Frequently Asked Questions

NHS DigiWell is a first-ever research study of communications intervention for NHS staff. The study is Health Research Authority (HRA) approved (22/HRA/372) and National Institute for Health and Care Research (NIHR) Clinical Research Network (CRN) adopted (HEAL 53838).

NHS staff are experiencing an increasing amount of stress when managing their emails (email technostress). NHSmail is used to communicate urgent and complex matters, including patient care tasks. Typically, staff have no dedicated time to read and respond to emails and meeting requests, leaving workers wrestling with these pressures alongside their daily roles, during break time and non-working hours for fear of jeopardising the delivery of patient care. Often this results in an inability to switch off and risk of burnout. To date, the 1.4 million healthcare workers in the NHS have no digital communications and wellbeing policy in place to help them navigate and regulate the demands of a full inbox.

The study was set up to determine the effectiveness of AirEmail, a new inbox and calendar management tool, developed for healthcare workers to make their work lives more sustainable and efficient.

NHS staff who are eligible to take part are invited to download the AirEmail tool in their NHSmail outlook. The study includes: a 2-week control period to gauge participants’ normal email usage without the AirEmail tool a 1-2-week onboarding period in which participants learn to use the tool (45 minutes training) a 4-week period when participants make use of AirEmail features as part of their daily work a 2-week after-study control period during which time participants do not use the add-on while email stats are collected. Only non-identifiable email use data are collected during the course of the study.

If you work for the study research site (currently Royal Free London NHS Foundation Trust and Royal National Orthopaedic Hospital NHS Trust) and meet the eligibility criteria, you are invited to take part in the study. To find out if you’re eligible, click Participate under the Sign Up section below.

Work-related communication volume within the United Kingdom’s National Health Service (NHS) has had little systematic research previously. The impact of communication volume on work-life balance of healthcare staff in the NHS is also not known and has not been an area of focus or governance. COVID-19 led to a shift to non-physical work, with greater reliance on digital communication for clinical decision making. We sought to elucidate the relationship between communication, work-life balance, and COVID-19. An online survey was conducted to assess the platforms used to communicate professionally, the volume of and time spent on work-related communications, how this has changed from before to during COVID-19, and the effect on work-life balance. 3047 healthcare staff provided consent and evaluable data. Emails were reported as the most frequently used communication tool, and the majority of staff asked, reported increased work-related communications due to COVID-19. Staff estimated receiving 14 emails on an average day before COVID-19. During the pandemic, staff estimated getting approximately 17 emails on an average day and 29 emails on a busy day. Work communications reportedly took up increased amounts of family and home time during COVID-19. A large proportion of staff were unable to switch off from work-related communications already before COVID-19, worsening during the pandemic. Work-related digital communication is a vital component of working in the NHS. We provide the first detailed data on the types, volume, and impact of such communication on NHS staff during the COVID-19 pandemic, compared to pre-pandemic levels. We found that 82% of staff support needing NHS guidance on work-related communications to help manage overload, protect emotional wellbeing, and increase resilience. Further work is urgently needed in this area to tackle the negative impact of communication technologies on work-life balance to reduce staff stress, burnout, and turnover on some staff.

