How patient and staff experiences affect outcomes

Introduction

Thinking about how patients actually experience care is fairly new, in an academic sense. Of course nurses have always done this, but patient experience only became part of our approach to quality with Lord Darzi’s Next Stage Review (Department of Health, 2008). As a result, it is still less understood than other established dimensions of quality, such as clinical effectiveness and safety. Experiences of care are something we all inherently understand and yet may find difficult to define. One reason for this is that our workplace is so familiar to us we may forget what it feels like to patients encountering it for the first time, when they may feel frail and vulnerable.

Wolf et al (2014) define patient experience as the sum total of all interactions a patient has with the service, not just the clinical encounter. For example, whether they can find their way to the right clinic, are expected there and how they are welcomed are important factors that will influence how comfortable patients feel.

Patient involvement and good communication also affect clinical outcomes and safety (Doyle et al, 2013). If patients do not feel involved in decisions about them, they are much less likely to follow advice given. The mantra “no decision about me without me” is small but full of meaning: if people do not understand what is happening, they will be less safe and are less likely to have gained from a clinical intervention (Doyle et al, 2013). As an example, poor communication at discharge is a well-known factor of readmission.

Patients’ perspectives

We must look at our services from the patient perspective. The Friends and Family Test has helped provide valuable insights; more than 3.7 million pieces of patient feedback have been received since the FFT has been used nationally. Teams around the country have made countless improvements by reading patient comments and acting on them. For example, disturbed sleep has been reduced with the introduction of soft-closing bins, breastfeeding support has been improved for new mothers, drug rounds have been improved and visiting times extended. Some of these may seem small but every experience counts to patients - a point also highlighted in the #hellomynameis campaign (Box 1).

Vulnerable patients

We need to take extra care to understand the experiences of our most vulnerable patients. Perhaps this is what is most unique about the NHS approach to patient experience: while colleagues in the US have been inspired to emulate the customer service standards of brands such as Disney and Starbucks, the NHS has sought to improve the lives of its most vulnerable patients, for example children, frail older people, those with dementia, learning disability, deafness or blindness. It can be harder to know what experiences are like for these groups but there is no substitute for asking. An example is the Quality Partners Network by Inclusion East CIC (tinyurl.com/InclusionEastCIC), a user-led assessment service by, and for, people with learning disabilities, which won a Participation Award at the NHS Expo this year. The awards celebrate contributions that are transforming and improving services.

User-led assessments are schemes inviting service users to check the quality of a provider or neighbouring provider’s services. NHS England aims to build on this and encourage more such assessments. It is also working with people with visual and hearing impairments to extend the Patient-led Assessments of the Care Environment to cover disability (NHS England, 2014a). By working with patients and service users and letting them judge care quality, we can address the issues that matter most.

Staff experience

Staff experience is the best predictor of patient experience (Point of Care Foundation, 2014). The best way to deliver consistently compassionate care is through empowered teams working in partnership with patients, being encouraged to improve practice and recognised for providing moments that patients value - moments as simple as holding their hand when they are in distress, helping them wash and feel composed, being there when they are afraid or in pain, showing empathy and human connection at times of suffering.

It is important for people at all levels to recognise that good staff engagement is related to patient satisfaction, safety measures, absenteeism, turnover and even mortality rates (Dawson, 2014). Getting this right is “core business” for health services. Organisations know it is not enough for staff to “feel” included; if care is to improve, staff must be able to participate in the creative process and have a strong voice when issues arise. We are seeing many different approaches to staff participation: Nottingham University Hospitals Trust, for example, has the Better For You programme that includes a Just Do It scheme, which encourages staff to try out their ideas.

The 2013 NHS Staff Survey (tinyurl.com/staffsurveyreport) showed staff feel increasingly engaged in their jobs and more confident to report concerns. The first results from the separate staff Friends and Family tests are just as encouraging: 76% of staff said they were extremely likely or likely to recommend their organisation to friends and family in need of care/treatment (NHS England, 2014b).

The NHS Staff Survey did also identify some areas of concern (such as the levels of abuse, bullying and harassment staff receive), but there is evidence of improvements in staff experiences and how staff relate with patients. New developments, such as the Freedom to Speak Up review, aim to create an open, honest reporting culture in the NHS, which should help cement this progress (freedomtospeakup.org.uk).

Staff wellbeing

Staff stress from challenging workloads can have an impact on staff engaging with the job and patients, so comprehensive health and wellbeing policies have expanded rapidly. By January 2014, 562,723 staff across 115 trusts were covered by these, compared with 275,421 from 70 trusts audited in 2010 (Royal College of Physicians, 2014).

Many managers lack confidence when responding to concerns relating to stress or mental health, so work is under way to help resolve this gap. NHS staff sick leave continues to fall but could be further reduced if wellbeing became a prominent feature in more organisations’ business plans.

Recruiting the right staff

There is an effort to recruit people who have positive and appropriate values into NHS roles. This spans everything from outreach into schools to developing a single framework for employers and universities. NHS Employers, NHS England, Health Education England, Local Education and Training Boards and others are all involved in fairly new and ambitious schemes to help the NHS recruit the right people. NHS Employers is working with HEE to deliver training packages that help trusts to seek the right values in job interviews. The two organisations are also working together to provide good-practice guides, mapping tools and a checklist.

Conclusion

We interact with patients, colleagues or managers a thousand times a day at work and we have an opportunity to create better experiences for everyone through each of these moments. We cannot make the NHS more compassionate simply by asking nurses to comply with initiatives or programmes, but we can if we work with nurses’ motivation to make the quality of care as good as it can be, especially for those who need it most.