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The impact of high turnover and burnout among behavioral health's clinical workforce (clinicians)

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The impact of high turnover and burnout among behavioral health's clinical workforce (clinicians)

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THE IMPACT OF HIGH TURNOVER AND BURNOUT AMONG BEHAVIORAL
HEALTH’S CLINICAL WORKFORCE (CLINICIANS)

by
Yvonnia Brown
___________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2020

Copyright 2020 Yvonnia Brown

ii

DEDICATION
I am dedicating this dissertation to a close friend who inspired me to embark on this
educational journey. Unfortunately, she was unable to complete the journey with me because she
lost the fight against cancer. Even though, she is in a better place, we both were looking forward
to celebrating this momentous occasion together; however, life had a different plan.
Nevertheless, I am extending my love and gratitude to her with the dedication of this research
study and doctoral degree to my dear friend, Chandra C. Jackson “Chan.”
LOVE YOU!

iii

ACKNOWLEDGMENTS

First, I want to give honor and praise to God because without Him, this major milestone
in my life would not have been achieved, so I am eternally grateful to Him. However, there are a
few individuals to whom I owe a debt of gratitude, because of their support and encouragement
through this educational journey; I am receiving this prestigious doctoral degree. This being said,
I would also like to thank all of the employees who participated in the study, as well as the
organization that allowed me the opportunity to study their site. Furthermore, I would like to
thank my fellow cohort (Cohort 10) and faculty at the University of Southern California, Rossier
School of Education for the professional and academic expertise you brought to this learning
experience, which has transcended my knowledge and analytical thought process.
In addition, I would like to thank my committee; Dr. Kenneth Yates, Dr. Themistocles
Sparangis, and Dr. Mary Andres. I appreciate the support and guidance you provided during this
educational experience. Because of your guidance and expertise, I completed my dissertation
and successfully defended my research. I am extremely grateful to Dr. Yates especially, for the
support and guidance he provided during my academic journey. It was a journey, but his
experience and knowledge helped me to stay grounded. So, I just want to say, Thank You.
Finally, I want to thank my family and friends for taking this journey with me over the
last two and a half years. Especially when I lost a close friend to cancer unexpectedly. Your
prayers, encouragement and support helped me to keep moving forward.
Undoubtedly, your support and motivational speeches contributed to my successful
graduation from this doctoral program. Indeed, words cannot describe how much I love you and
appreciate you for being a part of this journey. Love You All!

iv

TABLE OF CONTENTS
Dedication........................................................................................................................................ii
Acknowledgements........................................................................................................................iii
List of Tables................................................................................................................................viii
List of Figures..................................................................................................................................x
Abstract……...................................................................................................................................xi
Chapter 1: INTRODUCTION..........................................................................................................1
Introduction to the Problem of Practice.....................................................................................1
Organizational Context and Mission ........................................................................................2
Organizational Performance Goal ……………………………………………………………3
Importance of the Organizational Evaluation............................................................................4
Related Literature.......................................................................................................................4
Description of Stakeholder Groups............................................................................................6
Stakeholders' Performance Goals..............................................................................................6
Stakeholder Group for the Study ..............................................................................................7
Purpose of the Project and Questions .......................................................................................7
Definitions.................................................................................................................................8
Organization of the Study..........................................................................................................9
Chapter 2: REVIEW OF THE LITERATURE..............................................................................10
Turnover and Burnout among Clinicians.................................................................................10
Workforce stability ............................................................................................................. 11
Intrinsic and extrinsic influences……………………………………………………….….12
Organizational factors ……………………………………………………………………. 14
Consequences for lack of engagement …………………………………………………….15
Job Satisfaction........................................................................................................................16
Autonomy and inclusion influences......................................................................................16
Consequences for poor job satisfaction................................................................................18
Factors that influence job satisfaction..................................................................................19
Organizational Culture and Leadership...................................................................................21
Organizational culture influences on employee satisfaction................................................21
Leadership style and role effects on employee engagement............................................... 22
Organizational commitment influence on job satisfaction and engagement……………....23

v

The Clark and Estes Gap Analysis Conceptual Framework......................................................25
Knowledge and Skills ............................................................................................................ 26
Knowledge influences......................................................................................................... 31
Motivation.............................................................................................................................. 31
Expectancy value theory......................................................................................................32
Emotions ………………………………………………………………………………….33
Self-efficacy theory.............................................................................................................35
Attribution theory…………………………………………………………………………36
Organization.......................................................................................................................... 38
General organization theory............................................................................................... 38
Cultural models.................................................................................................................. 39
Cultural settings...................................................................................................................40
Conceptual Framework ……………………………………………………………………..45
Chapter 3: METHODOLOGY ....................................................................................................49
Introduction to the Methodology ...........................................................................................50
Sampling and Recruitment......................................................................................................51
Participating Stakeholders ...................................................................................................51
Survey Sampling Strategy, Criteria, and Rationale..............................................................52
Criterion 1. Job classification and educational level.........................................................52
Criterion 2. Role and responsibilities................................................................................52
Interview Sampling Criteria and Rationale..........................................................................53
Criterion 1. Clinical workforce..........................................................................................53
Interview Sampling and Recruitment Strategy and Rationale .............................................54
Data Collection and Instrumentation ......................................................................................54
Surveys...............................................................................................................................55
Interviews.......................................................................................................................... 62
Data Analysis.................................................................................................................... 62
Credibility and Trustworthiness..............................................................................................62
Validity and Reliability.....................................................................................................64
Ethics.................................................................................................................................64
Limitations and Delimitations.......................................................................................... 66

Chapter 4: RESULTS AND FINDINGS......................................................................................67
Participating Stakeholders...................................................................................................... 68
Survey Participants .......................................................................................................... 68
Interview Participants....................................................................................................... 71
Results and Findings............................................................................................................... 71
Knowledge........................................................................................................................ 71

vi

Declarative and conceptual knowledge about professional expectations...................... 71
Metacognitive knowledge...............................................................................................73
Motivation......................................................................................................................... 74
Value ……………………............................................................................................. 74
Self-efficacy................................................................................................................... 76
Emotions…….................................................................................................................77
Attribution……...............................................................................................................79
Organization.......................................................................................................................80
Organization culture.....................…….......................................................................... 80
Supportive and collaborative environment.....................................................................82
Shared decision-making, communication, and transparency..........................................83
Staff development ……………………………………………………………………..85
Summary of Validated Influences.....................................................................................87
Chapter 5: DISCUSSION AND RECOMMENDATIONS ..........................................................89
Introduction and Overview......................................................................................................89
Recommendations for Practice to Address KMO Influences..................................................89
Knowledge Recommendations .........................................................................................89
Metacognitive knowledge solutions.............................................................................. 90
Declarative knowledge solutions…................................................................................91
Motivation Recommendations....................................................................................…...92
Increase clinician’s sense of value…..............................................................................94
Increasing the emotions of clinicians…………………..………………...……….……95
Increasing self-efficacy of clinicians..............................................................................96
Increasing clinicians’ attribution …………….………………………..………….….. 97
Organization Recommendations....................................................................................... 98
Cultural model: trust and shared values……............................................................... 100
Cultural model: supportive and collaborative ............................................................. 101
Cultural setting: shared decision-making and transparency ........................................ 102
Cultural setting: strategic roadmap (plan) ....................................................................103
Integrated Implementation and Evaluation Plan..............................................................104
Implementation and Evaluation Framework............................................................. 104
Organizational Purpose, Need, and Expectations..................................................... 105
Level Four: Results and Leading Indicators............................................................. 105
Level Three: Behavior ............................................................................................. 108
Critical behaviors................................................................................................... 108
Required drivers..................................................................................................... 109
Organizational support ..........................................................................................111
Level Two: Learning...............................................................................................112
Learning goals.........................................................................................................112
Program...................................................................................................................112

vii

Components of learning..........................................................................................114
Level One: Reaction .................................................................................................115
Evaluation Tools........................................................................................................115
During and immediately following the program implementation ........................ 115
Delayed for a period after the program implementation.........................................116
Data Analysis and Reporting ....................................................................................116
Summary ……………………………………………………………………………….117
Strengths and Weakness …………………………………………………………….....117
Limitations and Delamination …………………………………………………………118
Future Research ………………………………………………………………….…….119
Conclusion ......................................................................................................................120
References…................................................................................................................................122
Appendices ……………………………………………………………………………………..136
Appendix A Survey Protocol.......................................................................................... 136
Appendix B Focus Group Protocol..................................................................................140
Appendix C Informed Consent for Non-Medical Research .......................................... 142
Appendix D Information/Facts Sheet for Exempt Non-Medical Research ....................144
Appendix E Blended Evaluation Tool............................................................................ 147
Appendix F Evaluation Tool ………………………………………………………….. 148

viii

LIST OF TABLES
Table 1 Stakeholder Goals............................................................................................................ 06
Table 2 Knowledge Influences .................................................................................................... 30
Table 3 Motivation Influences...................................................................................................... 37
Table 4 Organizational Influences................................................................................................ 42
Table 5 Assumed KMO influences, data collection and instruments……………………………56
Table 6 Survey Population by Age……………………………………………………………... 69
Table 7 Number of Years Employed with the Agency ………………………………………….70
Table 8 Survey Result for Declarative Knowledge of Patient Care Influences ………………....72
Table 9 Survey Result for Metacognitive Knowledge of Stress Management Techniques……..73
Table 10 Survey Result for Value Influences ………………………………………………….. 74
Table 11 Survey Result for Self-Efficacy Influences…………………………………………... 76
Table 12 Survey Result for Emotion Influences………………………………………………... 78
Table 13 Survey Result for Attribution Influences ……………………………………………...79
Table 14 Survey Result for Cultural Models 1 Influences ……………………………………...81
Table 15 Survey Result for Cultural Models 2 Influences………………………………………82
Table 16 Survey Result for Cultural Settings 1 Influences………………………………………84
Table 17 Survey Result for Cultural Settings 2 Influences………………………………………85
Table 18 Knowledge Assets or Needs as Determined by the Data………………………………87
Table 19 Motivation Assets or Needs as Determined by the Data……………………………....87
Table 20 Organizational Assets or Needs as Determined by the Data…………………………..88
Table 21 Summary of Knowledge Influences and Recommendations………………………….90
Table 22 Summary of Motivation Influences and Recommendations…………………………..93

ix

Table 23 Summary of Organization Influences and Recommendations...………………………98
Table 24 Outcomes, Metrics, and Methods for External and Internal Outcomes……………... 106
Table 25 Critical Behaviors, Metrics, Methods, and Timing for Evaluation…………………..108
Table 26 Required Drivers to Support Critical Behaviors…………………………………….. 109
Table 27 Evaluation of the Components of Learning for the Program………………………... 114
Table 28 Components to Measure Reactions to the Program ……………………………….....115

x

LIST OF FIGURES
Figure 1 Conceptual Framework: Interaction of Stakeholder Knowledge and Motivation within
Organizational Cultural Models and Settings ............................................................................. 45
Figure 2 Survey Population by Gender .................................................................................…...69
Figure 3 License and Program Areas …………………………………………………………...70
Figure 4 Sample Dashboard Reports …………………………………………………….…….116

xi

ABSTRACT
The purpose of the study was to evaluate the impact of high turnover and burnout among
behavioral health's clinical workforce (clinicians) and strategies for improvement at Trident
Behavioral Health (TBH) (a pseudonym). The stakeholders of focus for this case study were
clinicians who provided direct services (therapy) to individuals with serious mental issues (SMI).
The study collected and analyzed data about the knowledge, motivation, and organizational
causes that prevent TBH’s ability to effectively reduce burnout and turnover among clinicians by
applying the Gap Analysis framework (Clark & Estes, 2008). A mixed-method approach was
used to collect survey data from 24 participants, along with responses from phone interview
participants. This approach was instrumental in identifying and validating the knowledge,
motivation, and organizational root causes for high turnover and burnout among the clinical
workforce. Based on the findings, solutions drawn from the research literature are accentuated in
this study. In addition, this study, along with its concurrent studies, demonstrates how various
stakeholders can systematically apply the Gap Analysis framework, as well as creating a
collaborative work culture (inclusion and shared vision) can influence staff turnover, burnout,
and improve employee satisfaction and retention. Finally, the Kirkpatrick and Kirkpatrick (2016)
Four Levels of Evaluation was used to create an implementation and evaluation plan to measure
the effectiveness of the solutions.

1

CHAPTER ONE: INTRODUCTION

Introduction to the Problem of Practice
This study addresses the problem of high turnover and burnout among behavioral health
professionals in the public sector. The United States Bureau of Labor Statistics (2017,
September) forecasted the turnover rate in the addictive services workforce ranged from 18.5%
to over 50% in 2012. The evidence highlighted in the Job Openings and Labor Turnover Survey
(JOLTS, 2013) suggested the annual national turnover rate among all industries was 23%, and
within the category of health care, it was 19%. This problem is critical to address because
turnover can contribute to a reduction in productivity and performance, poor patient outcomes
and job satisfaction, and burnout (Van-Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015)
In 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA)
conducted a study that revealed a turnover rate of 33.2% for counselors and 23.4% for clinical
supervisors (SAMHSA.gov). Recent studies suggested that high turnover and compassion fatigue
influenced patient care and outcomes, and staff quality of life (QoL). Behavioral health
professional's quality of life (QoL) can be compromised, resulting in adverse psychological
implications (depression and anxiety), secondary traumatic stress, chronic sickness
(hypertension, heart disease, and diabetes). Additional results include family dysfunctionality
due to lack of parental engagement resulting from consistent exposure to trauma patients
(Brandt, Bielitz, & Georgi, 2016; Haik, Brown, Liran, Visentin, Sokolov, Zilinsky, & Korhabar,
2017).

2

Organizational Context and Mission Proposed Project Site
Research studies revealed that behavioral health professionals' quality of life (QoL) is
influenced by job satisfaction and work environment (Brandt, Bielids, & Georgi, 2016).
To evaluate and analyze local implications of high turnover and burnout among public health
clinical professionals, Trident Behavioral Health (TBH), located in Piedmont, California, was
studied [a pseudonym]. This organization has been providing community behavioral health
services since 1960. According to the organization's website, its mission is to embrace and
recognize the needs of consumers and families. Secondly, they also aim to provide high quality
and culturally responsive services to their diverse communities. Lastly, the core values and
fundamental principles that guide the work and motivate the workforce are client and family-
centered services, strength-based approaches, researched and data-driven decision-making, and
being respectful, accessible, and accountable.
The 2010 U.S. Census reported there are approximately 220,000 residents that reside in
Piedmont, California region, and demographics are: 57% of the population is Latino, 26% is
White, 9% is Asian Pacific Islander, 6% is African American, 2% is multiracial and less than one
percent is American Indian. Forty-three percent of the population has an income that is less than
200% of the federal poverty threshold. Roughly, 48% of the population speaks monolingual
English, while 42% speak Spanish as the primary language at home. Another 6.7% speak an
Asian Pacific Islander language as the primary language, and 3.5% of the population speaks a
language other than the ones already named. Finally, 49% percent of the population is male, and
51% is female. Currently, TBH has over two hundred professionals and paraprofessionals that
provide direct or indirect services to persistently or seriously mentally ill (PSMI/SMI)
individuals and their families (agency website, 2017).

3

Organizational Goal
Prior to 2013, Trident Behavioral Health (TBH) met or exceeded the Department of
Health Care Services' standard-based performance benchmarks. As a result of the new state and
federal mandates imposed on the behavioral health organizations; directors and staff are under
extreme pressure from local and state officials to perform, due to penalties and fines associated
with not meeting the performance standards. Due to these pressures, agencies across California
experienced high turnover and burnout among the clinical workforce and agency directors.
Unfortunately, TBH was not exempt from experiencing high turnover and burnout among their
clinical workforce. According to authors Bakker and Nijkamp (2015), staff turnover and burnout
are essential to address, because it can lead to poor performance outcomes and job satisfaction,
and it ultimately influences patient care.
Therefore, TBH administration established an organizational goal to reduce staff turnover
by 30% before August 31, 2021. The TBH Director and Board of Directors established this goal
six months ago during their Annual Executive Leadership Retreat. As a result, the organization
secured a change management firm to facilitate a department-wide infrastructure and system re-
engineering process. During the re-engineering process, staff and managers were interviewed
and surveys completed, which was designed to determine the causal influences for staff turnover
and to solicit system improvement strategies. Then, community stakeholders and partners from
the private and public sectors participated in key-informant and focus groups, which was
designed to glean their perspective on what areas within the behavioral health system need
improvement.

4

Importance of the Evaluation
The problem of high turnover and burnout among behavioral health professionals is vital
due to the negative influences of job satisfaction, staff performance, and productivity, and lost
revenue on patient outcomes (Van-Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015).
According to Josh Bersin, the founder of LinkedIn, the total cost of losing an employee can
range from tens of thousands of dollars annually, and many factors determine that cost. For
instance, the cost includes hiring a new person (advertisement and recruitment), cost of
onboarding (training and management time), and lost productivity and parental engagement. In
the healthcare system, high error rates and absentee costs can range from 20 to 30% of staff
annual salary (Bersin, 2013).
Relevant Literature
Numerous studies have suggested that high turnover and compassion fatigue has
influenced patient care and outcomes, and staff quality of life (QoL) (Brandt, Bielitz, & Georgi,
2016; Haik, Brown, Liran, Visentin, Sokolov, Zilinsky, & Korhabar, 2017). According to the
authors, behavioral health professional's quality of life (QoL) can be compromised, resulting in
adverse psychological implications (depression and anxiety), secondary traumatic stress, chronic
sickness (hypertension, heart disease, and diabetes) and family dysfunctionality due to lack of
parental engagement resulting from consistent exposure to trauma patients (Brandt, Bielitz, &
Georgi, 2016; Haik et al., 2017). Cooker and Joss's (2016) study affirms that high prevalence and
persistent and extreme exposure to trauma victims increased turnover and compassion fatigue
(CF), and also influences the physical and emotional well-being of healthcare professionals. The
authors also emphasize that healthcare professionals, emergency, and community social workers
are at risk of debilitating depression, anxiety, and post-traumatic stress disorder (PTSD) (2016).

5

Ultimately, the exposure to trauma among healthcare professionals increased absences,
psychological injury claims, reduced job satisfaction, and productivity (2016). Acker (2012)
affirms that mental health providers who are regularly exposed to individuals with serious mental
illness (i.e., bipolar and schizophrenia) have higher turnover rates, burnout, and stress levels, and
are more emotionally exhausted, compared to other mental health providers.
Subsequent multivariate analyses suggested that other work-related stressors such as non-
supportive work environments and non-supportive executive leadership are the best predictors
contributing to staff distress and high turnover (Devilly, Wright & Varker, 2009). While other
researchers yield the same results, they also concluded that low levels of trust among co-workers
and leadership are prognosticators of high levels of compassion fatigue and turnover among
behavioral health professionals (Cetrano, Tedeschi, Rabbi, Gosetti, Lora, Lamonaca, Manthorpe,
& Amaddeo, 2017; Acker, 2012). Additional studies emphasized the importance of positive and
supportive work environments that promote professional development and continuing
educational opportunities, positive reinforcements, and bi-directional communications, to
produce higher performance outcomes and lower turnover rates and burnout (Acker, 2012).
Furthermore, studies suggested that mental health organizations that provide
employees with adequate ergonomic conditions, career development opportunities, and foster a
work culture of trust and teamwork are essential elements to reducing staff turnover, burnout,
compassion fatigue, and improving employee engagement and productivity (Cetrano, Tedeschi,
Rabbi, Gosetti, Lora, Lamonaca, Manthorpe, & Amaddeo, 2017). The authors also emphasized
that organizations that fail to implement internal environmental changes to mitigate staff
turnover, burnout, and compassion fatigue could have devastating consequences to patient
outcomes and staff mental health (Cetrano et al., 2017). Coincidentally, Bakker and Demerouti

6

(2007), reaffirm the importance of organizations establishing internal or external programs that
promote self-care and wellness such as wellness and exercise programs, employee assistance
programs, discounted gym memberships in order to reduce the adverse effects of turnover and
burnout among mental health professionals.
Description of Stakeholder Groups
The identified stakeholder groups that will contribute to and benefit from accomplishing
the TBH organizational goal are the clinicians and administration. These two key stakeholders
will contribute to the success of the organization's performance goal by providing feedback
regarding the reasons for the high turnover rate among clinicians and by providing solutions. The
first stakeholder group is 54 licensed clinicians, and their participation includes completing job
satisfaction surveys and taking part in face-to-face interviews. The second stakeholder group is
the TBH Administration, which consists of the agency director, deputy directors, administrators,
and clinical supervisors. Their involvement includes using the results from the data collection
methods to develop a strategic plan to improve employee job satisfaction and engagement.
Stakeholder Groups' Performance Goals
Table 1.

Organizational mission, global goal, and stakeholder performance goals

Organizational Mission
Trident Behavioral Health's mission is to embrace and recognize the needs of consumers and
families. Secondly, they aim to provide high quality and culturally responsive services to their
diverse communities. Lastly, their core values and fundamental principles that guide the work
and motivate the workforce are client and family-centered services, strengthened-based
approaches, researched and data-driven decision-making, and being respectful, accessible, and
accountable (agency website, 2018).

Organizational Performance Goal
Trident Behavioral Health's (TBH) organizational goal is to reduce staff turnover by 30% before

7

August 31, 2021.

TBH Clinical
Workforce
The director supports
the stakeholders' goal
that 95% of the clinical
workforce was
satisfied with their
employment at TBH.
Administration or Consultant
By July 2019, 30% of TBH clinical
workforce was interviewed face-to-
face to evaluate the reason(s)
Children System of Care (CSOC)
turnover rate (10%) is much lower
compared to the Adult System of
Care (ASOC) (38%).
Director
By December 2019, TBH
Director, along with critical
internal and external
stakeholders will develop a
strategic plan to improve staff
engagement and job
satisfaction, thereby reducing
turnover by 30% by August
2021.

Stakeholder Group of Study
All stakeholders would contribute to the overall organizational goal, which is to reduce
the turnover rate by 30% before August 31, 2021. It is equally important to evaluate the status of
the TBH performance goal. Therefore, the focus in this study was all TBH clinical workforce
(clinicians and immediate supervisors). The director supports the stakeholders' goal that 95% of
the clinical workforce is 100% satisfied with their employment at TBH. Failure to accomplish
this goal will lead to continued poor employee satisfaction and retention, burnout, compassion
fatigue, loss of productivity (revenue), and poor patient outcomes.
Purpose of the Project and Questions
This project will evaluate the degree to which Trident Behavioral Health is meeting its
organizational goal of reducing its turnover rate by 30%. The analysis will focus on knowledge,
motivation, and organizational influences related to achieving this organizational goal. While a
complete performance evaluation would focus on all TBH's stakeholders, for practical purposes,
the stakeholder focus for this analysis was clinicians.
As such, the questions that guide this study are the following:
1. To what extent is Trident Behavioral Health meeting its goal to reduce the department's
turnover rate by 30% before August 31, 2021?

8

2. What are the stakeholder knowledge and motivation related to achieving this stakeholder
goal, that is, 95% of the clinical workforce is 100% satisfied with their employment at
TBH?
3. What is the interaction between organizational culture and context and stakeholder
knowledge and motivation?
4. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Definitions
The following words and terms appear throughout the remainder of this study. As such,
the definitions and citations from relevant literature explain their meaning as
utilized within this study. Although individual terms may adopt different meanings or
applications in other works based upon the context, the list provided outlines those terms
deemed pertinent to this study.
Employee engagement: is an individual's emotional and cognitive ability to focus on
work-related goals. Employee engagement also focuses on a positive, fulfilling, affective-
motivational state of work-related well-being (Maslach, Schaufeli, & Leiter, 2001).
Burnout: is a psychological response to chronic job stressors. Burnout consists of
three components: emotional exhaustion, cynicism, and personal efficacy (Maslach, 2004).
Compassion fatigue: is defined as the physical and mental exhaustion that is emotionally
experienced by individuals who persistently care for the individual that is sick or traumatized
(Cocker & Joss, 2016).

