The 2023 NHS staff satisfaction survey and the link with emergency department performance
For years we have looked at how well hospitals are doing via a variety of performance measures. In urgent and emergency care it has typically been the 4- hour standard which is the canary in the mine for emergency care performance across hospitals and the wider system. The 4-hour standard is a good measure. It originated from evidence around clinical risk / patient safety and the amount of time patients spend within emergency departments. We can see from graph 1 below that 4 hour performance has continued to decline over the past 4 years except during the COVID-19 pandemic.
The foundations of the 4 hour standard were in clinical risk and patient safety. The research paper written by Dr Cliff Mann, Dr Chris Moulton and others brings the patient safety risk sharply into focus. They identified that harm caused directly / indirectly by an elongated time in the emergency department could be measured. Their analysis found that the potential risk of harm increases with time spent in the ED, specifically for patients that meet two criteria (they are admitted and spend more than 8 hours total time in the emergency department). The table below shows that potential delay related harm (due to long waiting in emergency departments) has significantly increased with the decline in 4 hour performance. With this level of poor performance and harm all opportunities for improvement need to be considered.
One hypothesis I developed (purely based upon my personal observations) whilst I was head of the NHS Emergency Care Improvement Support Team (ECIST) and visiting multiple hospitals and systems was that teams that are happier, treated well and work in a psychologically safe culture performed better. But does any data back up this hypothesis? So, I looked at the results of the English 2023 NHS staff satisfaction survey, but in a slightly different way. Rather than just look at the results in isolation i.e. how many people are happy at work etc I looked at the results and 4 hour performance together. I grouped 4 hour performance for each English acute provider (for 2023) to the nearest 5%. My question was ‘do organisations with higher 4 hour performance have better staff survey results?’. If we start by looking at questions in the 2023 NHS staff survey relating to a compassionate culture, we can see that organisations that have lower 4 hour performance report a poorer culture of compassion, results improve with organisations that have higher 4 hour performance.
Graph 3.0 – NHS staff satisfaction survey - Culture of compassion
This is not the only staff satisfaction survey question that display similar results. There are multiple other instances, which include (see graphs below):
I am trusted to do my job (graph 3.1 below)
I often feel burnt out (3.2)
We have enough staff (3.3)
I can meet the demands made of me (3.4)
We know our responsibilities (3.5)
Enthusiastic to come to work (3.6)
Look forward to coming to work (3.7)
Work even when unwell (3.8)
Work well as a team (3.9)
The team has freedom to act (3.10)
Frustrated at work (3.11)
Looking at the data we can see that many of the results interact with one another i.e. we probably would expect that if people were frustrated at work, they are less likely to want to come to work and / or if we don’t have enough staff we probably feel burnt out / can’t meet the demands placed on us. Interestingly, the data suggests there are some measures that have a tipping point, e.g. high performing organisation ‘may’ put a lot of pressure on their staff, see the data ‘I look forward to come to work’ (graph 3.7). The challenge around this is a bit like the chicken and the egg, what comes first? Do we create the right culture, have the right level of staff, form strong teams, respond to staff work / life balance etc or do we do the usual approach and seek improved performance first and hope that staff respond accordingly? Unfortunately, no statistical model in the world could ever predict this but if we look at the sizeable evidence linking psychological safety and positive outcomes including improved performance we can make a fairly confident assumption that there’s a link and an improvement opportunity.
Staff Satisfaction and 4 hour performance Graphs
Y axis = staff satisfaction results, X axis 4 hour performance
Graph 3.1 – NHS staff satisfaction survey - Do you feel trusted to do your job?
Graph 3.2 – NHS staff satisfaction survey - Do you often feel 'burnt out'?
Graph 3.3 – NHS staff satisfaction survey - Do you feel there are enough staff?
Graph 3.4 – NHS staff satisfaction survey - Do you feel that you can meet demands?
Graph 3.5 – NHS staff satisfaction survey - Do you feel that you know your responsibilities?
Graph 3.6 – NHS staff satisfaction survey - Do you feel enthusiastic to come to work?
Graph 3.7 – NHS staff satisfaction survey - Do you look forward to coming to work?
Graph 3.8 – NHS staff satisfaction survey - Do you still work if you feel unwell?
Graph 3.9 – NHS staff satisfaction survey - Do you feel that you work well as a team?
Graph 3.10 – NHS staff satisfaction survey - Do you feel that you have the freedom to act / improve?
Graph 3.11 – NHS staff satisfaction survey - Do you ever feel frustrated at work?
So, what should we do with the knowledge that NHS organisations with more satisfied staff tend to have higher performance? Well, the first thing is to understand and accept that the two are linked and the data supports this. Don’t separate the NHS staff satisfaction results from performance be that operational or patient safety performance and definitely don’t say improving staff satisfaction results sits solely with the HR department as that’s not fair and won’t work.
You don’t really need to look far to know what to do. The NHS has some of the brightest and best people on the planet who are likely to know what is required, especially patient facing teams. It takes really brave leaders to move away from old mantra ‘it’s the way we have always done it around here’ or ‘we have to do it even if it makes no sense’ and break some of the perceived rules and behaviours that really don’t work for the people doing the work.
To improve staff satisfaction, which we know is linked to improved performance, the aim needs to be the creation of a workplace that is psychologically safe i.e. one which fosters a culture of trust, openness and collaboration. Google’s Project Aristotle researched what makes really effective and happy teams and found psychological safety was the most important factor, supporting the importance of the link between how people feel at work and higher performance.
Here are some starting points for leaders (at all levels) to consider. Ask yourself, could these be improved within my organisation and workplace?
Lead by Example: Leaders and managers genuinely demonstrate vulnerability, openness, and a willingness to listen. Leaders need to feel ok saying ‘I don’t know’. When leaders model behaviors such as admitting mistakes, seeking input from others, and providing constructive feedback, it encourages employees to do the same. Leaders should try to speak last, it’s not as easy as it sounds but very effective.
Encourage Open Communication: Create opportunities for employees to voice their opinions, concerns, and ideas without fear of judgment or reprisal. Establish regular team meetings, feedback sessions, and channels for anonymous feedback to encourage dialogue and transparency.
Provide Support and Recognition: Acknowledge and appreciate employees contributions and efforts. Celebrate successes, recognise achievements, and provide support when challenges arise. Encourage peer recognition and create a culture of appreciation.
Promote Inclusivity and Diversity: Ensure that all voices are heard and valued, regardless of background, experience, or perspective. Actively seek out diverse viewpoints without judgement and encourage collaboration across teams and departments. Promote inclusivity in decision-making processes and team dynamics.
Set Clear Expectations: Clearly communicate expectations, goals, and objectives to all employees. Provide regular feedback and guidance on performance and encourage employees to ask questions and seek clarification when needed.
Manage Conflict Constructively: Address conflicts and disagreements in a constructive and respectful manner.
Create a Safe Environment: Foster a physically and psychologically safe work environment where employees feel comfortable expressing themselves and taking risks. Make it ok to safely and intelligently fail whilst trying to make improvements.
Seek Feedback and Adapt: Continuously solicit feedback from employees about the organisational culture and climate. Actively listen to their concerns and suggestions for improvement, and be willing to adapt policies, practices, and behaviors accordingly.
What will you do with the latest staff satisfaction results? Wait to see if they improve next year or consciously use them to create higher performance within your organisation?
Information sources used in this blog:
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