Jill Maben: What is the impact of staff wellbeing on performance and patient experience?

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  • Posted:Wednesday 20 January 2016

Jill Maben, Professor of Research in Nursing and Director of the National Nursing Research Unit, King’s College London, shares the results of studies into the relationship between staff wellbeing and patient experience.

This presentation was given at The King's Fund's event, Encouraging staff wellbeing in health and care, on 14 January 2016.


So it is my great pleasure to be here. Staff wellbeing is my absolute passion. And as a nurse I have seen, and felt firsthand, the importance of that.  At one stage in my career I did leave nursing I thought for good.  I had experienced a lot of stress and burnout and I thought I would never come back, I did, but I never thought I would be standing here as a professor of nursing.  At one stage in my career I went and studied history for a while.

Anyway, I am here, and really delighted to speak to you. So what I am talking about today is what is the impact of staff wellbeing on performance and patient experience? And going to be drawing on that study and another study which was undertaken a while ago which was my PHD, which looks at the erosion of values and ideals in nursing students.  So I am going to be sharing some research, just to start with I just wanted to reinforce some key points that I think is really important about being a healthcare worker.  It is not the same as going to work in many other professions.  It is not the same as being a lawyer, or going to work in a shop, because one has to bring one’s own self to work in so many different ways.  And one experiences what I call the sort of 3Ds, distress, disease and death.

And I am going to start with the photographs. Some of you may have seen it, it actually went viral. For me it sums up a lot of what I hear about in my work and what I see, and it is an image of what I think is staff wellbeing at work, and it is one of those negative sides of it.  And I am going to tell you a bit about this photograph if you don’t know about it.  And what it is, it is a photograph taken outside a Southern California hospital, this is an ER doctor, and he is crouched down against a concrete wall grieving the loss of his 19 year old patient.  A paramedic snaps this photograph, and his co-worker, a close friend of the doctor, posts the photo with permission online, minutes after the photograph the doctor returns to work.  Thousands of people have commented on the web on this photograph.  It spoke to people, it facilitated others I think to speak, and it revealed what I see as the human side of healthcare professionals, that some of us may have experienced ourselves and some of us may see in our work, and which I think many patients appreciate and see too.  But I think the photographer has captured a really poignant moment in a stoic profession that trains doctors to remain professionally distant.  The photograph reveals the emotional reality of doctoring, and a side of physicians that people don’t usually see while uniting us all in our common humanity.

There was quite a number of other doctors and nurses and other paramedics and so on who posted comments sharing their emotions and prompted by the photos, and I just wanted to share a couple of those which I think sort of reinforces the point I am trying to make about the 3Ds, and the things that healthcare professionals have to experience. So this doctor said ‘I know what that person is feeling. Yesterday one of my 17 month old patients died.  I was in the bathroom crying between patients several times yesterday.  I have cried in stairwells and hallways, it eats at you.  Life is very fragile and the pain of losing those we are trying to help becomes a scar that doesn’t go away, it has shaped who I am as a person’.  And another has said ‘When it comes to our work, nothing is harder, and I mean nothing, than telling a loved one that their family member is dead.  Give me a bloody airway to intubate, give me the Heroin addict who needs IV access yesterday but no-one can get an IV.  Give me the child with anaphylaxis, but don’t give me the unexpected death.  We can only do so much and we can only hope to do our best, but it is that moment when you stop resuscitation and you look around.  You look down at your shoes to make sure there is no blood on them before talking with the family.  You put your coat back on and you take a deep breath, because you know you have to tell a family that literally the worst thing imaginable has happened.  And it is in that moment that I feel and I feel like the guy in this picture’.

There were many like this, incredibly moving, quite profound comments about what it is like to experience this day after day. And these are not only just one off experiences, some people experience in many settings this every day. And a doctor in my most recent study which examined relationships between staff while being in patient experience, I am going to tell you much more about.  She said ‘Everyone will say you need to be good at communicating, you need to be good at basic science.  One of the main things I think you need is resilience, because you work in a job that knocks you down constantly.  You have just got to brush yourself off, pick yourself up and say that was bad, that was awful, but here we go again.  I think if you take it all home with you and you take it all on board, you simply wouldn’t be able to come back to work the next day’.