9

Organization of the Study
The key concepts and terminology commonly found in a discussion about the impact of
high turnover and burnout among behavioral health clinical workforce are presented in this
section. The organization's mission, goals, stakeholders, and the framework for the project are
introduced. Chapter Two provides a review of the current literature surrounding the scope of the
study. Topics of employee engagement and job satisfaction, burnout, compassion fatigue, patient
outcomes, supports, and interventions are addressed. Chapter Three details the knowledge,
motivation, and organizational elements to be examined as well as the methodology of the study,
in addition to the sample of participants, data collection, and analysis. In Chapter Four, the data
and results are assessed and analyzed. Chapter Five provides solutions, based on data and
literature, for closing the perceived gaps as well as recommendations for an implementation and
evaluation plan for the solutions.

10

CHAPTER TWO: REVIEW OF THE LITERATURE
The literature review begins with a general research examination that evaluates the
impact of high turnover and burnout among the behavioral health clinical workforce, followed by
an overview of the literature on employee engagement, job satisfaction, and organizational
culture to help inform the problem of practice. Then, the chapter examines Clark and Estes's
(2008) knowledge, motivation, and organizational influences' lens used in this study to evaluate
the causes and gaps associated with high turnover and burnout among the clinical workforce.
The next chapter turns attention to assessing the types of knowledge, motivation, and
organizational influences examined, and the assumed clinician's knowledge, motivation, and
organizational influences on performance. Chapter Four ends with a presentation of the
conceptual framework guiding this analysis.
Turnover and Burnout among Clinicians
Numerous studies have suggested that high turnover, burnout, and compassion fatigue
can influence staff quality of life (QoL) and patient care and outcomes (Brandt, Bielitz, &
Georgi, 2016; Haik, Brown, Liran, Visentin, Sokolov, Zilinsky, & Korhabar, 2017). According
to the authors, a behavioral health professional's quality of life (QoL) can be compromised,
resulting in adverse psychological implications (depression and anxiety), secondary traumatic
stress, chronic sickness (hypertension, heart disease, and diabetes) and family dysfunctionality
due to lack of parental engagement resulting from consistent exposure to trauma patients
(Brandt, Bielitz, & Georgi, 2016; Haik et al., 2017). Cooker and Joss (2016) also emphasize that
healthcare professionals, emergency, and community social workers are at risk of debilitating
depression, anxiety, and posttraumatic stress disorder (PTSD) (2016). Resulting in increased
absences, psychological injury claims, reduced job satisfaction, and reduced productivity

11

(2016). Subsequent multivariate analyses suggested that other work-related stressors such as
non-supportive work environments and non-supportive executive leadership are the best
predictors contributing to staff distress and high turnover (Devilly, Wright & Varker, 2009).
Other researchers concluded that low levels of trust among co-workers and leadership as
prognosticators are the reasons for high levels of compassion fatigue and turnover among
behavioral health professionals (Cetrano, Tedeschi, Rabbi, Gosetti, Lora, Lamonaca, Manthorpe,
& Amaddeo, 2017; Acker, 2012). Additionally, Bakker and Demerouti (2007) emphasize the
importance of organizations establishing a supportive work environment that promotes self-care.
Additionally, internal wellness programs can positively influence the adverse effects of turnover
and burnout among the workforce. Acker's (2012) study reaffirms that a positive and supportive
organizational culture that promotes and values professional development and career
advancements, autonomy, transparency, and bi-directional communications have lower turnover
and burnout rates.
Employee Engagement Influence on Workforce Stability
Employee engagement is essential and becoming a hot topic among businesses, public
and private organizations, and decision-making bodies because of the impact on staff
performance and productivity. According to Saks (2006), there are six areas of work-life that
lead engagement and burnout: rewards and recognition, workload, control, support from society
and the community, professed fairness, and principles. Saks also notes that being engaged and
feeling a sense of purpose on your job is associated with many benefits. For instance,
engagement provides a strong foundation for longevity and other pertinent benefits, such as,
manageable workloads, decision-making ability, responsibility for reward, gaining and
maintaining rapport with the community, in addition to being respected and having purpose

12

(2006). However, organizational commitment differs from engagement in that it refers to a
person's attitude and attachment towards their organization (2006).
In 2008, several researchers defined employee engagement as a person's ability to engage
and cognitively, emotionally, and physically express themselves during performances of their
roles (Kular, Gatenby, Rees, Soane, & Truss, 2008). They later emphasized that employee
engagement can also be defined as the level of passion an individual has for work. However, the
level of engagement is primarily connected with the constructs of job involvement and flow. Job
involvement is identified with an emotional and internal belief as it relates to one's profession
(Kular et al., 2008). Authors Rasheed, Khan, and Ramzan (2013) affirm that an individual's level
of employee engagement is influenced by organizational commitment, involvement, and
investment in order to be successful.
Additionally, engaged employees' essential outcomes can be achieved because employee
engagement is an unceasing process of learning, improvement, measurement, and action
(Authors Rasheed, Khan, & Ramzan, 2013). Therefore, organizations must recognize how
employee engagement influences retention, productivity, and overall job satisfaction. Research
supports that employee engagement is an essential element in improving job satisfaction and
retention.
Intrinsic and Extrinsic Factors that Influence Employee Engagement
Intrinsic and Extrinsic Factors
Intrinsic motivational factors influence employee engagement and job satisfaction.
According to research, turnover and absenteeism are perilous indicators of job satisfaction. So,
our construction of motivation is broader than the arousal of effort. It also includes factors
relating to the motivation to come to work and engagement with the work environment

13

(Moyniham & Pandey, 2007). An individual's beliefs about what is essential in life and their job
can influence job satisfaction. However, an employee's maturity, background, and beliefs can
impact whether an employee is intermeshed while at the workplace or non-intermeshed (2007).
Tampubolon (2016) affirms that employee engagement positively and significantly influenced
employee performance as well as job motivation and job satisfaction.
Meyer and Gagne (2008) evaluated employee engagement from the Self-Determination
Theory (SDT) perspective. SDT distinguishes independent regulation (engagement) from
controlled motivation and motivation (i.e., withdrawal). Self-Determination Theory (SDT)
recommends two effective methods of motivation, which are extrinsic and intrinsic motivation.
When acting without seeking rewards, it is referred to as intrinsic motivation. Being motivated
for a purpose is known as extrinsic motivation. Although extrinsic motivation is arguably
predominant in a work context, it too can take different forms (Meyer & Gagne, 2008). Extrinsic
rewards have been characterized as "investments" that an organization uses to help strengthen
ties between itself and its employees (2008).
Job crafting is an intrinsic motivational factor for employees because it allows employees
to take an active role in initiating physical or cognitive changes to how they approach their work
(Slemp & Vell-Brodrick, 2014). Job crafting is an informal process that focuses on the positive
changes that employees can make to the task, relational, or cognitive features of their jobs. The
authors also emphasize that employees engaged in job crafting can predict the extent to which
their psychological needs were satisfied on the job, which, in turn, can predict their level of
subject-well-being (SWB) and psychological well-being (PWB) (2014). SWB is the scientific
term attributed to happiness or 'the good life' and can be broken down into two components
(cognitive and affective). The cognitive component refers to an individual's satisfaction with

14

their life as a whole, whereas the affective component refers to the presence of high positive
affect (P.A.) and the relative absence of negative affect (N.A.). PWB affects the pleasurable,
hedonic component of well-being through strivings toward optimal functioning, self-
actualization, and, more broadly, a life well-lived (Slemp & Vell-Brodrick, 2014).
Organizational Factors
Many other organizational factors influence employee engagement. For instance, person-
environment (P.E.) fit, person-job fit, and organizational support are essential antecedents of
career success. P.E. fit perspective is that the degree of fit or match between people and their
environment produces important outcomes or benefits for employees (Ballout, 2007). Person-job
fit is defined as the fit between the abilities of a person and the challenges of the job or the
needs/desires of a person and the attributes of the job. A person-environment (P.E.) fit is the
degree of fit or match between people and their environment that produces important outcomes
or benefits for employees (2007). Person-organization (P.O.) fit is when people and
organizations have what is needed by each other, and they share similar fundamental
characteristics, or both (Moynihan & Pandey, 2007). However, P.O. is associated with a person's
attitudes about the organization, based on congruent goals and values. Another extrinsic factor
that influences employee engagement is career advancement opportunities because advancement
opportunities are positively associated with job satisfaction (Moynihan & Pandey, 2007). When
opportunities are presented for employees to be promoted, they will exhibit higher levels of
involvement, in search of being rewarded (2007).
Successive organizational factors that influence employee engagement are person-
organization fit, and person-environment fit. These can influence employee retention,
engagement, and productivity (Ünal & Turgut, 2015b). Person-organization fit positively

15

contributes to a large number of organizational attitudes and behaviors (2015b). Person-
organization fit is correlated with job performance, organizational citizenship behavior, and
turnover rate (Kristof, 1996). The authors also state that the person-organization fit has two
distinctions: supplementary and complementary fit (2015b). Supplementary fit exists when there
is a similarity of relevant characteristics between an organization and a person, while
complementary fit exists when individual and organizational values are congruent (Ünal &
Turgut, 2015b). Multiple studies suggest that individual pursuit of meaning and fulfillment
predicts an enhanced state of subjective well-being and overall job satisfaction and engagement.
Research supports that intrinsic and extrinsic motivational factors influence high employee
engagement, high job motivation, and as well as high job satisfaction.
Consequences of Lack of Employee Engagement

Employee engagement and satisfaction influences organizational performance and job
satisfaction. Connections have been reviewed in many studies that have shown that there is a
connection between employee engagement as individual-level constructs and business results.
Authors Ram and Prabhakar's (2011) study suggest that employee engagement leads to both
individual outcomes (i.e., the quality of people's work and their own experiences of doing that
work), as well as organizational outcomes (i.e., the growth and productivity of organizations).
The study also makes the inference that engagement influences six work conditions: burnout,
increased withdrawal, lower performance, job satisfaction, and commitment (Ram & Prabhakar,
2011). Prior research by Harter, Schmidt, and Hayes (2002b) concluded that poor employment
engagement (satisfaction) leads to burnout and turnover.
Subsequent studies affirmed that employee engagement has a direct impact on the
organization's productivity (Harter, Schmidt, & Hayes, 2002b; Prato, 2013). These studies

16

concluded that employee engagement is linked to customer satisfaction, which is a link to an
organization's financial success and productivity (Harter, Schmidt, & Hayes, 2002b; Prato,
2013). However, Prato's (2013) study concludes that organizational success at improving
employee engagement depends on four primary workplace conditions: an organization's culture,
continuous reinforcement of people focused on policies, meaningful metrics, and organizational
performance. Employee engagement in the workplace is improved when people care about doing
a good job, and they care about what the organization is trying to achieve and how it goes about
doing it (Prato, 2013). Based on research, employee satisfaction and employee engagement have
a direct influence on an organization’s productivity and financial outcomes. Therefore, managers
and researchers of organizations should be concerned with employees' engagement at work due
to the implications of the overall organization's success.
Job Satisfaction: Reasons Employees Leave their Employer
Autonomy and Inclusion Influence on Job Satisfaction
Research has shown that autonomy, social support, and organizational climate influence
job satisfaction and retention (Ryan & Deci, 2000; Gagné & Bhave, 2011; Rees, Alfes, &
Gatenby, 2013). However, the existence of universal psychological needs, when satisfied, can
lead to optimal functioning and psychological adjustment. Namely, these are the needs for
autonomy, competence, and relatedness (Ryan & Deci, 2000). Autonomy requires the experience
of choice and being the initiator of one's behavior. Competence requires succeeding at
challenging tasks and ultimately attaining desired outcomes. Finally, relatedness requires a sense
of caring, mutual respect, and mutual reliance with others. The extent to which the three needs
are satisfied in the workplace determines the level of well-being that employees experience
(2000).

17

Notably, job autonomy has been linked to employee well-being across many cultures.
Self- determination theory research clearly shows such a link between the satisfaction of the need
for autonomy and well-being. Job autonomy is related to individual performance and other work
behaviors (Gagné & Bhave, 2011). Organizations with high job autonomy experience less
frustration, anxiety, turnover intentions, physical symptoms, and doctor visits among their
employees. Unfortunately, autonomous work groups typically do not have a supervisor and have
the following responsibilities: allocate jobs among themselves, reach production targets while
meeting quality standards, and solve production problems (2011). Autonomous work groups are
more satisfied at work and committed and perceived greater work role complexity. However,
employees who are allowed to participate in decision-making seemed to be more engaged, put
more effort into their work, and feel less strain (Gagné & Bhave, 2011).
A related study conducted by Rees, Alfes, and Gatenby (2013) highlighted several
benefits to autonomy. For instance, autonomy allows employees the opportunity to communicate
their opinions and engenders the belief that their contributions are valued. The study also
concluded that employees' voice creates a level of respect towards the leaders of the
organization. Employee voice and employee trust in senior management influence their level of
engagement and job satisfaction. Employers who deliver on their commitments reinforce
employees' sense of fairness and engender greater trust in the organization (2013). Additionally,
employees' trust level increases the assurance that they will fulfill their obligations in the future.
Employee voice processes within organizations, and specifically behavior directed towards
improving workgroup functioning creates an atmosphere where employees perceive themselves
as active participants, feel that their opinions are valued, and are more engaged. Finally, open

18

communication and employee relationships can improve overall job retention (Rees, Alfes, &
Gatenby, 2013).
These studies support the implicit theoretical assumption that job satisfaction is an
essential antecedent to well-being. These studies also support that trust in management and
employee–line management relationship is essential in achieving outcomes. Researchers
emphasize the impact and importance that employee voice, autonomy, and commitment have on
job retention, satisfaction, and level of engagement.
Consequences of Poor Job Satisfaction
Poor job satisfaction can influence patient care and employee well-being, both physically
and mentally. According to researchers, burnout and compassion fatigue have a significant
influence on retention and turnover, patient satisfaction, patient safety, and overall quality of care
(Potter, Deshields, Divanbeigi, Berger, Cipriano, Norris, & Olsen, 2010). Faragher, Cass, and
Cooper's (2013) study concluded that there was a strong relationship between job satisfaction
and both mental and physical health. Furthermore, employment conditions can impact the
physical and mental health of employees. Their findings also concluded that peer relationships at
work are an essential aspect of improving employees' mental health, reducing burnout, lowered
self-esteem, anxiety, and depression (Faragher, Cass, & Cooper, 2013).
Subsequent studies revealed that employees' mental and emotional health is affected by
their work environment and their physical, mental, and social well-being. Gender can also be a
significant factor since females seemed to enjoy better physical health compared to males
(Koinis, Giannou, Drantaki, Angelaina, Stratou, & Saridi, 2015a; Cocker & Joss, 2016).
According to Cocker and Joss (2016), stress leads to poor health outcomes, but it can also lead to
compassion fatigue and burnout. Employees who experience compassion fatigue are more likely

19

to exhibit the following behaviors: chronic fatigue, irritability, dread going to work, aggravation
of physical ailments, and lack of fulfillment (2016). Additionally, mental health professionals
that are particularly exposed to high levels of stress are at risk of becoming drug and alcohol
dependent, suicidal, and burnt out (Fleury, Grenier, & Bamvita, 2017). Research also concluded
that job satisfaction does influence employees' overall quality of life (QoL) (Cocker & Joss,
2016; Fleury, Grenier, & Bamvita, 2017). Based on the research, one may conclude that job
satisfaction does hurt patient care, primarily for providers working in high-intensity settings. The
research also concluded that stress, along with reduced job satisfaction, could influence the well-
being of mental health professionals.
Factors that Influence Job Satisfaction

The factors that influence job satisfaction among public service workers are captured in
four dimensions: freedom, responsibility, variety, and ability (Cooper, Rout, & Faragher, 1989).
According to research, general practitioners enjoy the diversity of their work and appreciate their
freedom and independence. However, the study also concluded that job stressors were negatively
predictive of high levels of job satisfaction among general practitioners (1989). Job demands and
patients' expectations were the two most significant job stressors because of the impact it has on
the employee's family and social life (Cooper, Rout, & Faragher, 1989). Additional stressors
include the physical, psychological, social, or organizational aspects of the job that require
sustained physical and or mental (cognitive and emotional) effort or skills (Bakker & Demerouti,
2007). A significant predictor of psychological strain and illness are high job demands and low
job control. Furthermore, job demands are not entirely negative, but they may become stressors
when they demand high effort (Bakker & Demerouti, 2007).

20

Even though researchers have identified several negative predictors of a high level of job
satisfaction, Ellickson and Logsdon's (2001a) study concluded that practical reasons had
motivated job satisfaction (e.g., to increase productivity and organizational commitment, lower
absenteeism and turnover, and ultimately, improve organizational effectiveness). Humanitarian
interests (i.e., the notion that employees deserve to be treated with respect and have their
psychological and physical well-being maximized). Satisfied workers tend to engage in
organizational citizenship behaviors, that is, altruistic behaviors that exceed the formal
requirements of a job while dissatisfied workers show a propensity for counterproductive
behaviors, including withdrawal, burnout, and workplace aggression (Ellickson & Logsdon,
2001a).
Other research suggests that energetic employees with productive connections with their
work activities are more engaged and able to meet work demands (Schaufeli & Bakker, 2004).
Engaged employees have a positive work-related experience, good health outcomes, and more
productivity. According to the authors, vigor, dedication, and absorption are defined as work
engagement characteristics (2004). Vigor is possessing high levels of energy and mental
resilience while working. Workers with vigor have the willingness to invest effort in one's work,
even when experiencing challenges. Dedication is being actively involved in one's work and
experiencing a sense of significance, enthusiasm, inspiration, pride, and challenge. Absorption is
characterized by being entirely concentrated or engrossed in one's work. Over time this could
lead to a worker having difficulties with detaching oneself from work (2004). An important
finding is that engaged employees have high retention rates and are more committed to their
organization's vision and mission (Schaufeli & Bakker, 2004).

21

Additionally, work conditions, good social relationships with co-workers and supervisors,
promotion opportunities, professional development opportunities, and participatory management
strategies can influence job satisfaction and turnover (Bright, 2008). Therefore, the level of
employee engagement in the decision-making process, job demands, resources, and personal
interest can influence job satisfaction. The research also suggests that human motivation is
another causality for poor job satisfaction and turnover.
Organizational Culture and Leadership Responsibilities
Organizational Culture Influence on Employee Retainment and Job Satisfaction
An organization's culture and values influence employee retention, satisfaction, and
motivation. Author Kahn (1990) highlighted in his study that an essential element to employee
job satisfaction and retention is having a supportive work environment and trusting interpersonal
relationships. This type of organizational culture creates psychological safety, where employees
are allowed to test their theories and try new things, which means they may also fail without fear
of the consequences (Khan, 1990). When employees believe that their organization is a closely-
knit team, this creates a sense of mutual expectation and commitment (Zammuto & Krakower
(1991). According to Moynihan and Pandey (2007), culture comprises four distinct dimensions.
Group cultures are associated with a focus on people rather than the organization, and flexibility
rather than control. Group cultures are also characterized by an emphasis on employee cohesion
and morale (2007). Research also suggests that group norms are potent shapers of individual
attitudes and actions, and "clan-like" cultures foster and reinforce a sense of shared commitment
among employees (Moynihan & Pandey, 2007; Ballout, 2007).
Furthermore, research shows how organizational culture exerts considerable influence on
employee performance and commitment and helps determine how well a person "fits" within a

22

particular organization (Ballout, 2007). The degree of congruence or compatibility between the
individual's values and the organizations' values is typically referred to as person-culture fit
(2007). Person-culture (P.C.) fit perspective is based on the notion that individuals adapt and
adjust better to their work environments when the organization's values match their values. Also,
culture has shown to have an impact on organizational performance and employee-related
variables, such as work satisfaction and individual career progression (Ballout, 2007). The
research concluded that organizational culture and a supportive work environment does influence
job satisfaction and performance. The research also suggests that organizational and supervisor
support, workplace safety, internal connections (group culture) are predictors of employee
engagement and commitment.
Leadership style and role effects on employee engagement, retention, and job satisfaction.
Research suggests that leadership style is an essential determinant of employee job
satisfaction. The characteristics of your employees and leaders demonstrate the reactions of your
employees and leaders of your organization (Mohammad Mosadegh Rad & Hossein-
Yarmohammadian, 2006; Hamidifar, 2010). Job satisfaction as it relates to employees is
influenced by the internal organization environment, which includes organizational climate,
leadership types, and personal relationships (Hamidifar, 2010). When employees are satisfied
with their leadership, they are more inclined to stay employed with the company and perform at
their highest capacity (Mohammad Mosadegh Rad & Hossein-Yarmohammadian, 2006). Other
factors that affect job satisfaction are that management operates with honesty and integrity,
promotes efficiency, and has open lines of communication with employees (2006). Furthermore,
employees' satisfaction is not influenced by salaries, benefits, work conditions, promotion, and

23

communication. Employees do receive more satisfaction from the nature of the job, their co-
workers, and supervisors. (Mohammad Mosadegh Rad & Hossein-Yarmohammadian, 2006).
Undoubtedly, if leadership is condescending and always putting employees down,
employees are more prone to leave the company (2010). Consequently, leaders that are mentally
pounding the employee and being repulsive toward the employee, job satisfaction begins to
suffer, along with increased absenteeism, reduced productivity, and high turnover rates
(Hamidifar, 2010). However, a turbulent environment can contribute to delivering sustainable
employment growth, and organizational profitability. It is the manager's leadership skills that can
influence the level of engagement of the workforce (Hamidifar, 2010; Batista-Taran, Shuck,
Gutierrez, & Baralt, 2013).
Consequently, leadership style is also a factor that influences employee engagement and
job satisfaction. Transformational leaders can increase employee engagement and
transformational leadership changes the way followers see themselves, from isolated individuals
to members of a larger group (Kaiser, Hogan, & Craig, 2008; Batista-Taran et al., 2013).
Transformational leaders also render an inspiring image of goals that can help overcome self-
interest and narrow factionalism in organizations (Batista-Taran et al., 2013). The research
concludes that there is a significant correlation between leadership behaviors and employee job
satisfaction. Additionally, research suggests that exceptional leaders (who demonstrate the same
characteristics as transformational leaders) will create an environment that fosters engaged
employees.
Organizational commitment influences job satisfaction and engagement.
Organizational commitment and support have a significant impact on work attitudes, such
as job satisfaction, performance, absenteeism, and turnover intentions. Organizational

24

commitment also refers to the relative strength of the identification of the individual and his or
her involvement with a particular organization (Yousef, 1998). There are three primary
components of organizational commitment: a strong belief in and acceptance of the
organization's goals and values (identification), a willingness to exert considerable effort on
behalf of the organization (involvement), and a strong intent or desire to remain with the
organization (loyalty) (1998). Ironically, organizational commitment mediates the relationship of
leadership behavior with both job satisfaction and job performance. According to Lok and
Crawford (1999), an organization's innovative and supportive subcultures has a significant effect
on organizational commitment. Along with age, pre-employment expectations, perceived job
characteristics, and the consideration dimension of leadership style can also influence
commitment and job satisfaction (1999).
A subsequent study by Yousef (2000) affirms that employees' age, educational level,
monthly income, tenure in the present organization, tenure in the present job, job level, marital
status, and an organization's activity does influence job satisfaction and organizational
commitment. The research also discovered that there is a significant correlation between
satisfaction and job security and organizational commitment. Employees who are satisfied with
the security of their job are more committed to their organization and demonstrate better
performance. Also, the Albdour and Altarawneh (2014) study suggested that direct service
providers who have high job engagement and organizational engagement will have a high level
of affective commitment and normative commitment. The study further highlighted that
organizational commitment includes three kinds of commitment: affective commitment,
continuance commitment, and normative commitment. The authors describe the types of
organizational commitment. When an employee shows emotional attachment, identifies, and is

