The Limitations of Rating Nursing Care by Customer Surveys

Ink and collage on paper by Julianna Paradisi 2017

Either They Loved It or They Hated It

While toasting the same English muffin for the second time that morning and cursing that it would make me late for work, I conceded we need a new toaster. It doesn’t matter whether I set the darkness level on 1 or 4;  the muffin comes out barely tinged. Select 5 or beyond, the muffin is burnt, and sets off the smoke detector. It’s time to buy a new toaster.

I found one I liked, shopping online. It had been purchased by over 1,500 other people; 55% of them rated it 5 stars. The other 45% of ratings ranged between 1 and 4 stars. The comments, however, were evenly split, 50/50. People either loved it or hated it. There was no in-between.

This made me laugh.

As with Toasters, So with Nursing Care

Likewise, many hospitals, in an effort to improve care, send out satisfaction surveys asking patients to rate their nursing care. In my experience, the results are similar to the toaster’s ratings: about half the patients rave about their care. Some mention their nurses by name, elaborating on specific details about their experience.

The other half complain bitterly that their hospitalization. The nursing care, they say, was the worst experience of their lives. It probably was. People don’t go to hospitals voluntarily as if they are vacation resorts. Admission to a hospital for disease or trauma truly is one of life’s worst experiences.

Nurses do not meet patients at their best. Patients are sick, afraid, often in pain, and adapt differently to crisis. Some patients view nurses as lifesavers; others experience hospitalization, and nursing care, as all part of an ordeal that must be endured.

For these reasons, I’m a bit skeptical about the overall value of customer satisfaction surveys as a quality metric. Certainly, tidbits of information can be gleaned, and I always appreciate positive comments from a patient who mentions me by name. Sometimes, however, the patients needing a nurse’s compassion the most are the most difficult to satisfy.

The Patient Who Fired Me

Nurses don’t get to choose which type of patient we care for, but all patients deserve safe, compassionate care.

I’m reminded of one who “fired” me. She was particularly vulnerable, and I had spent a great deal of time making arrangements to ensure that she received safe, compassionate care and her special requests were met. This included anticipating postprocedure problems in order to provide the extra layer of support she’d need for optimal recovery.

Despite all this, I was unable to establish a trusting bond with her. In a moment of extreme distress, she “fired” me.

I’d anticipated that this might happen at some point. But I took a bit of pride in the fact it happened after she received treatment—my goal wasn’t to win her over. It was to remove barriers to her receiving care, and I accomplished this. She received safe and compassionate care.

What surprised me was the buoying support I received from the patient’s providers and care team who were aware I’d been “fired”: the surgeon, the nurses, the support staff, all of whom made sure I knew they appreciated that I went out of my way for her care. They literally hugged me in thanks.

Given her social situation, I doubt this patient will return the customer satisfaction survey I know she will be sent. If I’m wrong, I expect a scathing review, rating mine as the worst nursing care she has ever experienced in her life.

However, I rate it as some of the best work I’ve ever done.

I haven’t made up my mind about the toaster, though.


About the Author:

Julianna Paradisi, RN, OCN, finds inspiration where science, humanity, and art converge, creating compelling images as both a writer and a painter. She is the author of, and also blogs frequently for and, the blog of the American Journal of Nursing (AJN).


  1. Livy Mayans April 18, 2017 at 10:26 pm

    Julianna, this is an interesting topic and one that I would think of frequently. Although I no longer practice at the bedside I remember those days where “customer” satisfaction was the driving force and sometimes the demands made from upper management to meet those standards were ridiculous, sometimes impossible and downright unsafe. Satisfaction surveys should be left for retail and not healthcare. I always think of our former medical director when family members would make unattainable requests from him, like curing CHF or ESRD, while the patient was admitted for acute care. He would say, “What do these people think I’m a magician? I don’t practice magic!” There are some things that just cannot be done and will not sit well with patients or their family members, it is a sensitive topic and perhaps these satisfaction surveys should be worded differently, it’s hardly ever and overall good experience for the patient, they are vulnerable, sick and not in control. We are just trying to do our best.

  2. Brent Thompson PhD RN April 1, 2017 at 2:21 pm

    Imagine you are a passenger flying to your destination and experience a rough landing. You may be tempted to give the pilot a poor rating; except that you did not know about the inflight emergency she handled in the flight deck before any passengers were affected. This is the same problem with patient satisfaction surveys. Patients are only rating what they can see in their rooms. Those things are important but not half as important as all the skill required behind the scenes that assured the patient’s recovery. Patients don’t know about our discovery of med order error, or our work with dietary to get the meal they wanted, or the communication with the physician about a change in condition that warranted a change in care, or even just knowing when to come in to be sure the IV is not about to run dry. The list goes on.

    Administration loves these surveys but they put too much stock in them. The hospital is not a hotel and we are not always able to make your stay a pleasant one. It’s time for administration to limit the use of these surveys to the appropriate degree.

  3. peggychinn March 31, 2017 at 1:03 pm

    Thank you for this! I have written about it on the NurseManifest blog! Check it out!

Comments are moderated before approval, but always welcome.

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