There is no element in patient experience more universally implemented and reviled than scripting. Frankly, I have avoided writing about it because people have such strong entrenched positions on it that I am not sure I can say anything about it that will resonate. But like so many things, it is widely discussed and poorly understood. It is treated like a boogeyman. But, since its actual meaning and execution varies so widely, I think it is more like the Dread Pirate Roberts of patient experience work. As my Princess Bride fans know, it’s the name strikes fear, even as the actual person changes.
Before launching into a discussion of scripting, a brief definition or description of scripting for my readers who are not deeply entrenched in the lingo of healthcare is in order. As I intimate above, scripting can take different forms and executions, but it is essentially telling a clinician how to talk to a patient about various elements of service in the hospital. It can be something as simple as having people answer phones with, “This is General Hospital’s 5West unit. I am Joe. How may I assist you today?” or ending conversations with patients by saying, “Thank you for trusting General Hospital with your care today. If there is anything else I can do for you, please let me know, as I have time.” They can also get a bit more complicated, by stressing a list of specific things. For example, when a patient arrives on an inpatient floor, the first nurse to visit the patient may be instructed to go through how the TV works, how to push the call light, how meal service works, how to adjust the blinds, or any other comfort concern a patient may have. Some scripting may have specific lines to be repeated. Others may come simply as talking points, where the actual words that a clinician uses are not written out, so much as simply making sure that certain topics are covered.
This seemingly simple, even innocuous, thing is hated more by frontline staff than anything else I have ever asked a clinician to do in the service of experience. But, why? We ask staff to hourly-round. We ask them to narrate care. We ask them to introduce themselves and sit down when appropriate. We ask them to do a hundred things, some clinical, some experiential, some a combination of both. And nothing generates more push-back than giving them lines to read.
Some will say that it is the prescriptive component that they don’t like. People don’t like being told what to say. The popular criticism voiced is “You want me to sound like a robot.” Clearly no one wants you to sound like a robot. Giving scripts is not intended to make you sound like a robot. In case you aren’t aware, most of the actors on TV and in movies are not speaking extemporaneously, they are delivering lines written by someone else. Outside of Keanu Reeves, none sound like robots.1 So, reciting lines written by someone else designed to deliver a message does not have to be robotic.
Plus, as I said in the essay on staging, all employment is acting. Everyone has a job that requires you to set aside your personal problems, the petty annoyances at work, and the fact that this customer is asking you the same question you have answered a dozen times already today. We are supposed to move past our emotional response and instead deliver an interaction will mollify and reduce anxiety.
Moreover, there are plenty of things clinicians are forced to say. It feels like half of the conversations I have with nurses or doctors are based upon clear protocols, clinical best practices or legal responsibilities. Medicine reconciliation2 is not just the least interesting conversation-starter a nurse can think of. They are obligated to go through this. I have had conversations with clinical staff about how boring this is or asking me how to jazz it up a bit, but I have never had anyone complain that it makes them sound robotic, even though it is probably the MOST robotic conversation I ever have with a clinician.
There are no complaints about the forced scripting when it comes to telling a patient to ask for help rather than trying to get up and go to the bathroom themselves. I have not had anyone argue that going through an informed consent document or interpretive services waiver was overly prescriptive. So, why, again, does this form of scripting cause ire?
Part of the problem, I think, is that these prescriptive things are not legally required. They may not like having to go over discharge instructions or a consent form, but they know the reasons for it and so they comply. This feels like busy work for something that really isn’t that important in the realm of healthcare. It is doubly-cursed when it feels fake or gimmicky. I will agree with some of this. There are scripts that I don’t like because they feel constructed by a marketing team and dedicated to making the hospital look good rather than honestly communicating with a pateint.3
For example, I don’t like lines like, “Thank you for choosing General Hospital…” because it assumes that the patient chose you, instead coming to you because you are the only health system in-network for their insurance, or because you are the closest emergency room. Maybe I am alone in this, but I dislike it when people thank me for something I did not choose to do. So thanking me for choosing the clinic that is under my insurance, and I have been going to for ten years seems silly.4 Having said that, though, there are lines, like “thank you for coming in today” or “you were right to come to us today” that can validate a patient and their decision-making and, in doing so, reduce their defensiveness when you tell them what they need to do to take better care of themselves.
