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Monitoring morale: Why collating staff feedback is essential to improving services

Chris Graham, Chief Executive of Picker, an international charity working across health and social care, considers how monitoring industry morale and culture can support improvements in the social care workplace.

Understanding workforce needs

What’s the most important metric to understand the performance of health and care providers? Service quality is a complicated thing to assess, comprising a range of separate but related factors such as user outcomes, safety and value for money. Few would be bold enough to go on record with a single measure that should take priority over others. Yet, in 2017, Sir Mike Richards, who at the time held the position of Chief Inspector of Hospitals at the Care Quality Commission, did just this – calling England’s NHS Staff Survey ‘probably the most useful single data source that we all have’ for understanding and monitoring service quality. Why? Because staff feedback provides insight into morale and organisational culture, as well as revealing the pressures that staff face: it tells you about the environment in which care is delivered from the perspectives of the people tasked with providing it.

Today, this idea that workforce issues are central to how effectively providers can function seems particularly important. Two years of a pandemic have greatly exacerbated existing challenges related to turnover, vacancy rates, pay and working conditions, thus creating a profoundly difficult set of circumstances for leaders and front-line staff alike. But do we know enough about the pressures facing the social care workforce – and what needs to change to ensure staff are heard and supported?

Workforce burnout and resilience

Last year, the House of Commons’ Health and Social Care Committee published a report titled ‘Workforce burnout and resilience in the NHS and social care’, describing the findings of an inquiry launched in July 2020. The inquiry sought to explore the resilience of the health and social care workforce pre-COVID, as well as the impact of the pandemic, and aimed to investigate what measures might be required to understand, manage and reduce burnout.

Evidence submitted to the Committee as part of the review highlighted the extreme conditions that care staff have been working under. Care England, for example, wrote ‘unprecedented … physical and mental strain’, describing how ‘adult social care staff [took] the place of relatives and loved ones [during lockdown] … they have felt bereft and grief stricken when residents have died’. Similarly, the Diocese of Rochester described care home staff as feeling ‘abandoned … exhausted and demoralised’: both heartbroken over excess deaths amongst residents and fearful for their own future employment as families avoided placing elderly relatives in permanent care.

Despite clear recognition of the significance of workforce burnout, the report found a lack of reliable evidence to quantify the problem for social care workers. This stands in contrast to the NHS, where the National Staff Survey – co-ordinated by Picker for NHS England and Improvement – provides detailed insight into stress and burnout in different organisations and staff groups. The report notes that ‘understanding the scale and impact of workforce burnout can only be achieved with a metric for staff wellbeing and staff mental health that covers both the NHS and social care’ and recommended the extension of the NHS Staff Survey to cover the care sector.

The idea that consistent measurement matters makes a great deal of intuitive sense. After all, evidence about the scale of burnout in the NHS can be used to direct support, ensure accountability and monitor trends. And the report rightly identified ‘a need to [put] recognition of the work of social care … on an equal footing with medical professionals’. But is parity of recognition as simple as extending NHS measures to social care – and is that even practical?

From our experience of co-ordinating the NHS Staff Survey since 2011, we predicted that there would be challenges in extending the model to cover the social care workforce. However, we wanted to understand wider perspectives from experts across the sector. Therefore, in December 2021, we convened a roundtable discussion focusing on staff experience in social care – especially in care homes and domiciliary care for older people. The discussion covered a range of themes, including what is already known about the experiences of the social care workforce, the priorities to address and how data could be gathered and used to support improvements in workforce experience.

Social care workforce experience

Strikingly, the early parts of the roundtable discussion centred not on the stresses of caring through the pandemic, but on the passion and dedication of the care workforce. We talked about why people choose to work in social care: about how satisfying and meaningful it can be, and about the impact that care workers can have. Attendees told us that staff ‘really do feel they can make a difference to people’s lives’. These positives can keep people going in the face of stresses and challenges; they are resilient because they offer constant reminders that people’s roles matter.

