Access provided by
London Metropolitan University
• To refresh your knowledge of the purpose of gathering patient feedback
• To enhance your understanding of effective strategies for gathering patient feedback
• To recognise the value of qualitative and quantitative patient feedback data in quality improvement projects
The primary purpose of gathering patient feedback is to listen to, reflect on and act on the feedback to improve patients’ experiences, interactions and health outcomes. Nurses use patient feedback to guide person-centred care or to inform healthcare decisions. However, when healthcare services attempt to improve the quality of care, there can be a lack of process clarity, clear measurement and evidence of improvements. This article provides an overview of the strategies used to capture patient feedback and offers guidance on how nurses can make use of such information to promote healthcare improvement.
Nursing Standard. doi: 10.7748/ns.2024.e12274
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
McIntosh GL, Hibberd C, McGregor S (2024) Capturing patient feedback to improve healthcare services. Nursing Standard. doi: 10.7748/ns.2024.e12274
Published online: 17 June 2024
The feedback provided by patients, families and carers about their care experiences is central to understanding, evaluating and improving healthcare at an individual, operational and strategic level. In recent years, healthcare services have prioritised efforts to improve patients’ experiences of care (Flott et al 2017). Patient experience programmes, which aim to gather feedback from patients and carers about their experiences, and patient and public involvement teams, are now commonplace throughout the NHS (NHS Inform 2023, NHS England 2024, NHS Wales 2024).
Compiling feedback on patients’ healthcare experiences can involve formal methods, such as surveys, and informal methods, such as nurses simply asking patients about their experience of care (Davis et al 2022). Patient feedback can be effective in improving care, primarily by recognising excellence, identifying problems and areas for improvement, and measuring or evaluating care provision (Boogaard et al 2018). Through listening to and working in partnership with patients, healthcare staff may come to perceive healthcare interactions more positively; in turn, care becomes more person-centred and responsive to individual needs (Holt 2018).
Nurses are at the forefront of care delivery and have a significant role in quality improvement activities. Their knowledge and skills contribute to the overall quality of care, and they are frequently involved in gathering feedback and measuring care quality. However, too often patient feedback is not used to its full potential for technical and organisational reasons, such as time constraints, and due to lack of staff training and support (Wong et al 2020).
This article gives an overview of the strategies that nurses can use to elicit patient feedback and use it for quality improvement, the strengths of each of these strategies and the potential barriers nurses may experience.
Patient experience has been defined as the perceptions people have concerning specific aspects of their healthcare (Burt et al 2017). The term is used interchangeably with ‘patient opinion’, ‘patient satisfaction’ and ‘patient perspectives’, with the various terms reflecting different elements of what is being communicated or measured. For example, patient experience relates to interpersonal aspects of the quality of care delivered and the effects on the person, whereas patient satisfaction is more subjective, indicating how the care provided met the patient’s expectations (Bull et al 2019).
Wong et al (2020) reported that feedback from patients can be used to measure specific aspects of care, such as staff communication, which is then used to provide evidence of care quality. Through actively seeking feedback, a nurse can contribute to a positive patient experience because the process increases nurse-patient communication and the opportunity for patients to be involved in their own person-centred care (Wong et al 2020, Davis et al 2022). However, Wong et al (2020) also emphasised the lack of evidence for measuring patients’ experience of healthcare using patient-reported experience measures (PREMs) – validated questionnaires that seek to collate patients’ and relatives’ views on the care they have received. The researchers also identified some challenges with the use of PREMs, such as lack of time and defensiveness on the part of some respondents.
In a concept analysis of patient experience, Holt (2018) identified some of the main influencing factors on patients’ experiences. For example, a patient’s experience can be influenced by their personal characteristics (such as their age or gender), the access to and timeliness of care and/or the communication skills and cultural awareness of care providers (Holt 2018). The care experience itself may be mediated by factors such as trust, communication, shared decision-making, the patient’s expectations, values and beliefs, and the perceived respect and acceptance shown to them by staff.
Quality improvement programmes are considered to be the ideal vehicle to promote person-centred and high-quality care, with feedback on patients’ experiences forming the crucial data from which ideas for quality improvement can be generated and outcomes measured (Santana et al 2020). In the UK, NHS Improvement (2018) developed a patient experience framework that detailed a whole-systems approach to collecting, analysing and learning from patient feedback, and which requires staff to understand the complex nature of healthcare interactions and have a collective willingness to support the improvement process. Without such frameworks, the tracking, measurement and promotion of quality improvement is challenging.
