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Putting patients in the spotlight

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With quality now at the very top of the healthcare agenda, Louise Hunt looks at the challenges facing frontline nurses

Patient-centred care has become the mantra of current health policy and a term that must be echoing across wards and clinics everywhere. But in a climate of staff shortages and budget cuts, to what extent are staff on the frontline of care succeeding in putting this ethos into practice?

According to the latest inpatient survey from the Healthcare Commission – based on a study last year of nearly 76,000 patients at 165 acute trusts across England – the overall picture is promising (NT Analysis, 27 May, p8).

Don Redding, head of policy at the Picker Institute, which coordinated the survey on behalf of the Healthcare Commission, says:

‘The picture we take from the national survey is that patients have confidence in nurses and that their general communication skills are good’, with 78% of patients saying: “yes they are always treated with respect and dignity”.’

However, a closer analysis of the survey reveals that the degree of effort that nurses put into seeking patient feedback is variable, and more needs to be done to address shortfalls in this area.

‘In the national survey only 7% of patients said: “yes they were asked for feedback during their hospital stay”. In our view I would not say that it is common practice for nurses to seek feedback from patients,’ says Mr Redding.

However, he points out that asking for feedback is simply the starting point in ensuring quality care. ‘True patient-centred care goes beyond asking for feedback to involving patients in their treatment,’ he explains.

‘Just about half of hospital patients said they are not involved in their treatment and that indicator is getting worse. We know from our evidence that being involved in treatment decisions is a huge determinant of what patients feel about
the quality of their care. And this is a huge part of the personalisation agenda.’

The survey also shows that 22% of patients felt unable to talk to someone about their worries. ‘This suggests there is a sizeable minority of patients who are not getting compassionate care and attention,’ says Mr Redding.

‘It is not just about communication skills and explaining procedures, it is about a cultural approach to sharing decision-making and talking through the alternatives,’ he adds.

Currently there is no equivalent national survey for primary care but Mr Redding says that the Picker Institute has begun work on tracking patients’ experience of nursing in the community. While it is early days, he anticipates that the feedback will be positive.

‘Patients are more likely to be positive about community nurses because they embody many of the things patients want out of nursing, for example close working,’ says Mr Redding.

‘I would not expect there to be problematic scores, if there are, it is more likely to be around access to community services,’ he adds.

The dramatically different personal accounts that appear on internet forum Patient Opinion illustrate to what extent patient and family experiences of care still vary across services.

Patient Opinion chief executive and GP Paul Hodgkin points out that, far from being a barrage of criticism, the forum is evidence of what nurses are doing right. ‘Over half of the postings are saying thank you,’ he says.

The majority of complaints about nursing care that appear on the site, Mr Hodgkin says, relate to rude behaviour, such as nurses chatting among themselves and not paying attention to patients, talking at night and a general lack of communication and listening skills.

Unsurprisingly, patients are especially concerned about hygiene issues and nutrition. ‘People comment that hands are not being washed, we often get former nurses or others who have worked in the NHS saying they have seen things that they knew shouldn’t have happened,’ he adds.

This correlates with views expressed to the Patient Association, a national charity that provides patients with an opportunity to raise concerns and share experiences of healthcare.

‘The standard of nursing is still very high but there is concern that the elderly are not always being looked after as far as food is concerned. Nurses are so busy and patients often feel they are neglected. They also tell us a lack of handwashing is a problem and they are concerned about the spread of infections,’ says association vice-chairperson Michael Summers.

‘The fear of hospital-acquired infections is putting people off having elective surgery. People need reassurance and nurses are in a position to do that. They should be doing everything possible to demonstrate to patients that they are washing their hands.

That sort of reassurance is really appreciated,’ he adds.

Last month patients’ views and their positive or negative assessments of the care they receive were officially enshrined at the heart of health service plans, with new government benchmarks specifically targeting quality of nursing care.

In his NHS Next Stage Review, junior health minister Lord Ara Darzi announced a range of measures to be introduced as a set of ‘metrics’ to assess whether nurses are delivering care with compassion, as well as doing so safely and effectively (NT News Special, 8 July, p2).

RCN head of policy Howard Catton says: ‘The move towards payment by results on quality, not just volume, is a powerful policy lever and organisational driver. For individual nurses there is a real opportunity to make a difference, because they are the biggest group and have the most contact with patients.’