But I have long argued and I think people often see this as a personal responsibility, and clinicians see that too, what am I doing, what am I doing wrong, how can I do this better? But I have long argued that this shouldn’t only be a personal responsibility, staff need a good work environment to flourish, and enable them to give good care, and I think we know much more about that now. And a lot of my work has been identifying what that good work environment looks like, and I will come back to that.

But I just wanted to take you back a little bit in time, because I think it was important, and I think many of you will remember this report, but in 2009 Steve Boorman report into staff wellbeing at work, I thought signalled the start or I hoped signalled the start of a new era where wellbeing at work began to be seen as important in healthcare. I leave it to you to tell me if we have still got that momentum. But just taking you back to the Boorman report, I know you will be very familiar with this many of you, but I thought it was worth recapping.  And the Boorman team undertook a staff perception survey of over 11,000 NHS staff.  And over 80%/85% of staff felt that their health and wellbeing did impact upon patient care, and virtually none disagreed.  And I think the data correlation you can show down the bottom there, goes back to many of Michael’s points about where organisations are doing well, what are the good organisations?  And the links between absence and turnover rates and patient satisfaction and so on.  And you can see those green and red ragged rated Trusts there, those that are doing well, and those that aren’t, and you can see the correlations I think between patient satisfaction and rising absence rates and turnover rates and so on.

So based on the last 20 years of my research, I have argued that supporting staff well at work is really key to enabling them to flourish, to be compassionate and to care well for patients. It is also key to creating positive environments for staff to work in, particularly attending to their psychological wellbeing. And I judged the Nursing Times Staff Wellbeing Awards.  And I don’t want to knock all of the fabulous health and wellbeing work that goes on, of course we need people to be healthy, physically healthy, to be doing Zumba classes and so on, but that is not what I am really interested in, and it is not what I am really talking about here, I am not.  Sometimes I see submissions and I think isn’t that what a good health department does?  I want to see something different, I want to see something that is really enabling staff to support them, to care, and to do this difficult work day in/day out.  So I am talking about psychological wellbeing at work and I am not particularly talking about exercise and physical health, not that that isn’t important, but it is not exactly what I am talking about.

So in 2008 I started this study, this is a study that finished in 2012, it was a nationally funded NIHL study. And it was looking at the relationships between staff wellbeing and patient experience at work. I think at that time it was sort of self evident.  We had Michael’s work and we had some work that it was self evident that patient experiences were influenced by staff wellbeing, we had some evidence, but we didn’t have that much evidence in the NHS, and we didn’t have that much evidence at the team and individual level.  Quite a lot of the work were linking staff surveys and so on that you couldn’t necessarily get down to the individual unit level and so on.  So I wanted to kind of really unpick that and unpack that and say okay well what does it look like when you actually talk to people in those teams, get to those teams, and get to the patients looked after by those teams?  So that is what I was doing in this study.

So it was looking at the link between staff wellbeing and patient experiences of care, and looking at which dimensions of staff experience and wellbeing impact on relationships of care, and which organisational and contextual factors most shape experience of work and experiences of care in healthcare organisations. So it is this point about does happy staff mean happy patients? There has been much work undertaken outside of healthcare, that continues.  Many large companies definitely believe that.  We are very, very close to one, and I am sure many of us will be there at 4:00 this afternoon, that is John Lewis, also the Disney Corporation.  But John Lewis’s motto, I don’t know if you know their motto, but their motto is partners first.  They don’t talk about customers, they don’t talk about us the punters.  They talk about their staff, their staff are partners.  And they say ‘Partners first’.  And for me that is really significant.  And the significance of that is that they understand that if they look after their staff, good customer care will follow.  That is their prime objectives, care for staff, and good customer care will happen.

