By Jennifer Thew, RN
Nurse leaders are quite familiar with this question from the HCAHPS survey: "During this hospital stay, how often did nurses listen carefully to you?"
And though the question seems straightforward, active listening in the healthcare environment is more complex than it sounds.
"Because listening is so integral to who we are as human beings, we have a sense of when somebody's listening but we can't necessarily articulate it," says Nancy Loos, PhD, RN, NE-BC, program manager, risk management at Dignity Health Northridge Hospital Medical Center in California.
Loos says active listening can influence HCAHPS scores and patient care compliance, and it can affect an organization's financial health.
"At the end of the day, you're going to get money taken away if you don't meet these scores," she says.
Loos says that nurse leaders must heed this advice: "If they're rounding on patients, ask them if they feel that the nurses were listening to them. These behaviors can be taught. Leaders can highlight that listening is a priority and acknowledge that it's important and not some soft, fluffy thing."
The Finer Points of Listening
To improve nurses' listening skills and create a better patient experience, nuances regarding listening must be understood.
That's why, when Loos was pursuing her doctoral degree, she decided to delve into patients' perceptions of nurses' listening behaviors.
Well before Loos began her doctoral study, she had an interest in the concept of listening. In a former position as director of nursing operations, she had been tasked with improving HCAHPS scores pertaining to nurse listening. She turned to the nursing literature for guidance but found little on listening from the patient's perspective.
"I thought, 'What do I tell my nurses to do? What behaviors do I tell them to work on?' " she recalls.
Now, thanks to Loos' research, nurse leaders can help nurses develop behaviors that patients say make them feel listened to and have a better patient experience.
How Patients Perceive Listening
The aim of Loos' qualitative study was to understand from the patient's perspective:
- Which nurse behaviors imply listening has or hasn't occurred
- How inpatient experience with nurses who either listened or did not listen affected the study participants during hospitalization and after discharge
Loos interviewed 23 patients from 15 different health systems in Southern California after they were discharged from their inpatient stay.
"I did not want to have to ask them questions while they were still in the midst of their stay and there is the power differential," she says.
Some of the questions she asked the study participants were:
- What comes to mind when you hear the word "listen" or "listening"?
- Consider your recent hospitalization and recollect a registered nurse who you believed listened to you. Can you please describe the setting and what the nurse did that made you feel he or she was listening?
- During your recent hospitalization did you encounter an RN who you believed was not listening to you? Can you please describe the setting and what the nurse did that made you feel he or she was not listening?
- In what way did the nurse's listening or not listening affect your experience in and beyond the hospital?
From the answers to these questions, Loos quantified the number of times study participants mentioned both verbal and nonverbal behaviors they described as listening behaviors. For example, 13 patients (57%) identified asking questions as a verbal listening behavior, and 16 patients (70%) mentioned eye contact as a form of nonverbal listening.
These concepts were then divided into themes related to listening and non-listening behaviors. They are described as follows:
1. Positive Listening Behaviors
Three themes emerged regarding positive nurse behavior that made patients feel listened to.
Loos describes this particular theme as the most "compelling" theme of all.
"It seemed like everything else that happened hung on that. How the rest of [the patient's] day went depended on whether that connection was made at the beginning of [the shift]," she explains.
What exactly did patients mean when they talked about making a connection?
"It means [the nurse] notes that [the patient] is different than the person in the next room," she says. "Once that connection was made, it's almost as if everything else the nurse did was okay. They were trusted," Loos explains.
Verbal behaviors that support making a connection include asking questions and personalizing care, prompting the patient to share, speaking to the patient directly, and talking to the patient before performing a care task, she says.
"[These behaviors] … didn't have to be for a long length of time. It was just enough time to say, 'I see you. I hear you [to the patient],' " she says.
Nonverbal behaviors that contribute to the nurse-patient connection include eye contact, body language (particularly sitting), and performing individual patient care preferences, Loos says.
- Putting the Patient at Ease
Loos found verbal behaviors that help put the patient at ease include narrating care, anticipating questions, providing reassurance, including family in discussions, and not complaining about job tasks.
Nonverbal behaviors found to support putting the patient at ease include follow-through, empathy, not rushing to get out of the room, and therapeutic touch, she says.
One patient who participated in the study mentioned the reassurance she felt when nurses rubbed her hand, Loos says.
"Patients have read [about] things that happen in healthcare environments, so they're concerned about their safety," Loos says.
Verbal behaviors that make patients feel they are receiving safe and effective care by nurses include answering patient questions, repeating back what the patient says, passing along information, and asking if interventions worked, she says.
Nonverbal behaviors that contribute to a sense of patient safety include nurses assisting when needed, noticing patient body language, believing what the patient says, taking notes, taking direction from the patient, and taking nothing for granted, Loos says.
2. Negative Listening Behaviors
Loos also identified themes and behaviors that make patients feel they are not being listened to.
In her dissertation, Loos describes arrogant actions by nurses indicating they knew better than the patient, even when it came to something subjective like the patient's experience of pain. Additionally, acting in ways that were dismissive of a patient's right to participate in his or her care were interpreted as arrogant by the patient.
Verbal behaviors that convey nurse arrogance toward patients include sarcasm, rude responses, speaking in a language the patient does not know, and blaming others for unfulfilled responsibilities. Nonverbal arrogant behaviors include not believing the patient and dismissing patient concerns, Loos says.
Patients often feel vulnerable in the healthcare setting. Perceiving that nurses are abusing their power leaves patients feeling that they are not being listened to, Loos says.
Verbal behaviors that imply an abuse of power by nurses include discounting or making light of patient concerns, arguing with the patient, rejection of patient input, refusing to clarify orders, and depending only on the chart. Nonverbal behaviors include not trying to understand the patient, "lazy" or uncaring body language, and standing at a distance from the patient, she says.
Verbal behaviors that patients say articulated nurse incivility and insensitivity include making up excuses, a gruff tone or attitude, and cutting off attempts at conversation, Loos says.
Nonverbal behaviors in this theme include lack of eye contact, eye rolling, acting put out, focusing elsewhere, and ignoring attempts at communication, she says.
- Abrogation of Professional Role Responsibilities
"[These are] things that as a nurse, as determined by our Nurse Practice Act, we ought to be doing, whether it's presence or ensuring things happen," Loos says.
Patients feel like they are not listened to when basic elements of nursing care are not performed, she says.
Verbal behaviors include nurses not assessing a patient or asking about his or her status, implying he or she is too busy to help, not assessing a patient's readiness to learn, and not assessing a patient's understanding. Nonverbal detrimental behaviors include not following through, lack of presence, not finding solutions, and appearing rushed or scattered, Loos says.
Make Listening a Priority
Loos found that patients' perceptions of being listened to or not affect their perceptions of care.
Those who felt listened to reported feelings of comfort and safety, a happier experience, and better able to make themselves comfortable at home after discharge, she says.
For example, four patients (17%) reported "maintained/improved patient wellness," and three (13%) reported being more willing to collaborate with the plan of care.
Those who didn't feel listened to reported exacerbations of their conditions, loss of trust, loss of confidence in care, and feeling less safe. Three patients (13%) even reported refusing treatment.
"When they do feel that we're listening, it allows them to relax and sleep and recover while they're in the hospital. If they don't think we're listening, they're afraid to go to sleep or they feel they have to stay up and be their own advocate," Loos says.
"[Listening] improved adherence to the plan of care. The plan of care is important. If patients are more willing to [follow their plan of care] because of the connections that they've made with the nurse and because they felt better about the care, we should be embracing [the value of listening skills]," says Loos.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.