Let’s ask them. 

Takeaways:

• Nurses want to know how their behaviors impact care and how patients perceive them.
• According to research, 95% of patients believe being listened to is very or extremely important.
• The best way to know patients perceive nurse actions is to ask them.

Here you are, beginning another day at work with another opportunity to care for patients and make a difference in their lives. You understand, as a nurse who believes in the therapeutic use of self, that you’re part of the healing process. But what if something you do, even some­thing you’re unaware of, has the opposite effect? What if you exhibit some behavior that adds to the stress or anxieties of those you mean to help?

I believe that you’d want to know what those behaviors are so you can avoid them, just as you want to know which behaviors have therapeutic effects. The best way to know how patients, from their vulnerable position, perceive our actions is to ask them.

Listening and the patient experience

My interest in this topic began as a result of a clinical issue I faced years ago as a nursing director when hospitals started measuring patient satisfaction. At that time, we took a prospective look at care (Did we meet your expectations?) rather than a retrospective look at the patient experience (Did we do what we said we were going to do?), as we do now. Nurse listening is tied strong­ly to patient outcomes, making it an important item in the Hospital Consumer Assessment of Healthcare Provid­ers and Systems (HCAHPS) surveys. According to work by Wolf, 95% of patients (consumers) believe being listened to is very or extremely important—even a higher percentage than that for speedy pain relief. (See Patient experience matters.)

The issue I faced was extremely low nurse listening scores and a mandate to raise them quickly. I looked to the literature and found almost nothing on the subject, especially in a setting with patients and nurses. That challenged me to do my own research.

In a 2018, institutional review board–approved qualitative study, published as a dissertation in partial fulfillment of requirements for my PhD in nursing, I interviewed a group of adults (≥50 years old) recently discharged (≤6 months before) after an inpatient stay on a medical/surgical or telemetry unit. I asked the following questions:

• Which nurse behaviors implied listening had occurred?
• Which nurse behaviors implied listening had not occurred?
• How did the perception of listening and non-listening affect you, both in and beyond the hospital?
• What advice do you have for nurses as it relates to listening?

I used a semi-structured questionnaire to initiate conversation in the in-person interviews, with additional refined queries to get a full picture of the patients’ lived experiences. Although the questions focused on recent hospitalizations, many patients shared stories from 50 or more years ago, especially when they believed they hadn’t been listened to. They never forgot how it made them feel, bringing some to tears. Of note, many had difficulty describing listening behaviors, but they had no trouble describing non-listening behaviors.

Below I’ve listed answers (actual patient quotes) to the fourth question (What advice do you have for nurses as it relates to listening?). For clarity, I’ve placed behaviors in one of eight categories (make a connection, trust, patient environment, listening, time, patient perspective, what nurses should do, and what nurses shouldn’t do). Some of the behaviors listed may surprise you, but participants consider all of them to be listening-related.

Make a connection 

• “Engage us more so we will open up and tell you things that could help you care for us.”
• “Get to know us on a personal basis. It creates a personal bond of trust, and we will believe you more and answer your questions better.”
• “Do a proper introduction.”
• “Understand that part (maybe the most important part) of the healing process is connection, the presence that a care provider should have with a patient.”
• “Look at me before you look at the computer.”
• “Try to get to know us as individuals.”
• “Ask us how we are (it could affect how we respond).”

Trust 

• “Control pain and give what is ordered (on time); don’t skimp—it builds trust.”
• “It is the nurse’s job to protect patients and bring them through with as much comfort as possible and create a trusting relationship.”
• “Listening builds trust.”

Patient environment 

• “After moving patients around, leave them and their things as you originally found them.”
• “Take in the entire environment when you listen.”
• “When the patient uses the call light, there’s a reason. Please take it seriously.”
• “Be aware of sleeping patients at night, and curtail the laughing and talking where we can hear you.”

Listening 

• “Listening brings out compassion.”
• “When you’re distracted, you’re only partially listening.”
• “The most crucial part of your job is listening to patients. To excel, you must first listen, then process what you hear, and then act.”
• “Nurses are no good to anybody if they don’t understand what the patient is saying or what the problem is. You must be listening.”
• “When you listen, I believe you will advocate for me.”

