Staff Survey Acute Psychiatric Ward of Oldham Hospital

Purpose- Engagement is a complex concept with varied definitions and frameworks of measurement. NHS employee engagement has become a hot topic in the recent years especially with NHS Trusts taking on Foundation trust status, where staff engagement is one of the key indicators for maintaining the foundation status. This research aims to evaluate the level of employee engagement in the non medical staff of one of the acute psychiatric ward of Royal Oldham Hospital.

Design- survey questionnaire was completed by a sample of 16 staff, working in different roles in the Northside ward of Royal Oldham Hospital. The survey included measures of job and organizational engagement, as well as the antecedents and consequences of engagement.

Findings- Results show a difference between job and organizational engagement, with higher levels of job engagement. This study also shows that contrary to the findings in the literature, job engagement is a stronger predictor of positive outcomes of engaged employee as compared to organizational engagement. The results also show that the link between engagement and its antecedents is complex and engagement is not always the outcome of some intervention but result of interaction between number of factors some of which cannot be intervened by the organization.

Introduction

The NHS is the largest employer in Europe with a steady increase in number of employees since its origin in 1948. There are recruitment and retention challenges across the NHS with recent survey done by Department of Health in 2009 shows vacancy varies across the main staff groups from about ‘one in four (28 per cent) for total medical & dental staff (excl. training grades) to about one in five for qualified nurses (21 per cent)'. This high turnover has impact on continuity and quality of patient care. This has a much bigger implication in the mental health sector, where the recent trend has been to move away from residential care to community treatment and psychosocial rehabilitation, making continuity of care and good therapeutic relationship between patient and provider as the most important factor in patient care. This requires a motivated and an engaged employee group but on the contrary mental health professionals report a much higher rates of burn out and dissatisfaction. Kumar (2007) found higher rates of burnout in psychiatrist contributed by factors such as patient violence and suicide, changing culture in mental health services, isolation, and poorly defined roles. Alexander et al (1998) found similar results in mental health nurses working in long term psychiatric units. High turnover also means recruiting and training new staff which has serious cost implications for the NHS (Gray et al, 1998).

Employee engagement has now become the new buzz word in the NHS. In 2007 the Department of Health conducted a research ‘What Matters to the Staff in the NHS' to identify important factors contributing to staff motivation and engagement (DoH, 2008). This survey looked at both emotional and behavioral drivers of staff engagement. The findings of this annual survey are used by the Department of Health to assess workforce strategies of the NHS Trusts and can have impact on provider registration. Employee engagement has become an important theme behind a number of initiatives within the NHS. NHS conducts yearly staff survey since 2003, and more recently the survey has taken on a holistic approach in measuring employee engagement by measuring engagement in various dimensions. Productive Ward strategy has been a recent initiative in an attempt to empower frontline staff and make them more engaged (Institute of Innovation). Penninecare NHS Foundation Trust has identified employee engagement as one of their major strategic goal in 2009/10. They aim on making the organization ‘A great place to work', and improve the working life of staff with emphasis on training and development. This research aims to identify if Penninecare has been able to fulfill its strategic goal of employee engagement by assessing the employee engagement in the staffs of Northside ward of Royal Oldham Hospital.

Research Objectives

The purpose of this study is to evaluate the employee engagement in Northside ward of Royal Oldham Hospital. This study intends to achieve this by looking at the emotional, cognitive and behavioral aspects of engagement. This study also looks at engagement at both organizational and job levels. Furthermore this study also investigates the work environment and other antecedents of engagement (Saks, 2006) along with consequences of employee engagement.

Literature Review

Defining employee engagement

There is no clear consensus on the definition of employee engagement with varied definitions across the literature. CIPD (2009) define employee engagement as a combination of commitment to the organization and its values and organisational citizenship. According to Macey and Schneider (2008) engagement has three dimensions; i.e. trait , state and behavioural engagement. Trait engagement is described as positive views of life and work characterized by enthusiasm, conscientiousness.The state engagement is characterized by feelings of energy, involvement, commitment, empowerment, satisfaction. This state is an antecedent to behavioural engagement which includes organizational citizenship behaviour, personal initiaitve, role expansion. Kahn (1992) approaches engagment as a psychological construct and talks about employees being ‘psychologically present' in that their thoughts, feelings and beliefs are accessible within the context of their role. According to CIPD(2009) emotinal, cognitive and physical engagement make the 3 dimensions to engagement. Engagement is not simply motivation but to be ‘ authentic' in their work which requires people to bring their ‘selves' fully into work (Kahn,1992). Gatenby et al (2009) distinguishes social, intellectual and affective engagement to assess the level of engagement in the public sector. Work engagement is not workaholism as engaged employee have interests outside work and are not addicted to work (Bakker et al, 2008).

