Listening well guidance

Publication reference: B1901

A blueprint for organisations to develop a local listening strategy


The People Promise provides a single unifying framework for us to talk about, understand, measure and improve employee experience across the NHS in England. This will help further improve the working lives of NHS people and support organisations in delivering the best possible care for patients.

Those best placed to say when progress has been made are our NHS people. Through national listening tools and developing robust listening strategies across organisations and systems, we aim to consistently understand and improve employee experience to make the NHS the workplace we all want it to be.

This document details the current landscape for listening to our people in the NHS, and how each vehicle for listening provides a complementary view of employee experience. It also proposes several ways that NHS trusts could expand on their approach to listening from local and national surveys through to staff networks and expert forums, using good practice from the NHS and private sector. Ultimately it provides a blueprint for organisations to lift and adapt to create their own listening strategies to ensure ‘We each have a voice that counts’.

1. Why is listening well important?

Why is now the right time to consider a holistic listening strategy?

The NHS is not alone in its desire to develop a more structured approach to listening to its employees.

Recent years have seen an increasing number of organisations realising the benefits of implementing more robust methodologies to gather the collective and individual views of their employees’ experiences and moving their listening and engagement programmes to a more structured format.

Annual surveys that measure employee engagement and its drivers continue
to be one of the most popular and robust modes of employee listening in understanding a collective view, but more organisations are combining their census with more frequent surveys, to realise the benefits of listening to employees more often. While the COVID-19 pandemic accelerated this trend, with organisations needing to ‘check in’ with employees on a more frequent basis, the drivers of more intentional listening are longer-term. CIPD (2022) recommends that organisations have holistic employee voice framework that combines individual and collective voice in order to improve working relationships.

The shift from once a year communication to the employee experience journey

Recent academic and business research has shown that, to build the highest-performing organisations, ‘employee communication’ is not enough.

To get the best patient care, organisations need to focus on broader aspects of the working experience such as enablement, intent to stay, inclusive culture, feeling recognised, feeling psychologically safe, growth and development, working as a team, and flexibility. The elements of the People Promise show what our NHS people believe will improve their working experiences. This calls for a different approach to employee listening, as these are best measured by more than a one-off annual survey.

Agility of understanding

Many organisations are transforming their strategy and processes to meet shifts in ways of working, either due to changes in flexible working, often accelerated by COVID-19, or longer-term trends such as increased automation, digitisation, or workplace transformation. Different ways of working are needed to meet our healthcare challenges and the requirements of the Long Term Plan.

Key to each of these shifts is the move towards being a more responsive organisation.

Employee listening is moving to reflect this shift, with more agile, data-led approaches combining with the use of advanced and predictive analytics. This is only possible when different data sources are integrated, leading to an increased demand for frequent, high-quality employee perception and behaviour data so organisations know how best to support employees throughout the year, placing this knowledge alongside regular financial and performance data collection.

The need to keep up with best practice and context

The employee listening space is moving quickly, with leading companies implementing multiple, advanced methodologies for capturing employee feedback. These use advanced analytics, integrating multiple metrics to predict future trends. As the benefits of this practice are becoming widespread, it is leading to the rapid expansion of best practice. Employee experience is not in isolation to the environment outside of work which has been changing rapidly – more regular listening helps to understand the impact on employee experience.

What are the key principles of an effective listening strategy?

Shifting to a more structured approach to listening will bring benefits.

These benefits will be amplified if the listening approach follows some best practice principles:

1. Credibility

Listening that enables regular insight with granular, statistically valid results for individual organisations but also at a national and regional level (such as the NHS Staff Survey)

2. Simplicity

Listening that reduces the burden locally by producing frameworks nationally that can be replicated and adapted – maximising specialist expertise – across organisations in England.

3. Actionability

Listening that always asks, ‘so what?’, to ensure any data or insights are actionable and used to inform the interventions of an organisation.

