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Staff engagement: six building blocks for harnessing the creativity and enthusiasm of NHS staff


This report, part of our Leadership in action series, looks at the issue of staff engagement in the NHS. It explores ways in which board members and other leaders can make a tangible difference in their organisations by focusing on six building blocks for harnessing the creativity and enthusiasm of NHS staff.

There is now an overwhelming body of evidence to show that engaged staff deliver better health care. Trusts with more engaged staff tend to have lower levels of patient mortality, make better use of resources, and have stronger financial performance and higher patient satisfaction, with more patients reporting that they were treated with dignity and respect.

This paper encourages boards and other leaders to focus on staff engagement and suggests a number of questions boards can ask to assess their organisation’s level of staff engagement.

What is staff engagement and why is it important?

Health care is a people business. The quality of care that patients receive depends first and foremost on the skill and dedication of NHS staff. Highly engaged staff – and by this we mean individuals who are committed to their organisations and involved in their roles – are more likely to bring their heart and soul to work, to take the initiative, to ‘go the extra mile’ and to collaborate effectively with others.

There is now an overwhelming body of evidence to show that engaged staff really do deliver better health care. The NHS providers with high levels of staff engagement (as measured in the annual NHS Staff Survey) tend to have lower levels of patient mortality, make better use of resources and deliver stronger financial performance (West and Dawson 2012). Engaged staff are more likely to have the emotional resources to show empathy and compassion, despite the pressures they work under. So it is no surprise that trusts with more engaged staff tend to have higher patient satisfaction, with more patients reporting that they were treated with dignity and respect (Review of Staff Engagement and Empowerment in the NHS 2014).

Yet despite the evidence, the question of how to create an engaged workforce still struggles to make its way on to the board agenda. It may seem like a vague concept, and there are always other, seemingly more immediate challenges. Mid Staffordshire NHS Foundation Trust had among the lowest levels of staff engagement in the NHS throughout the mid-2000s, but the alarm bells were not heard. While levels of staff engagement have risen across the NHS over the past few years, the disparities between organisations are wider than ever. Those trusts with the lowest levels of staff engagement are falling further behind the leaders (Review of Staff Engagement and Empowerment in the NHS 2014).

The good news is that we now know a huge amount, from the NHS and other sectors, about the conditions that create an engaged workforce. Developing engaged staff is a long-term endeavour and requires sustained effort throughout an organisation. But board members and other leaders can start making a tangible difference immediately, simply by focusing on the following six building blocks for success.

1. Develop a compelling, shared strategic direction

Research from health care and other sectors shows that leaders who help their organisations to develop a clear vision and a compelling narrative about mission and priorities achieve higher levels of staff engagement. Staff are more enthusiastic about their work and collaborate more effectively, and this is reflected in better performance (MacLeod and Clarke 2009).

In health care, there is evidence that developing a clear mission focused on high quality, compassionate care helps to bridge the fault lines between managers, clinicians and other groups (Bezrukova et al 2012).

Achieving this is no easy feat and requires more than a wellcrafted mission statement. In health care, leaders face a bewildering range of external expectations, which can lead to overlapping or disjointed goals (Dixon-Woods et al 2014).

Successful providers have articulated simple but persuasive visions for higher-quality, safer and more compassionate care and have maintained them consistently over time. Salford Royal NHS Foundation Trust announced its ambition to become the safest NHS hospital in 2008 and it has retained that vision, with minor changes, for the past seven years.

Just as importantly, the vision needs to be seen as authentic and meaningful. Leaders need to demonstrate their commitment to the vision through the way they spend their time, how they allocate resources, what they measure and what they reward, as well as by ensuring that the vision is reflected in staff objectives across the organisation. The most successful organisations set explicit and challenging goals for achieving the vision and they measure progress in meeting them. Salford Royal set an initial target of saving 1,000 lives in three years and reported on progress in meeting it. Northumbria Healthcare NHS Foundation Trust has published targets for quality improvement, such as a new zero-tolerance strategy towards hospital- and community-acquired pressure ulcers and falls in hospital. It has set the target of a 20 per cent reduction in harm from pressure ulcers and falls in 2014/15 and is publishing levels of performance in its annual report.

The ultimate test of a vision has to be whether it transcends the mission statement and enters the organisation’s bloodstream – the rites, rituals, cultural norms and stories about ‘how we do things around here’. In November 2014, staff at Wrightington, Wigan and Leigh NHS Foundation Trust wheeled a 77-year-old cancer patient into the hospital car park to say goodbye to the horse she had cared for for more than 25 years. For staff, the message from the story is clear: this is an organisation that really is trying, as it claims in its mission statement, to put patients ‘at the heart of everything we do’, and is giving staff the freedom and support to translate the vision into practice.

Board members should ask the following questions

  • Do senior leaders and staff agree that they are all working towards a clearly defined common direction?

