Take a bundled approach to improve the patient experience.
- The bundle approach to implementing the commit-to-sit initiative positively impacts patient experience scores.
- Focused efforts related to sitting with patients, nursing communication skills, nurse leader rounding, and transparent data sharing move nurse domain scores in the positive direction.
Best practices for providing patient- and family-centered hospital care include open visiting hours, patient involvement in the daily plan of care, evidence-based communication tools, bedside shift reports, and hourly rounding. For example, Commit to Sit, an evidence-based initiative, serves as a powerful communication tool for improving patient satisfaction. Sitting down gives the impression that the communicator isn’t anticipating moving on to the next task, and sitting at eye level builds trust and fosters human connection. Ultimately, when nurses and other healthcare providers sit to communicate, patients perceive the time spent with them as longer than if the provider stands. (See The evidence.)
The evidence
Commit to Sit has proven successful at enhancing patient satisfaction. After two months of implementing the Commit to Sit initiative on a medical–surgical floor, Westfall reported that the nurse listening scores increased from the 37th percentile to the 77th percentile. Likewise, Kleytman and Youssef achieved improved nurse composite scores from 70% to 100% after implementing Commit to Sit on a mother/baby unit.
Donovan and colleagues examined the impact of residents sitting at the bedside on patient satisfaction during team rounds. During this study, only one rounding member sat while the others stood. This cluster randomized crossover trial didn’t find improvement in patient satisfaction scores.
Nurse leader rounding also has a positive effect on patient experience scores. A systematic review by Bayram and colleagues found similar outcomes in structured, semi-structured, and unstructured nurse leader rounding. Jun and colleagues’ integrative review of eight peer-reviewed studies to assess nurse-led interventions concluded that nurse rounding, discharge follow-up calls, and communication education for nurses increase patient satisfaction.
QI project
The national, standardized survey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), endorsed by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality, measures patients’ views on their hospital experiences. Its reliability ranges from 0.66 to 0.89 (median=0.88), and internal consistency reliabilities range from 0.51 to 0.88 (median=0.72). For an Illinois hospital’s nurse domain to score within the 75th percentile, we initiated a quality improvement (QI) project using a Commit to Sit bundle. The bundle included nurse education on effective communication skills, nurse leader rounding, frequent and transparent data sharing, and listening sessions. For our theoretical framework, we selected Lewin’s Theory of Planned Change, which many healthcare organizations implement to address factors that play a role in adopting a permanent change. The three stages of Lewin’s theory include unfreezing (understanding change is needed), moving (initiating change), and refreezing (establishing a new status quo).
The Illinois State University Institutional Review Board approved the QI project, which included all discharged patients from the hospital’s medical–surgical unit. To measure the results of the bundle, the hospital administered the HCAHPS survey (in paper form or via a phone interview) to as many patients as possible and provided analysis of the survey results. They reported results as a percentage of patients who gave scores of 9 and 10 and the percentile of those results according to a nationwide benchmarking group of similar hospitals. In addition, unit leaders collected patient responses during rounding and the QI team asked nurses and patients to complete anonymous surveys.
Nurse education
Sharkiya proposes that verbal and nonverbal communication strategies can positively impact patient-centric outcomes, including patient experience. In addition, involving patients in the decision-making process, addressing emotions, and allowing patients to speak without interruption enhance the perception of effective communication.
Pong suggests that tailored education for nurses and other healthcare providers in effective communication skills can improve patient experience scores. In addition, a systematic literature review by Kerr and colleagues concluded that educational interventions enhance nurses’ communication abilities. Effective methods for providing this skill training include role-play, simulations, and video-based reflections.
The medical–surgical unit staff received education on the Commit to Sit initiative and effective verbal and nonverbal communication skills. Education included classroom sessions related to evidence for the initiative, case study scenarios, and skills lab training. In the skills lab, trainers assessed the staff’s competence in effective communication.
Data collection
After the completion of training and implementation of the initiative, unit leaders began daily patient rounding to assess adherence to Commit to Sit. Using Google Forms to collect patient responses to the rounding, unit leaders asked patients whether staff members sat when communicating and about the effectiveness of that communication. In addition, we developed anonymous patient and nurse surveys to gauge the effectiveness of the education and perception of the intervention. (See Anonymous surveys.)
Anonymous surveys
To gauge the effectiveness of the Commit to Sit bundle, we developed the following anonymous patient and nurse surveys.
Patient survey
We are seeking to improve communication between the nurses and their patients. We are implementing a practice that encourages nurses to sit when possible while talking to patients to facilitate communication. We would appreciate your feedback on how we may further improve. Your responses are anonymous and will not impact your current or future care. If you would take a few moments to respond to the 4 questions listed below and then place the survey in the provided envelope, we would appreciate it.
1. How often did nurses sit down while communicating with you?
1. Never2. Sometimes3. Often4. Most of the time5. Always
2. How well did your nurse communicate your plan of care (1–5, with 5 being the best)?
12345
3. How often do you believe the nurses caring for you listen carefully to you?
1. Never2. Sometimes3. Often4. Most of the time5. Always
4. Please feel free to write in any additional thoughts you may have that will help us improve nursing communication: ______________________
Nurse survey
We are seeking to improve communication between the nurses and their patients. We are implementing a practice that encourages nurses to sit when possible while talking to patients to facilitate communication. We would appreciate your feedback and how we may further improve. If you would take a few moments to respond to the 6 questions listed below and then place the survey in the provided envelope, we would appreciate it.