4. Relevance

Asking questions that add the most value to the NHS and employees, and are actionable by managers (where appropriate)

5. Rich

Research that doesn’t just provide answers to what employees are thinking, feeling, and doing, but also explains why they do so, making the insight more actionable.

6. Forward-looking

Insight that is focused on informing planning at a local level, helping organisations to create forward-looking operational plans. This allows consistent understanding to support system, regional and national understanding of employee experience to support improvement plans.

7. Feedback and involvement

Listening is important but it is only effective if employees feel heard. It is crucial to create a virtuous cycle of listening, involvement, action and feedback. Responding back to employees’ feedback creates a sense of being heard and involvement is a key sub theme to improve employee engagement.

What benefits does better listening bring?

The aim of any listening strategy should be to improve employee experience. Improvements in listening approaches can be linked with a range of benefits:

Employees feel more valued

By listening to employees, the organisation signals that their views and experience in the workplace are valid and important, particularly when the resulting insights drive action. This has significant impacts on perceptions of employee voice, empowerment, and a sense of feeling valued by their employer.

Gaining quantifiable intelligence

Listening surveys allow an organisation, team leaders and managers to understand the experience of their teams across all elements of our People Promise and identify issues such as emerging skills gaps, issues with burnout, wellbeing, and team culture. Crucially, it provides a sound evidence base for taking any remedial initiatives or action with confidence.

It is a great conversation starter

Sharing the results from listening with individual business areas or teams is a great way to start a discussion and collect ideas on what can be done to better the experience of employees.

Improved working experience

The more employees feel heard, the more connected they feel to the organisation. This leads to higher engagement and motivation which in turn leads to better retention and organisation performance (see case study 1).

Listening is important but it is only effective if employees feel heard. This means taking action on the back of listening and ensuring employees understand that the actions being implemented are based on the opinions and perceptions they shared.

When done effectively, this creates a virtuous cycle of listening and action, and leads to significant improvements in the overall employee experience. It also ensures that organisations do not start to suffer survey fatigue, which research defines as lower levels of engagement in colleagues who are asked their opinion frequently, but who see nothing change as a result.

What is the impact of a positive employee experience?

Listening and employee voice is a key pillar to improving employee engagement. Research specific to the NHS has demonstrated the relationship between employee engagement and improved patient outcomes. Engagement has been shown to have many significant associations with patient satisfaction, mortality rates, infection rates, employee absenteeism and turnover (West and Dawson, 2012; NHSE, 2020).

It is crucial for any listening strategy to address the entire employee experience and optimise listening across the employee lifecycle: candidate pre-hire experiences, employee onboarding experiences, employee development conversations, employee exit etc. In the NHS we can do this using the framework of the People Promise to consider the full breadth of experience and identifying targeted interventions to improve experience at work.

Wider research at Karian & Box has shown a tangible link between employee perception/behaviour and specific performance outcomes, including:

  • Employee sickness absence and attrition
  • Productivity
  • Customer satisfaction
  • Revenue.

Case study 1 – Global Financial Sector (FS) insurer

Line graph showing strong links between levels of employee engagement (such as pride, advocacy, satisfaction) and higher customer relationship scores. Research source is from the Global Financial Sector.
Research showed strong links between levels of employee engagement (pride, advocacy, satisfaction) and higher customer relationship scores.

Case study 2 – UK retailer

Bar chart showing leaders whose teams sat in the bottom quartile for team culture achieved lower commercial revenues than those in the top quartile scores. Research source is from a UK retailer.
Research showed leaders whose teams sat in the bottom quartile for team culture achieved lower commercial revenues than those in the top quartile scores.

In focus: to survey or not to survey?

One of the most significant trends in employee research in recent years has been the rise of big data analytics and machine learning.

This has led to a concurrent increase in organisations seeking to disrupt the employee research sector with new, algorithmic approaches to uncovering patterns of employee sentiment and behaviour; often using ambient or latent data sources. This has brought about a host of articles heralding (or questioning) the ‘death of the employee survey’. While these forms of analysis have significant power, our sense is the employee survey will form a significant part of any ongoing listening approach, for a few reasons:

Surveys are still great predictors of behaviour.

