The health care system is a complex and essential component of modern society, and while we tend to focus on illness, we must also be concerned with the promotion and protection of health and well-being. We know that health care is not just about diagnosing and treating illnesses; we must also understand that the human experience in the care process is an emerging and critical concept to ensuring care that is equitable, accountable, and of the highest quality. The human experience in health care is about understanding the psychological, emotional, and social aspects of illness and healing and their effects on the patient and their support system, as well as on those who provide both direct and indirect care. I have often said that, in health care, if you are not caring for the patient or client, you are caring for someone who is. The human experience crosses all sites of care, all types of care, and includes all those who play a part in the health care delivery system, regardless of which side of the bed, desk, or examination table they find themselves on.
WHAT IS THE HUMAN EXPERIENCE IN HEALTH CARE?
The human experience in health care encompasses a wide range of emotions, thoughts, and behaviors. Patients who seek medical care are often in a vulnerable state, and their experiences can be influenced by a variety of factors, including their social and economic status, their culture and beliefs, and their previous experiences with health care. Understanding the human experience in health care is crucial because it can affect the quality of care that patients receive and their overall health outcomes. Moreover, it is equally important to consider how many of the same factors affect the clinicians and providers who deliver health care, as many of these factors have been shown to have an impact on the outcomes of care.1
This series will explore the current science in the areas of workforce engagement; diversity, equity, and inclusion (DEI); safety; and the experience of care, and the unique impact that nurses at all levels have on these critical elements.
THE IMPACT OF TRUST
In his recent book, Healthcare's Path Forward: How Ongoing Crises Are Creating New Standards for Excellence, Press Ganey's chief medical officer Thomas Lee shares his belief that building trust in our patients and employees is critical to preserving what is great about our work in health care.2 He goes on to discuss the importance of trust as the foundational element in all relationships. Think about this for a moment in the context of your own life. When you are given information or advice, are you more likely to receive and/or act on it if it comes from someone you trust or someone whose motives you may question? Our work relationships are no different from those outside of work. When you boil it down, no matter how hard you try to build something, it will never be strong without trust as a foundation.
As clinicians and leaders, we should always be thinking about how our interactions, words, and actions (or lack thereof) are adding to or taking away from building trust. It is just as important to think about this in our patient and client interactions as it is in our interactions with each other. When patients or employees feel that their concerns are not being heard or that they are not being treated with respect, it can erode their trust in the health care system and the work environment. This can lead to a breakdown in communication between patients, providers, and colleagues, which can result in poor health outcomes and a crumbling work culture.
As a nurse leader, it always puzzled me when someone would refer to a nurse as "a good nurse" because they possessed strong technical skills, when they had an attitude and communication style that no one could stand. Strong skills are no longer good enough. To create trust, we must demonstrate a balance of technical skill with respect, empathy, and compassion-all precursors to a trusting relationship.
WORKFORCE ENGAGEMENT
There is no question that the COVID-19 pandemic exacerbated many of the negative aspects of the health care work culture and at minimum strained the positive ones. And while much has been said and written about how challenging things are in health care now, there are signs of hope. Our current data show that engagement, the measure of how employees feel about their work and work culture, has stabilized across all job categories. While this is a positive sign, the concern remains that engagement had seen a year-over-year decline since 2019, even before anyone had heard of COVID-19. This trend showed that health care cultures were in trouble before the pandemic and, in many instances, have been on life support ever since.
One of the driving forces in the stabilization of health care workforce engagement is a slight improvement in resilience, a major contributor to an employee's overall level of engagement. At Press Ganey, we measure resilience using two subscales called activation and decompression (see Figure 1). Think of activation as your "why." Why did you go into health care? Why did you become a nurse? Why are you connected to the mission, vision, and values of your organization? These are some of the intrinsic and extrinsic factors that impact your level of activation. Activation is also about the work itself. For example, an advanced practice registered nurse (APRN) who disagrees with the statement "I like the work I do" is 12.5 times more likely to leave an organization over a three-year period than an APRN who agrees with the statement.
Activation can be improved using several evidence-based interventions. Reconnecting employees to an organization's core mission, vision, and values through storytelling has been shown to have a positive impact on activation measures. No one is better positioned to tell the great stories of what happens on a day-to-day basis than your team members. These stories should be collected, curated, and most importantly shared. These stories can be used for everything from external recruitment to internal recognition. In addition, meaningful recognition and removing friction points in care processes have also been shown to improve resilience by increasing activation.