There is very little clarity as to what constitutes employee engagement which has practical implications on what should be measured within an organization to assess engagment of its work force. Engagement is a dynamic process with engaged employees sometimes showing poor performance (Bakker et al ,2008).According to Hartel et al (2002) employee engagement is involvement, satisfaction and enthusiasm for work. Their Gallup questionnare uses questions on resource availability, development opportunities, recognition and clarity in expectations to catergorize work force into engaged, not-engaged and actively dis-engaged groups. Engagement is charactertized by dedication, vigour and absorption (Schaufeli et al, 2008)According to Saks (2006) job satisfaction is an outcome of engagement. Macey and Schneider (2008 ) argue that job statisfaction measures engagement only when it measures feelings of energy, entusiasm and positive affective states. Constructs like commitment described as positive attachment to organization is also used to define engagement (Macy & Schneider, 2008). According to Macey and Schneider (2008 ) engagement can be a positive affective state with feelings of pride, energy,vigour, alterness and dedication, similar to Schaufeli et al (2008).

According to Macey and Schneider (2008 ) behavioural engagement includes organizational citizenship behavior (OCB), role expansion, proactive behavior, and demonstrating personal initiative. The notion is not only doing more than the usual but also doing something ‘different' (Kahn, 1992) also called as ‘extra role behavior' by Saks (2006).

According to Saks (2006) there are two levels of engagement, job and organizational engagement both of which are distinct constructs highlighted by differences in their antecedents and outcomes.

Antecedenats of engagment.

Pugh & Dietz (2008) approach engagement at an organizational level while Gatenby et al (2009) approach engagement as an individual phenomenon.

According to Macey and Schneider (2008 ) trait engagement interacts with situational factors to determine the state and behavioural engagement. Both personal and job resources are drivers of engagement (Bakker, 2008 ). Engaged employees are more likely to be extrovert, optimistic, self efficacious, resilient and have good coping skills.

Job characterstics and work enviroment are two important factors contributing to engagment (Macey and Schneider (2008 ). According to Kahn (1992) people are more likely to be psychologically present if the job offers variety, good skill mix, autonomy, and good feedback for the members to experience meaningfulness of their role. Similar findings is reported by Gatenby et al (2009) who found ‘person-job fit' where the type of work had a greater impact on engagement compared to duration and amount of work. If individuals find that their work roles fit with their self image they are more likely to be psychologically present (Kahn, 1992). Gallup research program identifies resources at work, supervisor support, team work, training and devlopment as some of the situational factors impacting on engagement. Shields & Ward (2001) found that job satisfaction in the NHS nurses was affected the perception of ‘low pay' as compared to other public sector organizations. They also found quality of work enviroment especially not having the preferred shift duties, not graded according to ones duties and unpaid overtime all increased dissatisfaction amongst the nurses. According to Maslach et al (2001) sustainable work load, having choice and control, appropriate rewards and recognition, good support at work , perceived fairness, and values can lead to job engagement. According to Kahn (1992) the incentives within the social systems of the work can influence the level of personal self an individual brings to work. Good work environment can promote self regulatory behavior in employees (Bakker et al, 2008). Saks (2006) uses the social exchange theory to explain the impact of perceived reward and recognition on engagement. The social exchange theory argues that relationship between the employer and employee can evolve as long as ‘rules of exchange' are followed, which involves one party responding to the actions of the other party. Work life balance was found to be more important in the NHS trust compared to hours of work in its impact on engagement (Gatenby et al, 2009). Job security was found not to be important in the public sector in UK explained by the constant restructuring making the employees immune to threats of job loss. According to Kahn (1992) availability, safety and meaningfulness can improve work performance. According to Benson & Dundis (2003) Maslow's model of hierarchy of needs can be used as a tool to motivate healthcare staffs who often have to work under high pressure with scarce recourses. They argue that if employees feel secure, needed and appreciated, then they are more likely to be motivated and committed to their job. According to CIPD (2009) breakdown of ‘psychological contract' can lead to dissatisfaction and disengagement. This psychological contract is informal and is the mutual understanding of the job obligations between the employee and the employer. According to Cartwright and Holmes (2006) addressing the imbalance between the organizational needs and expectations of the employee is very important because of an increase in organizational expectations from their employees, who often work with limited resources, in return for only employability, increases cynicism and disengagement amongst its employees. This concept needs addressing in NHS employee engagement strategies.

