Heartland Patients Want to Hear From Nurses

Julie Trivitt


It is more important to know what kind of a patient has the disease than what kind of a disease the patient has. ~Andrew R. Robinson, 1894

In retailing, the old adage for success is to train your employees that the customer is always right.  In healthcare we have all heard that practitioners are trained to first do no harm.  And in real estate the three most important pricing factors are location, location, location. In our complicated health care system where reimbursement policies increasingly consider the quality of patient outcomes and satisfaction, it turns out that modern hospital managers may be wise to pay attention to all three philosophies.

 In a recent article[i] exploring how hospital characteristics are related to patient experience ratings, I  teamed up with Elyria Kemp, Ph.D.  and Cassandra Davis, Ph.D., a couple of brilliant marketing professors, to analyze hospital survey data.[ii]We used survey data from 2019, so it does not include extenuating influences due to the COVID pandemic, but does allow us to explore how the characteristics of admitted patients and hospital experiences influence the ratings patients give hospitals. In that paper we found that higher hospital experience ratings are associated with the following hospital characteristics:

  • Quieter inpatient environments
  • Better communication from nurses
  • Better patient outcomes from two common inpatient conditions (pneumonia and heart failure)
  • Better attention to care transitions when leaving hospital
  • Serving fewer “at-risk” patients as measured by the Social Vulnerability Index.[iii]

As an economist focusing on human capital issues in the heartland,[iv] I was eager to see if location matters such that  the relationship between hospital attributes and patient experience scores was different for hospitals in the heartland states. There are several reasons the performance of hospitals and patient experience ratings might be different in the middle of the country. Heartland Forward’s recent report on rural healthcare access revealed different employment patterns of healthcare workers in the six states studied. Many heartland states also have lower income[v] and education[vi] levels and higher obesity[vii] and infant mortality[viii] rates than other parts of the country. To see if heartland hospitals were rated differently, I identified hospitals located in heartland states and replicated the analysis from the previous paper while also controlling for whether the hospital is in the heartland.

Here’s what I found:

Despite socioeconomic differences between the heartland and the U.S. as a whole, a similar set of hospital characteristics are associated with higher patient ratings in the heartland, the relationship between patient experience scores and patient outcomes, perceived cleanliness, and quiet environments were the same as the nation overall.

Several characteristics were not the same, however. A few interesting differences include:

  • Overall, patient experience ratings are lower for heartland hospitals even after adjusting for quality of care and patient characteristics.
  • Good communication from nurses is more strongly associated with higher patient experience scores, meaning good nurse communication raises the patient rating more for heartland hospitals.  Nurse communication seems to matter more to heartland patient experience ratings.
  • Heartland patients may not want to hear as much from doctors or about medications. Hospitals with higher scores on good communication from doctors or hospitals that always tell patients about medications when administered have LOWER patient experience scores.
  • Heartland patients value good discharge instructions more than patients in other states. Greater understanding of care responsibilities after leaving hospital are associated with higher patient experience scores in the heartland states, but not for the nation overall.

These differences raise some interesting questions. The differences in nurse and doctor communications might be the result of more care being provided by nurse practitioners and nurses of all levels  in the heartland. Patients may value communicating with nurses more and be less comfortable communicating with doctors in general. It’s also possible that patients who have more information about health and medical conditions overall are the patients most likely to understand the information shared by doctors and also the most likely to have higher hospital experience expectations.

Hospitals may want to consider the roles different personnel play in best informing patients about their condition and treatments as they are administered. Some patients may prefer to have a nurse in the room to help explain or interpret treatment information shared by physicians they are less comfortable with.

The higher value on discharge instructions may be related to heartland patients having to travel further for hospital care.  Once they are discharged, getting in touch with the hospital physician or staff may be a more involved and inconvenient experience, so they value detailed and clear discharge instructions more than patients who have hospitals close to home and are seen by a provider they already know while admitted.

Of course, these are just educated guesses as to why heartland hospital results are different. We can’t know with certainty based on hospital patient survey data alone. To the degree that patients may have different expectations in different parts of the country, better understanding of these differences is an important consideration if we are to close the gap in health outcomes. Additionally, our data is based on survey responses of patients hospitalized  in 2019, pre-COVID, and patient expectations of hospital experiences may have been fundamentally altered during the pandemic in ways that will only be known as we continue to explore data over time. Heartland Forward is committed to conducting good research on issues that matter. We will contribute to our collective knowledge of how Heartlanders care for themselves and each other to best inform the programs and policies needed to help us all thrive here in the middle.


[i] Journal of Healthcare Management 68(2):p 106-120, March/April 2023. | DOI: 10.1097/JHM-D-22-00147

[ii] Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (2019). HCAHPS survey. https://www.hcahpsonline.org/globalassets/hcahps/survey-instruments/mail/april-1-2019-and-forward-discharges/2018-2019_survey-instruments_english_mail_omb-expiration.pdf

[iii] Centers for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry/ Geospatial Research, Analysis, and Services Program. CDC/ATSDR Social Vulnerability Index 2018 Database.  https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html . Accessed on June 23, 2021.

[iv] The Heartland region consists of 20 states including: Alabama, Arkansas, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, and Wisconsin.

[v] https://www.census.gov/library/visualizations/interactive/2019-median-household-income.html

[vi] https://www.zippia.com/advice/most-highly-educated-states-in-america/

[vii] https://www.cdc.gov/obesity/data/prevalence-maps.html

[viii] https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm