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Caring for patients means caring for nurses

As far as patient and staff experience is concerned, no problem is too small. As well as tackling the issues, leaders must involve their teams in the solutions, says Jocelyn Cornwell. Leave a comment on on this story to contribute to a national debate on the future of NHS leadership

The research evidence that links staff engagement with enhanced patient outcomes and experience is powerful. We know that organisations with satisfied staff
score well on patients’ experiences. We also know that teamworking is good for the mental health of both staff and patients, and that hospitals with good human
resources and management practice, with training, appraisal and team building, have higher levels of patient satisfaction and staff motivation and, importantly, lower patient mortality than others.

Those investigating NHS hospitals where patients have suffered very poor care have all found: remote and inaccessible managers who refused to listen to staff
and would not involve them in decisions; bullying; low staff morale; fatalism among clinicians about management; and a reluctance to raise concerns.

There is much more to learn about the quality of relationships between managers and staff and how they affect patient outcomes and experiences. What exactly is
it that connects the way nurses feel at work to the way they look after patients?

There is much we do know: evidence tells us nurse leaders who care about patients and about their organisations pay attention to how their staff feel about work and
about their employing organisation.

‘In hospitals with poor care, investigators have found remote managers who refused to listen to staff’

Consider this story and what it tells us.

A patient, asked about his experience in hospital, says his only minor complaint is that his morning cereal arrives drowned in milk. Hearing this, the charge nurse
seizes the opportunity to explore staff assumptions about patients’ preferences.

Rather than solve the problem himself, he asks the team to find a solution. Having consulted kitchen staff, they find they can provide milk in pitchers. They decide they will take patients their breakfast trays and remain briefly to check whether they need help with pouring.

The ward staff are stunned to discover the variation among patients on such a small matter, a revelation that clearly has implications for other aspects of care.

The message the charge nurse has communicated is that patients’ experiences matter; that he is actively interested in helping staff to provide compassionate care; and that it is possible for the team to reflect together on the nature of their work and solve practical problems.

Is this a trivial story? No. Patients’ stories are full of “small” things. Cumulatively, it is the small things that serve to reassure, to build trust and confidence or, conversely, to fuel anxiety, mistrust and tension.

For me, the story speaks volumes about leadership that manages to communicate - through the behaviour of the charge nurse - that it does not take care-giving for
granted. What could be more important?

Staff engagement brings together “how staff feel” about work with “what managers do” and describes the two together in terms of the presence or absence of “engagement”.

You can find and measure engagement in staff surveys where it shows up in positive employee attitudes, commitment to and belief in the organisation and a
willingness to go the extra mile.

In business terms, it matters because it correlates with positive attitudes towards change and innovation, as well as higher productivity. It is associated with higher
satisfaction, which means that staff are less likely to want to leave, and therefore with lower staffing costs.

There are multiple connections between what happens at the top of the organisation and the shop floor. The behaviour and conduct of leaders is critically important.

There is a host of reasons why nurse leaders should be interested in staff experience. Even the act of taking an interest will improve staff engagement.

Jocelyn Cornwell, PhD, is director of the Point of Care Programme at the King’s Fund

The Department of Health and the National Leadership council want your views on how the NHS should be managed. You can contribute to the debate by posting a comment below

Readers' comments (16)

  • These are very useful debates, nurses' happiness and wellbeing is a clear precursor to happy and well patients. What I would like to see is tangible rules that ensure all this useful rhetoric is turned into tangible action that we can see on the wards.

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  • I agree with you Maria. I said on other posts: ‘everything is possible with happy health professionals’ or ‘protecting patients consists of protecting Nurses’.
    However, nursing leaders are not in a position to change fundamentally the politics that surround our health care system. Managers or Nursing Directors will never advocate for Nurses for one single reason: they are essentially representatives of their healthcare organisations; they are taught that they are no longer Nurses.
    So what I am saying is the above article is great in an ideal world where our human capacities exceed our workload. Unfortunately, we are far from it.

    I have read the report by the Prime Minister’s Commission on the Future of Nursing and Midwifery in England “Front line care”. What I have found is lovely intentions and a non-sense pledge that is supposed to deliver high quality care. They probably think that Nurses are naïve and would swallow the pill without acting. Do you think, for instance, that this report would have ever mentioned about a simple and concrete measure that can help Nurses do their job efficiently and safely such as a mandatory Nurse to Patient staffing ratio?
    In fact, the idea is to make accountable all health professionals for the collateral damage as a result of a drastic healthcare reform that has already started and would amplify after the General Election.

