Enabling and supporting staff to care well
30 April 2018
Jill Maben writes about her research into the challenges of working in healthcare and how these can be overcome to help staff to care well for their patients.
“I find it of huge benefit to know that we are all in this together that we don’t have our heads down in the dust and the dirt pretending everything is alright (…) we are all pushed to our limits on many occasions, affecting all aspects of our work. It makes us feel very uncomfortable because you want to give good care …”
(Schwartz Round clinical lead) (1)
So speaks a senior doctor, a clinical lead for Schwartz Rounds who spoke to us in our National evaluation of Rounds last year. They highlight the importance of the safe confidential space provided by Rounds to make sense of the messy realities of day to day healthcare work and to support staff to hold onto what brought them into healthcare in the first place: to really relate to patients and provide high quality care.
Forces beyond clinicians’ control
My research over 20 years suggests forces beyond the power of individual clinicians – increased standardisation and measurement, increased demand, fewer nursing staff and increasing numbers of older people with complexity and frailty in the service, to name but a few – have significantly shaped the way staff work. This affects their ability to relate well to patients; to deliver care with compassion and empathy and of a quality they would want for their loved ones. This is deeply troubling and demoralising for staff, creating moral distress and in some cases staff feel the only option is to leave the profession. Recent evidence suggests that of 4,544 who left the Nursing and Midwifery Council (NMC) register in 2016-17, 50% left for reasons other than retirement – with 44% citing the main reason as working conditions (staffing and workload) and 27% citing disillusionment with the quality of care provided to patients.
My own work supports this – with evidence suggesting few newly qualified nurses find environments of care where they can humanise healthcare. Only four of 26 nurses interviewed on two occasions during their first year of practice felt able to give care in a way they had been taught; with most compromising their ideals of care daily and some suggesting these ideals were crushed by the time they were just 15 months qualified and that as a result they were leaving the profession.
There is now good evidence of the links between staff experiences of work and patient experiences of care – with the experience of healthcare staff shaping patient experience for good or ill. In my recent keynote talk at the Humanising Healthcare conference I drew on Roy Porter’s work to suggest that nursing, like medicine, finds the bureaucratisation and rigid professional hierarchies in healthcare, and hospitals in particular, means that ‘hospitals are soulless, anonymous, wasteful and inefficient medical factories performing medicine as medicine demanded it not as the patient needed it’. A healthcare assistant in another recent study of mine lamented the lack of time and focus she was able to give individual older people in her care, needing to do everything at the fastest speed possible, which as she said is ‘rubbish really’ because ‘these aren’t loaves of bread that you’re pushing through a machine. They are people’.
Supporting staff to care well
So what can be done? How can we support staff better to enable them to care well? Reviewing data from a number of projects over 20 years I have identified a number of attributes/conditions that need to be met. These include having adequate staff and a good skill mix; a low demand-high control workload; support for staff and an environment where staff feel valued and receive feedback and where ideas are welcomed and change is encouraged, where staff feel heard and their voice counts.
Good role models are critical, especially for new staff and students, as they can show it is possible to deliver great care in challenging environments. Negative role models (showing staff how not to behave) can be useful in limited numbers but if there are too many and not enough positive role models then a toxic environment, where staff feel their only option is to leave, can result. Finally, excellent team leadership and good managers where co-workers are supportive is important as well as having space and opportunity to process work challenges with colleagues to avoid feelings of isolation and shame.
One such space is now provided in over 180 healthcare organisations in the UK through Schwartz Center Rounds. These multidisciplinary fora, brought to the UK by the Point of Care Foundation, usually last an hour and take place once a month to provide a supportive confidential space for staff to share the emotional, social and ethical challenges of their work with colleagues. Rounds are open to all and panellists share pre-prepared stories to trigger reflection in audience members and to generate insights and discussion collectively.
Impact of Rounds
Our NIHR Schwartz Rounds evaluation found interviewees described Rounds as interesting, engaging and a source of support and staff valued the opportunity to reflect and mentally process work challenges and learn more about colleagues and their management of difficult patient cases. Panellists experienced catharsis and some release of burden and Rounds offer a unique counter-cultural space providing time in which trust is built and emotional safety and containment is offered. Our study found that when staff show their human and vulnerable side it breaks down barriers and creates a level playing field for all staff. Attendance at Rounds also creates recognition of shared experiences and feelings, providing greater insights into patient, carer and staff behaviours, reducing feelings of isolation. Our study also found that of those staff who regularly attended Rounds, the proportion with poor psychological wellbeing halved – down from 25 per cent to 12 per cent. Conversely, there was little change in staff who hadn’t attended Rounds – a third of whom reported poor psychological wellbeing (measured by the GHQ12 questionnaire (2)). Rounds are thus one intervention that supports staff to care well.
In 2010 Kieran Sweeney, Jocelyn Cornwell and I wrote the following:
Really relating to patients takes courage, humility and compassion, it requires constant renewal by practitioners and recognition, re-enforcement and support from colleagues and managers. It cannot be taken for granted.”
This is as true today as it was then and our study would suggest that Schwartz Rounds are an important innovation in UK healthcare providing re-enforcement, support and renewal for staff to allow them to really relate to patients. As the clinical lead introduced at the beginning of this blog said: “I just find every meeting is enriching and a nourishment to one’s soul and psyche.”
1 – Maben J., Taylor C., Dawson J., Leamy M., McCarthy I., Reynolds E., Ross S., Shuldham C., Bennett L., Foot, C., A realist informed mixed methods evaluation of Schwartz Center Rounds® in England. NIHR final report, 2018. (Full report available July 2018).
2 – GHQ12: General Health Questionnaire 12 has twelve questions and is a measure of current mental health and minor psychological distress
This blog presents selected findings from independent research commissioned by the National Institute for Health Research (HS&DR – Projects: 08/1819/213; 12/129/10 and 13/07/49); awarded to King’s College London and the University of East Anglia. The views expressed in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, CCF, NETSCC, the HS&DR programme or the Department of Health.