This is when I was director of the national nursing research unit. Unfortunately our funding ceased so we no longer have a national nursing research unit. The Department of Health decided not to continue that, but that is another story.  We produced these policy plus, which are two sided briefings which summarise the research.  You can find those on our website, I can provide you with the links.  This summarises this research.  I have also given the link to the research report at the end of this presentation which I will make available so you have got access to the evidence.  But what we did was we looked at four organisations, and we did eight case studies.  So in each organisation we looked at two what we called Microsystems.  So it was where patients were cared for in the system.  So it was maternity, emergency admissions, medicine for older people.  So medicine for older people for example was four wards in this hospital.  So there were two acute trusts and two community trusts, we wanted to look at both acute and community.

And okay how did we decide they were low performing and high performing? Well we looked at nationally available data, we looked at the staff server, we looked at the patient server, but we also interviewed a lot of senior managers and people in the organisation, including occ health managers, including union representatives, including the chaplain, but also the CEO, and the chief nurse. And we said ‘Okay, where do you think staff wellbeing or patient experience is good in your organisation and where do you think it is poor?’  And do you think they knew?  They did, they absolutely did.  They could point us in the direction of these challenging areas, and they could say ‘This area is really, really good’.  And there was a lot of correlation across those different people we talked to, so that was really interesting for us as a sort of first finding of...people in organisations, you all know I am sure, where is doing really well and where the challenges are.

And interestingly in medicine for older people, one of the challenging environments, they had put in a tactical team if you like from HR, a sort of bit of a turnaround team to go and talk to staff. And that had started to bear fruit, but there were a number of other challenges there that I will come back to, because I think it is important and it unpacks a lot of what Michael was saying. So the study involved over 200 hours of observation.  We followed staff around, we stood in bays, we watched care.  We interviewed these 55 senior managers and other people I have talked about.  100 patients we interviewed, 86 staff, and we surveyed patients and staff as well, 500 patients and 300 staff.  And the staff in this, I am a nurse, we surveyed nurses, doctors, AHP’s, healthcare assistants, so it was a whole range of clinicians who give direct care.

So what do I mean by staff experiences of wellbeing at work? What I mean, and I have taken this definition from Warr, it means an individual subjective experience and functioning at work, what it feels like to be at work. What does it feel like to be a member of this organisation, this team?  What is my wellbeing?  We unpack that and I will show you the measures shortly to operationalise that, these measures of things like job satisfaction, feelings at work, as Michael said affect motivation, emotional labour for example and burnout.  And the staff experience varied quite significantly I guess across those eight case studies.  Now you say well that is obvious because you kind of went looking for poor and good. Well we did, true.  But staff in many settings spoke of high job demand and low control and that leading to emotional exhaustion, stress and some burnout.  Staff also spoke of bullying and an unsupportive work environment resulting in poor wellbeing at work, and that was the medicine for older people area I am talking about.

Other staff felt well supported by colleagues and managers, and suggested that this idea of buffering, that it kind of supports and buffers some of the pressures exerted by the challenges of day to day patient care. So support from colleagues and managers really, really important. Social support from supervisors and co-workers and the organisation more generally had a positive effect on wellbeing, by helping to reduce or cope with these feelings of exhaustion and at the same time enhance satisfaction and positive effect at work, these feelings and responses.

Interestingly high job skills and competence were identified as important in that they help to reduce or minimise emotional exhaustion. And I was talking in the break to a colleague around some of the challenges of twelve hour shifts, and I think some of the challenges I see presenting for nurses in particular is they don’t even now have autonomy about when they take breaks, who they take breaks with, whether they take breaks with their colleagues. When I was in practice, one of the ways that really helped buffer my feelings and the challenges I have had, if I was having a really difficult morning or someone had died and I wanted to talk about it, I would go and have lunch with my colleagues for an hour, and I would debrief there.  Or I would go to the pub quite frankly after work, after an early.  That can’t happen now, because people don’t finish shifts until 8:00 or 9:00pm, and they only get two half hour breaks.

