Psychiatric inpatient wards are potentially highly stressful places to work. In England, the shift towards community-based care in the post-deinstitutionalisation era has raised the threshold for admission, with more patients detained under section and shorter lengths of stay [1
]. Policy makers, managers, clinicians and service users have all expressed concerns regarding the quality of inpatient care [2
]. National audits report high rates of violence on psychiatric wards [5
] and difficulties identified in a national review of acute wards [6
] included high staff vacancy and sickness rates, lack of leadership from consultant psychiatrists, poor communication with community teams and limited availability of psychological treatments.
Staff morale in the NHS is important in several respects. Firstly, the NHS is one of the world's largest employers, and achieving the status of an exemplary employer has recently been defined as an important goal [7
]. Secondly, the cost to the nation of the current high rates of staff sickness in the NHS is around £1.7 billion per year. Thirdly, substantial correlations have been found in healthcare settings between staff well-being and patient outcomes [7
]. In inpatient mental health, there is increasing evidence that therapeutic relationships are key determinants of patient experiences [8
]: staff attitudes and well-being are likely to influence these. Finally, the problems identified in UK inpatient mental health care have resulted in a series of initiatives aimed at service improvement. A growing body of 'implementation sciences' literature [9
] indicates that negative professional attitudes to work are a major block to the successful dissemination of innovations intended to improve patient experiences and outcomes.
Until recently, there has been little comprehensive research on the morale of NHS inpatient mental health staff, with most studies employing small samples and confined to single sites or including only mental health nurses [10
]. The qualitative study described in this paper was the second component in a mixed methods national investigation of inpatient staff morale. The first part of this investigation was a quantitative questionnaire survey on 100 wards across the country, reported on by Johnson and colleagues [13
]. Findings from this quantitative study were that most NHS inpatient staff were fairly satisfied with their work and reported a sense of achievement from it. However, a substantial proportion were 'burnt out' on the 'emotional exhaustion' subscale of the Maslach Burnout Inventory [15
], ranging from 29% on rehabilitation wards to 49% on acute wards.
An understanding of the factors underlying good or poor morale on wards is likely to be required for effective strategies to improve morale to be designed, but empirical examinations of these are even rarer than studies of levels of morale [11
]. The quantitative study which preceded the current study and included the wards on which the current study was conducted [13
] examined associations between indicators of morale and a range of candidate influences. The demand-control-support model [16
], which proposes that work strain results from a combination of high job demands, low autonomy in the way these can be met, and low support from managers and colleagues, was largely upheld [14
]. Other organisational variables which were associated with morale indicators were staff ratings of role clarity and team communication, and perceived fairness in the work environment. Experiences of bullying and violence were also highly associated with morale. Ward type and various demographic indicators were also associated with morale, but staffing levels and specific physical characteristics of the ward were not.
Quantitative data of this type illuminate potential underlying mechanisms for good and poor morale to only a limited extent. Qualitative accounts have a major complementary role in allowing an understanding of how staff make sense of their experiences at work, their views about how to improve their experiences, and the mechanisms that might underlie their responses to particular sources of stress and satisfaction. A systematic review on staff morale in 2004 showed that 38 out of 39 qualitative studies included in the review were single site case studies [10
]. A qualitative study in three sites in London reported that ward staff complained of lack of autonomy and opportunities to develop an independent therapeutic role with patients. Informal peer support was the most frequently cited source of support [17
The current study reports findings from a substantial multicentre qualitative investigation of inpatient staff views regarding the factors that influence their morale. Aims were to extend current understanding of the mechanisms underlying good and poor morale on inpatient wards, and to generate potential strategies for improving morale. This qualitative study was nested within a national multi-site quantitative study [13
]: a secondary aim of the current qualitative investigation was to aid interpretation of the quantitative study's findings, and the discussion includes an examination of areas of congruence between the findings of the two studies.