In 2021, the term patient experience was expanded to human experience to describe the broader experience of health care.1 This expanded definition evolved as health care providers implemented strategies to provide care with greater intentionality. Thus, the concept of human experience evolved from clinical practice. The human experience is the sum of interactions shaped by an organization's culture that influence patient perceptions across the continuum of care.1 It views the health care experience through an ecological lens with the patient experience at the core. Given that the health care environment is shared by workers and patients alike, the central patient experience is shaped by the workforce experience. Both the health care workforce and patients are subsequently shaped in response to the external community and broader environmental factors.1, 2 The current literature is focused on the core patient experience. This article will serve to illustrate the symbiotic relationship between the patient and the workforce experience,1 and will explore how Press Ganey's Compassionate Connected Care framework can help organizations get back on track with respect to experience and quality initiatives.

THE HUMAN EXPERIENCE OF NURSES DURING COVID-19

National data from Press Ganey and other research strongly support that health care organizations must view the human experience as foundational to both caregiver engagement and the provision of safe, high-quality patient care if organizational improvement goals are to be achieved. However, three years of a global and national pandemic have had a significant negative impact on the patient and caregiver experience. Let's use the experience of nurses during the early days of the COVID-19 outbreak to advance our understanding of the symbiotic relationship between the patient and workforce experience.

Nurses are central to the way a patient experiences health care. In addition to providing direct care, they provide critical communication and coordination functions. These functions were disrupted during the initial phases of COVID-19. For example, nurses experienced extreme isolation from family, colleagues, and patients as they sought to limit exposure to and spread of COVID-19 infection. Organizational policy responses to COVID-19 reduced valuable support services such as dietary, volunteer, and administrative personnel from entering the hospital to reduce unnecessary exposure to the virus. Other health care professionals such as therapists and physicians asked nurses to provide their services in order to reduce these professionals' exposure to the virus. Many nurse leaders, clinical educators, and care coordinators worked remotely, disrupting critical communication and coordination pathways.3 Even basic protective equipment was in short supply. This resulted in nurses at the front line responding to novel patient needs and demands without the support of their usual care team. Nurses were left feeling abandoned. The increased volume and acuity of patient needs quickly overwhelmed nurses, leaving them exhausted and overworked, with no opportunity or outlet to recover. Moral distress and burnout quickly spread throughout the nursing workforce.

Once health care system leaders recognized the negative toll of COVID-19 on the workforce, they quickly acted to identify strategies to better support health care workers. Focus turned toward providing organizational support at the individual worker, team, and health care system levels. Interventions ranged from providing meals and housing to quiet rooms and emotional support.

The initial two years of COVID-19 yielded a battered nursing workforce. Senior nurses retired early, and many younger nurses left nursing altogether. The unanticipated loss of these nurses hit at a time when nursing was expected to enter a significant shortage cycle. The impact on nursing has been severe, and the profession has been slow to recover as leaders rebuild the health care environment and innovate to help the nursing workforce reengage in the profession.

CURRENT STATE OF THE NURSING WORKFORCE

Let's take a look at some data to understand the current and near future state of the nursing workforce. According to the 2022 National Nursing Workforce Study, the profession lost 100,000 RNs and 34,000 LPNs in the wake of the pandemic.4 The National Council of State Boards of Nursing also reported that an additional 800,000 RNs and 184,000 LPNs plan to retire by 2027.5 This projected shrinkage of the nursing workforce will converge with a projected need for almost 200,000 more nurses each year over the next decade.6

The experience of the current nursing workforce is not positive. Nurse leaders report that their nurses say they hate going to work. There is a loss of trust between nurses and organizational leaders as nurses and nursing advocacy organizations increasingly seek legislation to resolve staffing and workplace safety assurances.7-9 Press Ganey data show that engagement among nurses dipped during the pandemic and has been slow to recover. There is a reason today's nurses are less engaged than those prior to the pandemic: nurses are experiencing work environments that pose threats to their safety. An estimated two assaults on nursing personnel are reported every hour.10 Nurses are increasingly confronted with situations they are not prepared to handle and there is a lack of experienced nurses to provide guidance. Younger members of the workforce are not afraid to leave an organization to explore new opportunities that give them more control over their workload and schedule.

One opportunity is to reconnect nurses to their original calling. Our data demonstrate that although nurses have difficulty disconnecting from the stress of their jobs, they remain passionate and find nursing meaningful, This presents a foundation for nurse leaders to build on.

