Improving patient experience: it's the little things that matter

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It has often struck us, on the Point of Care team, how the smallest actions on the part of staff can make a huge difference to patients' experience of care. We've spoken in depth with patients and staff about their experiences of receiving and delivering care, with fascinating, insightful and, at times, emotional results.

When we carried out interviews with 15 cancer patients and 31 staff involved in a patient-centred project at Guy's and St Thomas' hospital and King's College Hospital everyone agreed that, despite excellent clinical care, there was potential to improve care in ways that did not involve more work for staff or great financial investment.

Patients remembered small acts of kindness with gratitude, and many were impressed at how their privacy and dignity had been safeguarded. One patient told us:

'Once, the nurse needed to wash my hair. She was quite young and she was aware that I didn't want to strip off. She said that if I wrapped myself in a towel, she could do it in the bath. I really appreciated that.'

Patients also recalled a volunteer offering nail care to distract patients on the ward; a clinic clerk who always gave outpatients the name of a specific member of staff to ask for on arrival; and staff arranging an early Christmas for someone who was dying.

But a single negative experience, particularly if it was perceived as unkind or grossly insensitive, could tarnish a patient's entire experience of care. Such instances were rare, however. More frequently, patients criticised that staff did not proactively offer support, even if they provided it on request.

Patient choice and the promised 'information revolution' are key to the government's proposals for NHS reform. Some patients we spoke to had problems finding good information, citing poor-quality leaflets and a failure to correct written information following feedback. One person we interviewed felt that patients were not always given the right information to give their informed consent to treatment. As she explained:

'With cancer care, we patients have to 'buy the product', but you don't get told the reality of what you are signing up for, eg that radiotherapy may only be ten minutes on the table but it is four hours in the department. It's not as though we are going to say we don't want it, so why don't they tell us?'

These concerns could be addressed without any major policy shifts or significant cost.

In particular, many patients spoke with emotion about their distress at poor environments, seeing them as symbolic of everything that was negative about their illness. Waiting areas were the biggest concern, and although some alterations might require considerable investment – refurbishing seating areas and 'airless, windowless, claustrophobic' chemotherapy units, for example – others could be addressed much more easily, such as adding pay-phones in areas where mobile phones do not work. As one patient eloquently put it:

'When I had my assessment CT scan they had a huge fish tank that was empty. Either get rid of it, or fill it with fish!'

Even in these financially challenging times, when refurbishing a waiting room may be pushed further down the to-do list, staff can make small changes to help to enhance the environment for patients. Bringing tea and other drinks for patients in the waiting area can make a real difference to a long wait. And introducing art into the patients' areas can also be beneficial:

'I am always struck by how art installations tend to be in the corridors and areas where people pass through – not where the patients are. There is evidence for the therapeutic benefits of art and beauty – these things do make a difference.'

Most patients appreciated efforts to involve their families. One staff member said that they would reschedule a patient's appointment if a family member was not able to make the appointment time. Simple considerations and small changes can make a big difference.

So how can we ensure that staff have the time and, more importantly, the motivation to make these changes? We know that doctors, nurses and other staff can make a huge difference to patient experience over and above the direct clinical work. And it is often nurses who patients speak to about the changes they would like to see. Yet over time and under pressure, health professionals feel they can become desensitised to patients needs.

The real challenge is not to tell nurses what to do more of: it is for NHS leaders and managers to recognise and respond to the fact that both patients and staff need support.

And where changes in policy or major environmental changes are required, the health care system needs to empower staff to contribute to – and often to lead on – these larger changes.

All of these interventions, large and small, are most likely to make the right kind of difference if they are based on continuing dialogue with those who use services – patients and their families and friends – and those who care for them. the Point of Care programme encourages these conversations to continue.

The interviews informing this blog were carried out by Ros Levenson and Nikki Joule at Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust between April and July 2009.


nilam mehta

Comment date
16 January 2011
I agree with most of the content of this blog. As a relative, I have unfortuntely witnessed too much poor care but also noticed and officially fed-back on good care. However, provision of good care was, I found, a rarity.

I'm not sure I agree with the idea that we shouldn't tell nurses what to do more of and that they need surport more importantly. Support is vital but all staff, be they junior or senior, doctors or nurses, need to be told what needs to be done in order to improve conditions.

Where they need more training, this must be provided, especially in cases of vulnerable groups where medical care, education and training is currently lacking.

Empathy for the patient within some nurses and doctors, is, in my opinion, in short supply nowadays and, although dispassion needs to exist in order to fulfil a medical role effectively, this can lead to coldness and unwilingness to care. Regardless of targets and busy schedules, staff should be reminded not to forget who they are employed to look after. After all, we will all probably become patients at some point in our lives regardless of who we are - illness does not discriminate.

Having said all this, medical staff should not be demonised as a group. We must differentiate from those who choose to give bad care and those who want to improve but don't know how to.

Currently, there is an impetus to improve patient care in the light of certain health scandals that have come to light so we must take advantage of this impetus, especially given the worries over the impending governmental healthcare reforms,

Mark Drury

Associate Director,
NHS Oldham
Comment date
24 January 2011
Excellent blog. I totally agree about the importance to patients of 'little acts of kindness' in care. A smile doesn't cost anything!

Mitzi Blennerhassett

medical writer,
Comment date
24 January 2011
I totally agree that both staff and patients need support. Health care professionals work in a system where training systems and hierarchy encourage bullying and officiousness. And patients are the vulnerable group at the bottom of the heap.

We all need to be needed and it's easy to feel powerful when in control of vulnerable people. And of course, power corrupts.

When there is no humanity in health care professionals' training and the workplace is a constant source of stress from meeting targets and dealing with ever increasing 'throughput', it is little wonder that doctors and nurses distance themselves from patients' feelings, not only for self preservation but because of time constraints.

Yet despite these pressures, it is possible to bring compassion into healthcare - for the benefit of both professionals and patients. Communication skills training can enable doctors and nurses to support patients and acknowledge their needs. Although they learn to acknowledge their own feelings, they also learn to offer a branch rather than jump in the pond. And job satisfaction is enhanced.

Organisations such as Compassion in Health Care and the Kenneth Schwartz Center are working to strengthen caring and compassion in health care.

And yes, little acts of kindness are important. The power of human touch can be immense. Try offering a hand to someone in need. Be non-judgemental - listen and accept what patients say - offer respect. Patients are people. But so are doctors and nurses.

Mitzi Blennerhassett

medical writer,
Comment date
25 January 2011
On the subject of health professionals needing support, it is good practice for professional Counsellors to have 'supervision' - to be able to offload disturbing or traumatic stories and experiences. Doctors and nurses, on the other hand, are expected to carry on as if nothing untoward has happened - all part of being a 'professional'.

Well, to my mind, this simply leaves them unsupported and encourages a culture of inhumanity. They are unable to acknowledge their own feelings, so they are unable to acknowledge the feelings and NEEDS of patients. This can result in neglect.

I feel all front-line healthcare staff should be obliged to undergo regular counselling offered by health services, so that it becomes routine and without a stigma. Counselling support would help them cope and at the same time retain their humanity.

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