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Survey results

Adele Waters analyses the results of our exclusive survey, in which readers explain what should be done to improve patients' experience

Today's nurses believe they are doing a reasonable job despite the odds being stacked against them, according to an exclusive Nursing Standard survey.

The survey of 2,554 nurses throughout the UK reveals widespread concern that standards of care are falling below levels the profession would regard as 'good'. But it also shows that nurses have identified the solutions to poor care and that safe staffing levels are their priority.

When asked to rate the quality of care they provided to their patients or clients during the past month (November 2011), 22 per cent of readers scored themselves 9 out of 10 (really good) and 27 per cent rated their care at 8 out of 10 (pretty good).

Overall, the mean score was 6.86 - somewhere between 'not bad' and 'reasonable' (Figure 1).

Nurses were more critical when rating standards of nursing care generally, however. The majority (58 per cent) described the standard as either 'mediocre', 'low' or 'worryingly low', indicating a relatively poor view of current professional standards (Figure 2).

Emotional responses
Experienced nurses - those who have been nursing for longer than ten years - were more likely to have a lower opinion of current standards. Almost 70 per cent rated current care standards as mediocre or worse.

Analysis of written responses reveals that nurses care a great deal about what they do and the outcomes of their work, as well as those of their peers.

A typical response was: 'Nurses do not get enough recognition for what they do. It is a hard and stressful job and the nurses out there in practice are fantastic. They do all these long hours, but still manage to have a smile on their face most of the time. There are only a few bad apples who spoil it for the rest of us, but unfortunately this is what people tend to dwell on.'

Many talked in emotional terms about their work. 'I still love nursing - you get out what you put in,' said one. 'I give 150 per cent and get the same back. Of course we all have off days, but generally it is great. I am an experienced nurse and patient privacy, dignity and care is at the heart of my work.'

A large number of comments indicate deep frustration. Many point to multiple factors that mitigate against nurses providing higher standards of care, such as high patient throughput, burdensome amounts of paperwork and poor leadership.

Workplace stress
But a lack of staff is the biggest single reason why nurses say they find it difficult to provide care of which they are proud. When asked what factor would improve their quality scores, 19 per cent of respondents opted for 'more registered and support staff' (Figure 3).

Interestingly, they also regarded lack of staff as 'the worst aspect' of their job (17 per cent), followed by paperwork and stressful work (both 11 per cent).

'If there were more staff then the quality of care given would be much higher and on a par with the care most nurses want to provide,' said one respondent. Claire Gibbs commented: 'The number of nursing staff compared to the number of patients is absolutely not enough. At times, it is dangerous. Nursing staff probably get more upset than patients about not being able to do their jobs properly. It is not fair that nurses get the criticism without the public understanding why.'

One respondent explained that she loves her job but added: 'I hate it that I cannot give the care I want to - or that people deserve - because we do not have enough staff. We are expected to cope with low numbers.

'My ward manager fights, but there is genuinely nothing she can do, and it is the same across the board. We need more staff.'

A clear source of stress is the inability to do a job to the appropriate standard. Respondents pointed to feeling valued at work, having higher morale and better leadership as other important factors that would help turn care around (Figure 3).

Many summed up their frustration using emotional language - a further indication that they care about standards. 'I love my job,' said one. 'It is a privilege to care for people, but it upsets me to see the deterioration of nursing standards over two decades.'

Another said: 'I am sad to see the direction that nursing is going in, and the criticism it receives. I am totally disillusioned with the employers and the educators. The career I have enjoyed for 30 years is making me unhappy and cynical.'

The increasing number of damaging stories about bad nursing in the media is a concern for some readers, who fear the profession's reputation is being tarnished. Some pointed out that this is a relatively new phenomenon.

'Often unqualified staff are referred to as nurses in the media. I believe that many patients and relatives are too quick to criticise nursing staff when they are extremely busy. The poor media representation plays a significant role in this,' said one respondent.

Student Kyle Sharp commented: 'Overall, the patient care I have witnessed has been second to none. But I see patients come in to hospital anxious about their stay and I believe this is partly due to the hype in the media.'

There was much criticism for the so-called 'bad apples' - those in the profession or unregistered nurses who were giving bad care and prompting negative headlines.

Authority figures
One band 7 nurse said: 'As professionals, we need to pull up those who are not providing adequate care. In my experience, the main problem is that when you tell a nurse about their poor attitude or lack of care, they run to their union representative or go off sick with stress. Bring back senior nurses with authority and a spine. If we don't stamp out this uncaring attitude, the profession will fall apart. Sadly, it looks as if we are pretty close.'

A community nurse agreed: 'Respect has to be earned and is easily lost. I am ashamed to be a nurse at times. I endeavour to be the best nurse I possibly can.'

Many respondents cited unrealistic expectations about the care patients should receive as a source of stress. 'Patients' and relatives' expectations are very high now and have grown in recent years,' said one reader.

Nurse Charles Spencer agreed: 'In general, expectations have risen to unrealistic levels. There are often reasonable explanations for the problems at the heart of complaints.'

Another respondent said: 'I think patients' expectations can be unreasonable at times, and it is sad that we as nurses have to accept far more verbal abuse than I have seen before.'

A further respondent commented that many foreign patients think their care in the UK is excellent compared to the care they would receive in their home country.

The pressures nurses face bring with them an increased risk of burnout. Lauren Mason, a band 5 nurse from London, said: 'Most nurses think they will never meet all the standards required of them, or they become sick trying.

'My colleagues and I are getting burned out trying to be everything to everyone. We go home after a shift absolutely exhausted - emotionally, physically and mentally. We have barely had time for a drink or a break because we are desperately trying to fulfil the demands put on us from all angles - and yet we still feel we have not done enough because someone has had to wait for something.'

Time to listen
Many echoed this feeling of having the odds stacked against them delivering a good service.

One band 5 nurse explained: 'When I started nursing, I felt more able to give the type of care I associate with being of superior quality. I now feel there is no time to listen, with reducing numbers of trained staff and extra paperwork overtaking hands-on care.

'I feel like I am chasing my tail all day - and the people who are suffering are the patients. Managers do not seem to listen to the shop-floor workers any more, yet it is us who are on the front line dealing with patients' complaints and frustrations - which we, as nurses, often share.'

Frustration is a common theme. Sandra Sadler says: 'I constantly struggle to stay in the profession. It is difficult when you are told, for example, "your standards are too high for us and you are too caring". I mourn the loss of a job and profession I once loved.'

Other nurses seem determined to be positive despite the tough situations. 'I want to do more to ensure that people are cared for properly. I want to turn this great profession back into one to be proud of,' said one.

Band 5 nurse Lucy John said: 'I will endeavour to maintain a positive attitude and pride. I believe a wise person once said, "You must be the change you wish to see in the world"'.

analysis: january 4 :: vol 26 no 18 :: 2012

The RCN Publishing Company is a wholly owned subsidiary of the Royal College of Nursing, the world's largest organisation for nurses. RCN Publishing produces one weekly, eight monthly and two quarterly nursing publications. Nursing Standard, the flagship journal, is the UK's biggest selling weekly for nursing. It is produced by RCN Publishing Company along with a suite of specialist nursing journals - Cancer Nursing Practice, Mental Health Practice, Learning Disability Practice, Nursing Children and Young People, Nursing Management, Emergency Nurse, Nursing Older People, Nurse Researcher and Primary Health Care. RCN Publishing Company also produce the RCN Bulletin, a major source of up-to-the-minute information for RCN members in all specialities, grades and working environments. With the latest nurse vacancies from trusts nationwide, it has become the most cost-effective nurse recruitment magazine available.