Poppets and parcels: the links between staff experience of work and acutely ill older peoples experience of hospital care

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1 ORIGINAL ARTICLE ‘Poppets and parcels’: the links between staff experience of work and acutely ill older peoples’ experience of hospital care Jill Maben RN, BA, MSc, PhD, PGCHE Professor, King’s College London, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, London, UK Mary Adams RGN, RM, BSc, PhD, PGCHE Doctor, King’s College London, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, London, UK Riccardo Peccei BA, B.Phil., D.Phil Professor, King’s College London, Department of Management, London, UK BSc, MSc Trevor Murrells Statistician, King’s College London, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, London, UK Glenn Robert BA, MSc, PhD Professor, King’s College London, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, London, UK Submitted for publication: 15 December 2011 Accepted for publication: 6 March 2012 Correspondence: G. (2012) ROBERT G. (2012) T. & ROBERT MURRELLS T. & R., MURRELLS PECCEI R., M., PECCEI ADAMS M., J., ADAMS MABEN J., MABEN Jill Maben ‘Poppets and parcels’: the links between staff experience of work and acutely ill King’s College London older peoples’ experience of hospital care. International Journal of Older People National Nursing Research Unit , 83–94 7 Nursing Florence Nightingale School of Nursing and doi:10.1111/j.1748-3743.2012.00326.x Midwifery James Clerk Maxwell Building Few empirical studies have directly examined the relationship between Background. Waterloo Road staff experiences of providing healthcare and patient experience. Present concerns London SE1 8WA UK over the care of older people in UK acute hospitals – and the reported attitudes of Telephone: +442078483060 staff in such settings – highlight an important area of study. E-mail: [email protected] Aims and objectives. To examine the links between staff experience of work and patient experience of care in a ‘Medicine for Older People’ (MfOP) service in England. Methods. A mixed methods case study undertaken over 8 months incorporating a 149-item staff survey (66/192 – 34% response rate), a 48-item patient survey (26/ 111 – 23%), 18 staff interviews, 18 patient and carer interviews and 41 hours of non-participant observation. Results. Variation in patient experience is significantly influenced by staff work experiences. A high-demand/low-control work environment, poor staffing, ward leadership and co-worker relationships can each add to the inherent difficulties staff face when caring for acutely ill older people. Staff seek to alleviate the impact of such difficulties by finding personal satisfaction from caring for ‘the poppets’; those Ó 2012 Blackwell Publishing Ltd 83

2 et al. J. Maben patients they enjoy caring for and for whom they feel able to ‘make a difference’. Other patients – noting dehumanising aspects of their care – felt like ‘parcels’. Patients are aware of being seen by staff as ‘difficult’ or ‘demanding’ and seek to manage their relationships with nursing staff accordingly. Conclusions. The work experiences of staff in a MfOP service impacted directly on patient care experience. Poor ward and patient care climates often lead staff to seek job satisfaction through caring for ‘poppets’, leaving less favoured – and often more complex patients – to receive less personalised care. Implications for practice. Investment in staff well-being and ward climate is essential for the consistent delivery of high-quality care for older people in acute settings. : acute care, nursing care quality, older people, patient experience, staff Key words well-being, team climate, unpopular patient alienation and emotional distancing from their work or from Introduction , 2007). et al. patients (Maben Against a background of continuing unease about the values To date, few empirical studies have directly examined the of patient care in hospitals (Goodrich & Cornwell, 2008; relationship between staff experiences of work and patient Maben, 2008) and the policy drive for efficiency, productivity experiences of care. The purpose of this study is to examine and ‘throughput’, the care experience of older patients is the links between staff experience of work and patient coming under increasing scrutiny (CQC, 2011; Patients experience of care in a ‘Medicine for Older People’ (MfOP) et al. , Association, 2011; Patterson et al. , 2011; Tadd service. This mixed methods study aims to highlight firstly, 2011). Older patients’ and their relatives’ experience of good the demands of the work; the inherent features of providing hospital care highlights relational care issues as being of care to acutely ill older people that present challenges to staff , 2009) but Iles (2011) et al. primary importance (Bridges and, secondly, specific contextual factors shaping staff describes show ‘transactional’ models of care (where the experience and impact on the quality of patient care. ) often eclipse ‘relational’ models of for individual is cared ). Tadd et al. (2011) care (where patients are cared about Research setting suggests wide variation in the experience of older people in This study draws on selected findings from a 3 year, mixed acute settings, with some patients receiving dignified care and methods, national study that examined the relationship others not, and the Patients Association helpline hears of between staff well-being, motivation and affect (observable ‘bad’ care on an almost daily basis (Patients Association, expression of emotion) and patient experience of care 2011). (Maben et al. , 2012). Despite these reported deficiencies in care, the majority of One element of this wider study was a series of in-depth NHS staff are motivated by ideals of altruism and making a case studies in eight different services (four acute and four difference to people’s lives (Becker & Geer, 1958; Maben community). One of these case studies was a MfOP depart- et al. , 2007) and strive to offer dignified and high-quality care ment, a dedicated service for older people situated in a large (Department of Health, 2007). However, these aspirations acute teaching hospital in England within an NHS trust with are often tempered through early nursing careers as staff an established reputation for good organisational perfor- realise the limits of their work or their workplace (Maben mance and high patient satisfaction. Hospital managers, , 2006, 2007). Iles (2011) suggests ‘the vast majority of et al. interviewed in Phase 1 of the overall study, perceived this people working with the NHS are good people: not saints, service as one with poor patient experience, low staff morale but competent people who have good intentions who are and an absence of ‘team spirit’ in an otherwise high- behaving rationally within the situations they face’ (p. 4). performing organisation. The other three acute case studies However, as staff feel increasingly unable to care for patients provide comparison data for the case study presented in this appropriately, they may experience moral distress (Corley, article and were identified and selected as a high-performing 2002) along with degrees of ‘burnout’ accompanied by felt 84 Ó 2012 Blackwell Publishing Ltd

