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What matters to nurses: does your organisation know?

One trust dared to open a conversation with staff – and faced some uncomfortable truths

One trust dared to open a conversation with staff – and acted on some uncomfortable truths to build a more credible vision for patient care and workforce well-being

  • Simple questions about values, behaviours and what matters at work prompted a trust-wide conversation, with responses from thousands of staff members
  • Ensuring staff members understood that the process would have a tangible outcome increased engagement
  • Acknowledging ‘the good, the bad and the ugly’ in the workplace helped to create a culture that everyone is signed up to
Asking staff what they think about their workplace can have benefits for morale and patient care
Picture: iStock

Can finding out what really matters to staff help your organisation to thrive?

That was the question at the heart of Steve McManus’s approach to leadership when he took over at the helm of the Royal Berkshire NHS Foundation Trust almost three years ago.

‘We didn’t have a common set of values that staff and volunteers had signed up to’

Steve McManus, chief executive of Royal Berkshire NHS Foundation Trust

The year before he became chief executive, work had been undertaken to establish the trust’s vision. ‘When I asked how many people had been directly involved in those discussions, the level of input was in the small hundreds,’ says Mr McManus, who originally trained as a nurse, qualifying in 1990.

‘I felt we didn’t have a common set of values that staff and volunteers had signed up to – they weren’t the values of our organisation as a whole.’

How what matters to staff became an organisational vision

Although staff were dedicated to providing high quality patient care, he found long-term organisational direction was missing and there was a lack of engagement.

So he set a goal to generate a trust-wide conversation among the organisation’s 5,500 or so staff and volunteers. The aim was to reach at least 3,000 employees over a six-month period, beginning in May 2017.

Based on simple questions posed by staff trained as facilitators (often holding group discussions outside their own clinical areas), conversations centred on what mattered to staff members as part of the trust and within their team; and to patients, carers and the community. Volunteers, governors and wider stakeholders, such as community groups, were included too.

‘I was always clear this wasn’t a one-off exercise,’ says Mr McManus. ‘It needed to develop into a cultural way of how we listened and engaged with staff.’

‘Around 80-90% of those employed here live in Reading or Berkshire. This is their own hospital, as well as where they work’

Mr McManus

By the end of 2017, the trust had gathered the views of more than 3,800 staff members, building up a picture of what they thought, believed and valued, in their own words.

This enabled the trust to recast the organisation’s vision as ‘Working together to provide outstanding care for our community’. ‘It’s derived from the language our people used, with all three components coming out very strongly,’ says Mr McManus.

The sense of community is especially important. ‘Around 80-90% of those employed here live in Reading or Berkshire. We also have two or three generations of some families working here. This is their own hospital, as well as where they work,’ he says.

Uncomfortable truths: listening to the good, the bad and the ugly

From the beginning, leaders were prepared to listen to some uncomfortable truths. ‘The good, the bad and the ugly,’ says Mr McManus.

While most contributions were overwhelmingly positive, some staff raised issues about more negative experiences, including poor behaviour, bullying and not feeling they had the same opportunities as their peers. ‘They’re not endemic problems, but we needed to hear them,’ he says.

Word cloud showing descriptions related to the value ‘compassion’. The trust’s four core values were developed based on the words of its staff
A word cloud showing terms related to the value ‘compassionate’ – one of four core values based on the words of the trust’s staff Picture: Royal Berkshire NHS Foundation Trust

In autumn 2018, the trust published its values and behaviours framework, based on four care values: compassionate, aspirational, resourceful and excellent.

‘Each one is brought to life with statements based on the words of our staff, with what they want to see and what they don’t expect,’ says Mr McManus. ‘It applies equally – whether you sit on the board, work in catering, finance or are a front-facing clinical team member.’

Embedding the four core values and behaviours

Now these values and behaviours are being embedded throughout the trust in areas such as recruitment, annual appraisals, resolving conflict, and various staff leadership and development programmes, including those at a senior level.

There are lots of different ways we’ve incorporated the What Matters programme into the life of the organisation,’ says Mr McManus. ‘It has helped us to harness the passion and commitment that was already there in our staff.’

