Nursing: The Highly Skilled Customer Service Representative

[gleanns]

Over the course of my nursing career I have heard endless spiels about "customer service" and "patient satisfaction" and the importance of these two things. What no one really explained was how I fit into that equation or what the ramifications of those scores meant to the organization or me personally. With that in mind, I am going to address those things now for all of you.

First, let's define customer service. In healthcare it seems to be this vague, arbitrary term that is interpreted to mean whatever makes the patient happy. Let's be clear on what we're talking about and not taking about here. The phrase "customer service" is an umbrella term that refers to how a person or entity (healthcare facility, professional association, business, individual practitioner) treats the people they serve. By "serve" I mean tending to those who come to us for help, advice, medical care. The phrase "customer service" is not "waiting on people" like a waitress in a restaurant. Nor does it imply that those we serve must be called "customers" rather than "patients." It's the concept not the terminology that matters. The phrase is universal.

I frequently hear things like, "I just want to come to work and do my job" or "I am a nurse not a waitress" or my personal favorite, "Employee satisfaction is going to decrease if I am expected to worry about patient satisfaction." Let's be honest ... nursing is an educational degree that equipped all of us with a certain set of clinical skills and knowledge however, in today's healthcare world, having the degree and skills isn't enough. Healthcare is a customer service industry. Granted, we are a highly educated customer service provider but we still provide a service. Today, being a good nurse also includes being able to provide good customer service. Treating patients and families with courtesy and respect, empowering patients to participate in their decision making, making them feel safe and cared for, providing them with information...all of those skills are part of what used to be called "bedside manner." That was a basic nursing skill because most people went into nursing with the desire to help people.

I've heard nurses say that we do these things "only" for patient satisfaction scores. Of course the scores are tool to measure how well patients perceive their overall care and hospital experience. A patient's perception does play a role in his/her care because we all know that the happier, safer, and more cared for patients feel, the better their recovery; the fewer times they hit the call button; the less inclined they are to initiate a law suit; and the more inclined they are to have good feelings about the facility and it's staff overall. These things are all important to any nurse because it impacts our livelihood. It impacts our livelihood!! I will explain how that happens...

Healthcare reimbursement is decreasing and costs are going up. We can save money on supplies and try to find other cost savings measures, but that will not close the gap. Payroll is around 65% of a healthcare organization's operating budget. With healthcare reimbursement being tied to performance on patient satisfaction scores, of course it will have an impact on payroll and your paycheck. Many organizations have had to freeze wages, decrease educational support, or reduce benefits. Raises cannot be given if there is a decreasing amount of money coming in to the organization.

Every employee is responsible for their piece of "patient satisfaction." Nursing is the single largest work force in the organization and the closest to the patient. We can have a large impact on our patient's perceptions of their care here. That is how you personally fit into this equation and how the organization's reimbursement ultimately affects you personally. Like it or not, the care you give, the attitudes you display, the interactions you have with patients and families have an impact on the scores...the financial health of the organization, and ultimately on your own paycheck.

It's a give/take relationship. It may be one you are not fully invested in or believe you should have to participate in. Perhaps you are feeling like you shouldn't be held accountable for those patient satisfaction scores. I challenge you to find a nursing job anywhere where you are not held accountable. Coming to work to "just do your job" now includes doing a great job with customer service. It does not mean you are a highly educated waitress. It does not mean that you are going to make every encounter positive at the detriment of clinical outcomes. We are never going to make every person happy. It does mean that you need to come to work prepared to spend time with patients and their families communicating clearly and helping those patients and families feel empowered to participate in their care.

[Libby1987]

2015 Press Ganey recommendations on maximizing reimbursement. In a nutshell, it says that management needs to stop blaming the nursing staff for low HCAPS and start providing humane working conditions.

Nurse work environment a key driver of performance: 4 findings

I'm not at all surprised that this conclusion was drawn by Press Ganey. Why they have always been the enemy baffles me. That some employers have tried to influence scores with a hotel service facade is not a reflection on the intent of patient surveys.

[Susie2310]

Excellent article, OP.

[calivianya, BSN, RN]

Whether or not we like the content of this article is irrelevant. It is the way things are now - this is what administration expects and this is indeed part of what "being a good nurse" is all about now.

This is why I'm going to be getting the heck out of nursing in a couple of years.

[imintrouble, BSN, RN]

The problem with this article is the writer totally believes in what they write.

We're being negative and defensive. We're not giving these ideas a chance.

The OP could be my manager since we just had a mandatory meeting highlighting most of what's in this article.

It's drivel.

[ProgressiveActivist, BSN, RN]

Nowhere in the Code of Ethics does it say that Nursing Professionals are responsible for hospital finances. The nurse's primary responsibility is to the patient. So management, you do YOUR job. I'll do mine.

Code of Ethics

ANA Nursing Ethics is part of the The Center for Ethics and Human Rights, which maintains the ANA Nursing Code of Ethics.