According to Saks (2006) perceived organization support (POS) and not perceived superior support (PSS) predicted job and organization engagement. Similarly Gatenby et al (2009) did not find any influence of the perceptions of managers and line managers in the public sector, except in the NHS Trust where they were significant. However CIPD (2005) argue that managers influence the employee perception of HR policy and need support and training in their role of performance management, appraisal and recognition. According to Luthan & Peterson(2002) managerial self efficacy was a partial mediator of employee engagement and they together improved managerial effectiveness. Transformational leadership and trust are two other factors contributing to engagement as identified by Macey and Schneider (2008 ). According to them an effective leader can make positive impact on both state and trait engagement. Similarlily trust in the leader and the organization will also lead to positive behaviour.

Consequences of Engagement

Saks's (2006) model identifies job satisfaction, organizational commitment, intentions to quit, and organizational citizenship behaviour as the consequences of employee engagement. Gallup Workplace Audit uses 12 survey questions to assess employee perception of management practices. Harter et al (2002) use the Gallup questionnaire in their meta-analysis to identify the relationship between employee engagement and business outcomes. Their study showed that employee engagement had a positive impact on staff turnover, customer loyalty, productivity and profitability of the business units. They stress the importance of organizations trying to create ‘well being in the work place' to influence employee engagement and positive behaviour in their staffs. Sibbald et al (2003) found an increase in the proportion of doctors intending to quit clinical work had increased between 1998 and 2000 and the rise was mainly due to poor job satisfaction. Shield &Ward (2001) found 65% higher probability of quitting amongst nurses if they were dissatisfied. According to Kahn (1992), psychological presence has both individual and organizational benefits. At an individual level, an engaged employee is more likely to be authentic in their work and be present both physically and emotionally. This can lead to increased productivity and make the organization more receptive to change. According to Bakker et al (2008) employee engagement can have both short term and long-term consequences but also raises questions on the possibility of burn out in employees in continuous state of high engagement. According to Schaufeli et al (2008) engagement and burnout are opposite of each other with workaholics sharing some features with both of them. They found that engaged managers enjoyed good mental health, good social functioning and worked in resourceful job with positive outcomes. Bakker et al (2008) talks about organizations with engaged employees having competitive advantage to their competitors. However engagement can also have a negative side especially as some of the personal characteristics of engaged employee can make them over confident with unrealistic optimism which can be harmful both to the individual and the organization (Bakker, 2008). There is also the danger of over engaged employees becoming workaholics leading to an imbalance of work life balance which can have a negative impact on job satisfaction.

Methodology

Questionnaire Design

Internet mediated questionnaire was used for data collection. This method of data collection made it possible to collect data from all the 24 staff employed in the Northside ward, who work on a shift system. As this research aims to study the opinions, behaviors and attitudes of staffs with regards to employee engagement, questionnaire was used as a data collection tool (Saunders, Lewis, Thornhill, 2009:362). The questionnaire was generated using ‘kwiksurveys.com', which is a free and simple to use survey design software. Speaking to the staff in the ward, it was clear that they were overloaded with requests for survey in the NHS. To improve the response rate the questionnaire was kept very simple and short. The responders were given only two options to consider for each question, agree or disagree. The option of neutral or not decided was not given as an option to make people commit to one of the responses. Likert scale has been widely used in literature for data collection in research of similar kind. This has not been used for the purpose of making the survey easy to respond and easy to analyze. The survey was launched after a pilot on 2 colleagues. The emails were personalized by using their name. The responders were informed that the survey was anonymous and given a brief description of the purpose of the survey. They were also given the option of requesting the results if desired. A total of 13 emails were sent, with 2 further reminders in an interval of 2 days. 9 staff members were given hard copies because of their difficulties in accessing email, after taking similar precautions to ensure anonymity. 2 staff were off sick, so were not included in the sample.

Sample

The sample included only non medical staff as their work commitments is mainly restricted to the wards in contrast to medical staff who have a number of non ward commitments. The staff mix in the Northside ward includes manager, sister, ward clerk, ward nurse, and nursing assistant.

Measures

Engagement

In this research employee engagement is measured in three dimensions, i.e. emotional, behavioural and intellectual engagement. Gatenby et al (2009) use ‘I get completely absorbed at work' as a measure of intellectual engagement. ‘I am energized at work' and ‘I am enthusiastic about my job' measure the affective component of engagement as described by Macey and Schneider (2008). Behavioral engagement also described as extra role behavior involves being adaptive, taking personal initiative and organizational citizenship behavior (Macey and Schneider, 2008). ‘I participate in meetings which improve the image of the organization' reflects organizational citizenship behavior. Saks (2006) uses ‘I am engaged in this job' to measure job engagement and ‘One of the most exciting things for me is getting involved with things happening in this organization' to measure organizational engagement.