3 Links between staff and older peoples’ hospital experiences is based on the Michigan supportive and participative haemato–oncology service in the same hospital as the MfOP leadership scale), job clarity and co-worker support (Price service and a high-performing maternity service and lower , 1992) (See Maben et al. et al. , 2012). performing emergency admissions unit (EAU) in a different NHS Trust (performance based on either or both patient experience or staff well-being). Patient survey The MfOP service comprised six wards including general older people’s care wards; acute care wards and a ward All patients discharged over a 2-month period were invited to specialising in patients with delirium and dementia. Many complete a 48-item patient survey ( = 111) and 26 did so n patients admitted through the service arrived with some (23% response rate). degree of confusion, dementia or delirium along with high This questionnaire employed Williamson and Kristjanson’s physical care needs. All wards had similar physical environ- (2008) ‘Patient Evaluation of Emotional Care During Hospi- 6-bedded bays and three side · ments; each with 27 beds; 4 talisation’ (PEECH) instrument (21 items) to capture staff rooms. There were two senior clinical nurses (one new in behaviours as experienced by patients (i.e. the relational post) and six medical consultants plus one locum consultant aspects of care). This instrument has four components or working across the service. Junior medical staff cover as well subscales; levels of security, knowing, personal value and as allied health staff had been recently reduced across the connection. We also used the 15-item short-form Picker service. On each ward, there was a ward manager (band 7) , 2002) and an additional 12 items et al. instrument (Jenkinson and 4–6 junior ward managers (band 6), with a team from the longer UK NHS national patient survey that gauge comprising Registered Nurses (band 5) and healthcare assis- patient experience in relation to courtesy, respect and dignity; 1 tants (HCAs; bands 2–3 confidence and trust; nurse staffing levels; involvement in care; ). help with meals; how well doctors and nurses work together; wanting to complain; rating of care received and willingness Methods to recommend the service to family and friends. The fieldwork was undertaken between January and August 2010 and comprised a 148-item staff survey; 48-item patient Qualitative fieldwork survey; patient, carer and staff semi-structured interviews and non-participant observation of staff and patient care interac- n = 18) were under- One-to-one semi-structured interviews ( tions. A favourable ethical opinion for this research was taken with staff across the MfOP service. These included granted in October 2009. = 4), senior clinical HCAs ( n = 4), Registered Nurses ( n = 1), operational manager n = 2), a student nurse ( n nurses ( ( = 6), which included four consul- n = 1) and doctors ( n Staff survey tants. Staff were asked to talk about what it was like to work in the department; any stressors in their job; whether n = 192) were invited to complete a staff Health care staff ( they felt ‘cared for’ and their perception of patient experi- survey and 66 returned completed questionnaires (34% ence in their ward. Qualitative data on patient experiences response rate). The survey used validated scales to explore = 13) of care in this service were collected from patients ( n a variety of self-reported dimensions of staff motivation, = 5) either by one-to-one n and their relatives or carers ( affect and well-being as well as patient care performance. The semi-structured interviews (30 minutes to 1 hour) or by less survey also included scales of organisational and local climate formal conversations with patients and family members , 1998), affective patient et al. (for patient care) (Schneider during fieldwork (varying from 10 to 45 minutes). Patients orientation (adapted Peccei & Rosenthal, 1997), work and carers were prompted by a topic guide to talk about dedication (Schaufeli et al. , 2006) and job skills and compe- their recent experiences of care; their relationships with tence (Peccei & Rosenthal, 2001), job demands (Caplan staff; what constitutes ‘good’ and ‘bad’ care; and what they , 1980), job control (Wall , 1995), and as well as et al. et al. thought it was like for staff to work in the service. , for perceived organisational support (Eisenberger et al. Qualitative data collection also included 41 hours of 1986), supervisor support (from national NHS surveys which unstructured non–participant observation of routine day- to-day interactions across three of the six wards. Observa- 1 In the UK all staff (except Doctors) are employed on the same pay tion was led by two of the research team with clinical scales which range from bands 1 to 8, with band 1 the lowest band, nursing backgrounds (JM and MA) and was undertaken for with the least pay. Registered nurses upon qualification start at whole or half shifts during which one researcher shadowed band 5. 85 Ó 2012 Blackwell Publishing Ltd

