The NHS remains challenged to empower staff to manage demands to pursue quality care. Despite continual initiatives to improve matters, much still needs to be done. Gordon Forbes explains the pitfalls of counter intuitive staff engagement schemes

Only 13 per cent of employees worldwide are engaged at work, according to Gallup’s 2013 study of 142 countries, State of the Global Workplace.

Gordon Forbes

Gordon Forbes

This means that about one in eight workers - roughly 180 million employees in the countries studied - are psychologically committed to their jobs and are likely to be making positive contributions to their organisations.

Writing in October last year, Steve Crabtree and Jennifer Robison highlighted the potential upside to engaging staff with a recognition that current low workplace engagement offers opportunities to improve business outcomes across all sectors.

On the pulse

The NHS fares no better with its perennial challenge around not only engaging, but also empowering its staff to manage the many demands and pressures on their time and energies in the pursuit of safe, high quality care to the constant stream of patients who come through its doors daily.

Over 85,000 staff responding to the Listening into Action “staff pulse check” over the past two years confirm that:

  • 77 per cent do not feel valued for the contribution they make and the work they do;
  • 84 per cent do not believe that day to day frustrations that get in their way are readily identified and resolved;
  • 78 per cent do not believe their organisation structures and processes enable them to do their job well;
  • 72 per cent do not feel their organisational culture encourages them to contribute to changes that affect their team/department/service;
  • 60 per cent do not feel able to prioritise patient care over other work; and
  • 80 per cent do not feel that communication between senior management and staff is effective.

In addition, when large groups of staff and leaders are asked how much of the personal energy at work is lost through all the things that get in their way, they say an enormous 60-70 per cent.

Why aren’t staff engaged?

So the challenge and the size of the opportunity is clear globally and locally, across all sectors including healthcare, and particularly so in the NHS.

‘Staff are disengaged and trends aren’t improving’

Staff are disengaged and trends are not improving on a widespread basis.

Paradoxically, the rewards for organisations that manage to engage and empower their staff are clear, substantial and of benefit to all - staff, patients, customers and the organisation itself.

So why is it so hard to get your workforce actively involved in what they do and make a difference every day?

And despite continual initiatives to improve matters within many organisations, why is any improvement in staff morale and motivation often fleeting, patchy and difficult to sustain?

What matters and what gets in the way

The Listening into Action approach to engaging and empowering staff offers a clear insight into “what matters to staff” and “what gets in their way”, based on adoption by more than 40 NHS organisations in the past two years alone, with over 50 more involved in pilot and “early adopter” work.

So, if your organisation’s approach to staff engagement and the results of current efforts have any of the following characteristics or components, it might be time to think again.

1. Your organisation has staff whose specific job title or role is staff engagement manager or director

Engaging and empowering staff is every leader’s role, regardless of seniority, size of team or nature of the work done.

Where staff engagement becomes a job description or a position rather than part and parcel of everybody’s day job, the implication for staff is that engaging their own team is someone else’s responsibility.

2. Staff engagement is a function of the HR department

The greatest challenge around staff engagement in the NHS is getting medics and clinicians to want to engage and lead the service again.

After decades of feeling “done to” by politicians, the NHS executive and management, many frontline staff have been demoralised to the extent that they have actively disengaged.

The effort required to re-engage and re-empower them is significant and isn’t about some “quick fix” solutions or interventions that work within a few weeks, months or even years.

‘To secure staff support there must be a sense that ownership of the solution lies with them’

The situation is compounded by “initiative fatigue”, where staff dare to hope that things might be different this time round, only to have their hopes dashed when the latest initiative fizzles out.

To secure the support of staff there must be a sense that ownership of the solution lies with them, and that the chief executive and clinical leadership will support them to make it happen.

Where engagement of staff is perceived as the domain of the HR function, or any other corporate function for that matter, the obstacles and barriers to buy-in from the workforce are large and intractable.

3. Vision and values statements adorn the walls whilst behaviours go unchecked, unrewarded and unsanctioned

As part of the NHS Constitution review for the NHS’s 60th anniversary, the Listening into Action approach was used to engage staff around the refreshed NHS values, which were developed with their input.

The most telling responses from hundreds of staff across dozens of trusts highlighted the challenge facing the system and local leaders. They included:

  • “We feel we adhere to these values every day, it’s our leaders who don’t”;
  • “The values mean nothing if behaviours underpinning them are not understood and supported by all within the trust, including the use of sanction and reward as appropriate”; and
  • “It’s the day to day interactions on the ground that make the difference, not a bunch of words on a wall”.

The reality is that “promising high” to staff with a fantastic, polished, widely communicated vision and values statement often leads to “delivering low” for staff when they see that leaders who don’t live and role model these values and behaviours suffer no consequence.

4. The organisation has an annual staff awards ceremony

On the face of it, a laudable goal of recognising staff for their contribution and annual recognition for achievement - when done well - has a role to play in engaging staff and building morale.

But there are things to watch out for:

  • How valid is the selection process for staff shortlisted for the awards?
  • Who is proposing staff for the award, who is sitting in judgment, and how well regarded are the judges?
  • How do staff not put up for an award feel about being overlooked?
  • How do staff who are shortlisted but not successful feel?
  • What “rewards” do staff receive and are these more relevant and effective than the day to day positive feedback and support they crave from their managers?

If staff are worthy of annual awards, why not promote them or reward them financially or recognise their contribution in other ways throughout the year rather than annually at a formal dinner event?

5. Staff suggestion boxes proliferate across the organisation

Fine again, if done well. But the challenges around “collecting mechanisms” for staff feedback are wide and varied: It suggests staff can’t or won’t feedback to their managers and leaders face to face directly.