Resilience is also affected by the opposite of activation, which is decompression. Simply stated, decompression is our ability to disconnect from work and recharge. We measure decompression using survey statements such as, "I can disconnect from work communications (email, phone, text) when I am not at work," "I can enjoy my personal time without focusing on work matters," and "I rarely lose sleep over work issues," among others. These statements give us a sense of how health care employees can reset and recharge. As care providers, we can only fill the tanks of others if we have something in our own tanks to give. Sadly, many providers go to work "on empty" and give and give until there is literally nothing left. We must find ways to decompress from the intense work we do in caring for others.
Respecting employees' time away from work is one of the most important ways to increase your team's ability to decompress. Most employees report an endless amount of text messages; phone calls; and automated notifications from managers, coworkers, and scheduling software solutions, primarily related to staffing, on their days off. This constant barrage has two untoward effects on employees. It reinforces negative messaging that the organization does not have the tools and resources to provide patient care, and it contributes to lower decompression scores among providers. Another important consideration is to focus on the things that make a great shift great. Recent data from the National Database of Nursing Quality Indicators (NDNQI) showed that fewer than 30% of RNs had one uninterrupted, 30-minute break during their last seven work shifts.3 This is an area where we must do better by providing the tools, resources, and opportunities for staff to reset and recharge during their shift.
Nursing workforce challenges have always been cyclical. Those of us who have been in nursing for a decade or more have seen shortages come and go in various forms. While we have seen these issues before, this cycle is very different in one unique way. This is the first time we have seen a nursing shortage against a backdrop of the lowest levels of resilience we have ever measured among bedside RNs. That, coupled with the barrage of negative messages about nursing prevalent in social and news media, is creating a complexity in the nursing pipeline that requires new and innovative thinking. Rethinking models of care delivery, ensuring top-of-license practice, and creating a positive practice environment-the new PPE-will all have a positive impact on our ability to recruit and retain the best and brightest in our profession.
One of the biggest lessons learned from the pandemic experience is that the only way organizations will be able to deliver on the promise they make to their patients- to provide safe, effective, compassionately connected care-is to rely on the foundation of an engaged and highly resilient team. The employee-first approach does not lessen the need to have a patient-centered approach to the care experience.
BUILDING A SENSE OF BELONGING: THE SECRET WEAPON IN REDUCING TURNOVER
Our data suggest that employees who have a strong sense of belonging-a connection to their leader, team, and the organization-are far less likely to leave the organization in the long term. There are several actions that frontline leaders can take in order to build a stronger sense of belonging. These interventions are applicable across organizations and care settings, and can even be implemented at the micro-team level.
1. Create a shared vision for your unit or team. Having a vision that the team can rally around helps new members understand the direction in which the unit is moving and provides a connection point to its values. Once that vision is established, make it visible across all employees. Embed your mission within day-to-day operations and continually reinforce it-from the initial job posting to onboarding and throughout the employment life cycle-so each RN embodies your values and is grounded in a clear purpose from day 1.
2. Know where you stand as a team or organization in terms of creating belonging. When employees report a sense of belonging, it means they feel that they, as individuals, and the work they do matter. They feel engaged with the organization, its mission, vision, and values, and they feel connected to and accepted by their peers and managers. But this can be hard to measure and track. Ensuring that your organization participates in some type of culture survey and ongoing listening is critically important to understanding your team's needs in real time and as they change. Regularly surveying your workforce helps you keep your finger on the pulse of employees' engagement levels and their sense of belonging. In fact, a strong predictor of turnover risk is participation in engagement or employee experience surveys: work units with low survey participation are at greater risk for turnover. Then, it's equally important that the leadership team communicates just how RN survey responses are used to effect positive change-so nurses know their feedback is used and their voices are truly heard.
3. Focus on DEI. Creating a sense of belonging goes hand in hand with inclusion. Are you, as a leader, creating an environment where people can bring their whole selves to work, honoring their differences alongside their similarities to develop a high-performing team? Do you actively try to make people feel they belong? Do you hire nurses from diverse backgrounds, encourage open dialogue, and create a sense of psychological safety, where each employee feels empowered to speak up when they observe biases, microaggressions, incivility, or unfairness? These elements have been shown to have strong correlation to overall long-term engagement and retention.
4. Talk openly about belonging and make the discussion part of your team's daily communication plan. We frequently acknowledge the most common drivers of turnover, like work schedules, personal reasons, internal conflict, and new professional opportunities, but rarely do we talk about employees' sense of belonging-or lack thereof. But the data show that when you consider the following elements collectively, employee engagement and nurses' overall sense of belonging improve.
* Leadership supports the nursing staff both professionally and personally.