    Just think of the following equation:

    o Life expectancy, life-style related illness, shortage of health professionals and Healthcare spending are increasing;
    o Hospital beds are decreasing.

    Is this report sincere about nursing when government play double standards?

    Let’s take, for instance, the problem of alcohol.
    First, we know that alcohol abuse is responsible for serious ill health and social effects such as road accidents, crimes, domestic violence, liver failure, birth defects, mental instability, absenteeism, etc…
    Yet, there is still no ban on ads of alcohol, despite numerous international studies showing the benefit of such a ban.
    Second, according to the Institute of Alcohol Studies (IAS), the revenue (Excise duties & VAT) collected from Alcoholic Drink in UK is approximately £15 billions, that is the equivalent of the cost of Nurses and Midwives within the NHS in terms of wages, training, recruitment, insurance or other associated costs ( see report “Front line care”).
    Third, The World Health Organisation’s European Charter on Alcohol states:
    ‘All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.’

    If the UK government are serious about public health, a few things they can do is to ban the advertising of all alcoholic beverages on TV and in cinemas as well as prohibiting sponsorship of sport or cultural events by alcohol companies, increasing further taxation on alcohol and tobacco products and capping significantly salt/sugar level within the food industry. These actions will reduce healthcare demand and, therefore, its burden. These savings and extra money could be used to recruit more health professionals, develop their continuous education, set up a mandatory Nurse/Patient ratio and invest further in primary health care.

    Abel Sidhoum (RN)

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  • I am a practice nurse but my employer GP flatly refuses to move forward. I really like him as a person, but as a GP he is behind the times and blocks my professional development. I gave up a team leadership role to develop the nurse team in his practice, but now I am stuck as he says 'things change' and now a majority of my time is doing tasks it does not need a trained nurse to do. I am excluded from meetings because as a GP he has full control over choosing to work 'backward'. He still uses written notes ... oh I could go on. I have worked for 'forward thinking' GPs previously and found they were the opposite end of the scale, still exclusionary as it all boils down to professional protectionism and power. I feel like a commoditiy, providing a high level of skilled care, intelligent enough to take on various GP roles, but just kept 'down' enough to prevent me having a voice in how the system works or how the money is spent. This isn't abouy 'my' pay as I am actually happy with it, but I am extremely frustrated at being a 'can do' person in a 'can't do' world. I have tried and tried to reason and present audit results that would show improved cost effectiveness and patient care, but without higher up improved delegation of sharing power on behalf of happy patients and staff I may has well reason with a brick wall.

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  • have the public audit bureau look at the NHS hierarchy do we need all these fat cats and matrons. despite having all these pen pushers mid staffordshire hospital (i think i got the right one) failed miserably. why do we need a nursing director? what for? maybe next time we are short on the floor the nursing director can come and deliver hands on care.

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  • Unless I feel cared for by management systems.Then I am unable to care for my service users

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  • I have been fortunate in my working life to have had an excellent clinical nurse manager and ward sister who encouraged me to develop and expand my toles until I became a charge nurse. I was then encouraged to develop a special interest in what has now become my post. Leading by example and knowing the staffs strengths and weaknesses needs personal involvement. Giving staff responsibility and delegating with support to junior staff encourages staff /patient involvement. Happy nurses who know they are doing their job well make for better and safer patient care

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  • For a long time we've known the Hawthorne Principle - that just being interested in your work force brings improvements to production values.
    When spouses feel valued by one another, don't the children thrive even more?
    Why are there still management principles that promote fear, the punishment mentality, and worse?
    We now even have a nobel prize winner who found that not everything is a competition in economics. Collaborations work too.

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  • It's all pretty basic stuff - look after your staff and they feel valued and therefore take a greater interest in the patients they are looking after. I applaud your efforts.


    However after 10 years of being bored and underdeveloped - paid for my own post grad training thanks, overworked and underpaid I'm getting out to do something with clear career path objectives, rewards for skills rather than a pay award ever year for turning up and getting fatter.

    The NHS is a an anachronism in more ways than one. You wonder why nurse leadership is so impoverished when you recruit from the most marginalized sections of the population and spend little or nothing on developing self actualizing skills.