Quality improvement programmes are a useful approach when tackling systemic challenges, such as staff not following guidelines or patients not receiving test results in a timely manner. In the UK, The Health Foundation defined quality improvement as the application of a systematic approach that incorporates specific techniques to improve care quality (Jones et al 2021). Ensuring the success of a change involves understanding the issue and the system in place, and recognising why the change is needed (Langley et al 2009). Quality improvement programmes encourage small ‘tests of change’ at the local level, which build the evidence for wider changes. These small tests of change are often based on a sequential cycle of ‘plan, study, do, act’, an approach that aims to empower healthcare staff to deliver tangible improvements (Langley et al 2009). However, such local changes can be difficult to achieve due to lack of resources and failure to collaborate with service users (Scottish Government 2019). Without the feedback and collaboration of the people who use healthcare services, quality improvement is not possible.
Nurses are well placed to gather patient experience data because of the time they spend with patients, but it is important that they have the knowledge, skills and confidence required to measure and analyse the data to ensure its trustworthiness. In the authors’ experience, gathering patient experience data effectively for a quality improvement programme starts with four main questions:
• Why are the data being gathered?
• Who should gather the data and from whom?
• How will the data be gathered?
• Will the data gathered be formal, informal or both?
Healthcare Improvement Scotland (2017) outlined a ‘family of measures’ that should be considered during a quality improvement project:
• Outcome measurements – used to determine the effectiveness of the proposed change; can include patients’ self-reported experience of the care received.
• Process measurements – the activities needed to achieve the change.
• Balancing measurements – possible side effects of the change that may occur in a complex healthcare system, such as staff not completing care tasks because they are spending time on the new ‘improved’ care process.
Nurses frequently gather patient feedback to improve care processes or routines, but patients can be reluctant to be honest or critical when giving feedback to those providing their care (Davis et al 2022). For example, one study showed that patients in palliative care were concerned about retribution from staff when divulging care experiences (Virdun et al 2022). Similarly, patients may express concerns about getting staff ‘into trouble’ (Burt et al 2017) or adversely affecting the therapeutic relationship.
It is also important to consider bias. Bias is where intentional or unintentional influence may affect the feedback gathered, either from the person collecting it or the patient providing it. To avoid bias in patients’ feedback, consideration should be given to who gathers the data and their relationship to the patient. However, there is inadequate evidence in the literature to guide data collection in quality improvement projects. As a minimum, the authors suggest that any data collection should be carried out by an independent staff member who is not involved in providing direct patient care and does not have a vested interest in the quality improvement project, but who can still provide support when required.
Wherever possible, patients should be encouraged to self-report their experiences, since they have first-person insight and should be empowered to provide their own feedback, free of influence. Where a patient lacks mental capacity, a proxy may be necessary, for example a family member. However, it is still important to consider potential biases given that any person acting as a proxy will have their own interpretation of the patient’s care experience (Graham 2016).
Marsh et al (2019) outlined the variety of patient feedback formats available, such as surveys and questionnaires, but provided limited guidance on their use in quality improvement projects. For healthcare professionals, this lack of guidance, alongside concerns about reliability, bias, confidentiality and potential lack of action, can limit the usability of the feedback gathered (Patel et al 2015). An enhanced understanding of the validity, reliability and utility of various forms of feedback should develop nurses’ confidence in gathering feedback.
The validity of any patient feedback tool concerns its ability to measure the target subject accurately and how it reflects the outcome or process, as well as variations in what is being measured. There are three types of validity – content, criterion-related and responsiveness (Devellis 2011).
Content validity evaluates how well a measurement tool covers all the main elements of the subject. For example, if measuring patients’ experiences of nurses’ communication, it would be important to identify the most important elements, such as whether patients felt listened to.
Criterion-related validity is an estimate of the extent to which a measurement tool agrees with a gold standard test; in the example of nurses’ communication, a relevant benchmark might be the ‘consultation and relational empathy’ (CARE) measure, a patient-rated measure of healthcare professionals’ empathy (Mercer 2024).
Responsiveness validity is the ability of the tool to show change over time – for example, whether nurses improve their active listening skills – and is essential for evaluating any improvement. Beattie et al (2015) noted that the patient experience questionnaires used in PREMs demonstrated limited responsiveness validity, which impaired their ability to demonstrate quality improvement and therefore undermined the value of patient feedback.
