University of Southern California Dissertations and Theses

Middle-management's influence on employee engagement in the ambulatory practices

(USC Thesis Other)

Middle-management's influence on employee engagement in the ambulatory practices

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

MIDDLE-MANAGEMENT’S INFLUENCE ON EMPLOYEE ENGAGEMENT IN THE
AMBULATORY PRACTICES
by
Laurie Miguel-Johnson

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 Laurie Miguel-Johnson

ii
Dedication
I dedicate this dissertation to my parents Benjamin and Jane Miguel who taught me the
importance of treating people with dignity, respect, and kindness; to my brothers, Dean and
Craig who always had faith in me, and said, “The skies the limit!” and my husband Mike, who
has been by my side through this journey. You would say, “Of course you are going to get your
doctorate, and you will be successful at whatever you choose!” Your confidence and your
support has meant the world to me. And Evie, your spirit will live forever in my heart.

iii
Acknowledgments
Thank you to my wonderful family and husband, who stand behind everything I do. You
all have taught me to persevere, be firm in what I believe, and take action with confidence. You
taught me that there are no obstacles in life, as long as you believe in yourself and God.
Thank you to a group of ladies that I have known almost all my life! “Supporch girls,”
your encouragement, unconditional love, faith, and confidence in me warms my heart! Thank
you for your late-night motivating texts reminding me that God is by my side and He has a plan
for me!
Thank you to my mentors. I listen to your wisdom and have achieved much because of
you have been by my side all these years.
Thank you to my work family who scheduled around school nights, assignments,
meetings with my dissertation chair, and made sure I had dinner on those late nights. You helped
me more than you know! A.P. you always encouraged me by telling me how proud you were!
Thank you to my colleagues in Cohort X! I will never forget the call I got at 4:00 a.m. to
say, “Are you ready to put your paper together?” You all made me laugh, you willingly shared
your time, and your support. It has been such a privilege to know all of you!
Thank you, Dr. Yates. You taught me what dedication means. Being an educator and
dissertation chair is not a job for you; it is a passion! I never felt like I was your assignment; I
felt like you genuinely cared about my topic and my success. I feel blessed by your wisdom,
patience, and knowledge. Thank you, Sir!
Lastly, thank you to the employees, managers, and directors that I have had the privilege
of knowing throughout my career. You touch my heart and are the reason I chose this topic.

iv
Table of Contents

Dedication ....................................................................................................................................... ii
Acknowledgments.......................................................................................................................... iii
List of Tables ................................................................................................................................ vii
List of Figures ................................................................................................................................ ix
Abstract ...........................................................................................................................................x
CHAPTER ONE: OVERVIEW OF THE STUDY ........................................................................1
Introduction of the Problem of Practice ..............................................................................1
Organizational Context and Mission ..................................................................................2
Organizational Performance Status .....................................................................................3
Press Ganey Survey ................................................................................................3
Clinician and Group Consumer Assessment of Healthcare Providers
Systems Survey ........................................................................................................5
Safety, Communication, Organizational Reliability Employee Survey ..................6
Related Literature ................................................................................................................7
Importance of Addressing the Problem ...............................................................................8
Organizational Performance Goal .......................................................................................8
Description of Stakeholder Group .......................................................................................9
Stakeholder Groups’ Performance Goals...........................................................................10
Stakeholder Group For the Study .....................................................................................12
Purpose of the Project and Questions ................................................................................12
Methodological Framework ..............................................................................................13
Definitions..........................................................................................................................13
Organization of the Study ..................................................................................................15

CHAPTER TWO: REVIEW OF THE LITERATURE ................................................................16
Influences on the Problem of Practice ..............................................................................16
Employee Engagement ......................................................................................................16
The Evolution of Employee Engagement in Healthcare ...................................................17
The History of Employee Engagement ..................................................................17
Difficulty in Defining Employee Engagement ......................................................18
Importance of Employee Engagement in Healthcare .......................................................21
Increasing Need for Healthcare Providers ............................................................21
U.S. Governments Influence in Healthcare and the Effects on
the Healthcare Employee..............................................................................23
The Impact of the Engaged Employee ..................................................................25
The Consequence of Disengaged Employees ........................................................27
The Effect of Organizational Culture on Employee Engagement .........................28
The Impact of the Manager and Director on Employee Engagement ...............................30
The Clark and Estes Gap Analysis Conceptual Framework ..............................................31

v
Stakeholders Knowledge, Motivation and Organizational Influences ..............................32
Knowledge ............................................................................................................33
Knowledge and Skills ...........................................................................................33
Motivation .............................................................................................................39
Organization ..........................................................................................................44
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and
Motivation and the Organizational Context ..........................................................51
Conclusion ........................................................................................................................55

CHAPTER THREE: METHODS .................................................................................................57
Participating Stakeholders ................................................................................................57
Survey Sampling Criteria and Rationale ...............................................................57
Survey Sampling Strategy Rationale ....................................................................58
Interview Sampling Criteria and Rationale............................................................59
Document Analysis Sampling Strategy and Rationale ..........................................59
Data Collection and Instrument .........................................................................................60
Survey ....................................................................................................................60
Interviews ...............................................................................................................61
Documents and Artifacts........................................................................................62
Alignment of KMO Influences and Data Collection Methods and Instruments ...............63
Data Analysis .....................................................................................................................76
Surveys ...................................................................................................................77
Interviews ...............................................................................................................77
Documents .............................................................................................................77
Credibility and Trustworthiness .........................................................................................78
Validity and Reliability ......................................................................................................79
Ethics..................................................................................................................................80
Limitations and Delimitations............................................................................................82

CHAPTER FOUR: RESULTS AND FINDINGS ........................................................................83
Participating Stakeholders .................................................................................................83
Determination of Assets and Needs ...................................................................................84
Results and Findings for Knowledge Causes.....................................................................85
Factual Knowledge ................................................................................................85
Conceptual Knowledge ..........................................................................................93
Procedural Knowledge ...........................................................................................97
Metacognitive Knowledge ...................................................................................103
Results and Findings for Motivation Causes ...................................................................104
Self-Efficacy ........................................................................................................105
Expectancy Theory ..............................................................................................109
Emotions ..............................................................................................................113
Attribution ............................................................................................................115
Results and Findings for Organizational Causes .............................................................118
Cultural Models ...................................................................................................118
Cultural Settings...................................................................................................134
Summary of Validated Influences ...................................................................................141

vi
Knowledge ...........................................................................................................140
Motivation ............................................................................................................141
Organization .........................................................................................................142

CHAPTER FIVE: RECOMMENDATIONS, IMPLEMENTATION AND EVALUATION ...144
Purpose of the Project and Questions ..............................................................................144
Introduction and Overview ..............................................................................................144
Recommendations for Practice to Address KMO Influence............................................146
Knowledge Recommendations ............................................................................146
Motivation Recommendations .............................................................................156
Organizational Recommendations .......................................................................163
Integrated Implementation and Evaluation Plan ..............................................................173
Implementation and Evaluation Framework ........................................................173
Organizational Purpose, Need and Expectations .................................................173
Level 4: Results and Leading Indicators .............................................................174
Level 3: Behavior ................................................................................................175
Level 2: Learning ................................................................................................180
Level 1: Reaction ................................................................................................184
Evaluation Tools ..................................................................................................185
Data Analysis and Reporting ...............................................................................187
Summary of the Implementation and Evaluation ................................................188
Strengths and Weaknesses of the Approach ....................................................................189
Limitations and Delimitations..........................................................................................190
Future Research ...............................................................................................................191
Conclusion .......................................................................................................................193

References ....................................................................................................................................195
Appendix A: Immediate Evaluation Tool ...................................................................................208
Appendix B: Delayed Evaluation Tool .......................................................................................211

vii
List of Tables
Table 1: Organizational Mission, Global Goal, and Stakeholder Performance Goals .................11
Table 2: Knowledge Influence, Knowledge Type and Knowledge Infuence Assessment ...........37
Table 3: Organization Mission, Global Goal Stakeholder Goal, Assumed Motivational
Influences and Motivational Influence Assessment .......................................................43
Table 4: Assumed Organizational Influences, Organizational Influence Assessment .................50
Table 5: Summary of Knowledge Influence and Method of Assessment ....................................63
Table 6: Summary of Motivation Influences and Method of Assessment....................................70
Table 7: Summary of Organization Influences and Method of Assessment ................................73
Table 8: Demographics .................................................................................................................76
Table 9: Factual Knowledge of Press Ganey and SCORE Surveys .............................................85
Table 10: Factual Knowledge – Meaning of Employee Engagement ..........................................87
Table 11: Factual Knowledge – Employee Engagement is My Responsibility............................88
Table 12: Factual Knowledge – Fostering Employee Engagement through Best Practices .........90
Table 13: Factual Knowledge – Employee Engagement Program Components ..........................92
Table 14: Conceptual Knowledge – Consequences of an Employee Engagement Program ........94
Table 15: Conceptual Knowledge – Managers and Directors Impact on Employee
Engagement .............................................................................................................95
Table 16: Procedural Knowledge – Managers and Directors Know How to Improve
Employee Engagement ............................................................................................97
Table 17: Procedural Knowledge – Managers and Directors Know How to Build an
Employee Engagement Program .............................................................................99
Table 18: Procedural Knowledge – Implementing an Employee Engagement Program ...........100
Table 19: Metacognitive Knowledge – Self-Reflection .............................................................103
Table 20: Expectancy Theory – Value to Improve Employee Engagement ...............................110
Table 21: Emotions – Positive Feelings about Developing an Employee Engagement
Program .................................................................................................................114
Table 22: Attribution – Attributing Success or Failure to Their Own Efforts ............................115
Table 23: Cultural Model – Organization Supports Improving Employee Engagement ............118
Table 24: Cultural Model – Organization Values Employee Engagement .................................121
Table 25: Cultural Model – Shared Decision Making ................................................................124
Table 26: Cultural Model – Individual Goals Align with the Organization’s Goals ..................127
Table 27: Cultural Model – Mutual Respect...............................................................................128
Table 28: Cultural Model – Autonomy ......................................................................................130
Table 29: Cultural Model – Mutual Trust ...................................................................................132
Table 30: Cultural Setting – Organization Visibly Supports Employee Engagement ................134
Table 31: Cultural Setting – Accountability ...............................................................................136
Table 32: Cultural Setting – Organization Supports Employee Engagement.............................138
Table 33: Assumed Knowledge Influences Assets or Needs as Determined by Data ................140
Table 34: Assumed Motivation Influences as Assets or Needs as Determined by the Data .....141
Table 35: Assumed Organizational Influences as Assets or Needs as Determined by
the Data ..................................................................................................................142
Table 36: Summary of Knowledge Influences and Recommendations ......................................146
Table 37: Summary of Motivation Influences and Recommendations ......................................157
Table 38: Summary of Organization Influences and Recommendations ...................................163

viii
Table 39: Outcomes, Metrics, and Methods for External and Internal Outcomes .....................174
Table 40: Critical Behaviors, Metrics, Methods, and Timing for Evaluation ............................177
Table 41: Required Drivers to Support Critical Behaviors .........................................................178
Table 42: Evaluation of the Components of Learning for the Program .....................................183
Table 43: Components to Measure Reactions to the Program ....................................................185
Table 44: Cost of Turnover .........................................................................................................190

ix
List of Figures

Figure 1: Conceptual Framework Showing the Interdependence of the KMO Influences ...........53
Figure 2: USE Organization’s Main Units and Sampling Criteria ...............................................58
Figure 3: Self-Efficacy – Confidence in Creating an Employee Engagement Program.............105
Figure 4: Self-Efficacy – Confidence in Influencing Employee Engagement in Work
Unit ........................................................................................................................108

x
Abstract
This study applies the Clark and Estes (2008) gap analysis framework to examine the
performance gaps of managers and directors in an ambulatory care department in a large hospital
setting for the knowledge, motivation, and organizational challenges to improve employee
engagement through the development of a best practices employee engagement program. Mixed
methods were used to collect survey data from 14 participants, interview data from five
participants, and organizational documents were reviewed to identify the knowledge skills,
motivation, and organizational influences that contribute to the stakeholder’s ability to meet their
goal. The causes for factual, conceptual, procedural, and metacognitive knowledge, self-efficacy,
expectancy-value, emotion, attributions, cultural models, and cultural settings were assessed and
determined as an asset or a need. Based on the findings, solutions supported by literature, were
offered to address the challenges. The study demonstrates how applying the knowledge,
motivation, and organizational framework help identify stakeholder's needs to improve employee
engagement, which contributes to the organization’s success in preventing medical errors,
increasing patient satisfaction, and increasing employee engagement.
Keywords: employee engagement, ambulatory employee engagement, patient
satisfaction, healthcare employee engagement, healthcare disengaged employees

CHAPTER ONE: OVERVIEW OF THE STUDY
Introduction of the Problem of Practice
A nurse at a major university was charged with reckless homicide because she ignored
multiple safety precautions that are intended to prevent medication mix-ups (Aller, B. 2019).
The patient received a fatal dose of the wrong medication, slipped into a coma, and died. She
states she was distracted by an unrelated conversation with a co-worker. The patient came in for
a common imaging diagnostic test.
One billion patients per year seek healthcare in an outpatient setting, and they are greeted
by a workforce that self-reports more than half are not highly engaged in their work and feel
disconnected and unsupported from their healthcare organization (Sherwood, 2013). In numbers,
this means of the 13 million healthcare employees in the United States (Kaiser Foundation,
2017), almost 8.6 million do not feel connected to their organization and state they are not highly
engaged. Moreover, with over four million healthcare jobs projected between 2012 and 2022
(Bureau of Labor Statistics, 2014), employee engagement becomes a focal point for healthcare
organizations.
Employee engagement is essential in all industries, but the effect on the healthcare
industry is complicated because it can have a direct impact on patient care and outcomes and
patient and employee satisfaction (Lowe, 2012; Peltier, Dahl & Mulhern, 2009; Pech & Slade,
2006; Scotti, Harmon & Behson, 2007). Conversely, employee disengagement is associated
with patient and employee dissatisfaction, escalating costs, medical errors, and death, (Kohn,
1999; Department of Health and Human Services, 2010; Makary and Daniel, 2016). The
problem for the healthcare industry is attracting and maintaining an engaged workforce and
understanding who in the organization has the most impact on employee engagement. As such,

2
this improvement case study examines employee engagement in one specific health care
organization.
Organizational Context and Mission
The University of St. Elsewhere (USE; a pseudonym) is an academic medical enterprise,
based in a large metropolitan city in the western United States. Offering scholastic excellence,
world-class research, and state of the art clinical care, the USE attracts world-renowned experts
who teach and perform research in the school of medicine and practice medicine in the hospitals
and outpatient facilities.1 According to the USE website, the health system consists of three
hospitals and 90 outpatient practices serving a diverse population. The hospitals are located near
the medical school campus, and the 90 outpatient facilities are adjacent to the hospitals and in
neighboring communities reaching 35 miles south and 90 miles north of the medical school
campus. The USE website indicates that the hospital and outpatient practices provide services to
mostly an adult population with over 50,000 inpatients per year, and close to 600,000 outpatients
per year. The hospital is highly ranked among hospitals in the United States. The 90 ambulatory
practices are the USE physician offices where patients are seen for primary care, internal
medicine and internal medicine subspecialties, general surgery and surgery subspecialties,
oncology, otolaryngology, orthopedics, ophthalmology, obstetrics and gynecology, dermatology
and the ancillary services which include laboratory, pathology, and radiology. The USE
ambulatory practices are usually the patients' first introduction to the health system and entryway
to the hospitals. The ambulatory practices are an integral part of the USE health system and
continue to be a focal point, as evidenced by the continued growth resulting in an additional 20
plus ambulatory practices in the surrounding community. The leadership and staff of these
ambulatory practices are a part of USE, and as such, they share the mission, values, and goals of

1 Source: Organization website

3
the health system. The mission, as recorded on the website, is to be a trusted leader in providing
quality healthcare that is personalized, compassionate, and innovative. The health system stands
for empowerment, integrity, respect, collegiality, vitality, and is committed to authenticity and
excellence in clinical care and teaching. The health system values focus on delivering healthcare
through service excellence while showing compassion and building strong relationships with
colleagues, patients, and their families. The health system contributes to innovation through
scientific discoveries and collaboration among employees who are empowered to improve the
performance of the organization. The website emphasizes an important part of the mission is
the employees pride themselves on acting with integrity and are accountable to the highest
professional standards through demonstrating open communication and respect for each other,
patients, and families.
Organizational Performance Status
Employee engagement is active throughout the USE mission statement. The words
“compassion, personalized, authenticity, empowerment, integrity, respect, collegiality and
vitality” are words that reflect a work environment that values patients and employees alike and
promotes a personalized, compassionate atmosphere. Nonetheless, the organization’s
performance problem is the perception of low employee engagement. Following the
development of the mission statement, the organization administered its first employee
engagement surveys intended to obtain a baseline of how engaged employees are in the
organization.
Press Ganey Survey
The Press Ganey survey measures employee engagement through a series of questions
which gauges engagement at the work unit level, assesses readiness for change, and identifies

4
key drivers of engagement unique to the organization (Press Ganey, 2018). The Press Ganey
survey administration occurred in 2017. The goal was to persuade the employees to participate
in the survey, but negligible activities occurred related to performance improvement.
Nonetheless, the Press Ganey survey results revealed that a total of 3934 employees took the
survey representing a 78% participation rate. Ambulatory employees made up 460 of the total
participants revealing a participation rate of 51% of the total ambulatory employees.
Press Ganey provides a comprehensive, scientific method of scoring employee
engagement. The engagement indicator score signifies the degree of commitment the work unit
feels towards the organization. On a scale of 1-5, the higher the score, the stronger level of
commitment the work unit will have towards the organization. The engagement indicator score
for the organization was 4.05, which is .07 points less than the national average. The ambulatory
engagement score was higher at 4.10, which is .02 points less than the national average. Press
Ganey also offers a Power Item Score and an Action Planning Readiness (APR) Score. The
Power Item Score also uses a scale of 1-5 with five being highest, reveals the work unit
members’ average response to survey items that most impact commitment. The APR score uses
a scale of 1-100, with 100 being highest, representing the employee’s readiness to engage in
feedback and action planning. The organization’s Power Item Score was 3.88, with an APR of
82, and the ambulatory units had a Power Item Score of 3.92 with an APR of 85. Another
significant score is the Tier scores, which are related to the Power Item score. The work unit is
assigned to Tier 1, Tier 2, or Tier 3 – based on the performance of the Power Item domains,
which are Organization, Manager, and Employee. The tier score is the level of action planning
that may be required, with Tier 1 work units requiring minimal action planning, Tier 2 work
units need some action planning, and Tier 3 work units need significant action planning and

5
perhaps additional training or other resources in getting action planning started. The USE
organization and ambulatory had a Tier Score of 2. The distribution of survey results to
executives did occur through an email which provided instructions on how to sign on to the Press
Ganey website. However, no other instruction or follow up took place and therefore,
performance improvement activities did not occur.
Occurring in parallel with the Press Ganey employee engagement survey was the
Clinician and Group Consumer Assessment of Healthcare Providers & Systems survey
(CGCAHPS) which focuses on patient satisfaction.
Clinician and Group Consumer Assessment of Healthcare Providers and Systems Survey
Benchmarking and goal setting activities for the USE ambulatory units have centered
around the Clinician and Group Consumer Assessment of Healthcare Providers and Systems
(CGCAHPS, 2018) patient satisfaction surveys since they are required by the Centers for
Medicare and Medicaid Services (CMS) for all hospitals and outpatient facilities in the United
States. The CGCAHPS survey is important as it provides information on how the patient sees
the organization in the areas of service and care, communication, responsiveness and access.
Since the research has demonstrated the link between patient satisfaction and employee
engagement (Lowe, 2012; Peltier et al., 2009; Pech & Slade, 2006; Scotti et al., 2007), these
scores can be a window to how patients see, feel and understand employee engagement. There
are two CGCAHPS scores that have been areas of focus are “Recommend this provider office”
and “Courteous and Helpful Office staff.” The score for “Courteous and Helpful Office staff” in
2017 and 2018 was 90.6 and 90.9 respectively. The score for the domain, “Recommend this
provider office,” was 91.1 for both 2017 and 2018. Although both scores are above 90%, in
comparison to other academic medical centers, the percentile ranking for “Courteous and Helpful

6
office staff” was in the 25th percentile ranking and for “Recommend this provider office,” the
percentile ranking was 55th. These patient experience scores provide additional insight to the
experience in the USE ambulatory work units.
Safety, Communication, Organizational Reliability Employee Survey
In 2018, the organization deployed a new survey tool which measures employee
engagement related to a culture of safety. The Safety, Communication, Organizational
Reliability Employee Survey (SCORE, 2016) is an anonymous, online tool that provides
information about culture, communication, and staff burn out. With the deployment of this new
tool, a rollout plan which supports the education of leadership and staff is underway. Specific
goals related to employee engagement are in the process of being developed through a
collaborative effort among senior and director level leadership. The organization’s focus was on
the development of process goals, not on an employee engagement score. The goal setting
activities occur through a retreat which is intended to re-energize and create a new structure for
engagement and alignment throughout the organization (Executive Administrator, personal
communication, August 2018).
The SCORE survey results revealed that participation increased to 1065, representing 76
USE ambulatory units. The SCORE survey results focus on two parts - culture and engagement.
The engagement drivers are defined as growth opportunities and intention to leave. In the
ambulatory unit, 63% feel they can achieve something in the organization (growth
opportunities), while 53% intend to stay with the organization. Therefore, 47% of the USE
ambulatory employees state they intend to leave the organization. Furthermore, 32% state they
experience burnout, 38% state they consistently deal with difficult colleagues and 71% state they

7
work a shift without any breaks. These key drivers of culture provide insight as to why 47%
intend to leave the organization.
To summarize, at first glance it appears the employees are engaged; they are ready to
make positive changes in the organization and achieve growth within the organization.
However, one-third state they experience burnout and close to half state they intend to leave the
organization. In the same way, the patient experience survey ranks customer service in the 25th
percentile which validates why the focus on employee engagement is crucial.
Related Literature
The healthcare industry is a high intensive people-oriented business. The employees in
this field are highly skilled or licensed professionals who provide services to individuals that
require restoration of physical, mental or emotional health. The literature supports the need for
employees to be engaged and aligned with the organizational mission to provide the best care for
the patient. Employee engagement is essential to the success of the healthcare organization
because research demonstrates disengaged employees impact the patient outcomes, employee
and patient satisfaction (Lowe, 2012; Peltier et al., 2009). Disengaged employees contribute to
the escalating costs of healthcare through lack of employee retention, additional cost associated
with hiring and training new employees (Altman, 2017; Markos & Sridevi, 2012), and
compromised quality care resulting in low patient satisfaction (Lowe, 2012; Peltier et al., 2009;
West & Dawson, 2012; Scotti et al., 2007). The evidence highlights the need for healthcare
organizations to understand employee engagement at all levels of the organization, to develop a
culture of learning and trust which will empower all employees to engage in the activities that
promote health and as a byproduct increase employee engagement scores.