Preface

Provision 1*

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

Provision 2

The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

Provision 3

The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

Provision 4

The nurse is responsible and accountable for individual nuring practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.*

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

Provision 6

The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provisiobn of quality health care and consistent with the values of the profession through individual and collective action.

Provision 7

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

Provision 8

The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.

Provision 9

The profession of nursing value, for maintaining the integrity of the profession and its practice, and for shaping social policy.

[SmilingBluEyes]

Nowhere in the Code of Ethics does it say that Nursing Professionals are responsible for hospital finances. The nurse's primary responsibility is to the patient. So management, you do YOUR job. I'll do mine.

Code of Ethics

ANA Nursing Ethics is part of the The Center for Ethics and Human Rights, which maintains the ANA Nursing Code of Ethics.

Preface

Provision 1*

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

Provision 2

The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

Provision 3

The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

Provision 4

The nurse is responsible and accountable for individual nuring practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.*

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

Provision 6

The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provisiobn of quality health care and consistent with the values of the profession through individual and collective action.

Provision 7

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

Provision 8

The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.

Provision 9

The profession of nursing value, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Well stated Libby.

[nutella, MSN, RN]

This is what happens when reimbursement is directed by patient satisfaction surveys and scores - HCAHPS. And of course administrators focus on maximizing profit because Medicare will reduce payments based on satisfaction scores (Long, 2012).

Targeting nurses with customer satisfaction training is all geared towards getting those satisfaction scores higher. There are also some places that actually provide training to other healthcare professions but nurses seem to feel the squeeze the most.

While I agree that some customer service skills are needed I feel that the system sets nurses up to fail. High nurse to patient ratio with increased amount of tasks, increased time to perform tasks due to computers (bar code assisted medication administration....and others), and not sufficient support by CNA leave nurses with the desire to perform great nursing care but not enough time! Instead of fixing the system and enable nurses to provide the care they would like to give we add checklists, more assessments, more responsibilities and so on and expect it all to work...

Bedside nursing is already a field that becomes more and more unattractive. Because nursing schools put out so many new graduates there is a huge market to "young" idealistic nurses to replace the ones who give up and leave the bedside. If it wasn't for that we would not have enough nurses anymore. Already now there is a lack of really experienced nurses who have time and are willing to mentor. The telemetry and med/surg floors are mostly home to young nurses who have the energy and need to work to pay off loans, get first experience and so on.

In my opinion, we need to fix the system all around and set nurses up to be successful.

Reference:

Long, L. (2012). Impressing patients while improving HCAHPS.Nursing Management (Springhouse), 43(12), 32-37. doi:10.1097/01.NUMA.0000422891.99334.68

[gleanns, ASN, MSN, RN]

Yes, I am a nursing director. No, I'm not out of touch. I do work in one of the more protected areas when it comes to nurse:patient ratios. Labor and Delivery, Postpartum, and NICU follow AWHONN guidelines for staffing. I'm sure that part of the reason for that is due to the fact that these areas are highly litigious areas.

Customer Service is one of the metrics that influence reimbursement, like it or not. I have seen articles that have brought attention to the fact that this is not perhaps the best practice. This asks the lay person to evaluate medical care based on their only frame of reference which may be similar to their hotel or restaurant expectations. Unfortunately, until that changes, these are the rules of the game we have to play by. CMS is in control of this and without changes private insurers are starting to follow their lead.

I understand the time crunch. Electronic documentation systems take up to a third of a nurses time. I've read that dealing with issues or barriers to patient care; missing meds, transport, etc, can eat up another third of the nurses time. I also agree that the patients who are admitted are sicker and require more care. Administration does expect more. I agree that there should be some work done from both sides to close the gap. Having adequate staffing and support is one of those things that definitely influence customer satisfaction. The patients know when their nurses are over worked.

I do absolutely believe in what I wrote. I have seen far too many nurse:patient interactions that have not been a result of short staffing or hurried nurses that have been lacking in just plain old kindness. The old saying that nurses eat their young is played out in many facilities every day. That it should over to patients is no surprise. Don't get me wrong, there are some absolutely fabulous nurses who run their socks off and provide excellent care. I work with some amazing nurses. I'm more concerned with the ones who just don't care.

I'm interested in the discussions that have followed this article. Always a learning experience!

[nutella, MSN, RN]

Yes, I am a nursing director. No, I'm not out of touch. I do work in one of the more protected areas when it comes to nurse:patient ratios. Labor and Delivery, Postpartum, and NICU follow AWHONN guidelines for staffing. I'm sure that part of the reason for that is due to the fact that these areas are highly litigious areas.

Customer Service is one of the metrics that influence reimbursement, like it or not. I have seen articles that have brought attention to the fact that this is not perhaps the best practice. This asks the lay person to evaluate medical care based on their only frame of reference which may be similar to their hotel or restaurant expectations. Unfortunately, until that changes, these are the rules of the game we have to play by. CMS is in control of this and without changes private insurers are starting to follow their lead.

