A Workforce for Good
Surveys show high numbers of NHS staff are suffering from chronic stress and others are burnt out and want to quit. We asked key NHS thought leaders how the NHS is rebuilding morale
It’s been a tough few years for the NHS and the people who work so hard in it. The Covid-19 pandemic, the sharp upsurge in demand that followed, financial constraints, long waiting lists, staff retention problems and the disruption of industrial action have all taken their toll on morale.
As of May this year, there were 100,000 staff vacancies in the NHS1, which obviously puts more pressure on the existing workforce.
A report published by the General Medical Council2 in April found the dissatisfaction with pay and feeling undervalued was driving thousands of doctors to consider leaving the UK.
Tanya Carter, Chief People Officer at East London NHS Foundation Trust says pressure both within the NHS and in wider society has had effects on staff morale.
“From my perspective, we’ve had two years of industrial action within the NHS and outside it, higher interest rates, the cost-of-living crisis and winter fuel allowances being cut. This all adds to the stresses and pressures on staff who have already worked incredibly hard going above and beyond during the pandemic. Some people are tired and burnt out, but others continue to work at that level,” explains Tanya. “Patients are potentially more unwell and further along in their diagnosis because they didn’t seek medical attention during Covid-19, so that’s another pressure.”
Is morale improving?
The latest findings from the 2023 NHS Staff Survey3 published in March this year confirmed that some staff feel undervalued, stretched and unwell. Only 61.12% said they would recommend their organisation as a place to work and just 31.23% were happy with their pay levels.
41.7% said they had felt unwell because of work-related stress in the previous 12 months and 30.38% said they felt burnt out because of their work. High numbers of staff said they were either thinking about leaving their organisation (29.12%) or probably looking for a new job in the next 12 months (21.44%).
“However, there were also some signs of improvement in how people were feeling about working in the NHS in most staff groups compared to the previous year,” says Danny Mortimer, Chief Executive of NHS Employers and Deputy Chief Executive of the NHS Confederation.
“The long-term trend is definitely back up, with some important caveats – namely, people of colour and doctors – who say they are not feeling this improvement. In terms of hard data, we’ve seen retention levels improve, with the number of staff who have left the NHS reducing over the past two years. So, we’re beginning to see some signs of improvements post-pandemic, albeit with those caveats,” Danny summarises.
“I have to stress, though, there is still a long way to go. There is still work to be done to get levels of staff engagement and satisfaction to where they need to be.”
Danny says the NHS has paid particular attention to addressing feedback from people of colour and has had the Workforce Race Equality Standard in place now for the last eight years.
“What we are seeing is that some of the process issues and gaps that the work tackled in recruitment, selection and HR processes between white and ethnic minority colleagues are narrowing. But of course, that hasn’t been enough to fully impact on how people of colour feel about their experience in NHS workplaces. Clearly, we have work to do on that as wider society does.
“When it comes to doctors, obviously we have had one of the longest running industrial disputes the government has had in the last couple of years. The dispute tells us something about how our medical colleagues are feeling. It absolutely reinforces (particularly for doctors in training), that there are a whole set of issues beyond pay that we’ve got to tackle, such as how doctors have to move around the country to train and the quality of their experience, and what they have in terms of communication about their working patterns. There is a whole set of things that we’ve got to get better at that are unique to doctors that other staff groups don’t experience to the same extent.”
How can morale be boosted, and staff retention improved?
NHS England and the NHS Improvement Retention Team have been running a programme of retention exemplars for the past 18 months covering flexible working, sustainable career paths (so staff can work for longer) and reducing healthcare support worker vacancies. “This programme of work is about galvanising and sharing good practice amongst employers and it is being rolled out across the whole NHS over the course of the next 18 months,” says Danny.
“Work to support new starters in the NHS, flexibility and predictability, and professional development are three things that can make a real difference to staff,” continues Danny. “It’s also about the culture of an organisation in general, the quality of the work people feel they can do and the quality of their relationship with their line manager.
“If you look at the NHS Staff Survey, more than three quarters of the NHS workforce said they felt really well supported by their line manager and I think that makes a tremendous difference, along with an organisation’s approach to flexible working.”
Creating safe spaces for staff
Dealing with the psychological and physiological fallout of working on the NHS frontline during the Covid-19 pandemic is another area receiving more attention from employers, particularly the issue of staff needing private space to rest and take breaks, as well as access to green space.
NHS Employers issued specific guidance4 on welfare facilities for staff back in 2021, stating that the pandemic had highlighted the importance of staff having private spaces to rest, get changed and leave belongings safely. It stressed that this was a legal requirement and not just something nice to have.