8
Importance of Addressing the Problem
It is important to solve this problem for several reasons. Medical errors and employee
disengagement are strongly linked to many reasons including lack of training, level of
competency, and stress and burnout (Business Reports, 2013; Daud-Gallotti et al., 2011). In
1999, the report by the Institute of Medicine, “To Err is Human: Building a Safer Health
System,” the authors assert that as many as 98,000 people die in hospitals each year as a result of
medical errors (Kohn, 1999). The statistics scared the nation into reframing the healthcare
delivery system focusing on quality and safety. However, the number of deaths continues to rise
due to medical errors. In 2008, the Department of Health and Human Services affirmed 180,000
deaths due to medical errors in Medicare beneficiaries alone (Department of Health and Human
Services, 2010), and Makary and Daniel (2016) assert the third leading cause of death in the US
is due to medical errors.
Moreover, healthcare is facing a shortage of providers. The Institute of Medicine (2008)
predicts by 2030, healthcare will need 3.5 million healthcare providers. The US census estimates
by 2050, 19.6 million Americans will be 65 years or older (Harrington & Heidkamp, 2013).
These aging Americans will need two to three times as many healthcare services (Physician
Shortage and Projections, 2017). Therefore, it is essential now and for the future, to have a
robust and engaged workforce to provide healthcare services to an aging population. Also, it is
critical for the healthcare industry to recruit and retain an engaged workforce and understanding
employee engagement is essential to the survival of healthcare organizations in the United States.
Organizational Performance Goal
The mission of St. Elsewhere focuses on being a leader in delivering quality healthcare
that is personalized, compassionate, and innovative. The organization is committed to

9
authenticity and providing uncompromising healthcare. As an academic medical center,
excellence in clinical care, teaching and research are the cornerstones of the mission. Employee
engagement is linked to high-value, innovative care through the establishment of a culture of
exceptional person-centered care, building a system of integrated care to meet patients’ needs
across the continuum of care, and to drive innovation in clinical information technology to
enhance patient care. Furthermore, a cross-cutting goal that applies to the health science
departments and the health system includes a commitment to a supportive work environment
ensuring an atmosphere of trust and respect.
Marketing and website materials use potent words such as compassion, personalized,
authentic, empowerment, integrity, respect, collegiality, and vitality. These words reflect a work
environment that values patients and the employee and promotes a personalized, compassionate
atmosphere.
In the organization’s published documents, although the words “employee engagement”
is not used or stated as an explicit goal, it is implied. The fact that the organization participates
in employee engagement surveys such as the Press Ganey and SCORE, the desire to measure
results is apparent. Therefore, although a performance goal is not stated, the organization is
committed to measuring and developing performance improvement activities. An aspirational
goal is to have 100% engaged employees in the ambulatory work units which should be clearly
stated and supported by performance improvement activities. These actions will give meaning
to the words stated in the mission statement.
Description of Stakeholder Groups
There are multiple stakeholders that contribute to and benefit from the achievement of the
organization’s goal. Three essential stakeholder groups are executive leadership of the health

10
system, directors and managers, and ambulatory employees. The executive leadership
contributes by providing financial and human capital to the project. Middle management is
crucial because they have direct contact with front-line employees, and they can connect,
influence, encourage and create an environment where employees thrive. Moreover, it is critical
for all leadership to create a climate that enables employees to be creative, innovative, and
engaged. The right environment and culture can create an atmosphere that generates engagement
(Seijts & Crim, 2006). Finally, employees are responsible for the relationship with their
employer; employees have a choice as to whether or not to engage with the organization.
Although each of the described stakeholders are important, for purposes of this study, the focus
will be on middle management which includes the directors and managers in the ambulatory
practices.
Stakeholders Groups’ Performance Goals
Since the organization does not have a specifically stated goal focused on increasing
employee engagement scores, it is essential to define goals which impact patient and employee
satisfaction. The literature supports, patient and employee satisfaction is dependent on employee
engagement (Lowe, 2012; Peltier et al., 2009; Pech & Slade, 2006; Scotti, et al., 2007). Thus, it
would seem reasonable that the goal would be to have, at least aspirationally, 100% engaged
employees. Since it is the middle level managers that can have a significant impact on employee
engagement in the Ambulatory Care unit, the goal will focus on these stakeholders. Table I
provides an explanation of the organizational mission, goals, and stakeholder performance goals.

11
Table 1
Organizational mission, global goal and stakeholder performance goals
Organizational Mission/Value
We are the St. Elsewhere Medical Center.
We strive to be the trusted leader in quality health care that is personalized, compassionate and
innovative.
We stand for empowerment, integrity, respect, collegiality and vitality.
We commit to authenticity.
We commit to excellence in clinical care, teaching and research.
You can count on us to be fully present in the delivery of uncompromising health care.

Organizational Global Goal
We believe the employees of the health system are critical to the continued success of the medical
center. Empowering our staff and creating a service-oriented culture with 100% engaged
employees will enhance the experience for our patients by providing health care that is
personalized, compassionate and innovative.
Five Strategic Pillars
1. Quality – Measuring and improving the quality of everything we do as we care for patients and
empower them to actively manage their health
2. People and collaboration – Coming together as a diverse community to achieve outstanding
teamwork across the entire medical enterprise
3. Growth – Developing our clinical networks, patient volumes and income, unique service lines
and a powerful brand that sets us apart
4. Resource Management – Realizing more efficient operations among all the components of the
medical center and optimizing our many resources
5. Service and Access – Becoming an empowered, service-oriented culture as we enhance service
and access for patients and referring physicians
Stakeholder 1 Goal*
Directors and Managers
Stakeholder 2 Goal
C-Level and Executive
Level Leadership
Stakeholder 3 Goal
Employees

12
By July 2020, directors and
managers will develop an
employee engagement
program (EEP) that
embraces best practices for
improving employee
engagement in the
ambulatory setting.
Provide support for the EEP
by fostering a culture of
trust, data-driven continuous
improvement, and resources.
(EEP)

The employees of the
organization will achieve
100% engagement in the
ambulatory practices which
will be evidenced through the
increase of the overall
employee engagement and
patient experience scores by
July 2021.
Stakeholder Group for the Study
Although a complete analysis would involve all stakeholder groups, for practical
purposes, the focus of the study will be on the Directors and Managers of ambulatory services.
This critical group of leaders includes managers, and directors who can positively or negatively
impact the employee’s perception and understanding of the workplace, tasks, and goals which
directly affects employee engagement. Further, because as mid-level leadership, the managers
and directors are close to the front-line employees, their communication, involvement, and
ability to create an environment that supports creativity, innovation and engagement are crucial
to an engaged workforce.
Purpose of the Project and Questions
The purpose of this project is to identify the problem and conduct a gap analysis to
examine the knowledge, motivation and organizational influences that contribute to USE
ambulatory service Directors and Managers middle management’s ability to develop a program
that encourages best practices for improving employee engagement through creating a culture of
trust and learning in the ambulatory setting by July 2020. The analysis will begin by generating
a list of possible or assumed influences that will be examined systematically to focus on actual or
validated influences. While a complete gap analysis would focus on all stakeholders, for

13
practical purposes, the stakeholders to be focused on in this analysis is middle-level managers
and directors in the ambulatory practices.
There will be two questions that will guide the gap analysis:
1. What are the knowledge, motivation, and organization needs and assets that influence
Directors and Managers goal to implement an employee engagement program (EEP)
program that embraces best practices for improving employee engagement in the
ambulatory setting by July 2020.
2. What are the recommended knowledge and skills, motivation and organizational
solutions for Directors and Managers to achieve their goal?
These questions will assist in examining the causes of the performance problem for middle
management.
Methodological Framework
Clark and Estes’ (2008) gap analysis, a systematic, analytical method that helps to clarify
organizational goals and identify the gap between the actual performance level and the preferred
performance level within an organization, will be implemented. Assumed interfering elements
will be generated based on personal knowledge and related literature. These elements will be
validated by using surveys, interviews, document review, literature review and content analysis.
Research-based solutions will be recommended and evaluated comprehensively.
Definitions
Ambulatory Practice - An environment in which health care services are provided to non-
hospitalized patients (Medical Dictionary for the Health Professions and Nursing, 2012).

14
Clinician and Group: The CAHPS Clinician & Group Survey (CG-CAHPS) is a
standardized instrument designed to assess patients' experiences with health care providers and
staff in doctors' offices.
Employee engagement: An individual employee's cognitive, emotional, and behavioral
state directed toward desired organizational outcomes (Shuck & Wollard, 2010).
Employee disengagement: The disconnection of individuals from their work roles to
protect themselves physically, mentally and emotionally from real or perceived threats. (Shuck
& Wollard, 2010)
Middle Management - An employee of an organization or business who manages at least
one subordinate level of managers, and reports to a higher level of managers within the
organization. The duties of a middle manager typically include carrying out the strategic
directives of upper-level managers at the operational level, supervising subordinate managers
and employees to ensure smooth functioning of the enterprise (Businessdictionary.com)
Patient Satisfaction: Patient satisfaction is an important and commonly used indicator for
measuring the quality in health care. Patient satisfaction affects clinical outcomes, patient
retention, and medical malpractice claims. It affects the timely, efficient, and patient-centered
delivery of quality health care (National Library of Healthcare National Institute of Health,
2010).
Press Ganey - The Press Ganey survey measures employee engagement through a series
of questions which gauges engagement at the work unit level, assesses readiness for change, and
identifies key drivers of engagement unique to the organization (Press Ganey, 2018).
SCORE Survey - SCORE is an integrated survey of Safety, Communication,
Organizational Reliability, Physician & Employee Burnout and Engagement, and provides in

15
depth and actionable insights into organizational clinical and operational performance and risk.
SCORE is administered to create detailed unit-level indicators, critical in today’s industry where
performance-based reimbursement incentives are challenging economic survival
(SafeandReliable.com, 2019).
Organization of the Study
Five chapters are used to organize this study. This chapter provides the reader with the
fundamental concepts and terminology commonly found in a discussion about employee
engagement and the effects of employee disengagement in healthcare. The organization’s
mission, goals, and stakeholders as well as the initial concepts of gap analysis were introduced.
Chapter Two provides a review of the current literature surrounding the scope of the study.
Topics of employee engagement, employee disengagement, and the relationship to patient
satisfaction, quality services and will be addressed. Chapter Three details the assumed
interfering elements as well as a methodology when it comes to choice 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.

16
CHAPTER TWO: REVIEW OF THE LITERATURE
Influences on the Problem of Practice
This literature review will explore the importance of the manager and the director’s role
in employee engagement in healthcare. The review begins with research on employee
engagement’s meaning and importance, followed by an overview of the literature on employee
engagement in healthcare and its relation to patient outcomes, patient satisfaction, and employee
satisfaction. Moreover, a review of how and whether the manager and director’s role influence
employee engagement. The analysis will present an in-depth discussion on scientifically based
studies of employee engagement, and the contributing factors that directly affect employee
engagement. Following the general research literature, the study turns to the Clark and Estes
(2008) Conceptual Framework and knowledge, motivation, and organizational influences on
employee engagement in healthcare.
Employee Engagement
Employee engagement is a term developed by William A. Kahn (1990), which centers
around an understanding of when individuals insert and remove themselves from tasks. This
“self-in-role” (Kahn, 1990) concept explains employee disengagement as the withdrawal and
defense of a person’s preferred self in behaviors that promote lack of connections, physical,
cognitive, and emotional absence, resulting in incomplete role performance. Employee
engagement is essential in healthcare as researchers have shown the correlation between
employee engagement and quality, clinical outcomes, patient satisfaction, employee satisfaction
and retention, including the finances of the organization (Lowe, 2012; Peltier et al., 2009; Scotti
et al., 2007). In the worst-case scenario, a disengaged employee can contribute to the medical
errors leading to death. Kohn (1999) highlights the Institute of Medicine data that 98,000 people

17
die in hospitals each year due to medical errors. The Department of Health and Human Services
(2010) reports 180,000 deaths due to medical errors in Medicare patients alone, and British
researchers state medical errors are the third leading cause of death in the U.S. (Makary &
Daniel, 2016). The evidence corroborates the need for healthcare organizations to focus on
employee engagement and understand and prevent employee disengagement (Altman, 2017;
Markos & Sridevi, 2010; West & Dawson, 2012).
The Evolution of Employee Engagement in Healthcare
The History of Employee Engagement
Merton (1957) enlightens the sociological world with the study of role sets which state
that individuals occupy a complement of role-relationships specific to their social status (Merton,
1957). Kahn (1990) further explores the concept of roles through how an individual actualizes
the role and the varying degrees and process of when an individual removes and inserts
themselves into task performance. He theorizes that people bring a part of themselves in and out
at varying depths, and they respond and express themselves according to the transitory flow of
the workday. Kahn’s focus was to determine the variables that provide insight as to when people
adjust their “self-in-role” (Kahn, 1990).
Kahn’s qualitative research took place with employees from a summer camp and an
architectural firm. The interviews with camp counselors provided data that starts to describe the
meaning of moving in and out of work tasks, while the architectural firm employees start to
differentiate feelings of when they are attentive and involved, and when they are distracted and
detached from their work. These findings start to shape the self-in-role concept with personal
engagement and disengagement being points of discussion. Personal engagement is
“simultaneous employment and expression of a person’s ‘preferred self’ in tasks behaviors that

18
promote connections to work and to others, personal presence (physical, cognitive, and
emotional), and active, full role performances'' (Kahn, 1990, p. 700). Conversely, personal
disengagement is the “simultaneous withdrawal and defense of a person’s physical, cognitive,
and emotional absence, and passive, incomplete role performances'' (Kahn, 1990, p. 701).
Personal engagement and disengagement are affected by three psychological conditions:
meaningfulness, safety, and availability (Kahn, 1990). Psychological meaningfulness refers to
the feelings one receives from investing physical, cognitive, or emotional energy through tasks,
roles, and work interactions. Psychological safety is the feeling and ability to show oneself
without fear or negative consequence to one’s self-image, status, or career. Psychological safety
is affected by interpersonal relationships, group and intergroup dynamics, management style and
process, and organizational norms (Kahn, 1990). Lastly, psychological availability is the
consciousness of having physical, emotional, or psychological resources to engage in a particular
moment.
Merton (1957) begins to describe the notion of “role sets,” while Kahn’s (1990) research
focuses on “self-in-role.” Both scholars shape the framework for the engaged and disengaged
employee and the relationship to meaningfulness, safety, and availability in work. Nevertheless,
the framework leads to more questions which intensify the ambiguity of defining employee
engagement.
Difficulty in Defining Employee Engagement
Three decades have passed since Kahn (1990) defined employee engagement as “self in
role.” While researchers continue to refine the meaning of employee engagement (Maslach,
Schaufeli & Letier, 2001; Harter, Schmidt & Hayes, 2002; Bakker, Schaufeli, Leiter, & Taris,

19
2008; Simpson, 2009), they acknowledge there continues to be a lack of clarity, which
contributes to the complexity of finding solutions that can address employee engagement and
disengagement (Shuck & Wollard, 2010)
Shuck and Wollard (2010) recognized that employee engagement is inconsistently
defined, resulting in a fragmented approach to understanding and developing employee
engagement strategies. In order to understand the term “employee engagement,” Shuck and
Wollard (2010) provided an integrative literature review that starts with Kahn’s work in 1990,
identifying the “self-in-role” concept. Maslach, Schaufeli, and Leiter (2001) define employee
engagement as the antithesis of employee burnout and state, it is “a persistent, positive affective-
motivational state of fulfillment in employees that is characterized by high levels of activation
and pleasure” (Maslach et al., 2001, p. 417). Harter, Schmidt, and Hayes (2002) performed an
empirical study of 7,939 businesses in various fields and linked employee engagement to profits
and outcomes of a business unit. May, Gilson, and Harter (2004) tested Kahn’s (1990)
conceptualization of employee engagement through an empirical study exploring the
determinants and mediating effects of meaningfulness, safety, and availability on employees’
engagement in their work. The findings indicate that psychological meaningfulness and safety
were positively linked to employees’ investment in their work roles. Moreover, supportive
leadership and positive co-worker relations had a positive relationship with feelings of safety.
Saks (2006) connects employee engagement drivers to consequences and states employee
engagement is, “A distinct and unique construct that consists of cognitive, emotional, and
behavioral components that are associated with individual role performance” (Saks, 2006, p.
602). Vance (2006) published a conceptual study in Society for Human Resources Management

20
(SHRM); however, little of what was written conceptualizes employee engagement as an
understandable or practical construct.
Czarnowsky (2008) published in the American Society for Training and Development
(ASTD) and defines employee engagement as “Employees who are mentally and emotionally
invested in their work and in contributing to their employer’s success” (Czarnowsky 2008, p. 6).
The integrative study ends with Macey and Schneider (2008), who theorize trait, state, and
behavioral engagement as distinct but related components of engagement. Macey and Schneider
(2008) define employee engagement as the “inclination or orientation to experience the world
from a particular vantage point” (Macey & Schneider, 2008, p. 5). They offer psychological
state engagement as satisfaction, involvement, commitment, and empowerment, as an antecedent
to behavioral engagement or the additional effort one puts into work. Simpson (2009)
performed a systematic review of the literature and identified four employee engagement
constructs that she found is related to improving nursing engagement in healthcare: (a) Kahn’s
Model of Personal engagement (1992), (b) Maslach and Leiter’s Work Life Model (1997), (c)
The Job Demands Resource Model (Bakker and Demerouti, 2007; Demerouti et al., 2001), and
(d) Employee Engagement Model (Harter et al., 2003). Her research revealed it is necessary to
determine the predictors of nurse performance to improve healthcare quality and decrease costs.
She feels this can be achieved by addressing and using current methodological limitations, “the
first of which involves building upon a conceptually consistent definition and measurement of
this construct.” (Simpson, 2009, p. 1002). Markos and Sridevi state, “To date, there is no single
and generally accepted definition for the term employee engagement” (Markos & Sridevi, 2010
p. 90).

21
The research offers words, phrases, and cognitive meaning to employee engagement as it
applies to individuals and groups of people in an organization. Moreover, the level of
engagement may be based on the individual’s personal history, values, and goals, which
augments the complexity of pinning the definition of employee engagement. Regardless, there is
the agreement that employee engagement is about individuals or groups of individuals that are
personally invested in their work and their success, contributing to the organization’s success.
Employee engagement in healthcare is paramount because it is the quintessence of
healthcare. Although Simpson’s research (Simpson, 2009) focuses on how nurses' engagement is
related to performance and patient outcomes, her research can be applied to all healthcare
employees. In healthcare, employee engagement is critical because it has an impact on patient
care and outcomes and employee satisfaction (Lowe, 2012; Peltier et al., 2009; Pech & Slade,
2006; Scotti et al., 2007). Conversely, the risks associated with a disengaged employee can
create low patient satisfaction, possibilities of injury, and even death (Kohn, 1999; Markary &
Daniel, 2016). Furthermore, employee engagement can be affected by various interest groups
outside of the organization, as well as sociological factors that influence healthcare organizations
and employees.
Importance of Employee Engagement in Healthcare
Increasing Need for Healthcare Providers

By the year 2030, there will be 7.1 million Americans over the age of 65 who will require
healthcare. Researchers state (Vespa, Armstrong & Medina, 2018) that based on U.S. census
projections, aging Americans will require 3.5 million health care providers. In 2020, 56.1
million people will be 65 years and older, and by 2060 this will increase to 95 million,
representing 23% of the population. In 2035, older adults will surpass the number of children;

22
life expectancy will increase, and the population of 85 and older will increase from 13% of the
population in 2016 to 200% by 2060. The U.S. will move from a youth-dependent population to
an elderly-dependent population. As a result, more Americans will require care, and the
healthcare industry will need more workers.
The Institute of Medicine (2008) projects the U.S. will need 3.5 million healthcare
workers in 2020 to support aging Americans, which is reinforced by the claim made by the U.S.
Bureau of Labor Statistics (2019) states healthcare projects to have one of the fastest annual
employment growth rates with more than 3.4 million new jobs by 2028.
Combined with an aging population, is an aging healthcare workforce. By 2020, almost
half of the registered nurses will be over 50, as will physicians (Institute of Health, 2008). One
in four of the 800,000 physicians in America is over the age of 65 (Institute of Health, 2008). In
2018, 29% of U.S. physicians were between the ages of 55 and 65 years (Elfin, 2019), indicating
that this statistic is growing faster than projected. There is a legitimate fear that there will not be
enough healthcare workers to provide care for the future geriatric population, which will
contribute to poorer quality and patient outcomes, and may affect employee engagement.
Thus, the U.S. is heading towards a shortage of healthcare workers in desperate
proportions; combined with the increase in the aging US population and the aging healthcare
workforce, the need to focus on employee engagement is crucial. Nevertheless, this is not the
only problem creating the necessity to address employee engagement. There are outside forces
that put pressure on the healthcare industry to see a higher volume of patients, with fewer
employees and decreasing reimbursement, which creates stressful work conditions. The U.S.
government programs claim to deemphasize volume and focus on value; however, the value-

23
based programs promoted by the U.S. government can create conditions defined by healthcare
workers as unsafe.
U.S. Governments Influence in Healthcare and the Effects on the Healthcare Employees

The U.S. spends 3.6 trillion dollars on healthcare annually (Sherman, 2019), of which the
1.2 trillion (Tax Policy Center, 2019) is paid for by the US government. Therefore, any
healthcare organization dependent on government dollars is subject to the various cost savings
programs developed by the government. Although these programs intend to bring value, they
can also trigger adverse effects on employee engagement.
Medicare and Medicaid government-sponsored programs are primary payers for most
patients 65 years and older. Physicians who care for this sector of the population are typically
the least paid, creating income and work disparity amongst physicians. The Institute of Medicine
(2008) looked at the consequence of these programs on healthcare workers and the effect on
primary care practices. Medicare pays about $182.52 for a moderately complex visit for an
ambulatory visit. The typical overhead for a primary care practice ranges from 41%-60%,
leaving a small profit margin.
Additionally, primary care physicians often act as the nucleus in coordinating specialty
physician and ancillary services. Although the model supports managing healthcare expenses,
the burden of activity is with the primary care office that performs time-consuming activities that
do not involve face-to-face interaction with the patient, which healthcare workers perceive as
barriers to care. Furthermore, the frustration of completing forms, requesting authorizations, and
documenting in the electronic health record can be overwhelming and unnecessarily
complicated. Therefore, the situation requires more staff to support these additional tasks, and
combined with an increasing volume of patients, this creates a stressful and challenging

24
situation. A couple of intended solutions provided by the Federal government is the Healthcare
American Reimbursement and Recovery Act and the Value-Based Purchasing program.
The Healthcare American Reimbursement and Recovery Act of 2011 (Institute of
Medicine, 2008) is a government program which provided incentives over multiple years of up
to $40,000 to $65,000 per eligible physician and up to $11 million per hospital (Steinbrook,
2009) for the meaningful use of health information technology, such as the electronic health
record (EHR), health information exchange of data, and reporting of clinical quality measures.
Starting in 2015, physicians and hospitals that do not use certified products in a meaningful way
were penalized. Instead of bringing relief, the electronic health system brought new stress to the
healthcare worker. The industry was thrust into to changing how healthcare was delivered, and
the EHR created more burden to the physician, decreased physician productivity resulting in
decreased revenue and negative patient-physician interactions and relationships, and pervasive
physician dissatisfaction (Gidwani, Nguyen, Kofoed, Carragee, Rydel, Nelligan, 2017). Staff
was also affected by this change, and instead of face time with the patient, staff were required to
give more attention to inputting information into the EHR.
Value Based-Purchasing (VBP) is a Center for Medicare and Medicaid program in which
hospitals and physicians groups receive incentive payments or penalties based on meeting
performance objectives related to quality, costs, and efficiency. The intent is to transform
healthcare by linking payments to value related to the patient experience and recognizing shared
accountability among providers (Tompkins, Higgins & Ritter, 2009). The Value Based-
Purchasing program was intended to shift the focus from volume to value, focusing on quality
and efficiency, yet operational and tracking systems such as the EHR are cumbersome and
tedious, creating more pressure on the healthcare worker.