On 30thJanuary 2020, the World Health Organisation declared a public health emergency of international concern in relation to the COVID-19 outbreak in China (World Health Organisation, 2020). The National Health Service (NHS) declared an internal Level 4 serious incident and commenced preparations. On 17th March, all NHS Trusts were instructed by the NHS Chief Executive and Chief Operating Officer to take immediate measures for reducing the spread of the virus and to prepare for an imminent surge of COVID-19 patients. This resulted in an unprecedented shift across all aspects of healthcare services to streamline efforts and optimise management of COVID-19 patients (Belkin, Becker & Conroy, 2020; Stevens & Pritchard, 2020). For many healthcare staff, this meant a notable overhaul of work patterns, as well as redeployment to emergency rotas in areas of urgent need. Many staff returned to frontline clinical duties from academia, research, or retirement (Blake et al., 2021). Conversely, some staff became unavailable for frontline clinical duties as they were unwell, shielding, or self-isolating. Remote working increased, minimising face-to-face contact with patients, relatives, and other staff (Wang & Low, 2019; Hutchings, 2020). Effective communication is a key domain of good clinical practice for doctors, nurses, managers, and all health professionals in the NHS (General Medical Council, 2019). Staff in the NHS often work in multidisciplinary or multi-agency teams, communicating with team members, other professionals involved in providing care, and with patients and their relatives or advocates (The King’s Fund, 2019; Dettmers et al., 2016; Iliffe 2008). Agile communication is paramount in crisis situations to co-ordinate a service under pressure, such as tracking patient capacity, coordinating movements of patients, coordinating staffing, or providing staff and leadership briefings (Hutchings et al., 2021; Skryabina et al., 2021). Instant messaging applications, particularly WhatsApp, are common in clinical practice (Morris, Scott, and Mars, 2021) and enhance communication during emergencies where rapid coordinated response is vital (Skryabina et al. 2021; Nikolic et al., 2017). Conversely, ineffective communication is associated with low staff morale, poor patient experience, adverse patient outcomes and increases staff stress and burnout rates (Patel et al., 2018; Nohammer & Stichlberger, 2019). Digital communication has been recognised as an important area of ‘technostress’, that is, a cause of workplace stress arising from the digitisation of work (Tarafdar et al., 2010). Excessive email communication has also been noted to be associated with a sense of being overwhelmed, which can lead to sub-optimal self-rated health, cognitive disturbances, and symptoms of burnout (Stich et al., 2018; Puranik et al., 2019, Marsh, Vallejos, and Spence, 2020). Higher email load (Stich et al., 2019), demands to reply rapidly (Becker et al., 2019), and organisational norms and expectations to monitor email in non-work hours (Gadeyne, 2018; Waldhouser, 2019) have been found to be associated with higher levels of stress. We set out to examine work-related communication and its relationship to the work-life balance of healthcare workers, aiming specifically to determine the impact of the COVID-19 pandemic. On 30thJanuary 2020, the World Health Organisation declared a public health emergency of international concern in relation to the COVID-19 outbreak in China (World Health Organisation, 2020). The National Health Service (NHS) declared an internal Level 4 serious incident and commenced preparations. On 17th March, all NHS Trusts were instructed by the NHS Chief Executive and Chief Operating Officer to take immediate measures for reducing the spread of the virus and to prepare for an imminent surge of COVID-19 patients. This resulted in an unprecedented shift across all aspects of healthcare services to streamline efforts and optimise management of COVID-19 patients (Belkin, Becker & Conroy, 2020; Stevens & Pritchard, 2020). For many healthcare staff, this meant a notable overhaul of work patterns, as well as redeployment to emergency rotas in areas of urgent need. Many staff returned to frontline clinical duties from academia, research, or retirement (Blake et al., 2021). Conversely, some staff became unavailable for frontline clinical duties as they were unwell, shielding, or self-isolating. Remote working increased, minimising face-to-face contact with patients, relatives, and other staff (Wang & Low, 2019; Hutchings, 2020). Effective communication is a key domain of good clinical practice for doctors, nurses, managers, and all health professionals in the NHS (General Medical Council, 2019). Staff in the NHS often work in multidisciplinary or multi-agency teams, communicating with team members, other professionals involved in providing care, and with patients and their relatives or advocates (The King’s Fund, 2019; Dettmers et al., 2016; Iliffe 2008). Agile communication is paramount in crisis situations to co-ordinate a service under pressure, such as tracking patient capacity, coordinating movements of patients, coordinating staffing, or providing staff and leadership briefings (Hutchings et al., 2021; Skryabina et al., 2021). Instant messaging applications, particularly WhatsApp, are common in clinical practice (Morris, Scott, and Mars, 2021) and enhance communication during emergencies where rapid coordinated response is vital (Skryabina et al. 2021; Nikolic et al., 2017). Conversely, ineffective communication is associated with low staff morale, poor patient experience, adverse patient outcomes and increases staff stress and burnout rates (Patel et al., 2018; Nohammer & Stichlberger, 2019). Digital communication has been recognised as an important area of ‘technostress’, that is, a cause of workplace stress arising from the digitisation of work (Tarafdar et al., 2010). Excessive email communication has also been noted to be associated with a sense of being overwhelmed, which can lead to sub-optimal self-rated health, cognitive disturbances, and symptoms of burnout (Stich et al., 2018; Puranik et al., 2019, Marsh, Vallejos, and Spence, 2020). Higher email load (Stich et al., 2019), demands to reply rapidly (Becker et al., 2019), and organisational norms and expectations to monitor email in non-work hours (Gadeyne, 2018; Waldhouser, 2019) have been found to be associated with higher levels of stress. We set out to examine work-related communication and its relationship to the work-life balance of healthcare workers, aiming specifically to determine the impact of the COVID-19 pandemic.