So I am going to come on to it shortly, but I am doing a national evaluation of Schwartz Rounds, and I am going to tell you a bit more about what they are if you don’t know. But they take an hour at least at lunch time. Well what I am finding in the study is mostly nurses can’t go, nurses and midwives can’t attend Schwartz Rounds, this place for reflective practice.  So what I see in our NHS at the moment is so little time for staff to get together and process feelings about what it is like at work, to talk, to even get to know each other quite frankly.  So I think that is a real challenge that we are experiencing nationally, and I think it has a really detrimental effect notwithstanding the challenges of caring over twelve or thirteen hours.  So I think that is a really interesting and negative development, and I can talk endlessly about twelve hour shifts because I have done some work on it.  So do come and talk to me about that, I will answer questions at the end.

But going back to this study, what we found was that staff wellbeing was this important antecedent. So that there is a relationship between staff wellbeing and staff reported patient care performance. We asked staff to rate their own performance and we asked patients to report patient experience.  So that staff wellbeing is this important antecedent so that it is the experience of healthcare staff that shapes patient experiences of care for good or ill and not the other way around.  I think there was some thinking that it was patient experiences that affected staff wellbeing, well it isn’t.  We are now saying this is an antecedent, so you need good staff wellbeing to enable patient care to happen.  And there were these seven what we called staff variables, and we called them the sort of wellbeing bundle, that correlated positively with patient reported patient experience.  And I am going to show you a slide that visually represents that in a moment.  But these were the seven.  And this was quite different from the evidence from outside of healthcare.  So from the evidence when I did this study, outside of healthcare, it was the organisational climate that was most important in other organisations.  And these are in order of importance.  You can see organisational climate is fourth on the list.

But what was most important was the local work group climate. Now I can see nods, and of course when you say it, it makes intuitive sense. It is who you work with, it is your team, it is the people you spend every day with.  Of course they affect how you feel.  And it was really important in a healthcare setting, because you rely on each other, and you support each other, and you help each other out, so that was critical, and I will come back to that.  And part of that was co-worker support, and that really helped job satisfaction.  The other things were important too, organisational climate, perceived organisational support, low emotional exhaustion and supervisor support.  But the local work group climate was the top one.  So bear with me, this is a busy slide, and I will explain it.

What you are seeing there is plotted. So along the bottom are the eight microsystems, the eight services, EAU, emergency admissions, maternity, medicine for older people, haematology etc. and then the community nursing services. And the hard lines are the staff survey report presented.  So you have got organisational climate, local work group climates, the red one at the top.  Job satisfaction is the green one, emotional exhaustion which is reversed, positive organisational support, supervised support, co-worker support.  And then the dotted lines are the patient experience data from the patient experience questionnaire.  Now we used a number of different measures.  And what you will see is not only do they follow each other, but they also pretty much mirror the staff experience.  So what I have highlighted there, and there, are two areas where staff wellbeing is low, and what you can see is so is patient experience.  So the different dots there was the picker for the patient experiences, different versions of picker, and then peach is actually a questionnaire of the patient’s emotional experience of care in hospital.

So we are quite specifically trying to pick up on how it felt for patients, you know? Were people giving them eye contact, were they standing too close, too far away? Were people raising their eyebrows at them?  Because you can get lots of non verbals as well as quite difficult language from staff, so peach measured that.  So hopefully what you can see here are the good areas which was haematology, next to the second red one, was where patient experience was really high, and staff wellbeing was much higher.  This is haematology here, so you can see that a lot of staff wellbeing issues were peaking and there was good local work group climate, that is this one, good co-worker support.  But look at this emotional exhaustion, this is not so good.  And what we found when we did the interviews there was that staff in the haematology environment were prioritising good patient care almost over their own wellbeing.

So what we hypothesised was that over time the new staff in that environment wouldn’t be able to stay, they would be leaving. They would be burning out quite quickly and leaving because they were putting all their energies into giving this great patient experience whereas here staff were having a really terrible time, very poor staffing and so on, very demanding environment, and patient experience was equally not good. And the same here which was community nursing service here, this was a Trust in a great deal of trouble quite frankly, a revolving door of managers.  Every time we went back to collect data there was a new leader, a new manager, it was really demoralising for staff.  They were going into patients’ houses, not really knowing what they were supposed to be doing, giving the minimum of care and frankly getting out which was very distressing for patients.