Although it’s hard to judge the programme’s impact on specific staff groups, figures for the past 12 months show that more nurses are staying. ‘We’re attracting and retaining more of our nursing workforce and that’s a shift we’ve seen over the past two years,’ says Mr McManus.  

How we created a framework for staff members, by staff members

When Jess Higson first heard about the What Matters project at Royal Berkshire NHS Foundation Trust, she was keen to become involved from the beginning.

Jess Higson, matron of Berkshire Cancer Centre, says the initiative has given staff a voice
Jess Higson: ‘We didn’t want to ignore
problems and concentrate on the good’

‘I’m very passionate about working with staff to develop a good culture and environment where people want to come into work,’ says Ms Higson, who has been matron of the trust’s Berkshire Cancer Centre for three years. ‘I think you get the best out of your staff if you offer somewhere that’s friendly, welcoming and where they feel looked after.’

At the programme’s outset, she joined a group of volunteers from across the trust whose aim was to engage with as many staff as possible, talking to them about values and behaviours. The goal was to create a framework, reflecting everyone’s thoughts and beliefs and setting out the standards expected. ‘We wanted something practical and operational,’ says Ms Higson. 

Address the negative, as well as the positive

Of course, not everything staff told them was positive. ‘Themes of discrimination or bullying came up and we did some focus work around them,’ says Ms Higson, who won the trust’s award for the most inspiring or innovative nurse, midwife or allied healthcare professional in its annual awards.

‘We didn’t want to ignore the problems and only concentrate on the good stuff.’

‘If you’re doing amazing work, but you’re actually being a horrible and challenging person, you’re not going to do so well’

Jess Higson, matron at Berkshire Cancer Centre

To encourage honesty, setting the scene was important. ‘A lot of the work I did was outside my own area, so I was someone new for staff to talk to and they felt safe,’ she says. ‘It’s always disappointing to hear that people in your organisation experience discrimination or bullying and it’s not something I want anyone to feel.

‘If there was a particular issue, I wouldn’t let it lie. As a senior manager, I took it forward, giving out my details if anyone wanted to get in touch afterwards – and that did happen a few times. You can meet with people separately, unpicking their issue and giving them support.’

Give staff the space to say what they think

Overall, she found staff really appreciated the chance to take part. ‘I was surprised that people actually liked the process,’ says Ms Higson, who manages around 100 nurses. ‘They enjoyed having the space to say what they thought and be listened to, with us giving them that time.’

Now the framework is contained in a booklet given to all staff, which covers expectations and specific behaviours that are unwelcome. For example, under ‘compassionate’, it includes expectations such as: giving people full attention; putting yourself in others’ shoes to understand their needs and perspectives; and supporting others through difficult situations.

Unwanted behaviours include: doing the minimum required to help others; talking over or interrupting; and treating others in a way you wouldn’t want to be treated. ‘I hope it makes the organisation feel like a place where we value how we treat each other, all the way down from senior managers and the executive team,’ says Ms Higson.

A table showing the good and bad points raised by staff. The trust recorded and considered both positive and negative comments received
A table showing the positive and negative points raised by staff – both of which were
welcomed by the trust as part of an open and transparent process
Picture: Royal Berkshire NHS Foundation Trust

A part of interviews and appraisals

In practice, it can also be used to stimulate discussions. ‘If someone is worried about a colleague’s behaviour, just being able to have a conversation makes it easier to raise concerns,’ she says. ‘It makes it easier to manage any incidents. It usually comes from somewhere, for example, if someone is stressed you can have a conversation about giving them more support.’

A model for giving effective feedback in a timely, non-judgemental and constructive way is also included in the booklet.

The framework has helped guide questions about values for candidates at interviews, and the programme is embedded in the trust’s staff appraisal system. ‘We talk about behaviours as well as achievements,’ explains Ms Higson. Scores are based on each, with both valued equally. ‘If you’re doing amazing work, but you’re actually being a horrible and challenging person, you’re not going to do so well,’ she says.

 

The impact on staff engagement figures

In its most recent Care Quality Commission report, published in January 2018, the Royal Berkshire Hospital moved from ‘requires improvement’ to ‘outstanding’, with the trust as a whole assessed as ‘good’.