25

involved with an organization, this person is demonstrating affective commitment. Continuance
commitment is when employees separate from companies often and are not aware of how much
was invested in having them hired. Finally, normative commitment represents a perceived
obligation to remain in the organization (2014).
Consequently, high-level employees' (managers’) job engagement can meaningfully
affect employees' continuance commitment (Albdour & Altarawneh, 2014). Based on research,
organizational commitment has a significant impact on work attitudes such as job satisfaction,
performance, absenteeism, and turnover intentions. Research also concludes that organizational
culture and subculture (i.e., innovation, leadership style, and support) does affect job satisfaction
and commitment.
Clark and Estes' (2008) Gap Analytic Conceptual Framework
In this section, the Clark and Estes (2008) gap analysis framework will guide this
study. The framework systematically identifies and then examines the difference between actual
and preferred performance. The model acknowledges that knowledge (K) and motivation (M) are
both essential to goal achievement. Understanding the interplay of knowledge and motivation
within the organizational culture (O) is critical to accomplish goals and realize change (Clark &
Estes, 2008). Also, Krathwohl (2002) indicates that knowledge and skills are divided into four
types: (a) factual; (b) conceptual; (c) procedural; and (d) metacognitive, which are used to
determine if stakeholders possess the knowledge and skills to achieve a performance goal.
Motivation influences include the choice to consider goal achievement, intrinsic motivation to
work towards the goal, and the mental exertion to accomplish the goal (Clark & Estes, 2008;
Rueda, 2011). Rueda (2011) stressed that to analyze performance gaps, one must consider self-
efficacy, attributions, values, and goals of an individual or organization. Finally, organizational

26

influences, such as work processes, organizational culture, and resources, must be considered
when evaluating stakeholder performance and outcomes (Clark & Estes, 2008).
During this study, each element of the Clark and Estes (2008) gap analysis was explored
in terms of clinician's knowledge, motivation, and organizational needs to meet their
performance goal of reducing the clinician's turnover rate by 30% by August 2020. The first
section of this study will discuss the assumed influences on the stakeholder performance goal in
the context of knowledge and skills. As the study continued to develop, the assumed motivation
influences on the attainment of the stakeholder goal were considered. Finally, assumed
organizational influences on the achievement of the stakeholder goal would be explored. In
Chapter 3, the assumed stakeholder knowledge, motivation, and organizational influences on
performance were examined through the mixed methodological approach.
Stakeholder Knowledge, Motivation, and Organizational Influences
This review will analyze relevant literature related to the knowledge, motivation, and
organizational influences that impede Trident Behavioral Health clinical workforce from
accomplishing their stakeholder goal. This stakeholder goal is that 95% of the clinical workforce
was 100% satisfied with their employment at TBH by August 31, 2021.
Knowledge and Skills
The knowledge influences are the primary components required for the TBH clinical
workforce to achieve their stakeholder goal. Clark and Estes (2008) emphasize that investments
in resources to enhance workforce knowledge and skills are essential elements for individual and
organizational success. The authors' rationale is based on the hypothesis that performance is
enhanced when employees implement new ideas and tools to solve their performance problems
and close performance gaps. Clark and Estes (2008) further assume that when employee

27

performance gaps are closed, the organization strengthens its ability to achieve organizational
goals.
In order for TBH to improve employee satisfaction and retention amongst the clinical
workforce, an assessment of the different knowledge influences, corresponding knowledge types,
and methods to assess any gaps is essential. There are four knowledge types needed for an
organization to solve their performance problems and achieve their goals, which are factual,
conceptual, procedural, and metacognitive (Krathwohl, 2002; Rueda, 2011). However, for this
review, procedural and metacognitive knowledge constructs were explored. Procedural
knowledge helps employees understand how to solve a problem (Rueda, 2011). Metacognitive
knowledge helps employees become aware of their mental processes in solving problems and
allows them to evaluate and address problems from their perspective (Rueda, 2011). According
to Mayer (2011), metacognitive knowledge encourages individuals to reflect upon what they
know or do not know about the process and their willingness to ascertain the information.
Based on a review of the current research, three knowledge influences of TBH clinical
workforce poor job satisfaction and retention were highlighted in the next section, followed by a
categorization of these influences of two knowledge types. The metacognitive and declarative
knowledge types are categorized to determine the methodology used to assess knowledge gaps of
the TBH clinical workforce in order to improve employee satisfaction.
TBH clinical workforce needs to reflect on its ability to manage his or her stress
level effectively. The first knowledge influence that TBH clinical workforce needs to implement
to achieve their performance goal is to learn how to manage their stress level effectively. This
knowledge influence is categorized as declarative knowledge because it focuses on TBH clinical
workforce understanding their role in managing his or her stress level in order to improve

28

employee satisfaction. Therefore, the method to assess whether a metacognitive knowledge gap
exists would be through surveying and interviewing (Clark & Estes, 2008) the TBH clinical
workforce. The surveys and interview questions would include open-ended questions requiring
the clinical workforce to articulate what techniques or strategies they used to reduce stress.
Employee stress can be defined as the harmful physical and emotional response that
occurs when the requirements of the job do not match the capabilities, resources or needs of the
worker (Harnois & Gabriel, 2002). Employee stress can cause poor health and increase rates of
work-related injuries and accidents. Some potential causes of work-related stress are employees
being overworked, the lack of clear instructions, unrealistic deadlines, the lack of decision-
making, job insecurity, isolated working conditions, surveillance, and inadequate child-care
arrangements (Harnois & Gabriel). However, research has shown that work-related stress
contributes to employees not recognizing the signs associated with stress nor seeking or
implementing coping strategies to reduce their stress (Koinis, Giannou, Drantaki, Angelaina,
Stratou, & Saridi, 2015). The authors’ study accentuates several strategies that individuals can
adopt to reduce work-related stress or stressors: 1) positive reassessment (reflection), which
means, recalling adverse events from a positive approach to solve the problem; 2) seeking social
support from his/her social environment in order to deal with problems; 3) seeking spiritual
mindfulness or adopt meditation methods; 4) be transparent about knowledge gaps and seek
support as needed; and 5) be an active participant in addressing the problem (Koinis et al., 2015).
An individual's lack of ability to manage their stress level can have devastating
consequences. For instance, research has shown that mental health professionals that are
particularly exposed to high levels of stress are at risk of becoming drug and alcohol dependent,
suicidal, and burnt out (Fleury, Grenier, & Bamvita, 2017). The authors affirm that the health

29

and well-being of mental health professionals and job satisfaction influence the quality of life
(QoL). Subsequent studies concluded that mental health professionals' quality of life (QoL)
could be compromised resulting in adverse psychological implications (depression and anxiety),
secondary traumatic stress, chronic sickness (hypertension, heart disease, and diabetes) and
family dysfunctionality due to lack of parental engagement (Brandt, Bielitz, & Georgi, 2016;
Haik, Brown, Liran, Visentin, Sokolov, Zilinsky, & Korhabar, 2017). Crocker and Joss (2016)
also affirmed that not only can stress lead to poor health outcomes, but it can also lead to
compassion fatigue and burnout. Compassion fatigue is the physical and mental exhaustion and
emotional withdrawal experienced by individuals who persistently care for individuals that are
sick or traumatized (Crocker & Joss, 2016).
The clinical workforce needs to recognize how their stress and job satisfaction
influences the quality of service to patients and organizational performance and
sustainability. The second knowledge influence that TBH clinical workforce needs to achieve
their performance goal is recognizing how their unmanaged stress and job satisfaction influence
the quality of service given to patients. This knowledge influence is categorized as declarative
knowledge because it focuses on the TBH clinical workforce, understanding how their stress and
job satisfaction impact patients' outcomes. In order to conduct an analysis, open-ended interview
questions would be needed to be facilitated to assess the clinical workforce’s awareness of their
job satisfaction.
Josh Bersin, the founder of LinkedIn, emphasizes that poor employee satisfaction and
turnover can have catastrophic financial implications that range in the tens of thousands of
dollars annually. Subsequently, several factors affect the cost, which includes the cost of hiring a
new person (advertisement and recruitment), the cost of onboarding (training and management

30

time), and lost productivity and patient engagement. Subsequent studies acknowledge that stress
and poor employee satisfaction influences patient outcomes, work performance, productivity,
and lost revenue (Van-Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015). Ackers’ (2012) study
suggests that when employees are unable to manage their stress appropriately, the quality of
service to clients and patient outcomes are compromised. Therefore, employees must be
amenable to re-evaluate and reflect on how they can manage stress so that other employees and
the organization as a whole are not negatively impacted.
Table 2 illustrates an overview of how the two knowledge influences of the TBH clinical
workforce analyze job satisfaction and retention, corresponding knowledge types, and methods
to assess any knowledge gaps that influence the stakeholder and organizational goals and the
mission of the organization.
Table 2.
Knowledge influences, knowledge types and knowledge influence assessments
Organizational Mission
Trident Behavioral Health's mission is to embrace and recognize the needs of consumers and
families. Secondly, they aim to provide high quality and culturally responsive services to their
diverse communities. Lastly, their core values and fundamental principles that guide the work
and motivate the workforce are client and family-centered services, strengthen-based approaches,
researched and data-driven decision-making, and being respectful, accessible, and accountable
(agency website, 2018).

Organizational Performance Goal
Trident Behavioral Health's (TBH) organizational goal is to reduce staff turnover by 30% before
August 31, 2021.
Stakeholder's Goal
Ninety-five percent of the clinical workforce is 100% satisfied with their employment at TBH by
August 31, 2021.

31

Knowledge Influence Knowledge Type (i.e.,
declarative (factual or
conceptual),
procedural, or
metacognitive)
Knowledge Influence Assessment
The clinical workforce needs
to reflect on its ability to
manage his/her stress level
effectively.
Metacognitive Surveys: The clinical workforce
will participate by responding to
questions that are designed to assess
their ability to manage his/her stress
level.
The clinical workforce needs
to recognize how their stress
and job satisfaction influences
the quality of service to
patients, organizational
performance, and
sustainability.
Declarative Interviews The clinical workforce
will ask questions that require
participants to demonstrate
knowledge of basic facts of how
poor job satisfaction and stress
influence patient care,
organizational performance, and
sustainability.

Motivation
Motivation is the ability to influence individuals to engage in a task until the desired
outcome is obtained (Mayer, 2011). Motivation is the second component of the KMO:
Knowledge, Motivation, and Organizational model used to evaluate performance problems and
their solutions (Clark & Estes, 2008). Clark and Estes (2008) suggest that employees are
motivated to perform at their highest level and achieve personal and organizational goals when
he or she has actively involved themselves and exert the mental effort to succeed. Jensen (2012)
affirms that employees who are passionate and inspired by their jobs are more motivated to
perform and contribute to the overall achievement of the organization. Knowing how
motivational influences and constructs affect a performance problem is essential. This is
especially true when an organization is performing a gap analysis or needs assessment to address
performance, productivity, and employee engagement (Rueda, 2011). To determine
the motivational factors that influence goal achievement, motivational needs, issues, and assets

32

should be examined through the lenses of active choice, persistence, and mental effort (Clark &
Estes, 2008; Jensen, 2012; Mayer, 2011; Rueda, 2011).
Based on a review of the current research, the two motivational theories captured in the
next section determine what motivational influences impede TBH's ability to improve employee
satisfaction among the clinical workforce. The expectancy-value theory and emotion have been
chosen to highlight vital motivational influences.
Expectancy Value Theory
This theory examines individuals' ability to increase their performance, establish high
expectations, and have the confidence to value the task in which they are engaged (Eccles,
2006). Expectancy value theory has two essential elements, which are whether individuals
believe they can do the task (expectancy) and whether they want to do the task (Eccles, 2006).
Expectancy can be measured by the amount of confidence an individual exudes about his or her
ability and capability to achieve a goal (Clark & Estes, 2008). Value speaks to the amount of
importance an individual associates with any given task (Rueda, 2011). Explicitly, Eccles (2006)
describes several ways in which an individual might find value in a task: 1) intrinsic value,
which is how positive an individual expects to feel when engaged in the task; 2) attainment
value, which is based on an individual's image of who they are or whom they want to be; 3)
utility value, which is determined by how well a task might satisfy a goal or plan; and 4) cost
value, which relates to the relative cost (e.g., time, energy, emotion) of the task. Based on the
previously mentioned principles of the expectancy-value theory, this was the catalyst for
choosing this theory to analyze the TBH stakeholder goal.
The clinical workforce needs to see the value or importance of their work. The first
motivational influence pertinent to TBH clinical workforce achieving their stakeholder goal is

33

seeing the value or importance of their work. Cetrano et al. (2017) explain the value and
importance of employees who are "mission-driven" and intrinsically motivated because these
self-regulatory factors influence job satisfaction and retention. Authors Whitebird, Asche,
Thompson, Rossam, and Heinrich's (2013) research concluded that intrinsic motivation and job
fulfillment influence job satisfaction and retention. Eccles (2006) asserts that when individuals
recognize and value the work or task, they are more susceptible and motivated to achieving the
mission.
Furthermore, employees' intrinsic motivation and job satisfaction are influenced by a
sense of personal accomplishment, being associated with a team, and commitment to their
profession (Onyett, Pillinger, & Muijen, 1997). Additionally, research indicates that "job
crafting" is also essential to improving job satisfaction and staff retention because job crafting
allows employees to take an active role in initiating physical or cognitive changes to how they
approach and value their work (Slemp & Vella-Brodrick, 2013). The authors also affirm when
employees feel valued, ultimately, workplace enjoyment and job satisfaction are enhanced
(2013).
Emotions
Emotions are the ability of individuals to maintain a positive disposition as they
experience a range of situational feelings and challenges (Clark & Estes, 2008). Pekrun (2011)
describes emotions as an individual's' ability to increase or decrease how effectively he or she
interacts with and navigates their environment and workload. Pekrun (2011) affirms that
emotions can affect one's ability to learn new material or recall and transfer previously learned
material, which decreases productivity and satisfaction (Pekrun, 2011). The author also suggests
that emotion can increase or decrease depending on an individual's ability to interact and

34

navigate his or her work environment and job responsibilities (Pekrun, 2011). Additional
studies suggest that emotion stimulates the brain with information that will either motivate or
prevent the individual from responding (Lord, Klimoski, & Kanfer, 2002). Likewise, the brain
can also send messages to the body that produce emotions that can either prohibit or inhibit an
individual's performance (Lord et al., 2002).
The clinical workforce needs to experience positive or epistemic emotions to
improve employee satisfaction. The second motivational influence relevant to the TBH clinical
workforce achieving their stakeholder goal is the need to experience positive or epistemic
emotions to improve employee satisfaction. The research indicates that engaged employees
consistently feel self-motivated and positive about their jobs due to the emotional connection
they make with their work (Lord et al., 2002; Radda et al., 2015). Working conditions influence
employees' satisfaction, career advancements, quality of supervision, and peer relationships,
along with building trustful relationships with management and teammates (Cetrano et al., 2017;
Onyett et al., 1997). Research has also shown when employees are active participants in system
improvements and the decision-making process, they are more committed and emotionally
connected to the task, which leads to better retention outcomes (Slemp & Vella-Brodrick,
2013).
An employee's (verbal or non-verbal) reaction to an assignment he or she does not fully
comprehend is epistemic emotion (Pekrun, 2011). Epistemic emotions are associated with
emotions such as anxiety, frustration, and confusion and can be prevented or delay an individual
from engaging with a task due to the emotions the task provokes within them (Pekrun, 2011).
Generally, when employees feel positive and experience minimal negative epistemic emotions
with their job or their organization, they are more willing to engage with their job roles and show

35

loyalty toward the organization (Unal &Turgut, 2015). Unfortunately, emotions can harm an
employee's performance and level of engagement, eliciting a form of disengagement, which can
impede their cognitive recall or ability to problem solve (Pekrun, 2011). Additionally, the
research identified other negative influences on the epistemic emotions of employees that impede
their overall level of engagement. For instance, epistemic emotions can influence an employee's
oral and nonverbal communication about assignments, job responsibilities and satisfaction (Lord
et al., 2002).
Based on the expectancy-value and emotion motivation influences, the methodology to
assess whether a motivation gap exists was through surveys and interviews (Clark & Estes,
2008) of the clinical workforce. Table 3 illustrates an overview of two of the motivation
influences of TBH clinical workforce job satisfaction and retention and the methods used to
assess motivation gaps, the impact on the stakeholder and organizational goals, and the mission
of the organization.
Self-efficacy Theory
The theory of self-efficacy assumes that belief influences an individual's motivation to
accomplish a task or goal in their ability to produce the desired outcome (Bandura, 1991). Self-
efficacy has been described as ones' mental and physical ability and exertion to accomplish a
goal and the willingness to endure through the challenges associated with achieving a goal
(Bandura, 1991). Moreover, high self-efficacious individuals experience joy or happiness when
confronted with a difficult task; conversely, low self-efficacious individuals exhibit despondent
behaviors.
According to Pajares (2006), an individual's self-efficacy can also be impacted by
feedback received during social interactions that occur within different cultural settings like

36

work or school (Gallimore & Goldenberg, 2001). Therefore, the clinical workforce (clinicians)
must have an awareness and capacity, both mentally and physically, to improve their stress
level. Clinicians need to learn and incorporate different strategies and techniques in their daily
routines to lower the stress level at work and in other environments.
Attribution Theory
Attribution theory is the construct that individuals attempt to analyze and interpret social
environments such as workplace settings (Rueda, 2011). Rueda (2011) also defined attributions
as the "belief one has about the reasons for success or failure at a task or activity as well as the
degree of control they have in affecting that outcome" (p. 41). Primarily, individuals attempt to
rationalize their failure or success in their lives or work domain. According to Rueda (2011), this
reflective process derives from three causal dimensions: stability, locus, and controllability.
Stability refers to whether the cause of an event is temporary or permanent, the locus is whether
the cause is attributed to internal or external forces, and controllability is whether the individual
has control of the attributions (Rueda, 2011).
Therefore, attribution could impact a worker's stress level, performance, and overall job
satisfaction. Hence the reason why TBH clinical workforce needs to assess how their internal
and external attributions can influence their personal and organizational outcomes (positive or
negative). Finally, the clinical workforce also needs to recognize their role and responsibility in
achieving the organization's mission and vision. Table 3 shows the motivation influences and
the method of assessment in this study.

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Table 3
Assumed motivation influences and motivational influence assessments
Organizational Mission
Trident Behavioral Health's mission is to embrace and recognize the needs of consumers and
families. Secondly, they aim to provide high quality and culturally responsive services to their
diverse communities. Lastly, their core values and fundamental principles that guide the work
and motivate the workforce are client and family-centered services, strengthen-based approaches,
researched and data-driven decision-making, and being respectful, accessible, and accountable
(agency website, 2018).

Organizational Performance Goal
Trident Behavioral Health's (TBH) organizational goal is to reduce staff turnover by 30% before
August 31, 2021.

Stakeholder's Goal
Ninety-five percent of the clinical workforce was 100% satisfied with their employment at TBH
by August 31, 2021.

Assumed Motivation Influences

Motivational Influence Assessment

Value: The clinical workforce needs to see value
or importance of their work.
Surveys: The work I do is important to my
department and organization. (not
important at all - especially important)
Interview: How important is the work you
do to the department and the organization?
Emotion: The clinical workforce needs to
experience positive or epistemic emotions to
improve employee satisfaction.
Survey: The emotion I feel while engaging
with my work is: (anger - joy)
Interview: How do you feel throughout the
day in your working environment?
Self-efficacy: The clinical workforce needs to
possess the confidence they can apply stress
management techniques to reduce his/her stress
level.
Survey: Using the scale below, how
confident are you in doing the following
right now to manage your stress: (items to
follow)
Attribution: The clinical workforce (clinicians)
needs to recognize their role and responsibility
for achieving the organization's mission and
vision.

Survey: My organizations’ achievement of
its vision and mission is due to my own
efforts.

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Organization
General theory
An organization's culture can be analyzed based on the cultural settings and cultural
models that exist in it (Gallimore & Goldenberg, 2001). Clark and Estes (2008) suggested that an
organization's culture, inadequate resources, and flawed policies and procedures are barriers to
employees accomplishing their goals. In Schein's (2004) study, the author views culture as a
powerful abstraction that consists of three levels: artifacts (i.e., language, attire, and
environment), espoused beliefs and values (i.e., ideological views or ideologies), and basic
underlying assumptions (i.e., unconscious beliefs or values). Clark and Estes (2008) define
culture as a multi-dimensional and dynamic construct that is both conscious and unconscious and
serves as a conduit for describing the values, goals, beliefs, and processes learned by people over
time. There are three types of culture: organizational or environmental culture, group culture, and
individual culture. Gallimore and Goldenberg (2001), however, diverged culture into two
categories: cultural models and cultural settings.
According to Rueda (2011), cultural models exist within organizations, societies, or
individuals, and cultural models can serve as an invisible toolkit on how to perceive or approach
situations (Gallimore & Goldenberg, 2001). Furthermore, cultural models are referred to as
cultural practices and shared mental schema within an organization (Gallimore & Goldenberg,
2001). Even though there is intersectionality between cultural models and cultural settings, there
are some significant differences. Cultural settings are where people work collaboratively to
accomplish shared goals or values (Gallimore & Goldenberg, 2001). Cultural settings are
concrete and include the employees, their tasks, how and why tasks are completed, and the social
context in which their work duties are performed. However, cultural settings are described as

39

visible and the social contexts in which cultural models are created and executed in working
conditions and environments (Rueda, 2011). Subsequently, both cultural models and cultural
settings can be positive influences or barriers to accomplishing a goal (Clark & Estes, 2008).
Trident Behavioral Health (TBH) global and stakeholder organizational goals are to
increase the employee retention rate and improve job satisfaction among the clinical workforce
(clinicians). However, this section will focus on the role the clinical workforce has in
achieving these goals. This being said, the two cultural models and two cultural settings influences
that were analyzed during the study will highlight several significant assumed clinical
workforce influences and the research that supports them.
Cultural Model. The clinical workforce needs to foster a culture of trust, shared
values, and autonomy to improve employee satisfaction and retention. The first cultural
model that needs to be addressed in order to achieve the organizational goal is the clinical
workforce's ability to foster a culture of trust, shared values, and autonomy to improve job
satisfaction, employee engagement, and retention. Authors Gagné and Bhave's (2011) study
emphasize the importance of creating a work culture that promotes autonomy and trust because
of the influence it has on job satisfaction and retention. Other studies revealed that employees
excel in a work environment where individuals believe in the organization's values and are active
participants in establishing a shared vision (Rees, Alfes, & Gatenby, 2013). To evaluate the TBH
organizational culture, interview questions were established to assess the level of trust, shared
values, and autonomy among the clinical workforce.
Cultural Model. The clinical workforce needs to see the value of creating a
supportive and collaborative work culture. The second cultural model that requires an
examination, in order to achieve the organizational goal is that the clinical workforce needs to
see the value of creating a supportive and collaborative work environment. Research has shown

40

that the employees of an organization with a collaborative and supportive work environment are
more productive and engaged in accomplishing the organization's vision (Ballout, 2015b; Ünal &
Turgut, 2015b). Ballout's (2007) study also concluded that job retention and job satisfaction are
predicated upon the employees' perceived-organizational fit, support, and inclusion. In order to
evaluate the TBH’s environment, interview questions were established to assess the inclusionary
process.
Stakeholder-specific factors. The cultural setting within many support programs is
dynamic and often unpredictable due to organizational commitment, which has a significant
impact on work attitudes such as job satisfaction, performance, absenteeism, and turnover
intentions (Yousef, 1998). Research also concludes that organizational culture and subculture
(i.e., innovation, leadership style, and support) affect job satisfaction and commitment
Mohammad Mosadegh Rad & Hossein Yarmohammadian, 2006; Lok & Crawford, 1999).
Schaufeli and Bakker (2004) have also shown several cultural settings that ignite problems
within an organization including job demands, staff turnover and burnout, leadership style, and
staff engagement (Schaufeli & Bakker, 2004).
Cultural Setting. The clinical workforce needs to build and support a work culture
that values and promotes shared decision-making, open and bi-directional communication,
and transparency. The first cultural setting that needs to be assessed, in order to achieve the
organizational goal is the clinical workforce and the need to build and support the administrative
effort that encourages shared decision-making, open and bi-directional communication, and
transparency. Research supports that employee engagement is an essential element to improving
job satisfaction and retention (Rasheed, A., Khan, S., & Ramzan, M., 2013; Saks, A. M., 2006).
Group decision-making, transparency, staff engagement, and input are effective strategies to

41

improve organizational culture and increase productivity (Rees, Alfes, & Gatenby, 2013).
Therefore, to assess the TBH communication platforms and decision-making process, the
researcher will develop interview questions that will help glean insight on the effectiveness of
their current processes and level of staff engagement.
Cultural Setting. The organization needs to develop a collaborative strategic
roadmap (plan) that supports staff well-being, career development, as well as improve
overall job satisfaction, performance, and retention. The other cultural setting that needs
exploring in order to achieve the organizational goal is the clinical workforce and
administration’s ability to develop a collaborative strategic roadmap that supports staff well-
being and development as well as improves overall job satisfaction, performance, and retention.
According to Ellickson and Logsdon (2001a), a collaborative approach to developing a strategic
roadmap influences performance, employee engagement, and physical and mental well-being.
Furthermore, group decision-making and shared-visioning within an organization can also
influence job retention and performance (Gagné, & Bhave, 2011; Bakker, & Demerouti, 2007).
In order to evaluate the organization's inclusionary practices, interview questions were
established to assess the level of inclusion among all levels of staff.
Table 4 illustrates an overview of how the four assumed organizational influences of the
TBH clinical workforce can be used to analyze job satisfaction and retention. Additionally, the
corresponding cultural models and cultural settings that influence the stakeholder and
organizational goals, and the mission of the organization are presented.

