Listening better to the experiences of staff, as well as patients and their relatives, is imperative for improving the patient experience, writes Jill Maben
Following the publication of the Francis report, NHS trusts will be keen to learn from Mid Staffordshire and to implement the inquiry’s findings to consistently improve the experience of patients in their care.
As a system, the NHS needs to listen better to patients and their relatives and act upon their stories and complaints. It is also imperative that they listen better to the experiences of staff. Mid Staffordshire shows us that staff wellbeing can act as an early warning sign, and individual stories and complaints can be red flags.
‘Wellbeing at work means much more than physical wellbeing and includes individual’s subjective experience’
Research suggests that situating staff experience (as well as patient experience) centre stage may be one of the best things senior leaders could do.
A study led by the National Nursing Research Unit at King’s College London identified variation in patient experience within trusts and suggests this is significantly influenced by staff wellbeing at work and work experiences. Published ahead of Robert Francis QC’s report, the research echoes some of the key issues he identified.
In environments where staff reported high demands on their time; little control over how best to meet those demands; where there was a culture of harassment and bullying; where there was little investment in the local team; and a situation where unsupported leaders tried to implement change but then left after a short time, leaving staff with a constant stream of new managers or none at all, staff were not enabled to provide high quality care for a range of patient groups.
Previous research has tended to focus on single aspects of staff experience or one staff group. Few studies have directly examined the relationship between staff experiences of work and patient experiences of care at the team or individual level.
Associations between various aspects of staff wellbeing and patient experience have been reported, mostly at whole-hospital or systems level. For example, the national staff and patient surveys have been compared and the national staff survey has been compared with various patient outcomes.
Our study was carried out in the English NHS and explored the links between patients’ experiences of healthcare and staff experiences at work, including staff motivation and wellbeing.
‘Staff in many settings told of high demand and low control over their work, leading to emotional exhaustion’
These were identified and measured at the team or unit level − whenever possible matching staff and patients individually to test associations between staff and patient experience. In this study, wellbeing at work means much more than physical wellbeing and includes individual’s subjective experience and functioning at work including job satisfaction, positive and negative affective reactions (feelings and responses) at work, motivation, emotional labour and issues of emotional exhaustion and burnout.
The study set out to examine if and how it differed between different clinical areas – with different patients, different nurse staffing and different degrees of emotional labour and different time available to staff to build relationships with.
Different areas for our eight case studies in four different trusts in England were selected − four acute case studies (emergency admissions unit; maternity service; care of older people and haemato-oncology) and four case studies in the community (two adult community nursing services; a community matron service and a rapid response team).
Our study involved more than 200 hours of direct care observation, more than 500 patient surveys, 100 patient interviews, interviews with 55 senior managers and surveys of more than 300 staff and 86 staff interviews at four different trusts in England.
Patients vividly recalled their own and other patients’ experiences, which focused mainly on the relational aspects of how staff interacted and cared for them; promptly, with kindness and compassion.
‘Seeking systematically to enhance staff wellbeing is not only important in its own right but also important for the quality of patient experiences’
In elderly care and acute admissions, community nursing service and rapid response we consistently found poor relational care and staff largely failing to “connect” with individual patients.
Staff in many settings told of high demand and low control over their work, leading to emotional exhaustion, stress and burn out for some.
High job demands had an adverse effect on staff wellbeing and were associated with significantly higher levels of exhaustion and reduced job satisfaction.
Other staff felt well supported by colleagues and managers and suggested this buffered some of the external pressures exerted by managers and the challenges of day to day patient care.
Therefore we found various forms of support at work have a strong effect on wellbeing. Social support from supervisors, co-workers and the organisation more generally have a positive effect on wellbeing by helping to reduce exhaustion and at the same time enhance satisfaction and positive affect at work. Analysis of our staff and patient experience surveys indicate seven staff variables that are linked to good patient-reported experience. These are:
- a good local team/work group climate;
- high levels of co-worker support;
- good job satisfaction;
- a good organisational climate;
- perceived organisational support;
- low emotional exhaustion; and
- supervisor support.