It puts a huge onus on the leaders running the staff suggestion scheme to respond to each and every staff suggestion, each and every time, which is time consuming and highly labour intensive against current operational and organisational resource pressures.

‘Staff suggestion boxes can quickly fall into disrepute when staff see no feedback to their ideas’

The process can quite quickly fall into disrepute when staff see no feedback or loop closing to their ideas.

Staff feel more demoralised as they fail to see action from their ideas. 

If understanding what matters to staff and what gets in their way is so important for the organisation, it should be part of everyone’s day job to elicit that input and work on it with the staff who feel as they do.

6. The primary mechanism for engaging staff is via electronic media

Many staff in the NHS do not use laptops, tablets or PCs on a daily basis. So often, well intended corporate information sent out never gets to its target audience, or if it does, it isn’t read, understood and acted upon.

And the feedback mechanisms and responses to those suggestions are often distant, disconnected and diluted.

The use of an intranet can help highlight ready sources of organisation wide information and resources available, but use of electronic media alone – in an era of huge volumes of emails and “cc” noise can often lead to more disengagement rather than its intended goal.

7. Communication is top-down, corporate in nature, and about “telling”, not “asking”

We know from the more than 96,000 responses to the “pulse check” from 42 trusts in the past two years, that 85 per cent of staff do not believe that communication between senior managers and staff is effective.

In other words, more than four in five of your workforce are switched off by this.

‘More than four in five of the workforce are switched off by top-down communication’

At a recent Listening into Action event focused on how to develop a “frontline led communication process”, it was instructive that all of the participating trust attendees were from the HR/communications function.

And on the day, their focus, despite promptings, was around how to improve corporate communications: team brief, cascade processes, “getting the message out there” better.

This is all very well, but what frontline staff ask more are things like:

  • Where do I go to find this?
  • Who is in charge and my primary point of contact for support at the weekend?
  • What is happening in our ward/team/department?
  • Why don’t we receive any response to DATIX serious incident reporting?
  • How do I escalate a concern I have about the quality and safety of care?
  • How do I share good ideas which would improve care for our patients?

These challenges are often not being addressed for staff through current ways of communicating. We know this because they tell us so.

8. Staff are surveyed with increasing regularity around how they feel and how they can contribute

The only reason to survey staff is when efforts have been made to change things - and you want to find out the difference it is making.

As one NHS commentator put it so succinctly recently on Twitter: “A pig doesn’t get any heavier by weighing it.” 

Staff in the NHS are fatigued by survey after survey when, despite their responses, nothing ever seems to change.

‘Make changes first, then ask staff how they are feeling. Ensure the change is staff led’

The latest survey imposed on NHS staff is the friends and family test, with plans in place to ask staff how they feel every quarter.

How do you think a staff member is going to respond at the fourth time of asking in 12 months if they personally have not benefited or seen any substantive change?

The corrosive effects on morale and motivation significantly outweigh any insight gained through the staff responses.

So make the changes first, then ask staff how they are feeling. And ideally, ensure the change is led by the staff themselves.

The impact on how they feel won’t need surveying – although you may want to validate this from time to time. The results will be obvious to all.

9. Sickness, absenteeism and turnover all trending negatively

Sickness and absenteeism in the NHS runs regularly between 3.5-5.5 per cent at an organisation level.

Not disastrous by any means looked at across the board. But on closer inspection, the averaged number often masks a far greater challenge around staff complements when the figures for wards and frontline positions are examined.

In some of the most challenging work environments in the NHS, it is not unusual to have staff absence levels of 10-15 per cent and we have seen numbers as high as 22 per cent non-availability over the past few years.

‘Happy, engaged staff are less likely to be sick’

Imagine trying to run a ward safely and effectively with almost one-fifth of your staff missing.

The challenge of addressing staff sickness and absence is one that resists traditional interventions around HR support and occupational health initiatives.

The root cause of much of the absence runs far deeper than a few short term fixes and running repairs.

If your trust is struggling with long term resource challenges that impact on so many other areas of the effective running of the trust, it’s time to look at some different, radical options to resolve underlying problems.

And remember, happy, engaged staff are less likely to be sick.

10. The never ending transformation programmes

Such are the pressures on trust executives from so many directions, it is easy to resort to a ready made, externally led transformation agenda.

Typically, this involves setting up a programme management office, staffed by external consultants, focused on delivering millions of pounds of savings each year or transforming the nature of the service provided.

Granted, such programmes have their place but they often come at a huge cost, not just in expenditure terms, but also in terms of the impact on staff morale.

It will ring true to many frontline staff and leaders to hear stories of never ending transformation programmes, missed targets, bureaucracy and administrative workloads associated with programmes that would test the most diligent of doctors and nurses and health professionals, plus a general sense of “being done to” by many of these initiatives.

‘Until frontline staff are crying out for a transformation programme, it will most likely be a distraction’

Bluntly, if frontline staff don’t have the time to do their day jobs, how will they find time to lead a work stream or an improvement project or a cost reduction initiative as part of your transformation effort?

For change to stick and sustain in the NHS, it needs to be led by frontline teams within their own areas, and it needs to happen as part of their day job.

It needs to be led and owned by clinicians, and they need to be supported by their fellow managers and corporate colleagues.

Until we get to the stage when our frontline colleagues are crying out “we need a transformation programme here”, the most likely outcome is that the well intended transformation programme will be a distraction, or, perhaps, occasionally, an even bigger headache for staff morale and motivation.

Gordon Forbes is director at Optimise, the architects of Listening into Action

For more information on Listening into Action