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Rounds+Scripts_FNL with art 11/6/10 2:07 PM Page 23 scores. It is also a major vendor of patient satisfaction surveys; according to its website, more than 40 percent of the nation's hospitals partner with Press Ganey for "service quality measurement and improvement." And for $279, your hospital can buy a webinar titled "Rx for Patient Communication: Using scripts to provide consistent, effective communication with patients." Giving RNs scripts, lines, or keywords to say is not required by the HCAHPS. But just as preparatory programs and products for the Scholastic Aptitude Test proliferated when colleges started requiring prospective students to score well on these tests, so have programs, products, and consulting services geared toward raising patient satisfaction scores. "I don't want to use the phrase 'teaching to the test,'" said Donna Hartman, vice president of clinical quality and patient safety at Long Beach Memorial. "But we do know that one of the measures on the HCAHPS is patient safety. Patients will be asked whether they felt their safety was important to the staff. So when a nurse checks the patient's armband, she makes sure to mention that she's doing it to keep him safe. When the survey comes in the mail and it asks 'Did you feel your safety was important?' he'll remember, 'Gee, that nurse kept mentioning to me that they were doing all these things to keep me safe.' It's that kind of triggering." Many hospitals, however, have taken scripting to extremes. Almost every nurse interviewed for this article had been given a laminated card detailing exactly what she was supposed to say to a patient at the start of each shift, even if she had cared for the patient just the day before. It goes something like this: "Hi Mrs. _______, my name is ______ and I'll be your registered nurse today. I want to let you know you are in very good hands. I've been a nurse in this department for 20 years. Working with me is Betsy and she's been a nurse for 30 years. Your physician is an expert in this procedure and has 15 years experience doing the kind of work you're here for. The director of medicine has 30 years of clinical experience. Thank you so much for choosing our hospital for your care." "This is the same malarkey I'd expect from a waiter in a restaurant," said Gail Jehl, an RN at Sparrow Hospital in Lansing, Mich. "You're not allowed to greet the patient the way you want. You're not allowed to use your own words. It's nuts." In some hospitals, nurses are required to do follow-up phone calls with patients – not to find out how patients are healing or if they have any questions about disease management, but to ask if they received excellent care and would recommend the hospital to their friends. Those conversations are scripted, too, and nurses report that they are told not to deviate from their lines, even when patients want to start a real discussion about a problem they encountered at the hospital. Besides being told how to talk to patients and sounding fake, RNs also object to scripts for other reasons. For instance, Sandy Reding not only feels uncomfortable "boasting" about herself, but she knew it would cause patients to unfairly compare nurses. "Our patients are separated by a curtain," said the operating room RN, who works at Bakersfield Memorial Hospital in California and is a CNA/NNU board member. "I did my spiel: 'Hi, I'm Sandy Reding, I'll be your OR nurse today. I want to let you know that you're in really good hands. I have 20 years of experience. I'm certified in the operating room, certified in pediatrics.' I did the whole thing and was disgusted. But then I heard the patient in the next bed say, 'I want that nurse.' The nurse he had had only one year experience. I find it really distasteful to have to do it." On a practical level, rounding and scripting adds more busy work onto nurses' already hectic shifts, and makes nurses choose between following management directives or attending to the clinical needs of their patients. Ironically, nurses have been making rounds on their patients since time immemorial to conduct patient assessments and familiarize themselves with their assignments. But RNs say this new type of rounding that management wants them to do is more about creating the illusion for patients that they're receiving a lot of attention by focusing on superficial comforts – such as whether the patient would like his pillow fluffed or her trashcan moved closer to the bed – rather than letting RNs prioritize for themselves the care they know they must deliver to keep patients safe and to heal better. Most nurses are asked to round every hour, always ending the conversation with the line, "Is there anything else I can do for you? I have the time." Many RNs particularly bristle at this closing sentence, because it's simply not true and makes it more difficult focusing on their real clinical nursing work. Some nurses are finding that the scripting and rounding orders can actually worsen relationships with patients and their families. Some patients have complained that nurses sound fake. And on one nurse's pediatric floor, she and her fellow RNs were instructed to hand off care at the end of their shifts in person – even waking patients if need be. At morning shift change, parents who had just gotten crying babies to sleep were furious when their newborns woke up and started screaming again after nurses entered the room and started reciting their scripts. The way rounding and scripting interfere with the nursing process and supersede nursing judgment is probably the most frustrating and enraging consequence of these programs. "This is like Stepford nurses," said Jehl. "It really takes away from the independent practice of the nurse. Patient care should be based on outcomes, period." Nurses are finding that if they don't comply with these programs, regardless of staffing, they could be counseled, reprimanded, or even worse. At Jehl's hospital, managers stand right next to the RN or outside the door to make sure that RNs are completing all five parts of the "AIDET" program. Recently, Garza learned that all the mental health RNs will receive only 2.5 out of a possible 4 points on the patient satisfaction component of their performance evaluations "until their Press Ganey scores are above 50 percent." He was incredulous that the hospital would unilaterally judge him and his RN coworkers based on how patients felt about their stay at the hospital. "We have schizophrenic and psychotic patients," said Garza. "Some are involuntarily placed there and held against their will. And you're asking them to score you? It's just ridiculous." "I feel like a butler or a concierge. It's the same thing a waiter or someone in the service industry would do. It has nothing to do with my clinical skills." O C TO B E R 2 01 0 W W W. N A T I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 23