Being Nice is Not Enough

I have written several essays where I have referenced some version of “Being nice is not an action plan.”  I thought it was time to explain why I said this.  It is not that being nice isn’t valuable or useful or that we shouldn’t try to be pleasant to people around us.  The problem is that “be nice” sounds reasonable, but is unfocused, and is unlikely to generate the buy-in or impact that we think it will.  We think that by keeping the message simple we will get more compliance, but it is too dumbed-down to be effective.  I agree that an action plan should be simple to implement, but simplicity should be with a focus on compliance; simplicity for simplicity’s sake is not useful.  Moreover, it is chasing a goal that may not be that useful.  Here are the reasons why being nice makes for a poor action plan.

Being Nice is a Precondition

What do I mean by being nice?  Well, that question contains within itself the problem with this model.  Most focus on niceness is a response to us seeing staff being rude to patients, so the desire is to create a plan to stop rudeness.  I have often talked about the fact that many action plans won’t work until we first “stop punching patients in the face,” so I agree with the concept that people need to be more courteous and less confrontational.  But, when I say this, I am saying that being civil, polite, nice, and courteous are table-stakes.  They must be present before any other work can be successful.  Unless we have that core principle locked down,¹ we won’t succeed at any other effort to improve scores.  If people are not being nice, nothing else will work.  It needs to be a precondition for any other action plan to work. 

Nice is Relative

One core thing that I taught in class and discussed in presentations is that definitions matter.  Words have meaning.  This is probably obvious when talking about democracy or statistical significance.  It is difficult to have a conversation about consequences, if you don’t agree on how to define the words we use in discussing those consequences.  But we often skip over some words whose definitions seem obvious.  After all, we can all agree what nice means, right?  Except that we can’t.  Consider this scenario.

A patient was diagnosed with an unusual form of cancer.  The patient was informed that the best-case scenario is to try and stop further progression, as the patient will never really be cancer-free and the mobility/dexterity that they have lost will never return.  Over three years, various efforts have been made to stop its progression.  Some have been successful for a while but lost their efficacy.  Others were successful but caused significant side-effects and had to be stopped.  Still others had no impact at all.  The most recent attempt at treatment has not been successful and two new lumps have been detected.  The patient is in their 60s, so they have had a long life, but certainly have interest in continuing to live.  There are always additional chemo-cocktails to try, as well as additional radiation as an option.  As anyone confronted with these options knows, these call carry with them the balance of quality-of-life vs quantity-of-life concerns.  There are also palliative care and hospice.  You must talk to the patient about next steps.  In this situation, what is NICE? 

• Is NICE keeping all options open?  Is it telling the patient that every failure gets us closer to success?  That there is always another process, drug, or procedure to try?  They should never give up hope that a solution exists?
• Is NICE providing an honest evaluation?  We have tried the things that were most-likely to work and they haven’t.  We can try more things, but each of them will have an incrementally less-likely ability to work plus provide incrementally more discomfort.  Perhaps it is time to consider more quality issues than quantity issues.

Some of you may leap to one of the two options.  Some will pick one option but acknowledge that the other could be reasonable as well.  Still others will seek to dodge the question with an “it depends.”  It depends on the mental state of the patient.  It depends on what the patient has said they have wanted in the past.  It depends on how far from home the patient would have to travel to get some additional treatment.  It depends on the financial stability or quality of insurance coverage for the patient.  It depends on the mental capacity of the patient to make reasonable decisions about their own life. 

This scenario and your response illustrate the problem with defining nice.  Who is judging what nice looks like?  Doctors often carry the stereotype that “tough love” is the only love they understand.  Speaking in clinical, logical, emotionless terms is the only way to navigate the conversation.  Of course, this is also often described as rude or disrespectful or even supercilious by observers.  On the other side, some patients want the unvarnished truth while others want everything colored with a level of optimism.  We cannot define nice without picking a side and a perspective, neither are one-size-fits-all.

It is true that without knowing a lot of surrounding information, it is not possible to really determine which of the responses is appropriate and which one is rude.  Nice and rude are relative terms.  They have confusing definitions and little value in healthcare.  One patient’s “rude” is another clinician’s “speaking plainly.”  One patient’s “nice” is another clinician’s “giving the patient whatever they want, regardless of its medical necessity.”  So, even if you watched the interaction, it would be hard to determine if the physician’s response was nice or rude. 

Nice Cannot be Action-Planned

All action plans, regardless of whether they address service issues, quality issues, housekeeping issues or any other issue, need to be concrete.  People need to know whether they are doing the right thing or not.  They need to know what triggers an action plan and when they have completed successful implementation. If you cannot outline what the proper process is, people will not be able to do what you want and you won’t be able to track and trend progress. 