In 2016, the trust was ranked 59th out of 89 trusts in the country in the annual NHS survey, which explores the experiences of staff members working in organisations. In 2018, it moved up to 6th place.

On staff engagement specifically, the trust was rated 43rd in 2016, and moved up to 8th two years later. Among the trusts taking part, Royal Berkshire was the second most-improved overall.

The What Matters programme has also been recognised nationally, winning an award from human resources professional organisation the Healthcare People Management Association in 2019 for excellence in organisational development. ‘It’s having a positive effect across all levels of the trust,’ says Mr McManus.

Changing staff sceptics into advocates

Turning around the cynicism of colleagues was among the initial challenges, says the trust’s chief people officer, Don Fairley.

‘I remember having conversations with two staff members in particular, who were saying they’d heard it all before and there was nothing radical here,’ he says.

‘But once the What Matters sessions started and the momentum began to build, it was as if we’d lit a blue touch paper. People were saying to each other, “have you heard about this?” and “have you had your session yet?”. It really took us by surprise.

‘The two negative people ended up being real advocates of it. They were saying that all the time they’d worked here, no one had ever asked their opinion. It became a bit of a movement.’

Step by step: how to put what matters into practice

  • Executive buy-in is crucial, says Jess Higson, matron at Berkshire Cancer Centre. ‘Some may say top-down doesn’t always work, but having the support and drive to make this happen was what was needed,’ she says

    Royal Berkshire NHS Foundation Trust chief executive Steve McManus
    Steve McManus: ‘Be ambitious’

  • Be ambitious about scale, says Steve McManus, chief executive of Royal Berkshire NHS Foundation Trust. ‘Set your expectations to have a conversation with a majority, not a minority, of your staff. It takes effort, planning and resources, but from a leadership point of view you need to make that commitment from the outset’ 
  • Consider instigating little changes if a large project seems too daunting. ‘Even just being able to implement a small part is good,’ says Ms Higson. ‘Structured conversations with staff on certain topics can be incredibly beneficial’
  • Be creative about how you provide opportunities for staff to engage, says Mr McManus. ‘You have to go to their environment, with an approach that’s bespoke to the teams you’re trying to work with. Don’t just get them to turn up to a lecture theatre, where they have their say and go away again’
  • Invite staff to volunteer as champions on the ground. ‘We had around 40 facilitators who were able to run sessions themselves across the organisation, really broadening the base,’ says Mr McManus
  • Invest in their training too, urges Royal Berkshire NHS Foundation Trust’s chief people officer Don Fairley. ‘They become your advocates,’ he says. ‘Without them, I don’t think we’d have been anywhere near as successful and it would have certainly taken a lot longer’
  • Make it a meaningful exercise (as opposed to a paper one), with continuing benefits, says Mr McManus. ‘You have to be able to demonstrate the outputs’
  • Tell staff from the beginning that there will be a tangible outcome, to encourage their participation. ‘People can see there will be an end product,’ says Mr Fairley. ‘There is a benefit to their working life’

 

Staff say ‘this is our framework, we wrote it’

It was also important that the trust delivered on its promises. ‘We gave a commitment that everything would be collated and fed back,’ says Mr Fairley. ‘We ran feedback sessions, where we told staff what was coming out.’

Most of it was positive, with staff welcoming teamwork, communication and providing quality care. ‘But some of it was shocking,’ he says. ‘There were negative messages, mostly about people’s perceptions of how they were being treated. We had to be open about those and deal with them collectively. If there’s an issue about how people behave, that’s all of us.’

Finding creative ways of engaging staff, tapping into the moment, and having a physical product, in the form of a documented framework, at the end all contributed to the programme’s overwhelming success, Mr Fairley believes.

Having staff so involved in producing the values and behaviour framework initially worried some board members.

‘Some asked whether we were sure about handing it over and wasn’t it their job,’ he says. ‘But we needed to have enough confidence that they would do the right thing. Now you’ll hear people say “this is our framework, we wrote it”.’


    Lynne Pearce is a health journalist

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