With the right question set, survey data can be used to build predictive or causative models of employee behaviour. A good example of this is questions related to intent to stay which, in the right format, have been shown to be highly predictive of actual attrition.

Surveys give employees the chance to feel heard.

There is strong evidence showing the impact of employee voice on wider employee engagement and advocacy. Surveys provide an efficient vehicle for this voice (though the positive impact relies on action being taken on the results of the research).

Surveys can, in themselves, be a vehicle for changing behaviour.

Several academic research studies point to the impact of being surveyed on later respondent behaviour, as questions can bring new concepts and lines of thinking to the awareness of respondents.

While there is undoubtedly the opportunity to improve and increase the use of ambient data within the NHS – a process that has been started with initiatives such as the Model Health System, surveys still sit at the heart of NHS England’s ongoing approach to listening well. Indeed, when combined with ambient data, the insight available from each source can be amplified further.

2. What is the approach in the NHS?

Survey landscape: national tools

The listening well guide looks at how the national tools can be integrated with local tools to create a cohesive approach to listening, understanding, and taking action to improve employee experience. Each national tool has a specific purpose and individual design:

NHS staff survey

Annually. (field-work Sep- Nov).

Hierarchy set at granular level.

Intense development of questions via academics, practitioners and cognitive testing.

Official statistic

Mandatory for all trusts to roll out. Open to all colleagues via individual URL (a set of eligibility criteria to protect data).

Aligned to the People Promise, it provides a rich and valuable source of data to support and inform continuous improvement and cultural change. The survey has the highest standards of quality and accuracy allowing organisational comparisons and trend data.

Long-er term plans of 3 to 5 years.

Weighted and standardised, national and local reports produced over 2 months for sound benchmark comparability.

Who uses the data
Local, regional national colleagues, and key data users such as: CQC, Pay Review Body, WRES, WDES, FTSU.

National Quarterly Pulse Survey

Quarterly (April, July, January).

Hierarchy set at organisational level.

Use of validated and correlated employee engagement questions.

Official statistic

Mandatory for all trusts to roll out. Open to all colleagues.

To provide insight into employee engagement across the NHS in England, more regularly and in a consistent approach, to support actions for improvement.

Short term plans, actions and decisions.

Reports are dependent on local method selected. National results available in third month of the quarter.

Who uses the data
Local, regional and national colleagues.

People Pulse

Monthly (frequency of use can be determined locally).

Hierarchy set at organisation level with breakdown into demographics. (optional local levels).

Robust core questions on employee experience, and flexible questions to provide an opportunity to deep dive.

Official statistic

Voluntary for organisations. Open to colleagues, at local choice.

To provide snapshot information of employee experience at a given time, concentrating on feeling informed, team support, feeling supported in health and wellbeing, and feedback to leaders.

Short term plans, actions and decisions.

Reports are available four working days after each survey wave closes via a dashboard. NHS average comparison available.

Who uses the data
Local, regional and national colleagues.

Introducing the NHS Staff Survey

The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year.
The survey is an official statistic and provides an accurate picture of what it’s like to work in the NHS, which is used by numerous different organisations to improve the working life of our NHS people.
It provides a rich and valuable source of data to inform continuous improvement and cultural change. The survey has the highest standards of quality and accuracy allowing organisational comparisons and trend data.

Each autumn over 1.3 million of our NHS people are invited to take part in the NHS Staff Survey, one of the biggest employee surveys in the world. The survey describes how people experience their working lives. Its strength is in providing a national picture alongside local detail, enabling employee voice to be heard, providing the data organisations need to improve employee engagement and track progress towards achieving great employee experience as described by the People Promise.