So I hope this sort of illustrates the point I am trying to make, that where you get poor staff wellbeing, you get poor patient experience. And I am going to just unpick some of that data here. So I am going to go back to one of these key factors that really shaped staff experience, and that was this local work climate.  And people talked about having a family at work, and how important that was to feel that you had colleagues that you could rely on and a family at work.  I am going to focus on the medicine for older people ward.  There were so many different challenges going on.  The ward manager on certainly one of the wards, they had had about three or four in the last year, so there was no continuity of leadership, no sustained leadership.  There were real fissures and fractures in the staff groups, so it was healthcare assistants or registered nurses, but quite frankly never the twain shall meet, and both distrusted each other.

There were different BME and ethnic groups. So often there were groups in the healthcare assistant workforce who either didn’t get on with each other or who didn’t feel included. There were quite a lot of Black African nurses who didn’t feel part of the team at all.  And there was a lot of bullying and quite difficult behaviour.  I was really quite shocked when we went into a meeting and somebody spoke and there was eye rolling by three or four other people in the room.  And I am thinking wow if you do that when I am here, an observer, what are you doing when I am not here?  Our interviews talked about this bullying, and people said ‘We used to be a family.  We used to be a family here and it is kind of something has happened’.  And all I am trying to say to you is this needs nurturing and sustaining and supporting by team leaders and managers, and you need to create environments where people can get together and be together.  And another ward was talking about how they very actively planned teas for staff so that they had an opportunity to do something that wasn’t work, to actually socialise together.  Because I was saying earlier, a lot of these experiences and opportunities to be together and talk and get to know each other as staff have been lost.

The keys here were the family at work, I have talked about, the importance of this local work climate, the demanding work, this high demand work with little control and what we saw in some areas with really poor staffing levels. And since we did this work, we have been sort of having much more of a national debate about what is good staffing, what does it look like, what should the numbers be? Should we have a minimum nurse ratio in this country as they have in Australia and other places like California?  And job satisfaction.  And key to that was the ability to deliver high quality care.  I don’t need to tell you that healthcare professionals come into the profession, and come to work every day wanting to do a good job.  Nobody pitches up for work thinking I am going to give bad care today.  And so that is really the core value for people, I want to give good care.  And the frustration in some of these wards, particularly in the medicine for older people ward, was if I can’t give that, I might as well not be here, it is really demoralising, I am de-motivated, and my job satisfaction is nil.

And interestingly from our data, patients noticed this too, they noticed the difficulties of caring work. So Gloria said ‘I shouldn’t like to work here’ and Rose said ‘I think it must be really traumatic in lots of ways’. Obviously they are faced with a number of people who don’t recover who die.  In fact on the first admission three people died in the ward I was in in a week, so that must be traumatic for them to deal with that.  Everybody in that ward was very ill and they spent so much time looking after them.  They could spend an hour changing someone’s dressing or giving them a bed bath or something.  So if we don’t think patients notice, my goodness they absolutely do.  And then not only do they judge their own care, they judge care by the care they see others receiving.  And the paperwork, not only something nurses moan about, but patients notice too, is so tremendous.  Everybody is filling in forms and charts and everything which leaves little time for the bedside.

And this was a paper we wrote, trying to make sense of some of this picture in this older people’s care environment in these four wards. And we drew on the unpopular patient literature. Some of you may know the original author Felicity Stockwell, she wrote a pamphlet about unpopular patients, in mental health settings actually, in the 1960s/70s.  And we drew on that to highlight how in poor ward and patient care climates, staff sought job satisfaction through caring for the poppets, leaving less favoured and often more complex patients to receive less personalised care.  These patients ended up feeling like parcels.  So staff make work satisfying by selectively giving compassionate care to the sort of rewarding poppets.