I understand the time crunch. Electronic documentation systems take up to a third of a nurses time. I've read that dealing with issues or barriers to patient care; missing meds, transport, etc, can eat up another third of the nurses time. I also agree that the patients who are admitted are sicker and require more care. Administration does expect more. I agree that there should be some work done from both sides to close the gap. Having adequate staffing and support is one of those things that definitely influence customer satisfaction. The patients know when their nurses are over worked.

I do absolutely believe in what I wrote. I have seen far too many nurse:patient interactions that have not been a result of short staffing or hurried nurses that have been lacking in just plain old kindness. The old saying that nurses eat their young is played out in many facilities every day. That it should over to patients is no surprise. Don't get me wrong, there are some absolutely fabulous nurses who run their socks off and provide excellent care. I work with some amazing nurses. I'm more concerned with the ones who just don't care.

I'm interested in the discussions that have followed this article. Always a learning experience!

OP - I have worked as a manager and left management because I did not agree with the way the current healthcare system is treating the bedside folks. It was all about productivity and money - quality of patient care, though important, did not seem to be the main focus.

Of course you write from your unique perspective, which is driven by the desire to stay financially viable. Your goals are increased patient satisfaction and quality of care.

I think that most nurses genuinely care when they become a nurse and have the desire to "do the right thing" and to provide good care. But nursing has become a high stress job in which so much tasks get piled up combined with expectations that boarder on unrealistic or are unrealistic. How do we reconcile this? Most nurses who snap at a coworker, patient or relative do not snap because they are mean or not considerate - it is because they are stressed, torn into all directions and are anxious to finish tasks. Everything has a timed value nowadays. Perhaps the nurse has lets say 10 minutes for a medication pass but the bar code does not read or the patient has more questions or the MD has to be called for a problem - perhaps now it takes 15 minutes and because the day is already usually planned out - where do you cut back? The mistake most nurses is to cut back on documentation and leave it to the end - which results in unpaid overtime (for example).

I have worked in critical care with the 1:1 or 1:2 ratio - I was not really stressed out in that setting. You have a great support, you are protected with a ratio, you have less distractions, you have CNA that actually work....

I have worked in med/surg tele and the stress is unreal - crying new graduates, stressed out nurses, hiding CNA, stressed out patients and relatives, stressed out physicians, and so on - people are not their best when they are stressed out to the max.

I do not excuse any rudeness and I believe that nurses should care with kindness, knowledge, empathy. Everybody should behave civilized. But fact is that even experienced sane nurses who are usually mild mannered and very caring snap when they are overburdened. Bedside nurses are constantly busy, try to get their work done. Why not advocate for changes in the system and set everybody up to succeed??

Unrealistic because of payment structures? Perhaps - but if we keep on going like this - where will it end?

[macawake, MSN]

When I read the OP I thanked my lucky stars that I live and work in a country with single-payer universal healthcare. Most people will go to the hospital or clinic that's closest to where they live or work. It's convenient for the patients and hospitals don't have to spend marketing funds (money better spent elsewhere in my opinion) to try to attract "customers".

Customer Service is one of the metrics that influence reimbursement, like it or not. I have seen articles that have brought attention to the fact that this is not perhaps the best practice. This asks the lay person to evaluate medical care based on their only frame of reference which may be similar to their hotel or restaurant expectations. Unfortunately, until that changes, these are the rules of the game we have to play by.

I think that you hit the nail on the head there. The patient is highly capable of deciding if they've been treated with respect (and of course they should be), but if the fact that they haven't been served their umpteenth soft drink in a timely fashion affects how they grade the service provided, then you're in trouble. It's vital that the right questions are asked. You need to nudge the patient away from the "hotel" frame of mind and towards the stuff that actually means a darn.

What really matters? Above all: Clinical outcome. Providing nutritional food, minimizing post-op and hospital-acquired infections etc. Patient autonomy. Making sure that patients are fully informed/consent. Ensuring that they understand their condition, procedures performed, medication, that they are provided the necessary information/tools to strengthen their health and increase their quality of life. Those things will impact outcomes for the patient. Snappy beverage service, not so much.

To accomplish all that nurses need to (as we all realize) have a manageable nurse-patient ratio.

TheCommuter, I agree 100%

Let patient care thrive. Let customer service die...

[peacockblue]

And that is why I could never go back to bedside nursing. If I wanted to be a resort manager, I would. Than goodness I don't have to work under the OP.

[PintheD]

I walked away from the bedside in 2011 after coming to the realization that this insufferable Patient Satisfaction nonsense wasn't going away. After fourteen years as an ICU nurse from New York to San Francisco I had learned a thing or two. All that experience now benefits no one, neither the critically ill patient or the less experienced nurses.

Think of how many, like me, who walked away from the dysfunction. What a tragedy.

So, OP, while I agree that maximizing reimbursement and playing to the patient satisfaction scores are the rules of the game, we don't have to play by those rules. Some of us have chosen to walk away.

There is life after bedside nursing!