Job variables

Autonomy, work life balance, sustainable work load, skill mix, variety, meaningful work and recognition& reward have been identified as some of the major situational factors contributing to engagement (Kahn, 1992; Saks, 2006; Gatenby et al, 2009; Maslach et al 2001& Bakker et al, 2008). Gatenby et al (2009) uses ‘My work load is manageable' to measure sustainability of work and ‘I am satisfied with the amount of variety in my job' to measure job variety. ‘My employer values my work' indicates if employees receive praise for performing their work well. ‘I choose how to perform my job' reflects autonomy at work. Meaningful work is one of the important motivating factors for engaged employees (Kahn, 1992; Benson & Dundis, 2003). It is measured by ‘My work is meaningful and makes a difference to patient care'. ‘My manager is an effective leader' and ‘I trust my manager' measures supervisor support and trust (Gatenby et al, 2009). Training and development is measured by ‘I am satisfied with my training and development.

Consequences

Job satisfaction and quitting behavior was measured by Saks (2006) to measure consequence of engaged workforce. ‘I am physically and emotionally exhausted at the end of my shift' measures burnout, which leads to disengagement (Schaufeli et al, 2008). Organizational citizenship behavior and organizational commitment have been described as outcomes of engaged employees by Saks (2006). ‘I am willing to attend functions which are not required but will improve the image of Penninecare NHS Foundation Trust' measures Organizational citizenship behavior and ‘I personally feel attached toA  Penninecare NHS Foundation Trust' measures organizational commitment.

Control variables

Job title and years of experience in mental health are included as control variables as it does not directly contribute to engagement but has influence on perceptions and work related behavior ( Gatenby et al, 2009).

Data Analysis

Data was analyzed using the cross tabulation in MS Excel.

Results

16 out of 22 staff responded to the survey.

Fig 1: job title of staff

NA nursing assistant

Engagement

88% 0f responders were engaged in their job, while 69% were engaged with Pennine care. This finding is similar to Saks (2006) findings that job engagement is a different construct to organizational engagement with employees showing a higher job engagement compared to organizational engagement. 54% of employee who were engaged in their job were enthusiastic about their work, felt energized by their work and got completely absorbed in their work. Only 23% of the job-engaged employee disagreed on both feeling absorbed in their job and feeling energized, making feelings of enthusiasm as the main predictor of job engagement. Literature describes engagement as a positive affective state with feeling of energy, vigour, enthusiasm and absorption (Macy & Schneider, 2008), (Schaufeli, Taris, & Rhenen, 2008). This research shows that only some positive affective states are related to engagement. Lack of clearly defined definitions for words like absorbed, energy and enthusiasm leaves such questions open to interpretation by the responders making in difficult to compare these constructs.

Antecedents of engagement

The results show that engaged employees responded positively to their work and work environment. 64% of the job-engaged employee found their work manageable, meaningful, work conditions as acceptable with good mix of skills and variety. They also reported higher levels of autonomy and control over their jobs. One interpretation could be that good work environment can influence employee engagement (Macy &Schneider, 2008 & Kahn, 1992) but it is also possible for engaged employees have greater influence and control over their environment ( (Bakker, Schaufeli, Leiter, & Taris, 2008).

The findings also suggest low perceived organizational support and value, which are important predictors of organizational engagement (Saks, 2006). 63% report not getting any feedback on their contribution to the success of the organization and 38% report not feeling valued by their employer. This highlights that organizational engagement is a different concept to job engagement and it has different antecedents compared to job engagement.

Perceived managerial behavioural is significant, with 93% reporting trust in their line managers and 85% of engaged employees found their line managers as effective leaders. This contradicts findings of Saks (2006) and Gatenby (2009), who did not find any association between perceived managerial behaviour and engagement. It is possible that engaged employees share much better relationship with their managers, which influences managerial effectiveness, which in turn increases employee engagement (Luthans & Peterson, 2002).

Consequences of engagement

The results show high rates of exhaustion (57%), which is one of the dimensional construct for burn out ( (Schaufeli, Taris, & Rhenen, 2008) . This study also shows low organizational commitment (37%), which could be related to low organizational engagement. However, in comparison, other positive outcomes like not quitting, organizational citizenship behaviour and job satisfaction were significantly higher. According to Saks (2006), all the above outcomes are predicted by job engagement and organizational engagement with organizational engagement a stronger predictor of the outcomes. This study shows that job engagement as much stronger predictor of positive outcomes. Inspite of low organizational engagement (69%), 87% report job satisfaction, 67% show organizational citizenship behaviour and only 7% admit to looking for a new job in the next 12 months.