A significant aspect of reliability is the capacity of a measurement tool to produce consistent results or scores under similar circumstances (Bull et al 2019). Reliability also relates to how well data are managed by the measurement process, therefore a highly reliable tool will have a lower risk of errors and process failures.
• Feedback provided by patients and families about their care experiences is central to understanding, evaluating and improving healthcare
• In quality improvement programmes, feedback on patients’ experiences forms the crucial data from which ideas for quality improvement can be generated and outcomes measured
• Nurses are well placed to gather patient feedback, but should have the knowledge, skills and confidence required to measure and analyse the data to ensure its trustworthiness
• Patient feedback data can be qualitative or quantitative and both have a valid role in quality improvement projects
• Patients and families have a vested interest in the feedback process, therefore nurses should share outcomes with them to demonstrate the benefits of their contribution
Utility relates to the usability of the data. For example, the use of data from national surveys can be valuable because of the wide population coverage but can also lead to delays between the respondents’ experiences and the publication of the report. Similarly, the data may not be specific enough for the population or service being measured (Gleeson et al 2016).
Following their scoping review, Marsh et al (2019) identified the four optimal feedback methods for measuring quality improvement in hospital patients’ experiences:
• Hospital-initiated quantitative surveys – for example, the NHS England Adult Inpatient Survey (nhssurveys.org/surveys/survey/02-adults-inpatients).
• Patient-initiated qualitative feedback – for example, complaints or online comments.
• Hospital-initiated qualitative feedback – for example, experience-based co-design (EBCD), a tool that focuses on the emotional aspects of patients’ and staff members’ experiences before supporting them to develop simple ways to improve a service (The Point of Care Foundation 2024), or care-specific interviews, which can be useful for exploring patients’ experiences of defined aspects of care, such as a hospital’s admission process.
• Other – for example, the NHS Friends and Family Test (www.england.nhs.uk/fft).
Patient feedback can be encouraged through a broad range of formal and informal mechanisms. Feedback can be captured through formal surveys or interviews, or informally though social media platforms and verbal interactions (Burt et al 2017). Many healthcare services direct people to independent websites where they can share their experiences, for example the social enterprise website Care Opinion (www.careopinion.org.uk/info/about), which is described as ‘a place where you can share your experience of health or care services, and help make them better for everyone’. Such websites can be helpful in identifying quality improvement opportunities, but any nurse considering this type of data for a quality improvement project should consider its usability; for example, information on specific elements, such as patients’ conditions or demographics, may be unclear.
Formal data captured through surveys or interviews have some advantages over informal data in terms of quality improvement projects. For example, formal data can be designed to answer specific questions, test changes in healthcare delivery or recognise small incremental improvements in care processes (Gleeson et al 2016).
As Marsh et al (2019) described, feedback data can be qualitative, such as patients’ quotes and stories, or quantitative, such as numerical data or statements represented by a scale running from ‘strongly agree’ to ‘strongly disagree’, for example. Both qualitative and quantitative feedback data have a valid role in quality improvement projects.
Issues in care quality are often identified initially through qualitative reports, such as patients’ complaints or staff members’ observations, which can then be followed-up by gathering quantitative data. In addition, qualitative data can be useful when undertaking early tests of change, where nurses implement small changes to improve patients’ experiences. Conversely, quantitative data are useful for monitoring improvements over time and can be used to compare various groups or data, or to prepare for the scaling-up of a successful quality improvement project.
Qualitative patient experience data can come from a range of sources, including formal interviews, focus groups, online forums, complaints, correspondence such as ‘thank you’ letters and informal verbal feedback. There are multiple reasons for using qualitative data, from improving team creativity to generating teaching tools (Healthcare Improvement Scotland 2023). Qualitative data is also useful for gaining insight into patients’ experiences, particularly where validated quantitative tools are not available or suitable, such as where improvements involve small numbers of patients.
Qualitative data can be valuable in exploring unanticipated or ignored aspects of patients’ experiences, particularly when it is important to avoid making assumptions, for example when planning improvements in the care of children with learning disabilities. In addition, qualitative data can be useful in the early stages of quality improvement projects or for examining people’s culture, customs and habits (The Point of Care Foundation 2024).
