staff attitude surveys: Most managers are happy in their jobs - but most other NHS staff are not, annual attitude surveys show. What use is a diagnosis unless the problems are treated, ask Professor Peter Spurgeon and Dr Fred Barwell

Published: 07/06/2002, Volume II2, No. 5808 Page 22 23 24

Countless NHS staff will have listened to speeches telling them 'staff are our most valuable asset'. Such platitudes are frequently greeted with scepticism by staff, who are likely to say that morale has never been lower. There is a contradiction in these two disparate positions, and the recent spate of NHS human resources policies recognises that rhetoric alone will not do.

The NHS plan recognised the need for more staff who are properly trained and motivated, and last year the NHS taskforce on staff involvement stated that staff should be involved in all decisions that affect them and that valuing them made a positive contribution to patient care.

This reflects a growing body of literature from the private sector that consistently good HR practice has a long-term impact on an organisation's profitability and market position. But a parallel 1This begs the question of what is meant by 'morale'.Most would probably agree that a working definition should include issues relating to teamwork, the work environment, workload, management style, communication, pay and conditions, interprofessional relationships, personal security and workplace stress. The annual staff attitude survey provides an opportunity to examine this wider perspective, but in some quarters this chance has not been grasped as incisively as it might have been.

Birmingham University's health services management centre, with Applied Research Ltd and NHSP (formerly NHS Personnel), has developed a comprehensive staff attitude survey instrument with psychometric properties and the capacity to incorporate local issues. By selecting relevant scales and including local topics, trusts can tailor the survey to meet local needs.

We have analysed the results of surveys in 18 acute and community trusts and 20 health authorities in England during 2001. The database may constitute one of the largest surveys conducted in the NHS of staff views. The results should enable managers to make informed decisions and to adopt initiatives that impact on staff morale. Internal benchmarking enables any staff group or grade to be compared to another, while the whole organisation can be compared externally to other similar organisations.

We benchmarked each organisation against the rest of the sample and informed it of its position.

Participants were given their own organisation's relative position, not the whole picture.

An overall picture of staff morale in NHS acute and community trusts in 2001 is summarised in the table below. It presents data which relates to the ten most commonly used attitudinal scales.

Several clear messages emerge from the results.

Except for managerial staff, there was widespread dissatisfaction with pay and conditions of service.

Administrative and clerical staff and technical staff were notably dissatisfied with their reward package.

Nurses and midwives were also unhappy with their pay and this raises real concerns.

This widespread dissatisfaction must be tackled if the service is to compete effectively in the labour market and meet the ambitious recruitment targets set for 2004. Unfortunately, the results for this year's round of attitudinal surveys do not reveal evidence of any real improvements in staff perceptions of the equity of reward structures.

Most staff groups tended to hold a relatively positive view of equality of opportunity with respect to training, development and promotion opportunities, irrespective of gender or ethnic origin. But despite this positive endorsement of equality of access to training, development and promotion opportunities, many staff are unhappy with the availability of such opportunities.Most staff groups saw the quality of working relationships with managers as good. But doctors and dentists were not so positive as most others (see table). This suggests that traditional tensions between managers and medical staff are still embedded within the NHS culture. Analysis at local trust level could highlight this crucial area and be a key to improvements.

Perceptions of communication were much less positive. Given the importance of open and honest discussion of work issues to a positive work culture, a great deal of scope exists for this aspect of working life to improve. In some trusts staff have identified the inability to discuss openly issues arising at work not only as a strong source of stress but also being indicative of a high-risk patient environment.

It is encouraging that staff groups tend not to consider that harassment and bullying is a problem at work. But such behaviour is not typically endemic or 'spread' across all organisational units, departments or work teams. Rather, since it tends to be localised, the negative views of those staff who are victims of this dysfunctional behaviour tend to become 'swamped' in the generally positive aggregated results. Unfortunately, analysis of local trust results shows that harassment and bullying are very real problems for many subgroups of staff.

Ill-specified work objectives and lack of role clarity are often seen as widespread problems in the NHS.

These results suggest that most staff groups do not think so. Indeed, this scale is often associated with a strongly positive level of staff endorsement. Administrative and clerical staff are an exception - they tend to feel that they have insufficient role clarity and often have to cope with conflicting or inconsistent demands. In many trusts these staff feel that they are expected to undertake unreasonably difficult tasks without having the authority to take independent decisions.

