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‘Employee engagement’: control or empowerment?

Roger Kline and Brendan Martin, 15 November 2012

Dean Royles, director of the National Health Service employers organisation in Britain, was among the signatories to this week’s launch statement of the government-backed Engage For Success website, which promotes ‘employee engagement’.

The statement points out: “Organisations with high engagement levels outperform their low engagement counterparts in both private industry and in public service. Engaged organisations also report lower staff absence, lower turnover, fewer accidents and are linked to increased employee wellbeing.”

The evidence is indeed strong that organisation that value their staff provide better services more efficiently, not least in health care. Robust research shows that:

  • patient experience improves, inspection scores are higher and infection and mortality rates are lower (1);
  • staff are significantly less likely to make mistakes (2);
  • staff provide safer patient care (3);
  • there is lower absenteeism and lower levels of turnover 4).

The Boorman Review of the NHS staff mental health (5) found a strong link between stress and poor trust performance. Healthcare Commission surveys repeatedly demonstrated that where staff rated the quality of leadership higher the trust performance was higher. Scores for clinical governance were also higher, and there were fewer patient complaints (6).

Unfortunately, in the NHS, despite the increasing acceptance of such evidence, the management culture of the last two decades is a parody of what the evidence would propose. Instead it was characterised by strong evidence of highly hierarchical, macho, and often bullying models of ‘leadership’.

Just eight months ago, a detailed assessment of 900 participants in the NHS Top Leaders programme concluded they are “high on over-confidence” and suffer from “an absence of attention to detail and completion of tasks”….They are “not necessarily understanding their own limitations” and do not tend to listen to others. (7)

By contrast, a ten year research project funded by the Department of Health (8) found that:

  • differences in human resources practices account for 33% of the variation between different hospitals in deaths within 30 days of emergency surgery and deaths after admission for hip fracture;
  • the greater the proportion of staff from a black or minority ethnic (BME) background who report experiencing discrimination at work in the previous 12 months, the lower the levels of patient satisfaction;
  • strong links between staff ‘engagement’ and clinical outcomes: well structured appraisals, a well structured team environment with clear goals, a supportive line management, good training, learning and development are all good predictors of patient satisfaction, patient mortality and staff absenteeism and turnover.

It concluded: “Good management of NHS staff leads to higher quality of care, more satisfied patients and lower patient mortality."

Mr Royles’s NHS Employers organisation has itself reported that trusts with higher levels of staff engagement deliver services of higher quality, and perform better financially, as rated by the Care Quality Commission. They have higher patient satisfaction scores and lower staff absenteeism. They have consistently lower patient mortality rates than other trusts. (9)

On the other hand, when good management and leadership are absent then: “Bad treatment of staff by patients (whether via bullying, harassment, abuse or discrimination) is associated with poorer patient experiences; clear staff goals and greater commitment to the organisation are associated with better communication with patients; an emphasis on health and safety and on patient confidentiality are associated with patients’ feelings of respect and dignity; and perceptions of insufficient staffing levels lead to poorer patient experiences.”(10)

The evidence of what makes for a good health care provider is clear -- and international. Beverly Alimo Metcalf (11) and Donald Berwick in the USA (12) reach similar conclusions.

So it is certainly good news that Mr Royles  -- who took up his present position two years ago and was voted the “most influential person in human resources” by HR Magazine earlier this year – is publicly committed to ‘employee engagement’. But the big question will be what kind of ‘employee engagement’ his NHS Employers organisation will promote.

Will it be a way of promoting compliance with top-down decision-making at time when the NHS is facing cuts, fragmentation and privatisation? Or will it be truly a way to mobilise, value and grow the experience and knowledge of health care workers about how to improve the services they provide? The difference will help determine the future of the National Health Service.

(1) West M, Dawson J Employee Engagement and NHS Performance. Kings Fund. 2012.
(2) Prins JT, Hockstra-Weebers JE, Gazendam-Donofrio SM, Dillaingh GS, Bakker AB, Huisman M, Jacobs B, Heijden FM (2010). Burnout and engagement among resident doctors in the Netherlands: A national study. Medical Education, vol 44, pp 236–47. 2010
(3) Laschinger HKS, Leiter MP (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/ engagement. Journal of Nursing Administration, vol 5, pp 259–67.
(4) Michael West and Jeremy Dawson. NHS Staff Management and Health Service Quality. Aston Business School, 2011.
(5) Dr Steven Boorman. NHS Health and Well-being Review – Final Report. Department of Health. 2009.
(6) Healthcare Commission. Research on assuring the Board that the care provided to patients is safe. London: Healthcare Commission, 2008
(7) Charlotte Santry. Most senior leaders failing to create 'strong work climates' Health Service Journal. 12 January, 2012
(8) Michael West and Jeremy Dawson. NHS Staff Management and Health Service Quality Aston Business School 2011
(9) NHSEmployers Fact Sheet
(10) Dawson J. Does the experience of staff working in the NHS link to the patient experience of care? Aston Business School. 2009.
(11) Beverley Alimo Metcalfe. Engaging leadership. Creating organisations that maximise the potential of their people. CIPD
(12) Donald Berwick. Improvement, trust, and the healthcare workforce BMJ Quality and Safety.


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