4 et al. J. Maben expectations) and others much less so. Many staff were staff (Registered Nurses, HCAs and students nurses) for committed and motivated to do their best for patients and varying periods of time, ranging from 30 minutes to really cared about older people but they were also ‘all very 5 hours, median 2–3 hours. These observations focused on tired’. Below, we present the inherent realities of nursing staff’s formal and informal interactions with patients, carers work in a MfOP service before exploring specific contextual and colleagues as well as their expressed feelings about this. factors shaping staff experience. Finally, we report patient The observation work also included organisational loitering, experiences of care in terms of how these relate to the when the wider and often rapidly changing work environ- staff’s experiences of work, focusing on the variation in ments and contexts of patient care and staff well-being were patient experience using ‘poppets’ and ‘parcels’ as signifying explored. For example, researchers also sat observing care examples. for a group of patients; sat in on staff breaks; on ward handovers; and in ward meetings. Staff experience of work Data analysis The inherent demands of nursing work in MfOP Our observational fieldwork identified particular inherent Staff and patient surveys challenges of nursing care in the MfOP service. These in- Summary statistics (means, standard deviations) were calcu- cluded the complex needs and high dependency of the acutely lated for each case study. We compared across the eight case unwell older patient; the unpredictability and repetitive nat- studies (four acute and four community) using analysis of ure of essential patient care tasks; and the length of time variance. We built variability into the design so we would taken to explain, undertake and complete such tasks for frail expect some differences. The small number of case studies or confused older people. We also observed the ongoing ( n = 8) placed limits on what could be performed statistically compromises in care delivery that staff were obliged to make; at that level in terms of comparisons between patient expe- staff frequently had to ‘double up’ to care for patients with rience and staffing variables. high and unpredictable physical care needs – inevitably taking one member of staff away from their planned care Qualitative fieldwork with other patients. This often meant staff having to choose All interviews were audio-taped and transcribed and field between, for example, meeting the toileting needs of one notes were written up as soon as possible or were ‘spoken’ patient or supporting another with feeding. At times staff had into an audio recorder for later transcription and analysis. to compromise the dignity of a patient to ensure that they met Thematic analysis of interview and field observation tran- their physical care needs quickly and safely. For example, scripts were undertaken through a series of general and without the time or availability of two care staff to help a focused readings by two researchers to identify emergent patient to walk to the toilet or move out of bed, a nurse or categories and open codes (Rapley, 2011). For example, care assistant would resort to a commode at the bedside or a codes relating to staff well-being included support; leader- bedpan in bed. Such alternatives, as nursing and medical staff ship; team cohesion and family at work; job demands; poor noted, impacted poorly on patient dignity and privacy and on staffing levels; the intensity of the work; satisfaction and the wards’ or services’ reputation for care. Similarly, qualified patient recognition. Codes relating to patient experience in- staff – with inadequate staff cover – found themselves ‘torn’ cluded low patient expectations; importance of relational between the completion of ‘drug rounds’ and meeting an care; the ‘favoured and unfavoured patient’; and patient unexpected and pressing physical care need of a patient. Staff emotional labour. Subsequent focused coding included the recognised such dilemmas and spoke of patient’s care identification of exception events and the search for negative demands yet sometimes saw these same patients as evidence (Hammersley & Atkinson, 2007). In tandem, we ‘demanding’, presenting different, but overlapping ideas that cross-checked the qualitative analysis with the survey data were apparently indistinguishable for staff at times. Many findings. After team discussion of these emergent codes, the staff highlighted that the care they wished to give was not relevant data (and exemplar quotations) were mapped onto only physical care but psychological care, to get to know tables, for within and cross case analysis. people and to have time to chat to them as well as attend to their most intimate and basic needs, yet felt this was not Results possible. All staff noted the distinctive demands of older people’s Patient experience varied in MfOP with some patients acute nursing care work (i.e. the complexity of acute care satisfied (i.e. reporting a good experience relative to their 86 Ó 2012 Blackwell Publishing Ltd

5 Links between staff and older peoples’ hospital experiences otherwise unsatisfying work environment. Staff job satisfac- needs combined with requirements for personal and psycho- tion in the MfOP department was second lowest (3.89 mean) logical care). Older patients were reported as increasingly of the four acute services, with EAU the lowest. However, on more dependent on nursing staff for care: ‘we’re getting a very those wards with poorer work and patient care climates, we much more complex, frailer, older patient, compared to ten ... noted episodes of very tender and attentive patient care, often years ago, .. we regularly have 100 year olds on our wards, ... delivered by unqualified staff or students who felt margina- and the majority are in their late 80s or 90s’ (Doctor 1). lised from their co-workers and ward teams. On a ‘difficult Whilst the staff survey showed that work dedication was ward’, as two young HCAs explained, it was possible to find the highest in the MfOP service (4.36 mean) compared with personal satisfaction from caring for ‘the poppets’, those the other three acute services we studied, nurses frequently patients who they enjoyed being with and for whom they noted the inadequacy of care provided to their patients: ‘some could ‘make a difference’. Sometimes such good care was .