The NHS People Plan5 calls on NHS Trusts to have safe spaces for staff to rest and recuperate, stating “Employers should make sure that staff have safe spaces to manage and process the physical and psychological demands of work on their own or with colleagues.”
“There’s some fantastic work going on by NHS England and NHS Charities Together to make available some extra investment to support the creation of more of these spaces, both in hospitals and the community,” highlights Danny. “They are going to be seeking expressions of interest from organisations locally and these will be very much tailored to what people need. It might be about extending a space, refurbishing it or creating a new one. It could be a place for staff to rest or a place specifically for staff working out of hours.”
How real-time feedback can boost morale
Annie Laverty, Director of Patient and Staff Experience at Newcastle Upon Tyne Hospitals NHS Foundation Trust, says the Trust is measuring staff morale and patient experience with the support of charitable funds throughout the year in real time.
“At the moment, we’re piloting real-time patient experience on 14 wards. We interview patients while they are in hospital about their care and at the same time each week, we check in with staff who deliver their care,” explains Annie. “This might be something as simple as asking people a single question once a week on some occasions. These findings will then be linked to our people strategy so that we can incorporate the things that staff want and that are associated with a positive experience at work.”
Annie says the evidence base for what staff wanted was really clear and included physical and psychological safety at work. “Violence and aggression against staff are an issue and sometimes the culture within workplaces means they are places where staff don’t feel psychologically safe either,” she states.
“Staff also want their work to have meaning and purpose and to do a job that is connected to things they care about. They want to have a certain amount of freedom and choice and autonomy as to how they do their jobs, so they don’t like their role to be too restricted. They don’t want to be micromanaged, and they want to be noticed for their contribution.”
Hearing positive feedback from patients is important for morale too, she says, so this is fed back to staff within hours of patient feedback being received. “There will be some things that need improvements too, but the majority of feedback is about excellence and everything staff are getting right, and unless you do these types of measurements, staff don’t have access to the good news, and they’ll only hear complaints about when something goes wrong. Hearing the good news is a morale lift for staff as they often do not realise the impact their care has on a patient.”
Annie says teamwork and camaraderie are very important and sometimes working remotely from home can make staff feel lonely and less connected to their team.
“Staff need to be involved in making things better. They like to be included, and when we involve staff, morale is better too.”
Staff also like to work in calm environments and that links to their physical and psychological safety as well, Annie explains. “People do want physical spaces that encourage them to reflect and build camaraderie and teamwork. Staff also want to work in buildings that are well maintained and clean – it generates a sense of pride. It’s quite demoralising to be working in estates that are not well maintained.
“Pressure on estates means that we sometimes don’t have enough space available, but we can adapt to existing spaces. For instance, we are refurbishing all the changing rooms so staff have a place to hang their coats and put their belongings in a locker where they will be safe.”
How buildings can ease chronic stress
There’s now a far more open culture of talking about chronic stress and feelings of burnout across the NHS, says Danny. “One of the strongest examples of that sort of culture and responsiveness and openness is at the Royal Berkshire Hospital where they’ve made a really concerted investment before, during, and after the pandemic.”
The Royal Berkshire NHS Foundation Trust launched Oasis Health and Wellbeing Centre, a dedicated space for staff to rest and recuperate, in October 2022 with investment from the Trust and the Royal Berks charity. In the first year of opening, the centre averaged 2,800 visits per month, with half of all staff visiting at least once. The 2023 NHS Staff Survey found a 6% improvement in staff feeling supported by the Trust and they are now 12% above the national average for all acute Trusts, agreeing positive action has been taken on their health and wellbeing.
The Trust also ran an onsite support service pilot with Citizen’s Advice Reading, which has now been extended. “There is also access to talking therapies for staff and an open culture of talking about chronic stress and burnout, as well as a gym and rooms for counselling and classes. There are many other examples like this around the country too,” continues Danny. “The quality of rest facilities staff have access to is important, but the quality of the facilities you work in is very important (for morale) too. There is a massive need for capital investment in the NHS.”
James Paget University Hospital in Great Yarmouth, Norfolk, is another Trust which has recognised the importance of providing dedicated rest and recuperation spaces for staff, with the provision of a new rest room which opens onto a private garden at its new modular Concept Ward designed and constructed by Health Spaces.
Empowering staff to make improvements
Tanya says the Trust keeps in close contact with staff morale through quarterly pulse surveys, “temperature checks on how things are going,” as well as the annual NHS staff survey.
