Staff experiences at work have an influence on patient experiences of care, says Jill Maben
Nothing can or will make up for the losses and distress that Mid Staffordshire Foundation Trust caused to its community - serious failings led to indignity, suffering and at least 400 deaths that should never have happened. We must all learn lessons from the inquiry led by Robert Francis QC, and champion the change of culture needed to allow all healthcare staff to deliver care with kindness and compassion.
Most health professionals are, at least initially, motivated by ideals of altruism and making a difference. However, in some environments a transformation occurs so that, over time, these same people are forced to abandon their ideals and protect themselves against a system that erodes humanity and caring.
A study undertaken by Isabel Menzies Lyth in the 1960s still has much resonance today. She states in caring for the sick, nurses deal with highly vulnerable people, such as children, babies, older people and the disabled. This inevitably creates high levels of stress, tension, fear and distress. To avoid feelings of anxiety, guilt, doubt and uncertainty she suggested nurses erect “social defences against anxiety” -mechanisms that provide distance. This self-protection can mean, over time, nurses and other health professionals shut down feelings of compassion to protect themselves or work in ways that mean they do not “get too close to patients”.
“Levels of burnout in English nurses are some of the worst in Europe”
Health professionals also burnout; this can happen early in their careers. I found ideals and values held dear by graduating students became abandoned and crushed in a short time, with nurses reporting some degree of burnout within two years of qualification, leading to job hopping in search of the ideal environment or abandonment of nursing altogether. A more recent study by the National Nursing Research Unit shows levels of burnout in English nurses are some of the worst in Europe.
While Mr Francis is right to emphasise the centrality of the patient experience, our research suggests staff experiences at work have an important influence on patient experiences of care. Staff wellbeing is an antecedent to, not a consequence of, performance. The patient experience is better when staff remain connected to the ideals and values that first brought them into caring professions; this means an environment that offers psychological safety and the chance to reflect on practice.
A good working environment also provides sufficient staff, a good skill mix, colleague and managerial support, and low emotional exhaustion. Positive practice environments help nurses care well, show kindness and compassion to patients and each other, and make a positive difference to people. Further, in a culture of psychological safety, whistleblowers feel more able to speak out if there are failings. Staff at Mid Staffordshire who spoke out were neither listened to nor had their warnings heeded. It is encouraging that health secretary Jeremy Hunt has written to all NHS trust chairs asking them to hold internal events to listen to staff and understand what is needed to make a lasting difference to them and patients.
Staff engagement is the antithesis of burnout but without a culture of support and psychological safety it could become a top-down exercise in box-ticking. This opportunity must be used to fully hear staff experiences, not once when encouraged by the health secretary but every day. This will help champion the culture change needed to allow staff to deliver care with kindness and compassion. It should also ensure they never reach the stage where poor care is the norm and they distance themselves as a means of self-defence against feelings of guilt, low morale and frustration.
Jill Maben is director of the National Nursing Research Unit at King’s College London