(and the) buzzers ... people wait a long time to get any help undertaken at the expense of time and attention owing to less might be going off for quite a while’ (HCA 1). favoured patients with less rewarding direct care needs (this is Registered Nurses and medical consultants noted the explored further below). contradictions between the Trust’s promise to ensure ‘excellence in patient care’, their personal and professional Contextual factors shaping staff experience aspirations for delivering good patient care and the reality Our fieldwork identified two broad contextual factors that of the workplace. Frontline staff felt senior managers – made an already challenging job more difficult: whilst appearing supportive – did not really want to listen A high-demand/low-control work environment. • to the complexity of the problems staff encountered on a • The local work climate. daily basis. Whilst some staff felt that their patients received a ‘fair service... hopefully’ (HCA 1), most nurses expressed Demanding work: high-demand work with little control feelings of guilt, low morale and frustration because of their Human organisation studies note that staff who work in felt inability to offer good patient care to patients, high-demand settings – such as the MfOP service under particularly those without urgent care needs. A manager study – require high levels of felt control over their work to who had previously worked as a nurse in the MfOP support their well-being (Karasek, 1979). Demands – also department recalled the stress of working in this high work called ‘role overload’ or ‘time pressure’ (Caplan , 1980) et al. demand service where she spent most of her day saying to – refer to the amount of work that employees have to patients, ‘I’ll be with you in a minute’ only to realise ‘Oh complete in a limited time (Karasek, 1979; Warr, 1987) and my God, Mr So and So has been sitting on the commode job control refers to the degree of discretion and autonomy for half an hour because I haven’t got back to him.’ employees have in making job-related decisions (Karasek, (Manager 1). 1979; Hackman & Oldham, 1980). Several qualified nurses also described the challenges of Compared with the other three acute services we studied, recruiting staff to a service area often regarded as ‘basic’, job demand for MfOP was the second highest (mean 4.17) in ‘dead end’ or ‘low esteem’ by colleagues elsewhere in the the staff survey. Self-reported data suggested that job control Trust; ‘Lots of people don’t want to work in MfOP because was also high, the highest across the four acute case studies it’s heavy and mentally quite taxing’ (Manager 1). Related (mean 2.96) (Haematology lowest at 2.63). However, in n = 44) of MfOP staff survey respondents to this, 64% ( those wards with a poor work climate, we observed acutely ill reported experiences of physical violence from patients in dependent patients creating a very high-demand environment the previous year which was higher than found in other and staff lacking control in a number of ways. Our three acute services (1%, 13% and 58%); direct care staff qualitative data indicated that three key factors exacerbated often noted the stressful and demoralising effects of the felt control of nursing care work, including: attempting to care for confused and aggressive patients. • Inadequate or unpredictable staffing levels. One HCA described the experience of taking ‘quite a The movement of staff at short notice into other staff- • I’ve been punched, I’ve been spat beating every morning ... at, I’ve been kicked. The men are very strong’ (HCA 2 in depleted service areas. field notes). • The felt lack or inadequacy of training in specialist care Our findings indicate that staff may manage these work skills (e.g. dementia and delirium) for nursing staff. challenges through discretionary care; that is, to not simply Staff nurses and HCAs emphasised that patients received favour some patients but by extension to offer good care inadequate care because of the shortage of direct care staff on selectively to them, which enhanced staff satisfaction in an wards. An experienced HCA described how ‘you need [staff] 87 Ó 2012 Blackwell Publishing Ltd

6 et al. J. Maben A family at work: local work climate numbers to keep your patients safe because of the risk of falls Our data allowed in-depth comparison of staff work expe- and wandering’ (HCA 2), whilst a staff nurse described the rience across the six wards in the MfOP service and suggest impact of reduced staff numbers on the emotional and that whilst organisational climate has a role to play in staff physical care of patients with less immediate or obvious care well-being, it is the local work climate that is key. Analysis needs: ‘The patients are innocent, they don’t want to disturb shows two key facets of local work/ward climate – ward you, I feel so sorry for them. You ask them, ‘Did you open leadership and co-worker relationships – were important in your bowels?’ and they say, ‘No, I felt I wanted to this explaining variations in staff work experience. Where ward morning but you were so busy’ [Staff nurse 3]. Twenty-seven leadership and co-worker relationships were good this alle- per cent of patient survey respondents felt that there were viated a difficult job; where they were not they further added sometimes enough nurses on duty to care for them and 8% to the inherent difficulties of the work. felt there rarely were. Medical staff interviewed agreed there were insufficient nurses: For ... 5 or 6 years, most doctors in Ward leadership the department have not felt that we have had sufficient Ward leadership was an important factor in determining the nurses’ resulting in ‘a significant deterioration in the nursing felt level of discretion and autonomy available to ward care of our patients’ (Consultant 1) which meant patients nursing staff in making decisions at work (cf. Hackman & ‘don’t have a good experience’. Another consultant felt it was Oldham, 1976; Karasek, 1979). In the MfOP service, nursing . things are definitely worse than ... ‘Definitely more stressful. staff were polarised in their opinions of ward managers: they were a year and a half ago’ (Consultant 2). some were often openly critical of their managers, whilst The inherent demands of working in an MfOP service were others were very positive, depending upon their evaluation of further exacerbated by a Trust policy of moving nursing staff them in terms of supporting the team to deliver good patient from their own wards to more