At the same time, there was a recognition that this sense of impact often carries with it a burden. The stakes are high, the consequences of mistakes severe. One former sector leader told us that they always felt they were ‘one well-meaning but ill-judged decision away from a crisis’. Also, pay and reward for front-line staff rarely feels commensurate with these high-stakes, high-pressure, demanding roles. We heard that expectations on the sector have increased over the last decade and that care home workers, for example, now do many tasks that were previously the preserve of district nurses – but care staff still receive lower pay and recognition than those in healthcare.

The social care workforce is, of course, hugely diverse and is made up of a number of organisations and includes a variety of job roles. But pressure is felt across the board, particularly during the pandemic. Front-line staff in care home settings faced extreme challenges during 2020 when sickness absence rates tripled due to COVID-19: this ramps up the workload for others and creates complications for leaders such as care home managers. We heard about the importance of good leadership and about the need to nurture and support leaders, as well as the front line – particularly as many managers are leaving the sector.

Good leadership is particularly important when many of the problems the front line experiences are borne from environmental pressures. Experts told us about how the fragmented nature of the sector leads to inconsistency in a range of areas that affects staff experience and development. First, it is difficult to develop collective bargaining to give employees a formal voice – contributing to variation in pay rates. Similarly, the lack of a consistent training infrastructure makes it difficult to develop staff. Strong leadership is needed to navigate these challenges – and leaders need insight from the workforce to understand their priorities.

Using data to improve people’s experiences of work

Survey respondents were united on the importance of building better data on the experiences and composition of the social care workforce. Co-ordination of administrative data is a part of this: for example, developing a systematic workforce register could help to track the changing composition of the workforce, shining light on sector-wide capacity and development issues. Hearing staff voices – and acting on them – was also recognised as being vital to improve staff engagement and to allow improvements to be identified and co-designed.

If social care needs a more systematic approach to hearing the voices of staff, we have asked is the solution as simple as extending the NHS Staff Survey to the sector? Experts at our roundtable were apprehensive. Social care is fundamentally different from the NHS in the way services are structured and staffed; a differentiated approach is likely required, rather than a one-size-fits-all solution. Whilst there are clear benefits to a model like the NHS Staff Survey – it is robust, replicable and fosters a sense of cohesion and commonality – it may need adaptation to be useful to social care organisations that are typically much smaller than large NHS providers.

Advancing workforce experience

Although extending the NHS Staff Survey to social care may be neither simple nor sufficient, attendees were clear about a number of priorities for advancing workforce experience in social care.

To understand the shape of the workforce and build an evidence base, a first step may be to use and synthesise existing data about the composition of the workforce. This could provide evidence to enable the development of a framework for measuring and improving staff experience across the diverse range of roles in the sector.

Ultimately, there was a sense that maintaining capacity through the sector is a critical issue: this means both retaining and developing existing personnel as well as attracting new people to careers in the sector. Whilst funding is tight, leaders should focus on interventions that can improve morale and retention in their own workforces – even through simple things such as listening to staff feedback and reviewing details such as how rotas are managed to support work-life balance. And nationally, a new, positive narrative is needed to highlight the potential rewards of working in the sector – including using the voices of current staff to bring to life the benefits of social care roles.

Readers would be forgiven for thinking that some of this may be easier said than done. There can be a sense that the challenges facing the workforce are so great that small steps are not enough. But the reality always is that we must work with what we have – and, in any organisation, workforce is a core asset and working culture is a key determinant of success. For those reasons, change will often start here – measuring, understanding and improving workforce experiences will be critical to success.

Chris Graham, Chief Executive of Picker. Email: Twitter: @ChrisGrahamUK

About Chris Graham

Chris Graham has been Picker’s CEO since 2017 and leads the charity’s work to understand and further the link between patient experience, person centred care and clinical excellence.
Before becoming CEO, Chris led the charity’s research division for five years and has held other roles within Picker and at the Care Quality Commission and Healthcare Commission. Chris has particular interests in person centred care and research on staff, patient and user experiences of health and care.

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