25
The impact of these U.S. government initiatives created unforeseen complications for
physicians and staff. The complexities led to employee and physician frustration, an increase in
healthcare expenses, and possible dangerous patient situations. Therefore, despite the attempts
of the government to make a positive impact on healthcare, it is the healthcare worker that bears
the burden of these programs, and their engagement and disengagement reflect in their work.
The Impact of the Engaged Employee

Employee engagement is particularly critical in healthcare because it directly affects
patient quality, outcomes, satisfaction, employee retention, and financial health. A high level of
engagement is a goal for healthcare organizations because engaged employees are committed,
satisfied with their work, and willing to give more effort to achieve the organization’s goals.
Additionally, the evidence suggests that employee engagement may influence human resources
goals, such as retention and job performance (Macey & Schneider, 2008) and patient satisfaction
(Lowe, 2012).
Graham Lowe (2012) conducted a quantitative study with 10,000 healthcare employees
to determine the relationship between engaged employees and organizational performance. The
key findings revealed that engagement levels are positively and consistently related to mission-
critical organizational outcomes. Moreover, the study showed a pattern in patient care and
service quality and suggested that achieving higher employee engagement levels will improve
quality and safety. Finally, based on the study, Lowe (2012) offers an evidence-based definition
of employee engagement relevant to healthcare, “Engaged employees have a strong emotional,
rational, and behavioral attachment to their job and the organization. They experience pride,
value congruence, and job and organizational satisfaction, and they feel enthusiastic and inspired
in their work” (Lowe, 2012, p. 38). The study also revealed that highly engaged employees trust

26
their employer and contribute to improving their work; they feel valued and have a clear sense of
job goals, teamwork, and team membership.
An empirical study at a major New York City hospital (Peltier et al., 2009) examined the
relationship between employee satisfaction and patient satisfaction. The data from employee
satisfaction surveys and patient satisfaction surveys were aggregated and analyzed to determine
if there was a relationship between specific metrics related to employee’s overall satisfaction and
the patient's likelihood to recommend the hospital, overall rating of care given, and summed
overall score. The results of the study showed that hospitals with higher levels of employee
satisfaction provide better patient experiences. Therefore, patients consciously or not, infer the
care received is better because of the environment created by a more satisfied employee. The
researchers concluded a key aspect of the findings is that health care leaders should add quality
of patient care to the benefits of having satisfied employees.
Scotti et al., (2007) suggest that high-performance work systems are organizations that
involve, empower, and engage their employees. Their study analyzed employee surveys from
ambulatory practices at Veterans Hospitals to determine if there is a link between high-
performance work environments, service quality, and patient satisfaction. The findings revealed
that engaged employees give more of themselves to their patients, which results in high patient
satisfaction and better quality of care. Moreover, there is a strong likelihood the employee will
refer to the healthcare organization as a good place to work, and the patient will refer the hospital
to family and friends because of a positive experience. The findings also revealed that
disengaged employees do not connect with their job and can be detrimental to a patient and the
organization.

27
Based on the research, there is a relationship between employee engagement and high
patient satisfaction and high-quality care. Conversely, the disengaged employee is
unenthusiastic, does not connect with their job, adds to the rising cost of healthcare, and, most
importantly, can place the patient at significant risk.
The Consequence of Disengaged Employees
Disengaged employees are a risk to the healthcare industry. In 1999, research by the
Institute of Medicine (2008) asserted up to 98,000 people die in hospitals each year as a result of
medical errors. In 2008, the Department of Health and Human Services reported 180,000 deaths
due to medical errors in Medicare patients. What is more, British researchers (Makary & Daniel,
2016) state medical errors are the third leading cause of death in the U.S. Disengaged employees
may not be the only reason for medical errors; however, the research shows disengagement is a
critical contributor to the cause of medical errors. Furthermore, in 2008, the economic impact of
medical errors was $19.5 billion annually (Andel, Davidow, Hollander & Moreno, 2012), which
is inclusive of the associated medical expenses such as ancillary services, prescription drugs
services, hospital, and ambulatory costs. Therefore, the disengaged employee is costly and a
detriment to the healthcare industry.
Kahn (1990) defines a disengaged employee as “the withdrawal and defense of a person’s
preferred self in behaviors that promote lack of connections, physical, cognitive and emotional
absence, and passive incomplete role performances” (Kahn, 1990, p. 692). West and Dawson
(2012) describe disengagement as burnout characterized by cynicism, exhaustion, and inefficacy,
which results in negative consequences.
In healthcare, it is crucial to have an engaged healthcare workforce because of the work’s
nature. Researchers (Lu, Dresden, McCloskey, Branzetti, & Gisondi, 2015) found emergency

28
department physicians to have the highest levels of burnout amongst all physicians, and surgeons
and internists have the highest rates of self-reported suboptimal care due to burnout.
Consequently, the argument is, there is a strong link between medical errors and suboptimal care
and employee disengagement, which is a threat to the healthcare industry. Furthermore, the
costs associated with medical errors are one expense; disengaged employees contribute to the
escalating cost of healthcare through the human resources aspect such as turnover, employee
retention, costs associated with hiring, and training new employees (Altman, 2017).
In a study by Markos and Sridevi (2010), they report employees who are disengaged miss
an average of 3.5 more days per year, are less productive, and cost the U.S. upwards $292 to
$355 billion per year. Moreover, according to Gallup’s State of the American Workplace: 2010-
2012 report, the cost of disengaged employees has increased to $450 billion to $500 billion in
lost productivity per year.
Disengaged employees in healthcare are a risk to the organization. They can provide
suboptimal care, contribute to unintentional consequences, which can lead to harm or death,
increase patient dissatisfaction, and influence the rising cost of healthcare. The evidence
corroborates the need for healthcare organizations to focus on employee engagement and
understand how to prevent employee disengagement. As such, healthcare organizations are
accountable to patients, physicians, and employees to ensure an engaged workforce.
The Effect of Organizational Culture on Employee Engagement

Organizational culture is dynamic, complicated, and directly affects how employees
engage or disengage in their work. Schein and Schein (2017) posits the employee brings
themselves to the organization as individuals, but they also carry with them the organizational
culture that directly affects their relationship with the organization which affects how they

29
perform their job. Therefore, it is important to define the organization’s culture by observing
behaviors, climate, or feelings expressed by members of the organization. The information
obtained will provide information about group norms, standards, and shared meanings, which are
essential variables in understanding organizational culture (Schein & Schein, 2017). This
evidence can help leadership identify why employees are engaged or not, and how to weave
influence into the organization.
In a study by Matziari, Montgomery, Georganta, and Doulougeri (2017), the relationship
between organizational practice and values, with burnout and engagement was examined in a
cross-sectional quantitative study of 214 nurses. Their objective was to understand the
characteristics that decrease burnout and increase job engagement and how the organizational
culture contributes to feelings of burnout. The results of the study showed that organizational
values are a predictor of emotional exhaustion and dedication. The highlights of the findings
were several: (a) nurses have higher feelings of engagement in a work environment where they
feel empowered and supported by the organization; (b) nurses experienced lower levels of
exhaustion when there were higher levels of support from co-workers; (c) organizations that are
highly governed by rules and bureaucracy led to higher levels of burnout; and (d) role clarity,
performance expectations, performance appraisals, and rewards all reduced emotional exhaustion
(Matziari et al., 2017)
These findings support Schein & Schein (2017) statement that defining characteristics of
the organization culture can help leadership identify why employees are engaged or not, and this
can be examined through the lens of artifacts, espoused beliefs, and basic underlying
assumptions. Organizational leadership has a responsibility to understand the consequences of

30
organizational culture and discover ways to support and insert new or different subcultures to
create change.
In sum, organizational culture and work-setting are significant factors in employee
engagement. Culture can be associated with dedication or burnout of employees who will either
attract or detract employees. Nevertheless, organizational culture is one of the many barriers to
employee engagement. These barriers may be visible or not. The more difficult challenge is the
inability to understand individuals and what they bring to the workplace. To better understand
the organization and individual barriers, the organization needs to rely on leadership with a pulse
on the business units. These leaders are the first line manager and directors of the organization.
The Impact of the Manager and Director on Employee Engagement

The managers and director’s role is essential to employee engagement because they can
be supporters or barriers to creating an environment that promotes employee engagement.
Tucker (2017) states that managers can anticipate resistance and gauge their workers’ capacity
for change, and by being change agents, managers can help employees adopt new ways of
thinking and working. Moreover, managers and directors can promote change by being
transparent, persistent, involving employees in the change process, identifying learning
opportunities, promoting continuous learning, listening, and sharing continuously. However,
these characteristics may not come naturally to managers and directors.
Imperatori (2017) states that managers are in the middle of the organization-employee
relationship, and they often lack the behavioral and relational competencies to manage their roles
in challenging and unpredictable organizational situations. Traditionally, the managers’ success
was about planning, controlling, and organizing resources, not about relational and behavioral
competencies. Reina, Peterson, Byron, and Hom (2018) examined the role of manager influence

31
on employee engagement and turnover and found employees state their managers’ behavior as
the primary reason for leaving the organization. Their quantitative study revealed several
findings: (a) managers that use pressure tactics are positively associated with employee turnover
and inspirational leadership is negatively associated with turnover; and (b) emotional
engagement mediated the relationship between these influence tactics. Therefore, the manager’s
role enhanced with knowledge, self-efficacy, and confidence may support an engaged workforce.
Luthans and Peterson (2002) performed an empirical investigation to learn how a manager's
psychological state of self-efficacy is related to employees' level of engagement and concluded
employee engagement and manager self-efficacy are antecedents that influence engagement.
Therefore, mid-level leaders have a direct impact on employee engagement through their
behavior, communication, and ability to engage with their employees emotionally. Managers
who lack skills, knowledge, self-awareness, and self-efficacy will foster a disengaged workforce.
To better understand the manager role and the relationship to employee engagement, it will be
necessary to understand their knowledge, motivation, and the organizational influences that will
attract and maintain an engaged workforce.
The Clark and Estes’ Gap Analysis Conceptual Framework
Clark and Estes (2008) offer a conceptual framework that provides a systematic approach
to identifying performance gaps from the organizational business goals, and a methodology to
close the performance gap. Knowledge, motivation and organizational (KMO) barriers are the
three critical influences that can alter the ability to meet performance goals (Clark & Estes,
2008). Knowledge and skills are facts, procedures, concepts, and beliefs that succors the
individual to meeting performance goals (Mayer, 2011). There are four types of knowledge: (a)
factual; (b) conceptual; (c) procedural; and (d) metacognitive (Krathwohl, 2002; Rueda, 2011).

32
These knowledge types provide a structure to assess and define the stakeholder’s knowledge.
Motivation is the action which involves energetic choice, persistence, and mental effort (Clark &
Estes, 2008). Motivation is the catalyst that causes the stakeholder to achieve performance
goals despite distractions and other priorities. Motivational influences such as self-efficacy
(Bandura, 1997), expectancy theory (Eccles, 2006), attribution and control beliefs (Rueda, 2011)
are motivational dimensions that evaluate the stakeholder’s level of motivation. Organizational
barriers such as inadequate processes, lack of resources or tools, and negative work environment
are elements that can prevent stakeholders from meeting performance goals (Clark & Estes,
2008).
The Clark and Estes (2008) model is the framework that will be used to examine the
knowledge, motivation, and organizational needs and assets that influence director’s and
manager’s goals to implement an employee engagement program that embraces best practices for
improving employee engagement. Additionally, the framework will help identify the gap and
recommended knowledge, motivation and organizational solutions for the directors and
managers to meet their goal. Three sections will be discussed. The first section will open with
the examination of assumed influences of knowledge and skills on the manager’s ability to meet
the performance goal. The next section will analyze the middle manager’s motivation to attain
the goal and the last section explores the assumed organizational influences on the manager’s
ability to achieve their goal. The knowledge, motivation and organizational barrier influences on
performance will be examined through the methodology discussed in Chapter Three.
Stakeholder Knowledge, Motivation and Organizational Influences
The first research question for this study is: What are the knowledge, motivation, and
organization needs and assets that influence Directors and Managers goal to implement an

33
employee engagement program (EEP) program that embraces best practices for improving
employee engagement in the ambulatory setting by July 2020. Each of these factors is discussed
in the sections that follow.
Knowledge

Knowledge, skills, and motivation are critical components of achieving individual and
organization performance goals (Clark & Estes, 2008). In the field of healthcare, this is
important because patients entrust their lives to employees whom they assume have knowledge,
skills, and motivation to perform optimally. Furthermore, the research supports that engaged
employees with knowledge, skills, and motivation are more likely to perform at their best while
achieving organizational goals (Lowe, 2012). The purpose of the following section is to examine
how knowledge, skills, and motivation are influential factors in middle-level management’s
ability to implement an employee engagement program that embraces best practices for
improving employee engagement.
Knowledge and Skills
Clark and Estes (2008) recognize that a key to organizational success is employees who
can solve problems, are adaptable to changing environments and possess skills and knowledge to
perform and execute their responsibilities. Mayer (2011) states that learning consists of three
parts: (a) a change, (b) in what the learner knows, (c) caused by the learner’s experience.
Change in what the learner knows is knowledge, and knowledge includes facts, procedures,
concepts, and beliefs. Furthermore, learning takes place when there is interaction with the
environment such as discussion with others, observation, or reading a book (Mayer, 2011).
Thus, learning is a precursor to knowledge, and knowledge is the act of understanding and
applying what is learned.

34
There are four types of knowledge: (a) factual; (b) conceptual; (c) procedural; and (d)
metacognitive (Krathwohl, 2011). Factual knowledge is the fundamentals one must know in
order to understand and perform effectively. Conceptual knowledge is the understanding of
categories, classifications, generalizations, theories about a specific area. Procedural knowledge
refers to the process of knowing how to accomplish a task through methods of inquiry or specific
skills and techniques required to accomplish a particular activity. Metacognitive knowledge is
the consciousness of one’s understanding of a mental process.
To further understand how knowledge applies, it is valuable to explore knowledge in
relation to the stakeholder goal to implement an employee engagement program (EEP) program
that embraces best practices for improving employee engagement in the ambulatory setting. The
belief is that employees are critical to the success of the health system and, as such, empowering
the Directors and Managers to implement an EEP will enhance the experience and quality
outcomes for the patients by providing safe, personalized, compassionate and innovative health
care (St. Elsewhere, 2013).
Factual Knowledge. Factual knowledge is the basic knowledge one must know to
understand and perform properly (Rueda, 2011). The organization states that employees are
critical to the success of the health system and creating a service-oriented culture is essential.
Yet, the question to consider is whether the director’s and manager’s know this is important and
if they understand their role in developing an EEP that will influence employees to promote an
engaged, service-oriented culture. The organization performs employee engagement surveys that
provide valuable information about how the employees feel about the organization, the culture,
and leadership. However, employee engagement survey results were not shared with the
Directors and Managers, and therefore, they do not have the factual knowledge that will assist

35
them in achieving their goal. The Directors and Managers need to know their role in order for
them to perform their role. The organization states that Managers and Directors are empowered,
yet it is possible they do not have the facts or the tools to feel empowered. The factual
knowledge the Directors and Managers must know and understand are (a) an understanding of
the employee engagement survey and the meaning of the score; (b) the baseline metric and
organization goal to increase employee engagement scores; and, (c) the manager’s role and
responsibility in developing and implementing an EEP program that embraces best practices for
improving employee engagement.
Conceptual Knowledge. Conceptual knowledge is about theories, generalizations,
classifications, models or structures that apply to an issue (Krathwohl, 2011).
Multiple studies (Lowe, 2012; Peltier et al., 2009; Scotti et al., 2007) have shown that
employee engagement in healthcare has a direct effect on patient quality, outcomes, satisfaction,
employee retention and financial health of the organization. This cause and effect relationship is
established through research; however, if the stakeholder does not understand the relationship, it
is difficult to effect change. Therefore, they may lack in the conceptual knowledge to implement
an employee engagement program for improving employee engagement. The act of
understanding employee engagement and how to develop an employee engagement program is
likely preventing employee engagement scores from increasing and is having an effect on patient
satisfaction and outcomes. Providing an understanding of the relationship between employee
engagement and providing the knowledge and tools to the managers and directors to implement
an employee engagement program, can provide the impetus towards improving patient
satisfaction and outcomes.

36
Procedural knowledge. Procedural knowledge refers to how a specific task is
performed (Rueda, 2011). Asking a group of managers to achieve the goal without providing
procedural knowledge can lead to frustration and disappointment. Often, front-line managers
have the skills to perform tasks such as register a patient and schedule an appointment, and they
excel at these tasks because they understand how to perform them. However, uncertainty lies in
whether the managers have the aptitude for developing an action plan that embraces best
practices for improving employee engagement. To build an action plan requires procedural and
metacognitive skills and knowledge. Therefore, procedural knowledge is vital to developing the
directors and managers and providing them with a framework for developing an employee
engagement program may be necessary. The creation of their plan will include identification of
key performance indicators, specific procedural tasks, metrics, milestones, and timelines that
facilitate goal achievement. The emphasis is on the procedures and processes that make up the
tasks that lead towards goal accomplishment.
The organization expresses the belief that employees are critical to the success of the
health system and empowering the directors and managers will enhance the experience and
quality outcomes for the patients. The investment in the managers and directors to provide them
with procedural knowledge will empower them to implement an employee engagement program.
Therefore, procedural knowledge will be impacted by developing a formalized training program,
which will enhance professionalism, self-efficacy, and self-confidence.
Metacognitive knowledge. While procedural knowledge is the act of defining tasks and
knowing how to accomplish a task, metacognitive knowledge is the manager’s reflective process
of how these tasks influence employee engagement. It is about making thoughtful observations
and the ability to modify and monitor tasks while being aware of one’s relationship and

37
contribution in achieving the goal. Metacognitive knowledge is being aware of one’s cognitive
process (Rueda, 2011) and the control of one’s cognitive processing (Mayer, 2011).
Metacognitive knowledge is an essential knowledge influence because it is about how the
individual thinks about their actions and whether they can accomplish the task. In the example
of building an employee engagement program, metacognitive knowledge is the act of choosing
what to do, how to measure it, why it is important, and reflecting on the results to assure the
tasks aligns with the goal of increasing employee engagement. It is the moment when the
manager realizes what to do, when to do it, and are fully engrossed and engaged in all aspects of
building, monitoring, and fine-tuning the plan. Researchers theorize that higher levels of
engagement lead to cognitive behaviors and tactics that improve learning such as increased time
on tasks, higher cognitive effort, and the use of concentrated processing methods (Padgett,
Cristancho, Lingard, Cherry & Haji, 2018). Teaching managers how to use metacognitive skills
is important because it empowers them to become stronger leaders and create a work
environment with clear and concise business goals (Clark & Estes, 2008). Metacognitive
knowledge influence entails a thoughtful, reflective process about oneself and the learning that
comes out of the reflective process.
Table 2 provides a summary of the four knowledge type influences and how they will be
assessed.
Table 2

Knowledge Influence, Knowledge Type and Knowledge Influence Assessment

Organizational Mission
We are the St. Elsewhere Medical Center.
We strive to be the trusted leader in quality health care that is personalized, compassionate and
innovative.
We stand for empowerment, integrity, respect, collegiality, and vitality.
We commit to authenticity.

38
We commit to excellence in clinical care, teaching and research.
You can count on us to be fully present in the delivery of uncompromising health care.

We believe the employees of the health system are critical to the success of the medical center.
Empowering our staff and creating a service-oriented culture will enhance the experience and
quality outcomes for our patients by providing health care that is safe, personalized,
compassionate and innovative.

Stakeholder Goal

Managers and Directors will implement an employee engagement program (EEP) program
that embraces best practices for improving employee engagement in the ambulatory setting by
July 2020.

Knowledge Influence

Knowledge Type Knowledge Influence Assessment
Managers and Directors need to
know the results of the employee
engagement survey tool;

Managers and Directors need to
know their role and
responsibilities.

Managers and Directors need to
know the definition of employee
engagement.

Managers and Directors need to
know the components of an EEP

Managers & Directors need to
know the best practices to foster
engagement.

Factual 1) Survey and Interview –
survey manager group to
determine
a. knowledge of
organization global goal,
b. understanding of
employee engagement
c. understanding of their
role and responsibility in
increasing employee
engagement
d. knowledge of the
components of an EEP
e. knowledge of best
practices
f. level of empowerment to
make the change.
2) Interview stakeholders
Managers and Directors need to
know the organizational
consequences of employee
engagement

Conceptual Survey and Interview managers
Managers and Directors need to
know how to increase employee
engagement through defined best
practices strategies.
Procedural Survey and Interview managers
and directors

39
Managers and Directors need to
know how to reflect on their
progress toward increasing
employee engagement.
Metacognitive Survey and Interview managers
and directors
Motivation
Motivation is a condition that introduces and sustains behavior; it is what pushes the
individual to become fully engaged in a process because of their interest, belief, attributions,
goals and social partnership (Mayer, 2011). Clark and Estes (2008) describe motivation as the
action which involves active choice, persistence, and mental effort. Motivation is the catalyst to
employee engagement, which is particularly critical in healthcare as it has a direct effect on
patient quality, outcomes, satisfaction, employee retention and financial health of the
organization (Lowe, 2012; Peltier et al., 2009; Scotti et al., 2007).
To achieve the goal of implementing an employee engagement program that embraces
best practices for improving employee engagement and identifying the recommended
knowledge, motivation and organizational solutions to achieve their goal, the directors and
managers must make an active choice, be persistent and have the mental stamina to accomplish
the goal. Active choice (Clark & Effort, 2004) involves the decision to pursue a goal. The goal
to develop an EEP to improve employee engagement is an active choice. The middle-level
managers must be persistent in achieving this goal despite distractions and other priorities. The
mental effort required to pursue this goal involves personal conviction, and a belief that they
have the knowledge, skills, and confidence to develop interventions to solve the problem and
meet the goals. The motivational influence of personal confidence is self-efficacy, while valuing
the task to achieve the goal is expectancy-value theory. Both self-efficacy and expectancy-value
drive choice and persistence (Clark & Estes, 2008). As such, these motivation constructs will be
the focus of this study.

40
Self-Efficacy. Self-efficacy is the capacity or personal conviction that the individual has
to successfully perform the required behavior to produce a particular result in a situation, activity
or domain (Bandura, 1997). More specifically, self-efficacy is confidence in one’s capacities to
mobilize the cognitive resources, motivation, and courses of action required to take on the
demands of a particular task (Wood, Bandura & Bailey, 1990). Self-efficacy forms through the
interpretation from mastery experience, vicarious experience, social persuasions, and
physiological reaction (Pajares, 2006).
The stakeholders are seasoned managers and directors with multiple years of experience
in healthcare. They are skillful and masters over the tasks they perform on a day-to-day basis.
However, understanding and knowing how to develop and implement an EEP to improve
employee engagement may require a different skill set. Self-efficacy, or their capacity and
personal conviction to perform the required behavior may not be strong, because they do not
understand their role, and their ability to influence employee engagement. In order to encourage
self-efficacy, the managers must understand that influencing employee engagement is not only
about a task or series of tasks, it is about the motivation, and belief that they can improve
employee engagement and achieve their goal. Bandura (1986) asserts that self-efficacy focuses
not only on the abilities of people, but also on their beliefs concerning what they are capable of
doing, regardless of the skills they possess.
One of the essential aspects of building self-efficacy is the skill to accomplish tasks. An
individual with high self-efficacy will not perform proficiently when requisite skills are lacking
(Schunk, 1991). The directors and managers may or may not have the knowledge, or skills to
build an EEP, but if they are self-efficacious, they will determine what is required to build an
EEP, and they will be motivated to accomplish the task. Self-efficacy and motivation increase

41
when the individual perceives they are progressing towards their goal. As such, as the directors
and managers move towards accomplishing the tasks and meeting the goal, they will become
skillful and motivated, and have a higher level of self-efficacy.
Expectancy-value Theory. Expectancy-value model (Eccles, 2009) asks, “Can I do the
task?” and “Do I want to do the task?” The answer “yes” to “Can I do the task?” is a predictor of
better performance and stronger motivation (Eccles, 2009). Expectancy refers to how confident
an individual is in the ability to succeed in a task, whereas task values refer to how critical,
useful, or enjoyable, the individual perceives the task. Four subcategories define task values:
attainment value which is the importance for self, intrinsic value which is enjoyment and interest,
utility value, which is the usefulness and cost value, which is the loss of time, high effort
demands, loss of alternatives, or negative psychological experiences such as stress (Eccles,
2009).
Expectancy-value theory (Eccles, 2009) applies to the managers as they pursue the goal
to implement an EEP that embraces best practices for improving employee engagement. In the
development of metrics, key performance indicators and goals, it is critical to set reasonable, fair
and attainable goals. If managers do not feel they are capable of accomplishing the task, the
perceived value of the goal diminishes which results in decreased motivation. Expectancy-value
theory suggests the keys to success is the value one places in the task, and the confidence in
oneself to complete the task. Therefore, the question lies in whether the manager finds value and
importance in the actions associated with reaching the goal, and if they feel the goals are useful,
attainable and valuable. It is possible that the perceived value of performing the task will result
in enjoyment which aligns with the individual’s identity, and the effort of engaging in the
activity results in positivity (Eccles, 2009).

