Friday, 26 July 2013

Improving the morale of NHS Staff

Improving the morale of NHS Staff

The vital role of improving the frequency of positive emotions and using positive feedback as a source for improvement. Time for the public/patients to be a part of the action.

Bad news all around

Poor care, cover ups, whistle blowers, gagging orders, complaints, et al; we very often hear about all of them these days through profoundly sad media reports, social media (twitter, facebook, blogs) and reports of various organizations. If you are following the news recently its bad news everywhere with Mid Staffs, Francis, Tameside, Morecambe Bay, Keogh 14 at the extreme end and A&E crisis, GP OOH crisis, rationing of services etc at the moderate end. (It is a worrying state of affairs, isn't it when the GP and A&E crises are called moderate?)

Dealing with what is wrong

When things go wrong there are a number of mechanisms present to address them – the immediate boss, PALS, complaints, medical director, nursing director, chief executive and other directors. There is the healthcare ombudsman if your local systems cannot sort it out. There are national bosses, DoH, NHS employers, NHS confederations and others who are very willing to intervene when things go wrong. Medico legal specialist lawyers who are very willing to take up and chase anything from the trivia to the grievous. There are regulators CQC, GMC (for doctors), NMC (for nurses), Monitor (for foundation trusts, more recently for all trusts). There are plenty of important bodies all willing to tell us how to practice clinical care; the Royal Colleges, NICE, various specialty organizations and others. All of these people and organisations issue the euphemistic 'guidelines' which are basically rules/regulations which if not followed clinical staff will be in trouble.

The NHS tracks its complaints and publishes it – quite rightly so. NHS bad news is reported big time when there is a serious complication or death or when there is a serious let down of an individual’s expectations – quite rightly so. Openness when things do not go right is very comforting for the affected patient and families; it also helps organisations learn and improve.

The Impact of Constant Bad News

'Bad news' i.e. news about poor performance, negligence, criminality, never events, serious untoward events, harm, complications and bad behaviour of healthcare staff even after accepting that it is grossly under reported forms a small part of the overall picture of healthcare and NHS. Vitally important part, but small part.

Majority of healthcare staff are well performing, well behaved, caring and produce good clinical and social results for their patients. An overwhelming majority of patients get good results. This is of course no excuse or balance and cannot be used to justify avoidable problems or even to defend the impact of unavoidable problems.

Having set that out very clearly, let us look at the impact of negative feedback, negative experiences or negative behaviour that healthcare staff get constantly from their newspapers, from their managers and from their patients. 

Studies by psychologists have shown that the effect (value or impact) of negative emotion we feel is twice (2.25 times) as stronger than the effect of a positive emotion. Here we explore how this plays a part in the morale of NHS staff. Let us say the impact of praise (and we feel a positive emotion due to that) is +1 and the impact of non-constructive criticism (we feel negative emotion due to this) is -2. So if we praised a person once and criticised them once, the net effect on an employee's emotion is not 0 or neutral, the employee ends up with a mental state or mood or feeling of negative emotion which in our scale will be rated at -1. Let us assume we praise an employee four times in a day and have a go at them four times in a day the net impact is likely to feel negative emotion rated (+4 -8 =) -4 and if we repeated this for a whole week the employee will have a mental state which on this scale will be valued at -20 or full of negative emotions.

It is indeed no wonder that NHS staff suffer from a low morale. There is plenty of negative news in every media, constant pressure from government and managers. The complaints from patients have reached record levels. It is indeed a surprise that NHS employees have any morale at all.

What can patients (service users) do to improve morale?

We now know that poor morale and unhappy staff results in poor healthcare delivery. As patients we would want to prevent that. We know that majority of the times, majority of the patients get very good results. We know that negative emotion has double the impact on the mind than positive feedback. So as patients I think we want to be congratulating, thanking, praising NHS staff every time we get a good service and/or a good result so that positive emotion can flourish. We should try to do that at a ratio of positive to negative feedback of at least 3:1 (you see a positive:negative feedback ratio of 1:1 leads to low morale staff and 2:1 will lead to neutral morale staff). We know positive and happy staff often translates into good results for patients.

As a patient it is in our specific and direct self interest to increase positive emotion in healthcare staff when things are going right for us as it does most of the time for most of us.

As a manager that is what you want to be doing to your staff, being aware of the impact of positive and negative emotions and using the ratio to boost morale.

Let us take a hypothetical example of a treatment which has a 90% success rate and a 10% failure/complication rate (this will generally be high rate of complications); let us assume that all patients provided feedback with 90% thanking and praising the staff for the successful treatment we have had and 10% of patients complaining about their result. We may have staff in great mood feeling very positive about themselves and are likely to deal with complications/problems in a confident positive manner.

Positive feedback as a source of improvement

The NHS has no system of capturing congratulations and kudos. Complaints are logged, measured and acted upon. Congratulations are not formally logged, hence not measured and almost never acted upon. If a patient writes in with a complaint hospital looks not only for resolution but also to try and prevent it from happening again. If a patient writes in with a compliment it will be a very rare place to study it immediately learn the lesson and roll it out. We learn if at all, on how to avoid bad things, we do not seem to learn on how to improve on good things. My premise is learning to avoid problems puts healthcare providers in a neutral position; learning to improve on what is already working well puts healthcare staff in a strong position. Here is why we need to do it, if you slip from a neutral position you go into a negative situation; if you slip from a strong position you either become less strong or even (though there is a small chance of getting into neutral).

Well we know that it is not exactly very British to be loud, vocal and break into a song and dance to praise when things go right but if we knew what is good for us that is what we would do. It is very wrong not to complain when things have gone wrong, it is very wrong not to whistle blow, it is very wrong not put in extreme effort into getting care right and not remedying problems effectively when they occur. It seems to me now that it is also very wrong not to praise NHS staff when things go right. The silence of the majority could be a major reason for the low morale. It is time patients and managers made the effort to improve the morale of NHS staff, it seems a route to good care.

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Notes: The strength of positive and negative emotions we feel and its impact is well described in N Taleb's Fooled by Randomness.


Anonymous said...

May I put this in issue 5 of please? It outlines precisely my motivation in starting the mag in the 1st place?

M HEMADRI said...

Yes you may Stuart and thanks