One of the assumptions underlying England’s National Health Service (NHS) policy is that giving feedback about patients’ experiences to healthcare organisations will drive improvements [1–5]. Specifically, in 2000, the NHS Plan pledged that a patient survey would “secure year-on-year improvements in patient satisfaction”. Since 2002, the Inpatient Survey for Acute NHS Trusts has been conducted in all acute NHS hospitals in England, sampling approximately 135,000 adult patients each year. The questionnaires, sent by post, cover waiting times, doctors’ and nurses’ attitudes, staff responsiveness, hospital food and cleanliness, patient information, co-ordination of care and patients’ dignity . To date, more than 700,000 questionnaires have been returned.
Over the last 10 years, the surveys have detected improvements in the national results, but the aspects of care that have improved are those that can be linked to national targets or high-profile media campaigns (such as waiting times for inpatient admissions and ward cleanliness). The results for most questions have stayed the same or, in some cases, have deteriorated. For example, in 2011, only 53% of patients said their call bells were usually answered within two minutes (10% worse than 2004) and 21% said nurses “talked in front of them as if they were not there” (3% worse than 2002) [7, 8]. There is little evidence that the survey programme itself has driven any improvements in patients’ experiences.
Qualitative research suggests that NHS staff recognise the national surveys’ methodological robustness [9, 10] but that there are a number of barriers to the surveys’ impact. Conducting trust-level surveys means that members of staff do not recognise the results as their own, often claiming “that doesn’t happen on my ward” [9, 11–13]. Currently, the survey results are communicated to senior hospital managers; they are not communicated directly to those who are towards the bottom of hospitals’ hierarchies, even though they are the staff members who are disproportionately responsible for making day-to-day decisions about the way care is delivered . The extent to which managers in many NHS trusts successfully “cascade” results to clinical staff is acknowledged to be inadequate . Other barriers to the impact of patient feedback include poor understanding of survey methods and statistics; scepticism of clinical staff about the relevance of survey data to their practice; and delays between data collection and feedback, so staff may argue that circumstances have changed and care has now improved [9, 11–13]. Clinicians’ engagement with patient feedback data may be enhanced by including patients’ comments alongside numerical data [9, 15, 16].
Arguably, the surveys’ lack of impact could also be attributed to an over-emphasis on data collection per se, rather than using results to improve the quality of care. The recent promotion of “real-time” feedback will increase the volume of survey data collected by NHS trusts while reducing the rigour of survey methods . Uniform data collection methods are not required to conduct the “Friends and Family” survey, which covers all NHS inpatients and emergency department attendees from April 2013 onwards, and there are no formal mechanisms in place to ensure that the survey data are used for quality improvement .
Very few randomised controlled trials have been conducted to test the effects of quality improvement programmes . The overall aim of this research programme is to refine and test an intervention intended to overcome barriers to the impact of patient feedback on clinicians’ behaviour. Nurses were selected as the target group of clinicians because many of the survey’s questions are about aspects of care that are provided by nurses; poor nursing care has been the focus of many recent media reports about negative patient experiences;  and nurses tend to work in coherent units (wards), which can be linked to specific groups of patients treated on those wards. The intervention was designed to: (1) improve nurses’ willingness to accept ownership of the patient feedback by making survey results ward-specific; (2) increase the immediacy of the feedback by shortening the time taken to return survey results to approximately twelve weeks after patients’ discharges (compared to approximately nine months to return national patient survey results to NHS trust managers); and (3) engage nurses’ interest by including patients’ comments alongside numerical results in printed reports. In addition, an enhanced version of the intervention included ward meetings to facilitate nurses’ engagement with the feedback; counteract scepticism about the relevance of the feedback to their practice; support them to act on the findings and give them an opportunity to ask questions about the surveys’ methodological reliability and validity.
To enhance the intervention’s acceptability to policy makers and NHS managers, and to maximise its chances of being adopted throughout England’s NHS hospitals, the Care Quality Commission’s (CQC’s) standard questionnaire and survey method currently used for inpatient national survey programme were used to obtain patient feedback . The pre-tested questionnaire and postal survey method conform to widely-accepted methodological standards : centrally monitored protocols ensure that participating organisations comply with a uniform sampling method and postal survey; questionnaires are tested to ensure that they cover patients’ priorities and can be understood by different demographic groups [22, 23]. Questions are purposely designed to facilitate quality improvements by providing actionable feedback to healthcare professionals: patients are asked to report what happened to them regarding specific aspects of their care episode, rather than asking them to rate their satisfaction more generally . The sensitivity of the inpatient survey to changes in patients’ experiences is supported by the changes in the national results noted above.
This was a pilot study, designed to guide the planning for a large-scale trial corresponding to phase III of the Medical Research Council (MRC) guidelines on developing and evaluating complex interventions [25–27]. The main aims of the pilot were: to test the feasibility of conducting ward-level surveys, providing ward-level data and conducting ward meetings; to provide preliminary evidence on the effectiveness of two levels of the intervention; and to provide an estimate of the number of wards that would constitute the sample size needed for a definitive trial. For the purposes of measuring patients’ experiences at different time points during the study, patients were surveyed in ward clusters and average composite Nursing Care Scores were computed at each interval using responses to nursing questions from different groups of patients who were recently discharged at each survey interval.