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Revisiting Patient Satisfaction Surveys

Kennedy, Maureen Shawn MA, RN, FAAN

AJN, American Journal of Nursing: August 2015 - Volume 115 - Issue 8 - p 7
doi: 10.1097/01.NAJ.0000470378.26416.f0

Are hospitals using the results properly?

AJN Editor-in-Chief E-mail:



When the subject of patient satisfaction surveys is raised among RNs working in hospitals, most will argue that the findings are either inapplicable or skewed. They'll say that patients’ expectations of care are unrealistic and not achievable. They'll say that such surveys, especially follow-up surveys, don't accurately reflect the quality of care because they don't ask the right questions and don't take into account myriad other issues that might have affected patients’ experiences.

Consider, for example, a survey question that asks the patient: “Was your pain relieved promptly?” It doesn't specify a time frame for “promptly,” and for someone in pain, even a few minutes can seem interminable. Furthermore, it doesn't acknowledge the many steps involved in providing pain relief: a nurse must assess the situation, log onto a computer (which might be several yards away or already in use), access the medication screen in the patient's electronic health record, verify the order and the time medication was last given, locate the medication cart, access the patient's drawer to retrieve the medication, return to the patient's room, and perform the “5 Rs” check (right drug, right patient, right dose, right time, right route)—all before administering the medication. The procedure can take a good 10 minutes, and that's assuming the nurse doesn't have to call the physician for an order or wait for a pharmacy delivery. And what if the nurse is interrupted or must attend to another patient's urgent need? Will our surveyed patient consider all this when deciding whether pain relief came promptly? It seems unlikely.

When we asked nurses a while back to weigh in on our Facebook page ( about the usefulness of patient satisfaction surveys, many were vehemently opposed to their use because of how hospitals are responding. With scores now tied into hospital reimbursement from the Centers for Medicare and Medicaid Services, hospitals are hiring consultants and mounting in-house campaigns to pursue higher scores. Measures might include adding cosmetic “touches” to patients’ rooms and improving food service. Some hospitals are even providing scripted language for nurse–patient interactions, language laden with phrases designed to subliminally influence the patient's perceptions. In our July 2012 issue, Nina Geiger's Viewpoint pointed out a crucial problem: that linking “government reimbursement to subjective satisfaction scores devolves the focus from improving patient care to manipulating patient perception.” Indeed, instead of focusing on the conditions that lead to low scores, hospitals look for “quick fixes” to raise them.

A recent report from the Hastings Center (a nonpartisan research organization)—“Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care, or Leading It Astray?”—supports nurses’ complaints. The report raises questions about the validity of ratings by people who are ill and in unfamiliar environments, and who may be capable of evaluating only the superficial aspects of their experience and not the technical aspects of care. Patients at “nice” facilities with friendly staff might rate their satisfaction higher than those at older facilities with more harried staff, regardless of the actual quality of care.

It's not news that research has found links between patient satisfaction levels and nursing care. In 1998, we published survey findings demonstrating that, in a large Texas facility, nursing care was the “primary driver” of overall patient satisfaction; two earlier studies had yielded similar results. More recently, in 2012 the BMJ published findings from a study led by Linda Aiken that showed that, across 1,105 acute care hospitals in Europe and the United States, patient satisfaction, safety, and quality of care were associated with aspects of nurses’ work environments (including managerial support, nurse participation in decision making, and physician–nurse relationships) and nurse staffing levels: the more “nurse-friendly” the hospital and the better the nurse staffing, the better the patient care and the more likely that patients and nurses would recommend the hospital. No surprises there.

The reality is that nurses are the ones who ensure that patients receive hospital care that addresses the problems they arrived with, prepare them for home management after discharge, and ideally, prevent rehospitalization. A patient's hospital experience—one that should leave the patient feeling good about the care rendered—depends largely on nurses. If hospitals really want more satisfied patients, they must pay attention to the evidence and ensure proper nurse staffing in a supportive environment.

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