42
Emotions. Pekrun, Goetz, Frenzel, Barchfeld and Perry (2011) offers the control-value
theory of achievement emotions as a theoretical framework where the motivation to learn,
learning outcomes, and the achievement of goals are directly affected by emotions. Emotions are
a phenomena which involve several psychological responses (Sherer, 2009). These responses can
vary from positive to negative emotions and moods. If the mood is negative such as anger and
anxiety, motivation may decrease, and the ability to accomplish a task is compromised.
However, if the mood is positive such as pride and satisfaction, motivation is high, and the
likelihood of completing the task is positive (Pekrun et al., 2011). Pekrun et al., (2011) posits
that activating a positive emotion such as joy, hope, and pride will encourage motivational
engagement while hopelessness and boredom will activate disengagement.
Therefore, if the managers and directors feel positive about the task of improving
employee engagement, they are more likely to be motivated to implement an employee
engagement program. However, if they feel angry or frustrated about improving employee
engagement, they may be demotivated and lack the desire to improve employee engagement. It
is essential to understand how the manager’s and director’s emotions and moods affect their
ability to develop and implement an employee engagement program. Creating an atmosphere
and environment that generates positive emotions is crucial.
Attribution Theory. Weiner’s (1985) seminal work on attribution theory of
achievement, motivation, and emotion posits that the perceived causes of success and failure
share three properties: locus, stability, and controllability. Locus refers to self-esteem and pride,
where an individual is more likely to experience a sense of pride associated with an
accomplishment. Stability is the concept related to feelings of hopefulness or hopelessness,

43
which is attributable to stable or unstable conditions. Finally, controllability is related to feelings
of shame, guilt, anger, gratitude, and pity (Anderman & Anderman, 2006).
In the case of the managers and directors, those who are hopeful (stability), and believe
they will be successful due to their focused effort (controllable), will experience a sense of pride
(locus) due to their accomplishment of developing an employee engagement program that
embraces best practices for improving employee engagement. The achievement of the goal is
enhanced when the individual attributes successful outcomes to their effort and the use of
appropriate strategies. In contrast, the achievement of the goal is thwarted when the individual
attributes their failure to lack of ability, which can either motivate the individual to put more
effort into achieving the goal or demotivate the individual to exert effort due to lack of skills. It
will be essential to understand how the managers and directors believe their skills and abilities
will motivate or demotivate them to achieve the goal.
Table 3 provides the organizational mission, global goal, stakeholder goals, and assumed
motivation influences and motivational influence assessments.
Table 3
Organization Mission, Global Goal, Stakeholder Goal, Assumed Motivational Influences and
Motivational Influence Assessment

Organizational Mission
We are the St. Elsewhere Medical Center.
We strive to be the trusted leader in quality health care that is personalized, compassionate and innovative.
We stand for empowerment, integrity, respect, collegiality and vitality.
We commit to authenticity.
We commit to excellence in clinical care, teaching and research.
You can count on us to be fully present in the delivery of uncompromising health care.
Organizational Global Goal
We believe the employees of the health system are critical to the continued success of the medical center.
Empowering our staff and creating a service-oriented culture will enhance the experience and quality
outcomes for our patients by providing health care that is safe, personalized, compassionate and
innovative.

44
Stakeholder Goal
Managers and Directors will implement an employee engagement program (EEP) program that
embraces best practices for improving employee engagement in the ambulatory setting by July
2020.

Assumed Motivation Influences

Motivational Influence Assessment
Self-Efficacy
Managers and directors are confident they can take the
steps to create an EEP.

Steps:
1.Managers and Directors have confidence that they can
impact employee engagement.

2. Managers and Directors have confidence in developing
an employee engagement plan.

3. Managers and Directors have confidence in
implementing an employee engagement program.
Interviews and surveys
Expectancy Theory
Managers and directors are confident in their ability to
influence improving employee engagement and they value
the goal to improve employee engagement.
Interviews and survey
Emotions
Managers and directors feel positive about developing an
EEP.

Interviews and survey
Attribution
Managers and directors attribute their success or failure of
improving employee engagement to their own efforts.
Interview and survey
Organization
Organizational influences are likely to be the most complicated among the Clark and
Estes (2008) conceptual framework because they are a series of dichotomies that can be visible,
invisible, audible, silent, difficult to understand, and identify, deep within the culture, and yet on
the surface. Moreover, because of the complexity of this influence, even a highly knowledgeable
and motivated employee can only be successful if organizational influences align and support
achieving the performance goals (Clark & Estes, 2018). These organizational influences are

45
significant in healthcare because of the direct impact it has on the patient. If there is a
misalignment between the employee and the organization culture, danger, and harm may result
to the patient. For instance, in the ambulatory setting, care starts with the call for an
appointment, and continues to when the patient checks-in, the examination with the physician,
and finally, the billing experience. Along the continuum of the patient experience, there is the
potential for misalignment between the employee and the organization. Too often in healthcare,
a patient can be greeted with a cultural setting that consists of beautiful buildings, with smiling
employees, and yet has a dangerous experience because the underlying organizational culture
does not align. Each touchpoint, each encounter, is affected by organizational influences. What
is more, these organizational influences can create barriers for the directors and managers to
implement an EEP that embraces best practices for improving employee engagement.
This section will explore the organizational influences defined by Schein and Schein
(2017) as artifacts, espoused values and beliefs, and underlying assumptions and their
relationship to organizational culture in healthcare. Moreover, the concept of cultural models
and cultural settings (Gallimore & Goldenberg, 2001) will be discussed to provide examples of
organizational influence.
Organizational culture. The definition of organizational culture has evolved over the
years. Parson’s (1961) foundational work defines organizational culture as knowledge, values,
and symbolic expression. Schein (1985) later expresses organizational culture as “conceptual
sharing,” or a pattern of internal, assumed, and shared knowledge and values that have worked
for the organization and is passed down to its members, which are seen and heard throughout the
organization. Erez and Gati (2004) provide a visual model that posits the individual in the
center of four concentric circles, each nested in the next, and each circle labeled as a group,

46
organizational, national and global cultures. Each circle represents a structural dimension of
multi-levels having its own culture, beliefs, and values. It is a dynamic process that interacts and
interrelates. Schein and Schein’s (2017) concept of macro-cultures as nations, occupations or
large organizations and micro-cultures as the subculture within the macro culture resembles the
Erez and Gati (2004) concentric circle concept. There are multiple factors in organizational
culture that can create turmoil when not aligned or can support a successful outcome when
aligned.
Organizational culture is an important factor in the ability for the directors and managers
to achieve their goal. Therefore, it is valuable to explore the structure of organizational culture at
USE Medical Group as it relates to the stakeholder goal to determine the needs and assets that
influence the directors and managers ability to implement an EEP that embraces best practices
for improving employee engagement.
Artifacts and cultural settings. Cultural settings and artifacts are the most visible and
audible behavior patterns in the organization (Gallimore & Goldenberg, 2001). It is the
constructed physical and social environment of the organization, the language, the products,
rituals, and ceremonies (Schein & Schein, 2017). USE cultural setting is fervent with its colors,
victory cry, and rich history dating back to the 1870’s. The historic red brick buildings and
expansive green lawns are in the center of a large metropolitan city. The traditions and pride run
deep with an overwhelming sense of self-assuredness. The health system was sold to the
University in 2010. The employees of the health system became employees of the University
and were enculturated into the traditions of the University. The employees proudly adopted the
colors, the victory cry and willfully accepted these organizational cultural settings. However,
what did not change was the employees themselves. The question is whether they unknowingly

47
brought with them the culture of the previous organization, which did not align with the new
culture. The new leadership went through the paces of establishing a new vision, values, and
service standards, and even provided how-to classes intended to increase the service culture.
Nevertheless, the patient and employee engagement surveys revealed these activities did not
make a significant impact on the patient experience.
Visibly, the artifacts and cultural settings were strong; however, they may have brought
unintended consequences of creating dissonance in the employees. To further explore these
phenomena, it is essential to look at the espoused beliefs and values of the organization.
Espoused beliefs and values. Espoused beliefs and values are the ideals, goals, values,
aspirations, ideologies, and rationalizations of the organization (Schein & Schein, 2017). USE
Medical Center established a value which is the belief that employees are critical to the success
of the health system and empowering the staff and creating a service-oriented culture will
enhance the experience and quality outcomes for the patients by providing safe, personalized,
compassionate and innovative health care (St. Elsewhere, 2013). This value establishes the
importance of the role of the employees. The words “empowering staff” and “service-oriented
culture” are powerful words that can promote employee engagement, but only if the words have
meaning to the employee.
Additionally, these words must have meaning to the directors and managers since they
are key to employee engagement. The leadership of the organization must work with managers
and directors to define these words, and then actively engage middle-level managers to teach the
meaning of these words to the employees. Espoused beliefs and values are important cultural
models because this pattern of basic assumptions that was learned, deemed valid and successful
by the group, are passed on to new members since it is now considered a requirement to success

48
(Schein, 2004). The connection and meaning of the words between senior leadership, middle-
level managers and employees must be established and observed in behaviors, actions, and
words (Argyris & Schon, 1978; Schon & Argyris, 1996). Moreover, the managers require
resources, tools, knowledge, and training to help them live the value of employee empowerment
and service-oriented culture in order to achieve the goal of improving employee engagement.
Understanding what the recommended knowledge, motivational and organizational solutions for
the director’s and managers to achieve their goal to improve employee engagement along with
the support of organizational leadership to provide resources, will provide a cultural setting that
promotes success. Closing the organizational gap and assuring there is a common understanding
of the espoused belief and value in the words “empowering staff” and “service-oriented culture”
is critical to supporting the directors and managers in achieving their goal.
Underlying cultural basic assumptions. Underlying cultural basic assumptions form
the foundation of most organizations. The healthcare system has an underlying cultural
assumption that healthcare is about providing service to patients. The Hippocratic Oath is about
a binding, accountable relationship between the patient, the community and the society of
medicine expressing the principles for the conduct of the physician and implies answerability to
the people they serve and the medical field (Medical Definition of Hippocratic Oath, n.d.).
Service, accountability, moral responsibility, respect, and compassion describe the assumed basic
underlying cultural assumptions of the healthcare industry. This level of culture provides self-
identity (Hatch & Schultz, 2002). It tells the members of the organization who they are, how to
behave toward each other, and how to feel (Schein & Schein, 2017); it is the DNA of the
healthcare organization. However, being employed in the service industry is not synonymous

49
with being service-oriented. Therefore, it cannot be assumed that managers and employees
clearly understand the underlying culture of the organization.
Furthermore, although the underlying cultural assumptions of healthcare remains, that
being a service industry, it is also a competitive business. Moreover, the clashing of these
concepts can create mistrust between senior leadership, managers, physicians, and staff, creating
an organizational gap that will impede the ability for managers to improve employee engagement
in the ambulatory practices. The organization’s basic underlying cultural assumption of service
should align with being a service-oriented culture, a competitive business, and an engaged
employee.
Researchers (Mallak, Lyth, Olson, Ulshafer & Sardone, 2003; Gebauer, Edvardsson,
Gustafsson & Witell, 2010; Savič & Pagon, 2008; Baradarani & Kilic, 2018) have studied the
impact of service orientation in corporate culture on business performance in manufacturing,
healthcare and hotel industries. The research reveals that the service orientation of a culture
includes specific interaction between value and behavior at the level of managers and employees.
Moreover, management behavior links to increasing service orientation through being aware of
the complicated interactions between values and behaviors that form a service-oriented culture.
Managers must behave in a service-oriented way and model what this means to the employee.
Managers must put effort into creating a norm of service-orientation, and they must hold
employees accountable for understanding the value of service.
Managers must be aware of the impact of the underlying assumptions in the organization.
Understanding that healthcare is about providing a service and, while separately running a
business, is a complicated endeavor. However, keeping these two cultures separate, but
understanding how each adds value, can open the way for improving employee engagement.

50
Gebauer et al. (2010) suggest that the key to improving employee engagement is the day-
to-day manager, and senior leadership needs to work with managers to help them understand
conflicting concepts and provide the necessary resources to bridge these conflicts. The authors
also point out that the organization’s efforts to close the gap between running a competitive
business while supporting the underlying assumption of a service-oriented culture that promotes
employee engagement requires a consistent message and role modeling from all levels of
leadership. As such, USE’s leadership support in providing resources and training to improve
employee engagement is essential to the directors and managers success in achieving their goal
to improve employee engagement by implementing an EEP.
In summary, organizational culture is complicated. It is looking behind and beyond the
visible cultural settings and examining the cultural models that may be invisible and difficult to
identify. The artifacts, espoused beliefs and values, and underlying basic cultural assumptions
are rich in complexity. Building an organizational culture comprises: (a) ensuring the
organizational goals are clear and understandable; (b) working towards building a culture of
trust; (c) supporting stakeholder goals, and (d) holding stakeholders accountable to the
organizational global and stakeholder goals.
Table 4 discusses the assumed organizational influence and organizational influence
assessments.
Table 4
Assumed Organizational Influences, Organizational Influence Assessment
Organizational Mission
We are the St. Elsewhere Medical Center.
We strive to be the trusted leader in quality health care that is personalized, compassionate and
innovative.
We stand for empowerment, integrity, respect, collegiality, and vitality.
We commit to authenticity.
We commit to excellence in clinical care, teaching and research.

51
You can count on us to be fully present in the delivery of uncompromising health care.
Organizational Global Goal
We believe the employees of the health system are critical to the success of the medical center.
Empowering our staff and creating a service-oriented culture will enhance the experience and
quality outcomes for our patients by providing health care that is safe, personalized, compassionate
and innovative.

Stakeholder Goal
Managers and Directors will implement an employee engagement program (EEP) program
that embraces best practices for improving employee engagement in the ambulatory
setting by July 2020.

Assumed Organizational Influences

Organizational Influence Assessment
(Cultural Models)
The organization has a culture of employee
empowerment and service.
Survey and interview directors and managers.

(Cultural Models)
The organization has a culture of trust.
Survey managers to determine the trust they
have in senior leadership to support them in
their efforts to increase employee engagement.
(Cultural Settings)
The organization supports the development of
an EEP
Develop open ended surveys directed towards
understanding the managers training needs and
resources required to increase self-efficacy.
(Cultural Settings)
The organization has a plan of accountability.
Engage managers in developing a plan for
accountability.
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
Maxwell (2013) explains that a conceptual framework is the ideas, hypotheses, and
viewpoints that support the research study. It is the speculative theory of what the researcher
believes about the phenomena; what is happening, why it is happening, and how it is happening.
The conceptual framework informs the research study design to assess and distill goals, design
relevant research questions, select a method of research, and recognize potential threats to the
research. The conceptual framework provides optics to the phenomena (Merriam & Tisdell,
2016) and draws upon the concepts, terms, definitions, models, and theories of a literature base

52
that supports the study, but it is experiential, iterative, and constructed based on the researcher’s
personal bias. This conceptual framework is based on the Clark and Estes (2013) gap analysis
framework which focuses on the interactions among knowledge, motivation and organization
influences.
The knowledge, motivation and organizational influences are critical components to
achieving the stakeholder goal of developing an employee engagement program (EEP) that
embraces best practices for improving employee engagement in the ambulatory setting. Clark
and Estes’ (2018) model for improving performance includes setting work performance goals
and analyzing the gap between current and preferred performance. The conceptual framework
provides a visual diagram that depicts how knowledge, motivation and organizational influencers
interrelate and are dependent on each other to achieve the goal. To illustrate the interdependence
of knowledge, motivation, and organizational influencers, a discussion of each component in the
conceptual framework represented in Figure 1 is provided.

53
Figure 1
Conceptual Framework Showing the Interdependence of the KMO Influences

Mid-Level Managers
Knowledge, Skills, Motivation

Factual/Metacognitive knowledge and
skills to understand the meaning of
employee engagement and motivation to
build competency, increase self-efficacy
and self-confidence to accomplish the
goal.

54
Figure 1 provides a visual framework of how these factors are interrelated. The two
concentric circles represent knowledge, motivation and organization influences. The large blue
circle represents organizational cultural settings and cultural models. Nested within the large
blue circle are the knowledge and motivation influencers. The knowledge and motivation circle
are inside the organizational circle because knowledge and motivation are ineffective without the
organizational influence. A highly knowledgeable and motivated employee can only be
successful and achieve the goal if the organization creates a supportive culture (Clark & Estes,
2018). Therefore, knowledge, motivation and organization influences must align in order to
achieve the goal depicted by the blue arrow pointing towards the goal in the yellow box.
To further illustrate the interrelatedness of the diagram, an example concerning USE
Medical Group is presented. The large blue circle represents the organizational global goal which
expresses the belief that the employees are critical to the success of the health system and
empowering the staff and creating a service-oriented culture will enhance the experience and
quality outcome for the patient. This organizational global goal is a cultural setting that is visible
and published. The green circle which is embedded in the blue circle represents the knowledge
and motivation influencers. The influences assume that managers and directors have a clear
understanding of their goals, they have a high level of self-efficacy, and they value improving
employee engagement. The blue arrow points to the gold box which states the stakeholder goal
of implementing an employee engagement program that embraces best practices for improving
employee engagement in the ambulatory setting by July 2020. If one of these components is
missing, the ability to attain the goal is compromised. For instance, if the manager does not have
the factual or conceptual knowledge of the global organizational goal, or the stakeholder goal,
the manager’s interpretation may not align with the organizational goal and the ability to be

55
successful may be compromised. This can create an atmosphere of mistrust (Krosgaard, Brodt &
Whitener, 2002).
Moreover, if the managers and directors do not have the knowledge or skills to reach
their stakeholder goal or understand why it is important, they may not be motivated to pursue
them. In order to achieve the stakeholder goal of implementing an employee engagement
program, which embraces best practices with the intent to improve employee engagement,
knowledge and goals must align. This will help to develop a culture model of trust (Krosgaard,
Brodt & Whitener, 2002). The organization needs to support the managers by building a
learning organization (Senge, 1990) focusing on the development of action plans with key
performance indicators, metrics, specific procedural tasks, milestones and timelines that facilitate
goal achievement. This encourages an organization culture setting of learning (Senge, 1990;
Schwandt & Marquardt, 2000) and accountability through benchmarking (Ebrahim, 2016;
Firestone & Riehl, 2005; Anderson-Miles,1994). The manager must feel confident in their
ability to improve employee engagement which is self-efficacy (Bandura, 1997) and the
managers need to be motivated to pursue the goal of improving employee engagement by five
percent in 10 of the ambulatory practices by December 2020.
Conclusion
The purpose of this study is to gain an understanding of the effects of employee
engagement in healthcare specifically in the outpatient setting, and the impact on patient care,
patient satisfaction and the future of healthcare (Lowe, 2012; Peltier et al., 2009; Scotti et al.,
2007). This chapter presents a literature review which explores the importance of the manager
role (Bandura, 1986, 1997; Eccles, 2006; Padgett et al., 2018; Pajares, 2006) in affecting
employee engagement and how it relates to the Clark and Estes (2008) gap analysis model which

56
focuses on knowledge, motivation and organizational (KMO) influences to achieve goals. As
such, the Clark and Estes (2008) conceptual model will provide the framework to collect data to
confirm these influences as assets or needs within USE’s managers and directors. Chapter
Three will present the study’s methodological approach.

57
CHAPTER THREE: METHODS
The purpose of this research was to examine the perception of low employee engagement
scores in the ambulatory care units at USE and explore the role of managers and their ability to
increase employee engagement using the Clark and Estes (2018) conceptual framework which
focuses knowledge, motivation and organization influences. The research utilizes purposive
sampling, and purposeful selection as the settings, people, and activities are intentionally
selected to provide relevant information (Maxwell, 2013) that answers the guiding questions:
1. What are the knowledge, motivation, and organization needs and assets that influence
Directors and Managers of the USE ambulatory care units’ goal to implement an
employee engagement program (EEP) program that embraces best practices for
improving employee engagement in the ambulatory setting?
2. What are the recommended knowledge and skills, motivation and organizational
solutions for Directors and Managers to achieve their goal?
Participating Stakeholders
Multiple stakeholders contribute to and benefit from the achievement of the
organization’s goal; however, for this study, the directors and managers of the USE ambulatory
care units are the stakeholders of focus. This group of individuals is crucial to the study because
they have direct contact with front-line employees, and they can connect, influence, encourage,
and create an environment where employees thrive. Therefore, the following criteria were
developed to define the purposeful sampling of the population.
Survey Sampling Criteria and Rationale
Criteria 1. The sample population must be an employee of the USE health system.

58
Criterion 2. The sample population must be an employee of USE Medical Group in the
USE ambulatory practices.
Criterion 3. The sample population must be a director or manager of a USE ambulatory
practice with direct responsibility for staff. This population will be inclusive of the 57 middle-
level leaders consisting of the directors and managers of the USE Medical Group ambulatory
practices. Figure 2 shows the organization’s main units and the sampling criteria.
Figure 2
USE Organization’s Main Units and the Sampling Criteria

Survey Sampling Strategy and Rationale
The survey initiated the data collection process. The purpose of the survey was to obtain
a broad understanding and information about the thoughts, feelings, attitudes, and beliefs
(Johnson, 2014) from the directors and managers about implementing an employee engagement
program in the USE Medical Group ambulatory practices. A sampling of the purposely selected
group of 57 managers was surveyed, which is shown in Figure 2. The goal of the survey was to
examine the knowledge, motivation, and organization assets and needs of the managers and

59
directors that influence their goal to implement an employee engagement program that embraces
best practices for improving employee engagement in the ambulatory setting.
Interview Sampling Criteria and Rationale
Collecting data through interviews provided additional detailed information and allowed
the interviewer to query and probe deeper by asking clarifying questions (Johnson, 2014). The
interview criteria was be as follows:
Criterion 1. The managers and directors will have participated in the survey.
Criterion 2. The managers and directors will have indicated during the survey process
that they are volunteering to participate in the interview process and are willing to relinquish
their anonymity with the interviewer
Criterion 3. The purposeful sampling represents a diverse population (i.e., gender, years
of experience, education) of six volunteers. The interview process allowed the interviewer to
establish a relationship with the interviewee, which prompted conversation specific to their
abilities, motivation, and knowledge in developing an EEP. Furthermore, interview questions
relating to organizational culture and their perception of support from the organization was
assessed. The interviews will commence immediately after the survey.
Document Analysis Sampling Strategy and Rationale
Documents are a part of the research setting and are valuable sources of data for
qualitative research (Merriam & Tisdell, 2016). There are multiple documents the organization
developed, and programs or events to promote employee engagement. These documents have
been designed by the patient relations and human resources departments and are publicly
available to all employees. The criterion for the documents to be analyzed in this research are:

60
Criterion 1. Documents developed by USE human resources, patient relations
departments.
Criterion 2. Documents are related explicitly to promoting employee engagement.
Criterion 3. Documents were developed within the past five years (2014 - 2019).
These documents served as primary sources to verify information determined during the
interviews and surveys. They are a part of the organizational culture and may provide insight
into the organization and the alignment with the goals related to employee engagement.
Moreover, as appropriate, employee engagement surveys will be reviewed to validate interview
findings and survey results.
Data Collection and Instrumentation
Survey
The survey method was selected because it provided a broad set of information that can
be analyzed in a relatively short time frame. Based on a review of results from past employee
engagement surveys, and more importantly, the influences revealed in the literature review in
Chapter Two, the survey addressed specific questions about whether the managers have the
confidence, knowledge and skills and motivation to realize the goal, and if there are
organizational barriers that prevented them from accomplishing the goal. Further, the survey
asked questions about the manager’s and director’s self-efficacy and whether they feel equipped
with the tools and resources to achieve the goal. The survey’s primary purpose was to
empirically evaluate the manager’s and director’s knowledge about employee engagement and
determine whether they have the skills and resources to accomplish the goal of developing an
EEP, with the ultimate intent to increase employee engagement. The survey focused on learning

61
the meaning of what the participants understand or know about the problem (Creswell &
Creswell, 2018).
The recruitment of the sample population of 57 managers and directors was conducted
through an email. A single-stage sampling design (Creswell & Creswell, 2018) was used since
this researcher has access to the names in the population. In order to prompt participation, the
survey was administered in the natural setting of the population (Creswell & Creswell, 2018) and
was sent through email to the managers and directors. The survey was administered over three
weeks and a start and deadline for participation were announced.
Interviews
Collecting data through interviews provided additional detailed information allowing the
interviewer to query and probe deeper by asking for clarification or more information (Johnson,
2014). The interview process allowed the interviewer to establish a relationship with the
interviewee, which prompted more conversation resulting in more information. This method
was used to interview a subset of participants to understand their responses to the survey data.
The interview instrument was used to obtain data about the stakeholder demographics
and knowledge, motivation, and organizational influences based on Chapter Two influences for
the directors and managers to create an employee engagement program. The interview questions
were a blend of semi-structured and unstructured questions. The demographic questions were
predetermined with a structured question design focused on obtaining socio-demographic data
about the individual stakeholder (Merriam & Tisdell, 2016).
Although it would be beneficial to interview all 57 ambulatory managers and directors,
due to time limitations, the goal was to interview six individuals from the USE ambulatory work
units. A request for volunteers to participate in the interview was included at the end of the

62
survey, after the participant submitted their responses. A positive response led the participant to
provide contact details in another online form.
Interviews occurred at the workplace during a time convenient for the participant. The
interview took place in a face to face manner in a conference room or office that is comfortable
and private, or through a video conferencing online meeting. The participants were in a private
setting where they feel they can easily express themselves. With the participant’s permission,
the interviewer used a recording software and took notes to augment the data. These interviews
were informal and conversational style. The questions were semi-structured or open-ended with
the intent to guide and assist the flow of the conversation.
Documents and Artifacts
Documents and artifacts are sources of data in qualitative research (Merriam & Tisdell,
2016) that help to paint a picture of the phenomena which can provide answers to the research
questions relating to the organizational culture. The document review was in two parts. The first
part was to review employee engagement promotional materials developed by the organization,
and the second part was a review of employee engagement and patient survey results from 2017
and 2018.
The organization has designed several programs to increase employee engagement and
patient experience (Patient Relations Director, personal communication, June 22, 2018). These
programs are a part of the visible aspects of the cultural setting, which are intended to promote
employee engagement, empower employees, and reward performance. Understanding whether
these programs are accepted as a part of the social-cultural norm may assist in defining an
organizational gap that will support the directors and managers in redefining an EEP that

63
embraces best practices. Information regarding these programs is available on-line through the
company intranet. A review of these programs is important because even though they are
developed to be a positive influence, they can be a hindrance to improving performance and
reaching goals even if the employee is knowledgeable and motivated (Rueda, 2011).
The surveys were produced by independent companies that specialize in the science of
employee engagement and patient experience. The survey information is an organizational
assessment of the culture and provides information about how the employees feel about the
organization. The request for the employee engagement and patient experience survey results
are available from the human resources and patient relations departments. The questions from
the two employee engagement survey tools are similar, and therefore, the analysis will include
cross walking each question to a component of the organization’s setting in the Clark and Estes
(2008) framework. An analysis of the results will inform the researcher of the culture, readiness
for change, gaps that relate to organization needs and assets that influence Directors and
Managers of the USE ambulatory care units’ goal to implement an employee engagement
program.
Alignment of KMO Influences and Data Collection Methods and Instruments
Tables 5-8 shows each KMO influence, the method and measure of the influence and
demographic. By examining the rows, the alignment of the influences and methods is
demonstrated.
Table 5

Summary of Knowledge Influences and Method of Assessment

Assumed Knowledge
Influence

Survey Item Interview Items Document
Factual Knowledge

64
Managers and Directors
know what is included in the
Press Ganey or SCORE
employee engagement
survey.
The Press Ganey or
SCORE employee
engagement survey
includes information
about:
(Check all that apply)

a) how the employees feel
about the organization*

b) how my work unit
compares to other
ambulatory work units
within the organization*

c) how my work unit
compares to benchmark
data outside of the
organizations*

d) a step by step plan to
improve employee
engagement

Tell me about the results
of the last employee
engagement survey and the
process that was used to
share results.