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Table 4.
Organizational influences and organizational influence assessments
Organizational Mission
Trident Behavioral Health's mission is to embrace and recognize the needs of consumers and
families. Secondly, they aim to provide high quality and culturally responsive services to their
diverse communities. Lastly, their core values and fundamental principles that guide the work
and motivate the workforce are client and family-centered service, with strengthen-based
approaches, researched and data-driven decision-making and respectful, accessible, and
accountable (agency website, 2018).

Organizational Performance Goal
Trident Behavioral Health's (TBH) organizational goal is to reduce staff turnover by 30%
before August 31, 2021.

Stakeholder's Goal
Ninety-five percent of the clinical workforce was 100% satisfied with their employment at
TBH by August 31, 2021.

Assumed Organizational Influences

Organizational Influence Assessment
Cultural Model
A clinical workforce needs to perceive a
culture of trust, shared values, and
autonomy to improve job satisfaction,
employee engagement, and retention.
Survey or Interviews
The clinical workforce will participate in a
series of questions to evaluate how to trust,
shared values, and autonomy is infused in the
organizational culture to improve job
satisfaction, employee engagement, and
retention.
Cultural Model
The clinical workforce needs to see the
value of creating a supportive and
collaborative work environment.

Survey or Interviews
The clinical workforce will participate in a
series of questions that will assess their
knowledge and benefit of creating a supportive
and collaborative work environment.
Cultural Setting
The clinical workforce needs a work
culture that values and promotes shared
decision-making, open and bi-
directional communication, and
transparency.
Interviews
The clinical workforce and supervisors were
interviewed to determine the level of
supervisory and organizational support that
encourages shared decision-making, open and
bi-directional communication, and transparency.

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Cultural Setting
The organization has a strategic
roadmap (plan) that supports staff well-
being, career development, as well as
improves overall job satisfaction,
performance, and retention.

Interviews
The clinician workforce and supervisors will
participate in a focus group to solicit strategies
that support staff well-being and career
development, as well as improve overall job
satisfaction, performance, and retention.

Conceptual Framework: The Interaction of Stakeholders' Knowledge and Motivation and
the Organizational Context
The purpose of the conceptual framework is to explain the interaction and relationships
between the various factors represented in a study (Maxwell, 2013). The conceptual framework
emerges from both personal discipline orientation and ideas supported by selected literature,
which is connected to the research questions (Merriam & Tindall, 2016). Furthermore, the
conceptual framework is critical because it serves as a tool to link ideas and concepts from the
literature inclusive of personal experience to the study, which is imperative to keeping the
researcher focused on what is essential. Therefore, the conceptual framework presented here
considers the previous body of research on employee engagement and job satisfaction, and how
organizational culture influences retention and burnout among clinicians. According to Maxwell
(2013), a concept map is a visual representation of the conceptual framework for the design of a
study.
Additionally, the researcher will incorporate multiple approaches to address the research
problem; in this case, the impact of high turnover and burnout among TBH clinicians. The two
listed studies will inform these worldviews: a postpositivist and pragmatic worldview.
Postpositivist is the worldview that represents the thinking of positivism, challenges the absolute
truth of knowledge, and recognizes that the researcher cannot be absolute about his or her claims

44

as a result of human behavior and actions (Creswell, 2014). A postpositivist develops knowledge
through the lens that is based on observation and measurement of the objective reality that exists
"out there" in the world (Creswell, 2014, p. 7). Postpositivist also seek to develop relevant,
accurate statements that explain the situation of concern or identified causal relationships of the
problems (Creswell, 2014). For instance, explaining how the managers' leadership style
influences employee engagement and job satisfaction. The researcher will use the postpositivist
worldview to examine the causes of high turnover and burnout among TBH clinicians.
Furthermore, the researcher will use Pragmatism to help understand the problem from
multiple perspectives while also generating new knowledge (Creswell, 2014). Pragmatism allows
the study to take the next step with the constructed meaning and concerns itself with what will
practically work within the TBH context and its unique influences. Previously, the assumed
knowledge, motivation, and organizational influences are presented as separate elements
influencing employee engagement and job satisfaction; however, in this study, these three
elements are intertwined and do not operate in isolation. According to Clark and Estes (2008),
knowledge, motivation, and organizational needs must be addressed simultaneously for goal
achievement to occur. This conceptual framework presented here introduces how knowledge and
motivation work in tandem within the TBH's organizational context to achieve the goal of 95%
of the clinical workforce was 100% satisfied with their employer. Figure 1 below illustrates this
conceptual framework.
Figure 1
Conceptual Framework: Interaction of Stakeholder Knowledge and Motivation within
Organizational Cultural Models and Settings

45

Organizational Goal: Trident Behavioral Health’s (TBH) organizational goal is to reduce
staff turnover by 30% before August 31, 2021.

Stakeholder Goal: Ninety-five percent of the clinical workforce (clinicians) was 100%
satisfied with their employment at TBH.
Clinicians Motivation:
Utility value: self-
motivated, purpose;
Emotion: emotional
connectedness; Intrinsic:
clinician engagement in
decision-making
Clinicians Knowledge:
Declarative: employee
engagement vs
performance
outcomes/Metacognitiv
e: implications of
unmanaged stress
Trident Behavioral Health:
Cultural Settings: Organizational
culture, collaborative work
environment, and employee
engagement Cultural Models:
Leadership styles, autonomy, and
commitment

46

The figure above illustrates the stakeholder's (clinicians) goal of improving overall job
satisfaction in the workplace. However, to accomplish this goal, they must pass through both
internal knowledge and motivation influencers, as well as internal organizational barriers. The
funnel represents Trident Behavioral Health as the organization of the study and the three circles
in the center of the figure depicts the different influences within the Venn diagram to
demonstrate their interrelatedness. In Figure 1, the large green circle represents the TBH
organization's cultural settings and cultural models. Then, the blue circle contains the stakeholder
declarative (factual) and metacognitive knowledge influences, and the red circle captures the
motivation influences. The diagram (the funnel) also illustrates the interrelationship between the
three circles, which demonstrates how organizational cultural settings and cultural models (i.e.,
leadership style, staff engagement, and support) can influence the knowledge and motivation of
the stakeholder group. Moreover, the two red bi-directional arrows illustrate the
interconnectedness between the intermediary goal (organizational goal) and the stakeholder goal,
which infers that these goals can directly influence the achievement of each performance
indicator.
This study sought to understand how clinicians' knowledge, motivation, and
organizational influences interact with each other to achieve the stakeholder goal, which is to
improve overall job satisfaction and employee retention. Therefore, this study will evaluate the
intrinsic factors within the organization that influence the global goal, which is illustrated in the
figure as a green circle. Within the global goal are the knowledge and motivation influences that
affect clinicians' turnover, employee engagement, and job satisfaction within the organization.
The knowledge influences are both declarative and metacognitive about the clinician's ability to
recognize and manage his or her stress level, as well as how unmanaged stress and lack of

47

engagement can influence patient outcomes and performance. The motivation influences include
utility value concerning the level of commitment and engagement, emotion, and personal
connections with job retention and satisfaction. According to Ram and Prabhakar (2011),
employee engagement is influenced by work conditions, burnout, increased withdrawal, lower
performance, job satisfaction, and commitment. However, employees who engage in meaningful
work could lead to better performance outcomes and job satisfaction (Ram & Prabhakar, 2011).
According to Moynihan and Pandey (2007), job satisfaction is a perilous analyst of turnover and
absenteeism, and job satisfaction and organizational commitment overlap. In other words,
although the barriers are presented as independent factors, there is a tangential relationship with
one another, and they do not operate in isolation. The knowledge needed is research-based and
focuses on the clinician's intrinsic motivation and organizational culture influences on job
satisfaction and the level of employee engagement and commitment (Clark & Estes, 2008).
Furthermore, the level of employee engagement and job satisfaction is influenced by
organizational commitment, involvement, and investment (Rasheed, Khan, & Ramzan, 2013).
Complementary fit and person-environment fit are also influencers of organizational
commitment (Ballout, 2007; Ünal & Turgut, 2015b). Complementary fit exists when individual
and organizational values are congruent, and the person-environment fit is the degree of fit or
match between people, and their environment produces important outcomes or benefits for
employees (Ballout, 2007; Ünal & Turgut, 2015b). The authors noted that in order to determine
the knowledge and skills of the clinicians and to improve employee retention and engagement
and job satisfaction, it is essential first to understand what they need to know and do (Clark &
Estes, 2008). Additionally, it is essential to identify the negative influences on employees'
epistemic emotions that impede engagement and job satisfaction (Lord et al., 2002). Within the

48

broader organizational context, these influences are interacting in a tangential relationship and
are addressed simultaneously to achieve best the stakeholder goal (Clark & Estes, 2008), which
is identified in Figure 1.
Conclusion
This evaluation study sought to understand and identify the causal influences that inhibit
Trident Behavioral Health from achieving its stakeholder goal of a 95% job satisfaction rate
among the clinical workforce. This review has outlined the impact of employee engagement on
job satisfaction and performance, as well as current trends and strategies for organizations to
improve employee engagement and retention. This literature review process has informed the
identification of the assumed knowledge, motivation, and organizational influences specifically
related to the achievement of the stakeholder goal and global goal (intermediary goal). The
knowledge influences are both declarative and metacognitive concerning employee engagement
and the impact on performance outcomes, along with the implications of unmanaged stress
among the clinical workforce. The motivation influences include utility value of self-motivation
and purpose, as well as emotional connectedness and intrinsic motivation of the clinical
workforce to engage in the decision-making process to improve job satisfaction and the work
environment. As a result, the organization has observable and measurable enjoyable benefits of
working at TBH as a member of the clinical department. Chapter Three describes the validation
process for these influences.

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CHAPTER THREE: METHODOLOGY
Purpose of the Project and Questions
The purpose of this study was to conduct an evaluation study to analyze the causal
influences of the high turnover rate and burnout among clinicians at Trident Behavioral Health
(TBH) (pseudonym). The stakeholder's goal is to ensure ninety-five percent of the clinical
workforce was one hundred percent satisfied with their employment at TBH by August 31, 2021.
This stakeholder's goal aligned with the organizational mission to embrace and recognize the
needs of consumers and families and provide high quality and culturally responsive services to
their diverse communities. This study employed the Clark and Estes (2008) gap analysis model,
which systematically analyzes the gap between actual and preferred performance. The model
adapted to identify and analyze the organization's needs. Then identified the assumed
knowledge, motivational, and organizational needs based on personal understanding and the
related clinical workforce (clinicians).
As such, the questions that guide this study were the following:
1. What are the knowledge, motivation, and organizational needs necessary for
TBH to reduce the turnover rate and burnout and improve overall job satisfaction
among clinicians?
2. What is the interaction between TBH organizational culture and context and
clinicians' knowledge and motivation to reduce the turnover rate and burnout and
improve overall job satisfaction among clinicians?
3. What are the knowledge, motivation, and organizational solutions to improving
staff turnover, burnout, and overall job satisfaction among clinicians?

50

4. What are the recommended knowledge, motivation, and organizational solutions
to improving staff turnover, burnout, and overall job satisfaction among
clinicians?
Methodological Approach and Rationale
The methodology approach for this study accounted for the KMO gap analysis efficacy
and TBH organizational culture that contributed to high turnover and burnout among
clinicians. With this in mind, the study employed mixed methods (Creswell, 2014), which
incorporated the collection of both quantitative and qualitative data. The mixed-methods model
allowed the researcher to first identify statistically significant themes across a target population
through the use of survey instruments designed to address the research questions. The qualitative
research design is a flexible process of discovery that allows the researcher to explore themes
through one-on-one interviews or focus groups (Johnson & Christensen, 2015; Maxwell,
2012). Therefore, the researcher collected qualitative data through semi-structured interviews
and used a priori coding to answer the research questions. Finally, the researcher incorporated
data triangulation and participant checking, which are strategies that can enhance the validity of
a qualitative study (Creswell, 2014).
In sum, this study sought to examine the causes of high turnover and burnout among the
behavioral health clinical workforce (clinicians) at TBH. The mixed-methods approach helps
answer the research questions about the gaps in knowledge, motivation, and organizational
culture that impedes TBH from achieving their organizational goal of reducing the overall
turnover rate by 30% by August 2021. Finally, this approach allowed the results and findings to
inform the recommended research-based solutions more holistically and more rigorously.

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Sampling and Recruitment
Participating Stakeholders
The stakeholder group of focus for this study was Trident Behavioral Health clinical
workforce (clinicians). This population consisted of 54 full-time license or associate clinicians.
Associate clinicians refers to individuals who have met the required educational components, but
still need to secure at least 3000 hours of supervision before they are eligible to take the licensure
exam. There are ten (10) associate clinicians within the TBH system. The study sought to
involve at least 50% of the clinicians in the survey process. Based on the number of participants
chosen for this study, the mixed-method needed at least 25 clinicians to respond to the survey,
which Johnson and Christenson (2014) suggested was an appropriate sample size for 54
participants. A sample of at least 5-8 clinicians participated in the semi-structured phone
interview process. However, the clinicians had to be employed with TBH for at least one year in
order to participate in the interviews. The survey and interview questions were conducted in
English because for 100% of the participants, English is their primary form of communication in
the workplace.
Given that there are convergent uses of data embedded in mixed-methods research
design, the researcher used different sampling methods for each set of data, which is known as
triangulating data (Johnson & Christenson, 2014). Therefore, subjects were identified using
purposeful mixed sampling, which allowed for the use of multiple sampling strategies. For the
quantitative portion of this study, surveys were administered electronically to the clinical
workforce who provide direct services to patients, despite his or her biography. For the
qualitative part of the study, the sampling had a specific criterion for interview participants,
which was that they had to be employed with the organization for at least one year. The

52

following sections describe each of the methods used in the sampling and recruitment for the
various pieces of data collected, including surveys and interviews.
Survey Sampling Strategy, Criteria, and Rationale
According to Johnson and Christenson (2014), the purpose of sampling data in
quantitative research is to make accurate generalizations about a population. The quantitative
survey data in this study provided the researcher with the opportunity to generalize about the
TBH clinical workforce population, by generating survey questions that solicit the knowledge,
motivation, and organizational influences related to staff turnover, burnout, and job satisfaction
at TBH. The researcher submitted surveys electronically to approximately fifty-four clinicians,
consisting of the entire clinical workforce. The following criteria were used to stratify the
sample:
Criterion 1. Job classification and education level. The clinician at TBH meet three
distinct categories:
1. Possess a master's degree in social sciences (i.e., Master of Social Work,
Marriage and Family Therapist, and Professional Counseling).
2. Possess a clinical license or a registered "Associate" with the California Board
of Behavioral Sciences (BBS).
3. One year of experience working in the behavioral health or healthcare arena.
Criterion 2. Role and responsibilities. Within TBH, there are several positions that
provide direct services to consumers; for instance, there are peer support specialists and
clinical support providers that provide case management services (i.e., transportation, life
skills training, support, linking, and referrals, home visiting services). However, for this
study, the researcher will focus on the clinicians who provide therapy to an individual with

53

mental health and substance use issues—approximately 54 clinicians who provide individual
and group therapy to over 2000 consumers annually.
Interview Sampling Criteria and Rationale
Interviews are a method of qualitative data collection in which data are conducted
privately and confidentially. Interviews are a viable choice when the topics are considered
something easily discussable in every day, yet for whatever reason, are not usually discussed
(Merriam & Tisdell, 2016). This study utilized phone interviews as a means to construct
meaning regarding the knowledge, motivation, and organizational influences related to
TBH's high turnover, burnout, and poor job satisfaction among the clinical workforce. The
interview will also consider organizational cultural models and cultural settings that
influence TBH global and stakeholders' goals.
Therefore, the researcher utilized simple random sampling based on the criterion that
clinicians had to be employed with the organization for at least one year to participate in the
interviews. The researcher facilitated the interviews concurrent with the quantitative survey in
the same general time frame, which was over six weeks. The interview method aimed to engage
at least 5-8 participants, which is the research standard for noncommercial or social science
settings (Krueger & Casey, 2009). Johnson and Christenson (2014) affirm that noncommercial
interview size should consist of at least 6-7 participants. In determining the formation of the
interviews, criterion three was used.
Criterion 1. Clinical Workforce. Clinicians are selected based on their program area
(children or adult services). There are twenty-seven (27) clinicians in the Children's System of
Care (CSOC) services and twenty-seven (27) clinicians in the Adult System of Care (ASOC).
The clinicians' tenure at TBH and years of experience are not a criterion for the random

54

selection process. The researcher felt the grouping by program area would provide a broader
clinical perspective and was a more equitable process. Therefore, based on the program area,
the researcher will randomly select at least four (4) participants from CSOC and four (4)
participants from ASOC to participate in interviews.
Qualitative Data Collection and Instrumentation
Interviews
Interview protocol. The two primary methods of data collection chosen for this study
are surveys and phone interviews. These methods provide the researcher with both quantitative
and qualitative understanding and insight into the way the knowledge, motivational, and
organizational influences at TBH affects job satisfaction and retention and employee
engagement. The semi-structured interview process was conducted for over three weeks. The
interview solicitation of participants was aimed to solicit respondents from Children's and
Adult's System of Care Divisions. The researcher aimed to solicit at least four clinicians from
each System of Care Division to participate in the interviews, which is considered an
appropriate size for a noncommercial or social science setting (Krueger & Casey, 2009;
Johnson & Christenson, 2014). The interview participants were asked to respond to 20 semi-
structured open-ended questions. These questions generated responses related to the knowledge,
motivation, and organizational influences that are potential causes for TBH high turnover and
reduced job satisfaction among clinicians. The researcher conducted the focus groups in a
training /conference room at TBH. Appendix B presents the Interview Protocol.
Quantitative Data Collection and Instrumentation
Surveys

55

Survey instrument. The researcher maintained the validity of the survey; the survey
items were linked to the conceptual framework and research questions of this project (Salkind,
2017). The online survey contained thirty-four (34) questions: eight (8) demographic and
twenty-five (25) Likert-type questions based on knowledge, motivational, organizational, and
social influences. Then, the Likert-type questions will consist of five (5) knowledge questions,
ten (10) motivation questions, and ten (10) organizational questions. Furthermore, the
response options to the Likert-type questions were listed as: strongly disagree, disagree,
strongly agree, agree, or neutral (neither agree nor disagree). The survey should take
approximately 20-25 minutes for participants to complete.
Survey procedures. The surveys were administered using Qualtrics online platform.
The quantitative survey consisted of demographic questions such as age, race, ethnicity,
gender, years of service, license or intern status, program area Children's Services of Care or
Adult Services of Care (CSOC or ASOC), and employment status (full-time or part-time).
Participants were asked to respond to the survey within two weeks. Before the survey launch,
the researcher sent an email expressing a sense of appreciation and gratitude for their
participation. The researcher also sent reminder emails to qualified participants. Then,
subsequent reminder emails were sent to participants to encourage participation. This
quantitative phase took place concurrently with the qualitative phase. The next section
described the sampling for the qualitative phase. The researcher administered the surveys in
English because (90%) of the participants are proficient in English. Appendix A presents the
survey protocol.

56

Alignment of KMO Influences and Data Collection Methods and Instruments
Table 5 shows each KMO influence and the method and measure of the influence. By
examining the rows, the alignment of the influences and methods is demonstrated.
Table 5

Alignment of KMO influences, data collection methods, and instruments

Organizational Mission

Trident Behavioral Health's mission is to embrace and recognize the needs of consumers and
families. Secondly, they aim to provide high quality and culturally responsive services to their
diverse communities. Lastly, their core values and fundamental principles that guide the work
and motivate the workforce are client and family-centered services, strengthen-based approaches,
researched and data-driven decision-making, and being respectful, accessible, and accountable
(agency website, 2018).

Organizational Performance Goal

Trident Behavioral Health's (TBH) organizational goal is to reduce staff turnover by 30% before
August 31, 2021.
Stakeholder's Goal

Ninety-five percent of the clinical workforce was 100% satisfied with their employment at TBH
by August 31, 2021.

Knowledge
Influence
Survey Item Interview Item
The clinical
workforce needs to
reflect on its ability to
manage his/her stress
level effectively.

(Metacognitive)
I self-reflect by
a. Taking 15 minutes breaks.
b. updating daily vision/task board or list
c. journaling
d. All these above
e. None of these above
Give examples of
how you self-reflect
to manage your stress
level.

The clinical
workforce needs to
recognize how their
stress influences the
quality of service to
Stress influence patient care by
a. Poor patient outcomes
b. Low customer service rating
c. High no-show rates
d. All these above
Please describe how
stress can influence
the quality of care of
patients

57

patients, and
organizational
performance and
sustainability.

(Declarative-
Conceptual)
e. None of these above

The clinical
workforce needs to
know how to manage
their stress.
(Procedural)

I manage my stress in the workplace by doing
the following: (Check all that apply)

a. Exercise*
b. Deep breaths/meditation*
c. Take 15-20 minutes breaks at least 2-
3 per day*
d. Develop an internal support system*
e. foils: Eat Healthier
Please describe an
average day.
What strategies have
you incorporated to
develop to manage
your stress?

Assumed motivation influences and motivational influence assessments
Assumed Motivation
Influences
Survey Item Interview Item
Value: The clinical
workforce needs to
see value or
importance of their
work.
I find the work that I do full of meaning and
purpose:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

What aspect of your
job that you find most
rewarding? Why?
Self-efficacy: The
clinical workforce
needs to possess the
confidence they can
apply stress
management
techniques to reduce
his/her stress level.
Using the scale below, how confident are you
in doing the following right now to manage
your stress:
a. Exercise*
b. Deep breaths/meditation*
c. Take 15-20 minutes breaks at least 2-
3 per day*
d. Develop an internal support system*
● Not confident at all
● Moderately confident
● Highly confident
Describe what
techniques or
strategies you have
used to manage the
stress level.