depleted areas of the service or care. Nurses appreciated ward managers who performed organisation. Many HCAs described how this practice some immediate patient care, had presence in ward areas and undermined their morale – reminding them of their ‘dispos- were felt to be accessible: ‘our manager’s very good; she’s ability’, leading them to question their personal investment in hands on; she’ll get on the ward and help out with the ward tasks and in establishing relationships with patients and patients’ (HCA 4). In addition, these managers were appre- other staff. They also recognised its impact on patient care: ciated by their colleagues because they were seen to be ‘you get quite a nice relationship going with your patient, and knowledgeable and able to facilitate effective patient care. they get continuity because they see you most of the week. If In contrast, staff identified autocratic, arrogant and unsup- you’re moved somewhere else, somebody else is coming in portive leaders as unhelpful, creating a poor work environ- that they don’t know, they don’t understand them (..) it must ment for staff well-being. Many staff spoke of a senior have an impact’ (HCA 1). clinical nurse who: ‘caused a lot of trouble (..) s/he’d come on Direct care staff also identified their need for more ‘hands the ward and order you to do something whether you were on’ training to enable them to care effectively and sympa- busy (..) or not. You immediately dropped everything to do thetically for patients with confusion, dementia and delirium: their bidding’ (HCA 1). This senior nurse was equally ‘we get a lot of confused patients, dementia patients (..); it unsupportive of ward managers: ‘S/he hasn’t supported them can be a bit stressful if they’re aggressive. I don’t think we when they’ve needed it, but s/he has gone over the top on have enough training to deal with that, really’ (HCA 1). Our small points when they’ve been really not in the mood for it’ observations of such ‘ward level’ training indicated it could (Manager 1). be rushed and piecemeal when delivered on wards lacking Changes in Trust policy also influenced the felt level of sufficient capacity to release staff and without ward-based discretion and autonomy amongst different ward leaders, structures and processes (including enough good role mod- particularly in terms of their capacity to personally recruit elling) to facilitate the ongoing dissemination and support of their own staff and so ‘hand pick a team’. A senior manager good practice. In essence, most direct care staff therefore reflected on the situation in one of the wards: ‘to have lost continued to manage the particular challenges of caring for 80% of her staff and have them replaced and never chosen patients with complex emotional and psychological needs by one of them, not one of them herself, it’s not surprising that ‘drawing on [their] own experience’ (HCA 3). there are problems’. On another ward, there was a very In all, our quantitative and qualitative findings indicated a different situation ‘she was able to choose her staff ... .she got service in which nursing staff are constantly involved in the opportunity to build, to construct a proper team and then high-demand work with limited felt control over their work do lots of team building work with them; And we do get demands. 88 Ó 2012 Blackwell Publishing Ltd

7 Links between staff and older peoples’ hospital experiences and chat. These days, we don’t do any of that. We don’t seem fewer complaints, fewer incidents, lower sickness, lower to be held together’ (HCA 2). turnover, and it is down to good leadership and building your Incivility between nurses at work was often observed on own team’ (Manager 1). those wards with less respected ward leadership, poorer co-worker relationships and poorer reputations for patient Co-worker relationships experience. Several staff noted that an ‘undercurrent of Our staff survey findings showed that across the MfOP bullying’ in the workplace caused tense atmospheres on the service co-worker support items scored lower for this service ward that could be felt by patients; such atmospheres (mean 3.83) than for the other three acute services included in compromised patient care and experience as staff felt unable our national study (highest-maternity mean 4.21). However, to challenge the poor behaviour and attitudes of colleagues. further data analysis revealed significant variations in these This meant for some staff an unsupportive workplace where items across the six wards (ranging from means 3.50 to 4.42). nurses in particular could not rely on colleagues to help them This variation correlated with the reported quality of ward with their work. On two wards as well as direct bullying, leadership on the six wards (highlighted during staff inter- many staff highlighted harassment, incivility and a generally views and observations) as well as staff-perceived variations unsupportive and tense atmosphere: ‘There was a lot of back- in patient experience (as reported by service managers, ward biting’ (HCA 4) and ‘eye rolling’ when certain members of managers and other staff). the team spoke in ward meetings; ‘There’s a fair amount of, We identified three particular fissures in co-worker rela- I’d say, bullying, if you like, goes on on the ward, depending tionships on wards where poorer local work climates and what staff you’re working with. (It’s) not outward. (..) There patient care climates were indicated by the staff survey is an undercurrent of bullying’ (HCA 1). Thus, local work findings. This resulted in a sense of family at work being lost. climate was perceived in some settings to undermine any These fissures were between: sense of a ‘family at work’, which impacted upon patient • Qualified staff (registered nurses) and unqualified staff experiences of care. (HCAs); Staff from different cultural or ethnic backgrounds; • Staff who practised or experienced incivility and bullying. • Patient experiences of care The division between qualified and unqualified staff centred on the difficulties of understanding one anothers’ work roles From the patient survey, patients appeared relatively and responsibilities. Several HCAs criticised qualified staff satisfied – with 85% rating the care they received as either who avoided ‘dirty’ direct care work (Hughes, 1984), in