  • Do staff across the organisation understand the vision and how their roles contribute to it?

  • Has the organisation set demanding goals for achieving the vision and is it monitoring progress in meeting them?

2. Build collective and distributed leadership

The most successful health care providers – like high performers in other sectors – are reducing reliance on top-down leadership in favour of collective and distributed leadership, where all staff are supported to play leadership roles. Rather than concentrating power at the top, these providers are devolving decision-making in their organisations, alongside major programmes of cultural change, so that staff at all levels have the authority, responsibility and resources to improve care.

We know that distributing power and authority in this way helps to create a more engaged workforce. Research from multiple sectors shows that staff are more engaged if they have responsibility for their work and influence over their working environment (Towers Perrin HR Services 2003).

Conversely, we know that staff are more likely to disengage when operating in overly bureaucratic environments with layers of hierarchy and control. According to Paul Plsek, Chair of Innovation at the Virginia Mason Center in the United States, ‘a learning organisation seeks to develop skills in the process of leadership at all levels of the organisation, and seeks to flatten hierarchy and eliminate rigid policies’ (Plsek 2013).

However, we cannot underestimate the challenges of developing a collective leadership culture within many NHS organisations, given the legacy of rigid hierarchies and ‘command-and-control’.

For many top-performing providers, it requires huge commitment to develop a new leadership philosophy. It takes time and effort to redesign decision-making structures and equip staff at different levels to play different roles, alongside concerted programmes to deliver the necessary cultural change. In the early 2000s, University College London Hospitals NHS Foundation Trust stripped out layers of management and gave clinicians joint managerial and clinical responsibility for the performance of their divisions, with the role of ensuring both quality of care and financial sustainability.

Alongside these types of changes, staff at every level must be given explicit authority to identify opportunities for improvement or to raise concerns, and – just as importantly – opportunities for these contributions to be considered fairly and acted on. In manufacturing, Toyota and Alcoa famously introduced the right for staff to stop the production line if they identified a defect or a safety concern. In health care, forwardthinking providers are developing similar approaches – not just to improve safety, such as finding a lost swab in an operating theatre, but also to tackle unacceptable behaviours in a caring profession, such as discourtesy, bullying or harassment.

For a further discussion of these issues, see our other recent publications: Exploring the CQC’s well-led domain: how can boards ensure a positive organisational culture? and Developing collective leadership for health care.

Board members should ask the following questions

  • Do we have a leadership strategy and a leadership development plan?

  • Do we have a clear understanding of our current leadership culture and the leadership culture we are trying to create?

  • What approaches have we developed to empower staff throughout the organisation to play leadership roles?

  • Are we absolutely sure that staff can speak up when they have concerns and that their concerns are considered fairly?

3. Adopt supportive and inclusive leadership styles

Research shows that leaders and managers who adopt supportive and inclusive leadership styles have more engaged staff. The most successful leaders deploy a range of leadership styles depending on the circumstances, but with greatest reliance on inclusive styles, such promoting collaboration, involving staff in decisions, encouraging and coaching staff, and supporting staff in overcoming organisational challenges.

Yet despite this evidence, studies suggest that NHS leaders and managers continue to rely first and foremost on directive leadership styles such as leading from the front, setting the pace or laying down demanding targets – precisely those styles that run the greatest risk of disempowering and alienating staff.

According to the Commission on Dignity in Care for Older People: ‘if senior managers impose a command and control culture that demoralizes staff and robs them of the authority to make decisions, poor care will follow’ (NHS Confederation et al 2012). A small number of high-performing NHS organisations have made concerted efforts to develop more inclusive and supportive leadership styles. For example, Oxleas NHS Foundation Trust made substantial investment to convince sceptical leaders and managers of the need to change, before helping them to ‘unlearn’ ingrained behaviours and develop a broader set of leadership skills. In 2013, Oxleas was the mental health trust with the highest levels of staff satisfaction in the quality of their work and in the patient care being delivered (NHS Staff Survey 2013).

For more information on the impact of leadership and management see Staff care: how to engage NHS staff and why it matters by The Point of Care Foundation.

Board members should ask the following questions

  • What do we think are the most prevalent leadership styles throughout our organisations?

  • What do our staff think are the most prevalent leadership styles? Do they think leaders and managers are inclusive and supportive?

  • What investment have we made to develop the leadership styles that support high levels of staff engagement?

4. Give staff the tools to lead service transformation

We know that staff are most engaged in their roles when they have a degree of authority and control over their work and environment, as well as the opportunity to stretch themselves and to develop. Conversely, the least engaged staff are often hourly workers with little authority or influence over their work.

The most successful health care providers – just like cutting-edge organisations in manufacturing, transport and other sectors – are giving their staff the tools and resources to lead transformation from the front line. Rather than calling in external experts to redesign services, they are using these resources to help frontline staff master modern methods of quality improvement.