What other techniques
can you incorporate
into your daily routine
to reduce your stress?

What barriers have
you encountered that
have prevented you

58

from adopting these
techniques?
Emotion: The clinical
workforce needs to
experience positive or
epistemic emotions to
improve employee
satisfaction.
At my job, I feel strong and vigorous:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

I am enthusiastic about my job:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,
Describe your degree
of comfort in TBH,
creating a culture of
inclusion and
anatomy.
Could you please tell
me what you meant
when you said?

If you were to change
two things related to
staff engagement,
what would be those
two things and explain
why?
The clinical workforce
(clinicians) needs to
recognize their role
and responsibility for
achieving the
organization's mission
and vision.

Attribution
My organizations' achievement of its vision
and mission is due to my own efforts.

a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

Trident Behavioral
Health (TBH)
mission statement
highlights several
key principles, which
includes creating a
work culture that is
client-centered,
respectful,
accessible, and
accountable and
motivates the
workforce.

● Tell me a little
bit about your
understanding and
experience of how
these principles
are infused within
the organization.

59

What contributes have
you provided or
demonstrated to
accomplish the TBH
mission and vision.

Assumed organizational influences and organizational influence assessment

Assumed
Organizational
Influences
Survey Item Interview Item
Cultural Model
A clinical
workforce needs to
perceive a culture
of trust, shared
values, and
autonomy to
improve job
satisfaction,
employee
engagement, and
retention.
There is a culture of trust among
employees and leadership in the
organization
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

The organization supports a culture of
autonomy in performing my daily job
responsibilities.
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,
Describe how your
values and beliefs
influence your
work and patient
engagement.

What values are
essential to an
organization's
success, and why
are these values
important to you?
What leadership
qualities are
essential for a
leader to possess to
build and/or
maintain trust and
enhance employee
retention?
● Why are
these
qualities
important to
you and/or
organization?

60

Cultural Model
The clinical
workforce needs to
see the value of
creating a
supportive and
collaborative work
environment.

There is a supportive work environment:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

Within your division, the supervisor
creates a supportive and collaborative
work environment:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

There is a culture of collaboration in my
department.
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

Please describe the
characteristics of a
supportive and
collaborative work
environment:
So, based on your
descriptions, how
would you describe
the TBH work
environment? [Ple
ase expound on
your response]

If you or a
colleague had an
idea that supports
the vision and
mission of TBH,
what platforms are
available to share
your thoughts and
ideas?
Cultural Setting
The clinical
workforce needs a
work culture that
values and
promotes shared
decision-making,
open and bi-
directional
communication,
and transparency.
My organization includes all employees
in the decision-making process
a. Strongly disagree,
b. Disagree
c. Agree
a. Strongly agree,

My organization promotes a culture of
learning and staff development
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

How would you
describe the
organizational
culture of TBH? If I
would like to ask
someone, what
would be your
perspective? Why?

Please speak about
goal setting at TBH.
How would you
describe TBH's
ability to engage
staff in goal settings
and the decision-
making process?

61

Cultural Setting
The organization
has a strategic
roadmap (plan)
that supports staff
well-being, career
development, as
well as improves
overall job
satisfaction,
performance, and
retention.
The organization has a strategic
roadmap/vision that promotes staff well-
being and career development:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

1. Let us talk about
professional
development at
TBH, how engaged
do you feel in the
process? As an
individual?

If you were to
change two things
related to staff
engagement, what
would be those two
things and explain
why?

As teams, suppose
you were in charge
and could make
one change that
would enhance the
organization. How
do you implement
change?

Data Analysis
Survey
In this study, the researcher conducted quantitative and qualitative data analysis in the
same manner as the data collection: concurrently. The data analysis was triangulated between
the quantitative survey data and the qualitative transcriptions of the focus groups throughout
the analysis process. Accompanying the analysis for the quantitative data, the researcher
calculated measures of mean and range and standard deviation from the ratio data. These
measures provided an in-depth quantitative comprehension of the participants (Johnson &
Christenson, 2014). Then the frequencies of responses were calculated for ordinal data. The
survey was conducted using the software Qualtrics, and thus the tool also supported analysis,

62

especially for cross-tabulations between data points to aid in disaggregation. Survey items
were presented in narrative form as well as with visualizations and tables in Chapter Four.
Interviews
In addition, the researcher employed several strategies and tools to analyze data for
qualitative interviews. After each interview, the researcher reviewed the recordings to ensure
that respondents' information was captured accurately. The researcher took additional notes
while reviewing the recordings to capture specific thoughts that are relevant to the study. A
transcription service was employed to assist with completing the focus group transcripts.
Once the transcriptions are received and reviewed for accuracy, the researcher will delete the
recordings to maintain the confidentiality of participants. During the process of reviewing the
transcripts for accuracy, the researcher plans to engage in member checking.
Subsequently, the researchers used the interview protocol items to code the data within
the KMO framework named priori coding. Also, open codes were used to capture responses
outside of the protocol questions that might pertain to another KMO dimension, and finally,
axial coding was used to categorize the open coding.
Credibility and Trustworthiness
This study acknowledged that the researcher is the instrument in the qualitative phase of
the research. The qualitative phase brought with its inherent bias (Merriam & Tisdell, 2016).
According to Clark and Estes (2008), the impetus for organizational change depends on whether
the manner through which data is collected is credible, the trustworthiness of the investigator, the
investigator's intentions, and an impeccable respect for the respondents. Therefore, this section
describes the steps the researcher took to minimize that inherent bias and increase credibility and
trustworthiness through all phases of the research. This study employs a multiphase, mixed-

63

methods approach with data collection efforts spanning four-months, which is paramount in
building and maintaining the trust of the respondents, in order to ascertain useful data.
Additionally, the researcher will encourage the increase of credibility by infusing the
following data collection and interpretation principles as an aspect of this study: sincerity,
transparency of methods, and ethical rigor (Merriam & Tisdell, 2016). Subsequently, the
researcher's interview questions were randomly administered to non-participants and field-tested
off-site in English. This field testing assessed appropriateness for the site, in both question
content and length.
As mentioned previously in the ethics section, the researcher is neither an evaluator nor
direct supervisor of any respondents participating in this study; however, the researcher holds a
department position parallel to the Director of TBH. Therefore, it is vital for developing
credibility that participants understand that their engagement in the study is held in confidence.
During data collection, the researcher provided a written statement and verbally communicated
to the participants the importance of confidentiality and maintaining confidentiality throughout
the process. These actions increased credibility and trustworthiness, so respondents feel
comfortable in responding to the survey and focus group questions honestly and openly
(Creswell, 2014).
In summary, this study acknowledged that there are multiple ways human beings
experience phenomena and the resulting narrative they form about their experience.
Research reminds us of the virtual impossibility of indeed "capturing reality" (Merriam &
Tisdell, 2016, p. 243). Like the instrument in qualitative research, the researcher must be
trustworthy and conduct the study ethically. The validity of the findings relies on this
trustworthiness.

64

Validity and Reliability
Primarily the reason for choosing interviews as a method of data collection is that it
allows ideas to be mutually constructed (Merriam & Tisdell, 2016). Therefore, contamination
as a threat to validity applies only to the quantitative phase of the study. To circumvent this
threat, the researcher provided a statement in the survey email, requesting participants not to
discuss the survey with colleagues until a specified date. Ultimately, the reliability then lies
upon the respondents to participate honestly, openly, and with fidelity to the survey
instructions.
The methods of sampling, both with the survey and the focus groups, lend themselves to
validity and reliability. The participants were selected both randomly and purposefully, which
will reduce selection bias and increase reliability (Krueger & Casey, 2009). The researcher
intends to have 80% of the population take part in the study, across the previously identified
constituents reflective of the various groups. This number of participants contributes to greater
validity in the study, providing enough data to reliably generalize about the population (Johnson
& Christenson, 2014). The participants' total was at least 80%, allowing the researcher to
generalize the study population, but not generalize to other contexts.
Ethics
The foundation of this study was established on fundamental ethical principles and
guidelines associated with the Institutional Review Board (IRB). According to Rubin and Rubin
(2012), an essential element of any study and the Institutional Review Board (IRB) process is
that of informed consent. Therefore, the researcher has a moral and ethical responsibility to
ensure that all participants were knowledgeable about the informed consent and agreed by
signing the informed consent, and the four research principles were executed (Glesne, 2011). The

65

four principles that must be followed with human research subjects are: providing full disclosure
(informed consent), allowing withdrawal from the study with no stipulations, eliminating all
unnecessary risks (doing no harm), and ensuring that the benefits outweigh all potential risks
(Glesne, 2011). Hence, the researcher adhered to the University of Southern California's
Institutional Review Board (IRB) requirements for informed consent. The researcher ensured
participation is confidential, data is securely stored, and permission is obtained to record
interviews. Then, the researcher informed participants of their protection through the University
of Southern California's Human Subjects Protection Program (HSPP).
During all phases of the study, the researcher declared that all participant's information
would be held confidential, and at no time would their responses be shared with supervisors or
directors. The researcher also reminded interview participants about their responsibility for
maintaining confidentiality, through verbal or written agreement, administered at the
beginning of the survey and interview. In addition, in the participant agreement, the researcher
informed participants that their participation is voluntary, and they are free to withdraw from
the study without retribution, at any time during the study. The researcher also requested
permission to record the interviews via audio. Following each interview, the researcher
transcribed the interviews verbatim. Then, the researcher stored all data temporarily outside of
any of the organization's databases during the analysis phases and plans to destroy all files
following the transcription, after six months.
Finally, the researcher made every effort to ensure participants' understanding of
confidentiality, credibility, and trustworthiness. The ultimate goal is for the respondents to
have a sense of security and comfort to speak honestly while completing the survey and
being an active participant in the focus groups (Creswell, 2014). While the researcher is

66

neither an evaluator nor direct supervisor participating in this study, the researcher is a
director of a similar organization. Therefore, it is critical that the researcher remains
objective, follows the protocol, and stays mindful of these roles and possible dilemmas.
Limitations and Delimitations
There are limitations and delimitations the researcher must be aware of as this study commences.
Limitations are the factors that are not in the researcher's locus of control. Some limitations that
existed in this study are:
● The study was dependent on the truthfulness of the respondents.
● The department continuously has high turnover within the clinical workforce,
specifically, the clinicians, which may lend itself to a historical threat to validity.
● The study was conducted over a relatively short period (three to four months) and
during the holiday season (Thanksgiving and Christmas), which could influence
respondents' participation and response.
Delimitations are the decisions the researcher makes that may have implications for the study.
The delimitations that affect this study include:
● Data was collected only from clinicians. The data did not include senior
managers, support staff, or paraprofessionals' perspectives.
● Data from each of the qualitative and quantitative phases were collected
concurrently.

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CHAPTER FOUR: RESULTS AND FINDINGS
This study seeks to evaluate and analyze the causal influences of the high turnover rate
and burnout among clinicians at Trident Behavioral Health (TBH; pseudonym). The
stakeholder's goal is ninety-five percent of the clinical workforce will be one hundred percent
satisfied with their employment at TBH by August 31, 2021. The stakeholder's goal aligns with
the organizational mission to embrace and recognize the needs of consumers and families and
provide high quality and culturally responsive services to their diverse communities. This study
will employ the Clark and Estes (2008) gap analysis model, which systematically analyzes the
gap between actual and preferred performance. The model will be adapted to identify and
analyze the organization's needs, then identify the assumed knowledge, motivational, and
organizational needs based on personal understanding and the related clinical workforce
(clinicians).
As such, the questions that guide this study are the following:
1. What are the knowledge, motivation, and organizational needs necessary for
TBH to reduce the turnover rate and burnout and improve overall job satisfaction
among clinicians?
2. What are the interactions between TBH organizational culture and context and
clinicians' knowledge and motivation to reduce the turnover rate and burnout and
improve overall job satisfaction among clinicians?
3. What are the knowledge, motivation, and organizational solutions to improving
staff turnover, burnout, and overall job satisfaction among clinicians?

68

4. What are the recommended knowledge, motivation, and organizational solutions
to improving staff turnover, burnout, and overall job satisfaction among
clinicians?
Participating Stakeholders
The stakeholder group of focus for this study is the Trident Behavioral Health clinical
workforce (clinicians). This population consists of 54 full-time license or associate clinicians.
The sampling included clinicians who provide direct services (therapy) to individuals with
mental health or substance use disorders. The study sought to involve at least 50% of the
clinicians in the survey process. Based on the number of participants chosen for this study, the
mixed-method needs at least 24 clinicians to respond to the survey, which Johnson and
Christenson (2014) suggest is appropriate for a sample size of 54. Then a stratified sample of
clinicians was asked to participate in a semi-structured phone interview, with at least one year of
experience with their current employer. Additionally, the study sought to engage at least 5 to 8
participants for phone interviews.
Determination of Assets and Needs
Survey Participants
The quantitative survey was sent by email to 47 clinicians who had at least a year of
experience working at TBH were represented in the quantitative phase of the study. The study
sought to develop a sample that represented all licensure levels of TBH clinicians and years of
experience. Based on 24 survey respondents, 82.61% were female, and 17.39% male. The
highest age group represented in this study was 25-34 years old at 70.83%. Figure 2 shows the
gender, and Table 1 shows the age represented in the survey.

69

Figure 2
Survey Population by Gender

Table 6
Survey Population by Age
# Response (n=24) Percentage Count
1 18-24 years old 4.17% 1
2 25-35 years old 70.83% 17
3 35-44 years old 16.67% 4
4 45-54 years old 8.33% 2
4 55 years and older 0.00% 0
Total 100% 24

The study sought to develop a sample that represented all licensure levels of TBH
clinicians and program areas. Figure 3 shows the licensing levels by program areas represented
in the survey. Based on 24 respondents, license clinicians made up 25% of survey respondents,
and associated clinicians represented 75% of survey respondents. In the different program areas,
37.50% of the respondents represented the Children's System of Care (CSOC), and 62.50%

70

represented respondents from the Adult's System of Care (ASOC).
Figure 3
Licensure and Program Areas Representation

As previously stated, during this study only clinicians who provide direct services
(i.e., therapy) to clients completed the survey. Table 4 outlines the number of years of clinical
experience represented in the sample population. The average number of total years for clinicians
was two. The standard deviation with experience in behavioral health, ranging from relatively
new (1 year) to the veterans' clinicians (5+ years), was three years.
Table 7
Number of Years Employed with the Agency
# Response (n=24) Percentage Count
1 Less than 1 year 12.50% 3
2 1 to 4 75.00% 18
3 5 to 9 12.50% 3
4 10+ 0.00% 0
Total 100% 24

71

Phone Interviews
As described in Chapter Three, a total of 3 clinicians participated in phone interviews.
The researcher was able to solicit volunteers through an email that was sent to all employees by a
"mutual third party" within the organization but included specific criteria for interview
participants. The criteria included having at least one year of experience working as a clinician
with their current employer. Additionally, a confidential online Google appointment link was
included in the email. There were representatives from the children and adult systems of care
who participated in the interview process, and their contribution is captured in the below
sections.
Results and Findings for Knowledge Causes
The results and findings of the survey are included in this section as it relates to the
research questions. Thus, the results and findings are reported through the
clear lenses of knowledge, motivation, and organizational influences identified in the conceptual
framework and the literature. The chapter concludes with a discussion of these results and
findings as they interact and triangulate each other. This study did not include observation nor
document analysis.
Declarative Knowledge
Influence 1: The clinical workforce needs to recognize how their stress and job
satisfaction influence the quality of service to patients, organizational performance, and
sustainability.
Survey results: The clinicians were asked to identify how stress impacts patient care
based on a list of four influences. The question and responses were designed to assess
participants' understanding and knowledge of stress can impact patient care. The results ranged

72

from 35.59% for one item to 16.95% for one item. Two items rated the same at
23.73%. However, to be determined as an asset, all four of the components were required to
meet the 70%. Therefore, this influence is determined in the survey as a need. See table 8.
Table 8
Survey Result for Declarative Knowledge of Patient Care Influences
# Declarative Knowledge Item (n=24) Percentage Count
Describe how stress can influence the quality of care of
patients. Please check all that apply.

1 Poor patient outcomes* 35.59% 21
2 Poor customer service rating* 23.73% 14
3 High no-show rates for services* 23.73% 14
4 Increased crisis episodes (i.e., hospitalization)* 16.95 10
Note. Asterisk (*) denotes the correct response.
Interview findings. Participants were asked to describe how stress can influence the
quality of care of patients. It is evident that all three participants knew and were able to speak to
the impact of stress on patient care. As for influences on patient care, Participant 1 asserted "that
I am not always present for my client, so I may not provide the most appropriate therapeutic
interventions." Participant 3, who works with children, agreed, and stated, "I sometimes lack
focus and am not able to give 100% to my clients, which could result in the poor quality of care
and high no-show rates." Participant 2 stated, "I am not able to connect to my clients nor stay
actively engaged during clinical sessions. Sometimes, I have difficulties monitoring clients'
progress, hence could lead me to make poor decisions."
Summary. The assumed influence is that clinicians know the impact that their stress has
on patients. Based on the survey results, the influence was determined to be a need however, the
influence was determined to be an asset in the interview responses. Survey results did not meet

73

the threshold and were determined to be a need. However, 100% of interview participants knew
and gave examples of multiple ways stress influences patient care. As more clinicians responded
to the survey (51%), and only 3 participants provided an interview, the surveys provided more
weight. Therefore, this influence is determined to be a need.
Metacognitive Knowledge
Influence 2. The clinical workforce (clinicians) needs to reflect on their ability to manage
their stress levels effectively.
Survey results. The clinicians were asked how they managed their stress at work, based
on a list of six strategies. The results ranged from 23.94% for one item to 1.41% for one item.
Two items rated the same at 19.72%. However, to be determined as an asset, all six of the
components were required to meet the 70%. Therefore, this influence is determined in the survey
as a need. See table 9.
Table 9
Survey Result for Metacognitive Knowledge of Stress Management Techniques
# Metacognitive Knowledge Item (n=24) Percentage Count
Clinicians were asked how they managed their stress at
work. Please check all that apply

1 Take short breaks* 23.94% 17
2 Mediation* 12.68% 9
3 Deep breaths* 22.54% 16
4 Exercise* 19.72% 14
5 Journaling 1.41% 1
6 Reflecting on the positive* 19.72% 14
Note. Asterisk (*) denotes the correct response.

Interview findings. Participants were asked to describe what stress management
technique they use to reduce their stress levels. It is evident that all three participants knew and

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were able to speak to the different strategies they used to reduce stress. For instance, Participant
1 asserted that they incorporate several different stress management techniques; "I listen to
music, talk with co-workers, take breaks, and call someone for support." Participant 1 also
asserted, "These strategies help me to reduce my stress and anxiety level." Participants 2 and 3
stated they incorporated similar strategies as Participant 1. However, Participant 2 and 3 asserted,
"they read the bible and pray at work." Also, Participant 2 stated, "My spirituality is what keeps
me grounded, so I'm not as stressed as some of my colleagues."
Summary. The assumed influence is that clinicians have different stress management
techniques to reduce their stress levels at work. Based on the survey results, the influence was
determined to be a need; however, the influence was determined to be an asset in the interview
responses. As more clinicians responded to the survey (51%), and only 3 participants provided
an interview, the surveys provided more weight. Therefore, this influence is determined to be a
need.
Results and Findings for Motivation Causes
Value:
Influence 1. The clinical workforce needs to see the value or importance of their work.
Survey results. The clinicians were asked if they find their work meaningful and
purposeful, based on a scale from strongly disagree to agree strongly. The results ranged from
58.33% for agreed to 41.67% for strongly agreed. The combined overall was 100%; therefore,
this influence is determined to be an asset. See table 10.
Table 10
Survey Result for Value Influences
# Value Influence Items (n=24) Percentage Count

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Employees need to see the value or
importance of their work. Please select from
the following:

1 Strongly disagree 0.00%% 0
2 Disagree 0.00% 0
3 Agree 58.33% 14
4 Strongly agree 41.57% 10
Total 100% 24

Interview findings. Participants were asked to describe what aspect of their job they
found most rewarding. All three participants were able to speak very passionately about the
reasons they found their work rewarding and meaningful. For instance, Participant 1 said, "I have
the ability to change people's lives, so they can live their best life, in spite of their mental
capacity." I also provide individuals with Hope." Participant 2 asserted, "My work is important
because people need to see that someone cares for their wellbeing and future. With this in mind,
I know I have the ability to improve clients' outcomes through my engagement and support I
provide them." Participant 2 also asserted, "When I see the visible transformation of my clients,
this is what brings me joy." Finally, Participant 3 asserted, "I have been chosen for this career, so
I take my job very seriously. I have the ability to influence a person's life in a way that can
change their pathway. My desire is to leave an imprint in their lives that is memorable and life
changing. This job is hard because we are dealing with the unknown (brain), but it is so
rewarding when I see my clients thrive."
Summary. The assumed influence is that clinicians see the value of their work. Based on
the survey results, the influence was determined to be an asset. Ironically, the influence was also
determined to be an asset in the interview responses. Therefore, this influence is determined to
be an asset.

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Self-Efficacy:
Influence 1. The clinical workforce needs to possess the confidence they can apply stress
management techniques to reduce his/her stress level.
Survey results. The clinicians were asked how confident you are with integrating stress
management techniques at work, based on a scale from no confident to confident. The results
were 83.33% for moderately confident and 12.50% for confidence. However, to be determined
as an asset, moderately confident, and confident were required to meet 70%. Combined results
are 95.83%, which exceeds the threshold; therefore, this influence is determined in the survey as
an asset. See table 11.
Table 11
Survey Result for Self-Efficacy Influences
# Self-Efficacy Influence Items (n=24) Percentage Count
How confident are you using stress
management techniques at work? Please
select from the following:

1 No confident 4.17% 1
2 Moderately confident 83.33% 20
3 Confident 12.50% 3
Total 100% 24

Interview findings. Participants were asked how confident they were about their ability
to use stress management techniques at work. It is evident that all three participants had different
degrees of confidence using stress management techniques at work, and only one of the three
was confident. For instance, Participant 1 asserted, "I would have a difficult time using stress
management strategies at work due to my busy schedule, caseload, and internal distractions.
Participant 1 also emphasized, "My supervisor does not support staff doing stress techniques on

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the job; therefore, impedes my ability to use stress management techniques at work." Participant
3 also stated that using stress management techniques on the job would be challenging.
Participants 3 asserted, "I have a supervisor that is not supportive and doesn't allow staff to take
additional breaks if needed. We get two breaks a day, but this job is stressful, and sometimes we
need additional breaks to make it through the day." However, Participant 2 asserted that there are
no barriers to performing stress management techniques at work. Participant 2 stated, "I have a
supportive supervisor who has an open-door policy, where I have a safe place to talk about
stressful situations. They support staff taking breaks, walking, and talking with peers through the
day."
Summary. The assumed influence is that clinicians are confident that they can apply
stress management techniques to reduce their stress levels. Based on the survey results, the
influence was determined to be an asset. However, the influence was determined to be a need in
the interview responses, because only one in three of the participants was confident that they
could use stress techniques on the job. As more clinicians responded to the survey (51%), and
only 3 participants provided an interview, the surveys provided more weight on the
results. Therefore, this influence is determined to be an asset.
Emotion:
Influence 1. The clinical workforce needs to experience positive emotions to improve
employee satisfaction.
Survey results. The clinicians were asked about their enthusiasm for their job measured
on a scale from strongly disagree to agree strongly. The results ranged from 75.00% for agreed,
and 12.50% strongly agreed. The combined overall was 87.50%; as a result, this influence is
determined to be an asset. See table 12.