And our field work observations and informal conversations with patients indicate how on one of these wards really staff tended to negotiate their work tasks with reference to bed numbers, so rather than saying ‘I am going to see Mrs Smith’. ‘I am going to see the fractured neck of femur in bed one’ or whatever it was. And patients on this ward were also less likely to be greeted by nurses who cared for them.  So I observed people going into the room and not even saying hello, just marching in and getting on with the work and tipping people out of bed or whatever.  And there was frequently very little personalisation of care.  Our observations indicate that these dehumanising aspects of care were not lost on patients.  So this patient said in the end ‘I feel like I am being moved around like a parcel, I am being moved like a parcel from chair to commode to bed.  I feel like a parcel and not a person anymore’.  And conversely the poppets, those patients for whom staff felt particular sympathy, those with no frequent visitors, or perhaps who reminded them of a close relative, said...this is a healthcare assistant actually talking about a poppet, and she said ‘They have got something that just endears you to them, and you feel oh she is gorgeous, you just click with them as well’.

And so we argued that staff may through this discretionary care, and some other of my colleagues have talked about nurses having to ration care, and I think that very much happens in a day to day moment. You have got to think do I do this, or that or the other thing, you know? There is only one of me.  And think about what that feels like as a member of staff, you know?  You have got two people falling out of bed and one person wants to go to the toilet, which one do you pick?  Who do you deal with, and who do you give good care to?  Actually you can’t give it to all of them.  And so through this discretionary care staff offer good care selectively to some patients enhancing staff satisfaction in an otherwise unsatisfying work environment.  Such good care was undertaken at the expense of time and attention owing to less favoured patients with less rewarding direct care needs.  Staff talked about patients being needy.  They didn’t talk about them having needs, they talked about them being needy in this very impoverished work environment, and you can see how these issues build.  And this is the place where there is bullying, and you haven’t got supportive staff, and inevitably it impacts on patient care, you can see that, you can see it happening.  You can see staff not wanting to work with the other member of staff, so it takes two people to get Mrs Smith out of bed.  You don’t ask so and so because they are not being very nice to you, they are the bully.

We could definitely see issues of staff wellbeing directly impacting on patients and that is what we were arguing here. And this paper was a paper I wrote some time ago with another colleague, and I think what we know is that nurses derive significant job satisfaction from patient care work. And reviewing the literature with colleagues, what we found was this consistent picture of an ideal nurse/patient relationship emerged.  And the ability to create therapeutic relationships emotionally impacted on nursing.  And nurses aspired to this, and they wanted to connect with patients, they wanted to get to know individual patients, and they wanted to involve patients in their care.  And meeting these aspirations I am arguing is my key to nurses’ wellbeing.  It is really key to their job satisfaction and their wellbeing at work.  And if nurses can deliver care of a quality that matches their personal aspiration and that is best for that patient, they experience feelings of gratification, personal enrichment and privilege, but if not, they experience moral distress.  And the same review found that that was particularly true with dying patients where they couldn’t relieve suffering, where they were caring for patients with dementia, and caring for older people where they actually didn’t have the capacity as I was just saying just a few moments ago, to provide adequate care.

And we quoted somebody from one of the papers who said ‘I think it is like a plastic shield that you put up. And I think if you stick at it long enough, and you are in the job long enough, it becomes a natural way’. So this idea that as an individual person managing your own wellbeing, you have to do something, you have got to protect yourself, and what you do is you stick up a shield.  And then we wonder why nurses are charged with not being empathic and compassionate and so on.  It is the work environment I am arguing, first and foremost.  And I have argued too related to this that in the Francis report there was one of the recommendations that we needed to recruit people with the right values, the right ideals, and of course I wouldn’t disagree with that at all.  But implicit in that was somehow that we hadn’t been.  That we had been getting the wrong people, that we had been recruiting all these bad people in the NHS.  I would ask a different question.  What if we had been recruiting the absolute best people, the right people, with the right ideals and the right values, coming into nursing for exactly the right reasons?  But actually that through our system and through the NHS and the culture that we provided, we were doing something to these good nurses?  And somehow we were eroding their compassion, and their ideals.

