Staff Experience in the NHS: A National Study—An Experience-Based Design Approach

Abstract

Introduction: A positive patient experience is a key component of good quality of care. Post-pandemic healthcare systems face the challenge of addressing burnout among healthcare staff, who are directly involved in the delivery of healthcare, which has implications for the patient experience. There is an established association between staff and patient experience; exploring the experience of staff may give insights into factors that negatively impact the patient experience. Experience-based design (EBD) is a quality improvement approach that uses the experience of service users to derive improvements. The purpose of this study is to design, validate, and test an EBD tool that may be used to capture the staff experience. Methods: A focus group of clinical and nonclinical staff (identified through the NHS Elect networks) and the development team coproduced an EBD survey based on nine “touch-points” of a typical working day. Once the survey questionnaire was tested and agreed with it was distributed to 1300 members of NHS networks. Results: A total of 377 NHS staff responded to the questionnaire. Analysis revealed effective teamwork had a positive psychological impact on staff. However, increased workload, missed meal breaks, and an increased administrative/IT burden were associated with the greatest negative responses by clinical and nonclinical staff. Conclusion: Overall, factors impacting staff well-being are multifaceted and varied between trusts. However, leaders in healthcare can use EBD to identify targeted improvements for the day-to-day experiences of staff.

Introduction

A positive patient experience is a key component of good quality of care; hence, it is of importance to organizational leaders of the NHS (1). However, post-pandemic healthcare systems face the challenge of addressing burnout among healthcare staff, who are directly involved in the delivery of healthcare, which has implications for the patient experience. Results from the 2020 NHS staff satisfaction questionnaire revealed that only 33% of employees felt that their hospital took positive action toward their well-being and health (2). Although causality is unclear, there are strong associations between the experience of healthcare staff and the patient experience (3,4). Similarly, the Institute of Healthcare Improvement has outlined that by improving how staff feel at work, staff morale, and patient outcomes will significantly improve (5).

Experience-based design (EBD) is a service improvement technique that captures the experience of service users so that recommendations for sustainable improvement can be co-designed, making improvements more meaningful and centered on the service user's needs. In the UK, this approach has become increasingly popular as a tool to improve patient care across various clinical pathways. Notably, the NHS Elect Acute Frailty Network, a national improvement program, has spearheaded the use of EBD in improving the care of older people living with frailty who present to the hospital acutely unwell (6). Their work has evidenced that involving patients in the quality improvement process leads to practical and sustainable improvements in service provision.

Despite the importance of the relationship between staff experience and patient experience, there is little evidence in literature of EBD tools specifically designed to capture the day-to-day experiences of healthcare staff. Therefore, the purpose of this study is to design, validate, and test an EBD questionnaire that may be used to capture the staff experience.

Methods

EBD has four phases: capture, understand, improve, and measure. This study focuses on the capturing phase of the EBD process which will be achieved with a questionnaire. The questionnaire is based on key aspects of a working day (touchpoints). They are defined as common moments or processes in a typical day that trigger an emotional response. To establish pertinent touchpoints for both clinical and nonclinical staff, a focus group of volunteers (from trusts who were familiar with EBD approach and the Acute Frailty Network) formed to co-design a “staff” experience-based design tool with the development team.

Nine touchpoints of a typical working day for NHS staff were determined as outlined below:

• Getting ready for work: thoughts/feelings and emotions prior to starting work

• Start of the day: arriving at work/parking, handover

• Administration: access to computer systems and ease of use, documentation in clinical areas

• Meal breaks: access of, duration, and facilities

• Workload: caseload, schedule, work plans

• Support: access and support from senior members of team/managers

• Teamwork: among members of immediate teams; bullying

• Patient interaction: communication and engagement with patients

• End of the day: hand-over, leaving on-time

The development team worked to incorporate these into a prototype EBD data collection questionnaire. This questionnaire was distributed to the focus group to test the approach and confirm the clarity and suitability of touchpoints and questions.

Once the format of the questionnaire was validated, an online version of the form was created using Microsoft forms. The link and QR code to the questionnaire was distributed across organizations who are members of the NHS Elect Improvement networks* or participants in their national programs.

The nine touch points were used as domains for the survey, participants were asked to choose an “emoji” to indicate generally how they felt about the domain in question (eg, sad, happy, or neutral).

They were then asked to express how they felt and share the emotion they were experiencing at this time (eg, frustrated when “getting ready for work”). Each question included a space to share comments to further explain their emotional response. The questionnaire was available to managerial, clinical, and nonclinical employees of the trust. Identifiable data such as name and date of birth were not required for participation. However, organization and job roles were included in the questionnaire as seen in Appendix 1.

*(NHS organisations being supported by NHS Elect or participating in large scale clinical improvement networks)

Results

A total of 1300 healthcare staff were invited to participate in the survey, however, only 377 NHS staff responded to the questionnaire (29% response rate). Occupation of participants varied and roles were grouped into 13 different categories (Appendix 2). Managerial staff were the largest group, making up 25% of the responses.

Results were collated and expressed as an emotional map¹ as seen in Figure 1 (nine touch points displayed on the x-axis, and percentage of positive, neutral, or negative responses along with y-axis). When splitting the data into clinical and nonclinical staff groups, the distribution of the emotional maps was similar (see Appendices 3 and 4).

Figure 1.

Emotional map showing the percentage of positive, neutral, and negative emojis felt at each of the 9 touchpoints.

How Staff Feel

Overall, the emotions experienced by staff during the working day were very varied.