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Table 12
Survey Result for Emotion Influences
# Emotion Influences Items (n=24) Percentage Count
I am enthusiastic about my job.

1 Strongly disagree 0.00% 0
2 Disagree 12.50% 3
3 Agree 75.00% 18
4 Strongly agree 12.50% 3
Total 100% 24

Interview findings. Participants were asked what aspect of the job is most satisfying, and
why? All three participants provided similar responses to the questions that demonstrated this
influence to be an asset. Participant 1 asserted, "I am most satisfied when I see my clients have to
see the "light come on," which means they are able to see the benefit of therapy in their lives. I
am extremely excited when I see a client become actively involved in their treatment; to the
point, their physical appearance is enhanced." Participant 2 asserted, "I am joyful and motivated
to continue this work; when a client has recovered to the point that he or she no longer needs
intense behavioral health services (successful discharge)." Participant 2 further elaborated, "I
know I am doing my job when clients obtain housing stability because a lot of clients I serve are
homeless." Finally, Participant 3 asserted, "I am most gratified when I see that therapy has made
a direct impact on the client's life and their families. I am more excited when clients who have
been estranged from their families due to their mental health or substance use are reconnected.
This is why I do this job."
Summary. The assumed influence is that clinicians experience positive emotions on the
job. Based on the survey results, the influence was determined to be an asset. Furthermore, the

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influence was determined to be an asset in the interview responses. Therefore, this influence is
determined to be an asset.
Attribution:
Influence 1. Clinical workforce (clinicians) needs to recognize their role and
responsibility for achieving the organization's mission and vision.
Survey results. The clinicians were asked if the organization's achievement of its vision
and mission is due to their efforts, based on a scale from strongly disagree to agree strongly. The
results ranged from 79.17% agreed to 4.14% strongly agreed. Combined results are 84.31%,
which exceeds the threshold. Therefore, this influence is determined to be an asset. See table 13.
Table 13
Survey Result for Attribution Influences
# Attribution Influences Items (n=24) Percentage Count
The organization's achievement of its vision and
mission is due to my own efforts. Please select
from the following:

1 Strongly Disagree 0.00% 0
2 Disagree 16.677% 4
3 Agree 79.17% 19
4 Strongly agree 4.170% 1
Total 100% 24

Interview findings. Participants were asked to give examples of their efforts to assist the
organization with accomplishing its vision and mission. All three participants were able to
articulate in a meaningful and passionate way about their efforts to achieve the organization's
vision and mission. For instance, Participant 1 asserted, "I give a 100% to client care and the job.
I am a hard worker and a committed employee. I work extremely long hours to make sure I meet
productivity standards and complete documentation before I leave the office." Participants 2 and

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3 asserted that their contribution to the organization's vision is to create a friendly and supportive
environment for their colleagues, in order to reduce staff turnover." Participant 3 stated, "I
volunteer for events, both internal and external. I even try to acknowledge and celebrate special
occasions (i.e., birthdays, childbirths, graduations) with my colleagues, to build team cohesion. I
believe it is everyone's job to improve the agency outcomes and ensure our colleagues remain
with the organization." Participant 2 asserted, "I love what I do, even though leadership doesn't
always acknowledge staff for their contributions. However, I still give it 110% every day
because of my clients and because I believe in our mission."
Summary. The assumed influence is that clinicians understand how their work efforts
influence the organization's vision and mission. Based on the survey results, the influence was
determined to be an asset. Moreover, the influence was determined to be an asset in the interview
responses. Therefore, this influence is determined to be an asset.
Results and Findings for Organization Causes

Cultural Models

Influence 1. An organization needs to perceive a culture of trust, shared values, and
autonomy to improve job satisfaction, employee engagement, and retention.
Survey results. The clinicians were asked if their organization supports a culture of
autonomy (make independent decisions) based on a scale from strongly disagree to agree
strongly. The result ranged from 66.67% agreed to 4.17% strongly agreed. Combined results are
70.84%, which exceeds the threshold; therefore, this influence is determined to be an asset. See
table 14.

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Table 14
Survey Result for Cultural Models 1 Influences
# Cultural Models 1 Influence Items (n=24) Percentage Count
The organization has a culture of inclusion
and autonomy. Please select from the
following:

1 Strongly disagree 12.50% 3
2 Disagree 16.67% 4
3 Agree 66.67% 16
4 Strongly agree 4.17% 1
Total 100% 24

Interview findings. Participants were asked if their organization has a culture of
inclusion and autonomy. It is evident that all three participants had different interpretations and
levels of degree of inclusion and autonomy. For instance, Participants 1 and 2, asserted that their
organization is very inclusive and allows staff to make independent decisions. Participant 1
stated, "The organization supports and encourages independent decision, especially with the
clientele served. If we cannot make independent decisions, we cannot do our job effectively, and
our patients will suffer." Participants 2 affirmed, "We have to work independently due to the
nature of our work, and my supervisor encourages the level of independence." However,
Participant 3 had a different response and experience than the other participants. "I have a
"micro-manager," and they like to be involved in every decision staff in their unit makes. They
say that they embrace and support staff making independent decisions, but their behavior and
response doesn't align."
Summary. The assumed influence is that the organization has a culture that supports
clinicians' autonomy, and based on the survey results, the influence was determined to be an
asset. However, the influence was determined to be a need in the interview response, because

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only two in three of the participants indicated they have autonomy. Even though, this influence
meet the threshold of a 70% rating, but based on the interview responses which were consistent
among participants and low overall survey rate; the researcher believes this influence need
further consideration and evaluation in order to be determined an asset. Therefore, this influence
is determined to be a need.
Cultural Models

Influence 2. The organization needs to see the value of creating a supportive and
collaborative work environment.
Survey results. The clinicians were asked if their organization was supportive, based on a
scale from strongly disagree to agree strongly. The results ranged from 54.17% agreed to 33.33%
strongly agreed. Combined results are 87.50%, which exceeds the threshold; therefore, this
influence is determined to be an asset. See table 15.
Table 15
Survey Result for Cultural Models 2 Influences
# Cultural Models 2 Influences Items (n=24) Percentage Count
The organization's work environment is
supportive and collaborative. Please select
from the following:

1 Strongly disagree 8.33% 2
2 Disagree 4.17% 1
3 Agree 54.17% 13
4 Strongly agree 33.33% 8
Total 100% 24

Interview findings. Participants were asked if their organization's work culture was
supportive and collaborative. All three participants had similar responses to this question.

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Participant 1 asserted, "There is no formal process to engage staff in decisions. There was a
"suggestion box" where staff could provide suggestions to leadership; however, no one has really
taken advantage of this process. To be honest, leadership rarely checks the box because papers
are still visible after several months." Participant 1 also stated, "The organization used to have
"All Staff" meetings, but it was discontinued several years ago. This was a great opportunity
where leadership (Director) would provide program updates from a local and state perspective.
This platform also allows staff to mingle with other co-workers." Participant 2 affirmed the
benefit of having "All Staff" meetings, "I wish leadership would consider bringing this forum
back because staff felt more involved and informed in the organization's goals and direction."
Participant 3 also supported the concept of reinstituting the "All Staff" meeting. We can use
different mechanisms to engage staff, such as "Zoom" or "Blue-Jean" to communicate and
engage staff. Leadership can even broadcast or record the meeting and upload it on the agency
intranet, they just need to do something different."
Summary. The assumed influence is that the organization has a work culture that is
supportive and collaborative. Based on the survey results, the influence was determined to be an
asset. However, the influence was determined to be a need in the interview responses. As more
clinicians responded to the survey (51%), and only 3 participants provided an interview, the
surveys provided more weight. Even though, this influence is determined to be an asset based on
the survey results; the researcher feels the structure of the question did not reflect the intended
response necessary to support overall survey finding. Therefore, interview responses provided
more weight, so influence is determined to be need.
Influence 1. The clinical workforce needs a work culture that values and promotes shared
decision-making, open and bi-directional communication, and transparency.

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Survey results. The clinicians were asked to support shared decision-making, open
communication, and transparency, based on a scale from strongly disagree to agree strongly. The
results ranged from 29.17% agreed to 0.00% strongly agreed. Combined results are 29.17%,
which did not meet the threshold; therefore, this influence is determined to be a need. See table
16.
Table 16
Survey Result for Cultural Settings 1 Influences
# Cultural Settings 1 Influence Items (n=24) Percentage Count
The organization has a culture that values
shared decision making, transparency, and
open communication. Please select from the
following:

1 Strongly disagree 37.50% 9
2 Disagree 33.33% 8
3 Agree 29.17% 7
4 Strongly agree 0.00% 0
Total 100% 24

Interview findings. Participants were asked if their organization included staff in the
decision-making process. The evidence shows that all three participants had similar responses to
this question. For instance, Participant 1, 2, and 3 asserted, "the department doesn't have a formal
or consistent structure or process that allows staff to provide input nor does the agency support
this type of structure." Participant 1 stated, "We are never invited to participate in policy or
program decisions; we are just expected to implement new or reviewed programs with no ability
to ask questions prior to the roll out." Participant 1 went on to say, "I feel if leadership would
engage staff prior to implementation, some pitfalls can be avoided." Participant 2 and 3
emphasized, "There is support and collaboration among individual teams or divisions, but not the

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entire department." Participant 2 asserted, "Leadership tends to make decisions independently,
then when the implementation strategy doesn't work, staff are the blame for the failure. However,
if we were included in the beginning, we could have shared our practical application perspective;
in order to avoid major gaps in the process, especially since we know how our clients respond to
program changes."
Summary. The assumed influence is that the organization has a culture that supports
shared-decision-making, open dialogue, and transparency between leadership and clinicians.
Based on the survey results, the influence was determined to be a need. Also, 100% of interview
participants affirmed that the organization's strategic goals do not embrace or foster a culture of
shared decision-making, open communication, and transparency. Therefore, this influence is
determined to be a need.
Cultural Settings
Influence 2. The organization needs a strategic roadmap (plan) that supports staff
wellbeing, career development; as well as improving overall job satisfaction, performance, and
retention.
Survey results. The clinicians were asked if the organization's strategic roadmap (plan)
supports staff development, based on a scale from strongly disagree to agree strongly. The results
ranged from 41.67% agreed to 4.17% strongly agreed. Combined results are 45.84%, which did
not meet the threshold; therefore, this influence is determined to be a need. See table 17.
Table 17
Survey Result for Cultural Settings 2 Influences
# Cultural Settings 2 Influence Items (n=24) Percentage Count
The organization has a strategic plan
(roadmap) that supports staff development.
Please select from the following:

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1 Strongly disagree 8.33% 2
2 Disagree 45.83% 11
3 Agree 41.67% 10
4 Strongly agree 4.17% 1
Total 100% 24

Interview findings. Participants were asked if their organization supports staff
development. The evidence shows that all three participants had similar responses to this
question that demonstrated that this influence is an asset. Participants 1, 2, and 3 asserted, "The
organization does a great deal with providing training to staff. We have the ability to attend
training outside the department, and we can get reimbursed." Participant 3 asserted, "Our Staff
Development Division under Quality Assurance does a great job with identifying relevant
clinical training curriculum that support our clinical practices. This is the "strongest" Division in
the department." Participant 1 agreed that the department does a great job with training staff;
however, Participant 1 asserted, "I wish the training unit would create more training
opportunities for new and veteran employees throughout the year. If you are a new employee,
you will receive 6 to 9 months training, but after that period, you have to look for training
yourself. However, our busy schedule and caseload makes it hard for staff to look and attend
training."
Summary. The assumed influence is that the organization has a strategic roadmap (plan)
that supports staff development. Based on the survey results, the influence was determined to be
a need. However, the influence was determined to be an asset in the interview responses. As
more clinicians responded to the survey (51%), and only 3 participants provided an interview,
the surveys provided more weight. Therefore, this influence is determined to be a need.

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Summary of Validated Influences

Table 18, 19, and 20 show the knowledge, motivation, and organizational influences for
this study and their determination as an asset or a need.
Knowledge
Table 18
Knowledge Assets or Needs as Determined by the Data
Assumed Knowledge Influences Asset or Need
Declarative: The clinical workforce needs to
recognize how their stress and job satisfaction
influences the quality of service to patients,
organizational performance, and
sustainability.

Need
Metacognitive: The clinical workforce
(clinicians) needs to reflect on their ability to
manage his/her stress level effectively.

Need

Motivation
Table 19
Motivation Assets or Needs as Determined by the Data
Assumed Motivation Influences Asset or Need
Value: The clinical workforce needs to see the
value or importance of their work.

Asset
Self-Efficacy: The clinical workforce needs to
possess the confidence they can apply stress
management techniques to reduce his/her
stress level.

Asset
Emotion: The clinical workforce needs to
experience positive or epistemic emotions to
improve employee satisfaction.

Asset
Attribution: The clinical workforce (clinicians)
needs to recognize their role and responsibility
Asset

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for achieving the organization's mission and
vision.

Organizational
Table 20
Organizational Assets or Needs as Determined by the Data
Assumed Organizational Influences Asset or Need
Cultural Models 1: A clinical
workforce needs to perceive a culture of trust,
shared values, and autonomy to improve job
satisfaction, employee engagement, and
retention.
Need
Cultural Models 2: The clinical
workforce needs to see the value of creating
a supportive and collaborative work
environment.
Need
Cultural Settings 1: The clinical workforce
needs a work culture that values and promotes
shared decision-making, open and bi-
directional communication, and transparency.
Need
Cultural Settings 2: The organization has a
strategic roadmap (plan) that supports staff
wellbeing, career development, as well as
improve overall job satisfaction, performance,
and retention.
Need

Recommendations for the influences determined to be needed will be addressed in
Chapter Five.

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CHAPTER FIVE: DISCUSSION AND RECOMMENDATIONS
Discussion
Chapter Four presented the results and findings from the survey and interviews in an
effort to answer the first three research questions, identifying the knowledge, motivation, and
organizational needs necessary for TBH to reduce the turnover rate and burnout and improve
overall job satisfaction among clinicians. The results and findings also considered the interaction
between TBH organizational culture and context and clinicians’ knowledge and motivation to
reduce the turnover rate and burnout and improve overall job satisfaction among clinicians. The
results in Chapter Four also considered the knowledge, motivation, and organizational solutions
to improving staff turnover, burnout, and overall job satisfaction among clinicians.
Chapter Five considers the final research question: “What are the recommended
knowledge, motivation, and organizational solutions to improving staff turnover, burnout, and
overall job satisfaction among clinicians?” This chapter presents these solutions to the identified
and validated needs within the context of the organization. Finally, the recommendations chapter
concludes with a proposed implementation and evaluation plan for the organization.
Recommendations from Practice to Address KMO Influences
Knowledge Recommendations
Introduction. The data collection for this study has been completed, and the knowledge
influences in Table 21 represent the complete list of assumed knowledge influences and their
probability of being validated. According to Clark and Estes (2008), declarative knowledge is
necessary before applying it to classify or identify. Therefore, the validation process is based on
the most frequently mentioned knowledge influences to achieving the stakeholders’ goal and is
supported by research. Also, Table 21, implies that the validation of these knowledge influences

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is highly probable for achieving the stakeholders’ goal. Finally, Table 21 shows the
recommendations for these highly probable influences based on theoretical principles.
Table 21
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence
Asset or
Need Principle and Citation Context-Specific
Recommendation
The clinical
workforce (clinicians
needs to reflect on its
ability to manage
his/her stress level
effectively. (M)
Need Learning and motivation
are enhanced when
learners set goals, monitor
their performance, and
evaluate their progress
towards achieving their
goals. (Ambrose et al.,
2012; Meyer, 2011)

Provide training to the
clinical workforce on
different self-reflective
strategies to help manage
their stress level.
Then provide staff an
opportunity to demonstrate
self-reflective strategies in
the learning environment,
for example, journaling.
The clinical
workforce needs to
recognize how their
stress and job
satisfaction influences
the quality of service
to patients,
organizational
performance, and
sustainability. (D)
Need Modeling to-be-learned
strategies or behaviors
improve self-efficacy,
learning, and performance
(Denler, Wolters, &
Benzon, 2009).

Provide training that models
and provide scenarios to
help the clinical workforce
better understand the impact
that stress can have on the
quality of service.

Increasing the metacognitive knowledge of clinicians to manage their stress level
effectively. The data showed that clinicians lacked metacognitive knowledge about identifying
symptoms of stress and how to manage their stress level effectively. Metacognition informs a

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practical recommendation for addressing this gap. According to Ambrose et al. (2012); Meyer,
(2011), learning and motivation are enhanced when learners set goals, monitor their
performance, and evaluate their progress towards achieving their goals. Educating and training
provide the needed practice and resources to help clinicians identify and manage job-related
stressors. The recommendation then is for TBH clinical workforce (clinicians) to be educated
and trained on different self-reflective strategies to help manage their stress level. Additionally,
clinicians can be shown self-reflective strategies in the learning environment, for example,
journaling.
In order for an individual to effectively manage their stress level, he or she must be able
to identify the stressors in their lives (Slemp & Vell-Brodrick, 2014). Education and training are
essential components to expanding one's understanding and knowledge. These are the intrinsic
and extrinsic factors impacting an individuals’ stress level (Moyniham & Pandey, 2007). It is
not enough to identify the stressors in a person's life, there must be tools and enhanced
knowledge that can be transferred in practical application. Self-reflection is a strategy that is
used to identify intrinsic factors that influence a person's life and perspectives (McEwin &
McEwin, 2004). Individuals can adopt positive reassessment (reflection) to reduce work-related
stress or stressors (Koinis, Giannou, Drantaki, Angelaina, Stratou, & Saridi, 2015).
Increasing declarative knowledge of clinicians how stress can influence the quality
of service. The data showed that clinicians lacked declarative knowledge about unmanaged
stress that can influence the quality of services. Social cognitive theory informs a useful
recommendation for addressing this knowledge gap. According to Denler, Wolters, and Benzon
(2009), modeling to-be-learned strategies or behaviors improves self-efficacy, learning, and
performance. This would suggest that providing training with modeling and scenarios could

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increase clinicians' understanding of the impact of unmanaged stress. The recommendation then
is that TBH clinical workforce (clinicians) receive training with scenarios that enhance their
understanding of the impact of stress on the quality of services. Also included in the training
environment will be modeling, which allows the learner to model behavior that reinforces their
understanding of the materials. An example would be to provide vignettes and allow the
clinicians to demonstrate how they address/manage the situation.
In order to enhance an individual’s declarative knowledge, he or she must have an
awareness and acknowledgment of their limitations (Schatzman & McDonald, 2011). Therefore,
the goal of training and staff development should be to increase a person's cognition and ability
to incorporate new learning into the work environment and beyond (Koinis, Giannou, Drantaki,
Angelaina, Stratou, & Saridi, 2015a). In some instances, training alone is not enough to increase
a person's knowledge and understanding of a particular subject matter; therefore, trainers must
construct different learning methods in training settings. According to Koinis et al. (2015a),
incorporating different techniques, such as modeling into the learning environment, can enhance
participants’ attainment and recall. Thus, training environments should be designed to infuse
various learning methods and aids to address the different learning needs of the participant; for
instance, integrating auditory and visual information to maximize working memory capacity
(Mayer, 2011).
Motivation Recommendations

Introduction. The data collection for this study has been completed, and the motivation
influences in Table 22 represent the complete list of assumed motivation influences and their
probability of being validated. According to Clark and Estes (2008), three motivational factors
influence an individual’s performance, which is choice, persistence, and mental effort. Clark et

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al. (2008) assert that choice is going beyond intention to start something, persistence is
continuing to pursue a goal in the face of distractions, and mental effort is seeking and applying
new knowledge to solve an innovative program or perform a new task (2008). Therefore, the
validation process is based on the most frequently mentioned motivation influences in achieving
the stakeholders’ goal during informal interviews and supported by research. Finally, Table 22
shows the recommendations for these highly probable influences based on theoretical principles.
Table 22
Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence*
Asset
or
Need

Principle and
Citation
Context-Specific
Recommendation
Value: The clinical
workforce needs to
see the value or
importance of their
work.
Asset Activating personal
interest through
opportunities for
choice and control can
increase motivation
(Eccles, 2006).

Provide employees the opportunity
to provide input in the planning and
development of programs and
policies; for instance, establish a
monthly or quarterly collaborative
decision-making platform, to
encourage a sense of choice or
autonomy.
Emotion: The
clinical workforce
needs to
experience
positive or
epistemic
emotions to
improve employee
satisfaction.
Asset Positive emotional
environments support
motivation (Clark &
Estes, 2008).
Support learners’ need
for autonomy and
choice (Bono et al.,
2007).

Persistence.
Create a quarterly platform (i.e.,
All Staff Meeting) that values and
supports staff creativity and
innovative practices, along with
giving them the autonomy to utilize
their skills and knowledge to
explore different methods to
achieve the organization’s mission.

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Self-efficacy: The
clinical workforce
needs to possess
the efficacy, so
they can apply
stress management
techniques to
reduce his/her
stress level.
Asset Self-efficacy is
increased as
individuals succeed in
a task (Bandura, 1997)
Provide a support system, such as a
wellness group that teaches and
demonstrates different stress
management techniques to enhance
self-efficacy; in order to reduce
stress.
Attribution: The
clinical workforce
(clinicians) needs
to recognize their
role and
responsibility for
achieving the
organization’s
mission and
vision.
Asset Learning and
motivation are
enhanced when
individuals attribute
success or failures to
effort rather than
ability. (Anderman &
Anderman, 2009).

Provide an employee recognition or
incentive program that identifies
ways to enhance a person's efforts
to achieve the organization’s
mission and vision.
Provide opportunities for
employees to see links between
their contributions and the agency's
mission.
Increase the clinicians’ sense of value. The clinical workforce (clinicians) inability to
see the value or importance of their work can have a direct impact on organizational
performance. The stakeholder’s lack of interest or effort indicates a solution rooted in the
Expectancy-Value theory to address this gap. According to Eccles (2006), activating personal
interest through opportunities for choice and control can increase motivation. This would suggest
that providing employees the opportunity to provide input in the planning and development of
programs and policies increases intrinsic motivation and value. The recommendation is for TBH
to establish a monthly or quarterly collaborative decision-making platform, to encourage a sense
of choice or autonomy of clinicians in making decisions about their work environment.