P= Probe

P: What do the results say
to you?

Managers and Directors need
to know the meaning of
employee engagement

Multiple choice. Please
choose one:

Employee engagement
means:

a) an employee who is
energetic and has an
emotional commitment to
the organization and
organizational goals.*

b) an employee who
comes to work and does
their work.

c) a happy, satisfied
employee.

c) All of the above.

d) None of the above

In your own words, please
describe employee
engagement.

Managers and Directors need
to know their role in
Multiple choice.
Complete the sentence by
As a manager or director,
what is your role in

65
improving employee
engagement.

choosing the best answer.

Employee engagement is
the responsibility of

a) the organization, since
the organization has
control over benefits,
compensation, and work
environment.

b) the employee since
they chose to work here.

c) leadership which
includes me, since I am in
a position that can directly
impact employee
engagement.*

improving employee
engagement?

Managers and Directors need
to know the best practices to
foster employee engagement.

Multiple choice.
Complete the sentence by
choosing the best answer.

Some of the best practices
to foster employee
engagement are about:

a) being honest and
truthful by creating an
environment of trust

b) strong leadership; if my
employees know I’m
engaged, they will model
my behavior

c) understanding the goals
of the organization

d) being in a culture of
learning and being open
to new ways to foster
engagement

d) All of the above*

e) None of the above
What do you think are
some of the best practices
that foster employee
engagement?

Managers and Directors need
to know the components of
Multiple choice. Choose
all that apply.
Please explain how you
would proceed with the

66
an EEP.

An employee engagement
program includes:

a) selecting the right
talent

b) Understanding the
mission, value and goals
of the organization *

c) understanding my goals
and how they align with
the organization*

d) involving my staff in
making decisions that
affect their work*

e) ensuring my employees
have the tools they need
to do their job*

f) providing opportunities
for advancement*

g) choosing my most
challenging employee to
gauge how I am
performing in improving
employee engagement.

next steps to build an
employee engagement
program.
Conceptual Knowledge
Managers and Directors need
to know the consequences of
employee engagement.

Multiple choice. Choose
all that apply.

An employee engagement
program will:

a) make work fun.

b) be a cost to the
organization that we can’t
afford.

c) improve employee
involvement which will
affect the patient
experience.*

d) has no impact on the
What do you think are the
consequences of having an
employee engagement
program?

67
employee or the
organization.

e) Creates job
satisfaction*

f) Improves employee
retention*
Managers and Directors need
to know the relationship
between their role and their
ability to impact improving
employee engagement.

Multiple choice. Choose
the best option to
complete the sentence.

I impact improving
employee engagement by

a) speaking to my
employees daily

b) making sure my
employees know their
assignments.

c) asking my employees
what they did over the
weekend.

d) assuring my employees
are satisfied and happy.

e) seeking input and
involving my employees
in work activities by
listening to their ideas,
brainstorming and
creating an environment
where their engagement is
important. *

f) All of the above

g) None of the above
Do you feel there is a
relationship between your
role as a manager or
director and the impact
you have on improving
employee engagement?
Please explain.

Procedural Knowledge
Managers and Directors
know how to improve
employee engagement
through best practices
strategies.

Multiple choice. Choose
all that apply.
Best practices for
improving employee
engagement include the
following (check all that
Can you walk me through
some of the strategies you
use to improve employee
engagement?

68

apply):
a. Conduct a survey to
determine if the
employees in my work are
happy and satisfied.
b. Develop a series of
parties and events that
create a positive
atmosphere for the
employee.
c. Seek feedback from my
employees and listen to
their ideas*
d. Involve employees in
making decisions about
their work*
e) have regularly
scheduled meetings*
f) create a climate that
supports and values the
employee*

Managers need to know how
to build an EEP.
Multiple choice. Please
choose all that apply.
Steps to building an
employee engagement
program include:
a) Wait for my leadership
to provide direction
b) Review the results of
previous employee
engagement scores to
determine where I need to
improve.*
c) Research and develop
the contents of the
program.
d) Seek feedback, and
input for design
Please describe the next
steps you would take to
design an EEP

69
refinement.*
e) Pilot the design and
refine as needed.*
f) Launch employee
engagement program.*
g) Measure and evaluate
the employee engagement
program.*
h) Develop a series of
parties to build teamwork
Managers and Directors
know how to implement an
EEP.
Multiple choice. Choose
the best answer to
complete the sentence.
My first task to
implementing an
employee engagement
program is:
a) make an announcement
to my work unit letting
them know we are
embarking on an
employee engagement
program.

b) seek approval from my
leadership to hire an
additional FTE because I
will need staff to develop
a program.

c) Do nothing. Employee
engagement is the
responsibility of the
organization.

d) Identify the current
levels of engagement of
my work unit and focus
my efforts on employees
that are somewhat
engaged to engaged. *

e) Choose my least
engaged employees and
implement my program.
How would you
implement best practices
in your work unit?

Can you walk me through
the steps to implement an
EEP?

70

f) All of the above

g) None of the above

Metacognitive Knowledge
Managers need to self-reflect
on their effectiveness of
implementing an employee
engagement program, and
their ability to improve
employee engagement in the
ambulatory work units.
Multiple choice. Choose
the best answer to
complete the sentence.

I self-reflect on employee
engagement by

a) thinking about the
effectiveness of my own
style of leadership in how
I engage with employees.

b) Understanding my role
in employee engagement

c) deciding how I can be
more involved in
employee engagement

d) deciding my next steps
in improving employee
engagement

e) All of the above*

f) None of the above.

Please describe what
comes to mind when you
self-reflect on your
effectiveness in developing
an employee engagement
program.

Table 6
Summary of Motivation Influences and Method of Assessment

Assumed Motivation
Influences
Survey Items Interview Items Document
Self-Efficacy
Managers and directors are
confident in their skills to
create an EEP.

I am confident in my
skills to create an
employee engagement
program (EEP).

Rate your degree of
To what degree do you feel
confident about your
ability to create an
employee engagement?

Probe:

71
confidence in doing the
following as of right
now, by recording a
number from 0-100 using
the scale given below:
0 Not Confident at all
10
20
30
40
50 Moderately Confident
60
70
80
90
100 Highly Confident

1. Create an EEP for my
work unit.
2. Seek feedback from
my employees and
listen to their ideas
3. Involve employees in
making decisions
about their work
4. have regularly
scheduled meetings
5. create a climate that
supports and values
the employee

What do you feel will
affect your confidence in
creating an EEP?

Managers and Directors have
confidence in building an
employee engagement
program.

Implement an employee
engagement program.

0 Not Confident at all
10
20
30
40
50 Moderately Confident
60
70
80
90
Tell me about your
confidence in launching an
employee engagement plan
in your work unit.

72
100 Highly Confident

1. Review the results of
previous employee
engagement scores to
determine where I
need to improve.
2. Research and develop
the contents of the
program.
3. Seek feedback, and
input for design
refinement.
4. Pilot the design and
refine as needed.
5. Launch employee
engagement program
6. Measure and evaluate
the EEP.
Expectancy Theory
Managers and directors value
the goal to improve
employee engagement.
I value improving
employee engagement.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
Do you value improving
employee engagement?

Probe: Why?
Can you provide examples
of how you value
employee engagement?

Managers and Directors have
confidence that they can
impact employee
engagement.
I am confident that I can
impact employee
engagement.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Tell me about your
confidence in impacting
employee engagement.

Emotions
Managers and directors feel
positive about developing an
EEP.

I feel positive about
developing an EEP.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
How do you feel about
developing an EEP?

Attribution

73
Managers and directors
attribute their success or
failure of improving
employee engagement to
their own efforts.
My success or failure to
improve employee
engagement is due to my
own efforts.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
Do you feel your work
effort in improving
employee engagement is
related to your success or
failure?

Probing:
What do you believe are
the reasons for your
success or failure?

Table 7
Summary of Organization Influences and Method of Assessment
Assumed Organizational
Influences
Survey Items Interview Items Document
Cultural Models
Managers and directors
perceive the organization
supports employee
engagement
There is an organizational
culture that supports
improving employee
engagement.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
Tell me about how the
organization supports
employee engagement.

Review the 2017,
2019 Employee
Engagement Surveys

Managers and Directors
perceive that the
organization values
improving employee
engagement.

The organization values
employee engagement.
(Strong Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
Does the organization
value employee
engagement?

Probe:
If yes, can you give me
examples of how the
organization values
employee empowerment?

Managers and Directors
perceive there is a culture
of shared decision making.
The organization has
involved me in the goal
setting process.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)
Do you know the
organizational goals?

Probe:
Are you involved in the
goal setting process?

74

Managers and directors
perceive their individual
goals align with the goals
of the organization.
The organization’s goals
align with my goals.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Do your goals align with
the organizational goals?

Probe: If so, how and
please provide an example.

Managers and directors
perceive there is an
organizational culture of
mutual respect.
My organization respects
my actions and decisions
to improve an EEP.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Do you feel the
organization respects your
actions to improve
employee engagement?

Managers and directors
perceive that they have the
freedom to make decisions
that affect their ability to
improve employee
engagement.
My organization gives me
the freedom to make
decisions that affect
employee engagement.
(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Do you feel the
organization gives you the
autonomy to make
decisions that affect
employee engagement?

Probe:
Are you able to participate
in the decisions that affect
employee engagement?

Do you feel the
organization provides you
with autonomy to
accomplish your goal to
improve employee
engagement?

Managers and directors
perceive there is an
organizational culture of
mutual trust.
There is a culture of
mutual trust to support my
efforts in developing an
employee engagement
program.

(Strongly Disagree,
Disagree, Neutral, Agree,
Do you have the trust of
your organization to
develop an EEP?

Do you trust your
organization to support
your efforts in reaching
your goals? Please explain.

75
Strongly Agree)

Cultural Settings
The organization organizes
a number of events to
encourage employee
engagement.

Multiple choice. Please
choose all that apply.

The organization supports
employee engagement by:

a. Performing an employee
engagement survey yearly

b. Rewarding employee
behavior through
Employee of the Month
program

c. Passing out university
football tickets to reward
positive employee
behavior

d. Developing safety
programs such as hand
hygiene and flu shot
programs

e. Having celebratory
parties

f. My organization does
not have events that
support employee
engagement.

Tell me about how you
have seen the organization
participate in improving
employee engagement.

The organization has a plan
of accountability to meet
employee engagement
goals.
My organization has a
plan of accountability to
meet employee
engagement goals.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Do you feel you are
responsible for meeting
your goals?

If employee engagement is
a goal, do you feel the
organization is supporting
your efforts?

76
The organization supports
the development of an EEP.

The organization provides
resources to design and
implement an EEP.

(Strongly Disagree,
Disagree, Neutral, Agree,
Strongly Agree)

Do you feel you have the
resources (people, supplies,
skills) to develop an EEP?
There are visible
signs that the
organization
supports employee
engagement.

Table 8
Demographics
Demographic Survey Question Interview Question Document
Analysis

I am a:
1. Director
2. Manager

2. How many years have
you been in the
organization?

3. How many years have
you been in your position?

I am a:
1. Director
2. Manager

2. How many years have
you been in the
organization?

3. How many years have
you been in your position?

Data Analysis
Data analysis is the process of evaluating and providing meaning to data (Creswell &
Creswell, 2018). The researcher used a mixed-method approach to gather quantitative data to
obtain a broad understanding of the research problem and followed-up with qualitative data to
have a deeper understanding of the problem and the changes that are needed to answer the
research questions.

77
Surveys
The survey instrument designed for this study focuses on the knowledge, motivation, and
organizational needs and assets that influence director’s and manager’s ability to implement an
EEP. An analysis of the central tendency (mean), standard deviation, and range of scores for
variables (Creswell & Creswell, 2018) will provide a quantitative understanding of the
participants. Frequencies of responses were calculated for data, which was categorized by
knowledge, motivation, and organization survey items. For Likert scale items, the percentage of
stakeholders who strongly agreed or agreed was presented in relation to those who strongly
disagreed or disagreed. Means and standard deviation were presented to identify average levels
of responses. The survey was conducted using Qualtrics, which allowed the analysis of the data.
Interviews
Interviews with the participants were transcribed and analyzed using a priori codes based
on the influences of knowledge, motivation, and organization. Open coding was used to identify
themes, or ideas, and axial coding (Merriam & Tisdell, 2016) to group and code participant
responses representing ideas, concepts, and beliefs (Maxwell, 2013), and strategies that fall
outside of the interview questions. Determination of each influence as an asset or need was based
on the responses made and relevant, and brief, direct quotes were captured to represent the
interview findings.
Documents
The organization’s documents related to employee engagement were examined using a
checklist based on the knowledge, motivation, and organization influences. The checklist was
used to note the presence or absence of any indicators of the influences in the work product. A
content analysis of the documents allowed the researcher to examine the data relative to

78
meanings, symbolic qualities, and content it communicates (Merriam & Tisdell, 2016) to the
directors and managers.
Credibility and Trustworthiness
Qualitative research is about an assumption of the view of the world that defines how the
researcher chooses a sample, collects, and analyzes the data. Qualitative research is an interactive
process that starts with a hunch, leading to the formulation of questions and review of data,
which can lead to the refinement of questions and more data review. This process allows the
researcher to produce believable and trustworthy findings (Merriam & Tisdell, 2016). It is
imperative that the research produces data that is credible, trustworthy, and accomplished
ethically with thoroughness and consistency.
Achieving credibility and trustworthiness was accomplished by using several strategies.
The triangulation of data was important to justify the theme (Creswell & Creswell, 2018). This
mixed-method study involved a survey of the 57 directors and managers of the ambulatory work
units, interviews with a sample population, and a review of past employee engagement and
patient experience surveys. If themes were developed based on the convergence of data, then the
process was stated as being valid (Creswell & Creswell, 2018). It was key to have an external
auditor to review the project ongoing (Creswell & Creswell, 2018). Therefore, committing to
weekly meetings with the dissertation chair served this purpose. The dissertation chair provided
an objective view of the project, asked questions, challenged the data, and provided a level of
analysis through a different lens.
An important strategy to assure credibility and trustworthiness is the researcher’s
commitment to assuring there was a constant reflection on potential biases. Since this researcher
is in the healthcare field and has intimate knowledge about the organization, it was essential to

79
maintain a journal of reflection (Merriam & Tisdell, 2016) to record thoughts, questions, issues,
and concerns. These concerns were reviewed with the dissertation chair to ensure the
researcher’s biases did not affect the study.
Validity and Reliability
The sampling methods for this research project included surveys, interviews, and
document reviews to duplicate critical aspects of the research with the intent to increase
reliability and validity. In order to reduce selection bias and increase reliability, the sampling of
participants was purposefully selected and, therefore included the entire group of managers and
directors in the ambulatory work units.
Threats to the validity of this study were research bias and reactivity (Maxwell, 2013). It
was necessary for this researcher not to make conclusions based on the biases and
preconceptions of the problem. Since this researcher has a history of working in healthcare for
over 25 years and is employed by the organization in the study, researcher bias was inevitable.
Reactivity to the participant’s behavior and organization response to the questions can also cause
unwanted variability. Trying to eliminate these threats may not have been reasonable, and
therefore it was important to acknowledge and understand these threats.
Mitigating research bias and reactivity was accomplished through assuring the data
collection is rich with details, and the information obtained from the survey and interviews were
triangulated, reducing the change for systematic biases due to a specific method (Maxwell,
2013). Research bias was further mitigated through peer debriefing and the use of an external
auditor (Creswell & Creswell, 2018). Peer debriefing involved working with a peer that
reviewed and asked questions about the study and provided an interpretation of the study. Using

80
an external auditor to review the project unfamiliar with the research provided an objective
assessment that enhanced the study’s validity.
Ethics
The objective of this study was to understand employee engagement in healthcare, the
role of the manager in comprehending, and supporting employee engagement. This research
study involved interviews and surveys with the middle-level managers in the ambulatory setting
at USE Medical Center. The participants understood that the study was to determine knowledge,
motivation, and organizational factors that enhanced or prevented the mid-level manager's ability
to affect employee engagement.
Ethics is a critical and integral part of the research and should be involved in all aspects
of the study, including conceptual design, question design, information gathering, and the role of
the researcher (Maxwell, 2013). For instance, the role of the researcher can affect the outcome
of the data collected (Glesne, 2011), and a significant factor in this study is that the researcher is
an employee at USE Medical Center and holds an executive management position whereby the
participants have a direct or indirect reporting relationship to the researcher. Thus, there are
compelling considerations relating to the ethics of this study that must be respected.
The informed consent process started at the commencement of the study; written
informed consent was reviewed with each participant to assure participants were fully aware of
their rights. The informed consent detailed participation was voluntary, how aspects of the
research may or may not affect their well-being, and that they may cease to participate at any
time (Glesne, 2011). The informed consent process included an information sheet that detailed
the study’s objective, disclosed the researcher was a doctoral student, and that all data collected
was used exclusively for research and not as an employee of the organization. The informed

81
consent assured participation in the study remained confidential, and any information obtained in
writing or through conversation was kept in confidence (Glesne, 2011). Any materials obtained
were de-identified, secured through password driven software, and were shredded or destroyed
upon completion of the study. Before all interviews, permission was obtained to record the
interview. Participants did not receive any incentives; however, after the study, a thank you note
was provided expressing appreciation of their participation. Because of the relationship between
the researcher and the participants, it was imperative that participants did not feel coerced or
pressured to participate. Rubin & Rubin (2012) speaks to four ethical responsibilities that are
important to this researcher, “show respect, honor promises, do no harm, and do not pressure.”
These basic principles are imperatives that were adhered to throughout the study. Therefore, the
researcher did not participate in the interviews, or distribution of the surveys, but sought a
qualified third party that assisted with interviews and survey administration. The Institutional
Review Board (IRB) guidelines and rules were followed to ensure the research’s integrity and to
ensure all ethical considerations related to human subjects were considered and upheld. The
study proposal was submitted to the IRB at the University of Southern California.
Tracy (2013) explains that relational ethics means being aware of one’s role and the
impact on the relationships and treating participants as people and not subjects in a research
study. It was essential to balance between knowing these individuals as employees, and
colleagues, and understanding and respecting their role as participants in the research study.
The researcher was aware of how preconceived ideas and personal viewpoints can have negative
consequences on the study (Maxwell, 2013). Therefore, understanding and reflecting on the
relationships, assumptions, or biases before and during the study begins, was critical to the
success of the study.

82
Limitations and Delimitations
There are limitations and delimitations the researcher must be aware of throughout the
study. Limitations are potential weaknesses in the study and are out of the researcher’s control
(Simon, 2011). Limitations that exist for this study are:
● The study is dependent on the truthfulness of the respondents;
● The study is conducted over specific intervals of time and therefore depicts a snapshot of
conditions during that time.
Delimitations are the decisions the researcher makes that may have implications for the
study; the delimitations are in the control of the researcher (Simon, 2011). The delimitations
that affect this study include:
● The choice of study, the research questions, theoretical perspectives adopted by the
researcher, and the sample population and the criteria used to be chosen;
● The choice of problem and the choice of the purpose statement which explains the intent
that clearly sets out the intended accomplishments, and also includes an implicit or
explicit understanding of what the study will not cover;
● The choice of the organization being studied, and the professions involved.

83
CHAPTER FOUR: RESULTS AND FINDINGS

Chapter Three delineates the assumed causes categorized under the knowledge,
motivation, and organizational influences. Chapter Four focuses on the research, which includes
survey results and interview findings. By using the Clark and Estes (2008) conceptual model of
knowledge, motivation, and organization influences, the needs and assets are identified that
encourage or prohibit the directors and managers from implementing an employee engagement
program that embraces best practices for improving employee engagement. The gap analysis
(Clark & Estes, 2008; Rueda, 2011) will help prioritize the recommendations to close the gap.
The 27 assumed influences were developed from the literature review in Chapter Two.
The multiple sources of quantitative and qualitative data included a survey, interview, and
document analysis. These data were collected to understand the knowledge, motivation, and
organization challenges the managers and directors experience in their efforts to improve
employee engagement. Also, multiple sources of data collection were used to validate the data.
The survey was sent through Qualtrics to the 57 managers and directors that make up the middle-
level management of the USE ambulatory managers. After the survey, the managers and
directors were asked if they wished to volunteer for a 30-minute interview. The interview data
were used to validate the findings of the survey.
Participating Stakeholders
The stakeholder group that was solicited to participate in this study are the 57 directors
and managers of the USE ambulatory care units. These potential participants are male and
female and have been in the healthcare field from 7-20 years. The managers' education level is a
high school or bachelor’s degree, while the directors have a bachelor's or master's degree.