* Nurses know how their survey feedback is used to drive positive change.
* Tools and resources are made available so nurses can provide the best possible patient care.
* Nurses feel respected and recognized for their work.
* Nurses are satisfied with their on-the-job stress levels, staffing at the organization, and work-life effectiveness.
5. Ensure you have a solid onboarding and orientation program to support new nurses and role transitions within your organization. Filling just one open RN position takes 89 days, according to the RN Recruitment Difficulty Index-which means you need to hang on to each new employee. Mentorship, new-graduate transition programs, and individualized orientation programs all help improve an employee's sense of belonging from day 1. A strong nursing shared governance or shared decision-making model is also key to making employees feel like they have a voice-and that their voice matters to leadership. Encouraging input from all RN caregivers is integral to cultivating a sense of belonging. Flattening hierarchies facilitates organization-wide transparency and opens the lines of communication from bedside to boardroom. Including executives and leaders in daily huddles and rounding helps them see what's happening on the ground. And bringing frontline nurses into leadership meetings ensures they're directly involved in the decision-making conversations that impact their day-to-day work.
Creating a sense of belonging is a key strategy for nurse leaders to reduce RN turnover during their critical first year at your organization-and in the years that follow. (These interventions can also be found on our blog at https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/care.)
CREATING A PATIENT-CENTERED HUMAN EXPERIENCE
The concept of human-centered care is based on the idea that health care should be designed with the patient at the center of everything. This means that health care providers must understand and meet the needs of the patient while also considering the patient's preferences and values. Human-centered care is more than just a philosophy; it is a way of providing health care that can improve outcomes and enhance the overall human experience.
Our data show that there is a strong, positive correlation between employee engagement and patient engagement. This is not to say that "happy employees make happy patients"-the connections are far more complex than that. One significant aspect of this connection is the patient's perception of safety. Nearly 95% of patients surveyed reported a "top box" experience when they felt safe in the care setting. When patients do not feel safe, the "likelihood to recommend" score plummets by over 30 points.
Nurses play a significant role in the patient's perception of safety. The key drivers that contribute to the overall feeling of safety include the provider's concern for the patient's questions and worries; the extent to which the patient (and family members when appropriate) is included in decision-making; and how clearly the provider explains the patient's problems and conditions. From the patient's perspective, these drivers translate to respect and empathy. Patients who feel that they are being treated with respect and empathy are more likely to follow their treatment plans and take their medications as prescribed. Conversely, patients who feel that they are not being heard or that their concerns are being dismissed may be less likely to follow their treatment plans, which can lead to poor health outcomes.
HIGH RELIABILITY AND DEI AS A FOUNDATION FOR IMPROVEMENT
Two crucial elements are required to build a culture based on connectedness: (1) a commitment to safety rooted in high reliability and (2) a focus on DEI. Although these two elements may seem unrelated, safety and DEI are integral to creating an environment where nurses have higher levels of engagement, and in turn deliver safe, effective care.
From an employee-engagement perspective, a focus on DEI is one of the top five drivers of long-term retention. Employees want to work for organizations that value DEI. Nurses who feel included and accepted for who they are-across the spectrum of gender, sexual orientation, ethnic background, race, religion, and other factors-are more engaged and feel safer psychologically.
Engagement translates to better outcomes, too. Employee engagement is correlated with a stronger safety culture, which leads to better safety outcomes for patients and the workforce. For example, nurses who work for organizations that prioritize their psychological safety are more likely to report errors and near misses. When nurses feel they can speak up and discuss what's happening within the organization-without fear of repercussions and retaliation-everyone benefits.
In addition to psychological safety, organizations must ensure nurses' physical safety as well. NDNQI data show that two nurses are assaulted per hour in the United States-and assaults against caregivers often go underreported.3 We might not fully understand the extent of the violence nurses face in the workplace. To address this, organizations must adopt zero tolerance policies regarding any type of threatening, abusive, or violent behavior and promote a culture of safety.
Data is the answer to delivering the human experience in nursing. When we talk about the human experience in health care, it might seem like an approach far removed from datasets and technological innovations. But, in reality, data and technology can help us deeply understand the human experience-both of people in need of care and of the people delivering it.
Looking holistically at quality, safety, and reliability data-through a human experience lens-can help organizations move their nursing workforce in a positive direction. When you combine that with a strong foundation of basic practices, nurses are more engaged, safer, and better able to care for patients. And that's what the human experience in health care is all about. (This information on DEI and high reliability data can also be found on our blog at https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/nurs.)
We look forward to sharing these concepts with you in greater detail in our upcoming columns.
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