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  • I am a senior nurse within an acute trust and agree that this is exactly what needs to happen to ensure ongoing improvements in patient care. High quality nursing care is what I strive to deliver everyday I am at work. I am continually undermined, told I set my standards to high by one of my managers and have had been on the recieving end of personal abuse because of my passion about maintaining and aiming for high standards of care. I cannot continue to keep fighting for this as much as I believe in it without a dramatic culture change in the NHS and without a change in the heirachy of the NHS. I feel that sadly this will not be possible especially where medical staff continue to be more highly valued than nursing staff and where bullying has been allowed to continue over many years.
    At the moment I am very sad that I do actually believe because of how I am treated by my employer, I am not now giving the best quality care to my patients and families, which is a place I never wanted to be in.

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  • Working in the NHS is unlike any other employment. Nursing is unlike most any other job, because of the stress and anxiety of being available, and responsible, 24/7 for the care and recovery of the nation's sick; young and old, and those who are at there most vulnerable, and look to us to 'be there' for them. This could be at the start of their life, or the end, at home, school, GP surgery or in hospital. How many people have said to you "I couldn't do your job". What we do is amazing, and we should be proud of what we achieve with the limited resources available. How do we achieve it? We love what we do, when it goes right. I write this because it saddens me so much to see the bitter and angry responses that come out of these message boards time after time. Morale is very low and that's because time after time what we need to be good nurses is not available; time, support (from sideways and above!) and the feeling that we are appreciated, not just in empty words but in deeds. Care for your staff NHS and the staff will care for your service users. It's what you pay us for.

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  • Excellent comments from all of you, especially Anonymous | 20-Mar-2010 10:33 am. Ok! The devil’s advocate may say to me that my judgment is subjective because they are all in line with my view. But this is a judgment I totally assume because it is mine. Whoever wishes to challenge it is welcomed. It is what we call a debate, isn’t it?

    I would suggest you to read the Economist Intelligence Unit ‘Doing more with less’. For instance, you find interesting statement from Professor Maynard such as:
    “The quality issues are really quite significant because if you start to cut people’s pay, you may affect motivation and affect treatment.” (2010, p.16)

    Based on the above statement, let’s try the following syllogism:
    All happy patients are linked to happy Nurses;
    The government is responsible for nursing pay rise, patient and staff safety;
    Therefore, the government is responsible for patient satisfaction.

    Abel Sidhoum (RN)

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  • oh, oh!
    Caring for patients means caring for nurses

    Excuse Me but shouldn't the title read 'Caring for nurses means caring for patients?'

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  • It's incredible to think this work needs to be done, surely it is well evidenced already isn't it? Nonetheless, in my experience when a team is lead by 'good' leaders even the difficult decisions are carried through with a much more positive approach, because they have informed, listened and taken the staff through with them. Yet, so many times management say they have involved staff, but in reality have only paid lip service to it in order to tick a box. The circle of influence and authority is fairly small in the health care field. Whilst the example of the milk was valid, if that charge nurse had wanted to change something that required agreement from another level of management, he may have had a battle on his hands. I agree it is at all levels that we need 'good' leadership, but so often our ward/dept sisters/charge nurses don't have the autonomy that is assumed and they too are thwarted when it comes to making improvements in care. I also think it is blurring the lines when we talk about nurse leadership as there are so many layers and titles......what exactly is that, who is that? Is it the sister, the ward manager, the matron, the clinical lead, the director of nursing, the manager etc etc...........

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  • .......forgot to add, whilst health care is totally target driven, nurses will remain at the bottom of the cue propping up the system and making the best of a bad job. I just wish nurses and nursing bodies would grow a set.......and be a bit more aggressive in our knowing what is required instead of always being so passive.

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  • Last comment - honestly - talking about targets.....the PCT I work for met it's length of stay target for every week for the last 3 months bar 1....as a result it has been 'fined' over £100.000. If anyone can tell me how that will help the situation out here, I'd be interested to know. In a culture when we are constantly being tasked with saving money, year after year after year. This is ludicrous......so what if we have 'good' leaders....is it keep the ants quiet?

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  • 'Targets' is management jargon used for those working in manufacturing industries with production lines and not a dignified term for the care human beings who are patients in hospital! Patients are not objects or labels and should be central to all activities in hospital involving care and not this obsessive striving to meet targets imposed by management just to satisfy them!

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