1. Do you believe the Commit to Sit initiative is effective in improving communication with patients?
a. Yesb. No
2. Do you believe Commit to Sit improves connection with your patient?
a. Yesb. No
3. How satisfied are you with the Commit to Sit initiative (1-5, with 5 being the best)?
12345
4. How often did you sit while communicating with your patients
1. Never2. Sometimes3. Often4. Most of the time5. Always
5. How often do you believe the patients you were caring for felt you were listening carefully to them?
1. Never2. Sometimes3. Often4. Most of the time5. Always
6. Please feel free to write in any additional thoughts you may have that will help us improve nursing communication: ______________________
Data sharing
During the implementation phase of the project, unit leaders met with the nursing team every 2 to 3 weeks to share the HCAHPS scores, nurse leader rounding results, and anonymous patient survey scores. In addition, nurse leaders asked the team to share moments in which they connected with a patient when sitting to communicate. Leaders also asked for feedback on the initiative, including any perceived barriers.
Results
The overall HCAHPS nurse domain score (from February to April 2024) increased by almost 27% (from 68.94% to 95.24%). The nurse respect and listening scores improved the most, from 81.8% to 100% and 66.67% to 100%, respectively.
During the 2 months of project implementation, 77 nurse leader rounds occurred, with 75% of patients reporting that nurses sat down while communicating and 95% reporting that nurses communicated effectively. Within the 29 anonymous patient surveys collected, patients reported that only 29% of nurses always sat down while communicating and 59% felt that nurses listened to them carefully. When asked how well nurses communicated the care plan, on a scale of one to five, 38% gave a four rating; 48%, a five rating.
Of the 21 anonymous nurse surveys collected, 18% of respondents reported sitting down most of the time and 19% reported always sitting down; 38% reported that their patients felt they were listened to most of the time and 52% felt the same was always true. When asked if they thought Commit to Sit improved communication effectiveness and connection with patients, 95% said yes. (See Anonymous survey results.)
Anonymous survey results
The anonymous patient survey results differ from nurse leader rounding responses. For example, when asked during rounds if nurses sat while communicating, patients reported that 75% did, whereas the anonymous survey responses showed that 59% sat down.
Nurses noted barriers to implementing Commit to Sit, including time constraints and lack of seating in patient rooms.
Discussion
The QI project results align with the evidence-based literature review. We expected to see an improvement in the overall nurse domain scores, which we did. When asked anonymously whether the nurses sat to speak with them, a lower percentage responded positively than when they were asked in person. One potential reason could be that they didn’t want to speak negatively about their nurses and potentially get them into trouble. We found the overall positive feedback about nurses’ communication skills encouraging, and the listening sessions in which the team shared their stories of connection with patients inspired everyone. For example, one nurse said that by sitting down while caring for a patient in hospice allowed her to create a stronger connection. Slowing down and sitting displayed respect for the patient and their family.
Cost effectiveness
Patients can use publicly reported patient experience data to make informed decisions about their care. Most hospitals struggle to attract as many patients as possible, making every admission significant for the organization’s bottom line. Koslow suggests that a good patient experience enhances patient loyalty and retention. In addition, since 2016, patient satisfaction has been part of value-based purchasing, which influences Medicare reimbursement rates. Hospitals with the highest patient satisfaction scores typically receive the best reimbursement rates.
The unit that participated in this QI project has 30 employees. Each employee spent an hour in education at an average salary of $35/hour. The cost of staff training amounted to $1,050; the cost of handouts, $200. The total cost for the project came to $1,250. The initiative’s potential positive impact on the organization’s bottom line far outweighs the cost of implementation.
Limitations
Limitations of this QI project include the low number of respondents for the HCAHPS survey and the use of a single site. The nursing team reported barriers related to limited chairs in patient rooms and lack of time to sit. To address the lack of chairs, the unit’s nursing leader and the QI lead conducted several chair assessment rounds, which found a sufficient number of chairs; however, nurses continued to report a lack of chairs. We reassured nurses that we weren’t asking them to spend more time with their patients but only to add sitting down to their routine. Despite these reassurances, some nurses still felt they needed more time to comply with the initiative consistently.
Successful bundling
Improving patient experience scores is one of the most critical initiatives a hospital can implement. Results can lead to increased overall financial performance and outcomes as well as improved publicly reported measures. However, the most crucial reason a hospital should implement a patient experience improvement project remains the patient.
Other organizations can implement this bundled approach to Commit to Sit, which includes nurse leader rounding and communication skills education for nurses, to improve nurse domain HCAHPS scores related to patient experience. Frequent listening rounds (round table discussion with the front-line team) and transparent data sharing also aid improvement. Future work should include replicating this initiative in multiple settings and for longer periods.
Marija Suvacarov is chief nursing officer at Ascension in Elgin, Illinois. Marilyn Prasun is Carle BroMenn Medical Center Endowed Professor at Mennonite College of Nursing at Illinois State University in Normal. Denise Massey is director of women’s services at Humboldt Park Health in Chicago, Illinois. Orin Reitz is an associate professor at Mennonite College of Nursing.
American Nurse Journal. 2025; 20(8). Doi: 10.51256/ANJ082538
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Key words: commit to sit, patient experience, patient engagement, nurse leader rounding, nurse communication skills