84
The participation in the survey and interviews were voluntary. The Qualtrics survey was
emailed to each potential participant that met the criteria. Two reminders were sent over three
weeks. If a survey participant volunteered to be interviewed, the interview was scheduled to take
place within the week. A total of 13 surveys and five interviews were completed. The
demographics for the individuals that participated in the survey are seven females and six males,
while the interview participants were three males and two females.
The participation rate for the survey is 23%, and the interview is 9%. It is important to
note that during the survey administration and interview timeframe, the 2020 Covid-19 pandemic
became a dominating factor for the managers and directors. These individuals had to shift their
priority to ensure a safe healthcare environment for patients, physicians, and staff. Therefore, all
survey and interview activities ceased, which explains the low participation rate.
Determination of Assets and Needs
The study utilized three sources of data, including surveys, interviews, and document analysis.
The surveys were the primary source of data used to assess the assumed knowledge, motivation,
and organization influences. The five 30-minute interviews were transcribed, coded, and used to
triangulate and validate the survey findings.
The criteria for determining the validity of assumed influences were as follows: Assumed
influences were validated as an asset when the threshold of 80% or more of the managers and
directors gave responses confirming the correct influence for both the survey and the interviews.
The survey required 11 out of 13 (84%) responses confirming the correct influence, while the
interviews required four out of five (80%) responses confirming correct responses.
If the survey is confirmed as an asset, but the interview is not, the influence is considered
a need. Likewise, if the survey has confirmed a need, but the interview is not, the influence is

85
considered a need. Both the survey and the interview need to have confirming results to be
considered an asset.
Results and Findings for Knowledge Causes
The managers and directors knowledge causes were assessed through survey results and
interviews findings. Results are presented in the following section for each assumed influence in
the areas of factual knowledge, conceptual knowledge, procedural knowledge, and metacognitive
knowledge. With exception to one factual knowledge cause, each assumed influence was
determined to be a need.
Factual Knowledge

Influence 1. Managers and Directors know what is included in the Press Ganey and
Score employee engagement survey.
Survey Results. The managers and directors were asked about their knowledge of the
Press Ganey and SCORE employee engagement surveys. To be considered an asset, all three of
the correct responses needed to meet or exceed the 80% threshold for this item. As shown in
Table 9, the correct answers chosen were between 64% - 78.6%. Therefore, from the survey
results, this influence is a need.
Table 9
Factual Knowledge of Press Ganey and SCORE surveys

Q1: The Press Ganey or SCORE employee engagement survey
includes information about: (Choose all that apply) (n = 14)
Checked
Percent
Checked
Count
How the employees feel about the organization*

78.6%
11

How my work unit compares to benchmark data outside of the
organization*
78.6% 11
How my work unit compares to other ambulatory work units within
the organization*
64.3% 9

86
A step by step plan to improve employee engagement
14.3% 2
Note. An asterisk indicates a correct response.

Interview Findings. Participants were asked to describe the information contained in the
Press Ganey and SCORE surveys. Five participants were interviewed; however, only two of the
participants accurately explained the components of the surveys and stated how they used the
survey results to guide their next steps. These findings did not meet the threshold of 80%
making this a need for this influence based on the interviews. Participant 3 stated the survey was
used as “my foundation for what I need to improve for the upcoming year,” and Participant 4
stated it was used to “develop an action plan with targets and timelines.” Three of the
participants expressed they did not understand the survey. Participant 1 states it was a “horrible
survey, irrelevant, didn't really feel that it was accurate.” Participant 1 and 2 used emotional
words such as “blindsided” and “fizzled” and “nothing ever happens (with results).”
Summary. The assumed influence that the managers and directors know what is included
in the Press Ganey and SCORE employee engagement survey reveals there is a need to have a
better understanding of what the survey means and how it can be used. Although the survey
results reveal more than half of survey participants selected the correct answers, the interviews
reflect three of the participants expressed feelings that they do not appreciate the survey, feel it
was not a positive exercise, and do not feel the organization provides support on how to use the
survey or how to identify next steps. Thus, this influence is determined to be a need.
Influence 2. Managers and directors need to know the meaning of employee
engagement.
Survey results. The participants were asked to choose the best answer that describes
employee engagement. To be considered an asset 80% of the participants needed to answer this
question correctly. The survey results revealed 46.2% or six out of 13 answered this question

87
correctly. Therefore, as shown in Table 10 in the survey, this influence is determined to be a
need.
Table 10
Factual Knowledge - Meaning of Employee Engagement
Multiple Choice. Please choose one
Q2: Employee engagement means: (n=13)
Checked
Percent
Checked
Count
An employee who is energetic and has an emotional commitment to
the organization and organizational goals.*
46.2% 6
An employee who comes to work and does their work. 0 0
A happy, satisfied employee. 0 0
All of the above 53.8% 7
None of the above 0 0
Note. An asterisk indicates a correct response.

Interview findings. Participants were asked to describe employee engagement. The
interviews revealed that four of the five participants, or 80% used the words and phrases that
described employee engagement. Participant 1 described employee engagement as, “About
people, the number one most important part of an organization, drives patient satisfaction ”.
Participant 3 stated employee engagement is “at its foundation, it is to have the employees,
realize their importance and value in the business and in the organization.” Participant 4 states
employee engagement is “an employee who is happy to come to work every day. And as a result,
gives their 110% in everything they do.” Participant 5 states, employee engagement is about an
employee that “... loves what they're doing; good positive energy of doing their job.” These
findings meet the threshold of 80% making this an asset. Participant 2 admitted they did not

88
know the exact meaning of employee engagement, but did use the words, “loyalty to the
organization.” Therefore, in the interview, this influence is determined to be an asset.
Summary. The assumed influence that the managers and directors have the knowledge
and understanding of the meaning of employee engagement appears to be in conflict between the
survey and interview. Given the small sample size, to be considered an asset, both the survey
and interview results should meet or exceed the 80% threshold. Since the survey results do not
meet the 80% threshold, this influence is determined to be a need.
Influence 3. Managers and directors need to know their role in improving employee
engagement.
Survey Results. The participants were asked to choose the best answer to the question
“Who is responsible for employee engagement?” To be considered an asset, at least 80% of the
participants needed to choose the correct answer. The survey results revealed 92.3% or 12 out
of 13 participants chose the correct answer. Therefore, as shown in Table 11, in the survey, this
influence is determined to be an asset.
Table 11
Factual Knowledge - Employee Engagement is My Responsibility
Complete the sentence by choosing the best answer.
Q3: Employee engagement is the responsibility of: (n = 13)
Checked
Percent
Checked
Count
the organization, since the organization has control over benefits,
compensation, and work environment.
7.7 1
the employee since they chose to work here. 0 0
leadership which includes me, since I am in a position that can
directly impact employee engagement.*
92.312
Note. An asterisk indicates a correct response.

89
Interview findings. The participants were asked to describe their role in improving
employee engagement. It is evident from the interviews, 100% of the participants used
appropriate words and phrases that describe their role in improving employee engagement.
Participant 1 stated, “it is my responsibility to consider the employees voice and having them be
a part of every decision that I can.” Participant 2 stated, “I am the conduit through which all
information from like senior leadership flows to the frontline employee.” Participant 3 states,
“My job is to make sure that employees are engaged; it is my responsibility, the managers
responsibility.” Participant 4 stated:
My role is making sure that they (employees) have their tools and resources to do their
job, they have the appropriate training, they feel and are competent and comfortable in
what they are doing, and I need to provide an appropriate work environment.
Participant 5 stated, “My role is to listen...is there anything that we need to help them with.” To
be considered an asset, at least 80% of the participants needed to describe that it is their role and
responsibility to improve employee engagement. Since all of the participants accurately
described their role in improving employee engagement, in the interview, this influence is
determined to be an asset.
Summary. The assumed influence that the managers and directors understand their role
in improving employee engagement exceed the threshold of 80%. The survey revealed 92.3%
understood their role, and the interview revealed 100% could accurately explain their role in
improving employee engagement. Therefore, this influence is determined to be an asset.
Influence 4. Managers and directors need to know the best practices to foster
employee engagement.

90
Survey Results. The participants were asked to choose the best answer about best
practices that foster employee engagement. To be considered an asset, at least 80% of the
participants needed to choose the correct answer which is all of the choices, or all of the above.
Since 92.3% answered the survey correctly, in the survey, this influence is considered an asset as
shown in Table 12.
Table 12
Factual Knowledge - Fostering Employee Engagement through Best Practices
Multiple choice. Complete the sentence by choosing the best answer.
Q4: Some of the best practices to foster employee engagement is
about: (n = 13)
Checked
Percent
Checked
Count
being honest and truthful by creating an environment of trust 0 0
strong leadership; if my employees know I’m engage, they will model
my behavior
0 0
understanding the goals of the organization 0 0
being in a culture of learning and being open to new ways to foster
engagement
7.7 1
All of the above* 92.3% 12
None of the above 0 0
Note. An asterisk indicates a correct response.

Interview Findings. The participants were asked what they thought are best practices
that foster employee engagement. To be considered an asset, the participants needed to be able
to use words and phrases that describe the best practices that foster employee engagement. The
interview revealed only one participant could describe best practices that foster employee
engagement. Participant 1 stated, “including your employees as a part of the solution.”
Participant 2 stated, “being communicative with employees, transparent, listening and hearing

91
their perspectives, ideas and viewpoints.” Participant 3 stated best practices to foster employee
engagement is about:
Taking time to meet with your employees, speaking to them for five to 10 minutes, alone;
helping them understand why certain decision are made, why you do what you are doing,
sitting down and finding out what their goals are and where they want to be in in the next
three months, six months and what they want to learn and encouraging, leading by
example, being visible where they can see you.
Participant 4 stated, “having open and clear lines of communication, listening, asking the right
questions to find out what is important to them.” Participant 5 stated, “being open to questions,
and allowing the employees to make suggestions.” Although each participant used some words
and phrases that described best practices that foster employee engagement, their answers were
incomplete. Participant 3 is the only one who included the goal setting process as a part of best
practices that foster employee engagement. Therefore, since only one participant or 20%
provided a complete description of best practices that foster employee engagement, in the
interview, this influence is considered a need.
Summary. The assumed influence that the managers and directors know best practices
that foster employee engagement appears to conflict between the survey and interviews. Due to
the small sample size of both the surveys and the interviews, it is important that both the survey
and interviews meet or exceed the threshold of 80%. Since the interview did not meet the
threshold of 80%, this influence is considered a need.
Influence 5. Managers and directors need to know the components of an employee
engagement program.

92
Survey Results. The survey question asked the managers and directors about the
components of an employee engagement program. To be considered an asset, all five correct
responses needed to be selected to meet or exceed the 80% threshold for this item. The correct
answers were selected four times, exceeding the threshold of 80%. However, one of the correct
answers was selected only 57.1% of the time which does not meet the threshold as shown in
Table 13. Therefore, from the survey results, this influence is considered a need.
Table 13
Factual Knowledge - Employee Engagement Program Components
Multiple choice. Check all that apply.
Q5: An employee engagement program includes: (n = 14)
Checked
Percent
Checked
Count
selecting the right talent. 85.7% 12
understanding the mission, value and goals of the organization.* 92.9% 13
understanding my goals and how they align with the organization.* 57.1% 8
involving my staff in making decisions that affect their work.* 92.9% 13
ensuring my employees have the tools they need to do their job.* 92.9% 13
providing opportunities for advancement.* 92.9% 13
choosing my most challenging employee to gauge how I am
performing in improving employee engagement.
28.6% 4
Note: An asterisk indicates a correct response.

Interview Findings. The participants were asked to explain the next steps to building an
employee engagement program. It is evident from the interview that the participants had a
difficult time describing next steps to building an employee engagement program. Participant 1
states, “when there's a mistake made or something goes wrong, that we all come together and fix
it.” Participant 2 speaks about, “transparency and open communication across all levels.”

93
Participant 3 stated, “number one, identify the goal.” Participant 4 did not answer the question.
Participant 5 stated, “collaborating on different, different topics and how to proceed with them,
but also having the support from your leadership, to be able to execute.” To be considered an
asset, four out of the five participants should be able to describe the next steps to building an
employee engagement program. Although most participants could describe one or two aspects
of an employee engagement program, none were able to verbalize important aspects such as
resources and tools, and mission, values and goals of the organization being important aspects of
building an employee engagement program. Therefore, in the interview, this is determined to be
a need.
Summary. The assumed influence that the managers and directors know the components
of an employee engagement program did not meet the threshold of 80%. The survey revealed
the participants did not select all six correct answers and therefore did not meet the threshold.
The interviews reveal they could not describe various components on an employee engagement
program. Therefore, this influence is determined to be a need.
Conceptual Knowledge

Influence 1. Managers and directors need to know the consequences of employee
engagement.
Survey results. The survey question asked the managers and directors to choose all the
answers that apply to the consequences of an employee engagement program. To be considered
an asset, all three correct responses needed to be selected to meet or exceed the 80% threshold
for this item. The correct answers between 85.7% - 92.9% were selected which is above the
threshold of 80% as noted in Table 14. Therefore, from the survey results, this influence is an
asset.

94
Table 14
Conceptual Knowledge - Consequences of an Employee Engagement Program
Multiple choice. Choose all that apply.
Q6: An employee engagement program will: (n = 13)
Checked
Percent
Checked
Count
make work fun. 42.9% 6
be a cost to the organization that we can’t afford. 7.1% 1
improve employee involvement which will affect the patient
experience.*
92.9% 13
has no impact on the employee or the organization. 0 0
creates job satisfaction.* 85.7% 12
improves employee retention.* 85.7% 12
Note. An asterisk indicates a correct response.

Interview findings. The participants were asked to provide their thoughts on the
consequences of having an employee engagement program. In the interview, only one
participant was able to describe consequences of having an employee engagement program, and
therefore did not meet the threshold of 80%. Participant 1 did not answer the question.
Participant 2 stated the consequences of employee engagement program is:
Just another meeting on our calendar or just another place for employees voices to be
heard when really, I think that it’s almost like a scapegoat for managers, supervisors
leaders of any kind (pause) doesn’t hold them accountable for ingraining it into their
everyday leadership style.
Participant 3 stated, “you're saving money, it increases retention, satisfaction both on the
employee side and patient satisfaction position, so there should be no consequences on a
program like this.” Participant 4 stated, “we'd all like to believe it would result in employee

95
retention and improved recruitment.” Participant 5 said, “I think so if you're going to do an
employee engagement, you have to follow through with what you set the goals to be.” To be
considered an asset, four out of the five participants should be able to describe the consequences
of an employee engagement program. In the interview, only Participant 4 described several
benefits of an employee engagement program. Therefore, in the interview, this does not meet the
threshold of 80%, and is determined to be a need.
Summary. The assumed influence that the managers and directors know the
consequences of having an employee engagement program appears to conflict between the
survey and interviews. Due to the small sample size of both the surveys and the interviews, it is
important that both the survey and interviews meet the threshold of 80%. Since the interview
did not meet the threshold of 80%, this influence is considered a need.
Influence 2. Managers and directors need to know the relationship between their
role and their ability to impact improving employee engagement.
Survey results. The survey question asked the managers and directors to choose the best
option to complete the sentence, “I impact improving employee engagement by?” To be
considered an asset, the correct answer needed to be selected at the 80% threshold or above. As
indicated in Table 15, the correct answer was selected, 23.1% which does not meet the threshold
of 80%. Therefore, from the survey results, this influence is a need.
Table 15
Conceptual Knowledge - Managers and Directors Impact on Employee Engagement
Multiple choice: Choose the best option to complete the sentence.
Q7: I impact improving employee engagement by: (n = 13)
Checked
Percent
Checked
Count
speaking to my employees daily 0 0

96
making sure my employees know their assignments. 0 0
asking my employees what they did over the weekend. 0 0
assuring my employees are satisfied and happy. 0 0
seeking input and involving my employees in work activities by
listening to their ideas, brainstorming and creating an environment
where their engagement is important.*
23.1% 3
All of the above 76.9% 10
None of the above 0 0
Note. An asterisk indicates a correct response.

Interview findings. The participants were asked to explain whether they felt there was a
relationship between their role as a leader and how they impact improving employee
engagement. In the interview, four of the five participants were able to link their role to
impacting employee engagement and therefore met the 80% threshold. Participant 1 answered
there is a relationship, “It's all about trust, I involve my employees in improvements and
decisions and in everything, I encourage their participation.” Participant 2 did not answer the
question. Participant 3 acknowledged it is their job as a manager to improve employee
engagement and stated, “It's your job as a manager, to assess, develop, and create what you need
to engage employees. And to recreate!” Participant 4 stated, “it is my position to influence,
guide, direct and lead everything within my purview within my areas of responsibility.”
Participant 5 also acknowledged the role of the manager or director to influence and impact
employee engagement. Therefore, in the interview, this meets the threshold of 80%, and it is
determined to be an asset.
Summary. The assumed influence that the managers and directors know the
consequences of having an employee engagement program appears to conflict between the
survey and interviews. Due to the small sample size of both the surveys and the interviews, it is

97
important that both the survey and interviews meet the threshold of 80%. Since the survey did
not meet the threshold of 80%, this influence is considered a need.
Procedural Knowledge

Influence 1. Managers and directors know how to improve employee engagement
through best practices.
Survey results. The survey question asked the managers and directors to choose all the
answers that describe best practices on how to improve employee engagement. To be considered
an asset, all four of the correct responses needed to be selected to meet or exceed the 80%
threshold. Table 16 shows the correct answers were selected between 71.4% and 92.9%. Since
one of the correct answers is below the threshold of 80%, from the survey results, this influence
is considered a need.
Table 16
Procedural Knowledge - Managers and Directors Know How to Improve Employee Engagement

Multiple choice. Check all that apply.
Q8: Best practices for improving employee engagement include
the following: (n = 14)
Checked
Percent
Checked
Count
Conduct a survey to determine if the employees in my work are happy
and satisfied.
50% 7
Develop a series of parties and events that create a positive
atmosphere for the employee.
28.6% 4
Seek feedback from my employees and listen to their ideas.* 85.7% 12
Involve employees in making decisions about their work.* 92.9% 13
Have regularly scheduled meetings.* 71.4% 10
Create a climate that supports and values the employee.* 85.7% 12
Note. An asterisk indicates a correct response.

98
Interview findings. The participants were asked to explain some of the strategies they
have used to improve employee engagement. In the interview, five of the five participants
described the strategies they have used to improve employee engagement, and therefore
exceeding the threshold of 80%. Participant 1said, “I ask my staff to participate in committees
in different areas; focus on their professional development; get out and learn about the
organization.” Participant 2 stated:
I have structured meetings, biweekly, I do one on one, I do 30 minute one on ones, if
there is someone who wants to help lead and guide them, I encourage them to do so, I
worked on building trust; focusing on their needs; and encouraging people to speak up.
Participant 3 described strategies as:
Meeting with them, eating with your staff members, relating with them, talking to them,
walking around I do hourly rounds; reassuring them that you will be their biggest
protector, visibly and your ears are open to what they're trying to tell you, follow up is
really big in employee engagement.
Participant 4 stated:
Daily huddles provide sacred time for us to meet with all of our direct reports, it's about
providing a platform in which the employees can feel that their voice is heard. And then,
the most important thing is closing the loop.
Participant 5 said, “Being upfront, honest, and just having an open dialogue, you know, not
making them feel like they can't come talk to you. ” Therefore, in the interview, since all five
participants could describe strategies, they use to impact employee engagement, this exceeds the
threshold of 80%, and it is determined to be an asset.

99
Summary. The assumed influence that the managers and directors know how to improve
employee engagement through best practices appears to conflict between the survey and
interviews. Due to the small sample size of both the surveys and the interviews, it is important
that both the survey and interviews meet or exceed the threshold of 80%. Since the survey did
not meet the threshold of 80%, this influence is considered a need.
Influence 2. Managers and directors need to know how to build an employee
engagement program.
Survey results. The managers and directors were asked about the steps to build an
employee engagement program. To be considered an asset, all six of the correct responses
needed to meet or exceed the 80% threshold for this item. As indicated in Table 17, the correct
answers were chosen were between 64.3% - 85.7%. Since only three of the six answers were
chosen exceeding the 80% threshold, this appears to be a need. Therefore, from the survey
results, this influence is a need.
Table 17
Procedural Knowledge - Managers and Directors Know How to Build an Employee Engagement
Program

Multiple choice. Please check all that apply.
Q9: Steps to building an employee engagement program include:
(n = 14)
Checked
Percent
Checked
Count
Wait for my leadership to provide direction. 0 0
Review the results of previous employee engagement scores to
determine where I need to improve.*
85.7% 12
Research and develop the contents of the program.* 71.4% 10
Seek feedback, and input for design refinement.* 85.7% 12
Pilot the design and refine as needed.* 78.6% 11

100
Launch employee engagement program.* 64.3% 9
Measure and evaluate the employee engagement program.* 85.7% 12
Develop a series of parties to build teamwork. 21.4% 3
Note. An asterisk indicates a correct response.

Interview findings. The question for the participants was to describe the next steps the
managers and directors would take to design an employee engagement program. This question
was inadvertently omitted during the survey and therefore no interview findings are available.
Summary. The managers and directors were asked if they knew the next steps to
building an employee engagement program. To be considered an asset, both the survey and
interview needed to meet or exceed the threshold of 80%. The interview question was
inadvertently omitted; however, the survey results revealed a need. Due to the small sample size
of the survey and since the interview question was omitted, the survey results will be used to
determine whether this influence is a need or asset. Since the survey did not meet the threshold
of 80%, this influence is considered a need.
Influence 3. Managers and directors know how to implement an employee
engagement program.
Survey results. The managers and directors were asked to choose the best answer
identifying the first task to implementing an employee engagement program. To be considered
an asset, the correct responses needed to meet or exceed the 80% threshold for this item. As
noted in Table 18, the correct answer was chosen 53.8% of the time which is below the threshold
of 80%. Therefore, from the survey results, this influence appears to be a need.
Table 18
Procedural Knowledge - Implementing an Employee Engagement Program

101
Multiple Choice. Choose the best answer to complete the sentence.
Q10: My first task to implementing an employee engagement
program is: (n = 13)
Checked
Percent
Checked
Count
to make an announcement to my work until letting them know we are
embarking on an employee engagement program.
30.8 4
to seek approval from my leadership to hire an additional FTE
because I will need staff to develop a program.
0 0
Do nothing. Employee engagement is the responsibility of the
organization.
0 0
to identify the current levels of engagement of my work units and
focus my efforts on employees that are somewhat engaged to
engaged.*
53.8% 7
to choose my least engaged employees and implement my program. 7.7% 1
All of the above 0 0
None of the above 7.7% 1
Note. An asterisk indicates a correct response.

Interview findings. The participants were asked to explain how they would implement
best practices in their work unit and the steps to implement an employee engagement program.
In the interview, to be considered an asset 80% or more of the participants needed to be able to
explain the next step in implementing an employee engagement program. In the interview four
of the five participants identified the next step, therefore this appears to be an asset. The
participant’s spoke about understanding the employees and where they are, setting groundwork
of trust, listening and being open to best practices. Participant 1 said, “you have to set the
groundwork in order to get people to trust change and feel comfortable with implementing
change.” Participant 2 stated:
If someone gave me a list of nationally recognized best practices to improve employee
engagement, I would roll my eyes at it. Because that seems very programmatic, but I
would then accept it and I would read through it and decide which of these are applicable

102
or would be impactful for my group. But you have to know your group, your audience,
their work struggles, their personal struggles, their work styles and then take it from
there.
Participant 3 stated:

I would ask the group what can we improve, do we need to bring up to management, can
we come up with our own solutions. I think the clinics are having a hard time engaging
staff, it could be a staffing thing and giving employees time to engage amongst
themselves to work together.
Participant 4 stated:
I try to listen to my colleagues, but once again, it’s not one size fits all; what works for
them may not work for me. So, I try to implement best practices whether it's been tried
and true in other areas and tweak it for what I feel would be successful in my areas of
responsibility.
Participant 5 said, “daily huddles, going over the daily huddle board and reiterating it so they
understand.” Therefore, since four of the five participants could describe the next steps to
implementing best practices for an employee engagement program, this meets the threshold of
80%, and in the interview is determined to be an asset.
Summary. The managers and directors were asked if they knew how to implement an
employee engagement program and what next steps they would take. Due to the small sample
size of the survey and interviews, both need to meet the threshold of 80% in order to be
considered an asset. Since the survey did not meet the threshold of 80%, this influence is
considered a need.

