Patient feedback is vital to service and care quality improvements

National Institute for Health Research review says senior nurses need more time to consider patient feedback

National Institute for Health Research review says senior nurses need more time to consider patient feedback

Illustration of staff giving feedback
Picture: iStock

Patient feedback should be at the centre of service development by senior nurses, say health experts following publication of a major review of how such information can be used better.

The National Institute for Health Research (NIHR) review, which examines the use and usefulness of patient experience data, defined as what patients say about the care they receive, finds that hearing and acting on patient feedback is complex and challenging for healthcare organisations.

What is the National Institute for Health Research?

The National Institute for Health Research was set up in 2006 and is the nation’s largest funder of health and care research, primarily funded by the Department of Health and Social Care

Staff across pay grades may need time and skills to collect, consider and act on this information, as well as to make changes in practice, says the NIHR, which reviewed nine new research studies exploring patient feedback.

One of these studies, published last October, highlighted a need for better collaboration between patient experience teams and nursing staff.

The authors of the study write: ‘Our study has identified a frequent disconnect between data generation and management work carried out by patient experience teams... and the action for care improvement resulting from those data, which is more often the responsibility of nursing staff.

‘Acute hospital trusts may be able to optimise the use of patient experience data by exploring configurations of and communication between professional figures and teams involved in patient experience work.’

Unsolicited patient feedback is valuable

A need for smarter working with patient feedback data is identified throughout the NIHR review.

The review says that large amounts of data, particularly from surveys and the mandatory NHS Friends and Family Test, are collected in the NHS, but that less attention is paid to other valuable types of patient feedback, such as unsolicited feedback.

The Friends and Family Test

A new version of the Friends and Family Test (FFT) with revised guidance for implementing it will be used from 1 April.

The FFT, which was introduced across England to most NHS-funded services from 2013, asks people if they would recommend the services they have used and offers supplementary follow-up questions.

Changes include:

  • A new mandatory question and six new response options
  • Mandatory timescales to be removed to allow more flexibility so people can give feedback at any time, in line with other services
  • Greater emphasis on the use of FFT feedback to drive improvement

Elaine Maxwell
Elaine Maxwell

NIHR Dissemination Centre clinical adviser and report author Elaine Maxwell says: ‘We have put a lot of effort in the NHS into collecting data about patient experience, but not so much in what we do with it.

‘There is a lot of data collection asking what we wanted to know from patients, rather than what they wanted to tell us.’

Accordingly, organisations are urged to embrace all forms of feedback, including complaints, unsolicited and positive feedback, as opportunities to review and improve care.

Dr Maxwell says: ‘Certain NHS trusts don’t know what to do with feedback they haven’t requested; they don’t know if they have permissions to use it or are concerned they didn’t frame the question.

‘There are issues about what we collect, how we collect it and whether people feel they can apply it.’

The NIHR review finds that:

  • Too few resources and too little energy go into analysing the information in ways that can lead to useful change.
  • Managers focus on ‘bad’ experiences and overlook the rich information about what goes right.
  • Staff who see patients on a day-to-day basis are rarely informed of the feedback or, when they are, struggle to make sense of it in ways that can lead to improvements.

Nursing staff need the right skills and support

One of the studies, the Evaluating the Use of Patient Experience Data to Improve the Quality of Inpatient Mental Health Care study, or EURIPIDES for short, involved a team from universities in Birmingham, London, Sheffield and Warwick, who found that too few organisations collect patient feedback to actively improve services.


research studies were used in the NIHR review

Of those care providers that do, only one quarter put their feedback to good use; the others use it mainly to create environmental change, rather than change to services.

University of Sheffield research fellow Elizabeth Taylor Buck says staff need to be given the right skills and support so they have enough time to collect feedback from patients correctly.

‘NHS staff should be encouraged to engage in the feedback process and be given timely access to patient experience data,’ she says.

‘Not only so they can react quickly to complaints, but also to learn what they are doing well for patients and empower them to improve care action plans.’

How senior nurses can encourage change

The Point of Care Foundation (PoCF) is one charity that aims to ‘humanise healthcare’ and has an interest in patient experience data.

Until 2019, PoCF facilitated and supported the Heads of Patient Experience (HOPE) network, now run directly by NHS England/Improvement.

PoCF chief executive Jocelyn Cornwell, who sat on the NIHR review steering group, thinks there is too much of a ‘mechanistic, routine, one-size-fits-all’ approach to gathering patient feedback.

‘It would be much better to target services in a deliberate and strategic way,’ Dr Cornwell says.

‘Money could be better spent by trusts targeting investment in collecting feedback and training staff to use that feedback to improve care, ideally in partnership with patients who use the service.’

But she adds that nursing leaders are in a strong position to make positive changes.

