An exploration of the relationship between professional wellbeing and caring. A comparative study of nurses and physiotherapists in NHS trauma care.
2013/19 - Kate Beckett
There is growing and enduring concern amongst patient groups and the media about lack of compassion in nursing care. A study of nursing care in A+E in 2004 found that uncaring aspects of care predominated and were characterised by impersonal, insensitive or instrumental care but nearly a decade later similar concerns prevail. This study stems from the ‘Impact of Injuries Study’ (IOIS) a multi-site longitudinal study of the impact of unintended injuries from patient, carer and service provider perspectives. Injured participants in the IOIS describe markedly different levels of ‘caring’ care in encounters with nurses and physiotherapists. Physiotherapy care is generally described as caring while nursing care is more varied and sometimes uncaring. This small additional study examines possible causes including parallels between the organisational, professional and personal wellbeing of these staff groups and standards of care. It is hoped that this will provide valuable insights for service improvement and development.
This study forms part of a nested qualitative study in the IOIS a larger mixed-methods longitudinal study of injured patients admitted to hospital in four areas across the UK. The IOIS includes; a) a quantitative study conducted with patients at four time intervals post injury to measure physical, psychological, social and occupational outcomes and b) a qualitative study to further explore the experiences of a sample of patient participants, their carers and service providers (SP).
Service providers in the four hospital trusts completed in-depth semi-structured interviews following a topic guide. This included questions on; 1) service provision; 2) recent changes; 3) the needs of injured patients; 4) evaluation of services. Additional questions were added later in response to emerging differences in patient accounts to further explore organisational, personal and professional barriers and facilitators to caring. These amendments gained ethical approval. The interviews were tape recorded with participant consent on NHS premises. They were analysed using NVivo software and thematic analysis following the methodology outlined in Braun & Clarke (2006 25). This report describes initial analysis and preliminary findings of nurse and physiotherapist interviews.
Twelve nurses and 11 physiotherapists were interviewed in the 4 hospital trusts (Bristol, Nottingham, Loughborough/Leicester and Surrey). All were female and involved in trauma care, but varied in terms of their seniority, role and length of service. The semi-structured interviews lasted 1-1.5 hours.
Preliminary analysis of data from nurse and physiotherapist interviews suggests broad themes to inform comparisons between nursing and physiotherapist roles. These include; 1) identity and role definition; 2) expectations versus reality; 3) patient and time pressures; 4) individual versus task orientation; 5) rewards and job satisfaction; 6) support and training; 7) evaluation of services; 8) internal vs. external control and change.
Initial analysis suggests that nurse participants (NPs) often feel ‘under siege’ and prevented from caring by external factors, such as workload, targets, paperwork and bureaucracy. They are nostalgic about ‘caring’ which feels out of reach. The realities of practice appear different to internal or external expectations of the role and the remit is broad and diffuse. NPs report being unable to always give the care they would like to but that they try their best with the resources available. However, this can lead to guilt, troubled conscience and lack of job satisfaction. The rewards appear limited with conflicting demands for quality and economic efficiency creating significant individual and professional tensions.
NPs demonstrate extensive knowledge about the needs of trauma patients but feel unable to always use the breadth of their knowledge in practice. Patient throughput is extremely fast, which makes it difficult to form therapeutic relationships. Task orientated and instrumental care enables NPs to manage the workload and meet targets. It can also lessen the personal emotional costs of caring in such circumstances. Professional and emotional support for nurses appears limited and generally informal. NPs appear to have relatively little power or control to effect change to improve their practice or patient care. They feel that they generally maintain compassion and caring in their practice but that this involves considerable personal cost. Their identity appears confused and the core principles of nursing somewhat overridden by a medical and business model of care
Physiotherapist participants (PPs) on the other hand report feeling fortunate and generally able to practice with personal and professional integrity (especially those working in out-patient rather than in-patient care) but fearful that this is unlikely to last. Their role is well defined and specialised and their identity appears cohesive and distinct. PPs manage their own diaries and decide on treatment protocols in collaboration with individual patients. There appears to be confidence in the profession and PPs in the study largely evaluate their care as of a high standard. They have considerable job satisfaction and congruity between expectations of the role and the reality of practice. Most PPs have continuity with individual patients and spend considerable time with them on a one-to-one basis. This is perceived as being rewarded by improvements in patient wellbeing which mitigate the emotional strains of the job. There are structured pathways for career progression, mentoring and support. Physiotherapists are subject to organisational changes and pressures but appear more likely to lead or initiate change than nurses. Physiotherapy departments appear less affected by current cost cutting exercises and resource limitations but have considerable anxiety about the future and how changes will affect practice and standards.
This study is still in progress and final conclusions cannot be drawn until analysis is complete. However preliminary findings suggest both professions face challenges which impact on their ability to care and that nurses in particular feel the organisational context of their work is not conducive to caring. This has implications for service delivery. Future full analysis will inform recommendations for practice and form the basis for submission to a peer reviewed journal. Caring is intangible and difficult to cost but professionals and patients clearly feel it contributes to patient outcomes. Being able to provide caring individualised care also appears to effect service provider’s professional and individual wellbeing. Enabling staff to provide the type of care they consider they should could possibly improve patient outcomes and impact on sickness and attrition rates of service providers.