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Nurses not only ones 'at fault' over patient experience

Nurses should not be held solely responsible for patient experience, one of the country’s most senior nursing figures has warned as ministers press ahead with new plans to rank hospital care.

Poor results from the new “friends and family test” should not be seen as entirely  the “fault” of nurses, according to Sally Brearley, chair of the Nursing and Care Quality Forum – set up in 2011 to advise the prime minister.

New health secretary Jeremy Hunt has championed the national roll out of the friends and family test as a way of driving up standards in quality of care, with organisations competing to perform well against it.

Under the test, inpatients who stay overnight in an acute hospital and patients treated in accident and emergency will be asked whether they would recommend the care they have received to their friends and family.

Scores on the test are calculated by deducting the number of respondents who would not recommend a service from those that would, and range from 100 to -100. Results will be published in a hospital league table.

The test, due to come into effect from April, is also likely to form part of the Ofsted style ratings system that Mr Hunt also wants to introduce for healthcare providers.

But Ms Brearley, a former nurse, told Nursing Times the way the test was being discussed by the government implied that the results were all down to nurses.

For example, she highlighted a previous announcement that trusts performing well against the test could be let off repaying government loans to buy new technology designed to free up nursing time.

Ms Brearley said: “It implies the results are all down to the nurses, which is not the case, and if we do poorly on the friends and family test, it’s the fault of nurses.”

A version of the test is already in use for hospitals across the NHS Midlands and East region where it was first developed.

Nottingham University Hospitals Trust scored 61 against a regional average of 68 in the latest round of results in October.

Anne Crompton, the trust’s corporate clinical lead for patient experience, told Nursing Times the question on friends and family was useful as an indicator of where to look deeper. But the most value for nurses on the wards came from asking patients about why they had responded in the way they had, she said.

Unsurprisingly, she added that initial data showed that positive staff attitude and kind caring treatment were the biggest drivers of good performance in the test. However, she noted that issues such as waiting times – for drugs or transport to go home, for example – were another significant element affecting scores. Such factors are largely beyond the control of nursing.

Mid Staffordshire Foundation Trust scored 51. Its director of nursing Colin Ovington told Nursing Times that, despite initially seeing it as something imposed on them, his nursing staff were now enthusiastic about the test and using the information to drive improvements.

Professor Peter Griffiths, chair of health services research at Southampton University, told Nursing Times it was “very important” that the test was used to get results about specific teams, rather than just at trust level.

“[The test] has been put forward in the context of concerns about nurses and, while nurses are not the only group who shape a patient’s experiences, there is lots of evidence that they are pretty important,” he said.

Ms Brearley’s comments come in a week in which the profession continued to face high profile criticism from the new health secretary.

In a speech interpreted by unions as an attack on staff, Mr Hunt described a “crisis in standards of care” as one of the biggest problems facing the NHS. He said: “In places that should be devoted to the patient, where care and compassion should be uppermost, we find its very opposite; coldness, resentment, indifference to human feelings.”

Separately Mr Hunt also told the Commons he had “some sympathy” with views expressed by a backbench MP that caring nursing had been lost in the move to an all graduate profession.

Readers' comments (28)

  • tinkerbell

    well said that woman. At last a voice in the wilderness talking sense.

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  • i agree tink. We are not the only ones that work in hospital although at imes it feels like that

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  • nurses are always the first to get blamed, if someone has to wait for tto's or transport home you can bet they think it's the nurses fault. In fact if patients have to wait for anything it's always the nurses fault.

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  • michael stone

    Of course things are not 'all the fault of nurses' - oh, for crying out loud !

    'Fault' rests where it should rest - that could be on nurses, or on doctors, or on maangers, or on goverments, or on some sort of 'systemic non-coherence', or on patients or relatives, etc.

    But if nurses are part of the problem they are part of the problem: a inadequate number of nurses/staff on duty is also, it seems, a major part of this problem, and in my opinion you can throw in 'unnecessarily restrictive tick-box guidance written mainly by 'defensive' managers'.

    Grrr !

    PS

    Anonymous | 4-Dec-2012 10:46 am

    I suspect (I'm not there, I not evidence-based here) that nurses often do get blamed fastest - perhaps informing patients and relatives of the actual problems, might prevent some of that ?

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  • tinkerbell

    Whilst no one should argue with the facts and everyone would want to see improved care demonising nursing is not the way to go about it. There are probably countless nurses who raise concerns, a few good whistleblowers who have spoken out and what actually happens. Nothing mostly.

    These nurses have raised concerns about facts and the facts have been ignored swept under a very lumpy carpet in room 101.

    It is a culture change that is required amongst management where concerns are taken seriously and changes made and whistleblowers (let's find another name for them with more positive connotations) are taken seriously rather than hounded out of the profession.

