Scripting Nurses is Bad for Patient Care

This might be a new low in nursing management. Instead of actually providing caring, empathy and compassion, some hospitals would like nurses to provide a simulacrum of caring, empathy and compassion, believing patients are stupid enough not to tell the difference:

Nurses unions say an increasing number of hospitals nationwide are asking nurses to adhere to standard scripts when talking to patients, down to how often they use a patient’s name (at least three times per shift)

At several Massachusetts hospitals, nurses have been given laminated cards to hang around their necks with the words they should utter at the end of every visit: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’

These particular words, consultants say, are important because of research showing that patients are more satisfied with their care when they believe nurses made time for them. [Emphasis mine.]

This is called “scripting.”  It’s the newest shiny object for nurse managers. The underlying philosophy is that it doesn’t really matter if the nurse in reality establishes a therapeutic relationship, administers a medication properly and safely, completes a thorough and accurate assessment, or does all the myriad (and out-of-sight) procedures and processes necessary to ensure a successful and healing visit. All of that falls by the wayside: what’s most important and valuable is that the patient believes they got good care.

Of course, there is a fairly large gap between reality and belief. When I worked in the United States, my employer was exceedingly concerned with customer relations (I use the phrase advisedly), and regularly called nurses on the carpet for (allegedly) dissing patients. I personally was the recipient of a patient complaint in this regard: she believed I was missing in action for her entire visit. Fortunately I had charted extensively and nearly hourly because she was also receiving some high doses of narcotics and spent most of her visit sleeping. My care, in fact, and I will blow my own horn here, was exemplary. But you see the point. There is no such thing as the completely satisfied patient. It is a myth. The capacity for patients being satisfied on every aspect of their care is nearly infinite. Unfortunately, our capacity to make patients satisfied in all things is rather constrained. Patient care is complicated. It’s impossible to account for every contingency. Furthermore, patients sometimes equate nursing care to hotel room service. Sadly, we aren’t bellhops or waitresses. Trying to achieve patient satisfaction in each and every case  is a ultimately a losing game.

In any case, the value of scripting nurses, at least in the Emergency department setting, might be limited. One study indicates patient satisfaction scores remained constant pre-and-post introduction of scripts in an ED. This suggests to me, anyway, that scripting is just another in a long series of quick fixes for a problem which is actually hides the real elephant in the room: the link between nurse working conditions and job satisfaction, and patient mortality, morbidity and overall satisfaction. Nurse Keith at Digital Doorways excellently discusses this in blog post on the same subject. I won’t rehearse the argument at length, which basically boils down to “happy nurses make for happy patients.

So in the end, do you think treating nurses like idiots would increase or decrease job satisfaction? And how do you think that affects patient care?

[Update: corrections in formatting made. I sometimes forget WYSIWYG blogging isn’t always WYSIWYG.]

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  1. #1 by amandatrujillo on Sunday 25 March 2012 - 1358

    Despite the scripts posted on my monitor by management, I never used them. It is not authentic. I participated in the spirit of the initiative, but Ive never used a script as a nurse. It does little if nothing to develop the spirit connection with the patient—and as ive told you before, my abilities as an empathare best served remaining true and authentic in my interactions with patients and their families.

  2. #2 by Benoit on Sunday 25 March 2012 - 1440

    I’m a frequent patient in the oncology department at a local hospital (Montreal, Canada). Does management think we are stupid to the point of not seeing the difference between someone who cares and someone who goes through the motions?

  3. #3 by amandatrujillo on Sunday 25 March 2012 - 1555

    Benoit—the scripts also suggest that we are not educated enough or intelligent enough to form our own words. I see it as degrading to us as professionals. How many times have we seen scripts put on the doc computers? I mean, really?

  4. #4 by Marie on Sunday 25 March 2012 - 1910

    Honestly it is important for patients to have a good experience. My hospital has provided us scripts as well but they don’t hang them in cards around our neck. when I use my scripting I always modify it so it sound genuine.

    • #5 by torontoemerg on Sunday 25 March 2012 - 2034

      In a way I’m thinking that if we as a profession we have lost the ability to communicate, we are in serious trouble, and if we need our “superiors” to tell how and what to speak to our patients we might as well close up shop and go home.

      • #6 by Marie on Monday 26 March 2012 - 1544

        AMen

  5. #7 by ellen-ottawa on Sunday 25 March 2012 - 2034

    it’s all part of the trend to “Form not Function”. As long as things appear good, it apparently doesn’t matter if they are good….. Makes me glad I’m not going to live forever to see where this will lead, cuz it’s very scarey….I much prefer real to fake, but it’s becoming “impolitic”

  6. #8 by jenjilks on Sunday 25 March 2012 - 2050

    This is so sad.
    Totally different story from checklists, where doctors forget to wash their hands, amputate the right limb.
    Excellent post.