Data users include:

  • individual NHS trusts in England
  • regional employee experience experts
  • trust SMEs
  • NHS England
  • regional /integrated care system leads
  • Care Quality Commission
  • employee networks
  • LGBTQ+ networks
  • Workforce Race Equality Standard
  • Workforce Disability Equality Standard
  • Freedom To Speak Up and National Guardians Office
  • Social Partnership Forum
  • Temporary Employee team, Retention team
  • Patient Safety, Equality and Health Inequalities team
  • employee survey leads
  • Pay Review Body.

For the first time, in 2021 the questions were aligned with the People Promise to track progress against its ambition to make the NHS the workplace we all want it to be by 2024. The fieldwork for the NHS Staff Survey is carried out between September and November.

The Staff Survey Coordination Centre at Picker Institute Europe and the survey’s independent advisory group support NHS England with the implementation of the survey.

For the first time in 2022 eligibility to participate in the NHS Staff Survey has been extended to bank only workers in NHS organisations, using a tailored version of the survey. This enables more voices to be heard and contributes to understanding of experience of those who are play a vital role in the delivery of safe and effective patient care.

Introducing the People Pulse and National Quarterly Pulse Survey

The People Pulse comprises a monthly survey reported at monthly and quarterly intervals.

These are open links shared with NHS Trusts and include core questions, flexible questions, and engagement questions. Trusts can choose to use the People Pulse for the National Quarterly Pulse Survey or use their existing mechanisms and download the data as required.

Core questions:
These questions focus on elements of organisational and team support, feelings of anxiety, and communication:

  • My organisation is proactively supporting my health and wellbeing
  • I feel well informed about important changes taking place in my organisation
  • In my team we support each other
  • Overall, how anxious did you feel yesterday?
  • Mood and reason for mood
  • Open text to for feedback

Flexible questions:
Flexible questions differ by wave, and this is based on different elements of the People Promise, employee engagement or focus on specific initiatives happening within the NHS at the time. The development of questions is agreed through the People Pulse Advisory Group.

Employee engagement questions:
The employee engagement questions are asked three times a year as part
of the National Quarterly Pulse Survey requirements.

These are based on three sub-themes of engagement: motivation, involvement and advocacy:

  • Time passes quickly when I am working (motivation)
  • I look forward to going to work (motivation)
  • I am enthusiastic about my job (motivation)
  • There are frequent opportunities for me to show initiative in my role (involvement)
  • I am able to make improvements happen in my area of work (motivation)
  • I am able to make suggestions to improve the work of my team/department (motivation)
  • I would recommend my organisation as a place to work (advocacy)
  • Care of patients/service users is my organisation’s top priority (advocacy)
  • If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation (advocacy).

How do the People Pulse, National Quarterly Pulse Survey and the NHS Staff Survey complement each other?

The NHS Staff Survey is an annual, validated survey that provides a robust measure of employee experience, including the seven elements of the People Promise.

This enables more reliable peer group comparisons and provides a trend view of longer-term cultural change requirements for organisations’ strategic priorities. The People Pulse is a continuous, flexible survey with a greater focus on wellbeing.

As the People Pulse is also an official vehicle for the National Quarterly Staff Survey, it can be used to gain insight on in-focus topics in a timely fashion, but also to check direction of travel for employee engagement. This can provide tweak points to action plans stemming from the longer-term local people strategies.

Interlocking concentric circles representing the three national listening tools (including NHS Staff Survey, National Quarterly Pulse Survey, People Pulse) and how they work together with local listening tools to support cyclical listening.

National listening tools support cyclical listening

People Pulse Survey/National Quarterly Pulse Survey


  • More timely data that is better suited to monitoring what colleagues know and feel – as this changes quickly
  • Regular tracking allows early identification of trends
  • Understand the impact of change
  • Data available rapidly through online reports
  • Greater flexibility to add questions on more immediate business priorities
  • Local burden reduced by providing a national platform and process
  • Best practice harnessed and shared through national work.


  • Limited opportunity for coordinating participation and action planning
  • Lower response rates
  • Smaller sample size could limit reporting and analysis options
  • Shorter survey limits collection of optional demographics.