And I don’t ask this lightly, it is based on research, and I am going to take you now to a study. It was my PHD undertaken over ten years ago. And what I did was I asked nurses at the end of their course... so these were student nurses in their third year.  And I said to them, “As a qualified nurse, what do you anticipate will be your ideals for practice?  That is if you were able to nurse in practice in any way that you wanted to, what would be the kind of care you would like to give?”  So trying to tap into what were their motivations, what they learnt on the course, what did they think the core essence of nursing was and how did they want to work?  And they said ‘I want to be at the bedside’.  ‘I want to give individualised care’.  ‘I want to be holding the hand of a dying patient’.  ‘I don’t want to be away from the bedside doing the paperwork’.  ‘I want to give evidence based care’.  ‘I want to give good care’.  So they talked about that.

And so I then rather cruelly went back to them when they had been qualified six months, and when they had then been qualified again between twelve and fifteen months, same people. And I said, “Remember you said this?” Had it all written down.  “Remember you said this?”  So their individual statements of what they had said, I took it back to them.  “Can you do this?  And if you can what helps, and if you can’t what gets in the way?”  And these are the results.  So there were 26 people who I followed longitudinally, and I found these three groups that I have called here sustained idealists, compromised idealists and crushed idealists.  And the sustained idealists there are only four, that is the blue segment, they were people who felt that they could, they could practice these values and ideals.  The way they wanted to nurse, they could do it, they could do it in practice.  And they talked about that environment, what enabled them to do it?  And they had good role models, they had good feedback, they were in environments where they felt very supported.  I didn’t ask them if they had appraisals.  But they did get feedback and they felt supported, and they felt that they were in an environment that had the same philosophy of care as them.  That they were supported by their ward manager and others to give those values, to do that.

Interestingly of those four, two had to move areas to find that, so it wasn’t immediate. They had to move to a different area. And what I saw was quite a number of these people what I call job hopping.  They were seeking this ideal environment.  They couldn’t find it in one place, so they went somewhere else.  Compromised idealists were actually the ones most in crisis really, because the crushed idealists quite frankly had already had such a terrible time that even by fifteen months they were thinking of leaving nurses.  Think about that, these are new nurses.  We have invested in their education, and they want to be nurses, and they are finding that they are compromising their ideals on a daily basis.  They are not able to give the care they want to give, that might be because of poor staffing, but often they were in environments that had no good role models.  And although they talked about negative role models being quite helpful...so if you saw somebody who you would think oh I don’t want to be like her, I definitely don’t want to be like her, that could be quite helpful as a counter balance.  But if there were too many of those people and not enough good role models, it was actually very detrimental, and you just thought you were sort of swimming against a tide, and I can’t do it here.  So they would try and get another environment.

But the compromised idealists were still trying. They were the ones sort of stuck in the middle. They were compromising one or more of their ideals on a daily basis, but they still felt that it was possible.  And actually they were in quite a lot of moral distress going back to that earlier slide.  And it is not only nurses.  I found this when I was making this argument about recruiting the right nurses, but in eroding their ideals, I found this in the Boston Globe saying that there was an empathy gap in medical students.  ‘Stress can harden students’ attitudes towards patients’, well that sounds quite familiar around nurses.  But what they also found, this study, found that medical students come in with a lot of idealism, they want to be of help and service, and then something starts to happen when they are exposed to clinical care.  I could have written that from my study.  So it is not only happening in nursing, it is happening in medicine too, and there is other evidence to suggest that the high ideals that students bring into the profession get eroded and get replaced in practice.

So to conclude, what I argued here with Jocelyn, from the Point of Care programme, we were talking about the importance of compassion here. But what we have talked about is really relating to patients takes courage, humility and compassion. And it requires constant renewal by practitioners and a recognition, reinforcement and support from colleagues and managers, and it can’t be taken for granted.  And I guess what I want to put to you is my suggestion that actually it has been taken very much for granted, and that we haven’t been investing enough in the support for our new students, our newly qualified nurses and others, in terms of supporting them well, creating these work environments where it is good to be, good to work, that reinforces why you want to be here, why you came into the profession in the first place.