A request under the Freedom of Information Act (FOIA) 2000 was made to NHS Digital, a body responsible for the operation of NHSmail, to obtain data on the volume of emails sent from/to nhs.uk addresses in the period November 2019 to May 2020. The self-reported volume of emails received by the survey respondents was extrapolated into an estimate of the total monthly email volume received by NHSmail users and compared with the actual total as reported by the NHS Digital FOIA response (NHS Digital 2020), dated 10th July 2020 for the month of November 2019. A request under the Freedom of Information Act (FOIA) 2000 was made to NHS Digital, a body responsible for the operation of NHSmail, to obtain data on the volume of emails sent from/to nhs.uk addresses in the period November 2019 to May 2020. The self-reported volume of emails received by the survey respondents was extrapolated into an estimate of the total monthly email volume received by NHSmail users and compared with the actual total as reported by the NHS Digital FOIA response (NHS Digital 2020), dated 10th July 2020 for the month of November 2019.

Sponsored by the Royal Free London NHS Foundation Trust, the survey was conducted using the QualtricsXM online survey platform (Qualtrics XM, 2022), made available via desktop and optimised for Smartphone access. A secondary website was licenced via the Jisc Research Surveys (Jisc Online Surveys, 2022) website for users unable to access the Qualtrics platform for any reason. The survey opened on 21st May 2020. All NHS organisations included in the National Directory of NHS Research Offices maintained by the NHS Research and Development (R&D) Forum were invited to take part in the study. 10 NHS Trusts issued survey permission and distributed the study invite to their staff, with other organisations still processing permission at the time of survey closure. Some Trusts used an internal internet advert, whilst others included the invitation in regular executive updates to all staff. An invite was also sent to the members of the UK Research and Development Directors (UKRD) forum – a body representing UK NHS R&D leaders.

The initial sample size of 400 participants was informed by the limited body of research on work-related communication surveys. The sample size was considered significant compared to Barber, Conlin and Santuzzi (2019), who surveyed 254 respondents in their survey of telepressure. However, as further NHS Trusts were issuing permissions and distributing the survey to their staff, the types of centres and roles represented were expanding. Therefore, the survey was kept open to collect additional data and allow the more recently invited staff to participate, such as staff from mental health trusts and ambulance trusts. After 30 days, an interim analysis using a temporal analysis by tertiles was conducted in order to confirm data saturation. The analysis data to be similar between the first, second and third thousand respondents except for COVID-19 exposure patterns. Over time, data show a slight increase in staff working part time from 18.7% to 21.4%, and remotely from 21.5% to 27.3%. An increase from 19.2 to 25.9% was seen in reported frequency of physical exposure to patients with COVID-19 across the survey period. Other data were stable, and respondents included hospital trusts, community trusts, mental health trusts, and ambulance trusts. Academic locations and GP practices were slightly less represented as these organisations took longer to approve this form of research and share the survey links internally. As further insights were unlikely, and we did not wish to cause further survey distraction to staff during the pandemic, the survey was closed on 19th June 2020.