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Nurses balk at bid to guide dealings with patients

In a push to improve patient care and make it more customer-friendly, hospitals are training nurses to be courteous, listen carefully, and check on patients at least every hour. But some nurses say their employers - in an effort to boost scores on patient satisfaction surveys and the revenue that can come with high ratings - have gone too far.

Nurses unions say an increasing number of hospitals nationwide are asking nurses to adhere to standard scripts when talking to patients, down to how often they use a patient’s name (at least three times per shift).

At several Massachusetts hospitals, nurses have been given laminated cards to hang around their necks with the words they should utter at the end of every visit: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’


These particular words, consultants say, are important because of research showing that patients are more satisfied with their care when they believe nurses made time for them.

Hospital executives and consultants deny they require nurses to follow scripts and argue that having nurses use “key words at key times’’ - as the Florida consultant StuderGroup puts it - makes patients more comfortable and less anxious, thereby promoting healing. But nurses say “scripting’’ - which is standard practice in hotels and fast-food restaurants - feels insincere and is an attempt to teach to the test rather than solve the real problem: Many nurses are simply too busy to nurture their patients.

In October, Medicare, the federal health insurance program for the elderly, will start basing 1 percent of payments to hospitals in part on their “patient experience’’ scores. Good scores can mean millions of dollars to a hospital that treats large numbers of Medicare patients, and the percentage will grow in subsequent years. Private insurers, including Blue Cross and Blue Shield of Massachusetts, also are using the Medicare survey results as one factor in calculating providers’ fees.


As a result, hospitals are rushing to hire consultants to help improve patients’ experiences through steps such as hourly check-in visits and having nurses, doctors, and other caregivers introduce themselves to patients. Among the companies providing advice is Disney, famous for referring to employees as “cast members’’ who are always on stage. It recently began offering a three-day training program at its resorts in Orlando called Building a Culture of Healthcare Excellence.

These companies often promise on their websites that their customer service programs can improve Medicare survey scores. And some companies, like HCPro Inc. in Danvers, make the goal of scripting explicit: On its website, the company tells executives that “you can speak to patients using language that they will be able to recognize when taking the survey. It’s almost like an open-book test.’’

Summarize the Medicare questions in a short paragraph at discharge and “try to remind patients and/or their families of the ‘right’ answers,’’ a tip sheet on the website advises.

During mandatory training for nurses at Baystate Franklin Medical Center in Greenfield, managers advised nurses to use patients’ names at least three times per shift.

Instead of saying, “Let’s review these instructions,’’ managers recommend saying, “Do you mind if I review these instructions? I want to make sure I’ve been clear so you will feel confident that you know what to do.’’


Hospital spokeswoman Amy Swisher said that these were meant as examples of the words nurses could use but that nurses in each unit decided themselves the best way to communicate with patients.

The Medicare survey asks patients whether nurses explained things in ways they could understand.

Ann Lewin, a nurse on a medical-surgical unit, said she felt like a “Stepford nurse’’ and worried that patients would be suspicious if nurses were using the same phrases. She decided to continue “to do what I’ve always done. Of course, I try to assess the patient and make sure they are comfortable.’’

Medicare’s patient experience survey is central to its plan to increasingly reward hospitals and doctors for good care, rather than for the volume of services provided. And, overall, it is considered an important advance for patients, in that it forces hospitals to consider their needs more carefully.

It is given randomly to patients from across the United States each year and asks 27 questions about nurses, doctors, and overall experience, including whether the room was kept clean, if it was quiet at night, and whether caregivers listened and were courteous. In most cases, patients answer never, sometimes, usually, or always.

“Hospitals are not permitted to attempt to influence or encourage patients to respond in a particular way,’’ Ellen B. Griffith, a spokeswoman for the Centers for Medicare & Medicaid Services, said by e-mail. “Efforts to help hospitals improve are permitted as long as these efforts focus on improving the actual care provided rather than simply encouraging patients to respond in a certain way to survey items through scripting or coaching by hospital staff.’’


At Lawrence General Hospital, which hired the StuderGroup and gave nurses the laminated cards to hang on their lanyards, the nurses union objected to the initiative. Elizabeth Hale, the new chief nursing officer, said “it’s important to provide standard language as a way to insure that introducing oneself, for example, becomes hardwired into our communication. It reminds us what a difference our words can make.’’ But she said she is not “going to shove it down their throats and hold them to the exact words. It’s a foundation.’’

Susan Frampton, president of Planetree in Connecticut, which provides coaching on “patient-centered care,’’ said the company tries “to get staff in touch with how patients and families might be feeling and when to offer that reassurance, but to offer it in their own words so it’s genuine and not something they’ve been told to do.’’

But, she said, scripting is common across the industry because “there is so much pressure on hospitals right now . . . that everyone is looking for an overnight solution to something that is really not that simple.’’ Schools teach to the test so “kids spit out the right answers . . . The health care industry is in the same situation. We’re trying to get patients to spit out the right answers.’’


At Disney theme parks, cast members use scripts for “high-volume interactions,’’ said Patrick Jordan, senior business programs facilitator for Disney Institute, and “very early on, when you first put a cast member on stage.’’

Similarly, the company may suggest a nurse say to a patient in advance of a shift change, “I am here all afternoon. Then Jane is coming on. She is great. She works this unit all the time.’’ But as nurses becomes more comfortable, they can “make it their own,’’ Jordan said. “While we use some scripting, it is not the primary part of our approach.’’

StuderGroup executives balked at the word “scripting’’ and said they have been removing that word from their website because it is outdated. Brian Robinson, executive vice president, said: “Those are words we provide as an example. The goal is to personalize those so they are sincere.’’ But he said it’s important to standardize customer service, just like patient safety practices are standard, if a hospital is going to see results.

Julie Rosen, executive director of the Schwartz Center for Compassionate Care, a Boston nonprofit organization devoted to improving the relationship between caregivers and patients, said she is not especially concerned about scripting because if it’s insincere, it will backfire on the patient experience survey anyway.

“The nurse can’t say, ‘I will be back in an hour,’ or ‘press your call button, and I’ll be there,’ and not do it,’’ Rosen said. “If they make claims they can’t support, I would assume the patient is not going to give them a good score.’’

Liz Kowalczyk can be reached at