Patient and staff experiences have a direct impact on patient outcomes and are important measurements of the quality of healthcare provision
Exploring patient and staff experiences is a new discipline but is providing key insights into the quality of care patients receive. This article explores how patient and staff experiences are measured and how this information is used to change practice.
Citation: Churchill N, Warden R (2014) How patient and staff experiences affect outcomes. Nursing Times; 110: 48, 18-19.
Authors: Neil Churchill is director of improving patient experience, NHS England; Ruth Warden is assistant director of employment services, NHS Employers.
- This article has been double-blind peer reviewed
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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.
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).
Box 1. #hellomynameis campaign
Aspiring for service excellence is a worthwhile ambition. This is a driver behind the most inspiring patient experience campaign of recent years.
#hellomynameis is a campaign by Kate Granger, a doctor who is terminally ill with cancer. During a hospital stay she observed that many staff looking after her did not introduce themselves before delivering care. Supported and encouraged by her husband, Kate started a campaign to encourage and remind healthcare staff about the importance of introductions in the delivery of care, believing it to be about making a human connection, beginning a therapeutic relationship and building trust.
She appeals for us all to introduce ourselves and explain our role when we meet patients. Just say, “Hello, my name is…”. Compassion stems from the connections we make between people, and introducing yourself is the first step in that journey. But introducing yourself is only one of a number of things that should always happen.
UCLA Health, an American healthcare provider, has devised the CICARE programme (pronounced “See I care”). This encourages staff to use a patient’s preferred name, ask if they have questions, provide answers and say, when leaving, what will happen next or when they will return. tinyurl.com/CICARE
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 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 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.
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.
- Exploring patient and staff experiences is a relatively new approach to quality improvement
- Patient experience is the sum total of all interactions a patient has with the service
- Patient involvement and good communication make a difference to clinical outcomes
- The Friends and Family Test has helped provide valuable insights
- Staff experience is the best predictor of patient experience
Dawson J (2014) Staff Experience and Patient Outcomes: What Do We Know?
Department of Health (2008) High Quality Care for All. NHS Next Stage Review Final Report.
Doyle C et al (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open; 3: e001570. doi: 10.1136/bmjopen-2012-001570.
NHS England (2014a) Patient-led Assessments of the Care Environment (PLACE).
NHS England (2014b) Statistical Commentary. Friends and Family Test Data (Staff). Quarter 1: April-June 2014.
Point of Care Foundation (2014) Staff Care: How to Engage Staff in the NHS and Why it Matters.
Royal College of Physicians (2014) NICE Public Health Guidance for the Workplace Organisational Audit.
Wolf JA et al (2014) Defining patient experience. Patient Experience Journal; 1: 1, 7-19.