excellent or very good and only one patient stating they were preference for ‘paperwork’, whilst several staff nurses not treated with dignity and respect. Yet 12% were unlikely to lamented their lack of opportunity for ‘hands on care’ and recommend the service to their family or friends, 27% stated worried that patient care relied on unqualified staff. Such nurses and 31% doctors mostly or always talked in front of mistrust sometimes undermined the exchange of important them as if they were not there (highest in the four acute information on patient care and support for each other in services) and almost a fifth (19%) did not get the help they delivering patient care. needed from staff to eat their meals. It is notable that, of the The MfOP service had problems recruiting staff and whilst four acute services we studied, the greatest disparity between it had a long history of overseas recruitment of registered staff self-reported care performance and patient rated care nurses, the challenges of multi-ethnic or multi-cultural team performance occurred in the MfOP service; staff consistently working came to the fore in those wards with poorer local rated the patient care they provided much higher than the work climates. In such situations, misunderstandings around ratings of the patients themselves. MfOP patient survey results communication, language or cultural norms – which were revealed the second lowest ratings of the four acute services often noted by the older patients we talked to – were less we studied and PEECH ‘connection’ levels were particularly likely to be managed well by the nursing or healthcare teams. low suggesting staff were not creating meaningful relation- For staff, there was a reported lack of shared identity and ships with patients – failing to get to know patients as people. lack of cohesion as a team; in some wards, staff from the Our qualitative data revealed a vulnerable patient group same ethnic group coalesced into working together to the with low expectations and little desire to complain, for fear of exclusion of other team members. One healthcare assistant becoming unpopular with staff or care worsening as a result. suggested that a sense of ‘family’ had been lost: ‘Well, it used Whilst patients and relatives expressed satisfaction with to be more of a family affair. We used to go out. We used to overall care in the MfOP service, and some reported very enjoy – not the same things – but we used to be able to go out positive patient experiences, there was often a marked 89 Ó 2012 Blackwell Publishing Ltd

8 et al. J. Maben of whom said ‘in the end, I feel like I’m being moved around difference between care experiences reported in public like a parcel, I’m being moved like a parcel from chair to accounts (in questionnaires) and those reported in personal commode to bed. I feel like a parcel and not a person any- accounts (during one-to-one interview). These differences more’ (Patient 3). This echoes findings from interviews with were explained by one patient: ‘I didn’t want people to think, other older people in acute care where patients experienced ‘Oh, she’s always complaining,’ you know, take that sort of being moved around the hospital: ‘One patient talked about attitude’ (Patient 1). feeling like a parcel and a consultant talked of patients as As significant for patient experience was the care that ‘pushed around like a piece of packaging’ ‘(Goodrich & participants saw other patients receive. Patients tended to Cornwell, 2008, p. 10). note, and reflect upon, the witnessed care of patients who Conversely, several nursing staff reflected on the inevita- they felt to be more vulnerable than themselves: ‘I saw people bility of having particular patients for whom they preferred sat in the chair, who didn’t complain, without any slippers on to care – the poppets. These patients were often those for their feet and it was quite chilly (..) and there were a number whom staff felt particular sympathy, those with no frequent of quite sick older people, (..) who could not feed themselves visitors or who reminded them of a close relative: ‘(they’ve) (..) and I would see their meal placed on their bed table and got something that just endears to you and you just feel, left there and no one appeared to come along except to take it ‘Oh, she’s gorgeous.’ You just click with them as well’ (HCA away again, which I felt should not have happened’ (Patient 3). Staff were aware of the difficulties this presented and tried 2). not to show favouritism or get too close to patients but said Our qualitative data identified three dimensions of care they often ‘could not help it’. Concurrently, staff also experience that were particularly important to older patients discussed the challenges of caring for patients who were with acute care needs. These were: more demanding, difficult or ‘hard to please’. ‘There’s Timeliness of care, particularly around toileting needs; • somebody who I go into see, nothing is ever right really, no • Relational aspects of care; interest in the person, kindness, matter what you do. Nothing is ever right’ (Student nurse 1). compassion and attending to the ‘little things’; Observation of staff caring for this patient revealed the care • The consistency and reliability of good nursing care and ... the patient received to be: ‘quite brisk and businesslike caring behaviours (both between individual nurses and ... . there staff didn’t really have any affection for the patient between ward shifts). was no warmth or real greeting in their dealings with her’ Our analysis also showed that many patients reflected on the (field notes 070710). As we have noted staff may not simply observed difficulties of nursing work and sometimes assessed favour some patients but through ‘discretionary care’ offer the quality of care they received not only in relation to their good care selectively to them enhancing staff satisfaction in expectations but also in relation to what they felt was an otherwise unsatisfying work environment. Such good care possible for nurses within the context of this particular was undertaken at the expense of time and attention owing to MfOP service: ‘everybody in that ward was very ill and they less favoured patients with less rewarding direct care needs. spent so much time looking after them. They could spend an