The Impact of Ethnicity on Doctors' Responses to Employee Engagement Practices in English NHS Hospital Trusts

Abstract

The NHS is the fifth largest employer in the world and has heavily depended on a foreign skilled labour force since its inception. This has resulted in the NHS employing the highest number of ethnic minority staff in the UK, with 41% of hospital doctors identifying as belonging to an ethnic minority. There is a call for research to investigate Employee Engagement (EE) in relation to different ethnic groups, to contextualise EE, and to define both EE and ethnicity through insights from the experiences of social actors. The thesis propounded here investigates the impact of ethnicity on the variations in doctors’ responses to EE practices. It explores firstly, the factors influencing the self-perceived ethnicity of doctors; secondly, the experiences of EE of doctors working in English NHS hospital Trusts; and thirdly, the influence of doctors’ ethnicity on their responses to the EE practices. Based on the literature reviewed, ethnicity is conceptualised as an identity which is self-perceived, fluid, subjective and contextual. The social experience of living with an identity, even if it is entirely internally defined, involves an external attribution of characterisation that can vary subject to the constitution of the audience. The consolidation of all such internal and external processes are, in this research, collectively referred to as the dual nature of ethnicity. EE is conceptualised as a two-way relationship, where hospital Trusts aim to create a conducive environment that is in alignment with the ‘professionalism in action’ guidance for doctors by the General Medical Council (GMC). This should, in turn, encourage doctors to advocate for their Trusts as a place of work and treatment, as well as to participate in improving its performance. The research follows an interpretivist philosophy based on subjectivist and social constructionist epistemological and ontological assumptions. It draws upon the findings of 56 semi-structured in-depth interviews with doctors, which are thematically analysed, along with insights from a research diary, field notes, documentation and archival records. The findings reveal that identification of self-perceived ethnicity, without using a predefined list of ethnicities, can enable a unique context to be expressed by the participants. The primary data supports the argument that individuals can express or identify themselves subject to the setting, and could selectively consider their country of birth, ancestry, and the culture and language they adopt based on their exposure. The change in exposure can impact self-perceived ethnicity, supporting the argument that it is fluid. Analysis of the empirical evidence indicates how a high-pressure work environment, as well as certain protocols and systems can frustrate doctors. These frustrations, along with a lack of resources can hinder the creation of a conducive environment for EE. Findings also suggest that encouraging patients to appreciate their doctors’ work, supporting collegiality and providing training or information about the impact of the business context on the Trust, can be beneficial in creating a conducive environment for EE. Such an environment could encourage doctors to advocate for their Trusts, hence supporting the argument that EE is a two-way relationship. It was found that altruism and collegiality are the key motivating factors for participation in improving the performance of the Trust, rather than as a direct response to a conducive environment for EE. Overall, the findings reveal that the dual nature of ethnicity can impact doctors’ responses to EE practices and policies. In particular, doctors of non-British ethnicities were sometimes found to be less aware of the business context, but potentially more resilient to the factors that could hinder the creation of a conducive environment for EE due to the exposure that they have outside of the NHS. These ethnic minority doctors risked facing discriminatory policies and behaviour from staff and patients. Collegiality was also sometimes found to be at risk due to misunderstandings caused by varying communication approaches, which could negatively impact doctors’ responses to EE practices. Nonetheless, analysis also revealed that some shared values and beliefs held by participants, along with heightened cultural awareness, seemed to have a positive impact on their responses to EE. Evidence suggests that some ethnic minority doctors can feel the need to perform well intrinsically and some doctors of Asian ethnicity gave greater emphasis to education as well as respecting the elderly and women. In both situations, a positive impact was found on their responses to EE. This study contributes to our knowledge and understanding of ethnicity, EE and the relationship between them. It identifies practical implications for managing EE of a multi-ethnic cohort of doctors working in English NHS hospital Trusts. It contributes to the ongoing endeavour of the NHS to maximise the benefits of ethnic diversity and addressing the challenges of integration along with identifying avenues for further research.