It may be reasonable to presume that patients receive better care from staff who feel happier in their work
Citation: Nursing Times (2013) Does NHS staff wellbeing affect patients’ experience of care? Nursing Times; 109: 27, 17.
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- Policy+ was a publication from the National Nursing Research Unit at King’s College London. Its editors were Jill Maben, Sarah Robinson, Jane Ball and Caroline Nicholson. Some issues were published in Nursing Times to mark the 35th anniversary of the unit
However, little is known about the strength or possible impact of associations between staff wellbeing and patient outcomes, including their experiences of the care provided. Previous research has tended to focus on single aspects or one staff group (Taylor et al, 2007; Michie et al, 1996), or has looked at associations at the whole hospital level, for example by using national staff and patient surveys, and hospital-level outcomes (Boorman, 2009; Raleigh et al, 2009). Researchers at the National Nursing Research Unit have completed a study in the English NHS exploring the links between patients’ experiences of healthcare and staff experiences at work such as staff motivation and wellbeing at work (Maben et al, 2012a; Warr, 1987). Staff and patient views were captured at team/unit level; where possible, staff were matched to the individual patients they cared for to test associations between staff and patient experience (Maben et al, 2012b).
What do we mean by wellbeing at work?
This has been defined as an “individual’s subjective experience and functioning at work” (Warr, 1987), which includes job satisfaction, positive and negative affective reactions (feelings and responses) at work, motivation, emotional labour and issues of emotional exhaustion and burnout.
How did we explore staff wellbeing and patient experience?
We selected eight case studies (four acute and four community) in four trusts in England: an emergency admissions unit, a maternity service, a care of older people ward and a haemato-oncology ward, and two adult community nursing service teams, a community matron service and a rapid response team.
The study involved 200 hours of direct care observation, interviews with 55 senior managers, 100 patients and 86 staff, and surveys of 500 patients and 300 staff (nurses, healthcare assistants and medical staff).
What did patients tell us about their experience?
Patients recollected their own and other patients’ experiences vividly in the interviews. They focused largely on the “relational” aspects of their care, that is how they felt cared for by staff.(Cornwell and Foote, 2010). Patients wanted prompt, kind and compassionate care. Their views of the relational care they received informed their judgements of whether the care was generally “good” or “bad”, and whether individual staff were “good” or “bad” at their job. They made a distinction between staff who seemed to treat their work as “just a job” and those who regarded it as a vocation, and were clear on the importance of the latter.
In the case studies where patients rated their experience more negatively (older people’s care, acute admissions, the community nursing service and the rapid response team), we consistently found poor relational care and staff largely failing to “connect” with individual patients. Patients and relatives considered that they had limited ability and/or desire to directly question staff about poor care and poor caring behaviours. Some patients commented on the influence of the workplace on staff behaviour towards patients - busy or challenging service areas, a poor built environment and poorly managed wards.
What did staff tell us about their experiences of wellbeing at work?
Staff wellbeing was defined as an “individual’s subjective experience and functioning at work” and included measures of job satisfaction, feelings at work, motivation, emotional labour and burnout (Warr, 1987).
Staff experience varied across the eight case studies. Staff in many settings spoke of high job demand and low control over their work, leading to emotional exhaustion, stress and burnout for some (Adams et al, 2012; Maben et al, 2012b). Some also spoke of bullying and an unsupportive work environment, which resulted in poor wellbeing at work (Maben et al, 2012a; Maben et al, 2012b). Other staff felt well supported by colleagues and managers and suggested this buffered some of the pressures exerted by the challenges of day-to-day patient care. A multi- level analysis of the survey data revealed that both job demands and job resources (support at work) have a strong effect on wellbeing at work (Adams et al, 2012). Social support from supervisors, co-workers and the organisation more generally had a positive effect on wellbeing by helping to reduce or cope with feelings of exhaustion and, at the same time, enhance satisfaction and positive affect (feelings and responses) at work (Adams et al, 2012).
Work dedication was consistently positively associated with higher levels of wellbeing, including lower exhaustion and higher job satisfaction and a relatively positive affect (Maben et al, 2012b). High job skills and competence were also identified as important in that they helped to reduce or minimise emotional exhaustion (Maben et al, 2012b).
Is there a link?
Individual employee wellbeing is an antecedent rather than a consequence of patient care performance. That is, if staff wellbeing at work is good, it is likely that staff will perform better in their jobs, rather than the other way around.
Analysis of our staff and patient experience surveys indicate seven staff variables (“wellbeing bundles”) that are linked to good patient-reported experience. These are:
- Good local (team)/work and group climate;
- Perceived organisational support;
- High levels of co-worker support;
- Low emotional exhaustion;
- Good job satisfaction;
- Supervisor support;
- Good organisational climate.
A strong climate for patient care, particularly at the local level (the ward, unit or staff team), can amplify some of the positive effects that individual wellbeing can have on patient care performance. A good local climate can also act as a substitute for individual staff wellbeing in the sense of “making up” for the absence of high levels of wellbeing in terms of performance.
This study strongly suggests that there is a relationship between staff wellbeing and staff- reported patient care performance and patient-reported patient experience. Seeking systematically to enhance staff wellbeing, therefore, is not only important in its own right but can also improve the quality of patient experience.
- Team leadership Team leaders have a critical role in setting values, behaviours and attitudes to support patient-centred care. Supportive local leadership and supervision needs to be in place
- Supportive teams Attention needs to be paid to the nature and quality of the team environment
- Monitoring staff absence High sickness absence may indicate a poor work climate and organisational and wider contextual issues. Sickness absence levels should be seen as a barometer of wellbeing issues that affect care quality
- Occupational health departments These should work with organisational development (OD) departments to view staff experience as an organisational rather than an individual issue. Instead of tackling high sickness levels in a reactive and punitive way, staff wellbeing is actively managed and supported
- Good governance re staff wellbeing A strategic approach to staff wellbeing is likely to have a positive impact. Examples include high sickness absence raised at board level and measures taken through OD to manage this, and appointing a board executive champion for staff health and wellbeing to ensure this gains greater prominence in NHS trusts
Adams M et al (2012) “Catching up”: The significance of occupational communities for the delivery of high quality home care by community nurses. Health 1–17.
Boorman S (2009) NHS Health and Wellbeing Review. London: Department of Health.
Cornwell J, Foote C (2010) Improving Patients’ Experiences. An Analysis of the Evidence to Inform Future Policy Development. London: The King’s Fund.
Maben J et al (2012a) Poppets and parcels: the links between staff experience of work and acutely ill older people’s experience of hospital care. International Journal of Older People Nursing: Special Issue: Acute Care; 7: 2, 83-94.
Maben J et al (2012b) Patients’ Experiences of Care and the Influence of Staff Motivation, Affect and Wellbeing. Final Report. Southampton: NIHR Service Delivery and Organisation Programme.
Michie S et al (1996) Stress in nursing and patients’ satisfaction with health care. British Journal of Nursing; 5: 16, 1002-1006.
Raleigh VS et al (2009) Do associations between staff and inpatient feedback have the potential for improving patient experience? An analysis of surveys in NHS acute trusts in England. Quality and Safety in Health Care; 18, 347-354.
Taylor C et al (2007) Impact of hospital consultants’ poor mental health on patient care. British Journal of Psychiatry; 190, 268-269.
Warr P (1987) Work, Unemployment, and Mental Health. Oxford: Clarendon Press.