ENHANCING THE HUMAN EXPERIENCE THROUGH COMPASSIONATE CONNECTED CARE

Compassion, caring, and empathy are shared characteristics among those of us who have pursued careers in health care. It would be challenging to care for people otherwise. But as critical as these character traits are—and necessary for positive workforce and patient outcomes—they can get lost in an organization's day-to-day operations. The pressures of competing priorities, meeting regulatory guidelines, and maintaining safe, quality care can make these critically important character traits less visible than we would like.

About 10 years ago, Press Ganey's leaders revised its organizational mission and focus to reflect a new direction that emphasized partnership and collaboration with health care organizations. Press Ganey's mission to reduce patient and caregiver suffering by supporting the delivery of safe, high-quality, patient-centered care was adopted throughout the company. The organization next sought to find the best way for hospitals and health systems to approach improvement work to achieve exemplary patient and caregiver experience and outcomes. We know that patients may experience unavoidable suffering related to their diagnosis and treatment, as well as through unmet needs such as long wait times, poor communication, and lack of compassion and empathy. Caregivers, too, experience suffering.

Press Ganey senior leaders, under then chief nursing officer Christy Dempsey, began working on a framework to answer the question, “How can we best leverage the data we have to enhance health care improvement?” In 2014, the Compassionate Connected Care framework was introduced to the health care community. Dempsey has described it to colleagues as an “action model to reduce suffering for both patients and the people who care for them.” The framework includes two components—caring for the caregiver and caring for the patient. The model has both quantitative and qualitative elements. The quantitative element includes questions from both the workforce and patient experience surveys that are grouped into four buckets:

Caring behaviors Clinical excellence Operational efficiency Culture

Grouping questions in this way makes it easier for clinicians to understand directionality—that is, where the greatest opportunities for workforce and patient experience improvement exist.11 The qualitative element of the model was derived through affinity diagramming, which involved sending hundreds of surveys with open-ended questions to caregivers and patients. For each component of the model, six qualitative themes were identified (see Table 112).

Table 1. - Compassionate Connected Care Themes12 Caring for the Caregiver Caring for the Patient Acknowledge the complexity and gravity of the work: caregivers need to receive recognition for the work they do from leaders and colleagues. Rewards may be tangible or intangible. Acknowledge suffering: caregivers should acknowledge that patients are suffering and show them that they care. Support caregivers with emotional, material, and human resources: management has a duty to provide support in the form of material, human, and emotional help. Leaders create a positive and healthy work environment. Body language matters: body language is as important as the words we use. Foster teamwork as a vital component for success: team members support one another. Multidisciplinary teamwork is organized around patient needs. Anxiety is suffering: anxiety and uncertainty are negative outcomes that must be addressed. Model empathy and trust: trust is built on accountability, integrity, and fidelity at levels of the organization. Caregivers demonstrate empathy to each other and to patients. Care should be coordinated: patients need to know that their care is coordinated and continuous, and that providers are always there for them. Reduce compassion fatigue through a positive work–life balance. Caregivers feel their work is meaningful. Their perception of a positive work–life balance reduces compassion fatigue. Autonomy reduces suffering: autonomy preserves patient dignity. Communication at all levels is foundational to success: listening is a critical component of communication. Communication and transparency are fundamental for the demonstration of empathy and trust. Real caring transcends medical diagnoses: real caring goes beyond delivery of medical interventions to the patient.

Caring for the caregiver. Concerns about caregivers' compassion fatigue, burnout, and turnover are not new. Clinician engagement had been declining prior to the pandemic for over a decade, with nurses and physicians consistently ranking at or near the bottom of engagement surveys in Press Ganey's national database. The COVID-19 pandemic only exacerbated the situation. Significant declines were noted between 2020 and 2022, with the largest declines in 2021. Although engagement is rebounding across caregiver roles, nurses continue to have the lowest engagement scores (see Figure 1).

Figure 1.:

National Caregiver Engagement Trends

As nurses, we have chosen an often rewarding, but very challenging profession. In addition to the challenges presented by the needs of patients in today's health care environment, nurses and other health care professionals may work long hours. Care often includes physical stress such as being on one's feet most of a shift and potential injury from lifting and turning patients. Emotional stress and compassion fatigue that may lead to burnout and increased turnover are of constant concern to nurse leaders.

Stress and burnout can be mitigated by enhancing human connection among teams and between team members and their leaders. Understanding that workforce engagement has a critical impact on quality, safety, clinical, and patient experience outcomes, leaders need to think first about prioritizing how best to support caregivers, keeping in mind that human connection is just as crucial to caregivers as it is to patients.