Staff comments

Staff Nurse: ‘would like to see manager more on wards, some choice in work other standard procedure'

Ward staff: ‘as most other staff I feel undervalued and under paid'.

Nurse: ‘trust to make way for feeding back to staff'

Conclusion

Engagement is a very complex concept to define and measure Engagement is multidimensional, described to have an emotional, cognitive and behavioural aspects to it (CIPD, 2009) and Macy & Schneider (2008) describe engagement as trait, state, behavioural engagement. Positive psychological states, like feelings of energy, vigour and absorption are more likely to measure engagement ( (Macy & Schneider, 2008), (Schaufeli, Taris, & Rhenen, 2008). However, these states are difficult to define and open to interpretation, hence difficult to measure. This study highlights this problem, where 23% of engaged employee did not report of feelings of energy and absorption, which contradicts the concept of engagement found in the literature.

This research also shows that job and organizational engagement are two different but related constructs, with staff reporting higher levels of job engagement as compared to organizational engagement. This highlights the need for separate strategies in addressing the two constructs of engagement.

In this study, the antecedents of engagement were similar to that in literature, with sustainable work, variety skill mix, meaningful work, work family balance, autonomy, control and good work environment as important associations of engagement. Saks (2006) uses the SET theory to explain the influence of the good work environment and good perceived organizational support on engagement but it is also possible that engaged employees are able to make use of their personal resources and adapt quickly to changing environment (Bakker, 2008). This makes person-job fit essential (Gatenby, Alfes, Truss, Rees, & Soane, 2009). One possible mediator between work environment and engagement could be years of NHS experience. The employees in this sample have long years of experience in the NHS (average 12 years). It is possible that years of working in the NHS has adapted people to their work and its environment and made them person-job fit. It is also possible that years of working in the NHS has helped in bringing employee psychological contract in alignment to the organizational needs, leaving the employees more satisfied in their job. Therefore, engagement is not always the outcome of some intervention but result of number of factors some of which cannot be intervened by the organization.

Majority of the responders were nursing assistant, who often take on a supporting role to the nurses. This responder bias in the sample raises questions about the level of engagement in the nurses.

The antecedent to organizational engagement is clearer, with low perceived organizational support and value associated with low engagement with Penninecare, which explains low organizational commitment. Low organizational engagement does not appear to have much impact on other positive outcomes of engagement, which contradicts Saks (2006) findings. This is an opportunity for Penninecare to engage these employees with low engagement, who continue to express positive behaviour and attitudes to prevent them from being disengaged completely.

Inspite of some evidence of burnout, there is no impact on quitting behaviour. It is possible that years of experience in the NHS, has made people more accepting of high work load and exhaustion and aware of the possibility of experiencing similar work load in a different job in the NHS. The low quitting behaviour could also be related to the current financial crisis and perceptions around finding a new job. Various confounding factors make it is difficult to make any associations between engagement and outcome.

Finally, the employees in this research are engaged in their job, report high levels of satisfaction in their job and work conditions. However, the level of organizational engagement is low as compared to job engagement. Penninecare needs to address organizational engagement amongst its employee, to improve organizational commitment and citizenship behaviour amongst its staff, which is extremely significant for its foundation status.

Recommendations

The organization needs to do further in dept research on employee engagement especially in places of high pressure like the acute wards, which are the major cost centres of the organization. The research should address both job and organizational engagement as separate constructs.

Foundation Trust is a more recent creation within the NHS as a means of engaging local communities. Foundation Trusts are owned by their members drawn from staff, patients and local people, in an attempt to empower its major stakeholders in shaping organizational strategy. Penninecare should conduct staff survey to identify any misconceptions and variability of staff understanding of Foundation status. Addressing staff perceptions will improve staff membership, which in turn can influence organizational engagement by giving their employees a voice in decision- making. Penninecare needs to educate its staff about the importance of local representation in the membership as it will help in raising local concerns to higher authorities but will also help the staff in receiving feedback about their contribution to organizational success.

Factors contributing to exhaustion should be explored as it not uncommon to find staff shortages in acute setting often leading to increased work pressure and low morale in the staff. Effective communication between staff and line managers, who are often the first point of contact between staff and management, can influence staff work experience. Therefore line managers should be assessed for their ‘soft management skills' and trained on their deficiencies. Work environment especially in acute settings should support staff autonomy, provide opportunities to learn and develop, provide task variety and channels to receive feedback. Frontline staff should be freed from unnecessary time consuming bureaucratic paper work to free time for patient care.

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