  7. #9 by Nurse Lee on Sunday 25 March 2012 - 2247

    I find it personally insulting as an independent, thinking person nevermind practitioner. I do not make telemarketing phone calls, nor do I work at a desk doing customer service for a telephone company. As someone has already mentioned, many patients can and will be obviously aware of the repetition and fake odor to the language we would be speaking. What sort of nurse-patient relationship can be genuinely developed if based on someone else’s ideas/words of care, and from those are not at the bedside? I have to practice independently and therefore will think independently. I fail to see how “what the hospital scripted for me to say” would stand up or hold merit within governing nursing bodies if one was pulled in front of them.

    • #10 by torontoemerg on Monday 26 March 2012 - 1056

      This last point is very true. Woe to the nurse who thinks scripting will save her from a nursing board/college of nurses complaint because it was employer endorsed and mandated. Scripting is NOT a substitute for good old therapeutic communication.

      Sadly, you can see how some nurse (and nurse managers) might think differently.

  8. #11 by jess6577 on Monday 26 March 2012 - 1100

    This post hits many nails on their heads! I agree SO much…even to the point that focusing on “customer satisfaction” in the healthcare environment is a pipe dream solution to the widespread dissatisfaction of patients. Scripting nurses is indeed yet another bandaid that does nothing to heal the underlying condition.

    Patients in a hospital, by definition (I hope), are SICK. I know when I’m sick I have a negative view of the world regardless of what goes on…attempting to make people “satisfied” when they’re sick takes Herculean efforts with very poor payout…even for those that may have the time to devote to one patient’s needs exclusively (those that have that kind of time don’t exist, amen?).

    As a patient, even knowing what goes on behind the scenes, and how busy nurses are…what makes me feel cared for is being listened to, taken seriously, and my concerns validated…regardless if my actual illness can be cured or eased at all.

  9. #12 by Beenthere! on Tuesday 27 March 2012 - 1542

    This is such an insult to any intelligent being……………….words cannot express my feelings on this. At least not the words I would like to use. Why is it I find that the nurses in Arizona don’t even question using scripts? What is wrong with Arizona? Are they Stepford Nurses or what? Are they that dependent on others that they cannot rely on their own brains? I don’t get it.

  10. #13 by Beenthere! on Tuesday 27 March 2012 - 1648

    With regards to my prior post I have worked at a hospital in Arizona where they suddenly came out with “scripts” for nurses in the ED to use. I was referring to my coworkers just standing there and saying “oh ok” I was looking around and suddenly said “why?” Everyone (including the manager) attempted to make me look like I was the one from Mars. Or the rebel nurse. I am so glad you wrote this piece. I was beginning to think my thinkin’ is stinkin’. But then again……………..that is how it works. They make YOU begin to question yourself. Do other states have many Stepford Nurses?

    • #14 by Robin on Thursday 12 September 2013 - 2232

      We are going through the same thing here in New Jersey, in the large healthcare company, where I am employed as an NP. I find it repulsive to be handed a script denoting what I will say to a patient, in various scenarios. However, when I expressed my concerns on the subject, via email to my immediate management team, I was threatened with termination, unless I remain “…an active, engaged, member of the team”. It is so disheartening to see the damage done by corporations, to the profession of Healthcare. It seems that they will ultimately prove to be the demise of the Art of the Profession. They have already outlawed critical thinking.

  11. #15 by Anonymous on Monday 02 April 2012 - 0026

    I have an even better example. Dialysis nurses are supposed to say “it is a great day to be at
    D_ _ _ _ _” (*Business name withheld but since there are only 2 major for profit HD corps, you can guess which… The other isn’t any better if you are interested)

    The patients are totally confused by that statement. First because it is never great to need dialysis. Second becayse they are suffering & need direct care not simpleton phrases. For instance,they are 5 times as likely to need hospitalization. Moreover few will get the transplants that they need b/c we only do 15K per year.. So lets get real with these patients & not ad to their suffering by diminishing what it is.

    Oh and BTW D _ _ _ _ _ incorporated non clinical MBAs who cut direct staff. Good to know right..
    So while we have simpleton phrases, you don’t know who is monitoring HD for: significant
    blood loss, strokes, infections, falls, multiple RX interactions, & IV antibiotic dosing that might induce permanent sensory……. But of course MBAs w/ scripts are more important than that.
    They have all the answers..

    So ask yourself if the 2500% increase in nonclinical staff everywhere will help the poor patients including our parents & our children….. The answer to any thinking clinician is clearly NO< NO Lets organize!!!!

  12. #16 by Beenthere! on Tuesday 03 April 2012 - 1443

    Perfect example! They are attempting to incorporate a Business Model to a HD patient. It just does not compute. You are so right. It is not a great day in paradise for them. As a nurse we are to ask them their needs, their feelings it is about THEM! It makes me want to scream. This isn’t Fulton Home Sales where there are selling Model Homes. These are sick people for heavens sakes. Nurses need to be running this show.

  13. #17 by pissed off on Saturday 07 April 2012 - 0142

    scripting is inanane. “is there anything else I can do for you? I have the time!” HELL no! I don’t have the time! I haven’t eaten or pissed for 12 hours! It’s an insult to my intelligence; and it’s an insult to the intelligence of the patients that I am trying to take care of. We used to have a program called “walk in my shoes” where someone from another department could shadow us for a shift. This really needs to be reimplimented and aimed at management with no bedside healthcare education.

