Surveys Aside, One Crucial Precondition for Real Patient Satisfaction

callbellBy Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
1. Never
2. Sometimes
3. Usually
4. Always
5. I never pressed the call button

Everyone is talking about patient satisfaction these days. Purposeful rounding, responsiveness, and customer service are discussed in meetings, on blogs, and in conversations at work. An entire science has been created out of satisfaction, with whole journals devoted to patient experience and paid officers tracking scores and strategies. Since hospital reimbursement is linked to how happy patients are, we’ve suddenly gotten serious about satisfaction.

But behind the sterile questions on the HCAHPS survey, real stories about real people reside. I find myself often forgetting the flesh and blood that’s represented by each checked box, and am learning to realize that, while satisfaction is something to be striven for, dissatisfaction is something to be learned from.

In a series of posts, starting with this one, I’ll share stories of my own missteps—ones that may have caused my patients to answer never instead of always to questions about my care. The events described here helped me realize that, score or no score, responding to call bells actually matters at the human level:

Sarah was a difficult patient. Not even five years my senior, she looked five times older than us both. Sarah had a cache of needs that most of my colleagues found infuriating, but she was also deathly ill from a congenital disease, and hooked up to the most complex monitoring devices the ICU had available, making it almost impossible for her to find a position of comfort. The other nurses whispered. They refused to take her as their assigned patient, and rolled their eyes at Sarah’s requests and her steadily ringing call bell.

As a young nursing student, I had a professor tell me that whenever a patient presses a call bell multiple times, they’re doing so for two reasons. If the obvious reason—bathroom assistance, pain medicine, thirst—were the only reason, they’d likely stop calling at some point. However, patients who constantly call may be using the call bell to say something their voice, and their tangible requests, cannot—that they are afraid, don’t trust their care, or feel better with a nurse present.

My professor gave an all-money-back-guaranteed solution: solve every physical need in a timely or upfront way, and then set care intervals: intentionally tell your patient you will return in a set amount of time, and then keep your appointment. Promise again, deliver on the promise, and repeat at increasingly longer intervals, until they no longer call.

As a new nurse, I tried this, and it worked like magic. It always worked, in fact, so it became how I always patterned my care. Patients like Sarah didn’t bother me—I knew her reputation for frequently calling, so I started my first shift with her by being overwhelmingly present. I pulled up a chair and introduced myself. I began by asking her what she wanted from me during our time together, what she expected, and what she needed.

She grew to trust me, not because I always came when she called, but because I made her an active part of her care, and I helped her to see that I was proactive in meeting her needs. Also following my professor’s advice, I set limits with Sarah, but they were soft limits–“I’ll come back in 15 minutes, okay?”

This didn’t mean she stopped calling me; it just meant she called me purposefully, because I also attended to her subliminal need to call.

She didn’t want her hair combed or her bed changed, as much as she wanted to sleep and be pain free. But her care expectations were rigorous, and I answered, and bargained, and advocated, and propped, and pulled up, to make sure that her pain was gone and she felt safe under my watch. So, after a time, when Sarah did call, I ran, because I knew she really needed me. Our agreed-upon schedule kept me in and out of her room so often that the unsolicited sound of her bell rang like an alarm.

Because I was able to push past her “neediness” and see it for what it was, I got assigned to her all the time, and I got to know her as a person. Sarah’s voice sung like a tiny yellow bird, and she was smart. We talked about real life things, joked about her stack of bills—“Last time you looked at those, you got tachycardic; please take it easy tonight”—and began to know and respect each other far beyond the nurse–patient level.

One night, I came in to find Sarah assigned as one of my patients. I said my hellos, asked her what was up, settled her in, sharing her hopes that she’d be able to sleep. My other patient, a change-of-shift admission, needed my minutes more urgently, so I couldn’t spend my usual time chatting at Sarah’s bedside to start my shift.

This new patient had a serious infection, was smothered under a bipap mask, and painfully anxious. She squirmed as I worked, swatting at the mask, confused about my instruction to relax and be still. My patience was slight with her—I had too much to do trying to save her life and little time for the tenderness I bestowed on sick-but-stable Sarah.

As I struggled with her confusion, which affected my ability to administer her ordered care, I ran through my new patient’s orders. Penicillin stuck out. I knew that an order for antibiotics was crucial, but I thought penicillin a rare choice to make in the land of high-powered antibiotics like vancomycin and Zosyn that I so frequently gave in the medical ICU. I checked her allergies and penicillin wasn’t one of them.