Caring for the patient. Caregivers don't come to work saying, “Hey, I think I'm going to coast today and provide marginal care to my patients.” They want to give great patient care every day, and they know that compassion, empathy, and caring are vital to its provision. This bolsters their sense of joy and meaning in the work they do, which in turn enhances workforce engagement.

Most caregivers believe they are compassionate, caring, and empathetic people, and that is true—they are. However, those beliefs are challenged when patient experience scores do not reflect that patients are satisfied with their care. This can create frustration, skepticism, and sometimes outright disbelief on the part of caregivers who work hard to manage patient care in highly complex work environments. So why the disconnect? And how do we close the gap between what we as caregivers perceive as providing compassionate and empathic care, and what our patients are perceiving?

A myth among caregivers about patient experience work is that the focus is to make patients happy. That notion is easily challenged by asking health care professionals, “In your experience, are patients happy to be in hospital beds, on ED gurneys, or awaiting a colonoscopy in the ambulatory procedural area?” I think most would agree that the answer is no. So, if patient experience isn't about making patients happy, what is it about?

The most common feeling that patients experience within the health care system is anxiety, and perhaps even fear. Anxiety over what is happening to them now and what might be coming. Fear of pain, suffering, financial impact, and how their future and family might be affected. What patients really want is to feel safe under our care—not just to be safe by virtue of our training and expertise. For caregivers to establish that sense of safety, they must be able to create a sense of trust by connecting with patients as human beings. With the inherent busyness in health care systems today, how can caregivers and teams do this consistently and reliably with all the patients and families they care for?

Leveraging data to guide best practices to enhance the human experience. Hoping that caregivers and team members can meet improvement objectives by “being nicer” is not a strategy. Key behaviors must be defined. Operationalization of a caring model that is a good fit for the organization to embed best caring practices into everyday interactions within teams, and with patients and families, is a key to success. And to ensure forward momentum and sustainment over time, there must be alignment at all levels of leadership that this work is a strategic priority to improve quality, safety, workforce engagement, and patient experience.

Press Ganey data help us to better understand what is most important to patients and caregivers with respect to the care they receive and provide. When the statement “This Hospital/Entity promotes a caring environment” was added to a workforce survey administered to over 11,000 health care employees and physicians, it ranked as the top key driver for overall workforce engagement. The higher ranking a key driver has, the more heavily weighted it is to drive overall engagement. So, it isn't just patients who want to be in a caring environment, caregivers also want to work in one.

Patient experience data also tell a compelling story. When examining both organization level and larger patient experience key driver datasets, the top 10 ranked items are frequently those predicated on staff and physicians being able to establish human connection with the patient and the patient's trust (see Figure 2). Patient experience key drivers are those items most heavily weighted to drive overall patient experience scores.

Figure 2.:

2023 National Key Drivers: HCAHPS Recommend the Hospital

In a Press Ganey pilot study conducted in 2021, NarrativeDx, Press Ganey's artificial intelligence–driven comment analysis platform, was leveraged to analyze 50,000 patient experience surveys from five hospital systems. Data were aggregated to identify correlations between the top five key driver focus items and the most frequent comments written by patients for each key driver (see Table 213). For the top five key driver items, the most frequently mentioned comments that drove those top box scores were kindness, helpfulness, empathy, and compassion.

Table 2. - NarrativeDx Comment Analysis13 Top Five Key Driver Focus Items No. of Top Box Positive Insights Staff worked together to care for you Kind 1,140 Helpful 625 Empathy/Compassion 457 Nurses' attitude toward requests Kind 1,132 Helpful 608 Empathy/Compassion 463 Attention to needs Kind 1,132 Helpful 608 Empathy/Compassion 463 Response to concerns/complaints Kind 1,132 Helpful 608 Empathy/Compassion 463 Nurses kept you informed Kind 1,132 Helpful 608 Empathy/Compassion 463

Using data such as patient experience key drivers and comment analysis to better understand the impact of initiatives on outcomes, and to course-correct when necessary, helps organizations to advance strategic goals in a meaningful way.

IMPLICATIONS FOR NURSING

A study conducted by the Schwartz Center for Compassionate Healthcare demonstrated that only 42% of nurses and 60% of patients felt that U.S. health care systems provided compassionate care.14 As we know from data presented earlier that compassion, empathy, and caring have a significant impact on both patient experience and workforce engagement outcomes, these survey results suggest that hospitals and health care organizations in general should be prioritizing ways to operationalize a robust caring framework within their organizations.