Patients reported inconsistencies in the care practices and hour changing someone’s dressing or giving them a bed bath behaviours of different staff, particularly at night. One or something’ (Patient 1). This also often meant patients did patient recalled how she had to renegotiate her request for not always ask for help when needed because ‘staff were so a commode by her bedside on a nightly basis ‘according to busy’. the sort of mood of the night worker’ so that each evening she ‘dreaded whether she would get one or not’ (Patient 4). Other Variations in patient experience: poppets, parcels and ‘being patients and their carers also reported a felt lack of a nuisance’ investment in them and their care. Patients reported staff Fieldwork observations and informal conversations with did not or were not able to take the time to get to know them patients indicate that patients experienced more varied and and their circumstances, and others reported rough handling: unpredictable nursing care on those wards with a poor local ‘I said ‘you’ve hurt me (..) it’s still sore (..) she was rough, not work climate for staff. We observed how on one of these only with me (..) a couple of people make it a bit awkward, wards staff tended to negotiate their work tasks with refer- being rough and tone of voice’. This patient did not use the ence to bed numbers rather than patient names; patients on analogy of a ‘parcel’ but as a research team we felt rough this ward were also less likely to be greeted by nurses who handling and an uncaring tone was another feature of this cared for them and there was frequently little personalisation category. Seeing other patients treated as ‘parcels’ also had an of care. Our observations indicate that these dehumanising impact as this patient went on to explain: ‘You get one or two aspects of care were not lost on the majority of patients one 90 Ó 2012 Blackwell Publishing Ltd

9 Links between staff and older peoples’ hospital experiences with cancer patients – notes that patients often feel the need of the old hands do a bit of bullying. The other night one to ‘to give something back’ emotionally or in token gifts to couldn’t get her own way with one of the ladies and had her ‘replenish’ and value nurses and describe the emotional crying. I felt sorry. I suppose I was a bit of coward I should connection as ‘circular’ and a ‘two-way street’; making have said I didn’t like what I heard’ (Patient 6, field notes patients active participants in the nursing care relationship by 070710). being ‘good patients’ and helping the nurse to help them. We also found that, in a high demand patient care Being a ‘good patient’ can result in a lack of complaint and a environment, patients are cognisant of their vulnerability to satisfaction with care based on low expectations which becoming seen by staff as ‘difficult or demanding patients’ manifest in relatively high patient experience scores on NHS and seek to manage their relationships with nursing staff (in patients surveys of older people’s experiences. Our data particular) accordingly. We saw patients being extremely suggest that most insight is gained from specific survey polite and grateful to staff, offering treats and almost questions (re ‘staff talking over you’; help with food etc.) or ‘courting’ staff favour – both potentially as a way of giving from one-to-one narratives or interviews. back to staff and perhaps trying to manage the relationships Our findings highlight the inherent relational care chal- to gain good or better care for themselves. On the whole, the lenges faced by both older people and the nursing staff who patients we spoke to did not wish to complain for fear of care care for them. They also suggest a clear relationship between worsening, yet one patient noted that ‘making a nuisance’ staff well-being and patient experience of care. Eighty per could be used as a strategy to improve care delivery: ‘there’s cent of over 11 000 NHS staff surveyed for a review in 2009 always one that doesn’t want to work and turns away, and felt that their health and wellbeing impacts upon patient care, unless you make them do it by being a nuisance, it doesn’t get and virtually none disagreed (Boorman, 2009). Across our done (..) none of them really helped me [get back into bed] four acute services where there were poor local work and I said ‘I’m sorry you think I’m a nuisance’ and then he climates, poor leadership and where staff well-being was was alright’ (Patient 7, field notes 100710). In effect, our low – patient experience was also poor and conversely where findings suggest that the emotional labour involved in being a staff well-being was high so too was patient experience patient is greater in poor care climates where the quality of (Maben et al., 2012). This supports Nolan’s senses frame- care is unpredictable and patient experience variable; patients work, particularly the idea that if staff were to create a need to ‘manage’ relationships with a plethora of staff as well culture in which older people experienced the six senses of as their own responses so as not to be seen as a nuisance or a security; belonging; continuity; purpose; achievement and ‘problem’ patient. significance, then staff also had to experience them in their day-to-day work (Nolan , 2006). Where this was et al. Discussion possible, the environment for care was said to be enriched and where staff and patients do not experience the senses an The tendency of nursing staff to identify difficulty in the care impoverished environment is said to exist (Nolan et al. , of older patients in hospital has been noted and examined in 2001). previous studies (Melanson & Downe-Wamboldt, 1985; From our work, we suggest that there are particular et al. English & Morse, 1988; Patterson , 2011; Tadd et al. , organisational, service and ward-based factors that either 2011). Drawing from Stockwell’s (1972) seminal study that support or undermine the efforts of nursing teams to ‘keep identifies ‘patients whom the nursing team enjoys to care for the show on the road’ (Staff Nurse 3). In particular, our data less than others’ (p 11) subsequent studies observe the the suggest as Patterson firstly (2011) note these include et al. important distinction between ‘difficult’ and ‘difficult to , 2009) – where et al. pace-complexity continuum (Williams