Cultures of engagement

Michael West

Previously we explored three elements of culture: high quality, safe, and compassionate patient care as the top priority of leadership– a vision enacted not just espoused by leaders; clear challenging objectives focused on improving quality at every level of the organisation; and effective, enlightened people management that ensures staff are treated with respect, dignity, care and compassion. The next element in creating the conditions for cultures of high quality care is staff engagement.

Engagement at work

Engagement describes an experience of work as being involving; at times, exciting, meaningful, energising, affirming, stretching and connecting. In the NHS, the term includes three elements: the extent to which staff are intrinsically motivated and excited by their jobs; the extent to which staff would act as advocates for their organisations, recommending family or friends to get treatment there or to work there; and the extent to which they are involved in decisions, proposing and implementing ideas for new and improved ways of doing things for example. 

Health care is rightly evidence based so what evidence is there that engagement is important for creating cultures of high quality care?

Data from the National Staff Survey reveals that staff engagement trumps all other measures (staff satisfaction, leadership, HRM practices) as the best overall predictor of trust outcomes collectively. It predicts care quality and financial performance (based on CQC ratings), patient mortality (in the acute sector), patient satisfaction, and staff absenteeism, health and well being and stress (negative relationship).

The results are consistent across primary care, ambulance trusts, mental health trusts and acute trusts. Moreover, the data show how increases in staff engagement in trusts over time are associated with subsequent improvements on these outcomes. In other words we know that the direction of the relationship is more strongly from engagement to outcomes than from outcomes to engagement. It is not simply that the trusts of high performing trusts feel more engaged as a consequence though that does follow to an extent also.

Particularly noteworthy is that involvement in decision making is the most important component of the engagement measure in predicting outcomes. That is a key challenge for leaders in the NHS. To radically promote innovation and involvement of staff at all levels in meeting the challenges the service faces in delivering high quality, safe and compassionate care to all. Command and control cultures do not work in health care organizations in the UK or elsewhere as our recent review of the international literature shows (contact me for a copy of this review on

What do leaders need to do to promote staff engagement?

Good leaders create a positive climate for staff so that they feel engaged and have the emotional capacity to care for others. There is enough negativity in health service organisations – fear, pain, anxiety, loss, uncertainty – that we must counterbalance it with positivity. This is both fundamental to leadership in the NHS and not widely understood. Expressions to staff of gratitude, appreciation, support and encouragement cost nothing but profoundly impact patient care. Good leaders work to build cohesion, optimism and a sense of efficacy in their teams and organisations.

Creating a positive environment for staff does not mean faking happiness and adopting an irritating ‘happy clappy’ approach to work life. It means being genuine, open, curious (wanting to learn), kind and appreciative. We can nurture such cultures by encouraging team cohesion, developing a sense of team optimism about the work and building a sense of efficacy. Good leaders enable their team members to feel confident in the ability of the team to achieve its goals and deliver high quality, compassionate and inspiring care.

Good leaders listen constantly and carefully in order to learn about the obstacles and hindrances that frustrate front line staff and then work with them to overcome them. And they take the insoluble problems to more senior leaders and mandate them to help find lasting solutions that enable staff to deliver the care they wish to. Such approaches are essential if the NHS is to meet the challenges of the sector and deliver the care the public wants and needs. That includes the most senior NHS leaders challenging politicians where necessary.

It also means confronting and dealing with those behaviours which create negativity, stress and disengagement within the team or organisation. Dealing with them with supportively but dealing with them decisively. Great leaders spend time working with individuals who are abusive, have bad interpersonal relations with others, are rude or brusque with staff or patients, or who are not performing effectively and coach them to change. Because if such behaviours are tolerated, everyone’s motivation and engagement is weakened and patient care suffers. Ultimately, if people’s behaviours threaten the development of cultures of high quality care for patients and they cannot or will not change, they need to go.

Negative emotions are inevitable in health care

Sometimes a patient or member of the public will be rude and it hurts. Another role of the leader is to look for opportunities for turning negatives into positives, helping staff learn from experiences such as this and developing strategies for prevention or coping. Or it might be debriefing and affirming the constructive way in which she dealt with the situation.Helping staff turn negatives into positives is neglected in leadership training but a key aspect of nurturing cultures of compassion.

At the heart of engagement is trust

Staff will commit their precious life resources of motivation, emotion, energy, creativity, commitment and kindness towards patients to the extent they trust their leaders. Treating staff with respect, care, compassion, dignity, supportiveness and honesty is essential. This includes not obviously having favourites (though we all do) or, at least, not unfairly favouring those staff who you find it easiest to get on with and are most like you. Good leaders strive to be transparent, just and genuine and engaged in their roles as key in nurturing culture.Further excellent guidance on developing a culture of staff engagement is available in the form of a staff engagement toolkit.

In the next blog we will explore the role of team working in health care and the simple but powerful ways in which we can dramatically improve patient care by working more effectively in real rather than pseudo teams.

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