“Our treasures are people participation, quality improvement [QI], clinical leadership, our kind and caring staff, and our approach to inclusion,” says Tanya. “Our QI approach empowers our workforce and gives them the tools to influence change and to measure its impact. We have a new campaign at the moment where we ask staff to tell us about things that waste their time and how they could be improved. People who do the job day in and day out will know where the waste is and where the processes are inefficient.”
Quality improvement is embedded in 30 corporate teams and the Trust is well known for it nationally, as well as for involving former service users in the design of services.
“We also offer staff support around wellbeing, which we would hope would mitigate burnout. For the past four years we’ve given all staff vitamin D supplements in winter, we have given access to health and wellbeing hubs during Covid-19 and continue to offer support via an employee assistance programme. We advocate for flexible working, such as nine-day fortnights and compressed work patterns, and are exploring a self-rostering pilot. We also provide occupational health support, sexual safety support and employee assistance programmes,” summarises Tanya.
“We’ve launched a new leadership and culture framework, plus support for staff after incidents. We get very detailed feedback when people have left and have launched some tools to enable staff to have informal conversations and encourage a speak-up culture.”
The Trust’s approach seems to be working, with 67% of staff in the NHS Staff Survey 2023 saying they felt they were able to make improvements in their area of work and 68% saying they were able to access the right learning and development opportunities (up from 60% the previous year).
“Staff turnover has stabilised, the proportion of staff who say they would recommend us as a place to work and the number of people who have left but say they would come back and work for us again are both good,” says Tanya. “We are well known for quality improvement it’s in our DNA as an organisation. So, everyone is offered pocket quality improvement training, and some do more in-depth quality improvement courses to enable them to lead a project.”
Although East London NHS Foundation Trust has achieved success with empowering staff to make improvements, Tanya says they are not complacent. “We’re challenged like most organisations, and we’re doing our best to keep morale going, and to lead with hope, but we know there are pockets of dissatisfied staff.”
Compassionate leadership for healthcare workers
Manley Hopkinson, Director of the Compassionate Leadership Academy, has been working with NHS Trusts in Brighton and Plymouth to try to change the culture within the organisations.
“There is no overnight solution to improving morale in an organisation, there really isn’t. We are trying to change a longstanding culture and that takes time,” explains Manley. “The pressures in healthcare are extraordinary and come from different places. People get into healthcare because they really want to do it and there’s a joy to doing it when it goes well. The downside is that when what you want to deliver isn’t possible, you can take on the emotional burden of that and become stressed, develop mental health problems and sadly even become suicidal.”
Compassionate leadership is about understanding with positive action, says Manley, with the focus on gaining commitment by raising self and team awareness.
“We believe that leadership comes from influence, not hierarchy, and to be completely inclusive you must afford everyone the right opportunity to grow. The programme works on all levels of an organization, from the CEO to apprentice.
“We believe everyone has a sphere of influence and can make a difference within an organisation if they can do their job in a very compassionate and human way with energy, motivation and enthusiasm.”
In Brighton at the University Hospitals Sussex NHS Foundation Trust, Manley’s team has been running a Compassion 4 Healthcare Workers (C4HCW) programme over 13 months, providing 27 online workshops and four live events for all types of staff working on the surgical floor, from consultant surgeons to hospital porters.
“The completion rate for the course is 80% and we’ve had detailed feedback about whether the training helped, whether it was relevant and made a difference, which has been very positive. Before the course was started, the Trust was spending £20 million a year on sickness and absenteeism, and now it’s down to £18 million.
“It’s vital to be able to monitor the impact of such a programme as this, so we commissioned the behavioural science experts MindAlpha to help.”
MindAlpha created the Compassion Index, a scientific measure of the development of compassion. The Compassion Index factors are directly correlated to performance, motivation and wellbeing. “This has been a game-changer,” comments Manley.
The MindAlpha verdict on the C4HCW programme was that it had a significant impact on the attitudes of participants towards the eight key components of compassionate interaction. “The report said research suggests this should lead to reduced anxiety, lower burnout risk and improved job satisfaction and performance. These changes should impact not just the participants, but their colleagues and their patients,” says Manley.
The Trust is now considering rolling out the course to other parts of the organisation and another project is underway at Derriford Hospital in Plymouth with the site services department. Another 15 Trusts have expressed interest in the personal development and cultural change programme, as have some private health care companies.
By: Jo Waters
FOOTNOTES
https://www.bma.org.uk/news-and-opinion/a-third-of-doctors-consider-leaving-uk
https://www.nhsstaffsurveys.com/results/interactive-results/
https://www.england.nhs.uk/our-nhs-people/
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This article was taken from the November 2024 edition of FORTIS magazine.
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This article was written for the November 2024 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy. FORTIS magazine is managed and owned by Health Spaces Ltd.
