Having asked and listened – will we hear?

Prof Peter Gillen, Associate Professor of Surgery in RCSI and Clinical Advisor to the National Healthcare Communication Programme, outlines the value of the recently published National Maternity Experience Survey

Surveys are everywhere these days. Healthcare has not remained immune to the survey surge. While many object to patients being labelled as ‘consumers’ it is interesting to follow this thread in business terms. Consumers shape markets, and although acknowledging health as an atypical market, we nonetheless aspire to patient-centered care. This suggests that listening to patients might allow policy makers to place patient views at the centre of shared decision-making.

The first attempt to listen to what patients had to say about their experiences of healthcare while in hospital in Ireland was published in 2018 under the National Patience Experience Survey (NPES). Sponsored by HIQA, this survey achieved a 50 per cent response rate. This alone is informative. Survey response rates are influenced by a myriad of factors – from survey design to target audience buy-in, but a response in excess of 50 per cent is excellent by any measure. This response rate was replicated this week in HIQA’s first survey of maternity services – the National Maternity Experience Survey (NMES) – across the country’s 19 maternity sites sent to women who had given birth during a two-month period last year.

At the outset it must be stated that there were similar satisfaction ratings for both surveys in the 85 per cent range. Both surveys reported room for improvement in 15 per cent.

These two surveys have more in common than simply excellent response rates, but it is interesting to reflect on why they produced these rates. Marketing analysts suggest that often the greatest incentive for respondents to complete a survey is the belief that their views will be listened to and their opinions will shape future improvements. Given the negative coverage of the health service and its obvious struggles in recent years, these response rates could be interpreted as an encouraging signal from patients that all is not yet lost in the court of public opinion. In contrast, an apathetic population might have been expected to return much lower response rates which has not been the case.

Response rates apart, the surveys’ design relied heavily on a battery of more than sixty questions with suggested answers to be selected by the respondent. Completion of such a format can be tedious unless well-motivated but the real information is often contained in the ‘free-text’ boxes where patients are invited to record comments freely. It takes courage to write about personal experiences to strangers even with a guarantee of anonymity. Reading such comments reflects the entire gamut of patient emotions both good and bad. It is incorrect to assume such an invitation to comment will enlist only negative responses as evidenced here in both surveys.

The scientific analysis of free text comments is complex. I suspect not many of us are experts in inductive thematic analysis but the coding and theme development are driven by the content of the comments. Put simply this involves reading all the comments initially and codes being selected by identifying recurring words or units of meaning. These themes are then applied in recoding the comments on further analysis. The first NPES produced over 20,000 such comments alone with the NMES recording in excess of 6,000, indicating the enormity of the task.

The HSE, which partnered HIQA in the NPES survey, commissioned an analysis of comments and the largest group of comments were found to be in relation to communication. Using similar analysis for communication in the NMES recurring themes have been identified.

These themes reflect the importance of making connections with patients and women in the respective surveys. Over and again patients and women reported not being listened to or not having time to tell their story. This frequently resulted in patients recording that staff had a ‘bad attitude’. Midwives being ‘too busy’ to listen was also a frequent comment reflecting no doubt staffing deficiencies as much as poor attention to non-verbal modes of communication.

The stark emergence of communication deficits in the original NPES led the HSE to set up the National Healthcare Communication Programme (NHCP) in 2018. Working closely with EACH (the International Association of Communication in Healthcare) the NHCP has designed modules of communication, which specifically address key areas for improvement in healthcare communication. Working on a cascade approach of ‘train the trainer’ the NHCP has trained over 600 facilitators, with in excess of 2,000 staff participating in communication training.

The results of the NHCP initial roll-out, published in the September issue of the Irish Medical Journal, indicate that over 80 per cent of participants reported improvement in communication skills having attended training modules.

The national maternity services are to be similarly commended for collaborating with the NHCP in addressing communication issues following the recent survey. Already specialty – specific training modules have been developed and are being delivered in an innovative online format given the current restrictions caused by Covid-19.

The belief that one’s comments in a survey will be respected, listened to and ultimately lead to change should remain paramount here in responding to patients and women. Given the emergence of communication issues in the NPES and in the NMES, the HSE should take every opportunity to respond by supporting staff in the pursuit of excellence in communication skills. To fail to do so would devalue the courage of those who reached out in the surveys.