Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Communication and Information



First Advisor

Derek R. Lane


For more than a decade, hospital leaders have focused on boosting patient experience scores as part of the federal government’s value-based purchasing (VBP) program. Hospitals that receive federal financial assistance (such as Medicare) are mandated to participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a standardized survey that measures patients’ perceptions of their care. Results are publicly reported, and hospitals may be penalized on their reimbursements if they do not reach established benchmarks for patient experience. However, much debate has occurred about whether VBP has increased the quality of healthcare and whether the HCAHPS is an accurate measure of patient experience. Nurse managers on inpatient hospital units are, for their part, the ones held accountable for their units’ patient experience scores, which are scores that they often cannot control. This dissertation project is a qualitative exploration of how such accountability impacts nurse managers. With structurational divergence theory (SDT) as a framework, the study seeks to gain a deeper understanding about gridlock that exists and the resulting negative spirals of communication that occur when patient experience expectations by hospital leaders conflict with the needs of nurses on the frontline. Findings of this research suggest that the pressure to earn optimal patient experience scores is, by and large, a source of stress to inpatient nurse managers. Furthermore, findings reveal that opportunities exist within hospital organizations to enhance communication processes about patient experience, with the overarching finding being a need to better communicate to frontline staff the “why” behind the rationale for working toward patient experience goals. Also, findings indicate that expectations by hospital senior leaders to meet established patient experience goals can create conflict for nurse managers who are often caught in the middle between satisfying organizational goals and tending to the needs of frontline staff. Such conflict can spur a reactive work approach that is task- oriented and impedes the visualization of patient experience as a holistic concept. Several recommendations are offered to address issues from macro (policy), meso (organizational), and micro (nurse manager) levels. Additionally, this dissertation proposes an expansion to SDT. Ultimately, the research deduces that hospital organizations should work toward a more holistic consideration of patient experience, in lieu of an intense focus on patient experience metrics. This includes honing mutual understanding and embracing communication processes that will facilitate collaboration, rather than polarization, among organizational structures.

Digital Object Identifier (DOI)

Funding Information

This study was supported by a patient experience scholar grant from The Beryl Institute in 2022.