But this “hmm” moment shot up a tiny red flag in my mind—first dose, watch for reaction. I made a plan to stay in the room while the bag infused, even though it wasn’t required and I had plenty of other things I needed to run for.

My new patient was already confused, but her mood changed almost as soon as the penicillin hit her bloodstream. She flushed and scratched at her chest, and from under her bipap mask, I heard her moan. I knew what this was, and was glad for the extra caution I’d taken. I stopped the penicillin, broke the seal of the mask on her face, and she answered the question I was about to ask: “I’m itching! I’m itching!”

With saline flushing in its place, I pitched the penicillin. Benadryl, steroids, cool air, a break from the bipap, an assessment from the resident, and my new patient immediately improved. With oxygen running in a high-flow mask, she held my hand and we breathed together. I could still see the redness in the soft tissues of her neck, but its spread soon slowed. The worst was over, but there was no way I’d leave her side until I was sure that the reaction had fully subsided.

It was then that I saw Sarah’s call light go on. Knowing that my colleagues were slow to respond to her when she was my patient, I stuck my head out to see who was around. My heart sunk to see no one in sight, but my new patient was my priority. I stayed with her, listening to Sarah’s call light ring, and ring, and ring. I checked her cardiac monitor from my new patient’s room; nothing was amiss. I figured all she likely needed was repositioning, but I still feared for her, hoping someone would answer her bell.

As soon as my new patient’s reaction fully resolved, I placed her back on the bipap machine, assured her I’d return quickly, and headed across the hall. What I found still brings a dark feeling to my stomach. I found Sarah, a woman who would likely have been my friend had we met in different circumstances, crying.

“Amanda, I’m so sorry. I had to go to the bathroom. I couldn’t help myself. No one came.” There sat this educated, beautiful, unjustly ill woman, in her bed, in her own stool, helpless and mortified.

Tears came to my eyes as I rushed to help my patient, my friend. I don’t remember the cleanup, or the smell. The room was dark, and I worked quickly, doing my best to comfort Sarah at the same time. My face felt hot with failure, my breath quick with my own grief. I remember an intense desire to hug Sarah, but I just apologized as I completed my task. I knew we’d never cure her, and I knew she’d likely die in this very bed—could we not at least keep her dignified and at ease?

Sarah might’ve been angry at me and my colleagues, but she wasn’t. She never asked why no one came when she called that night, and as far as I know, she never formally complained. I didn’t ask my colleagues why they let her light go. My response to her bell wasn’t tracked in a log or discussed in a huddle. I just cared for her as well as I could.

Despite this event, had she been able to fill out a patient satisfaction survey, Sarah would probably have given our team glowing reviews. She ended up dying in the same bed, only a few weeks after we didn’t give her help “as soon as she wanted it,” to quote the patient satisfaction surveys.

I’ll never forget what it felt like to find Sarah that night. At its most basic, the lifeline that is the call bell leads to one thing, and one thing only: a life, not a task. All the frustrating and reductive HCAHPS surveys aside, we may never truly achieve real patient satisfaction until we honor, own, and internalize this fact.

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About the Author:

I’m a nurse with a critical care background who works in administration in Manhattan. My blog is This Nurse Wonders. I also blog for Off the Charts and Healthcetera, and tweet as @ajandersonrn.

9 Comments

  1. Laurie Emery July 10, 2015 at 12:46 pm

    Amanda, your article is very moving and so true. Thank you for reminding us all about why we are in healthcare to begin with: the patient! I have always felt that nurses need time allotted in their busy day to attend to the needs of the whole patient not just their physical needs.

  2. Ellarene Duis Sanders July 8, 2015 at 7:19 pm

    Another perspective is that you demonstrated nursing presence with your patient(s) by truly connecting with them at the human level first and establishing that you were trustworthy. After an experience as a patient in ICU on life support when I was a very young nurse, I decided that this was of critical importance to patients like myself who could not communicate other than to push the call button. I found that spending a few minutes establishing a relationship was time well invested even when I worked on busy Med/Surg units and had multiple patients. If my patients connected with me and knew a little about what was going on in the unit or that I might unintentionally get tied up with someone else, they had more patience if there were delays in my responding to their calls. Have to end now due to a scheduled obligation but will definitely follow this discussion!