nurse’, based on notions of patient volition, and how these the pace of care is being prioritised at the expense of quality notions are shaped not only by nurse-patient interactions but with an ever increasing focus on tasks and technology. also by wider contexts of care and care demands (Johnson, , the importance of a strong and visible ward leader Secondly 1995). Our observations and conversations with direct care exerting important influence on the caring and work culture staff indicated that across the MfOP service staff often lacked (Ballatt & Campling, 2011). Smith (2012) suggests that the capacity to either examine, understand or seek to address ‘patients and nurses are sensitive to ward atmospheres and the reasons for patient’s apparently ‘demanding’ behaviours. social relations created by ward sisters’, and that when nurses Patients themselves also work hard to shape these rela- are appreciated and emotionally supported by these same tionships, demonstrating empathy towards nurses and feeling ward sisters they had both role models for emotionally concerned for the busy, time-pushed, emotionally exhausted explicit care and also felt better able to care for patients in nurses. Gull (2011) – examining compassionate nursing care 91 Ó 2012 Blackwell Publishing Ltd

10 et al. J. Maben offering selective care that brought rewards to themselves and this way (Smith, 2012, p. 194). the importance of the Thirdly, a few favoured patients. immediate team environment and the crucial role of ward et al. leadership in shaping this (Patterson , 2011). Ballatt and Campling (2011) argue persuasively that ‘in general, the NHS Acknowledgements gives little thought to group dynamics and how to get the best out of its teams. Too often structure and culture impede Our grateful thanks to the staff and patients who participated Finally, rather than enable good team working’ (p. 81). our in this study. This study reports research funded by the data suggest the need for staff to be emotionally supported National Institute for Health Research Service Delivery and themselves (Firth-Cozens & Cornwell, 2009) to be able to Organisation programme (project number 08/1819/213). The have staff support structures such as clinical supervision views and opinions expressed are those of the authors and do , 2004) and to be encouraged to talk about (Ashburner et al. not necessarily reflect those of the NIHR SDO programme or their feelings and their own emotional needs (Youngsen, the Department of Health. 2008). There is an extensive literature suggesting excessive work Contributions demands leads to poorer well-being. Nursing teams on older people’s wards report having fewer resources to meet the Study design: JM, MA, RP, TM, GR; data collection and needs of their patients and evidence suggests a significant analysis: JM, MA, RP, TM, GR and manuscript preparation: association between having too much to do and feeling JM, MA, RP, TM, GR. , 2011). High levels of social motivated (Patterson et al. support from supervisors, co-workers and the organisation Implications for practice has a positive effect on well-being in that it helps to reduce exhaustion, whilst also enhancing satisfaction and relative Senior managers and leaders need to invest in staff work positive affect at work (Maben et al. , 2012). Work experi- environments to ensure quality patient care: ences directly contribute to the satisfaction of important Review quality of patient experience: • Use different individual needs at work, such as autonomy, support, approaches (not only patient surveys); what does belonging. Our data suggest that these experiences also have ‘demanding’ mean for staff- and for patients; educate staff strong links to patient experience. to recognise the ‘unpopular patient’; discuss the quality of Our findings suggest that without good local work and care received by all patients in the ward – ‘poppets’ and patient care climate staff sometimes seek job satisfaction in ‘parcels’ and how might this be the case in all wards. care of ‘poppets’; potentially leaving less favoured and more Resilience building and renewal for staff: Create support • complex patients to receive rushed and less personalised and supervision for staff to reflect on the emotional and care – leaving them to feel like ‘parcels’. In this way, the physical challenges of caring for older people, for exam- work experiences of staff impact directly on patient care ple, regular opportunities to discuss ‘difficult patients’ experience. 2 and how these might be managed; Schwartz Rounds are one way to create space to talk about the emotional aspects of care work in the multi-disciplinary team. Conclusion Through a mixed methods case study in one MfOP service, 2 Schwartz rounds have been brought to the UK by the King’s Fund we have been able to describe the experiences of care for Point of Care programme from Boston Massachusetts where they older people in acute hospital settings as well as to begin to originated. The rounds take place in 195 sites in the USA and understand the significance of the work experiences of staff currently 10 in the UK with expansion planned. The rounds for the quality of patient care. Gordon (2005) argues that (usually 1 hour each month) provide space for ‘renewal’ by practi- tioners and recognition, re-inforcement and support from colleagues care environments that are inadequate for meeting the and managers. http://www.kingsfund.org.uk/applications/site_search/ emotional needs of patients will inevitably foster nurses index.rm?instance%5Fid=0&filtering=0&keywordsweight=1%2E5& who avoid attempting to meet such needs. Being unable to old%5Finstance%5Fid=0&old%5Fterm=&searchreferer%5Fid=0& engage with patients in a meaningful way dehumanises nurses categories=&term=Point%20of%20care%20Schwartz&include%5F themselves (Austin, 2011). ‘The emotional work of health- documents=YES&debug=0&similarpagesto=&filter=&titleweight=1% care teams deserves to be prioritised’ (Ballatt & Campling, 2E5&isajax=0&skip=10&count=10&subject=0&summaryweight=1 2011, p. 82). Our research identifies the tendencies of %2E5&contentweight=1%2E0&id=0&sort=relevance&searchreferer demoralised and inexperienced staff to resist this process by %5Furl=%2F404%2Erm. 92 Ó 2012 Blackwell Publishing Ltd

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