NHS Staff Survey


  • More robust data that allows more granular reporting and comparisons around organisational culture to support longer term strategic planning
  • Can coordinate communications to increase participation
  • Higher levels of statistical validity
  • Wider reporting available for directorate/teams
  • Built on a rigorous validated question set and handled to the quality of an Official Statistic.


  • Only reflects a single point in the annual cycle
  • Difficult to identify potential causes/reason for short-term movements
  • Fixed questions and long-term focus is slow to respond to change.

Blended approach


Robust and well-rounded process which allows:

  • Timely insights into key events
  • Regular tracking of sentiment
  • Builds on the annual survey actions and priorities
  • Flexibility to measure key priorities throughout the year
  • Robust quarterly / annual process for in-depth reporting
  • Enables informed business planning for implementing both long- and short-term initiatives
  • Progress supported nationally to reduce local burden.


Requires managers/leaders to continuously communicate and process insights into action for improvement.

In focus: supporting the national programme with local listening

While the nationally administered surveys provide an effective way for employees to have their say, effective voice is unlikely to result from top-down initiatives alone.

It will be key to ensure that wider local listening channels continue to be established and embedded at a Trust and directorate level. These can cover a number of interactions, including but not limited to:

New starter and exit surveys

Running focused research on employees soon after they join the NHS can identify gaps in onboarding experience and help to reduce new-joiner attrition.

Understanding why people leave is critical. Unhealthily high turnover leads to lower performance and increased cost. An exit survey can identify cultural drivers of attrition and drive remedial action.

Focus groups/team conversations

Surveys are, by their nature, diagnostic. They can be used to identify priorities for action and monitor change. They do not, on their own, provide deeper insights around why a problem exists or what the solution may be.

Focus groups and team-based conversation can help to provide the answers to questions which arise following insights from surveys. .

When twinned with ideation/co-creation activity, they also allow teams and local groups to improve perceptions of innovation, psychological safety, and collaboration.


One-to-ones give managers and employees a chance to talk about aspects of their experience that may be impacting motivation and satisfaction at work. They provide an opportunity for managers to build a trusting relationship with their direct report and show that their views and experience are important to the organisation, thus making them feel more valued.

Research conducted across a range of sectors has shown frequent, high-quality interactions between managers and their teams drives significant positivity in a number of areas; most notably, perceptions of career development and personal growth – these are key drivers of employee advocacy and engagement.

Conversations with FTSU Guardians

FTSU Guardians are available to support people to speak up when they feel unable to do so by other routes. They ensure that people who speak up are thanked, that the issues they raise are responded to and make sure that the person speaking up receives feedback on the actions taken. This feedback loop helps people to feel valued and encourages them to continue to engage with FTSU Guardians.

Patient feedback

Feedback from patients offers invaluable insights into their experience, be it positive or negative. This feedback helps organisations to learn from negative experiences and replicate good practice, helping improve both staff and patient experience. Evidence suggests that positive feedback has a positive impact on employees and can be maximised to improve recognition.

Locally identified effective ways of employee voice

Employee engagement and experience specialists in the NHS contributed their views at a national event in January 2022 where they listed the following listening initiatives which take place in their organisations:

  • Executive listening events – weekly, monthly, ad hoc
  • Executive ‘live’ briefings with Q&A opportunity
  • Schwartz rounds
  • ‘Ask the Exec’ sessions every week
  • ‘Meet the Exec’ sessions.
  • Freedom to Speak Up
  • Health and wellbeing
  • Employee engagement
  • Employee experience.
  • Closed Facebook group
  • Private trust app
  • Happy app
  • Online bulletins
  • Microsoft Teams listening events.
  • Drop-in sessions
  • A listening ear, on the ground conversations
  • Employee accessing clinical psychologist
  • Change agents talking to employees directly.
Local surveys
  • New joiner survey
  • Exit survey
  • Pulse surveys
  • Feedback surveys
  • Cultural barometer.
  • Staff networks
  • Staff forums
  • Listening events
  • Focus groups
  • Employee Voice forum
  • Team development sessions
  • Employee experience committee
  • Big conversations.

