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How do trusts engage with their ‘most important asset’?

Jocelyn Cornwell 12 September 2018

As reports are published today on the first in-depth look at staff engagement in the NHS for several years, Jocelyn Cornwell discusses the key lessons to draw from case studies of three NHS trusts.

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Today we publish a new report with analysis of case studies of staff engagement in three NHS trusts.

Over the course of the last 18 months we have carried out research into NHS staff engagement, commissioned by the Health Foundation. Engagement is an important topic because it is associated with outcomes that are critical for patient care and organisational performance. Other outputs from the study are also published today: The Work Foundation has produced an overview report of the project, including a literature review and findings from our case studies; and RAND Europe has compiled a detailed analysis of the secondary data.

Taken together, the reports offer the first serious look at NHS staff engagement since West and Dawson’s 2012 report, and whilst they confirm the findings from this earlier report, they also offer new insights into how staff at the ‘sharp end’ of care (whose voices, paradoxically, we rarely hear) feel about their jobs and their employers.

The three case study trusts differ in size, the patient population they are designed to serve and degree of geographical concentration/dispersion. We chose them because they scored well on staff engagement in recent NHS staff surveys. At the time of the field work (autumn into winter 2017-18), all three had published values statements developed in consultation with their staff, and their executives were publicly committed to putting patients ‘at the heart of care’ and routinely referenced staff as the organisation’s ‘most important asset’. In these respects none of the three is exceptional, but although there are other NHS trusts that say the same, our researchers found that here, front line staff really did believe senior leaders meant what they said to be real.

Staff and managers’ different viewpoints on engagement

Having said that, what staff cared about much more than what higher-ups were doing, was whether they felt able to do their jobs and if they were patient-facing, whether they felt able to care for patients in the way they felt was right, and whether the trust as a whole cared about patients. Their engagement, in other words, was with patients and their own role, much more than with the trust as their employer or as NHS entity. The other thing staff mentioned spontaneously was the quality and importance of relationships in their immediate team and with their line manager. If their immediate team worked well, if they felt supported by their peers and if their managers made time for them to meet with colleagues and reflect on their work, then they felt engaged.

The connection between staff at the sharp and the blunt ends of the organisation seemed to depend on whether and how the top team (and senior and middle managers further down the hierarchy) shaped the climate for team-working in the organisation. They did this by modelling it themselves; creating the conditions for the staff immediately below them to behave respectfully towards with one another (and so on down the organisation); and making visible choices about where they focussed their personal attention and invested discretionary resources.

The report describes the leadership behaviours that staff said enhanced their well-being at work and job satisfaction. They valued leaders who were empathetic, inclusive and open; who actively listened to everyone, regardless of level of seniority; who were appreciative and said thank you; and who were approachable and willing to be flexible in response to staff who faced conflicts at work or personal difficulties at home.

Two of the three trusts are so big and so dispersed geographically that it seemed, on the face of it, to be physically impossible for front line staff to know the executive directors personally. But the researchers found that despite the constraints, front line staff did seem to feel they knew and trusted senior leaders: even if they had not seen them with their own eyes they heard about them from others, and what they heard suggested their behaviours were consistent with the trust’s values. They could also see for themselves whether the trust was investing in staff welfare programmes (such as the Schwartz Rounds) that felt meaningful. Even when they couldn’t access these resources themselves, knowing about their existence fostered trust in management.

What should trust leaders do?

These insights are not new, but they have practical implications for where to focus management action to boost engagement. Analysis of the findings indicates that the main contribution policy makers could make to boost staff engagement would be to relieve the pressure on resources and offer staff a compelling vision of the future of the NHS and of NHS staff within it. But the heavy lifting is up to local leaders in NHS organisations.

In trusts that have not yet made staff engagement and well-being a board level priority, it is time to do so. Every trust should have a board level strategy for staff engagement and well-being, supported by meaningful plans for operations; communications; governance (including meaningful metrics to monitor the effectiveness of the engagement and well-being strategy); and training and development.

More than that, staff will see the rhetoric about putting patients first and valuing staff as assets is empty unless they can see it is grounded in real resources and practices that show the organisation is prepared to invest in them and their well-being. The key players in the hierarchy, on whom staff engagement stands or falls, are line managers – most of them clinical managers who are promoted into management for professional reasons and should, as a matter of priority, receive training and support in everything to do with managing people and teams.

Read our full report