103
Metacognitive Knowledge

Influence 1. Managers and directors need to self-reflect on their effectiveness of
implementing an employee engagement program, and their ability to improve employee
engagement in the ambulatory work units.
Survey results. The managers and directors were asked to choose the best answer on
how they self-reflect on employee engagement. To be considered an asset, the correct responses
needed to meet or exceed the 80% threshold for this item. For this survey item, the correct
answer was selected 100% of the time as noted in Table 19. Therefore, from the survey results,
this influence is considered an asset.
Table 19
Metacognitive Knowledge - Self-Reflection
Multiple choice. Choose the best answer to complete the sentence.
Q11: I self-reflect on employee engagement by: (n = 13)
Checked
Percent
Checked
Count
thinking about the effectiveness of my own style of leadership in how
I engage employees.
0 0
Understanding my role in employee engagement 0 0
deciding how I can be more involved in employee engagement. 0 0
deciding my next steps in improving employee engagement 0 0
All of the above* 100% 13
None of the above 0 0
Note. An asterisk indicates a correct response.

Interview findings. The managers and directors were asked to describe what comes to
mind when they self-reflect on their effectiveness in developing an employee engagement
program. In the interview, to be considered an asset, at least 80% of participants need to be able
to describe how they self-reflect on their effectiveness in developing an employee engagement

104
program. Two of the participants or 40% answered the question using words to describe how
they self-reflect; therefore, this influence appears to be a need. Participant 1 did not answer the
question. Participant 2 stated, “When I reflect on my effectiveness, I think there’s always room
for improvement and that’s always what I’m trying to be, a better leader, and I want my group to
be better.” Participant 3 stated, “I think it’s pointless. You’re asking questions that aren’t on
track.” Participant 4 states, “It’s about creating that right base where people feel empowered to
make their own decisions and not always have to double check with somebody. I create an
environment that my boss affords me, meaning autonomy, not to micromanage.” Participant 5
stated, “Am I doing the right thing and am I having an impact, but I’m a new manager, so I’m
not sure.” Since only two of the participants answered the question correctly, the interview did
not meet the threshold of 80%. Therefore, in the interview, this appears to be a need.
Summary. The managers and directors were asked how they self-reflect on their
effectiveness in developing an employee engagement program. Given the small sample size, to
be considered an asset, both the survey and interview results should meet or exceed the 80%
threshold. Since the interview results do not meet the 80% threshold, this influence is
determined to be a need.
Results and Findings for Motivation Causes
The managers and directors motivation causes were assessed through survey results and
interviews findings. Results are presented in the following section for each assumed influence in
the areas of self-Efficacy, expectancy, emotions and attribution. With exception to one
expectancy cause, each assumed influence was determined to be a need.

105
Self-Efficacy
Influence 1. Managers and directors are confident in their skills to create an employee
engagement program.
Survey results. The managers and directors were asked to rate their degree of confidence
in five areas: (a) creating an employee engagement program for their work unit; (b) seek
feedback from employees and listen to their ideas; (c) involve employees in making decisions
about their work; (d) have regularly scheduled meetings and; (e) create a climate that supports
and values the employees. For this influence to be considered an asset, the managers and
directors need to rate their level of confidence at the threshold of 80% or above, in all five areas.
The results represent the mean of each question for the 13 participants. As shown in Figure 3, the
survey revealed that the managers and directors rated their level of confidence between 68.85% -
95.62%. Two of the ratings were below the threshold of 80%. Therefore, from the survey, this
influence appears to be a need.
Figure 3
Self-Efficacy - Confidence in Creating an Employee Engagement Program
Rate your degree of confidence in doing the following as of right now, be recording a number
using the scale below: 0 - Not Confident at all, 50 - Moderately Confident, 100 - Highly
Confident.
Q12: I am confident in my skills to create an employee engagement program. (n = 13)

106

Interview findings. The managers and directors were asked to what degree do they feel
confident in their ability to create an employee engagement program. To be considered an asset,
80% or above of the managers and directors needed to affirm their confidence to create an
employee engagement program. All participants expressed confidence in their ability to create an
employee engagement program; therefore, in the interview, this appears to be an asset.
Participant 1 stated, “Yes! I am very confident.” Participant 2 stated, “I feel confident in my
abilities because my staff validates my abilities.” Participant 3 said, “Very, Very confident. I’m
super confident because employee engagement is not a one-day event. I do it every day. I have
confidence because my director trusts and has confidence in me to handle it, and I don’t need the
different levels of approval to make it happen.” Participant 4 said:
So very comfortable with my first level direct reports. A little more challenging when it
comes to the levels down because I don’t have the daily influence. So, I empower my
managers to work directly with their employees because I don’t have the direct influence
with their employees. I’m not as comfortable, but I try to hold my managers accountable
for doing their part in the respective employee engagement with their direct reports.

107
Participant 5 stated, “I think I’m fairly confident and having the experience of being on the front
lines helps me, because I have been in their shoes.” Since all five participants expressed they
are confident, in the interview, this influence exceeds the 80% threshold and therefore appears to
be an asset.
Summary. The managers and directors provided their level of confidence in their ability
to create an employee engagement program. Given the small sample size, to be considered an
asset, both the survey and interview results should meet or exceed the 80% threshold. The
interview revealed that managers and directors are confident in their ability to create an
employee engagement program. However, the survey results do not meet the 80% threshold. In
particular, Item 1 in the survey directly asking the level of confidence to create an employee
program did not meet the threshold. As this item addresses the primary focus of the study, this
influence is determined to be a need.
Influence 2. Managers and directors have confidence that they can impact
employee engagement.
Survey results. The managers and directors rated their degree of confidence to influence
employee engagement in four areas: (a) seek feedback from employees and listen to their ideas;
(b) involve employees in making decisions about their work; (c) have regularly scheduled
meetings; (d) create a climate that supports and values the employees. To be considered an asset,
at least 80% percent of the managers and directors need to express their confidence to influence
employee engagement in all four areas. The results represent the mean of each question for the
13 participants. As shown in Figure 4, the survey results revealed that the confidence level to
influence employee engagement in the four areas was between 76.31% - 95.42%. Therefore, in
the survey, this influence appears to be a need.

108
Figure 4

Self-Efficacy - Confidence in Influencing Employee Engagement in Work Unit

Rate your degree of confidence in doing the following as of right now, be recording a number
using the scale below: 0 - Not Confident at all, 50 - Moderately Confident, 100 - Highly
Confident.

Q13: Influence employee engagement in my work unit. (n = 13)

Interview findings. The managers and directors were asked how they felt about their
confidence to influence employee engagement in their work unit. In order for this to be an asset,
at least 80% of the managers and directors needed to express confidence in their abilities to
influence employee engagement in their work unit. It is evident from the interviews that four of
the five participants felt confident in their ability to influence employee engagement. Therefore,
in the interview, this appears to be an asset. Participant 1 stated, “Yes!” Participant 2 stated,
“Yes, I feel confident in my abilities to influence employee engagement.” Participant 3 did not
answer the question. Participant 4 said:
Yes. I feel I have a good relationship with all of my employees, which is close to 100
staff. In my region collectively, I’ve always tried to create an open-door policy and
communication. I tell them they are free to go up the chain of command, but they can

109
always call me. They have my cell phone and they freely call me. So, in terms of
influence, I feel that I have the influence and competence to the extent that I have time,
and tools to implement.
Participant 5 stated, “I do believe I have the ability to influence employee engagement because I
believe in my team and they believe in me” In order to be an asset, at least 80% of the
participants needed to express they feel confident in their ability to influence employee
engagement in their work units. Since four out of the five participants expressed they are
confident in their ability to influence employee engagement in their work units, in the interview,
this appears to be an asset.
Summary. The managers and directors were asked about their level of confidence to
influence employee engagement in their work units. Given the small sample size, to be
considered an asset, both the survey and interview results should meet or exceed the 80%
threshold. The interview revealed that managers and directors are confident in their ability to
influence employee engagement in their work units. However, the survey results did not meet
the 80% threshold. Therefore, this influence is determined to be a need.
Expectancy Theory

Influence 1. Managers and directors value the goal to improve employee
engagement.
Survey results. The managers and directors were asked if they value improving
employee engagement by indicating if they: (a) Strongly Disagree; (b) Disagree; (c) Neutral; (d)
Agree; and (e) Strongly Agree. In order for this to be an asset, 80% or more of the managers and
directors needed to state they agree or strongly agree. As shown in Table 20, the survey revealed

110
that 100% of the managers and directors agreed or strongly agreed that they value improving
employee engagement. Therefore, from the survey, this influence appears to be an asset.
Table 20
Expectancy Theory - Value to Improve Employee Engagement
Q14: I value improving employee engagement.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

#
Answer % Count
1
Strongly Disagree 0 0
2
Disagree 0 0
3
Neutral 0 0
4
Agree 23.08% 3
5
Neutral 76.92% 10

Total 100% 13
Interview findings. The managers and directors were asked if they valued employee
engagement and to provide examples of how they value employee engagement. For this to be
an asset, 80% or more of the managers and directors needed to state they value employee
engagement. All five participants stated they valued employee engagement and could provide
examples of how they value employee engagement. Since this meets the threshold of 80%, for
the survey, this appears to be an asset. Participant 1 stated:
Employee engagement leads to success of the organization, I mean it’s what drives
employee satisfaction and ultimately patient satisfaction. An example of how I value
employee engagement is I give people time away to participate in different committees;
we have people on the Ambassador Committee, Patient Navigator, and Safety

111
Committee. So, I think allowing people time away to focus on their professional
development is valuing employee engagement.
Participant 2 stated, “Yeah above all else, I think that's the core; the core upon which everything
else sits with patient experience, our business operations, our efficiency and effectiveness.”
Participant 3 said, “Absolutely! I think people like to be acknowledged, recognized, thanked. I
value employee engagement by valuing the employee and acknowledging, recognizing and
thanking them for what they do.” Participant 4 stated, “Absolutely! If I have an engaged staff
that translates to patient satisfaction and retention. And I show them by valuing them, asking
about their work, thanking them, asking them about their families and being a part of them.”
Participant 5 said:
I do value employee engagement because when you do, it really can change the whole
experience for the patient. I show how I value employee engagement by celebrating my
team. If we receive a compliment from a patient, it doesn’t sit with me. I share it with
everyone.
In order to be an asset, 80% of the participants needed to express how they value employee
engagement and could provide examples of how they value employee engagement. Since all
five participants expressed how they valued employee engagement and could provide examples,
in the interview, this appears to be an asset.
Summary. The managers and directors were asked whether they valued employee
engagement and to provide examples of how they value employee engagement. Given the small
sample size, the survey and interview results should meet or exceed the 80% threshold to be
considered an asset. The survey revealed that managers and directors agreed or strongly agreed
that they value employee engagement, and the interview results revealed all participants stated

112
they valued employee engagement and could provide examples of how they value employee
engagement. Therefore, since the survey and interview met or exceeded the threshold of 80%,
this influence is determined to be an asset.
Influence 2. Managers and directors have confidence that they can impact
employee engagement.
Survey Results. This survey question was inadvertently omitted.
Interview Findings. The managers and directors were asked how they felt about their
ability and confidence to influence an employee engagement program in their work units. For
this to be an asset, 80% or more of the managers and directors needed to state they have the
ability and confidence to influence employee engagement. The five participants agreed they are
confident in their abilities to influence employee engagement. Participant 1 said, “Yes! Let’s do
it.” Participant 2 said, “Yes, I am confident. I get feedback from my staff even when I don’t
solicit it. So, yes, I am confident in my abilities to influence my employees and their
engagement.” Participant 3 said, “Oh, very, very confident. I think that’s something I’m very
confident in because I do it daily, you know it’s not something I have to think about. I’m supper
super confident that’s one thing I do rather well.” Participant 4 stated:
Yes. I feel I have a good relationship with all of my employees, which is close to about
100. In my region, I've always tried to create an open-door policy and communicate and
tell them I appreciate it when they go up the chain of command, but they can always call
me. I feel that I have the competence and confidence to the extent that I have the time
and tools.”
Participant 5 said, “I do believe in my ability and am confident I can influence employee
engagement. I believe in my team and I am open to them. They listen, and I listen to them. I

113
know they are engaged. In order to be an asset, 80% of the participants needed to state they are
confident in their abilities to influence employee engagement. Since all five participants
expressed they are confident in their abilities to influence employee engagement, in the
interview, this appears to be an asset.
Summary. The managers and directors were asked how they felt about their abilities and
confidence to influence employee engagement. Given the small sample size, the survey and
interview results should meet or exceed the 80% threshold to be considered an asset. The survey
question was inadvertently omitted and therefore no results were gathered for the survey. The
interview revealed that all five participants stated they felt confident in their abilities to influence
employee engagement. Therefore, the interview findings exceed the threshold of 80%, and for
this influence is determined to be an asset.
Emotions
Influence 2. Managers and directors feel positive about developing an employee
engagement program.
Survey results. Using a Likert scale of (a) Strongly Disagree; (b) Disagree; (c) Neutral;
(d) Agree; (e) Strongly Agree, the managers and directors were asked if they feel positive about
developing an employee engagement program. In order for this to be an asset, 80% of the
managers and directors needed to state they agree or strongly agree with the statement that they
feel positive about developing an employee engagement program. As shown in Table 21, the
survey revealed that 76.92% of the managers and directors agreed or strongly agreed that they
feel positive about developing an employee engagement program; 15.38% were neutral, and
7.69% disagreed. Therefore, since the survey results did not meet the 80% threshold, this
influence appears to be a need.

114
Table 21
Emotions - Positive Feelings about Developing an Employee Engagement Program
Q15: I feel positive about developing an employee engagement program.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 7.69% 1
3 Neutral 15.38% 2
4 Agree 38.46% 5
5 Strongly Agree 38.46% 5
Total 100% 13

Interview findings. The managers and directors were asked how they felt about
developing an employee engagement program. For this to be an asset, 80% of the managers and
directors needed to express positive emotions about developing an employee engagement
program. Four of the five participants expressed positive emotions about developing an
employee engagement program and, therefore, meets the threshold of 80%. Participant 1 stated,
“As a manager, it is my number one job, it is my focus.” Participant 2 stated, “I feel confident in
it. I want to figure it out! I don’t pretend to have the answers, but I think that’s what I value! I
want to figure this out and I’m excited to figure this out together.” Participant 3 said, “I would
love to develop an employee engagement program; I can help create a program for the institution
that can be beneficial!” Participant 4 expressed, “It’s a little intimidating because it’s so
encompassing!” Participant 5 said, “I have ideas! I don’t know if I would be the head person,
but I would like to be on a committee and provide my ideas and feedback. I think I can be useful
and helpful. I would like that.”

115
In order to be considered an asset, 80% of the participants needed to express positive
feelings about developing an employee engagement program. Since four of the five participants
indicated they felt positive about developing an employee engagement program, for the
interview, this influence appears to be an asset.
Summary. The managers and directors were asked if they feel positive about developing
an employee engagement program. Given the small sample size, to be considered an asset, both
the survey and interview results should meet or exceed the 80% threshold. Although the
interview met the threshold of 80%, the survey did not. Therefore, this influence appears to be a
need.
Attribution

Influence 3. Managers and directors attribute their success or failure of improving
employee engagement to their own efforts.
Survey Results. Using a Likert scale of (a) Strongly Disagree; (b) Disagree; (c) Neutral;
(d) Agree; and (e) Strongly Agree, the managers and directors were asked to indicate if their
success or failure to improve employee engagement is due to their own efforts. In order for this
to be an asset, 80% of the managers and directors need to agree or strongly agree with the
statement that their success or failure to improve employee engagement is due to their own
efforts. As shown in Table 22, since only 69.23% agreed and strongly agreed to this statement,
this did not meet or exceed the threshold of 80%. Therefore, for the interview, this is considered
a need.
Table 22
Attribution - Attributing Success or Failure to Their Own Efforts
Q16: My success or failure to improve employee engagement is due to my own efforts.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

116

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 15.38% 2
3 Neutral 15.38% 2
4 Agree 46.15% 6
5 Strongly Agree 23.08% 3

Total
100% 13

Interview Results. The participants were asked if they feel that their work effort in
improving employee engagement is related to their success or failure. In order to be an asset,
80% of the participants needed to be able to attribute their work effort in improving employee
engagement to their success. All five participants acknowledged their efforts in improving
employee engagement is related to their success. Participant 1 said, “Yes. I believe the reason
I’ve been able to be successful is because I have created an environment of high trust which
improves employee engagement. It is directly related to my success.” Participant 2 stated:
The success of my people will make or break me as a leader. I think just being a human
and being vulnerable with them and saying, I don’t have all the answers but I’m going to
help us figure this out. I equate my success to their engagement, their effectiveness and
their success.
Participant 3 said:
Yes. I think they go hand in hand. I take this personally. If you are competent in what
you do, it reflects and people feed off you, so it’s that same energy. What I do in
improving employee engagement is directly related to my success.
Participant 4 said:

117
Yeah, I’d say at least, 51% and the reasons I say that is because sometimes no matter how
much you try, it is not always a testament to your level of commitment, desire or intent.
Keeping focused and engaged for the long term will help my success.
Participant 5 stated:
I think so. It’s about the relationship between the manager and getting your employees
engaged. Overall, whether it's dealing with employees that aren’t satisfied and, you
know, you have to try to figure it out, talk to them, what’s the issue, what’s going on,
how can I help. So, I think yes, totally, it will determine whether I succeed or fail.
In order to be an asset, 80% of the participants needed to indicate their work effort to improve
employee engagement is related to their success. Since five out of the five participants stated
their work effort in improving employee engagement is related to their success, in the interviews,
this appears to be an asset.
Summary. The managers and directors were asked if their success or failure to improve
employee engagement is due to their own efforts. Given the small sample size, to be considered
an asset, both the survey and interview results should meet or exceed the 80% threshold. The
survey revealed only 69.23% agreed and strongly agreed that their success or failure in
improving employee engagement is directly related to their own work efforts, while all five of
the interview participants acknowledged their success in improving employee engagement is due
to their work efforts. Due to the small sample size, both the survey and interview need to meet
or exceed the threshold. Since the survey did not meet the threshold of 80%, this influence
appears to be a need.

118
Results and Findings for Organization Causes
The managers and directors organization causes were assessed through survey results and
interviews findings. Results are presented in the following section for each assumed influence in
the areas of cultural models and cultural settings. With exception to one influence in cultural
models, each assumed influence was determined to be a need.
Cultural Models
Influence 1. Managers and directors perceive the organization supports employee
engagement.
Survey results. By using a Likert scale of (a) Strongly Disagree; (b) Disagree; (c)
Neutral; (d) Agree; and (e) Strongly Agree, the managers and directors rated whether there is an
organizational culture that supports employee engagement. In order to be considered an asset,
80% of the managers and directors need to agree or strongly agree that there is an organizational
culture that supports employee engagement. Table 23 reveals that the survey results do not meet
the threshold of 80% since only 76.93% agree or strongly agree that organizational culture
supports employee engagement, 15.38% are neutral and 7.69 strongly disagree. Therefore, in the
survey, this appears to be a need.
Table 23
Cultural Model - Organization Supports Improving Employee Engagement
Q17: There is an organizational culture that supports improving employee engagement.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 7.69% 1
2 Disagree 0.00% 0
3 Neutral 15.38% 2

119
4 Agree 53.85% 7
5 Strongly Agree 23.08% 3
Total 100% 13
Interview findings. The managers and directors were asked how the organization
supports employee engagement. In order to be an asset, 80% of the participants need to
acknowledge that the organization supports employee engagement and can provide examples of
support. Participant 1 does not feel the organization supports employee engagement and said:
There is too much focus on giving away presents rather than allowing people the
opportunity to make a difference. Like these USE points and employee of the month
programs I really don’t think that they have a whole lot of meaning.
Participant 2 stated:
They throw holiday parties. I think the execution is where we’re still missing a little bit. I
think they make a solid effort. So, there’s things like the Employee of the Month and
there’s the huddle shout outs to recognize someone, and the annual parties, but I think
what is missing is - asking the employees.
Participant 3 stated, “I don’t think our organization supports employee engagement that much.”
Two participants felt that the organization supports employee engagement. Participant 4 stated,
“The organization supports employee engagement through the USE point program where anyone
can give points for a job well done. The CEO started a lunch that allows employees to have face
time with the CEO.” Participant 5 acknowledged the organization supports employee
engagement and said, “The organization supports employee engagement through huddles, food
trucks or ice cream parties.”

120
In order to be an asset, 80% of the participants need to acknowledge that the organization
supports employee engagement and can provide examples of support. Three of the interview
participants or 60% said the organization does not support employee engagement, while only
40% said they felt it did support employee engagement. Therefore, in the interview, this
influence is considered a need.
Document Analysis. Organization documents were reviewed to confirm the interview
findings. The managers and directors refer to a number of events such as parties, presents,
employee of the month, huddles, and holiday parties. A review of the organization website, and
miscellaneous internet sites reveals the organization celebrates major organizational
achievements, employee achievements, and holidays. Employees enjoy the benefits of attending
University events such as football games, participating in employee of the month, and employee
of the year celebrations. The organization publishes a daily huddle sheet which reminds
employees of the priorities for the day. These multiple events are indicative of an organization
promoting a culture that supports employee engagements. Therefore, for the document analysis
this appears to be an asset.
Summary. The managers and directors were asked if they perceived the organizational
culture to be supportive of employee engagement. Given the small sample size, to be
considered an asset, both the survey and interview results should meet or exceed the 80%
threshold. The interview results revealed that 60% of the participants said they thought the
organization supports employee engagement, and the survey results revealed 76.93% agreed that
the organization supports employee engagement. The document analysis confirms what the
managers and directors stated in the interviews; the organization does have a number of events
that promotes employee engagements, and therefore is considered an asset. However, as stated

121
by Participant 1, “There is too much focus on giving away presents rather than allowing people
the opportunity to make a difference,” is indicative of the overall perception. Therefore, since
the interviews and survey did not meet the threshold of 80%, this influence appears to be a need.
Influence 2. Managers and directors perceive that the organization values
improving employee engagement.
Survey Results. By using a Likert scale of (a) Strongly Disagree; (b) Disagree; (c)
Neutral; (d) Agree; and (e) Strongly Agree, the managers and directors were asked to rate
whether the organization values employee engagement. In order to be considered an asset, 80%
of the managers and directors need to agree or strongly agree that the organization values. Table
24 reveals that only 69.23% of the participants agree or strongly agree that the organization
values employee engagement, while 15.38% are neutral and 15.38 disagree or strongly disagree.
Since this does not meet the 80% threshold, in the survey, this appears to be a need.
Table 24
Cultural Model - Organization Values Employee Engagement
Q18: The organization values employee engagement.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 7.69% 1
2 Disagree 7.69% 1
3 Neutral 15.38% 2
4 Agree 30.77% 4
5 Strongly Agree 38.46% 5
Total 100% 13
Interview Findings. The managers and directors were asked if the organization values
employee engagement and to provide examples of how the organization values employee

122
engagement. In order to be an asset, 80% of the participants need to acknowledge that the
organization values employee engagement and can provide examples of how the organization
values employee engagement. Since three out of the five participants acknowledged the
organization values employee engagement, this appears to be a need. Participant 1 stated:
Yes, they have these programs with the innovation programs and these kinds of things,
the Lean program where people can participate in learning about Lean. I think they value
it; I just think it needs to be beefed up a lot.
Participant 2 said:
I think they make solid effort so there’s things like the employee of the month, and
there’s huddle shout outs, annual parties, buy I think what is missing is - do they ask the
audience, meaning the employees if those things resonate with them? I think there is a
solid effort made, I’m just not sure how effective each of those things are for ambulatory
vs hospital which I hate to separate the groups, but I think we’ve gotten big enough to
where we should feel separated.
Participant 3 stated:
The organization values employee engagement when they want to. That’s me being
blunt. A good example is when there was talk about internal medicine going union,
that’s when upper leadership was actually walking the floor and talking to employees.
Why does it take a union rep to recruit and start talking to employees about union. And
then cheers for upper leadership comes in and says ‘Hey, let’s talk.’ Let’s listen to your
needs. Why does it need to be a trigger? I could be wrong, but that is how I feel.
Participant 4 said, “Yes, the organization values employee engagement, it is driven from an
enterprise wide level.” Participant 5 acknowledged the organization values employee