Teams focusing on patient experience can support each other

Dr Cornwell points out that, in some organisations, teams such as those focusing on patient experience and quality improvement (QI) could support each other’s work, but do not always know of each other’s existence.

‘People work in silos but senior nurses are in a position that they could, for example, bring complaints people, safety people and QI people together.

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‘The question for senior nurses to ask is, if their organisation is not doing anything with its patient experience data, why not?

‘Most organisations these days have a QI team and senior nurses can ensure these people take action.’

Equally, she contends, if nurses lack the time or the skills to work with the data, they can get help from these QI teams.

Heads of patient experience also feel strongly that they would like to be working more closely with doctors, says Dr Cornwell.

‘They think senior nurses might be in a position to help with that because they sit on boards with the medical directors or know most of the senior doctors around the trust.’

Patients are active partners in implementing change

Picker Institute chief executive Chris Graham also sat on the review steering group. He hopes senior nurses will take on board all the review’s findings.

‘The core messages are important and worth taking time to understand,’ says Mr Graham, who was also principal investigator on one of the studies.

‘Feedback and experience data is everywhere but there is not a great understanding of how to use it and we need to improve and address that.’


Friends and Family Test introduced in England

He urges senior nurses to ‘embrace both formal and informal data’ and not fall into a trap of thinking data should always be ‘triangulated to some underlying truth’.

Mr Graham says his own study found that senior support is important to how well organisations use feedback to improve.

‘In some trusts, we found senior leaders were very involved and in others there was much less engagement; that tended to be reflected in how much action was taken.’

King’s College London professor of healthcare quality and innovation Glenn Robert thinks the NHS needs to break out of a cycle of seeing patients and families ‘solely as passive sources of increasing amounts of anonymous data, which we then collate into metrics and performance dashboards’.

Proactive and interactive quality improvement

Instead, he says, we need to welcome them much more as active partners in implementing changes to local services shaped directly by their personal experiences.

Professor Robert says: ‘This would help shift thinking about the various forms of patient experience data away from the reactive, formal features of performance management towards more proactive, interactive forms of local QI.

‘Our research also shows that integrating different types of data in our formal quality improvement initiatives – so that patient experience feedback is not seen as entirely separate from, say, clinical effectiveness or as a less valid/meaningful item – is worthwhile in practice.’

The NIHR review suggests a major obstacle to understanding feedback is a lack of dedicated staff time, and staff need training to increase their understanding and confidence in different methods of data collection.

Motivating front-line staff to explore aspects of feedback

As well as improving the transactional aspects of care, such as waiting times and appointments, organisations need to consider how data on relational aspects of care – how staff made patients feel – are better presented to staff.

Summaries and infographics, together with patient stories, are suggested as ways of motivating front-line staff to explore aspects of feedback about how staff made patients feel.

Patient experience data should be presented alongside safety and clinical effectiveness data and the associations between them made explicit.

Learning from positive feedback

Research included in the National Institute for Health Research (NIHR) review on patient experience data finds that, while many patients provide feedback about good experience, staff do not always recognise and value it.

University College London Hospitals NHS Foundation Trust (UCLH) deputy chief nurse Vanessa Sweeney features in the review. She shared with staff a letter of thanks she sent a patient who left positive feedback.

In the NIHR review, Ms Sweeney says that she has shared the feedback with the UCLH sisters’ forum, which is attended by more than 40 senior nurses who lead wards and departments across the trust. ‘I asked them to think about the words they used, the impact of care, their reflections and how it will influence their practice.'

Kindness, compassion and thoughtfulness

In her thank you letter to the patient, Ms Sweeeney wrote: ‘Your letter had an powerful impact on us as a group and made us think about how we pay attention to compliments, especially the detail of your experience and what really matters.’

Ms Sweeney says staff are often moved by patients' kindness, compassion and thoughtfulness.

She concludes: ‘We are now making this a regular feature of our trust sisters’ forum and will be introducing it to the matrons’ forum: sharing a compliment letter and paying attention to the narrative; what matters most to a person.’

Wishlist presented to England's chief nursing officer

A wishlist of key actions to take forward following the NIHR review has been presented to the chief nurse for England, Ruth May.

Ruth May
Ruth May

The ideas came from service users, researchers, policymakers, clinical staff, patient experience leads and NHS trust directors who attended a summit about the NIHR review last month.

They include ideas based on five themes:

  1. Collecting data.
  2. Resources for acting on patient feedback.
  3. Holding organisations to account through a single national framework for all regulatory bodies.
  4. Creating capacity and capability to use patient experience data.
  5. Ensuring senior managers, organisational boards and those taking part in performance meetings monitor the actions resulting from patient experience feedback.

A spokesperson for NHS England/Improvement says the chief nurse is currently looking at the action list and will respond in due course.

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