Hospitals increasingly allocate substantial resources to improve the inpatient care experience: chief experience officers, overhauled food menus, parking discounts, and Disney customer service training for staff are just a sampling of the various investments hospitals have made in recent years to increase satisfaction and experience scores.1,2 Attention to the patient experience is important not just as a competitive business strategy but as an ethical practice; children and their parents expect to receive appropriate, respectful, and timely care; they expect to be treated in a safe and clean environment; and in the vast majority of instances, they expect to leave the hospital in better health than when they arrived. However, identification of specific modifiable mechanisms influencing formal parent and child ratings of the pediatric inpatient experience has lagged until now. In an analysis of 17 727 parent-submitted Child Hospital Consumer Assessment of Healthcare Providers and Systems surveys on care in 69 hospitals across 34 states, Feng et al3 found that of 10 items, 2 were consistently and strongly associated with top-box willingness-to-recommend scores across all modeling strategies: child comfort and nurse-parent communication.
It should come as no surprise that families highly value a hospital environment that supports their child’s comfort and where communication is bidirectional and respectful. Indeed, evidence already demonstrates positive effects of the work of frontline professionals who foster child comfort and positive communication during the inpatient encounter. For example, procedures attended by child-life specialists, health care professionals who help children cope with the trauma of illness and hospitalizations, result in lower child distress and higher parent ratings of satisfaction with care.4–6 Parent experiences of communication with nurses, with whom parents engage most frequently and share a caregiving role during hospitalization, influence parent satisfaction with inpatient care and enable a sense of parent inclusion as an integral member of the care team.7,8 Children themselves have identified nurse behaviors as influential to their hospital experience, including nurses’ use of kind words, pain reduction efforts, offering humorous diversion and conversation, promotion of a sense of well-being, attention to basic needs, respectful interactions and treatment as an individual, and giving comfort and reassurance. Importantly, Feng et al3 not only show that high child comfort and nurse communication ratings are associated with top-box recommendation scores but also show that the lowest child comfort and nurse-parent communication ratings are associated with bottom-box recommendation scores, indicative of the discriminating role these particular factors play in parents’ assessment of both good and bad hospital experiences.
Creating a comforting inpatient environment and ensuring good communication with children and their parents are fundamental aspects of caregiving, which is primarily relational work that requires time for meaningful interpersonal interactions. Time is a commoditized resource that many caregivers (especially frontline nurses) severely lack. Rising pediatric acuity levels and workload, coupled with demands of ever-expanding guidelines, quality improvement projects, and clinical documentation require nurses to do more work in less time, often while multitasking, and frequently at the expense of core caregiving work such as communicating the care plan with a family.9 Research on missed nursing care in pediatric environments reveals that when nurses’ workloads are high, they focus on technical, auditable aspects of caregiving, such as medication administration, and deprioritize time-consuming relational aspects of care, including comfort care and parent engagement.10,11 In addition, comfort and good communication are fundamentally rooted in caregiver respect for children and their families. Emerging evidence documenting implicit bias among nurses12–14 highlights that even the most trusted group of health care professionals (and the organizations that employ them) must reckon with how larger societal forces shape care delivered within hospital walls.
Where should hospitals invest to receive the best return on patient experience? The work by Feng et al3 strongly suggests that the best opportunities to improve the inpatient experience are found in supporting and improving frontline caregiving. Hospitals must ensure that caregiver workloads are manageable through sufficient staffing and resources, elimination of redundant and non–value-added tasks, and design of work that enables more focus on children and families and less focus on navigating ineffective systems. Hospitals must also address implicit biases influencing nurse-parent interactions and take steps to mitigate its impact. Although robust evidence to support specific individual-level interventions is lacking,15 hospitals can structurally address bias through recruiting and retaining a more diverse nursing workforce as well as through investing in pipeline development of future nurses and health professionals from local communities and neighborhoods. Health care is still fundamentally about people caring for people, and investing in the human side of health care appears to be the patient experience intervention that children and their families would endorse most.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1264.
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Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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