Some 156,000 staff were quizzed
Less than half of NHS staff believe patient care is the top priority for trusts, an annual staff survey shows.
The rest either did not believe their NHS trust saw it as a priority or neither agreed nor disagreed, the poll of 156,000 staff in England showed.
The Healthcare Commission report also revealed wide variations in infection control standards and no reductions in the number of staff being attacked.
Unions said some results were worrying, but noted staff seemed to be happy.
Three quarters said they were satisfied with their jobs, although only one in four said they felt valued by bosses.
On patient care being a priority, 46% said it was, 25% said it was not and 29% neither agreed nor disagreed.
Meanwhile, levels of abuse and violence have remained fairly constant with the previous two surveys.
One in four workers said they had been harassed, bullied or abused by patients or their relatives, while 13% said they had suffered physical violence, rising to 29% for those who worked in ambulances.
Ambulance staff were also critical about the condition of the vehicles with half saying they were in a poor state of repair.
On measures being taken to tackle hospital bugs such as MRSA and Clostridium difficile, 82% said their trust was doing enough to promote good hygiene - up from 70% in 2005.
However, only 61% said hand-washing equipment was always available to them and there were significant variations across trusts.
HAVE YOUR SAY
NHS staff get blamed for not being able to meet the false promises made by politicians
On the positive side, there was a decrease in the number of staffing witnessing potentially harmful errors, from one in four last year to one in five in 2007.
Healthcare Commission chief executive Anna Walker said there was much positive news in the survey.
But she warned: "There are challenges to making the NHS a better place to work."
Karen Jennings, head of health at Unison, said the results about care being a priority were worrying.
"Trusts must refocus attention on their patients and away from competition and privatisation," she said.
And she added there were still "disturbing levels of violence".
Dr Peter Carter, of the Royal College of Nursing, added some aspects of the report were pleasing, but warned tough action was needed to reduce the number of attacks on staff.
But health minister Ann Keen said the NHS was improving in many areas.
"I know from past experience as a nurse that working in the NHS is demanding but immensely rewarding and it is encouraging that in its 60th year, the majority of staff continue to report high job satisfaction."
Meanwhile, a government poll of 77,000 patients in England showed that cleanliness and low infection rates were more important when choosing a hospital than location - the traditional main consideration.
Three quarters mentioned cleanliness and infection rates as a factor as opposed to 53% who said location and transport.