It is important that nurses consider whose experiences they want to represent with qualitative data. For example, do they want to understand the range of patient experiences in a whole hospital or focus on a specific group? One principle of quality improvement is the ‘good enough’ principle, which states that the minimum amount of data should be used to gain the understanding required at any specific point. Unfortunately, however, quality improvement reports rarely state how many people were interviewed, despite guidance recommending that such details should be reported to ensure transparency (SQUIRE 2020).
Focus groups enable discussion between participants and can generate unanticipated insights. As a general guide, the optimal number of participants required to encourage interaction in a focus group is between six and ten (Moule et al 2017). Alternatively, individual interviews can elicit a patient’s unique views. In the authors’ experience, nurses should consider the subject they want to understand when undertaking interviews; for example, they may wish to explore the experiences of both the men and women using a particular service. It is also important to consider under-represented populations, for example those with learning disabilities, dementia or sensory impairment, who may be overlooked due to assumptions about their mental capacity or ability to access research materials.
Collecting qualitative data for a quality improvement project can be more flexible than a formal research study, but questions should still be designed to address the needs of the project and to limit bias while maintaining confidentiality. Larger projects may require resources, such as protected staff time to transcribe interviews. Conversely, smaller projects can provide answers to specific questions and identify significant themes relating to the improvement project quickly (Braun and Clarke 2013).
Quantitative data from patients’ experiences enable researchers to identify wider patterns in a service and track changes over time. Surveys or questionnaires are often used as an economic way to gain self-reported quantitative feedback from large numbers of participants (Gleeson et al 2016). Questionnaires should use predetermined and specific questions to ensure that the findings reflect the realities of patients’ experiences. In their review of patient experience measures, Beattie et al (2015) identified a range of scales designed for use in quality improvement projects and indicated that some had an optimal balance of validity, reliability and utility, particularly where resources are limited. One example was the short form of the Quality from the Patient’s Perspective (QPP) questionnaire (Larsson and Larsson 2002).
Quantitative questionnaires are usually validated for use in their entirety rather than for ‘picking and choosing’ questions. For example, the CARE measure has ten questions that are designed to work together to represent the complex construct of care and relational empathy; the questions are not validated to measure individual aspects, such as whether a nurse made a patient ‘feel at ease’ (Mercer 2004). Using questionnaires as they were developed involves adhering to a traditional statistical approach (Fowler et al 2021).
When the aim is to use quantitative data to test smaller changes with focused targets, such as whether patients on a single ward have their medicines explained to them consistently, nurses may prefer to use a quality process approach such as a run chart, where data are collected over regular intervals and mapped in a graph to identify patterns of change (Provost and Murray 2011).
Table 1 provides an overview of qualitative and quantitative patient feedback strategies.
(Adapted from Burt et al 2017, Marsh et al 2019)
The barriers to using patient feedback include issues related to protecting patients’ anonymity and confidentiality, and ensuring the security of the data. Issues such as nurses’ lack of confidence in analysing data, for example, can impede any improvements (Gleeson et al 2016, Wong et al 2020). Other barriers can be organisational, such as a lack of resources, or relate to the patient population, such as functional literacy issues. Table 2 provides examples of potential barriers to using patient feedback.
(Adapted from Holt 2018, Bull et al 2019)
In the authors’ experience, whichever approach to gaining patient feedback is adopted, nurses should remember that patients and families have a vested interest in the process and outcomes and how their feedback could benefit them or others. Therefore, nurses should share outcomes with patients to demonstrate the benefit of their contribution and ensure continued participation.
Feedback gathered from patients is central to understanding, evaluating and improving their healthcare experiences. A working knowledge of the various feedback strategies, such as whether to use quantitative or qualitative data, will enable nurses to engage in meaningful quality improvement projects. Similarly, an awareness of the barriers that can prevent patients from providing useful feedback can assist nurses in designing quality improvement projects that will have a positive effect on patients’ outcomes.
02 October 2024 / Vol 39 issue 10
Survey evaluates quality of patient information at end of treatment
A patient experience survey was undertaken by the South West...
Evaluating the efficacy of a telephone follow-up clinic
This article presents the findings of an audit of patient...
Effectiveness of a neutropenic sepsis clinical pathway
This article reports the findings of a re-audit across a...
Developing a clinic to meet patients’ pre-operative needs
This article describes a practice development project at a...
Emergency assessment bay for cancer patients
The annual Quality in Care (QiC) Excellence in Oncology...
