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Is the "best" nursing all about being "polite and communicative"?

U.S. News & World Report logoOctober 20, 2009 -- Today U.S. News & World Report posted an online item as part of its extensive annual "Best Hospitals" survey that actually lists the "best" and "worst" of the hospitals for nursing. Historically, the magazine's "best hospitals" analysis has focused overwhelmingly on physicians. In recent years, the survey has started to factor in nurse staffing and magnet status as very minor elements in its overall scores (as this year's does), but to our knowledge this is the first time it has broken nursing out in its own listings. And the simple suggestion that there is such a thing as the "best" nursing is helpful. So the item is a real step forward. Sadly, nursing is still greatly undervalued. The nursing lists are based solely on patient surveys and filed under the heading of "patient satisfaction," along with similar lists for hospitals that were judged best and worst at "pain management." That suggests nursing is important, but still just a part of what we might call "patient care services," rather than a key factor in patient outcomes. The U.S. News lists also treat nursing as if it was generic across all units at a hospital, and there is no sign that nurses have specialties, in contrast to the specialty-based analysis for physicians that is central to the overall listings. Perhaps most troubling are the standards patients were given to evaluate nursing: whether nurses were "courteous," "listened carefully," and "gave clear explanations." These standards are important, but they reinforce the prevailing public sense that nurses are about customer service and being nice, failing to measure nurses' main roles in using advanced science training to save lives and improve outcomes. That would never happen in the overall "best" U.S. News & World Report logoanalysis, which relies heavily on the hospitals' reputations among physicians. Even so, we thank U.S. News for this advance, and urge it to continue improving. Next year, perhaps the magazine could also seek the opinions of those who know the most about nursing--and about hospitals in general: nurses.

The online item is headed "Which Hospitals Have Great (and Not So Great) Nurses:   Patient satisfaction surveys weigh responses to requests, courtesy, and more." The authors listed are Avery Comarow and Megan Johnson, though there is not much explanatory text. In fact, this is pretty much it:

Among elite centers in the U.S. News "America's Best Hospitals " rankings that reported patient satisfaction survey results for the year ended December 2008, the 10 percent below were judged best for nursing care. They had the highest percentages of patients who said their nurses were "always" courteous, listened carefully, and gave clear explanations.

The chart then lists 17 U.S. hospitals by "% of Patients Whose Nurses Were 'Always' Polite and Communicative." The worst chart has a similar introductory statement, and it lists 16 hospitals by "% of Patients Whose Nurses Were 'Sometimes or Never' Polite and Communicative."

pull-out quoteWe agree that the qualities these surveys asked patients to assess are important in nursing care. Polite nurses who listen carefully and communicate may well be more likely not only to make patients happier, but also to improve outcomes, catching small changes in patient conditions, providing the adequate pain relief that is vital to recovery, ably explaining key aspects of patient conditions, treatments, and home care, and doing a host of other things that can all make the difference between life and death. "Clear explanations" implies that nurses have something that matters to explain to patients.  

But defining nursing solely in these interpersonal terms also reinforces the sense that nursing is mostly about being polite and helpful in a lay person's sense, rather than about health knowledge, critical thinking, and advanced skills. And what about patient advocacy? We could easily imagine an expert nurse saving a patient's life through forceful advocacy with the patient, the family, physicians, and/or other nurses--but being judged too pushy or insistent to score well in a survey like this. At a minimum, "polite and communicative" are woefully inadequate standards to measure the "best" in nursing care.

Of course, we can't really expect patients to understand nursing well enough to evaluate it to any great extent, particularly given the unskilled handmaiden and angel stereotyping that continues to dominate public discourse about the profession. That's why it would be helpful to ask nurses themselves to evaluate nursing--just as the U.S. News surveys rely heavily on physicians to evaluate care. In fact, relying solely on physicians for subjective judgments about hospital care, as the magazine does, is especially ironic because hospitals exist primarily to provide nursing care. If patients do not need ongoing nursing care, their procedures can likely be performed on an outpatient basis.

Despite these problems, we commend U.S. News for the advances it has made in its surveys' treatment of nursing, and we hope to see even more in the years to come.

See the article: "Which Best Hospitals Have Great (and Not So Great) Nurses: Patient satisfaction surveys weigh responses to requests, courtesy," by Avery Comarow and Megan Johnson, posted October 20, 2009 on the U.S. News & World Report site.

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