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In order for an individual to see the value of their work, he or she must have a sense of
purpose and belief that their job makes a difference (Saks, 2006). Moyniham and Pandey (2007)
state that an individual’s beliefs are essential in life and job satisfaction and performance. Kular
et al., 2008) affirms that job involvement and group decision-making increases employees’
intrinsic motivation and expectancy-value. In some instances, job autonomy is well-being across
many cultures, and individual performance and other work behaviors (Gagné & Bhave, 2011).
According to Rasheed, Khan, and Ramzan (2013), an individual’s ability to have autonomy in
their work environment has shown to increase employee satisfaction and engagement. Thus,
organizations need to establish a work culture that encourages autonomy and inclusion to
increase job retention and satisfaction (Tampubolon, 2016).
Improving the emotions of clinicians. Clinicians need to demonstrate positive or
epistemic emotions in order to improve employee satisfaction. The stakeholder’s inability to
display positive or epistemic emotions demonstrates that Emotion theory is an appropriate
solution to addressing this gap. When one is in a positive emotional environment that supports
motivation and autonomy, the mere option of choice improves the overall job satisfaction (Clark
& Estes, 2008; Bono et al., 2007). This would suggest that creating a work culture that supports
autonomy and employee choice could influence the epistemic emotions of clinicians. The
recommendation is for TBH to create a platform, such as “All-Staff meetings” or “collaborative
learning sessions” that supports and values staff creativity and innovative practices. This will
provide TBH staff the autonomy to utilize their skills and knowledge to explore different
methods to achieve the organization’s mission.
In order for an individual to exhibit epistemic emotions in the work environment, they
must feel supported and engaged in efforts to improve and meet work demands (Schaufeli &

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Bakker, 2004). Engaged employees have positive work-related experience, performance, and
longevity (Ellickson & Logsdon, 2001a). In some instances, engaged employees have high
retention rates and are more committed to their organization’s vision and mission (Schaufeli &
Bakker, 2004). According to Bright (2008a), work conditions, good social relationships with
coworkers and supervisors, promotion opportunities, professional development opportunities,
and participatory management strategies can influence job satisfaction and turnover. Therefore,
creating a supportive environment that values and supports creativity and innovation are positive
motivators in improving the epistemic emotions of employees ((Slemp & Vell-Brodrick, 2014).
Increasing self-efficacy of clinicians. The clinicians need to possess self-efficacy so
they can apply stress management techniques to reduce their stress level. The stakeholder’s self-
efficacy is a critical component to a person's ability to apply and learn different stress
management techniques. Self-Efficacy theory is a solution to addressing this gap among
clinicians. High self-efficacy can positively influence motivation, and self-efficacy increases as
individuals succeed in a task (Pajares, 2006; Bandura, 1997). The increase of self-efficacy
suggests that providing clinicians with the support and resources that teach and demonstrate
different strategies and providing feedback on their performance would continue to increase their
self-efficacy. The recommendation is for the organization to develop a support system, such as a
wellness group that teaches and demonstrates different stress management techniques in order to
enhance self-efficacy and stress reduction among clinicians.
In order to increase self-efficacy, training, and direct feedback regarding an employees’
performance has shown to be an effective method to increase one's confidence level (Gallimore
& Goldenberg, 2001). Additionally, creating a learning culture within an organizational construct
has been demonstrated to increase self-efficacy, which ultimately improves performance and

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retention (Lok and Crawford, 1999). According to Bandura (1991), high self-efficacious
individuals experience joy or happiness when confronted with a difficult task; conversely, low
self-efficacious individuals exhibit despondent behaviors. Thus, organizations must invest and
support staff development and training to increase self-efficacy among its stakeholders (Albdour
& Altarawneh, 2014).
Increasing clinicians’ attributions. The clinical workforce (clinicians) needs to
recognize their role and responsibility for achieving the organization’s mission and vision. The
stakeholder’s clinician lack of awareness of how the attributions of their behavior contribute to
organization success and failures is a significant gap. Therefore, Attributions theory is identified
as a solution to address this gap among clinicians. According to Anderman and Anderman
(2009), learning and motivation are enhanced when individuals attribute success or failures to
effort rather than ability. Attributing success or failures to effort suggests there is a program that
identifies ways to enhance a person’s efforts to achieve the organization’s mission and vision.
The recommendation is for the organization to develop recognition programs. Built within the
guidelines of these programs are the organization’s core values, which allows the employee to
see links between their contributions and the agency's mission.
In order to increase employees’ attributions, the organization must create ways to
acknowledge a person’s contribution to the performance goals (Khan, 1990). Ram and Prabhakar
(2011) suggest that employees who engage in meaningful work and are recognized for their
efforts lead to better performance outcomes. Additionally, constructing a system that encourages
and rewards others for their efforts increases self-efficacy and productivity (Ryan & Deci, 2000).
Therefore, organizations must create ways to acknowledge employees for their contributions
toward achieving its mission and vision (Prato, 2013).

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Organization Recommendations
Introduction. The data collection for this project has been completed, and the
organization influences in Table 23 represent the complete list of assumed organizational
influences and their probability of being validated. According to Fix and Sias (2006), practical
communication skills can enhance organizational capacity and build positive relationships with
employees. Notably, Clark and Estes (2008) assert when policies and procedures are aligned and
communicated from the top with all stakeholders, organizational performance increases.
Therefore, the validation process is based on the most frequently mentioned organizational
influences in achieving the stakeholders’ goal during informal interviews and supported by
research. Finally, Table 23 shows the recommendations for these highly probable influences
based on theoretical principles.
Table 23
Summary of Organization Influences and Recommendations
Assumed Organization
Influence*

Asset or
Need
Principle and Citation

Context-Specific
Recommendation
Cultural Model
An organization needs to
perceive a culture of trust,
shared values, and
autonomy to improve job
satisfaction, employee
engagement, and retention

Need

Organizational
effectiveness increases
when the leaders are
trustworthy, and in turn,
trust their team. The
most visible
demonstration of trust
by a leader is
accountable to
autonomy.

(Colquitt, Scott &
LePine, 2007 as cited in
Starnes, Truhon &
McCarthy, 2010, p. 6)

Construct a quarterly
collaborative group
platform that allows
service providers (line-
staff) and administration to
discuss and develop
policies and procedures.
Subsequently, build within
the construct “peer
ambassadors” who are
responsible for
communicating the
outcomes from the meeting
and solicit feedback from
their peers to share with

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the collaborative group
meeting.
Cultural Model
The organization needs
to see the value of
creating a supportive
and collaborative work
environment.

Need
Effective organizations
ensure that
organizational
messages, rewards,
policies, and procedures
that govern the work of
the organization are
aligned with or are
supportive of
organizational goals
and values (Clark and
Estes, 2008)

Organizational
effectiveness increases
when leaders identify,
articulate, focus the
organization’s effort on
and reinforce the
organization's vision;
they lead from the why

(Wigfield & Eccles,
2000)
Expectancy value
Develop a leadership
culture that understands
the importance of
communicating the reason
(why) behind the change
and allows staff to process
their thoughts and provide
input in a safe
environment.
Then support and
encourage staff to actively
participate in policy and
system development.

Cultural Setting
The clinical workforce
needs a work culture
that values and promotes
shared decision-making,
open and bi-directional
communication, and
transparency.

Need
Effective leaders
understand the
intricacies of
organizational
communication

(Fix, B., & Sias, P. M.,
2006; Lewis, L.K.,
2011; Conger, J., 1991)
Develop an environment or
system where all
stakeholders are involved
in the decision-making
process. This is
accomplished by
developing a collaborative
decision-making model or
providing opportunities
(set-time) for line-staff
representatives to
participate in leadership
meetings.

Cultural Setting

Need
Organizational
effectiveness increases
when leaders help the
organization set clear,
Develop a strategic plan in
collaboration with line-
staff that establishes
SMART goals to reduce

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The organization needs
a strategic roadmap
(plan) that supports
well-being, career
development, as well as
improving overall job
satisfaction,
performance, and
retention.

concrete, and
measurable goals,
aligned with the
organization’s vision
(Elmore, 2002)

Effective change efforts
ensure that
everyone has the
resources (equipment,
personnel, time, etc)
needed to do their job,
and that if there are
resource shortages, then
resources are aligned
with organizational
priorities (Clark and
Estes, 2008)
staff turnover and improve
overall employee
satisfaction. In addition,
develop a communication
plan that includes bi-
directional communication
strategies and performance
dashboards; to keep staff
engaged and motivated.

Develop a workgroup to
evaluate and explore
different funding
opportunities and strategies
that support the strategic
objectives.

Building a work culture of trust, shared values, and autonomy (Cultural Model).
The organization's inability to create a work culture that fosters trust, shared values, and
autonomy can have a direct impact on employee’s job satisfaction, engagement, and retention.
According to Colquitt, Scott, and LePine (2007), organizational effectiveness increases when the
leaders are trustworthy, and in turn, trust their team. They also emphasize that the most visible
demonstration of trust by a leader is accountability to autonomy (2007). The researcher has used
Leadership theory to develop a recommendation to close the gap. This would suggest that
including employees in the decision-making process and allowing them freedom (autonomy) to
explore new, innovative approaches would improve job satisfaction and retention. Therefore, the
recommendation is for TBH to construct a quarterly collaborative group platform that allows
service providers (line-administration) to discuss and develop policies and procedures. For
instance, staff can provide a status report on system or policy implementations or provide
improvement ideas from their perspective. Subsequently, the organization will build within the

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collaborative decision construct, “peer ambassadors,” who are responsible for communicating
the outcomes from the meeting to their peers and solicit feedback to share with the collaborative
group meeting.
In order for an organization to become more productive with improving employee job
satisfaction, engagement, and retention, creating a supportive work environment, healthy
interpersonal relationships, and open communication are essential factors to incorporate (Kahn,
1990). According to Zammuto and Krakower (1991), employees who believe that their
organization is a closely-knit team creates a sense of mutual respect and commitment among all
stakeholders. Likewise, Yousef (1998) emphasizes three primary components of organizational
commitment: a strong belief in and acceptance of the organization’s goals and values
(identification), a willingness to exert considerable effort on behalf of the organization
(involvement), and a strong intent or desire to remain with the organization (loyalty). Therefore,
organizations must create a collaborative culture that values open communication and group
decision-making to improve job satisfaction and retention (Kahn, 1990).
Creating a supportive and collaborative work environment (Cultural Model). An
organization must create a supportive and collaborative work environment to achieve its
organizational goal (Prato, 2013). Organizational effectiveness increases when leaders identify,
articulate, focus the organization’s effort on, and reinforce the organization's vision; they lead
from the why (Wigfield & Eccles, 2000). Clark and Estes (2008) affirm that an effective
organization ensures that organizational messages, rewards, policies, and procedures that govern
the work of the organization are aligned with or are supportive of organizational goals and
values. The researcher has used the expectancy theory to develop a recommendation to close the
gap. Hence, this would suggest that creating a work environment that supports staff and

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embraces collaborative learning and decision-making improves organizational performance.
Therefore, the recommendation is for TBH to develop a leadership development program and
mentor program that focus on effective communication, change management, building internal
collaborative partnerships, and other factors in order to nurture the value of internal partnerships
among employees.
In order for an organization to be successful and accomplish its vision, leadership must
understand the benefits of creating a collaborative work culture (Ryan & Deci, 2000). When
employees are allowed to participate in the decision-making process, they are more engaged, put
more effort into their work, and feel less strain (Gagné & Bhave, 2011). According to Prato
(2013), organizational success with improving employee engagement depends on four (4)
primary workplace conditions: an organization’s culture, continuous reinforcement of people
focused on policies, meaningful metrics, and organizational performance. Finally, when
employees are involved in group decision-making, they are more motivated and engaged in their
work assignments and more productivity (Clark & Estes, 2008).
Creating a work culture that values and promotes shared decision-making and
transparency (Cultural Setting). An organization must create a work culture that values shared
decision-making, transparency, and bi-directional communication if they want to improve
employee retention and satisfaction and overall performance. The researcher has used leadership
theory to develop a recommendation to close the gap. Effective leaders understand the intricacies
of organizational communication and are willing to take the necessary actions (Fix, B., & Sias, P.
M., 2006; Lewis, L.K., 2011; Conger, J., 1991). Hence, this would suggest that creating a work
environment that supports and embraces collaborative learning and decision-making can have a
sufficient impact on job retention and satisfaction. Considering the amount of research in the

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area of collaborative learning and decision making, it is beneficial for TBH to develop an
environment or system where all stakeholders are involved in the decision-making process. For
instance, allotting time in the leadership meetings so line-staff can provide their input on policy
decisions or system improvement strategies.
Organizations that value honesty and integrity and promote efficiency and open lines of
communication have a more significant impact on job satisfaction and retention (Mosadegh-Rad
& Hossein-Yarmohammadian, 2006). Employees’ voice creates a level of respect towards the
leaders of the organization; employee voice and employee trust in senior management influence
their level of engagement and job satisfaction (Rees, Alfes, & Gatenby, 2013) Additionally,
employees who perceive themselves as being active participants and opinions are valued and
more engaged at work (Rees, Alfes, & Gatenby, 2013).
Creating an organizational strategic roadmap (Cultural Setting). An organization
must develop a strategic roadmap that clarifies and reinforces the organizational vision and
mission. The researcher has used Leadership theory to develop a recommendation to close the
gap. Organizational effectiveness increases when leaders help the organization set clear,
concrete, and measurable goals, aligned with the organization’s vision (Clark & Estes, 2008).
Consequently, the organization must create a strategic planning process that includes all levels of
staff, as well as establish concrete, attainable and measurable goals. Therefore, the
recommendation is for TBH to develop a strategic plan in collaboration with line-staff that
establishes SMART goals, to reduce staff turnover and improve overall employee satisfaction.
In addition, TBH should develop a communication plan that includes bi-directional
communication strategies and performance dashboards to keep staff engaged and motivated.

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Organizational effectiveness increases when leaders help the organization set clear,
concrete, and measurable goals, aligned with the organization’s vision (Bogue & Hall, 2003).
Marsch (2012) asserts that strategic roadmaps are most effective when all stakeholders
(leadership and staff) are involved in the process. In addition, establishing benchmarks in goal
settings is critical to measuring organizational performance and outcomes (Clark & Estes, 2008;
Marsch 2012). Therefore, setting clear objectives and measurable performance milestones is an
effective way for an organization to monitor and evaluate performance, and hold stakeholders
accountable (Dowd, 2005; Levy & Ronco, 2012). So, it is essential that organizations develop a
strategic roadmap that can provide direction and guidance over the next three to five years to
improve job retention and performance.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The researcher utilized the New Work Kirkpatrick Model (NWKM) to implement and
evaluate the plan due to its straightforwardness, simplicity, flexibility, and accountability
safeguards (no shortcuts) (Kirkpatrick & Kirkpatrick, 2016). The New World Kirkpatrick Model,
which evolved from the original Kirkpatrick Four-Level Model of Evaluation, includes four
levels of training. However, the New World version plans levels in reverse order from the
original. The New World version begins with the end in mind (Level Four). Level Four (Results)
refers to the degree to which participants achieve the stated outcomes from the training. During
this level, leading indicators or observable measurements are defined. Then Level Three
(Behavior) identifies the critical behaviors and required drivers to reinforce on-the-job
performance. Level Two (Learning) then determines the degree to which learning occurred in the
areas of knowledge and skill, attitude, confidence, and commitment. Finally, Level One

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(Reaction) measures the impressions of the participants and the degree to which they have found
the experience relevant and engaging (Kirkpatrick & Kirkpatrick, 2016).
Through careful planning and evaluation, the demonstrated value of the
recommendations to the organization will be presented to TBH stakeholders. Emphasizing the
NWKM, the researcher also embedded the conceptual framework in this study, which
emphasizes the importance of addressing all areas of knowledge, motivation, and organizational
influences in an organization. Therefore, methods and milestones were developed to monitor and
evaluate the strategic lead indicators, as well as target knowledge, motivation, and abilities to
identify and manage intrinsic and extrinsic factors that influence job retention and satisfaction.
Organizational Purpose, Need, and Expectations
Trident Behavioral Health (TBH) mission is to embrace and recognize the needs of
consumers and families. Secondly, they aim to provide high quality and culturally responsive
services to their diverse communities. Lastly, the core values and fundamental principles guide
the work and motivate the workforce are a client and family-centered service, strength-based
approach, research, and data-driven decision-making, and being respectful, accessible, and
accountable (agency website, 2018). The problem of practice is to evaluate the impact of high
turnover and burnout among behavioral health’s clinical workforce (clinicians). The stakeholders
for this study are clinicians, and the recommendations are to reduce the turnover rate by 30% and
improve overall job satisfaction over the next two years.
Level 4: Results and Leading Indicator
To achieve the organization’s mission is the highest priority for the organization.
According to Kirkpatrick (2016), identification of leading indicators is an essential component to
evaluating organization progress towards mission fulfillment. Concerning TBH's ability to

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reduce staff turnover and improve employee engagement, the leading strategic indicators are
staff retention and productivity. To measure these indicators, the researcher has chosen the
employee retention rate (turnover) and employee engagement and satisfaction. Therefore,
developing and measuring leading indicators to support organizations is essential to determining
whether goals are met (Kirkpatrick & Kirkpatrick, 2016). As such, a clinician's ability to manage
his or her stress level is significant in reducing staff turnover and burnout. There are specific
leading indicators that act as the benchmark throughout the implementation and evaluation
process. Infused in this process are both internal and external short-term outcomes. As TBH
achieves the internal outcomes, it can then expect to see the external outcomes also realized.
External outcomes include increased retention and job satisfaction rates and employee
engagement in meaningful ways. Table 24 below outlines these internal and external outcomes
and the related metrics and methods for measuring them.
Table 24
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased patient
satisfaction rate by 30%
each year.
Scores on the patient survey.

Quarterly and/or annual
patient survey reports
collected by administration.
Improved community
perception of TBH
services.
Ratings of consumer group
surveys.
Administration participation
in consumer group survey
results.

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Decreased complaints
from patients, family
members, or community
stakeholders
.
Number of complaints Monthly
complaint/compliance
tracking reports
Quarterly or annual
community survey results.
Annual community focus
groups or informant interview
results
Internal Outcomes
Improved employee
satisfaction among the
clinical workforce.
Employee satisfaction survey
scores.
1. Monthly or quarterly
employee satisfaction survey
reports.
2. Monthly productivity
reports
Reduced turnover
among clinicians
Number of clinicians leaving.

1. Monthly or quarterly
retention and vacancy reports.
2. Employee Exit Interview
reports
Increased line-staff
participation in
leadership meetings
Number of participants

Attendance sheets collected
by supervisors.
Improves relationships
among staff and
leadership
Number of complaints
Number of reassignments or
terminations
Supervisor tracking of
monthly complaints and
personnel action reports

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Level 3: Behavior
Critical behaviors. The most significant and the most challenging part of an
implementation and evaluation plan is Level Three, because of the difficulty in supporting and
holding stakeholders accountable for applying their learning (Kirkpatrick & Kirkpatrick, 2016).
Therefore, leadership and clinicians’ behaviors must be monitored to ensure goal achievement.
These behaviors include learning and creating a new organizational culture, which encompasses
collaborative learning and decision-making opportunities, bi-directional communication
platforms, leadership and staff development cohorts, and job aides to accomplish the stakeholder
and organizational goals. Table 25 below outlines each of these critical behaviors, their related
metrics, methods, and timing.
Table 25
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s) Method(s) Timing
1. Clinicians
demonstrate an
effective way to
manage their stress
level
Number of stress-
related claims

Retention rate
Comparison to
prior year claims &
leave requests

Retention report
Quarterly
2. Clinicians more
engaged in the
decision-making
processes
Attendance at
leadership meetings
or workgroups

Retention rate
Documentation
from meetings
(agendas, sign-in
sheets & minutes)

Review retention
report
Monthly/Quarterly

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3. Clinicians meet with
clinical supervisor for
wellness checks (10-
15-minute huddles)
Establish a wellness
or engagement log
and calendar
Submit calendar
and engagement
log to TBH
Administration
Monthly
Required drivers. There are four types of drivers: reinforcing, encouraging, rewarding,
and monitoring that support the above-mentioned critical behaviors. Reinforcing drivers are
those that emphasize the importance of the transfer of the new skills into daily activity
(Kirkpatrick & Kirkpatrick, 2016). These include the knowledge related solutions outlined
previously in the chapter, such as job aids teaching clinicians’ different techniques to manage the
stress level, develop approaches to improve employee engagement, and creating an
organizational culture of inclusion. Encouraging drivers are those systems, supports, and
processes that provide consistent inspiration for participants to continue the transfer of the skills
(Kirkpatrick & Kirkpatrick, 2016). Additionally, encouraging drivers include motivation related
solutions such as rationales that provide utility value for student-centered learning, the modeling
of strategies, and targeted and useful feedback. Rewarding drivers are those that recognize the
appropriate implementation of the skills (Kirkpatrick & Kirkpatrick, 2016). These rewarding
drivers include public or private recognition and publication incentives for the employee’s work.
Table 26 below outlines the reinforcing, encouraging, and rewarding drivers necessary
for teachers to implement student-centered learning in their daily activities, and which critical
behaviors they support.
Table 26
Required Drivers to Support Critical Behaviors

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Method(s) Timing Critical
Behaviors
Supported
1, 2, 3 Etc.
Reinforcing
The HR/Training Department will educate and train the
clinical workforce on different self-reflective strategies
to help manage their stress level.
Quarterly 1
HR/Training Department will develop a support system,
such as a wellness group that teaches and demonstrates
different stress management techniques, to enhance self-
efficacy, in order to reduce stress
Six months 1, 3
HR/Training department will update the New Employee
Orientation module to infuse principles of collaborative
partnership, (internal and external stakeholders), self-
care
Ongoing 1, 2
Provide employees the opportunity to provide input in
the planning and development of programs and policies;
for instance, establish a collaborative decision-making
platform.
Monthly 2, 3
The training department will create
supervisory/leadership cohorts that focus on
collaborative decision-making, change management, and
effective communication.
Quarterly or
more frequently
if needed
2, 3
Encouraging
Clinicians provide debriefs to the leadership and director
regarding improvement strategies or new ideas.
Quarterly 2, 3
Rewarding
Establish an employee recognition or incentive program
that identifies ways to enhance a person's efforts to
achieve the organization’s mission and vision.
Monthly 1, 2, 3

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Monitoring
HR will monitor and track the number of employees exit
related job satisfaction concerns.
Quarterly 1, 2, 3
Senior-level Executive staff (Director/Assistant
Directors) will connect with clinicians and supervisors
to assess employee engagement and satisfaction.
Quarterly 2, 3
Senior-level will allow direct reports to participate in
leadership meetings to provide input in policy decisions
or program development prior to implementation.
Quarterly 1, 2, 3

Organizational support. In order to achieve the organizational outcomes, organizational
support for the drivers must occur continuously so that the implementation of the
recommendation is successful (Kirkpatrick & Kirkpatrick, 2016). The organization must be
willing to implement a collaborative decision-making platform that encourages and values staff
input. Built within the collaborative construct is the ability to create “peer ambassadors,” who are
responsible for conveying and soliciting information from their peers to share with leadership.
The organization must develop leadership training cohorts that focus on effective
communication, change management, and the importance of collaborative partnerships; in order
to improve employee engagement and retention.
For this purpose, senior managers must develop a strategic plan in collaboration with
direct reports. The strategic goals must be clear and align with the vision and mission of the
organization. The plan must include an evaluation and monitoring process, along with providing
status reports to the employees quarterly. Leadership must have a willingness and flexibility to
modify the plan, specifically if the strategies are not producing the desired outcomes.
Furthermore, the organization must develop a communication plan that includes bi-directional

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communication channels between direct reports and leadership, and performance dashboards to
keep staff engaged and motivated to complete the plan objectives. Finally, the organization must
provide the necessary resources (i.e., budget, hardware, software, equipment, and facilities), as
well as time and physical and emotional endurance to build to achieve the strategic vision.
Level 2: Learning
Learning goals. After completion of the below-recommended solutions, the stakeholders
will be able to:
1. Accurately recognize job stressors and implement strategies to lower their stress
level before it affects their mental and well-being, (D-P)
2. Effectively self-evaluate and manage one’s stress level, (M)
3. Enhance self-efficacy, so they can apply stress management techniques to reduce
his/her stress level (SE)
4. Recognize the value of clinical practice and how it contributes to the
organization’s ability to achieve its vision and mission, (V-A)
5. Experience positive or epistemic emotions to improve employee satisfaction (E)
Program. The learning goals listed in the previous section will be achieved by
developing a platform that encourages and supports a collaborative partnership framework. This
framework is designed to promote group decision-making and open and bi-directional
communication (transparency) in order to improve employee retention and satisfaction. Building
a collaborative partnership framework illustrates to an employee that their feedback and ideas are
valued and supported by administration. Subsequently, this leads to higher retention and job
satisfaction rates (Ram & Prabhakar, 2011). Ultimately, employees who are more engaged in
group decision-making have lower stress levels and more productivity (Ellickson & Logsdon's,

113

2001a). Therefore, this framework is being done in order to support addressing the organization's
gaps.
As part of the collaborative partnership framework, the agency director will create a
venue where leadership and direct reports have an opportunity to discuss and develop system
improvement ideas and policies. The program that will be developed is called the “Collaborative
Partnership (CP) Meeting,” which will meet monthly for at least two hours. The purpose of this
forum is to review, discuss, or develop policies and procedures for the agency, as well as
achieving the learning goals. Participants for this meeting will consist of the director, assistant
directors, clinical managers, and direct reports. However, the direct reports for the CPM will be
identified by their peers. Each division or program area will select two lead peers to be their
representatives. The leads are responsible for gathering input and ideas from their peers as well
as sharing information from the meeting. The rationale for this structure is to engage all staff in
the decision-making process and to promote team cohesion.
In addition to creating a collaborative partnership framework, it is imperative the
organization develop a stress management program to reduce stress among the clinical
workforce. The program will train staff on different self-reflective strategies to help manage their
stress level. This program will also incorporate opportunities for staff to demonstrate self-
reflective strategies in the learning environment, for example, breathing techniques and
meditation; along with, providing job aides (i.e., videos) to lower stress. To monitor the
effectiveness of the stress management program on staff retention, job satisfaction, and stress
management; senior leadership will review and analyze survey and evaluation data. The rationale
for this program is to support and sustain the mental and physical wellbeing of the clinical
workforce.

