Identified themes relevant to staff morale and well-being were in four main categories: (a) the staff team; (b) the management and leadership context: (c) organisational structures and (d) being with patients. Below we describe themes within each of these categories. A fifth area, physical environment, will be briefly summarised here and more extensively described in a separate publication.
(a) The staff team
Ward staff recurrently identified the composition of the front-line ward team and relationships within it as crucial for morale.
Staffing Levels
Staffing levels were viewed as central to morale by staff on all wards, some describing them as intermittently and others as constantly very problematic:
We need more staff desperately and yes, that's probably the one thing more than anything else really because that would free up everything. That would free up the off-duty and the annual leave, the morale, the pressure and people would enjoy their job more. (Nursing Assistant, PICU)
Many front-line staff felt overworked, describing the physical and emotional toll of a busy shift. Staffing levels could make it difficult to find time for a break, and to organise supervision and training, particularly on acute wards, where the risk of incidents intensified the need for adequate staff presence:
Just getting on with the day to day work means that some of the things that might actually be more supportive for people, like meeting together...get pushed to one side. (Consultant Psychiatrist, Acute)
A further concern on four wards was sickness absence and problems with recruitment leading to a perceived over-reliance on "bank" staff. Participants spoke of their uncertainty about the skills of bank staff, particularly regarding "control and restraint" procedures and adherence to ward routines and protocols. Staff also noticed that patients were generally reluctant to approach staff they did not know:
I suppose the anxiety is if it kicks off, they're not going to know the best way to respond. (OT, Child & Adolescent)
Peer relations and teamwork
Effective team working and good relationships with colleagues were the most highly valued positive influences on morale. Staff on two 'high morale' wards - the Rehabilitation ward and the Child & Adolescent Unit - were especially positive about a sense of shared responsibility and their reliance on peer support:
It's probably one of the most important things that gets me out of bed in the mornings to come here, that, generally speaking, I have pretty good relationships with people here. (Consultant Psychiatrist, Child & Adolescent)
Oh the team here are excellent. You couldn't wish for better people and everybody gets on well and there's a mixture of sort of staff and the ideas that everybody has, so we get on ever so well, yes definitely. (Staff nurse, Rehabilitation)
A culture of openness and acceptance, where staff are encouraged to give their views regardless of seniority, was associated with good morale:
Sometimes nursing assistants aren't seen as part of...domestics are not seen as part of the team. Consultants are put on a pedestal and that doesn't really happen here does it? Everyone seems to have an equal opinion and an equal say. (Student, Rehabilitation)
But some tensions were also reported from such tight-knit ward communities, where very close relationships created the risk of fallouts and cliques.
(b) The management and leadership context
Themes emerged relating both to clinical leadership within the ward, generally perceived as originating from the ward manager and to some extent the lead psychiatrist or psychiatrists, and to the senior management team beyond the ward, such as those responsible for the hospital or mental health Trust as a whole.
Leadership within the ward
Senior staff stressed the importance of strong and effective leadership. Consistency in leadership, aided by effective communication within the managerial team, was thought to be reassuring for staff, whilst weak leadership was linked to ambiguity and uncertainty. On one ward, multiple references were made to the impact of a new consultant psychiatrist:
This guy is very direct, very clear about what plans he wants in place, and he's very open and warm, and, you know, very good, so I think it's made a big difference. (Lead nurse, Acute)
Several others on different wards made reference to the way inspiring individuals could boost morale, and the importance of a reliable leadership team:
I think that the things that influence morale in a positive way are stability of the staff team, particularly in leadership functions... this kind of work brings its troubles but overall there's a leadership team which I think is very responsive, containing and supportive of the wider staff team and very good at its job... I think that's absolutely 90% of the whole thing. (Clinical Director, Child and Adolescent)
Support and supervision
This was the most discussed issue among lead/managerial staff working on the ward. Managers and senior managers unanimously believed that formal support mechanisms and supervision are vital for a successful team. Formal supervision was said to help solidify roles and responsibilities and improve confidence. Four wards had staff support groups, on which views were mixed. Senior staff regarded them as a source of mutual emotional support but several front-line staff members said they found them uncomfortable.
Front-line staff spoke more about the value of informal support from managers than about supervision. They appreciated the visible presence of leading staff on the "shop floor", their availability for guidance and reassurance, and their responsiveness to work-related problems. On all wards there was discussion of the importance of feeling valued, with frequent comments that praise and recognition could be more forthcoming.
Support following violent incidents was seen as important by staff on every ward, not just for immediate reassurance but because it sent a message that staff were being looked after. One group talked about how they used to receive letters following an incident, which had since ceased. Although it was "the exact same letter" every time, said one person, "at least you felt they were thinking of you".