Time 

• “Spend just a little more time with the patient (Sorry…we know you’re busy!).”
• “Take a few minutes to get to know us a little bit.”
• “Take a few minutes to get some rapport going and your shift would be a lot nicer.”

Value the patient’s perspective 

• “Just because my body has failed doesn’t mean my mind has.”
• “Patients do not fit into a one-size-fits-all basket.”
• “I am not going to say something unless there’s something I really need.”
• “We are individuals—we don’t express ourselves exactly like you might.”
• “What we need to know is that we’re going to be ok and what to expect, even if it’s unpleasant.”
• “Listening puts patients at ease.”
• “We sense whether we’re getting cared for or not.”
• “Patients are fearful of the unknown.”
• “The most important thing for patients’ ‘satisfaction’ is whether the patients feel like human beings and that they matter.”
• “Understand that every patient is different; if you give us compassion, we will get well quickly.”

What nurses should do 

• “Be respectful.”
• “Sit down, even briefly.”
• “Look at the patient (me).”
• “Use kind words; they go a long way.”
• “Just touch someone and make sure he or she is ok.”
• “If you think my request is unreasonable, ask more questions before saying ‘no.’”
• “If I tell you something you don’t know, check it out!”
• “You can save yourself a lot of time/effort if you just do it right the first time.”
• “Repeat back what the patient said so we know you know what was said.”
• “Do as much as possible to prepare patients for what to expect since we’re not experts and have thousands of questions.”
• “Tell patients what their experience will look like; set expectations, narrate care, explain why you’re doing things, and give a full picture, not partial.”
• “Be honest.”
• “Positively impact the patient’s mental health.”
• “Treat each patient as if it is his or her first time there or find out what he or she knows.”
• “Look up from your screen, or leave the computer outside.”
• “You must invite the patient to talk to you.”
• “Lay out the plan so the patient understands it.”
• “Set realistic expectations with the patient.”
• “When the request is simple, just do whatever it takes, and you’ll avoid grief later.”
• “Present yourself as someone there to help.”
• “Ask what the best thing you can do for me is; you’ll see a difference.”
• “Partner with me in my care.”
• “Be a guide.”

What nurses shouldn’t do 

• “Give excuses about why you can’t do something without looking for another way to meet the need.”
• “Make excuses; just make it happen.”
• “Disbelieve your patient; that is akin to calling them a liar.”
• “Talk down to me.”
• “Make patients feel like they’re interrupting your break or conversation when they call.”

Enhance healing journeys

The patients who responded to the survey had both good and bad interactions with nurses. Their answers told us how they want to be perceived and what they want. They want to be heard and to be “good” patients who don’t bother nurses. They also want their self-knowledge respected and incorporated into the plan of care and to have the nurse’s full attention for whatever length of time they’re together.

According to the study participants, patients thrive when their connection with the nurse occurs early in the relationship. Once trust is established, patients are more likely to share information, partner in their care, and feel they can rest knowing someone is advocating for them.

Since first being included in the Gallup Honesty and Ethics poll in 1999, nurses have topped the list in all but one year—2001 when, not surprisingly, firefighters edged out nurses. I believe nurses rise to the top, in part at least, because we continually strive to be better. In our quest to provide the best possible care, I believe we need to ask patients how our behaviors convey (or don’t convey) listening. Those who participated in the study and shared their experiences provided us with insight into how patients view our behaviors and what we can do to enhance their healing journeys.

Nancy E Loos is the quality and patient safety program manager at Dignity Health – Northridge Hospital Medical Center in Northridge, California. 

References:

Loos NE. Adult patient perceptions of nurse listening behaviors in an acute care setting. 13805585. Azusa Pacific University; 2019.

Loos NM. Nurse listening as perceived by patients: How to improve the patient experience, keep patients safe, and raise HCAHPS scores. J Nurs Adm. 2021;51(6):324-8. doi:10.1097/NNA.0000000000001021

Wolf JA. Nurse leadership and the human experience: A framework for elevating care and caring. Nurse Leader. 2019;17(4):347-51. doi:10.1016/j.mnl.2019.05.012

Key words: communication skills, listening skills, patient perspective