Workload

Workload was most associated with negative emotions by nonclinical and clinical staff (45% and 44%, respectively). When asked to provide an emotion to describe how they felt about their workload, common responses were that of feeling pressured, stressed, frustrated, and/or undervalued (Figure 2). Staff attributed these feelings to high workload and low staffing levels. Many staff commented on feeling unable to leave on time, with there being an expectation to stay late. Free-text feedback on this included:

“I go to bed at night worrying that I have too much work, and wake up—if I have slept—worrying about how much more work will have come in by e-mail overnight”

“It doesn't matter how many people (staff) leave or who cannot attend work due to illness, we're expected to meet demand and provide the usual standard of service…Despite escalating to senior managers, there's no improvement in workload or pressure.”

Figure 2.

The top 20 emotional words selected to describe the participant's experience at the “workload” touchpoint.

Teamwork

Both clinical and nonclinical staff expressed positive emotions toward teamwork within their immediate teams (72% and 78%, respectively). Many respondents expressed that they felt happy, supported, and proud of the teams they work in (Figure 3), and this was supported by the free text responses:

“When I feel stressed at work, my colleagues usually make me laugh and feel better. It is nice to be reminded that we are all in this together.”

Figure 3.

The top 20 emotional words selected to describe the participant's experience at the “teamwork” touchpoint.

“The Pandemic showed how well we can all work together and how quickly we can rise to the challenge as a team.”

Administrative Demands and Breaks

Administrative demands and lack of time/opportunities for meal breaks were two other factors associated with negative experiences by staff. It was highlighted that there is an increased requirement for staff to have an online presence (for virtual meetings), which reduces the ability of staff to keep up with clinical workload. Staff also reported not having enough time for meal breaks (due to workload), not enough spaces to take their break and poor choices of healthy options in the canteen.

“I feel confident and competent with my admin tasks; however, they are extremely timely and take away from face to face clinical time. Often, emails do not get read properly due to time constraints which may lead to miscommunication within and between teams…”

“Prior to the pandemic, meetings were rationed by the limits of meeting rooms available. With many meetings now virtual I often feel inundated and overwhelmed with how many meetings I must attend.”

“Many feel ashamed to take a lunch break when work load is high, [we] need to change to a culture where taking a break is the norm”

“Managers should consider protected meal times for staff.”

Discussion

Key aspects of the working day that are associated with a strong emotional response (common to both clinical and managerial staff) have been summarized below:

• Teamwork—Having a sense of comradery has a positive psychological impact on healthcare staff

• Meals and meal breaks—staff report not having protected time for meal breaks; inadequate spaces to take their break and poor choices of healthy meals in the canteen

• Staffing levels and a large workload—staff report feeling overworked due to low staffing levels. Many also feel underappreciated which has contributed to poor morale

• Administrative burden for clinical staff—Many feel overwhelmed by the variety and number of IT systems required for the completion of tasks. Those in leadership may wish to consider the implications of frequent online meetings that require the participation of clinical workers as this may strain the clinician's ability to complete clinical and other administrative tasks

• Support managers to provide better support for their teams—factors impacting staff well-being are complex and varied between trusts. Priority should be made to minimize the number of staff who experience abuse from patients and address the prevalent issue of bullying in the workplace. Managerial staff feel that supplementary leadership training for managers (concerning staff well-being) would be beneficial.

Results from this survey have revealed the factors that contribute to a poor “staff experience” are complex and intertwined, as summarized above. Staffing levels and slow/poor IT systems undoubtedly impact the day-to-day experiences of staff, but these are larger organizational issues that are beyond the capacity of influence of departmental leaders. However, there are other touchpoints where practical improvements can be made on a departmental level. For example, enforcement of protected meal times for staff; ensuring staff feel valued and have access to suitable break areas are few of many suggestions.

The intended outcome of this survey was to capture the experiences of our frontline staff during the COVID-19 pandemic using an EBD approach. However, this study has not identified factors that are unique to the context of a pandemic, but rather existing issues that have been exacerbated by an increased demand on service provision.

At present, rates of burnout and staff turnover in healthcare systems are at record highs, and it is likely that COVID-19 has exacerbated the issue (7). A recent survey by the British Medical Association revealed that 44% of doctors were suffering from depression, anxiety, or burnout (8). Higher rates of burnout are associated with poorer patient outcomes and experience (9). Organizational culture, working relationships, and increased workload are a few of many factors that exacerbate burnout (10).

Although the experience of employees/healthcare staff is important in its own right, addressing factors that negatively impact staff experience can cause staff to provide better care, feel empowered, and motivated to make improvements to their area of work, which will consequently improve the patient experience.

Worldwide, the use of EBD is growing. A review of EBD practices between 2005 and 2013 revealed that 59 EBD projects had been completed across six countries (11). On average, EBD projects took 6 months to complete, and leaders of these projects felt that the success of this approach is that it engages service users.

The needs and experiences of NHS staff will undoubtedly vary between regions and trusts. Should leaders be interested in identifying factors that impact the experience of their employees, EBD might be a useful approach to achieve this end. Leaders can use outcomes of this improvement tool to codesign targeted, meaningful, and often small improvements that have a significant impact on the day-to-day experiences of their staff.

Limitations

Response bias is a limitation of this approach; people who were interested in the study were more likely to participate, as reflected in this study's response rate. Participants also felt that the questionnaire was time-consuming despite it having an online format.

Conclusion

It is important that healthcare staff feel empowered to discuss and make recommendations on how their daily working life can be improved; hospitals can use an EBD approach to work collaboratively with their employees to achieve this end. This tool gives staff the opportunity to work in codesign with leadership teams to identify what impacts their working day and to agree with effective improvements that can be implemented. Future studies may wish to conduct staff and patient experience studies in tandem so that causalities for this relationship can be better understood.

Appendix 1. Format of Online Questionnaire

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Appendix 2. Job Roles of Participants

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Appendix 3. Emotional Map for Non-Clinical Staff

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Appendix 4. Emotional Map for Clinical Staff

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