They used to come down afterwards and check if everyone was alright and that's important, you know? The small things make a big difference. (Staff Nurse, PICU)
The availability of formal supervision and the extent to which staff felt supported in their roles varied between wards and between individuals on the same ward. Many staff reported good relationships with their immediate managers. The Rehabilitation ward emerged as maintaining a very supportive environment, with the staff support group also highly valued on this ward. On other wards comments were mixed, with some staff feeling under-valued:
I think a major problem as well is that I think we're bending over backwards to look after the patients, but we're not being looked after. Breaks are really hard to take and it's just that more and more is being taken and it's a case of well, it's effective, and it's not really a case of 'you're doing a good job, so good on you'. (Nursing Assistant, PICU)
The ward within the wider organisation
A view that senior managers, who were rarely seen on the wards, had a poor understanding of front-line work emerged on all seven wards:
I just think sometimes the managers are up there, they have their job we have our job, but I don't think they understand what we really do. They'd have to spend like two weeks solid working with us 12 hours a day to understand what's going on. (Staff nurse, Acute)
However, on the Rehabilitation ward, relative independence from senior management was also seen as having some advantages, with staff valuing their insularity and internal community.
Ward managers were also aware of the perceived remoteness of senior managers from front-line staff, feeling uncomfortably "sandwiched" between two tiers. They felt pressured from above by budgetary constraints and sometimes having to implement unpopular policies.
Having a Voice
Ward managers and other senior ward staff on every ward saw considerable benefits to morale of involving front-line staff in decision making, and described efforts to increase their currently limited 'voice' in the workplace:
I think if the staff are not feeling contained and heard and as though they have a sense of agency, then it's almost as though they then can't give that to the patients that they're caring for and the whole thing falls apart - and I think, at times, it has felt very much like that. (Clinical Psychologist, Acute)
One nursing assistant was frustrated at being excluded from ward rounds despite spending a great deal of time with patients:
...I feel like I'm just here to go through processes and the mechanics of the day... I don't feel that I have an opinion that's really valued, or taken into account. (Nursing assistant, Acute)
In general, for front-line staff, feeling unheard was more of an issue in relation to ward policies and organisation, especially workload, than clinical decisions.
I would just like whatever issues I raise to be dealt with without me having to chase them up three or four times and it's really, like... You know, it kind of undermines... You feel, like, you know, no one cares. (Nursing Assistant, Acute)
While negative comments predominated, some positive experiences were also reported. One ward has a system for lodging complaints or proposals to senior managers:
We've got a good formal system management group with people high up in the Trust. So if you have a proposal it will be heard and taken seriously by management meetings. If they can't deliver at that meeting then it's certainly put on as an agenda item for another time. (Social Worker, Child and Adolescent)
Experiences of feeling heard on other wards tended to be attributed to the approachability of particular senior ward staff.
(c) Organisational structures
A further group of themes related to the definition of roles within ward teams and the protocols and guidelines in place for organising work on the ward.
Role Clarity and Confidence
Role clarity was highly valued throughout the sample, though only a minority currently described a lack of this. Managers were especially concerned with coupling responsibility with role clarity, and described strategies such as delegation of clinical and domestic responsibilities and the use of visual aids such as notice boards:
And, I think, that's the thing for me, as well: give people the responsibility. But, in order to do that you have to explain to them what the responsibility entails. Don't just expect them to do something because if they don't understand why they're doing it and what the benefit is, and all that, they'll never really put their heart into it. (Acute Care Service Manager)
As a caveat, staff did vary in the extent to which they wanted greater responsibility. One nursing assistant described her contentment with her role facilitating cooking groups:
I'm quite happy with my job, being a nursing assistant and I even got a chance to go and do my training, I said I didn't want to. I'm happy with this job. (Nursing Assistant, Forensic)
Consistency of structures
Consistent protocols and guidelines for organising work on the ward were found to help maintain clarity and confidence, whilst change was felt to create anxiety:
If you can have cohesion in terms of a cohesive, communicating staff group and cohesion in the sense of structure, in terms of the way ward rounds (and) business meetings operate, that acts as a defence against the anxiety and chaos of psychosis. In my experience, that really assists the efficiency of the ward and that leads to pepping up and, sustaining morale. (Consultant Psychiatrist, Acute)
Formal frameworks were also seen as vital for the maintenance of regular supervision and team meetings, which otherwise tended to fall by the wayside. Flexibility within a well-organised system was also valued, particularly in relation to shift systems. Several staff complained about a lack of flexibility around shifts, whilst a more flexible system on the Rehabilitation ward was seen as contributing to high morale.
On all seven wards there was discussion of recent structural or organisational changes and managers were aware that the frequent waves of change experienced by NHS staff, driven sometimes by central policy and sometimes by local reorganisation, have a considerable impact on staff.