Next steps: building your organisation’s strategy

What stakeholders in local trusts can do to maximise the benefits of the new listening strategy

1. Organisational alignment

  • Build organisational intent by creating a document detailing the organisation’s listening approach – providing clarity across the organisation – utilising relevant information provided here.
  • Ensure the document is owned by senior leaders/board.
  • Ensure the information provided through the listening tools are aligned to key meetings, board meetings, performance meetings, to facilitate discussion and decision-making opportunities. This is significant if our NHS people are to see that their opinions count. This will help you select the regularity of ‘listening’ beyond yearly and quarterly and how local listening feeds into the governance structures.
  • Involve wider groups in the presenting and understanding of the data.

2. Building the insights

  • Build the narrative to increase understanding of what is being measured and how this helps organisations and employees.
  • Use survey data to identify, validate and course-correct areas of employee experience.
  • What is driving the results? Is it external context or internal activity?
  • Who is driving the results? What differences are there by population/demographic?
  • Why are the results the way they are? Are there consistent themes, or individual questions that seem pivotal?
  • How do leaders feel about the results? Comfortable? Disappointed? Proud? Do any of the results need a deeper understanding?

3. Engaging leaders

  • Build the story, backed by data from the surveys and other listening initiatives.
  • Where possible, enrich survey data with other operational data to provide context – eg patient feedback, involvement from staff networks.
  • Ask coaching questions that either allow leaders to reflect on current state, or move them to action:
    Action-oriented questions
    What will make the biggest difference to employees and their performance? Is that the same or different to what will make the biggest impact on Trust performance?
    What do we need to investigate further?
    What is so important we need to address it – no matter what resources are available?
    What would happen if we did nothing?
    What will success look like 12 months from now?
  • Share key findings and help explore insights, but don’t just ‘tell’ leaders what the insight says.
  • Facilitate discussion, providing your own reflections, but allow space for leaders to input their own reflections.
  • Start discussing what actions can be taken off the back of the results and who should be involved in this.

4. Keeping the conversation going

  • Plan check-ins: add conversations about surveys to weekly or monthly meeting agendas.
  • Use the calendar of activity (national NHS Staff Survey, National Quarterly Staff Survey, People Pulse) to plan for moments across the year where you can enrich the leadership discussion with employee data.
  • Review governance and decision-making timescales and regularity, so that insight is driving strategy, not missing the potential for discussion.
  • Bring in the right people: identify the right people to take actions forward or create small working group for each action.

Appendix: Methodology

NHS England (NHSE) have been working with industry experts Karian and Box to create a blueprint for employee listening in the NHS, as part of our wider support on the provision of listening tools.

The work has consisted of three phases:

Phase 1: Literature review

Focused desk research of existing information including documentation related to the NHS Staff Survey, People Pulse, National Quarterly Pulse Survey, People Promise, and NHS Long Term Plan and People Plan(s).

Phase 2: Stakeholder engagement

Ongoing engagement with Karian and Box with the core Staff Experience and Engagement (SEE) team, but also a wider range of People stakeholders through regular People Pulse Advisory Group (PPAG) meetings throughout 2021. In addition, a community of practice has been developed with almost 1000 contacts – if you would like to join this community of practice, register now.

Phase 3: Reporting and recommendations

This document comprises the synthesis of insights from the discovery and engagement process.

There is no one-size-fits-all approach to employee listening. We have tried to create a programme that matches up to what we have heard from trusts, and what reflects best practice elsewhere, but elements will be subject to ongoing validation and adaptation to create a plan that remains fit for purpose for each individual trust.

Our process in numbers

2 listening programmes assessed for best practice within other industries.

21 trusts represented in PPAG stakeholder meetings

1,000 community of practice members who have joined workshops and FutureNHS platform.

12 core SEE team review and Karian and Box industry experts.