What can hospital staff do to improve the quality of care for patients?

Comments: 10

11 Oct 2012

The forthcoming Francis report into events at Mid Staffordshire is likely to provide a salutary reminder of the impact on patients when staff either don't or can't put patients at the heart of what they do, says Bev Fitzsimons, Programme Manager, Point of Care programme.

My work as part of our Point of Care programme has made me recognise that frontline staff often feel powerless to challenge practice in the face of what feels like a monolithic system. Caring for patients makes serious demands on staff – both physically and emotionally. Teams we have worked with have described the unprecedented pressure they face working in today's NHS, with increasing intensity of work, and patients with more complex needs than ever before. They are dealing with illness and distress day in, day out, seeing patients at their most vulnerable.

The impact on health care staff is real. Staff health is poorer in health care than in other sectors, and stress and sickness rates are higher. Unless these stresses are recognised and dealt with, health care staff are at risk of burnout and can become disengaged from their patients. This does not excuse the failings by staff working in Mid Staffordshire, but this burnout and disengagement is undoubtedly a factor we need to consider where the quality and compassion that patients need is lacking.

So what can be done to support staff to provide high-quality care? Most importantly, they must have well-designed roles with good support. Staff can (and many do) cope well with heavy work demands as long as they have good support from managers, good teamworking and a high level of control about how their work is undertaken.

Alongside this it is vital to allow staff time to deal with their own feelings. The Point of Care’s multidisciplinary Schwartz Center Rounds® offers one approach, providing a forum for staff to explore issues related to the emotional challenges of providing care: a multidisciplinary team of staff present the story of a patient they have cared for and then there is a facilitated discussion. Our evaluation has shown that staff really value the Rounds and feel they have a positive impact on their day-to-day work and their relationships with patients and colleagues.

There are other things that can help. Stressed staff groups experience more self-criticism and team conflict; we have delivered workshops to promote resilience among staff. Evidence suggests that focusing on solutions and generating curiosity about how staff manage from day to day – what goes right and why – helps them to be aware of their strengths and the personal qualities and values that sustain them in their work. Many staff who have attended felt that they helped them to reconnect with why they had gone into health care, which can get lost in the relentlessness of the day-to-day work. This can translate helpfully to their relationships with patients and colleagues.

Engaging staff as well as patients is essential to protect the service from the sorts of failures that occurred at Mid Staffordshire and are the key to making change and improvement happen. Organisations with engaged staff deliver a better patient experience and offer better-quality care.

Many health care staff tell us they are surviving, not thriving. Staff stress should be addressed across the system rather than as an individual problem or weakness for the benefit of patients, staff and the system as a whole.


#2424 Lucianne Sawyer
social care consultant
Community Care Research & Consultancy

My comment is mainly about personal experience, having had to undergo some difficult and unpleasant investigations lately. To walk into a room and find upwards of 8 - 10 medical students watching, and a nervous one having to do it - an endoscopy - obviously for the first time and very incompetently, so that parts were repeated several times - with me very physically distressed, gagging uncontrollably - and then at the end - no communication - I was just a body being wheeled away. It was a dreadful experience and although the physical side of it probably couldn't have been made much better, the presence of so many students made it much worse for me and for the one who was perfoming the procedure. But most important was the almost complete lack of communication - either from the 2 nurses who were assisting, or from the consultatnt - or anyone.

While waiting for a scan, I saw a very distressed elderly gentleman on a trolley in the waiting room, who was calling out for his wife - and was completely ignored by the nurse who was in the room.

In the social care field we are increasingly pushing the message that the way in which staff relate to the people using the service is one of the most important aspects of quality. If you can do anything to help healthcare staff to understand how important it is that they relate to patients in a kind, friendly and caring manner - you will be doing a great job.

#2568 Dr Paquita de Z...
GP, Therapist, mentor and medical ethics teacher
Includes Imperial College, King's College and London Deanery

I agree with you that healthcare workers' stress and burnout has to be addressed - some of this stems from the nature of the work itself (emotional labour), some from personality factors and low self-compassion, but much of it from unsupportive teams, coercive management, emotionally unintelligent leadership and unrealistic expectations. Above all there is a loss of direction as to what really counts in healthcare. Professionals experiencing loss of control and autonomy and the inability to deliver the kind of compassionate and competent care that they aspire to leads to moral distress and cynicism.
I would put in place on-going regular resilience training (including CBT, mindfulness and compassionate mind training) and embed mentoring and supportive supervision at all levels, as well as leadership coaching. I would ensure that institutions prioritise patient outcomes and quality indicators, as well as the wellbeing of their staff, NOT financial and spurious targets . We need a more systemic approach and a real paradigm shift away from old-fashioned management view of the organisation as machine. I fear that this will not happen in time to avert yet more damage and dehumanisation of vulnerable patients.