Training
Opportunities for training were valued, and those in high-morale wards tended to be more positive about them. Ward managers also saw training positively as a way of improving standards, maintaining role clarity, imbuing confidence and maintaining morale. Good provision of mandatory courses was reported, but resource limitations restricted access to other courses, especially longer term ones, to which staff often had to dedicate their own time.
(d) Being with patients
A final group of themes related to staff experiences of direct contact with patients on the ward.
Client Groups
The impact on staff of patients' severe disturbance was especially felt on acute and PICU wards:
I think psychosis has a way of inducing chaos and fragmentation, and it's kind of like a manifestation of the condition but also, somehow that gets projected into structures and organisations and systems, in my experience, and there's plenty of room for chaos in a ward environment - especially within a busy ward environment. (Consultant Psychiatrist, Acute)
Staff who had worked in a variety of settings commented that this made acute work more stressful, but some also valued the intensity of the work and pace of change:
I've always loved this ward and the challenge, the busy-ness of the ward, you know, the range of people here. (Charge Nurse, Acute)
Aggression and violence
The volatility of acute wards made violence frequent and risk highly salient to staff. A common sentiment running was that in cases of assault, "there's no reparation really that can be made" (Ward Manager, Child & Adolescent). Staff described how one or two individuals could shift the whole atmosphere of the ward:
The worst time we had here was some time last year when we had a sort of gang mentality on the ward - like them and us, and that was pretty frightening sometimes really. (Staff nurse, PICU)
Staff, especially on acute and PICU wards, appeared stoically to accept that some potential for violence was a given, but strategies for reducing risk were widely seen as inadequate. Higher staffing levels were seen as key, and some concerns were also raised about aspects of the physical environment, including locks and alarms:
We haven't got enough staff, we haven't got enough time and we haven't got enough pagers and alarms to do it safely. That's the trouble. (Staff nurse, Acute)
Knowing one's colleagues and feeling able to rely on them both for help in managing difficult situations and for emotional support was crucial. One nurse described how adverse incidents, when managed effectively, had the potential to enhance team morale:
No incident is nice, but if we deal with it correctly and no one gets off really hurt or whatever and all the procedures are done, it's a good feeling. I think it's good because that shows we've got team work. (Staff Nurse, PICU)
Dealing with social problems
Attitudes varied as to whether dealing with social problems was a legitimate role for ward staff. On the Rehabilitation ward, it was seen as rewarding:
Here it's seeing people moving on and getting their own independence and living in their own flats and being a part of that really. (Staff nurse, Rehabilitation)
On one acute ward however, suspicions were raised that some patients' problems were not really as they seemed: some service users were seen as 'using the system' to gain access to social resources, possibly preventing 'genuine patients' from accessing a bed.
Conversation and activities
Spending time with patients was seen as a core source of satisfaction; on six wards, staff felt that inadequate staffing and excessive administrative duties were impediments:
You can't spend enough time with them and you're stressed out, and then that makes it even more stressful, because they're telling you you're basically not doing your job properly, because you're not spending time with us as much as you should. (Healthcare assistant, Child & Adolescent)
On Rehabilitation and Child & Adolescent wards, staff valued having more time for this and for engaging in social and recreational activities with patients, building relationships with them. Staff who could find time for patients seemed to value their roles more and to see them as better defined.
I was doing the cooking... and I remember one of the patients said, 'Today I felt like I'm a human being'. I said, 'Why are you saying that?' She said, 'You know the food that you gave me, it made me feel good, like I'm still alive.' (Healthcare Assistant, Forensic)
Helping patients recover
Across all the wards, seeing patients get better was a positive influence on morale. Those working in Rehabilitation and Child & Adolescent units gained fulfillment from a long-term emotional investment in clients. For those in acute/intensive care, success was rated on a more short-term basis in terms of "stabilising" patients and discharging them home. Staff on these wards who maintained more consistent positive morale embraced the "challenge" of acute psychiatric care. Acute care staff were also more likely to see patients return to the ward. For a few, particularly on one acute ward, the "revolving door" phenomenon was a cause of frustration. Some felt disillusioned at the way factors beyond their control contributed to repeated readmission.
(5) Physical Environment
Participants were also asked directly about the impact of the physical environment on their morale. Qualitative data pertaining to this topic will be reported elsewhere, so only a brief summary is given here.
A comfortable and attractive environment was not surprisingly seen as conducive to a good atmosphere, especially where staff and patients had access to outdoor space. Problems identified varied from ward to ward and included insufficient staff areas, poor air quality and lighting and lack of designated spaces for group activities or one-to-one sessions with patients. Particularly demoralizing were enduring problems, which could lead staff to feel neglected, though several people also described the joining effect of having to make do in adverse circumstances. Improvements to the physical environment were viewed as highly morale enhancing, sending a message that staff were valued.