There is a growing body of literature that highlights the importance and impact of caring, compassion, and empathy on team and clinical outcomes.15 However, some of the barriers to providing compassionate care, including clinician beliefs that their technical skills and academic preparation are the most important things they bring to health care and skepticism about patient experience and workforce data, can create formidable challenges. Additionally, there are some individuals who believe that empathy and compassion cannot be taught. In fact, research demonstrates that they can.16 Think about your transition to practice after graduating from nursing school. When your first patient passed away, or you had to interact with patients and families to deliver distressing news, did you feel you had the skills to compassionately and empathetically have those conversations? For many of us, the answer is a resounding no. So then, how did we learn? It might have been through seeing how more experienced caregivers handled those conversations. Or possibly through formal training at different points in our career. The point is that we can and do learn from those interactions and experiences.

Let's fast-forward to the present. Many of us say that as nurses, we are data driven and use data to ensure we are employing best practices in caring for patients and families. This certainly holds true for technical skills. If data demonstrates that catheter-associated urinary tract infection rates are rising, a root cause analysis is conducted to identify any unintentional lapses in practice. Those findings are then used to alter clinical practice as needed to ensure that the issue is corrected. Does the same hold true when we see that patient experience scores or employee engagement scores are not where we want them to be? We have to start thinking about caring, empathy, and compassion as a skill set that is just as important to achieving great outcomes as our ability to provide technical care of variable complexity. We must learn how to better leverage patient experience and workforce data to strengthen our knowledge, skills, and abilities with respect to caring behaviors in a concrete and proactive way, and then build on the caring and empathy skills we already have and apply them consistently within teams and in caring for patients and families. Organizations should not be focusing on survey scores as the main event. Instead, organizations and leaders should focus on advancing a human experience strategy by investing in their staff and teams and prioritizing the implementation and sustainment of a robust caring model that includes best practice behaviors. Once those vital structures and processes are in place and being employed by teams and leaders, the scores will follow.

REFERENCES 1. Wolf JA, et al. Reexamining “defining patient experience:” the human experience in healthcare. Patient Exp J 2021;8(1):16–29. 2. Doucette JN. Exploring the human experience in health care. Am J Nurs 2023;123(9):38–42. 3. Zipf AL, et al. The experience of the nurse during the COVID-19 pandemic: a global meta-synthesis in the year of the nurse. J Nurs Scholarsh 2022;54(1):92–103. 4. Smiley RA, et al. The 2022 national nursing workforce study. J Nurs Regul 2023;14(1 Suppl 2):S1–S90. 5. National Council of State Boards of Nursing. Leaders in U.S. nursing workforce research. Chicago; 2024. National nursing workforce study; https://www.ncsbn.org/research/recent-research/workforce.page. 6. Bureau of Labor Statistics. Registered nurses. In: Occupational outlook handbook. Washington, DC; 2022. https://www.bls.gov/ooh/healthcare/registered-nurses.htm. 7. Aiken LH, et al. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. JAMA Health Forum 2023;4(7):e231809. 8. Aiken LH, et al. A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: implications for action. Nurs Outlook 2023;71(1):101903. 9. Williams K. Workforce shortages, nurse retention among legislative priorities. Nursing CE Central 2024 Apr 15. https://nursingcecentral.com/workforce-shortages-nurse-retention-among-legislative-priorities. 10. George N, Potter C. The buck stops with you: zero tolerance for violence toward nurses. Nurs Manage 2023;54(11):41–5. 11. Dempsey C. The antidote to suffering: how compassionate connected care can improve safety, quality, and experience. New York: McGraw Hill; 2017. 12. Dempsey C, Assi MJ. The impact of nurse engagement on quality, safety, and the experience of care: what nurse leaders should know. Nurs Adm Q 2018;42(3):278–83. 13. Assi MJ, Guney S. Understanding the patient's perspective on nursing excellence: insights from patient experience data. J Nurs Adm 2023;53(10):508–14. 14. Schwartz Center for Compassionate Healthcare. National survey data presented at the Compassion in Action conference show mixed reactions on state of compassion in U.S. healthcare [press release]. 2017 Jun 27. https://www.theschwartzcenter.org/media/2019/05/Natl-Poll-and-Conf-Press-Release-Final.pdf. 15. Trzeciak S, Mazzarelli A. Compassionomics: the revolutionary scientific evidence that caring makes a difference. Pensacola, FL: Studer Group; 2019. 16. Bas-Sarmiento P, et al. Efficacy of empathy training in nursing students: a quasi-experimental study. Nurse Educ Today 2017;59:59–65.