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Components of learning. A person's ability to apply declarative knowledge to a
particular situation is a critical component to solving a problem. According to Schatzman and
McDonald (2011), a person must have an awareness and acknowledgment of their limitations in
order to enhance their declarative knowledge. Thus, stakeholders (clinicians and leadership)
must acknowledge their role and responsibility in creating a healthy and productive work
environment. Therefore, the goal is to construct a collaborative decision-making platform to
illustrate to the employee their thoughts and ideas are valued and heard. As such, Table 27 lists
the evaluation methods and timing for these components of learning.
Table 27
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Ask clinicians to share different improvement
strategies to address organizational gaps

Formative: During collaborative
partnership meetings
Clinicians are sharing stress management
strategies with their peers

During team meetings
Complete an evaluation of the partnership
framework process

After each CP meeting for the next three
months
Procedural Skills “I can do it right now.”
Demonstrate procedural skills by providing
different stress management techniques
.
During team meetings
Attitude “I believe this is worthwhile.”
Clinical workforce recognizes the value of their
work and how it contributes to the organization’s
ability to achieve its vision and mission

Employee Satisfaction surveys during the
Program

Customer Satisfaction surveys during the
Program
Confidence “I think I can do it on the job.”
Survey items using scaling questions

After each CP meeting for the next
months
Commitment “I will do it on the job.”

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Survey items using scaling questions After each CP meeting for the next three
months

Level 1: Reaction
It is essential to determine how clinicians react to being a part of a collaborative
partnership framework that encourages group decision-making and staff inclusion. Table 28 lists
the methods of evaluating engagement, relevance, and satisfaction of participants' reactions to
the learning event(s).
Table 28
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Staff participation during the meeting Collaborative partnership meeting and meeting
minutes

Leadership engagement and solicitation of
with staff input during the meetings
During partnership meetings and meeting
minutes

Attendance at the leadership meeting Sign-in sheets from each collaborative
partnership meetings
Relevance
Participant’s evaluations of the new
collaborative partnership framework and its
relevance to their work

Participant evaluations after the first meeting in
the Program
Pulse checks with participants via a
roundtable discussion

During CPF meeting
Customer Satisfaction
Pulse checks with participants via a
roundtable discussion

During CPF meeting

Evaluation Tools
Immediately following the program implementation. Built within the collaborative
partnership framework model, there will be two Blended Evaluation tools developed to measure

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the efficiency and vitality of the collaborative decision-making process. The primary evaluation
tool will be administered after each meeting to assess the level of staff engagement, satisfaction,
and effectiveness of collaborative partnership meetings (Level 1). The evaluation approach also
calls for brief, periodic pulse checks with participants during the meeting to assess the relevance
of the content and structure of the meeting (Level 2). See Appendix A for the survey tool.
Delayed for a period after the program implementation. Approximately eight weeks
after the implementation of the collaborative partnership meeting, and then again at eight weeks,
leadership will administer a survey containing scaled items to measure the participant’s
perspective, satisfaction, and vitality of the meeting (Level 1), confidence and value of (Level 2),
and the influence of the framework on staff retention and satisfaction (Level 3). See Appendix B
for the survey tool.
Data Analysis and Reporting
The Level Four goals for the implementation of the Collaborative Partnership Framework
consist of increased staff engagement in policy and program development, increased clinician
retention and increased employee satisfaction. For the greatest impact, program evaluation
outcomes must be visible to stakeholders (Bright, 2008a). Therefore, leadership should visually
display program outcomes on the performance dashboard on the agency’s website and intranet.
Figure 4 below demonstrates a dashboard with example data regarding job retention and
employee satisfaction among clinicians. The Department of Quality Performance Management
(QPM) could create similar dashboards to monitor Levels One and Three.
Figure 4
Sample dashboard to report progress toward goals

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Summary
The noted implementation and evaluation plan were designed using the New World
Kirkpatrick Model. Through this process, success is defined from the beginning and offers the
organization a clear return on expectations as well as places learning at the center (Kirkpatrick &
Kirkpatrick, 2016). Based on this model, an organization can address the knowledge, motivation,
and organizational influences defined and validated in this study by setting the conditions for an
actively engaged, productive, and satisfied clinical workforce.
Strengths and Weaknesses of the Approach

The strengths and weaknesses of the approach will be discussed in this section. KMO
influences demonstrated some strengths and weaknesses. The information will be analyzed to
enhance the pros and cons here. The Clark and Estes (2008) Gap Analytical Framework and
provided an exceptional framework for researching factors influencing turnover and burnout
among behavioral health clinical workforces; specifically, clinicians. The Gap Analytical
frameworks facilitated the transition of turning results into recommendations. Three factors that

118

reinforced the quality of the study: (a) the research methodology and design; (b) relatively
medium survey sample size for clinicians; and (c) sample size for interview participants. The
mixed-methods approach offered a unique lens to triangulate data collected from multiple
methods. In doing so, significant findings, supported by two and, in some cases, three forms of
data compose a compelling argument for research-based change.
There are two significant areas of weakness in the study: (a) the singular stakeholder
approach: and (b) the limited number of participants who participated in phone interviews.
Of note, 24 clinicians completed the online survey, which represented 51% of the clinical
workforce. However, only three clinicians participated in the qualitative interview process. The
conditions in which the interview participants were solicited, along with the short timeframe to
engage participants, did influence the number of participants. Initially, the study design was to
facilitate a focus group with 5-8 clinicians, however, due to the solicitation process being
compromised, the researcher decided to eliminate the focus group and conduct phone interviews
instead.
Limitations and Delimitations

The purpose of this study was to examine the knowledge, motivation, and organizational
Influences affecting high turnover and burnout among clinicians at TBH. Due to the nature of the
environment and design of the research, three fundamental limitations were present. First, the
selection of a single stakeholder group provided a narrow perspective on a complex problem. By
selecting the clinicians, the hope was to understand the challenges from their perspective and to
receive insights on organizational barriers affecting their performance.
Second, this study addressed items related to personal knowledge and motivation, as

119

well as information regarding the organizational culture. Depending on the clinician’s work
experience, their response could have painted a negative light on the organization. Therefore, it
could lead to potentially less than truthful answers from respondents, representing a limitation.
The survey questions generated for this study were primarily multi-choice responses and
interview questions, with semi-structured open-ended questions. The mixed-method approach to
design was to capture different perceptions and limit incorrect responses. According to Merriam
and Tisdell (2016), erroneous responses or responses targeting what respondents believe to be
the correct answer, general reflexivity, consistently represented a study limitation.
Finally, the study was designed, and targeted stakeholders offered several delimitations
that were notable. First, the study was sufficiently narrow in both breadth and depth due to the
level of participation from the respondents. Additionally, the timing of the study from the THB
leadership perspective was exceedingly relevant to their organization’s strategic plan objectives.
As such, there was an increased willingness to participate, to reflect on current efforts, and to
provide feedback on their potential struggles. These aspects were shown to be both insightful and
invaluable to the data collection and analytical process.
Future Research
Historically, employee engagement and retention are essential and have become an
important topic of discussion among businesses, public and private organizations, and other
industries (Saks, 2006). Consequently, researchers have invested numerous hours researching to
understand the causal influences that impact employee engagement and retention. However,
there is still additional research that is warranted to understand this complex topic that many
organizations seem to struggle with daily. Therefore, future research is needed to consider the
unique viewpoints of the clinical workforce (clinicians) through engaging clinicians directly. The

120

majority of current research on high turnover and burnout reviewed within this study involved
surveys with employers, recidivism data, state, or federal data. Undoubtedly, there has been
significant research conducted on employer engagement, retention, and burnout. However,
further in-depth qualitative data surrounding employer work experience and culture could prove
beneficial to addressing specific issues that arise for employers around employee retention and
satisfaction. Also, it could be proven beneficial if employers consult and learn from employers
across industries through interviews or focus groups, designed to determine employer needs and
operational strategies could prove valuable.
Another potentially beneficial focus for future research could be to look at organizational
culture, workload, and caseload density that impact employee retention and burnout. For
example, research has shown longitudinal data on the short-term and long-term impacts of high
turnover and burnout among clinicians. The data could be achieved by evaluating behavioral
health providers who provide chronic severe mental illness services, in comparison to providers
who provide mild to moderate behavioral health services. Data points could be retention rates,
caseload size, employee satisfaction, and other facets of stability, and so forth.
Conclusion
This evaluation study sought to understand and identify the causal influences that inhibit
Trident Behavioral Health from achieving its stakeholder goal of a 95% job satisfaction rate
among the clinical workforce. First, the study evaluated the impact of employee engagement on
job satisfaction and performance, as well as current trends and strategies the organizations had
implemented to improve employee engagement and retention. The literature review informed the
identification of the assumed knowledge, motivation, and organizational influences specifically
related to the achievement of the stakeholder goal and global goal (intermediary goal).

121

Coincidentally, the knowledge influences both declarative and metacognitive were analyzed to
determine the potential impact of job retention, satisfaction, and performance outcomes.
Secondly, the motivation influences included utility value of self-motivation and purpose, as well
as emotional connectedness and intrinsic motivation of the clinical workforce to engage in the
decision-making process; in order to improve job satisfaction and the work environment. Third,
organizational influences were evaluated to determine how culture influences retention and job
satisfaction. Finally, the Gap Analysis Framework and KMO influences were instrumental in
proposing recommendations with a clear and concise strategic roadmap to address high turnover
and burnout among clinicians at TBH.

122

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136

Appendices
Appendix A
Survey Items

Research Question/
Data Type
KMO
Construct
Survey Item (question and response)
Demographics
Description
NA I have been employed at TBH ____ years.
Demographics
Description
NA I am assigned to the Children's System of Care (CSOC) or
Adult System or Care (ASOC) Division
Demographics
Description
NA I am a: license ____ or intern_____ clinician
Demographics
Description
NA I am: Male Female Other: _____
Demographics
Description
NA Age: month/day/year
Demographics
Description
NA Race: Black, White, Hispanic, Asian, Native American or
other: _________
When encountering a stressful situation at work, I usually
(Check all that apply)

a. Put it out of my mind
b. Identify the reason*
c. Ask myself what strategy can, I use to reduce the stress*
d. Monitor the result of the strategy*

Stress influences patient care by (Check all that apply)

a. Poor patient outcomes
b. Poor customer service rating
c. High no-show rates for services
d. Increased crisis episodes (i.e., hospitalizations)

137

I manage my stress in the workplace by doing the following: (Check all that apply)
a. Take short breaks
b. Meditation
c. Deep breaths
c. Exercise
d. Journaling
f. Reflecting on the positive

I find the work that I do full of meaning and purpose:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

Using the scale below, how confident are you in doing the following right now to manage your
stress (Not confident at all, Moderately confident or Highly confident):

a. Take short breaks
b. Meditation
c. Deep breaths
d. Exercise
e. Journaling
f. Reflecting on the positive

At my job, I feel empowered to improve employee satisfaction:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

I am enthusiastic about my job:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

My organizations' achievement of its vision and mission is due to my own efforts.

1. Strongly disagree,
2. Disagree
3. Agree
4. Strongly agree,

138

There is a culture of trust among employees and leadership in the organization
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

The organization supports a culture of autonomy (i.e., make independent decisions) in
performing my daily job responsibilities.
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

There is a supportive work environment:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

Within your division, the supervisor creates a supportive work environment:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

Within your division, the supervisor creates a collaborative work environment
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

There is a culture of collaboration in my department.
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

139

My organization includes all employees in the decision-making process
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

My organization promotes a culture of professional learning.
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree

The organization supports my professional learning by allowing me external trainings:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

The organization has a strategic roadmap/vision that promotes staff well-being:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

The organization has a strategic roadmap/vision the promotes career development:
a. Strongly disagree,
b. Disagree
c. Agree
d. Strongly agree,

140

Appendix B

Interview Protocol
Welcome and Introductions:

First, I would like to take this opportunity to thank you for your commitment, time,
and participation in today's phone interview. This phone interview should take approximately
1 hour to facilitate.
Before we begin the interview, I would like to provide you an overview of my study
and answer any questions you might have about the process.
Currently, I am enrolled as a doctoral student at the University of Southern
California in Los Angeles, California. I am studying Organizational Change and
Leadership. As part of the doctoral degree program requirement, I am required to complete
a dissertation. Therefore, I decided to evaluate The Impact of High Turnover and Burnout
among Behavioral Health Clinicians. This study also evaluates how job satisfaction
influences employee retention and engagement. To facilitate this process, I am conducting
what is called an Evaluation Study, which means I am evaluating the impact and causal
influences of high turnover and burnout among clinicians.
As a reminder, I want to assure you of my role here today, which is to collect
information that can assist your organization with achieving its vision and mission, as well as
me collecting research data that could add value to the research community in the future.
Dually note that questions are not intended to be at all evaluative, accusatory, or make
judgments about your performance or role as clinician or supervisor, but to gain insight into
the organization's culture and environment.
Confidentiality and Consent:
As a researcher, I commit to keeping all the data collected here in strict confidence.

141

However, I also encourage interview participants to adhere to the same confidentiality standard.
Prior to today, everyone should have received information about the study. Do you
have any questions or clarification needed before we begin the study?
● Questions and Answers: If there are no other questions or clarifications needed,
may I have your permission to begin the interview?
● Consent: As we discussed in our initial communication, I was recording our
conversation in order to capture your feedback/thoughts with me accurately.
[Recording was a requirement for participation in the focus group]
Transition to the Interview Process: Thank you, everyone.

Now, as we begin the interview, which is the most exciting part of the process, however, I
need to provide a quick overview of the structure of our time together over the next two hours.
First, I am going to pose some questions, and I encourage you all just to have a conversation
with each other, build on each other's ideas, feel free to agree or disagree with each other as it
is appropriate, and offer as many different ideas to the questions as you think are appropriate.
There are no right or wrong answers, and the goal of bringing everyone together is to hear as
many different points of view as possible.

142

Appendix C

University of Southern California
Rossier School of Education
3470 Trousdale Parkway Los Angeles, CA 90089

INFORMATION SHEET FOR EXEMPT RESEARCH

STUDY TITLE: The Impact of High Turnover and Burnout among Behavioral Health's
Clinical Workforce (Clinicians)

PRINCIPAL INVESTIGATOR: Yvonnia Brown

FACULTY ADVISOR: Dr. Kenneth Yates

You are invited to participate in a research study. Your participation is voluntary. This
document explains information about this study. You should ask questions about
anything unclear to you.

PURPOSE
The purpose of this study is to evaluate the impact of high turnover and burnout among
behavioral health's clinical workforce (clinicians) and strategies for improvement at
Trident Behavioral Health (TBH) (a pseudonym for our organization). The stakeholders
of focus for this case study (online survey) are the clinicians (therapists). We hope to
learn what influences (knowledge, motivation, and/or organizational) impede TBH's
ability to reduce turnover and burnout among clinicians effectively. You are invited as a
possible participant because, as a clinician, you provide direct clinical services (therapy)
to individuals with serious mental illness (SMI).

PARTICIPANT INVOLVEMENT
As a participant, you asked to complete an online survey that will take approximately 20
minutes to complete. The survey questions were designed to assess TBH clinicians on
the knowledge, motivation, and organization's level of staff engagement,
communication, inclusion, and overall organizational culture. An online survey link
emailed to the current license or associate clinicians (therapists) from Children and
Adult System of Care Divisions.

PAYMENT/COMPENSATION FOR PARTICIPATION
N/A. There is no payment for participating.

ALTERNATIVES TO PARTICIPATION
N/A

143

CONFIDENTIALITY
The members of the research team and the University of Southern California
Institutional Review Board (IRB) may access the data. The IRB reviews and monitors
research studies to protect the rights and welfare of research subjects.

When the results of the research are published or discussed in conferences, no
identifiable information was used.

The data was coded with a false name or pseudonym; identifiable
information was kept separately from your responses.

The data was stored on a flashed drive that would remain solely in the
researcher's possession and held for 3 to 6 months after the study has been
completed and then destroyed. Recorded audio files were destroyed
immediately upon transcription.

Any identifiable information obtained in connection with this study will remain
confidential and was disclosed only with your permission or as required by law.

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Yvonnia Brown,
yvonniab@usc.edu or 301-357-2948, or Dr. Kenneth Yates, Faculty Advisor,
kennetay@usc.edu.

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.

144

Appendix D

University of Southern
California Rossier School of
Education
3470 Trousdale Parkway Los Angeles, CA 90089

THE IMPACT OF HIGH TURNOVER AND BURNOUT AMONG BEHAVIORAL
HEALTH'S CLINICAL WORKFORCE (CLINICIANS)

You are invited to participate in a research study conducted by Yvonnia Brown,
candidate for Doctorate of Education in Organizational Change and Leadership under
Dr. Kenneth Yates at the University of Southern California because you are clinicians
who provide therapy to individuals who have behavioral health issues (mental health
and/or substance use disorder); along with, you have been employed as a clinician at
Trident Behavioral Health (TBH) (a pseudonym) for at least one (1) year. Your
participation is voluntary.

You should read the information below, and ask questions about anything you do not
understand, before deciding whether to participate. Please take as much time as you
need to read the consent form.

PURPOSE OF THE STUDY
The purpose of this study is to examine the influences of the high turnover rate and
burnout among clinicians at Trident Behavioral Health (TBH) (a pseudonym). The
researcher in this study was inquiring about the knowledge, motivation, and
organizational resources necessary to reduce staff turnover, burnout, employee
engagement, and overall job satisfaction of the clinical workforce (clinicians).
STUDY PROCEDURES
If you volunteer to participate in this study, you will take part in a phone interview,
which will take approximately one hour to complete. The interview will consist of
questions related to knowledge, motivation, and organization about staff engagement,
communication, inclusion, and organizational culture. Participants were selected from
those clinician volunteers who have a minimum of one (1) year of employment.

Each interview was audio recorded. You may choose not to have our conversation
recorded. You may stop the interview at any time. A transcript was created for the
interview, and your name de-identified. The recording was erased.

INFORMATION SHEET FOR NON-MEDICAL RESEARCH

145

POTENTIAL RISKS AND DISCOMFORTS
There are no foreseen risks to your participation in this study. You may be
inconvenienced for at least one hour to participate in the phone interview.

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
This study anticipates a contribution to the organization and field as a result of your
participation. This study anticipates that the professional development at TBH was
greatly enriched, translating to greater employee engagement, job satisfaction, and
retention. The study also anticipates this study to inform the ways in which the
organization can continue to grow in order to achieve the organizational goals of
improving employee retention and overall job satisfaction rates.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will not be compensated for your participation.

CONFIDENTIALITY
The members of the research team and the University of Southern California
Institutional Review Board (IRB) may access the data. The IRB reviews and monitors
research studies to protect the rights and welfare of research subjects.

When the results of the research are published or discussed in conferences, no
identifiable information was used.

The data was coded with a pseudonym; identifiable information was kept
separately from your responses.

The data was stored on a flash drive that would be solely in the researcher's
possession and held for 3 to 6 months after the study has been completed and then
destroyed. Recorded audio files were destroyed immediately upon transcription.

Any identifiable information obtained in connection with this study will remain
confidential and was disclosed only with your permission or as required by law.

Phone Interview: Participation in the phone interview process was confidential, which
means the researcher and participant were the only ones who knew the interview
occurred. To schedule a phone interview, a confidential link or google document was
distributed to participants to ensure confidentiality. The researcher will not share any
information regarding who has participated in the phone interview with anyone in the
organization. No direct quotations were used in the research study.

146

PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss
of benefits to which you are otherwise entitled. You may withdraw your consent at any
time and discontinue participation without penalty. You are not waiving any legal claims,
rights, or remedies because of your participation in this research study.
INVESTIGATOR'S CONTACT INFORMATION
Principal Investigator: Yvonnia Brown
Phone: 301-357-2948
Email: yvonniab@usc.edu

RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research
participant or the research in general and are unable to contact the research team, or
if you want to talk to someone independent of the research team, please contact the
Social Behavioral Institutional Review Board (SBIRB), 1640 Marengo St., Suite 700,
Los Angeles, CA 90033, (213) 821-5272 or upirb@usc.edu.

147

Appendix E
To evaluate the effectiveness and vitality of the collaborative partnership framework, we have
created this evaluation tool to learn from your experience. Therefore, your feedback is essential
to help us improve this process. Please circle the number that represents your assessment.
Strongly Strongly
Disagree Agree
The meeting environment is inclusive 1 2 3 4 5
I feel the meeting is meaningful and relevant 1 2 3 4 5
to my professional development
I am confident that my feedback is being valued 1 2 3 4 5
The process has improved my understanding of the 1 2 3 4 5
organizational structure
I am clear about the meeting objectives 1 2 3 4 5
I am committed to the joint decision-making process 1 2 3 4 5

What suggestions do you have to improve the joint decision-making process?
______________________________________________________________________________
What barriers do you anticipate that could limit your ability to engage in meaningful
discussions?
______________________________________________________________________________
What specific outcomes are you hoping to achieve from this meeting structure?
______________________________________________________________________________

148

Appendix F
We want to hear from you regarding your experience participating in the Collaborative
Partnership Meetings. The information you provide to us will continue to improve the process
and the agency’s objectives. This being said, please take time the next few minutes to respond to
the below questions. Please check the number that represents your experience.
Strongly Strongly
Disagree Agree
Questions 1 2 3 4 5
6 7 8 9 10
Looking back at the purpose of the
meeting structure, it was a good
use of your time.

As a participant, I have a better
understanding of how policy
decisions are made and
implemented as a result of the
meeting(s).

My feedback and ideas are valued
and taken seriously by leadership.

I have observed leadership being
intentional about soliciting
feedback from line-staff.

I recognize how my job influences
the organization’s vision and
mission.

I am more confident about my role
as a clinician as a result of being a
part of this process.

Line-staff participation in the joint
decision-making process will

149

influence staff retention and
satisfaction.
The communication platforms
established to update the entire
department of the outcomes of the
meeting have been effective.

Abstract (if available)

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Asset Metadata

Creator Brown, Yvonnia (author)

Core Title The impact of high turnover and burnout among behavioral health's clinical workforce (clinicians)

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 07/30/2020

Defense Date 07/29/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Burnout,high turnover,OAI-PMH Harvest,poor employee engagement,poor job satisfaction

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth (committee chair), Andres, Mary (committee member), Sparangis, Themistocles (committee member)

Creator Email yvonniab@usc.edu,Yvonniab36@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-356852

Unique identifier UC11664021

Identifier etd-BrownYvonn-8830.pdf (filename),usctheses-c89-356852 (legacy record id)

Legacy Identifier etd-BrownYvonn-8830.pdf

Dmrecord 356852

Document Type Dissertation

Rights Brown, Yvonnia

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA