Engagement is up according to the NHS Staff Survey, but at what cost? 

When the concept of engagement at work was introduced by William Kahn in 1990, he described it as the expression of our ‘preferred self’ in tasks that promote connection with our work and with others. Engagement underlies effort, involvement, flow, mindfulness and intrinsic motivation. The good news then is that levels of engagement, as recorded in the NHS Staff Survey, have increased since last year. So can we all relax?

Far from it. While the survey results can be presented from a ‘glass half full’ perspective, if we see the glass as half empty then the results are disturbing. They suggest that of the 1.4 million people who make up the NHS workforce:

  • 41 per cent would not recommend their trust as a place to work
  • 57 per cent say they are unable to meet the conflicting demands on them at work
  • 13 per cent report being bullied by their managers
  • 15 per cent have been assaulted at work in the previous year
  • only 39 per cent feel they are able to deliver the quality of care they wish to patients
  • 31 per cent did not agree that they would feel happy with the quality of care in their organisations if a friend or relative needed treatment
  • only 42 per cent agreed that their roles actually make a difference to patients.

And the list goes on: only 52 per cent of staff report feeling satisfied with the recognition for their contributions; only 42 per cent feel their work is valued by their organisations; 27 per cent do not have the opportunity to show initiative and 25 per cent do not feel able to make suggestions to improve the work of their team or department; and only 56 per cent say they are able to make improvements happen in their area of work.

NHS staff are highly skilled and extraordinarily motivated. They dedicate their working lives to caring for those in their communities. They are motivated by a core value of compassion and almost all of them wish to provide the best quality care that resources will allow. Compassion is therefore at the heart of the NHS and the staff who make up the service. Yet the Staff Survey data suggests that the way the service is being led and managed is creating conditions that do not enable staff to fully live that value at work, or to fulfil their personal missions of delivering high-quality care.

How are managers and leaders to respond? Not by making financial performance the overriding priority, but by developing models of compassionate leadership in the NHS. Compassion is paying attention and listening with fascination to the other person (patients for example); understanding their distress or difficulties; having an empathic response; and taking skilful or intelligent action to help. So we need leaders to lead with compassion, and this means paying attention to staff. Leaders play a powerful role in shaping cultures, and when their behaviour is less than compassionate they contribute to a drift in culture that produces the disheartening responses in the Staff Survey.

This compassionate style of leadership is required at every level of the system. Bullying at senior levels, as we know, can be replicated up to five levels down in organisations. So compassion will similarly be replicated if it is established as the dominant style of interaction. Of course there are tough situations to face alongside financial pressures, but then all the more reason for listening, understanding, empathising and taking intelligent action to help at every level. At The King’s Fund we’re currently working with NHS Improvement to provide a series of online tools which will help trusts to support positive cultural change and compassionate leadership.

So returning to the Staff Survey results, why then is engagement shown to be up? It’s possible that all the pressures in the system mean staff are having to give more of themselves to enable high-quality patient care; they are having to put in more effort, longer hours, and give greater emotional support and creativity than they would have had to otherwise.

But ever-increasing levels of engagement without increased support are not sustainable. The high levels of staff stress in the NHS tell us that the system is under huge strain, and that it is NHS staff who are suffering. Only 31 per cent agreed there were enough staff for them to be able to do their jobs properly; 60 per cent were working unpaid overtime; 63 per cent attended work when feeling too unwell to perform their duties; and 37 per cent reported feeling unwell as a result of work related stress in the previous year. Ultimately high levels of staff stress begin to erode compassion and affect care quality, patient experience and patient outcomes. It is vital that all NHS leaders recognise the imperative of developing a style of compassionate leadership to sustain the core values of the NHS. The real cost will be too great if they do not.

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#545864 Jill Gould
Senior Lecturer & District Nurse

Great article Michael - so important to highlight this. Discussed the staff engagement survey in class this week (Leadership module) because of the links made between engagement, motivation and ultimately; patient outcomes. When I've discussed this with front line staff before, and also gained information through my national networks, an even more worrying picture emerges: almost without exception these community based practitioners report they are fearful of completing the survey. Most specifically, they are concerned it is not truly anonymised and that there could be consequences for being open and honest in their responses. The wording of some of the questions doesn't help; so for instance staff wouldn't want to express that they are unable to provide the high quality care they would like to, as they are nurses and it could be seen as in breach of their professional code of conduct. As the percentage of NHS staff undertaking the survey is only 41% and the findings represent the ones 'brave' enough to respond, it could be seen as the cup is even less than half full - it's nearly drained dry! Would be very helpful to get more staff undertaking the survey, perhaps by alleviating some of the fear around it. PS really appreciate your work & always refer to it in my teaching

#545871 Julia Smith

Compassion is all very well but it needs adequate structure and funding for it to be delivered effectively. I feel the key issues are: The overall number of AHP students educated; continuing professional development and setting boundaries around your professional integrity: thereby seeking to protect both of your colleagues and yourself against the service being underminded through a systematic and ongoing lack of funding.

#545872 Terry Roberts
Member of the public

Thankfully the old style of professional led by consultants is being replaced by more professionally competent people and by that I mean in people skills as well as practical ones.
That said, the new breed are being indoctrinated into a 'be ultra careful as you could be sued' regime which makes them cower and often ineffective.
The system too allows them to hide away from decision making by keeping their head down, endless meetings, continuous reviews and other delaying tactics coupled with a knowledge that often the ineffective and incompetent get rewarded and promoted.

#545873 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

As they say 'when going gets tough - tough get going'. With the current financial challenges, increasing demand, difficulty in recruiting well trained doctors and nurses due to national shortage and more and more pressure to get patient safety and quality right; leading and managing NHS is becoming a night-mare even for good leaders.

The only way to keep staff morale high is to care for staff and engage them fully. NHS needs leaders who are kind, caring, compassionate but also must have courage to tackle those staff including consultants, midwives, nurses and managers who create bullying culture or behave in a way that put patients lives and staff well-being at risk.

In Wrightington, Wigan and Leigh FT by defining our values, culture, appointing values based leaders, implementing good governance and good staff and patient engagement we have transformed the Trust and today, in spite of all the pressures of NHS staff feedback has improved from bottom 20% in 2010 to 4th best Trust to work in the NHS! Our patient safety and quality outcomes have improved significantly.

Happy staff - happy patients.

#545880 Michael West

Thanks Jill. Perceptive and helpful comments. I will seek to pass them on to those running the survey.

#545898 Arthur Gardiner
p/t semi-retired OT

I didn't fill in the questionnaire because I'm "surveyed out" and realistically I can't seeing how it will make any difference other than to keep survey organisers in jobs. The emphasis now is on numbers not quality, with its concomitant fear of 'breaching' some manmade standards. Quality of care is more important. E.g. so what if I have to wait longer than 4 hours in A & E if when I do see a doctor I get the best care from an unstressed clinician. Rather this than being rushed through to meet some meaningless government target and end up being readmitted because my needs were not met in the first place!

#545920 Fergus Murray

Thanks for that! Very enlightening. How depressing that this survey - despite all the massive problems you point out - has allowed the government to dismiss a 400,000-strong petition calling for a vote of No Confidence in Jeremy Hunt with the bland and deliberately misleading (but technically accurate!) statement 'The latest staff survey showed NHS staff engagement is at a 5 year high.'

#545922 Fergus Murray

Sorry, that should have read 300,000, not 400,000 (actually 328,970).

#545977 Rab McEwen
Care Home Education Facilitator (RGN)

I work in Scotland and we have similar surveys both nationally and local. I have to ask apart from comparison regarding levels of engagement and the actual feedback is anything done with the data? So often we audit and collect data but never actually seem to see change or improvement come from it. So where is the value?

#545982 Elizabeth Angier
Portfolio Gp

Dear Michael,
I'd like to see a similar Gp and primary care staff survey available to all gps, portfolio, salaried ,locum and partners and primary care workers.Is there any work being done on this?,the Health Select committee mentioned that it is missing and I think it could tell us a lot about the current system. You could also ask about the delivery of integrated care and service improvement.It seems as though this space is missing on the surveys.

#546040 Peter Brooks
Governance Consultant

What can be done by, those who encounter it, to deal with bullying, and the culture of bullying?

#546051 Ian Richardson

A great discussion, unfortunately many of the solutions are not in the hands of the people, or their leaders. You may like to review the issues caused by our traditional organisations www.stoosnetwork.org

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