However, Mr Catton says that the question of whether nurses are providing patient-centred care has to be balanced with the changing role of nurses, from hands-on care providers to advisers in patient self-management. He points out that patient expectations are also changing. ‘We are a more consumerist society and more vocal if services are not up to our needs. People are expecting services that are specific to them and nurses have to be able to respond to these different demands,’ he says.

With patient opinion now perhaps more important than it ever has been, it will undoubtedly become more common for organisations to use patient feedback to learn how to improve practice. There are a number of ways in which this can be done.

The Picker Institute, for example, can provide services with handheld feedback devices to log patients’ experiences that can then be downloaded onto a server.

‘If they are used on a regular basis it allows trusts to track over time whether things are improving and it gives immediate frontline ownership,’ says Mr Redding.

Decision aids – a technique for establishing priorities – can also be useful. ‘It is better if they are tailored locally. There is certainly a role for nurses who are familiar with treatment and care pathways in developing decision aids,’ he adds.

Patient feedback services, such as the one provided by Patient Opinion, which sends subscribing trusts relevant comments, have also been useful in influencing nursing practice.

Jackie Bird, chief of quality and standards and chief nurse at Rotherham NHS Foundation Trust, says that in her trust a complaint posted on Patient Opinion has resulted in a trust-wide learning exercise.

The complaint involved a patient’s death and the bereaved family’s feelings.

‘The family said that nurses hadn’t made an effort to speak to them, instead staying in their nurses’ station. They said it was
like they had an invisible wall around them,’ Ms Bird explains.

As a result, a theatre group will be acting out the complaint for clinical staff and managers at an event in October to elicit feedback on what could have been done differently. It will also be videoed and used as a learning and development tool.

Ms Bird is also implementing a ward manager leadership programme that she hopes will promote patient-centred care throughout the wards. This includes obtaining patient feedback throughout their journey, handing out business cards for patients to contact them directly and generally being more visible and accessible.

‘The thing nurses often forget is that they are on view 24 hours a day, whether it’s washing their hands or being around for patients. Ward managers are absolutely pivotal in spreading this good practice because how they behave determines how others behave,’ she explains.

While patient feedback may sometimes make for uncomfortable listening, Mr Catton sees it as an opportunity to unite nurses’ causes with those of patients.

‘Communication is a stand-out issue and that is why we [the RCN] are vocal about the factors that get in the way of fostering that relationship, such as coping with 100% bed occupancy and low staffing levels,’ he says.

‘What’s helpful about patient feedback is that patients, as well as nurses, are talking about the importance of time. We are all joining up the dots.’

‘I felt this was my chance to make a difference’

Diane Miller is lead critical care outreach nurse at South Tyneside District Hospital. Her experience of being a patient profoundly changed her approach to nursing.

In 2000 she went through the traumatic experience of a stillbirth.

She haemorrhaged severely and needed emergency surgery. She then spent days in ICU – where she happened to work at the time.

Ms Miller does not criticise the care she received during this time but she says that the experience opened her eyes to what critical care patients go through.

She describes how she suffered hallucinations and terrifying nightmares while still in the hospital and for a long time after, when back at home.

‘Before the experience I never anticipated that you could have hallucinations and nightmares, memory problems and flashbacks and that it feels like you are losing your mind.

As an ICU nurse I just thought “great, we’ve done our bit – the patient is alright”,’ she says.

After recovering, Ms Miller took the opportunity of a new position in critical care outreach, which provides support to ICU patients who have been transferred to other wards.

‘Having had my experience I felt I could empathise much better. I felt this was my chance to make a difference,’ she says. She has since introduced a number of ways to help critical care patients through their experience. This includes patient diaries, where nurses and relatives can write down what has happened to a patient while they are sedated as a way for them to come to terms with their experience.

She also spends time with patients talking through what they may be feeling. ‘Having had my experience I can delve a bit deeper. I know exactly what I am looking for,’ she says.

Ms Miller also provides training sessions to all clinical staff on what critical care patients go through and is now producing a recovery manual for patients.

‘I think nurses need to have more awareness that being a critical care patient is a unique experience,’ she concludes.

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