If we treat being nice as an action plan, we have no triggering event.  When should people be nice?  Um, always.  Or the second they punch-in for work.  Maybe you immediately see that this approach won’t work, so you suggest that the triggering event is “every encounter with every employee, patient or family member, regardless of whether it is face-to-face, via email or telephonically.”  Of course, in reading that, you know that it is just “always” with a lot more words.  If an action plan is always ON, it is extremely difficult, even impossible, to evaluate compliance and track progress in implementation.  This fails the check-list test.  That is, if you want to track performance, imagine holding a clipboard with an evaluation sheet where you will be checking boxes while watching an interaction.  Now, what is on that check-list?  How will you score people?  If your list of behaviors to observe is double-digit and your scoring scale is YES/ NO/ IT DEPENDS/ KINDA, then you have a crappy tool for evaluation.  It is too subjective and imprecise.  It fails the check-list test. 

Nice Has No Goal

Everyone had a grandmother or teacher who said that “Being nice is its own reward.”  This is true, at least in the sense that being nice will not always make life easier nor will it always lead to better outcomes.  You do it because it is the right thing to do and even if it is not returned by the other person.  In fact, looking for some preferential treatment based upon your niceness is being manipulative which challenges the very essence of being nice.  The best reason for being nice is, at least in my experience, that it doesn’t create more problems.  That is the best one could reasonably expect.  The nicer you are now means the less you have to apologize for later. 

But if being nice has no tangible goal, then how do you know if it is working?  Again, please let me stress that being nice is laudable.  It is table-stakes.  By saying it has no measurable goal only means that it is not valuable as an action plan target.  It has intrinsic value, as does being honest or doing one’s best, which are also things that have vague definitions and limited expected goals.²

Nice as Limited Up-Side

After a lot of words on the inability to build a useful action plan to operationalize niceness, we need to examine whether it actually has any value in the first place.  I will certainly agree that being nice can avoid creating additional problems.  Being wrong and a jerk is worse than simply being wrong.  Being right and a jerk seems to have some currency in our on-line universe, but that doesn’t mean it is better than simply being right.  Being nice is always in the service of some other social interaction.  If that interaction is positive or neutral, being nice is, well, nice.  The challenge is that many conversations in healthcare contain charged language or difficult decisions.  Even though most encounters are not life-threatening, they can still be difficult to navigate.  Take something as straightforward as a discharge plan.  Since half of the patients think that you are discharging them too early and the other half think you are discharging them too late, that conversation about when they get to go home can get complicated.  Being courteous in those conversations is certainly valuable.  But if the final decision is not satisfactory to the patient, that niceness doesn’t matter.  If a patient feels like they are not being heard, or they feel that their personal property has been damaged or are concerned about whether their loved one received appropriate treatment, having a clinician or patient advocate being nice will not address the underlying concern.  It may not make it worse, but it won’t help make it better.

People Want Help Not Empty Courtesy

I just said that being nice won’t make a situation worse, except that sometimes it can.  Not only does nice not have much up-side, if people think that niceness is a façade, it can have a down-side.  The point of most interactions, especially consumer interactions, is not to have a pleasant conversation, but to get some issue resolved.  When the person being nice cannot resolve an issue, it almost feels like the niceness is a manipulative ploy. 

I cannot be the only person who as a customer has experienced this niceness as a replacement for actual assistance.  You can tell me:

• Your call is very important to us…
• Thank you for your patience…
• Thank you for being a loyal customer…
• I am sorry that this happened…
• Let me see what I can do…

But at the end of the experience, you cannot rebook my flight, honor my reservation, or do anything about the extra room service charge because I asked for two more towels, your niceness means nothing to me.  In fact, I find it patronizing and annoying.  Likewise, while it is important for financial services not be rude to a patient calling about a bill, if they cannot provide a useful explanation or provide patients with a next-step with their concern, that nice even tone can be infuriating because it just feels like corporate-speak. 

Let me end where I started.  Being nice should be a goal for all human interactions.  Everyone deserves to be treated with basic human decency.  Especially with those who we disagree with, since it is so easy to paint them as a caricature.  But any organization that makes being nice as the cornerstone of their service plan will fail.  It is not a useful end in-itself, and staff will not know how to be nice, or will define nice using their own terms.  Patients deserve courteous treatment, but demand so much more than that bare minimum.  If you are struggling with that basic level of human decency, you have more pressing issues than an action plan to improve service. 

¹But how do we get people to be nicer?  That is a subject for another essay, as not surprisingly, I have thoughts on that.

²For those who push back on honesty not having a clear definition, I would ask if you really want to know if those pants make your butt look big, or if your child’s prowess at piano-playing or sports is really that impressive.  If you think all “honesty” must be brutally accurate, then I hate to inform you, but everyone thinks you are being a jerk.