Examining older people’s acute care in more detial, we explored the implications of allowing “rational and competent” staff to reach a stage of defensiveness, which can cause them to distance themselves from the compassionate side of care as a means of self defence against the “guilt, low morale and frustration” they feel at their inability to offer good patient care.
The paper, called Poppets and Parcels, also points to the differential levels of care experienced by patients on the same ward from the same staff. Part of this, we argue, is about staff seeking to alleviate the difficulties they face when caring for ill, older people.
Drawing on the unpopular patient literature, we argue they do this by finding personal satisfaction from those patients they enjoy caring for and for whom they are able to make a difference(“the poppets”). Other patients − noting dehumanising aspects of their care − felt like parcels.
The paper identifies a range of possible contributors to poor quality of care:
- The particularly high inherent demands and challenges of caring for vulnerable elderly people compared to 10 years ago. The challenges of recruiting staff to a service area often regarded as basic and low esteem where the number of confused and aggressive patients leads to higher levels of physical violence from patients and greater demands than other areas of care.
- Inadequate or unpredictable staffing levels, movement of staff at short notice and lack of, or inadequate, training in specialist skills such as managing dementia and delirium.
- The “senior management failure−– while appearing supportive − [of] not really wanting to listen to the complexity of the problems staff encountered on a daily basis”.
- The local work climate with ward leadership, co-worker relationships and a strong sense of team being key to driving high quality care. On the latter, there were a range of complex factors, including “fissures between qualified (registered nurse) and unqualified staff (healthcare assistants); staff from different cultural and ethnic backgrounds; and staff who practiced or experienced incivility and bullying”.
The study strongly suggests there is a relationship between staff wellbeing and various dimensions of staff-reported patient care performance and patient-reported experiences. Seeking systematically to enhance staff wellbeing is, therefore, not only important in its own right but also important for the quality of patient experiences. Therefore, it is important to invest in and support individual staff wellbeing at work in order to enable staff to better deliver high-quality patient care.
‘A strategic approach to improving staff wellbeing is likely to have a positive impact upon patient care experience’
NHS organisations should consider how best to target their limited internal resource in areas that are known to be problematic either in terms of low patient experience (using complaints or real-time feedback) and/or poor staff wellbeing (indicated by high sickness absence, reports of bullying or disciplinary issues).
Also, how best to disseminate the learning from those areas that have good patient experience and high staff wellbeing and are known to be places where staff want to work (such as by linking specific wards through buddying of ward mangers to help challenge and transfer learning from one to the other), and also how to enable team leaders to invest time and energy in team building activities to benefit patient care delivery.
Finally, our study suggests that in order to enhance staff wellbeing NHS organisations should invest in unit level leadership and supervisor support (for example, ward sister level in acute and team leaders in community care) that promotes good team working and supportive peer relations. We further suggest:
- Senior leaders need to recognise the importance of the team, and the team leader role in supporting and nurturing staff, in building a strong climate for patient care. Local leaders have a critical role in setting expectations of values, behaviours and attitudes to support the delivery of patient-centred care.
- Supportive local leadership and supervision needs to be put in place for every member of staff.
- Reports of high sickness absence are indicative of the context of the ward or team climate. Individual (stress; injury), team (lack of support; bullying), organisational and wider staff experience issues need to be monitored regularly and seen as a barometer of staff wellbeing issues that affect patient care quality.
- An agreed minimum dataset for NHS staff experience and wellbeing is critical to effectively using staff wellbeing and staff experience as an early warning system.
- A strategic approach to improving staff wellbeing is likely to have a positive impact upon patient care experience and we suggest issues such as high sickness absence need to be highlighted at board level and measures taken through organisational development departments to improve and manage them.
- Boards embed staff stories and patient stories into its core business and acts upon them. The appointment of a board executive “champion for staff health and wellbeing” is one way of ensuring staff experience and wellbeing gains greater prominence in NHS trusts.
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Professor Jill Maben is director of the national nursing research unit, Florence Nightingale School of Nursing and Midwifery, at King’s College London. The project was funded by the National Institute for Health Reasearch health service research and delivery programme. The views expressed are the author’s own.