I also think that there is something inside of us that takes offense at being told what to do, especially when we think that we have been doing it already. “Oh, Joe, thanks for telling me to explain how the TV remote and call-light work. Because before, I was just tossing the remote at them and then punching them in the face. Thanks for telling me that this is not what we should be doing.” I might be more irritated at this, if it were not for the fact that I also suffer from this response. It was like, in college, when the professor would lecture the class on how attendance was important. Um, dude, the only people hearing this message are already IN ATTENDANCE.
This comes down to how we are instructing the scripting. If your first comments are “This is what you need to do” you will turn off your audience. Instead, you need to start off with a more welcoming message, akin to, “I want to talk today about something that almost all of you are doing in some form already. I simply want to codify and clearly state some key points of communication. This isn’t to say many of you are not already doing this, but simply to stress how valuable it is to reduce patient anxiety and even reduce the number of call lights you need to respond to.” Yes, these are more words. My father will quickly point out that my motto is why use five words when seventeen will do? But you can see that by acknowledging that the point is not to get you to do something new, but simply to standardize the work you are already doing, you can placate the petulant five-year-old in all of us.
I think the other reason that clinicians push back at some of this is more healthcare-related. Telling them how to tell patients about the importance of using the call light makes sense, as a patient might not understand that. Giving them a checklist on prepping for a conversation is valuable, because in the middle of the conversation, they might forget an important step. But giving them scripting on how to be nice feels like you are telling them that they are not human. Someone in IT may have enough self-reflection to know that they are not naturally engaging in interactions with fellow humans and could use some tips.5 But healthcare workers, clinical staff and non-clinical staff alike, often take pride in their career choice that highlights their compassion to other humans. So, giving them scripting can be taken as an insult that they insufficiently caring to have come up with this on their own.
When I discuss scripting, I focus on three core elements to increase the likelihood of acceptance by staff.
- I will talk about the key messaging and purpose before addressing any scripting. By stressing the value of anxiety reduction and fewer call-lights, I am connecting this to purposes they can relate to. By personalizing the creature comforts, I can connect the scripting to important elements of care. Imagine being blinded by the setting sun and not being able do anything about it. Imagine your family coming into the room to talk and not being able to mute or turn off the TV. This is the reason behind the training.
- The work feels easier than it is. The challenge is not that you can tell me in a training session about the TV. The challenge is to do this seven times in quick succession as patients hit the floor. All of this communication is easy until it isn’t. It isn’t that you are not doing it, so much as trying to help you remember when a thousand other things are competing for your attention. It is more about muscle memory rather than learning new skills.
- In the end, the words are optional. The sentiment is mandatory. If you already have your patter down, I am not telling you to change it. I might suggest you add things that you are currently not covering, but I am never going to tell you to supplant my words for your words. My only request is that you understand the purpose, so you can deliver meaningful communication.
When approaching an audience with scripting, stress the patient’s perspective and expectation. For example, think about the last time you called a business, and the person answered the phone with a simple “Hello?” If you are like me, your first thought was, “did I just dial a wrong number?” There is an expectation that when calling a business there will be an introduction. Hospitals can be even more complicated, because that caller may have gone through two or three transfers to get to the number you just answered. Starting by flipping the conversation around and asking them to think about when they have been a customer or patient is a great way to solidify the purpose of your training session.
In the end, identifying and training in core competencies is critical before trying to add any embellishments on the work. Too often, we want to avoid the conflict on scripting by focusing on other elements. But without this clear cadence, those other things won’t be effective. You can add new coat of paint to an old barn, but it won’t prevent it from falling down.
1Sorry, Keanu, for catching collateral damage here. I was going for a humorous observation. I really like your movies. Of course you will likely never read this, so it doesn’t really matter.
2Medicine reconciliation is that thing where every time you go to the doctor, the rooming nurse runs through all the medications you have been prescribed to determine if you are still taking them, including any over the counter medications or vitamins you are taking. Since it is meant to be comprehensive, even a short list can feel like an exhausting quiz.
3Marketing is now getting shade as well. I am making new friends everywhere I go.
4Oh, and don’t even get me started on the “Thank you for your patience…” line, said when you are making me wait for something that should not take this long. Please do not thank me for something I have not given you. I interpret it as passive-aggressive and it makes me less patient.
5Come on, now! IT as well? Is there no one that I cannot denigrate in a 2000-word essay?
PX Matters with Joseph Snipp 
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