  3. Margaret Erickson July 8, 2015 at 7:04 pm

    Amanda, if you are interested in finding a network of like minded nurses who support your definition of nursing and way of being, check out Holistic Nursing at http://www.ahna.org. Margaret Erickson

  4. Margaret Erickson July 8, 2015 at 6:56 pm

    Amanda, thank you for writing this story and reminding everyone what nursing can and needs to look like. You are the nurse that I would entrust with my loved ones.
    I am very happy to see that patient satisfaction is now tied to reimbursement. Why shouldn’t it be? We are gifted with people’s most vulnerable moments and often their care providers, nurse, and others act like they are doing the patient a favor to show up. No one goes back to a bad restaurant, mechanic, or any other service provider if the service is bad. How many people would tolerate being at a restaurant, seeing their food is ready and no one brings it to them as their waiter is busy for an extended period of time. Yet when people are down and out, have the most needs, are most stressed and most vulnerable they frequently are threatened, intimidated, coerced, neglected, called difficult, manipulative, and demanding,or ignored. Nursing is challenging and hard but it is a honorable profession and we are “gifted” with the people we care for. You gave an excellent example of providing holistic care; of recognizing that all the different parts of Sarah affected one another, and that you needed to care for all of her. Not just the physical problems. I have worked in very difficult places, very short-staffed, etc. But it isn’t about the time we have (although we know that helps) or the number of staff but rather how you show up. We are going to interact with our patients and their families but how we do it is what makes us great nurses, or just adequate technicians. Nurses always have to be competent, that is a given. However, the main question is; Is the focus on being with the patient or the tasks?

  5. Stacy Slater July 7, 2015 at 12:27 pm

    Thank you for the great perspective. I am part of a small team that has been presenting HCAPHS information to the nursing units and all departments of the healthcare organization in which I work.

    Patient satisfaction is an awareness – it doesn’t require additional charting or efforts. Our goal is to make everyone aware that we are all part of the patient’s healing environment.

  6. amygetter July 2, 2015 at 5:26 pm

    Thankyou for sharing so eloquently what it means to provide nursing care to our patient who indeed represents “a life, not a task”. The person lying in the bed using their call light deserves to be seen and heard. Whether or not our shift has been harried and frustrating, we can still provide compassionate care and patients do know the difference.

  7. Amanda Anderson June 30, 2015 at 1:00 pm

    I don’t typically comment on my writing, because I believe in the power of organic discussion, but I feel a disclaimer must be made here:

    I did not write this story as an example, or statement, about short staffing. If you read carefully you will see that I made no mention of staffing in this story, because there was no numeric shortage of personnel leading to this occurrence. While I agree, the number of professionals is often an issue that causes missed care such as this, there was no such shortage in this case.

    I am saddened and amazed, the longer I work in hospital settings, to see units staffed adequately, with professionals that do not work together as a team, or in dynamic ways. “That’s not my patient” culture is too often the reason for these stories — not the number of professionals on the floor.

    Until we take responsibility for our own personal part in “staffing,” in tandem with the evidence-based allotment of personnel, we will continue to flounder as a profession. Staffing is not simply a game of numbers, and if it was, then our care could (and should) be reduced to this very survey that we demand differentiation from.

  8. Betsy Marville RN June 29, 2015 at 1:33 pm

    Excellent article. This is why unsafe, inadequate staffing is the number one issue with nurses. Every time a nurse cannot respond in time for a patient need, we are failing. The terms “failure to rescue,” and now recently “missed care,” represent a person who is within reach of the best technology and nurses, but unable to obtain the care needed to heal and/ or to stay alive. The PPACA pays for outcomes. Nursing care determines outcomes. Every call light needs an answer and nurses must advocate for staffing levels that will enable them to respond to every call.

  9. Tricia June 29, 2015 at 12:48 pm

    I have been here myself and it makes me so frustrated, not at patients but at myself and the situation. I know that situations like this that I have been apart of would have never happened if there was. ..adequate staffing. I know, same old story. As nurses, I think most of us WANT to respond to call lights immediately and take our time to get to know our patient’s needs. I have found that so much of my nursing seems to be reactive instead of proactive. Satisfaction scores will rise when nurses have the ability to care for the whole patient.

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