    If there are less nurses, who have to work harder and faster then even more serious mistakes are going to happen.

    Unless serious, dedicated action is taken when things go wrong, there is an even bigger list of catastrophe waiting further down the road.

    Meanwhile the problem will remain and get even worse.


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  • In recent months the CQC has served complaince notices on a couple of NHS trusts for unstaffing and lack of support(outcomes 12&13, CQC Quality & Safety).
    About time that the NHS Trust Boards signed up to the PSA Standards for NHS Managers & CCG'S that way the trial will lead to the CEO office door where understaffing is a issue and where your post reg training/development is cancelled and you are recalled back into work.

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  • transport and waiting for meds to take home are not 'largely' out of nurses control, they are completely out of nurses control. As are most things within the NHS.

    when is this going to stop, we work damn hard, we cannot be held responsible for every single thing that ever happens.

    when are the govt puppets going to stop playing up to the media and get their facts right first.

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  • This is nothing new nurses get the blame for everything. However nurses also need to speak up about things that are not their fault. All problems that I know are not my fault or beyond my control when relatives and friends complain I give them the name, work telephone and work address of the Trust Directors and the complaints department.

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  • Rick Harris

    Reading through the comments thus far, it's clear there is a sense of anger, and of defensiveness too.
    As an outsider ( i.e. I'm not a nurse, but a researcher working with carers and patients with chronic conditions), I think it's the language of 'at fault' which is unhelpful here.

    The friends and family test is not a diagnostic for where fault lies, but simply but one indicator of overall patient satisfaction. When taken with more specific research, it is a useful indicator. Patients do not score high or low without good reason, and it is the role of well designed research to ensure that diagnostic as well as directional data is available.

    PS: you would think that, being so close to a clinical context would make such diagnostics obvious, but apparently not!

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  • Mr Harris,
    You said the f&f test is not a diagnostic for where fault lies.
    Professor Griffiths said the test has been put forward in the context of concerns about nurses.
    Mr Hunt said there is crisis in standard of care. I agree, however, he went on to say in places that should be devoted to the patients where care and compassion should be uppermost, we find it the very opposite; coldness,resentment, indifference to human feelings.
    Anne Crompton said positive staff attitude & kind caring treatment were the biggest drivers of good performance in the test.

    Now this f&f test to me seem to be another attack on nurses.
    I will tell you who is cold and indifferent to human feelings. The people who think it is OK for nurses to work for free and understaffed with a lovely smile, patients to wait forever to get a bed pan because there is not enough staff on the ward. Patients not to get a hot cup of tea because they cut out the tea lady and depend on voluntary people to come in twice a week to help on the ward so the patients can get a cup of tea. One care assistant having to divide themself to assist two nurses with moving and handling as there are not enough carers. The managers doing their own thingh no one supervising them.
    These people who allow these and more terrible situations to happen are cold and uncaring towards humans.

    I also know of uncaring nurses, but the nursing profession just reflect the make up of our society. Look around you, do you find all nice pleasant, helpfull people. NO!
    Don't believe that just because one puts on a nurses uniform they will automatically change into an angel.
    Or should we look deeper into who is recurited and make damm sure they are slim, healthy, fit, hard working and smiley with good white teeth.



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  • Rick Harris

    Reading through the comments thus far, it's clear there is a sense of anger, and of defensiveness too.
    As an outsider ( i.e. I'm not a nurse, but a researcher working with carers and patients with chronic conditions), I think it's the language of 'at fault' which is unhelpful here.

    The friends and family test is not a diagnostic for where fault lies, but simply but one indicator of overall patient satisfaction. When taken with more specific research, it is a useful indicator. Patients do not score high or low without good reason, and it is the role of well designed research to ensure that diagnostic as well as directional data is available.

    PS: you would think that, being so close to a clinical context would make such diagnostics obvious, but apparently not!

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  • Rick Harris | 5-Dec-2012 3:50 pm

    I think that you have rather missed the point. I watched and listened to news reports about Hunt's 'Friends and Family Test'. Regardless of TV/Radio channel, the 'test' was reported almost exclusively in the context of care given by nursing staff. Sally Brearley has recognised that fact and felt the need to issue a warning.

    Let's be clear. The nursing profession in this country is in the middle of the perfect storm. Persistent low (and frozen) pay for the job we do (particularly measured against other professions), a decimation job on our pensions, employers who threaten redundancy unless we accept even poorer working conditions, shrinking staffing levels and a government intent on destroying the NHS. So the addition of a vehicle by which the government can shift the blame for many avoidable problems caused by their shameful policies onto nurses, isn't exactly going to produce smiles and applause all round. The descriptor of 'defensiveness' is puerile and shows absolutely no understanding of the depth of anger and frustration felt by nurses.

