience for a patient that is its hallmark. The emphasis needs to be on the development of that experience and focusing on its achievement for all patients and their families. Drawing upon the work of theorists and examples from industry, Kerfoot recommends that healthcare organizations identify a vision of the ideal experience, develop educational programs to help staff understand how to apply the signature experience in different situations and scenarios, and then measure the patients’ perceptions of that experience. Furthermore, efforts need to be made to intervene promptly to eliminate negative experiences.

Implications for Practice

Nurse managers are critical to the successful development of signature experiences for patients. When employees are involved in creating the signature experience for patients, the employees are engaged, performance is improved, and patients are satisfied.

Organizations desiring to have a competitive edge strive for a standardized signature experience—the ideal experience for a patient that is its hallmark (Kerfoot, 2007). The nurse leader and the nursing staff members need to partner in developing that experience and focusing on its achievement for all patients and their families. People are looking for an environment that meets their needs for safety and security, support, and psychological and physical comfort.

Hospital leaders value the role of the Magnet Recognition Program® in terms of promoting competent care and a service orientation. Magnet™ designation demonstrates excellence of nursing care through transformational leadership; structured empowerment; exemplary professional nursing practice; and new knowledge, innovations, and improvement, which lead to empirical quality outcomes (Wolf, Triolo, & Ponte, 2008). These attributes cannot be achieved without excellence in a consumer service orientation. This culture of excellence must be exemplified in every aspect of the organization, from the chief executive officer, to the chief nursing officer, to the nurse manager for nurses at the front lines of care to feel empowered to promote excellence in consumer service.

A service orientation is consumer-driven and consumer-focused, and it places the emphasis on the quality of the nurse-patient relationship. The importance of relationships is reflected in current nursing theory in the caring philosophy. Caring has been described as the essence of nursing. It denotes a special concern, interest, or feeling capable of fostering a therapeutic nurse-patient relationship. Caring is important, but simply caring is not enough. The ability to think critically and take appropriate, timely action must be a part of the therapeutic process. The nurse must do the right thing right at the right time.

The concept of nursing as a caring service is seen in the reality of “high tech–high touch.” High tech denotes a mechanistic perspective, whereas high touch denotes a caring, humanistic perspective. Caring for patients is challenging in an environment driven by technology. At the same time, patients depend on nurses to deliver high-tech care in a caring, humanistic manner. The more high technology is used in health care, the more the patient wants and needs high touch—someone who is trusted and respected and who will add human touch to the experience. The quality of these human contacts becomes the measure by which the consumer forms perceptions and judgments about nursing and the health agency. In health care, consumers frequently cannot judge or evaluate the quality of interventions but they always can evaluate the quality of the relationship with the person delivering the service.

Patient satisfaction ratings, along with measurable healthcare outcomes, are important data used by healthcare organizations to provide quality care and to maintain a competitive edge. Nurses, because of their 24-hour accountability for patient care, are integral to high patient-satisfaction ratings. Healthcare organizations collect patient satisfaction data and want high ratings, so much so that they advertise their ratings in the community. Standard-setting organizations, such as The Joint Commission and the National Quality Forum include patient satisfaction as a quality indicator. The patient’s satisfaction and perception of the quality of care are affected by patient-centered care which focuses on individual needs and preferences (Wolf, Lehman, Quinlin, Zullo, & Hoffman, 2008).

Hospitals and other healthcare organizations contract with vendors to measure patient satisfaction or use their own instruments. Very often, patient-satisfaction ratings are clustered together at the high end of the scale, making it difficult to interpret results and make improvements. One needs also to consider the range and the depth of the information that is collected. For example, some hospitals collect data only on the hotel amenities, such as the cleanliness of the room and data required by government or regulatory organizations. Other hospitals collect more specific data on satisfaction with nursing care, including such elements as how promptly the call light was answered and whether patients were satisfied with a specific aspect of nursing care, such as pain management. The National Database of Nursing Quality Indicators (NDNQI®) is a national repository for unit-based quality data that can be used by organizations to benchmark their outcomes against those of other institutions (ANA, n.d.). Unit-based quality indicators, including satisfaction with nursing care, are a key feature of the NDNQI®, enabling nurse managers and nurses to make improvements.

Nurses have a responsibility to exercise critical thinking and decision making with respect to patient satisfaction with nursing care. For example, postoperative patients may not want to cough and deep breathe, yet we know that failure to do so can result in pneumonia. National survey data indicate that pain management is suboptimal (Jha, Orav, Zheng, & Epstein, 2008). One of the challenges in providing effective pain management is that research demonstrates that patients can be quite satisfied with pain management yet still experience severe postoperative pain (Sauaia et al., 2005). This paradox illustrates the responsibility that nurses have for (1) advocating on behalf of their patients, (2) ensuring that their patients’ pain is relieved, (3) correcting patient misconceptions, and (4) implementing pain-management strategies that are consistent with established standards. Reviewing and analyzing patient satisfaction survey results are invaluable tools to improve consumer relationships.

A service recovery program needs to be put into place in order for an organization to be responsive to its customers. Service recovery is a strategy for identifying complaints and rectifying service failures to retain or “recover” dissatisfied customers. Axioms for service recovery are listed in Box 22-2. Effective service recovery includes encouraging healthcare providers, rather than just hospital administrators, to talk with patients about a serious error. In the past, healthcare organizations have been concerned with the potential risk for liability when the person making an error talks with the patient or family about it. However, research suggests that the content of the message has a significant effect on how the person feels about an error. Messages containing both an apology and an effort to address the problem in the future are the most productive (Kiger, 2004). Patients want to be treated with fairness and respect, want a change in hospital performance as a result of the complaint, and are more interested in an explanation than an apology (Friele & Sluijs, 2006). Consideration must be given to deciding which person in the organization is the most appropriate to offer an apology as well as planning its content. A nurse making a medication error that did not harm a patient is the best person to make the disclosure and apology. However, if a patient’s discharge is delayed by a day because of an omission or error in preparation for a diagnostic test, then the nurse manager and/or nurse administrator might be the more appropriate person to initiate discussion with the patient. Nurse managers can work with staff to help patients have their concerns addressed. Some organizations use scripts for use with situations in which care has not gone as planned. For example, when there is an excessive delay in the emergency department, staff training on when and how to use a script for this situation can help a patient or family member feel less distressed.

BOX 22-2

Axioms of Service Recovery