  14. #18 by Beenthere! on Saturday 07 April 2012 - 2052

    “walk a day in my shoes” Oh yes! I have been screaming this for awhile now. No one believes me. They think I made it up. Management has no clue, some managers that have been away from the bedside for awhile have forgotten it themselves. Plus with all of the new technology and new computer systems it does NOT make our jobs easier or quicker. It is just MORE PAPERS and more COMPUTER WORK to do. They don’t get it. Walk a day in my shoes definitely needs to be brought back!

  15. #19 by The Nerdy Nurse (@TheNerdyNurse) on Friday 20 April 2012 - 0115

    During my recent 7 day stent at a large university hospital it felt ilk every phrase spoke to me was scripted. This also lead to believe that the level of critical thinking had to be reduced as well. It was also as if they were either not understand the questions or just didn’t have a scripted answer. Everything was “I can call the doctor for you on that one.”
    It was really quite sad.

  16. #20 by suki on Friday 20 April 2012 - 2333

    I keep saying “what have they done to my career?” and “what more do they want to do to my career?” Which I so cherished. Why do they call this progress? Someone tell me.

    • #21 by torontoemerg on Saturday 21 April 2012 - 0710

      I keep thinking if this is what nursing has come to, we’re in real trouble.

  17. #22 by Larry on Monday 05 November 2012 - 1318

    When I first became a nurse (1983) we called them “patients”. When I retired 2007 we were calling them “clients”. The answer is caring has become a big business. People may now be entering the helping profession for the wrong reasons. ie: Nursing shortage, lack of jobs in other areas and $.
    I miss the patients and the families but not the politics, or the BS, like scripting.

  18. #23 by Chris on Monday 05 November 2012 - 1743

    Seriously???? I haven’t heard of this (small-town Minnesota), but you can bet if I am handed a script and told what to say to my patients, I will melt the icicles off the roof.
    Nurse since 1981

  19. #24 by suki on Monday 05 November 2012 - 2000

    They have been doing “scripting” for quite a few years here in Arizona. Very icky to do. Some hospitals have even sent in “spies” to see if the staff is actually using the “scripted” words provided! Yep. They will pay money to see if staff follow a script. People that complain or question it are told they are “noncompliant” and not a team player. When I have been a patient in the facilities that use the “scripts” I cut the staff off. Sorry, tell them I am a real person. To save the “script” for when they are on camera. It is generally the bigger hospitals so staff is not always aware who is an employee and who is just another patient.

  20. #25 by Susan on Sunday 15 June 2014 - 2303

    Having recently had two hospital stays (my first ever, and I am not young) here is my take on this. I don’t care about scripting one way or the other. What I DO care about is that the nurses know what they are doing. I found this often to be not the case. And yes, I was grumpy, because I felt threatened by the stupidity of some nurses. Some of what I experienced I didn’t know was bad care till afterward and I talked to people and looked things up. Nurses are not doctors. I don’t look to them for mothering, either. I just want them to know what they are doing and how to do it right. And guess what. I will be needing further care from the surgeon who had me in the hospital. And I like him. But the two of us will have to find another hospital because I will not go back to that one. Who knows, nurse-reader, it might be yours and you might be one of the dumb ones. The nurses I ran across there lacked insight, grossly so, across the board. Frankly, I don’t like nurses now. Didn’t know many before, will not add any to my phone book.

  21. #26 by Susan on Sunday 15 June 2014 - 2320

    It appears to me that some nurses think “care” means empathizing when in fact care is doing what patients need done, doing it right and doing it on time. I REALLY don’t like nurses because most of the ones I have encountered are unprofessional.

  22. #27 by Susan on Monday 16 June 2014 - 0630

    And furthermore, on this site or another, I have read posts where nurses brag about all the science courses they had to take, like anatomy/physiology, chemistry, microbiology, etc. Let me say this about that. Those courses are dumbed-down versions meant specifically for nurse-training programs. I have an advanced degree from a major university, have taken both regular and dumbed-down courses. If you think you are in some way as knowledgeable or “professional” as a doctor, think again.

  23. #28 by Melissa on Tuesday 11 November 2014 - 2000

    I’ve been called to the carpet for this several times. I’m now in a “Performance Improvement Plan”. If I’m not overheard by Big Brother using the words “rounding” for instance, and several others, I will be further disciplined. I’m one of the strongest nurses (clinically) on my unit. However, I’m being disciplined for not kissing a$$ good enough. Though I love taking care of patients I am currently looking for something away from the bedside because of these reasons. I cannot continue in an environment where if given a choice my employer will believe the other person every single time.

  24. #29 by Robin on Wednesday 12 November 2014 - 0942

    I find it extremely disheartening that Susan would judge ALL nurses by one or two unfortunate experiences. The analogy would be to have bad service in a restaurant, an airline, or essentially, anywhere, and, as a result, write off the entire industry as inept and inadequate. If you did not like your interaction with a group of physicians, would you say, ” I don’t like doctors”?
    I am sorry that you were not treated properly by those nurses, but I believe that your response is quite narrow-minded and ignorant.

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