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  • Rick Harris

    Reading through the comments thus far, it's clear there is a sense of anger, and of defensiveness too.
    As an outsider ( i.e. I'm not a nurse, but a researcher working with carers and patients with chronic conditions), I think it's the language of 'at fault' which is unhelpful here.

    The friends and family test is not a diagnostic for where fault lies, but simply but one indicator of overall patient satisfaction. When taken with more specific research, it is a useful indicator. Patients do not score high or low without good reason, and it is the role of well designed research to ensure that diagnostic as well as directional data is available.

    PS: you would think that, being so close to a clinical context would make such diagnostics obvious, but apparently not!

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  • Rick Harris

    Anonymous | 6-Dec-2012 5:34 pm

    My comments were made purely in the context of the usefulness and accuracy of research - I have no political axe to grind here (unlike your own comments describing "a government intent on destroying the NHS")

    You say you think I have "missed the point".
    The point I am making is that the F&F test question was thoroughly researched by the CQC and the Picker Institute Europe, and developed after rejecting the initial Net Promoter style question. When taken along with other measures, this is a useful piece of data.

    For those that are interested in improving the patient experience, this kind of data should be welcomed.

    http://customerfaithful.com/net-promoter-score-fails-its-first-test-in-nhs/

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  • Rick Harris | 6-Dec-2012 6:46 pm

    No. You are still missing the point. Ms. Brearley and others here have picked up on the fact that the F&F test will not be taken along with other measures to improve the patient experience. I am not stupid enough to believe that this is anything more than smoke and mirrors which will result in nothing positive being done.

    I have no political axe to grind. This and previous governments, of whatever persuasion, have all played their part in the mismanagement of the NHS. For those of us insiders, who have actually spent years working to improve the experience of our patients (in my case, many years as an A&E Nurse Practitioner and the last 3 years as a Research Nurse), we have seen it all before. There already exists plenty of good quality research on the experience of patients. What we need now is the implementation of effective policies or nothing will change.

    Re-posting your original comment again and again really isn't necessary. We understood the first time.

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  • "Nurses not only ones 'at fault' over patient experience"

    As nurses, we are very aware of the importance of research and of its mechanisms. I am also sure that those who comment on these threads, and many nurses who don't, are extremely interested in improving the patient experience. And when you spend years doing just that, I think that you are entitled to be angry when yet another "care-ranking system" is rolled out. We can "rate" until we are blue in the face. Without an undertaking to act upon the findings, then it is pointless.

    It is how the Friends & Family Test will be perceived and used which is important. Will it be taken along with other measures to ultimately improve the experience of our patients? If so, then how?

    We live in a sound-bite society, where only the "headlines" are served up to the public. I too was angered by the media coverage of the F&F test. We have become accustomed to the Daily Maul approach to Health issues reporting (particularly nurses and the NHS). The nurses commenting here are tired and angry, not defensive. But they do need to speak up more, as a profession.

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  • Rick Harris

    Anonymous | 6-Dec-2012 5:34 pm

    My comments were made purely in the context of the usefulness and accuracy of research - I have no political axe to grind here (unlike your own comments describing "a government intent on destroying the NHS")

    You say you think I have "missed the point".
    The point I am making is that the F&F test question was thoroughly researched by the CQC and the Picker Institute Europe, and developed after rejecting the initial Net Promoter style question. When taken along with other measures, this is a useful piece of data.

    For those that are interested in improving the patient experience, this kind of data should be welcomed.

    http://customerfaithful.com/net-promoter-score-fails-its-first-test-in-nhs/

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  • It isn't often that I agree with a senior nursing figure, but Sally Brearley is bang on.

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  • Look, the problem is systemic. There may be specific examples given where nurses are the reason for a poor experience and that may even be about attitude. But we have to ask why that is.

    It is a well known fact, that one's ability to care for others is undermined if you don't feel cared for yourself. It's not about being professional, it's what makes us human.

    The challenge for nurses is how to try not to let how we feel impact the experience of our patients negatively.

    Attitudes too, extend beyond the attitude of the nurses, but to everyone, from the cleaner to the Consultant to the Chief Nurse or Medical Director and even to the Chief Executive. We are all accountable and low scores should be used to help us identify what we all need to do in order to improve.

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  • michael stone

    Rick Harris | 6-Dec-2012 6:46 pm

    This interests me - I am not awfully keen on the F&F test question because I see it as far too simple: I like an invitation to provide narrative answers, because simple questions do not make it clear exactly 'what the problem was' (as perceived by the patient/relative).

    Howwever, I agree with you about defensiveness - and one problem is that defensive behaviour on the part of staff, comes across as evasiveness to the patient or relative, and this leads to escalation and the creation of a conflict, when in reality sometimes the original incident was simply a misunderstanding.

    However, it is clear that nurses tend to feel very 'picked on' as a group, and that is probably why they are currently so defensive, Rick ?

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