#2800 Mike Stone

'My work as part of our Point of Care programme has made me recognise that frontline staff often feel powerless to challenge practice in the face of what feels like a monolithic system.'

Whenever 'why don't nurses seem to really care ?' crops up on the Nursing Times website (and, indeed, often when a case of a nurse having amde a mistake comes up) the standard cry is:

'We don't have enough time - we need more staff !'.

That then moves on to 'nurses are routinely ignored' and 'many of the nurses who move into ward management, instead of fighting our corner for increased staffing levels, seem to just push the senior management line of 'you are not using your time properly''.

I recently posted the following, in an NT piece about 'new money to promote 'caring'':

The first 5 comments aside from mine, in my opinion touch on almost all of the issues for this one.

Judy Mewburn’s comment is the way most aggrieved patients and relatives see the problem: ‘they didn’t really seem to care’ to put it plainly. That isn’t saying that nurses on the whole do not care, or that nurses are not sometimes prevented from ‘caring’ by being over-worked – I said ‘most aggrieved patients’. As I have said before, passengers do not concentrate on the good landings.

There is a fairly widely-held perception, that somehow some of the emphasis on ‘caring’ has been lost, as treatments have become more sophisticated and complex over the years, and as nursing has developed to include things such as prescribing: I am aware that various reports, and NT and many nurses, say the perception is flawed – however, some ex-nurses have expressed the same perception.

When Anonymous | 14-Oct-2012 10:40 am writes ‘The fact that senior nurses are now having to go on a course to learn how to be a decent caring nurse is pathetic and a sign that nurse training/recruitment has gone down the plughole.’ I tend to agree: also, it isn’t 100% clear to me whether the nurses on these courses are there to be taught how to be ‘caring’, or whether they are being taught how to promote ‘caring’ amongst colleagues. Either way, surely the ‘caring’ is so fundamental, that the intention to ‘care’ should be present by the time a nurse qualifies ?

I think this approach, is probably a bit ‘cart before the horse’. I think the right ordering is:

1) Make sure there are enough staff working, for them to have a little time for ‘caring touches’ – at the very least, enough time to not invariably appear ‘brusque’;

2) Make sure that nurses can challenge management diktats that promote ‘non-caring’ without fear of being victimized;

3) AFTER doing the previous two things, so that the working enviroment gives nurses the opportunity to be caring and compassionate, THEN investigate/address any remaining problems re ‘caring’.

#2882 Kimi

I feel that Nurses are the scapegoats everytime issues about care come up. Its good that the article talks about hospital staff and not just doctors and Nurses It is interesting to note that complaints about Doctor's are rising. Therefore the issue of "caring" goes beyond nurses. Any action taken should target all clinicians.
At Mid Stafford the nurses got reprimanded severely and the Doctors only got a slap on the wrist.

#5528 Richard Arkle
Dinwoodie Settlement

All the discussion is about the staff not the patient. There is not a single suggestion for empowering the patient....surely that is where "care" has to start....by listening to and understanding their needs and meeting them at the time of the treatment and subsequently in reviewing the outcome. What steps are being taken to improve this basic process and to put the patient at the centre of things rather than the staff?

#6939 Mike Stone

Richard Arkle

Spot on - you need to work outwards from the patient !

#39919 Dr Paquita de Z...
GP, mentor and clinical ethicist
Imperial College, Human Values in Healthcare Forum

I agree. Patients should be involved at all levels of decision making and should be included in executive board meetings regarding patient care. This has been done successfully in some hospitals. Patient participation groups in some general practices work well too. I have been a patient with a life threatening illness as have two of my children so I know what it is like on the other side of the tracks.

#544305 kenneth skeete
Iwokrama International

As a medical personnel my aim is to improve the standard of care in such a remote part of my country. i am looking forward to implement this timely information within our institution.

#544307 kenneth skeete
Iwokrama International

I totally agree

#544559 dr fiaz fazili

When establishing performance standards you first need to determine what to ... Performance expectations must be about the individual, not the team or the business. To perform well, employees need to know what is expected of them. The starting point is an up-to-date JOB description that describes the essential functions, tasks, and responsibilities of the job...policy procedures..OVA_ observsation avvidenta variation reports--
how can we do better?...
Performance Expectations = Results + Actions & Behaviors

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