By investing in and empowering their staff, these organisations are unleashing their employees’ enthusiasm and creativity to improve how they do their work, creating a constituency of leaders of change, rather than stubborn opponents to change. In doing so, they are creating ‘learning organisations’ where staff at all levels participate in continuous, daily improvements in care – rather than one-off flurries of activity when an organisation or service hits the buffers.

There are many ways of going about this. Like Virginia Mason, the Mayo Clinic and other international leaders, Salford Royal NHS Foundation Trust has established a Performance Improvement Directorate to support staff in developing and testing service improvements. Others, such as University Hospitals of Leicester NHS Trust, are using Listening into Action or similar methodologies to deliver staff-led service improvement. At Leicester, frontline staff are leading a range of improvement projects, for example to improve anaesthetic checks, introduce floor-control visits in orthopaedic theatres and simplify recruitment processes. While there are differences in the approaches used, the focus is on developing rather than disempowering frontline staff, building a foundation of technical knowledge in the organisation and creating a culture that promotes innovation.

Board members should ask the following questions

  • Do we have a strategy to support continuous learning, innovation and improvement?

  • Have we invested resources in building the capacity needed to help staff innovate and improve services?

  • How much senior leadership time is dedicated to supporting frontline staff in trialling innovations and delivering improvements?

5. Establish a culture based on integrity and trust

Research shows that staff are more engaged in their work and committed to their organisations if they believe that their leaders act with integrity and if they have confidence in the fairness of their organisation and its procedures. Staff are also more engaged if they feel valued by leaders and operate within a supportive community (Maslach et al 2001).

Conversely, we know that NHS staff are more likely to want to leave organisations that tolerate high levels of bullying or discrimination (Review of Staff Engagement and Empowerment in the NHS 2014).

The message is that values are important. NHS leaders need to attend to creating organisational cultures that help to maintain high levels of engagement and underpin safe, highquality patient care. At Frimley Park Hospital Foundation Trust, for example, there has been a conscious effort to define the trust’s core values and the behaviours that should underpin them, including honesty, fairness and compassion.

Statements on culture can play a useful role. But it is critically important that leaders are seen to act authentically and that organisations live by the values they espouse. Staff are likely to become cynical and detached if they detect a gap between what leaders say and what they do, what leaders claim is important and where they really focus their energies, or between the stated values and the behaviours that are encouraged or tolerated in practice.

As well as defining their values, successful trusts such as Frimley Park Hospital Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust are identifying ways of embedding them within their systems and processes, such as their recruitment procedures, appraisals and reward systems. A small number of trusts, such as Wrightington, Wigan and Leigh NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust, are developing more effective procedures to address behaviours that are inconsistent with their values, such as incivility, aggression, bullying and harassment, whether in relation to patients or other staff.

Board members should ask the following questions

  • Do we have a clear sense of the values and behaviours that we want to promote in the organisation?

  • What are we doing to promote those values and to address behaviour that is inconsistent with them?

  • What actions have we taken recently to tackle bullying and harassment in the organisation?

6. Place staff engagement firmly on the board agenda

Our final message is that the boards of NHS organisations need to dedicate greater time and attention to staff engagement, not as a passing fad, but as a subject demanding regular discussion and reflection. Senior leaders need to place staff engagement in the ‘too-important-to-ignore’ tray, alongside patient experience, patient safety and clinical outcomes, given the sheer weight of evidence that engaged staff raise these measures of the quality of care.

In a major recent study, researchers investigated what the boards of NHS trusts and foundation trusts considered to be their strategic priorities and what types of innovations they were introducing to improve quality and safety. The boards of 38 per cent of the providers investigated identified staff engagement as a key priority. But only 30 per cent of these had introduced any innovations to increase engagement in the 18 months from January 2010 to June 2011 (Dixon-Woods et al 2014).

Other research has shown that senior leaders need to treat staff engagement as an ongoing priority and, in many cases, make gradual changes in a potentially wide range of areas to create highly engaged organisations (Review of Staff Engagement and Empowerment in the NHS 2014). For example, the board of Bromley Healthcare discusses staff engagement at each of its board meetings, as a standing item alongside quality of care. Wrightington, Wigan and Leigh NHS Foundation Trust has monthly staff engagement meetings, led by the chief executive, with other board members, staff and staff-side representatives.

Boards can use the NHS Staff Survey as an excellent starting point for these discussions. It also offers a basis for ongoing innovation and evaluation, given the range of comparative data that it provides on both the conditions for engagement and levels of engagement within trusts, such as leadership styles, fairness of procedures, levels of trust and other features of the working environment.

Board members should ask the following questions

  • How often does the board discuss levels of staff engagement and how they could be improved?

  • Are we making best use of the NHS Staff Survey and do we need other data to assess levels of engagement in different teams?

  • What steps have we taken to increase levels of staff engagement in the past year?