And just dipping back into the Boorman report, we haven’t got a question like this since then, but I suspect this hasn’t changed, given the situation in the NHS, but in the Boorman report less than 40% of staff believe their service proactively tries to improve staff health and wellbeing. And these other issues also exist that the staff talked about. So the cultural barriers, the management practices, less than half of staff believe their concerns are listened to.  And we also had that from the Francis report.  It wasn’t that staff weren’t speaking up, there were plenty of staff speaking up, no-one was listening.  And staff believed it would require a massive cultural change to see it as a professional duty to take care of ourselves and each other.  And I think that is our challenge in this room really.  How can we put this centre stage?  How can we make it as important to take care of each other as it is to take care of our patients?  So that it is not all doom and gloom, I will end on a little bit of an upbeat notion.  And I am going to talk to you very briefly about Schwartz Rounds.  So Schwartz Rounds came from the Centre for Compassionate Care in Boston in the US.  The man in this picture here is Kenneth Schwartz, he was a man who had lung cancer in his forties and died.  And during his experience he noticed that some care givers as he called them, nurses, doctors, some were able to connect with him, and be empathic, and talk to him about their children, and his children, and really engage and support him, and others weren’t able to do that.  And interestingly the same staff were able to do it one day and not another.  So it made him think what is it like to be a member of staff?  What is it like to be in an environment caring for young people who are dying for example, who might be your age, who might have children the same age as you, what is that like?

So in his memory when he died the Schwartz Centre for Compassionate Care was set up. And his oncologist and his cancer nurse specialist and his sister in law, decided that they would create what became Schwartz Rounds. And they created this environment where staff could reflect on the social, emotional and ethical challenges of caring for patients.  So it is a reflective space, it is a multidisciplinary reflective space, where staff come together to talk about these difficult situations.  They run for an hour, they have now been brought to the UK by the Point of Care Foundation, I am currently evaluating them nationally.  So we are looking at nine case studies and we are trying to measure impact, really difficult.  How does being in a room for an hour, how does that impact on your own wellbeing?  How does it change your practice if it does at all?  But the idea is it makes you more empathic and compassionate, by sharing and reflecting, that makes a difference.

And so there is a panel of clinicians who will talk about either one case, they all talk about the same case from a different perspective, or they might talk about different things. So it might be like a patient I will never forget. And they will each talk about a patient they never forgot.  They talk for about 20 minutes, then it is opened up to the floor and others reflect, it is facilitated.  The important thing is to make it a safe space for staff to reflect and be able to share with each other these challenges.  And there were also other support systems like restorative supervision.  Some places have been buddying staff like they do in the Samaritans, putting staff together so they have got someone to talk to, and so on, and emotional resilience for staff.

So there are some interventions that I think help support staff, but watch this space. That was all I really wanted to say to you, I hope that was helpful.


Phil Strong

Designer MD,
Ergo Ike Ltd
Comment date
25 January 2016
All reactive!Wheres the initial proactive approach?Presented in a rushed
typically medically orientated manner and language.Knee jerk united!

Jenny Firth-Cozens

Comment date
30 January 2016
Good to hear the ways that Jill has taken forward the work I started in the eighties and in the ways we discussed back in 2008. Sadly studies like this have to be redone every decade to remind employers that staff health matters in itself and to patient outcomes. This is particularly important in the current bullying, understaffed and driven culture of the NHS under the present government. But how sad we need to repeat such obvious research over and over rather than accepting what every patient knows - that healthy satisfied staff produce safer, more compassionate care.

Sally Pezaro

Doctoral researcher,
Coventry University
Comment date
01 February 2016
Absolutely love this programme of work. So desperately needed! Working on this topic myself - agree we need to be working on a solution. Most importantly - lets keep this on the agenda!

linda latham

Service Manager/ RGN,
Health Service Executive, Ireland
Comment date
12 July 2021

Very interesting and motivating speaker! Love her ideas on moving out of nursing and now wholly embracing reflective care.
Very relevant currently and to my particular services caring for victims of trafficking in the state.
thank you.

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