How nurses assess care goals to boost patient satisfaction

Setting the goal for more person-centered care

LaNeve and her colleagues' project is part of the NICHE program (Nurses Improving Care for Healthsystems Elders) out of the NYU Rory Myers School of Nursing. The program operates under the tenet that nurses can and should be leading clinical quality transformation.

At Valley Hospital, that started with a desire to improve patient satisfaction and, specifically, the nurse-patient connection, according to Kelly Kennedy, one of the hospital's advanced practice nurses and architects of the "What Matters Most" program.

"We'd been talking about this probably for a year and a half prior to implementing 'What Matters Most,;" Kennedy said in an interview. "We thought that was one thing that we were lacking on our side -- finding out what really matters most to that patient. As a nurse or as any of the caregivers going into the room, you often think, 'Going to go into this patient encounter, I just want to get them better and I want to get them out of here.'"

"But that might not be the most important thing to that patient," Kennedy continued. "So, getting to know what the patient's needs and preferences are and helping to drive and focus the care on that -- we thought could be a big satisfier for not only the patients, but also our staff, as well."

Outlining patient preferences isn't just about end-of-life care, although that's one key use case. Just as it's good to know if a patient has a do not resuscitate order, it's also good to know that a bedridden patient wants to try walking that day.

Goal setting with patients can also help drive better adherence to care plans, including medications. When patients know certain procedures and medications will help them achieve their personal goals, they're more likely to engage.

But despite the promising results of patient goal setting, Kennedy, who was joined by LaNeve and their colleague Lynnelle Tampac on the project, knew they'd have to be considerate of how to operationalize this.

First and foremost, the trio needed to discuss the logistics with the rest of the nurses in their unit.

Using shared governance to guide change management

Using a shared governance structure for this change in workflow -- stopping to ask about and discuss care goals with elderly patients -- was a high priority for Kenney, LaNeve and Tampac. After doing their own research into the benefits of patient goal setting and some approaches to it, they took that information back to their teams to collectively brainstorm a process.

"A huge part when we started was gathering all the staff during our shared governance meeting and asking them, 'what do you think is the best time to do this? Do you think it's in the morning or middle of the day?'" LaNeve recalled.

In addition to being considerate of nursing workflows, the team at Valley Hospital wanted to make sure these conversations were happening at a time that made sense and allowed nurses to have deep conversations with patients. They didn't want it to seem like another checkbox.

The group landed on asking in the morning and again when the night shift took over. That's when clinicians are doing some physical assessments, opening the door for an organic conversation about how the patient wants to see their health improve for that day.

After asking the patient about their care goals for the day, nurses document those goals in direct quotations within the EHR. This change required teamwork with the hospital's clinical informatics team but ultimately set the stage to help clinicians truly deliver on patient needs.

It also lets new clinical care teams taking over during a shift change to check in on the patient and assess whether the patient's goals had been met.

Supporting better patient experiences

The "What Matters Most" program has been successful, yielding a 14% improvement in patient satisfaction scores and earning organization-wide adoption. That means every patient that visits Valley Hospital, regardless of age, has their nurse ask them their care goals daily.

But according to LaNeve, it's the family members who appreciate the program the most.

"She was really appreciative of the staff taking the time to ask those questions and trying to strive for that goal," she said, recalling the conversation she had at the top of this article. "She said at the end of the day, the goal was met -- what mattered most to dad. We did it, and they both were very happy about it and satisfied."

"What Matters Most" is more complex than an "ask and ye shall receive" philosophy. Nurses need to practice strong patient-provider communication skills and ensure adequate patient education to ensure the care team and the patient are on the same page.

Notably, there are very few occasions when the patient's goal is too unrealistic, according to Kennedy.

"We really try to think that no goal is unrealistic," she said. "When we are framing these conversations, we are trying to say, 'what's an important goal for you today,'" she emphasized.

If a patient has two broken legs, for example, they won't be walking that day. But what if the patient still states that as their goal?

Kennedy said it's the nurse's job to dig a little deeper.

With more probing, the patient might say they want to walk because they really want to feel fresh air or get a look outside. That is something nurses absolutely can make happen.

"Although the goal could sound a little unrealistic, maybe we're just not interpreting it fully," Kennedy explained. "Diving a little bit deeper into the patient's needs is how we could handle it in that moment to see what we can do."

Tampac said it's not unusual to work with patients who say their goal is to go home that day. In the best cases, Tampac can make that happen, but a lot of the time, patients still have a variety of tests that need to get done before they return home. In those cases, better patient education about their care plan can help patients reset expectations.

"It's educating the patient and the family and also constantly communicating with them, giving them progress of where we are at," Tampac stated. "It's a good opportunity to make them realize that we're taking them and their goals seriously, but these are the steps that we need to complete first."

Empowering nurses for clinical quality improvement

"What Matters Most" was launched by nurses out of an NYU-based program empowering nurses to drive clinical quality improvement.

"The model begins with bringing evidence to practice by empowering frontline nurses, nurse leaders and specialists to bring evidence-based practices -- things that are shown in the research to be the right thing for older adults -- to bring them into daily practice," Karen Mack, executive director of the NYU NICHE program, said in an interview.

According to Mack, it's essential for programs like "What Matters Most" to be nurse-led, given the direct care experience most nurses bring to the table.

In terms of this project specifically, it fills a key gap in the nursing experience that emerged in 2020: the personal connection to patients.

The COVID pandemic sparked high burnout rates among all medical professionals and heralded an era of personnel turnover that ultimately harmed the patient-provider relationship.

"One of the things we see routinely at NICHE is how that nurse-patient connection is amplified because it's very important for the patients, but it's also really important for the nurses in terms of careers," according to Mack. "The satisfaction with your professional impact on care is really important to growth and sustainment and energizing the workforce."

Sara Heath has reported news related to patient engagement and health equity since 2015.