Many staff who work directly with patients are becoming increasingly worried about levels of aggression and violence directed at them by patients and relatives. This is reflected in fairly negative feelings of concern for their health and safety. As the table shows, staff such as managers, who do not have to deal with the public, have a more positive perception of their organisation's concern for health and safety issues.

Three parts of the questionnaire - recognition and independence, participation in decisionmaking and empowerment and creativity - are concerned with how valued NHS staff feel at work.

Feeling a valued member of an organisation is often discussed as a crucial component in maintaining staff morale.

Our results show that many NHS staff feel they are not properly recognised for the work they do and that they have little influence on those decisions which impact on their work practices. This feeling is common across all groups except managers.

Many feel that they have insufficient authority to take initiatives and act independently. Staff who feel that they are more empowered to make real changes at work tend to occupy more senior job positions.

Without a radical restructuring of the traditional hierarchical command structures, it may be inevitable that those in less influential jobs feel undervalued and unempowered.

Managers have positive feelings about all aspects of their job that the survey asked about. This could be because their jobs involve a degree of autonomy, good financial rewards and clear targets.

It could be argued that managers have a vested interest in seeing their organisation, and perhaps indirectly their own performance, receive a positive endorsement.Managers may be reluctant to report negative perceptions of the system for which they carry a responsibility.

Alternatively, it may be that the reward and status of managers' positions offset the pressure to deliver organisational targets. Although the demands are heavy, senior positions offer more latitude and discretion as to how tasks are undertaken. Research shows that this sense of control is critical to coping with pressure. Also, it could be argued that despite the stated goals relating to patient care, the NHS reform programme is at heart managerial.

Many clinicians seem disaffected with a reform process where targets set seemingly for public consumption conflict with, or divert, clinical activities. Managers, in contrast, may feel empowered to deliver reforms that perhaps shackle traditional clinical freedoms. The key messages of concern for those who aspire to tackle and improve staff morale relate to participation in decisionmaking, more open communication and recognition. Our findings endorse some of the messages of focus groups conducted by the King's Fund.

2Participants, who included clinical directors, managers, doctors and nurses, considered that the key determinant of morale and motivation was a sense of being valued, and that morale was generally low in their organisations.

The comprehensive approach to these surveys is providing insights into how staff view the quality of their working lives, and many of the prevalent myths about morale are being challenged. Several factors emerge:

Staff morale is not a unitary concept: many aspects of working life can influence motivation and perceptions of the working environments.

However, a full and balanced picture of staff morale can be reliably captured using a fairly small set of established scales. The service needs to collect such information systematically and consistently rather than making general unsubstantiated claims about aspects of morale.

Staff morale is not stable. It varies not only over time, but also between staff groups and organisations. Regular assessment is vital to assess the impact of changing policies, procedures, and working practices.

Staff morale, job dissatisfaction and work stress are inter-related aspects of the quality of working life which often reflect and reinforce one another and influence staff attitudes in complex ways.The causes and consequence of these negative workplace perceptions need to be better understood.

As important as describing staff perceptions of the quality of working life is the possibility of establishing systematic links between HR practice, staff morale and organisational performance.As performance data emerges for different health provider groups it will be possible to develop our understanding of the causal relationships between HR strategies and performance in the health sector.

If we really want to move from rhetoric to informed policy about staff morale, the capacity to do so already exists.

The comprehensive survey methodology provides potentially powerful data for both local and national consumption. Instead of relying on vague statements about fluctuations in staff morale, real information can be provided, based on the perceptions of many staff groups.

But these surveys are primarily diagnostic in that they indicate areas that need attention. If the NHS is encouraged to conduct surveys, follow-up action is crucial.And, for its part, the Department of Health needs to support policies that deal with the problems identified.


1Department of Health. Working Together: staff attitude surveys - measuring the quality of working life in the NHS.HMSO, 2000.

2Finlayson B. Counting Smiles: morale and motivation in the NHS workforce. King's Fund, 2002.

Key points

Since April 2000, it has been mandatory for all NHS organisations to conduct annual surveys of staff morale.

Analysis of staff attitude surveys in 18 trusts and 20 health authorities in 2001 showed that most staff groups were not happy with their pay or the recognition they received.

Managers were happy with all aspects of their jobs.

Doctors and nurses were concerned about their safety.

All employing organisations must act on these results to improve employment practice and help to develop motivation.

Professor Peter Spurgeon is professor of health services management, Birmingham University.

Dr Fred Barwell is managing director of Applied Research Ltd.