123
engagement and stated, “We have employee of the month and all nominated employees get a
shout out and lunch with upper leadership, there are meetings with directors and managers with
upper leadership.” To be considered an asset 80% of the participants need to acknowledge the
organization values employee engagement. Participants 1, 2, and 3 stated the organization
values employee engagement with reservation. The statements such as, “The organization values
employee engagement when they want to,” or “they make a solid effort, but not sure how
effective they are,” and “I think they value it,” indicated doubt. Moreover, only Participant 4 and
5 could state with confidence they felt the organization valued employee engagement.
Therefore, 40% agreed the organization values employee engagement while 60% do not agree
the organization values employee engagement. Consequently, for the interview, this influence
appears to be a need.
Summary. The managers and directors were asked if the organization values employee
engagement. Given the small sample size, to be considered an asset, both the survey and
interview results should meet or exceed the 80% threshold. The survey results revealed that
69.23% of the participants said they thought the organization values employee engagement, and
the interview results revealed 40% % of the participants agreed that the organization values
employee engagement. Therefore, the survey results and interview findings reveal this influence
appears to be a need.
Influence 3. Managers and Directors perceive there is a culture of shared decision
making.
Survey Results. By using a Likert scale of (a) Strongly Disagree; (b) Disagree; (c)
Neutral; (d) Agree; and (e) Strongly Agree, the managers and directors to indicate what to rate
the statement, “The organization has involved me in the goal setting process.” In order to be

124
considered an asset, 80% of the managers and directors need to agree or strongly agree that the
organization has involved them in the goal setting process. Table 25 reveals that only 69.23% of
the participants agree or strongly agree that the organization has involved them in the goal
setting process, while 23.08% are neutral and 7.69% disagree. Since this does not meet the 80%
threshold, in the survey, this appears to be a need.
Table 25
Cultural Model - Shared Decision Making

Q19: The organization has involved me in the goal setting process.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 7.69% 1
3 Neutral 23.08% 3
4 Agree 53.85% 7
5 Strongly Agree 15.38% 2
Total 100% 13
Interview Findings. The managers and directors were asked if they knew the
organizational goals and whether they are involved in the goal setting process. In order to be an
asset, 80% of the participants need to acknowledge that they know the organization goals, and
state they have been involved in the goal setting process. It is evident from the interview, that
four out of the five participants do not know the organization’s goals or whether they were
involved in the goal setting process. Participant 1 stated they knew the organizational goals but
did not feel they were involved in the goal setting process. Participant 2 stated, “I could think
through them, but if you were to ask me what our specific goals are this year, I know I couldn’t
tell you.” Participant 3 said:

125
No, I’ll be honest, I don’t know the organization’s goals. I know my goals and I know
my directors goals. I think goals should be transparent to everyone and I understand if
not everything is shared with the staff, but it should be laid out for everyone to know. A
lot of people are lost and trying to tread above water, so I think they could be a lot more
transparent with goals so that people can relate and understand. I’m nosy, so I like to
know what the next steps are, I want to know our successes. For me, I know what I need
to do to stay afloat, but I would like to know how I contribute to the organization and
whether my goals are in line with what the organization wants.
Participant 4 stated:
Yes, I know the organization’s goals, but I have not been involved in the past couple of
years now. Well, I have been involved at a different level. There are system goals,
ambulatory goals and department goals. I am not involved in the creation of the
ambulatory goals, but I drive my department goals.
Participant 5 said, “No, I do not know the system goals, maybe not as clear as I should. and I’m
not involved in the organizational goals, but I may be involved in the clinic goals.” To be
considered an asset, 80% of the managers and directors needed to say they know the
organizational goals and have been involved in the goal setting process. Only one of the
participants acknowledged they knew the organizational goals, and a few of the participants said
they were involved in the goal setting process, but none could consistently say they knew the
organization goals and that they were involved in the goal setting process. Therefore, for the
interview this appears to be a need.
Document Analysis. The 2018 SCORE survey was reviewed to determine if the
outcomes in the survey validate the current survey results and interview findings. The 2018

126
SCORE survey revealed 64% of the employees felt they could participate in decisions about the
nature of their work which is considered a strength. However, the SCORE survey also reveals
36% of the ambulatory employees feel they have a direct influence on the organization’s
decisions, which denotes 64% do not feel they have a direct influence on the organization’s
decisions which is considered a weakness. Therefore, as it relates to the shared decision making,
it appears the SCORE survey results confirmed this as a need.
Summary. The managers and directors were asked whether they knew the organization’s
goals and if they were involved in the goal-setting process to determine if there is a culture of
shared decision making. To be considered an asset, both the survey and interview results should
meet or exceed the 80% threshold. The survey results revealed that 69.23% agree or strongly
agree they know the organization’s goals, which does not meet the threshold of 80%. The
interview results revealed there was no consistency in whether the managers and directors knew
the organizational goals, or participated in setting the goals, therefore, for this too did not meet
the threshold of 80%. The document analysis of the SCORE survey results revealed 64% of the
ambulatory employees did not feel they had direct influence on the organization’s decision.
Therefore, since the survey and the interview did not meet the threshold of 80%, this influence
appears to be a need, which is reflected in the 2018 SCORE survey results.
Influence 4. Managers and directors perceive their individual goals align with the
goals of the organization.
Survey Results. The managers and directors were asked to indicate if their goals
align with the organization's goals by using a Likert scale of (a) Strongly Disagree; (b)
Disagree; (c) Neutral; (d) Agree; and (e) Strongly Agree. In order to meet the threshold and be
considered an asset, 80% of the managers and directors need to agree or strongly agree that their

127
goals align with the organization’s goals. As indicated in Table 26, the survey revealed 92.31%
agree and strongly agree that their goals align with the organization’s goals, with 7.69%
indicating they were neutral. Therefore, since the survey results exceed the threshold of 80%,
this influence appears to be an asset.
Table 26
Cultural Model - Individual Goals Align with the Organization’s Goals
Q20: The organization’s goals align with my goals.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 0.00% 0
3 Neutral 7.69% 1
4 Agree 53.85% 7
5 Strongly Agree 38.46% 5
Total 100% 13

Interview Findings. The managers and directors were asked if their goals align with the
organization’s goals. In order to be considered an asset, 80% of the participants need to state
that their goals align with the organization’s goals and can provide an example of how they
align. The findings from the interviews revealed that only one of the participants stated their
goals align with the organization’s goals. Participant 1 said, “Yes. We look at the organization
goals, and then we look at the different pillars of the organization and we come up with our goals
to support the organizational goals.” Participant 2 said, “I don’t remember. I’m sure because
they do because during the goal setting process, we made sure they aligned, but we haven’t
talked about it in six months.” Participant 3 said, “I don’t know. I know growth is a strategic
goal.” Participant 4 stated, “I believe so, they are required to be aligned.” Lastly, Participant 5,

128
“I believe so.” Since only one of the participants answered, “Yes,” this does not meet the
threshold of 80%. Moreover, none of the participants could provide an example. Therefore, for
the interview, this appears to be a need.
Summary. The managers and directors were asked whether their goals align with the
organization’s goals. Given the small sample size, to be considered an asset, both the survey and
interview results should meet or exceed the 80% threshold. The survey results revealed that
92.31% of the participants said agree or strongly agree that their goals align with the
organization’s goals. However, the interview revealed that one participant described how their
goals align but did not provide an example. The remaining four participants could not state if
their goals aligned and could not provide examples. Therefore, since the interview did not meet
the threshold of 80%, this influence appears to be a need.
Influence 5. Managers and directors perceive there is an organizational culture of
mutual respect.
Survey Result. The managers and directors were asked to state whether they think the
organization respects their actions and decision to improve employee engagement by using a
Likert scale of (a) Strongly Disagree; (b) Disagree; (c) Neutral; (d) Agree; and (e) Strongly
Agree. To be considered an asset, the managers and directors needed to meet or exceed the
threshold of 80%. Table 27 indicates that 69.23% agreed or strongly agreed, 23.08% was neutral
and 7.69% disagreed. Since only 69.23% agreed or strongly agreed, this does not meet the
threshold of 80%. Therefore, for the survey, this appears to be a need.
Table 27

Culture Model - Mutual Respect

Q21: The organization respects my actions and decisions to improve employee
engagement.

129
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 7.69% 1
3 Neutral 23.08% 3
4 Agree 30.77% 4
5 Strongly Agree 38.46% 5
Total 100% 13

Interview Findings. The managers and directors were asked whether they felt the
organization respects their actions to improve employee engagement. In order to be considered
an asset, 80% of the participants need to state that they feel the organization respects their
actions to improve employee engagement. The interview findings reveal three of the five
participants feel the organization respects their actions to improve employee engagement which
does not meet the threshold of 80%, and therefore is considered a need. Participant 1 said,
“Yes.” Participant 2 stated, “I’m probably neutral, I don’t feel disrespected, but they probably
don’t know what I’m doing over here, I don’t know.” Participant 3 stated, “No. I’ll be honest, I
think especially for me because I’m not on site. I don’t think they see the value in it, to be
honest.” Participant 4 said, “Yes.” Lastly, Participant 5 said,
I do. Our leadership empowers us to do what we need to do. If it’s something we can
ask for, we are not afraid to ask. They have an open-door policy, or we can call them,
email them just to discuss what we want to do.
Three of the five participants or 60% felt the organization respects their actions to improve
employee engagement which does not meet the threshold of 80%. Therefore, for the interview,
this appears to be a need.

130
Summary. The managers and directors were asked whether they felt the organization
respects their actions to improve employee engagement. Due to the small sample size, to be
considered an asset both the survey and interview need to meet or exceed the threshold of 80%.
Both the survey results and interview findings did not meet the threshold of 80%. Therefore, for
the influence of culture of mutual respect, this appears to be a need.
Influence 6. Managers and directors perceive that they have the freedom to make
decisions that affect their ability to improve employee engagement.
Survey Results. The managers and directors were to rate whether they felt the
organization gave them the freedom to make decisions that affect their ability to improve
employee engagement. In order to be considered an asset, 80% of the managers and directors
need to agree or strongly agree that the organization gives them the free to make decisions that
affect their ability to improve employee engagement. Table 28 indicates 92.31% agree or
strongly agree that the organization gives them the freedom to make decisions that affect their
ability to improve employee engagement, while 7.69% disagrees. Therefore, for the survey, this
appears to be an asset.
Table 28
Cultural Model - Autonomy
Q22: My organization gives me the freedom to make decisions that affect employee
engagement.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 0.00% 0
2 Disagree 7.69% 1
3 Neutral 0.00% 0
4 Agree 38.46% 5

131
5 Strongly Agree 53.85% 7
Total 100% 13

Interview Findings. The managers and directors were asked if they felt the organization
gives them the autonomy to make decisions that affect employee engagement. In order to be
considered an asset, four of the five participants need to state that they do feel the organization
gives them the autonomy to make decisions that affect employee engagement. The interview
findings reveal all five participants agree that the organization provides them with autonomy to
make decisions that affect employee engagement. Participant 1 stated, “I don’t know that the
organization gives it to me, but I take it.” Participant 2 said, “Oh yeah. For the most part, I don’t
feel micromanaged.” Participant 3 said, “Yes. I think my boss does a great job on doing that
because he has enough trust in me to do it. I have enough autonomy and trust with my boss and
his superiors to run my ship because I know what is best which is why I have a better buy in with
the employee.” Participant 4 and 5 said “yes” acknowledging that the organization gives them
autonomy to make decisions that affect employee engagement. Since all five participants agree
that the organization gives them autonomy to make decisions that affect employee engagement,
for the interview, this appears to be an asset.
Document Analysis. The 2018 SCORE survey was reviewed to determine if the
outcomes in the survey validate the current survey results and interview findings. Sixty-six
percent of the ambulatory employees stated they have freedom in carrying out work activities.
Sixty-three percent stated they have opportunities for independent thought and action. For the
SCORE survey both of these results are considered a strength.
Summary. The managers and directors were asked if they felt the organization gives
them autonomy to make decisions that affect employee engagement. Due to the small sample

132
size, the survey results and interview findings need to meet or exceed the threshold of 80%.
Since the survey results revealed 92.31% of the managers and directors agreed that they have the
autonomy to make decisions that affect employee engagement, this exceeds the threshold of
80%. Moreover, the interview findings reveal 100% of the participants agreed the organization
gives them autonomy to make decisions that affect employee engagement. Therefore, for this
influence, this appears to be an asset, which is supported by the 2018 SCORE survey results.
Influence 7. Managers and directors perceive there is an organizational culture of
mutual trust.
Survey Results. The managers and directors were asked to rate whether there is a culture
of mutual trust to support their efforts in developing an employee engagement program using a
Likert scale of (a) Strongly Disagree; (b) Disagree; (c) Neutral; (d) Agree; and (e) Strongly
Agree. In order to be considered an asset, the managers and directors needed to agree or
strongly agree that a culture of mutual trust exists to support their efforts to improve employee
engagement. As shown in Table 29, 69.23% agrees or strongly agrees that a culture of mutual
respect exists, 23.08% are neutral and 7.69% strongly disagrees. Therefore, for the survey, this
appears to be a need.
Table 29
Cultural Model - Mutual Trust
Q23: There is a culture of mutual trust to support my efforts in developing an employee
engagement program.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

# Answer % Count
1 Strongly Disagree 7.69% 1
2 Disagree 0.00% 0
3 Neutral 23.08% 3

133
4 Agree 30.77% 4
5 Strongly Agree 38.46% 5
Total 100% 13

Interview Findings. The manager and directors were asked if they had the trust of their
organization to develop an employee engagement program and, in the interview, if they are able
to participate in decisions that affect employee engagement. In order to be considered an asset,
80% of the participants need to state that they have the trust of the organization to develop an
employee engagement program. Participant 1 stated, “I think that their intentions are good, but I
think sometimes when push comes to shove, they're not there. The resources aren’t actually
there.” Participant 2 stated, “I trust the organization to support my efforts, but I feel it is up to
me to be effective.” Participant 3 stated, “Yes and no. No, because I don’t think we have the
foundation to do it yet. I think we have the talent, but we don’t have the time to create a plan.”
Participant 4 said “Yes. My boss allows and trusts me to create a program that is tailored to my
offices. I have seen a lot of growth and changes in the organization.” Participant 5 stated, “I
believe they trust me. It is about a relationship, the relationship I have with my leadership. I
believe they trust and support me.” In order to be considered an asset, 80% of the participants
needed to state that they thought the organization trusts them to develop an employee
engagement program. Participant 1 and 3 expressed reservations, while Participants 2, 4 and 5
stated they believed the organization trusts them to develop an employee engagement program.
Therefore, since only 60% stated they believed the organization trusts them to develop an
employee engagement program, this appears to be a need.
Summary. The managers and directors were asked whether they thought a culture of
mutual trust exists for them to develop an employee engagement program. Due to the small
sample size, both the survey and interview need to meet or exceed the threshold of 80%. Since

134
the survey results revealed 69.23% agree that there is a culture of mutual trust, and the interview
findings indicate 60% believe the organization trusts them to develop an employee engagement
program, neither meet the threshold of 80%. Therefore, for this influence, this appears to be a
need.
Cultural Settings
Influence 1. The organization organizes a number of events to encourage employee
engagement.
Survey Results. The managers and directors were asked to select all the statements that
apply to how the organization supports employee engagement. In order to be considered an asset
all five correct answers needed to be selected to meet the threshold of 80%. As shown in Table
30, the correct answers were chosen between 15.15% to 27.27%. Therefore, from the survey
results, this appears to be a need.
Table 30
Cultural Setting - Organization Visibly Supports Employee Engagement
Choose all that apply.
Q25: The organization supports employee engagement by: (n = 13)
Checked
Percent
Checked
Count
Performing an employee engagement survey yearly.* 21.21% 7
Rewarding employee behavior through Employee of the Month program.* 27.27% 9
Passing out University football tickets to reward positive employee
behavior.*
18.18% 6
Developing safety programs such as hand hygiene and flu shot programs.* 15.15% 5
Having celebratory parties.* 18.18% 6
My organization does not have events that support employee engagement. 0.00% 0
Note. An asterisk indicates a correct response.

135
Interview Findings. The manager and directors were asked to speak to how they have
observed the organization participate in improving employee engagement. Participant 1 referred
to an ambulatory retreat and said, “I think the retreats, especially in ambulatory have been really
positive. We used to have town halls which involved our employees, but since the staff had to
cover the phones, not everyone got to attend.” Participant 2 said, “There is constant
conversation, especially in leadership settings. So that is encouraging, they are at least
considering employee’s perceptions. But I think the jury’s still out on whether what they do
really makes a difference.” Participant 3 states:
They have tried huddle boards and daily huddles, but that is all I have seen. Aside from
that, I see staff joke around that we never see upper leadership here only when there’s a
problem. You know, I think there should be a lot more upper management involvement,
like make us spend one day making rounds just saying hi to everybody. A lot of staff and
even the physicians have never heard of this administrator or CEO.
Participant 4 did not provide an answer to the question. Participant 5 stated, “The organization
wants to hear what employees are saying and doing. Sometimes, leadership doesn’t know
because they are not always out in the satellites to meet with staff.” In order to be considered an
asset, 80% of the participants needed to state they felt the organization participates in improving
employee engagement. Three of the participants responded with hesitancy, one disagreed and
one did not answer the question. Therefore, for the interview, this is considered a need.
Summary. The assumed influence that there is a culture setting that the organization
supports events to encourage employee engagement reveals the managers and directors do not
feel the organization is supportive of the effort. The survey results indicated 15.5% - 27%
selected the correct answers, while four of the participants or 80% stated they were not sure

136
whether the events planned by the organization garnered employee engagement. Therefore,
since the survey and interviews did not meet the 80% threshold, this influence is determined to
be a need.
Influence 2. The organization has a plan of accountability to meet employee
engagement goals.
Survey Results. The managers and directors were asked if the organization has a plan of
accountability to meet employee engagement goals. In order to be considered an asset, 80% of
the managers need to agree or strongly agree that the organization has an accountability plan to
ensure the managers meet their goals. Table 31 reveals 23.08% agree that the organization has
an accountability plan, while 46.15% is neutral and 30.77% disagree that the organization has a
plan. Therefore, for the survey, this appears to be a need.
Table 31
Cultural Setting - Accountability
Q26: My organization has a plan of accountability to meet employee engagement goals.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

Answer % Count
1 Strongly Disagree 0% 0
2 Disagree 30.77% 4
3 Neutral 46.15% 6
4 Agree 23.08% 3
5 Strongly Agree 0% 0
Total 100 13

Interview Findings. The managers and directors were asked if they felt responsible for
meeting their goals and whether there were consequences if they did not meet their goals.
Participant 1 stated:

137
I’m currently in a leadership academy where employee engagement is our project. We’re
developing an application where employees are going to be able to track all the
extracurricular activities they participate in. This application will help track activities
such as employee engagement activities. I appreciate the support I’m getting by being in
the leadership academy, but I’m not sure the organization held us accountable in the past
for meeting goals. I’m not sure if we had organizational goals.
Participant 2 stated, “I don’t know. Maybe the organization puts in 20%, but the other 80% is
my responsibility.” Participant 3 said, “100% employee engagement is a goal, but I don’t think
the organization holds me accountable. And to be honest, I don’t need the organization support
because I am accountable for my own actions.” Participant 4 said, “Yes, the organization holds
me accountable for meeting my goals; my yearly bonus is based on how I meet my goals.”
Participant 5 said, “I am a new manager and I haven’t participated in the goal setting process.
But I think the organization would hold me accountable, I don’t know.” Only one participant
answered that they are held accountable for meeting their goals and how it tied into their bonus
structure. The remaining participants were hesitant or answered no. Therefore, for the
interview, this did not meet the threshold of 80%. Consequently, this is considered a need.
Summary. The assumed influence that there is a culture setting that the organization
holds the managers and directors accountable for meeting their goals was not supported. The
survey results indicated 46.15% were neutral and 30.77% disagreed. The interview findings
revealed only 20% of the participants agreed the organization holds them accountable for
meeting goals. Therefore, since the survey and interviews did not meet the 80% threshold, this
influence is determined to be a need.

138
Influence 3. The organization supports the development of an employee
engagement program.
Survey Findings. The managers and directors were asked to rate if they felt the
organization provides resources to design an employee engagement program using a Likert scale
of (a) Strongly Disagree; (b) Disagree; (c) Neutral; (d) Agree; and (e) Strongly Agree. In order
to be considered an asset, 80% of the participants need to agree or strongly agree the
organization provides resources to design, and employee engagement program. As indicated in
Table 32, the survey revealed only 23.07% agreed or strongly agreed that the organization
provides resources to support employee engagement, while 38.46% were neutral and 38.46%
disagreed or strongly disagreed. Therefore, for the survey, this influence is considered a need.
Table 32

Cultural Setting - Organization Supports Employee Engagement

Q27: The organization provides resources to design and implement an employee
engagement program.
(Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)

Answer % Count
1 Strongly Disagree 15.38% 2
2 Disagree 23.08% 3
3 Neutral 38.46% 5
4 Agree 15.38% 2
5 Strongly Agree 7.69% 1
Total 100% 13

Interview Findings. The managers and directors were asked if they felt they have the
resources to develop an employee engagement program. In order to be considered an asset, 80%

139
of the participants needed to acknowledge they have the resources needed to develop an
employee engagement program. Participant 1 said:
I hope so. I think one of the things that can be discouraging is that we start things and
don’t finish them. And so that can drive disengagement because you feel like you start
something, the focus dries up and then you stop.
Participant 2 stated:
Interesting question. I don’t like the idea that supplies are what helps engage employees.
I think it’s a leadership style. I am stretched thin as a leader and as my group grows, my
time does not allow me to be more available. My desire to be engaged with them does not
change, but I feel like I don’t have the time. I could use a supervisor so that I can work
on engagement projects.
Participant 3 said, “Yes, I do have the resources. I feel like between my director and my
staff, I can develop a program.” Participant 4 said, “Yeah, it goes back to time commitment in
terms of developing a hard wire program and process.” Participant 5 said, “I think there are
people around that can help, but my skills in building a program is my weakness. But I think
with how great the leaders are and open to communication, I think I have the resources.” In
order to be considered an asset, 80% of the participants needed to acknowledge they have the
resources needed to develop an employee engagement program. Participant 1, 2 and 5 were
hesitant in answering the question, while Participant 3 and 4 stated they felt they had the
resources. Therefore, since 40% felt they have the resources to develop an employee
engagement program, this does not meet the threshold of 80%. Therefore, for the interview, this
is considered a need.

140
Summary. The managers and directors were asked if they had the resources to develop
an employee engagement program. The survey results indicated 23.07% agreed or strongly
agreed that the organization provides resources to support employee engagement, while 38.46%
were neutral and 38.46% disagreed or strongly disagreed. The interview findings revealed only
40% of the participants agreed they have the resources to develop an employee engagement
program. Therefore, since the survey and interviews did not meet the 80% threshold, this
influence is determined to be a need.
Summary of Validated Influences
Tables 33, 34, and 35 show the knowledge, motivation and organization influences for
this study and their determination as an asset or a need.
Knowledge
As shown in Table 33, one out of eleven assumed knowledge influences were validated
as assets through survey results and interview findings. The recommendations to improve the
knowledge influences that were determined to be needs will be discussed in Chapter Five.
Table 33

Assumed Knowledge Influence Assets or Needs as Determined by the Data

Assumed Knowledge Influence Asset or Need
Factual
Managers and Directors know what is included in
the Press Ganey or SCORE employee engagement
survey.

Need

Managers and Directors need to know the meaning
of employee engagement

Need
Managers and Directors need to know their role in
improving employee engagement.

Asset
Managers and Directors need to know the best
practices to foster employee engagement.

Need

141
Managers and Directors need to know the
components of an EEP.

Need
Conceptual
Managers and Directors need to know the
consequences of employee engagement.

Need
Managers and Directors need to know the
relationship between their role and their ability
to impact improving employee engagement.

Need
Procedural
Managers and Directors know how to improve
employee engagement through best practices
strategies

Need
Managers need to know how to build an EEP.

Need
Metacognitive
Managers need to self-reflect on their effectiveness
of implementing an employee engagement
program, and their ability to improve employee
engagement in the ambulatory work units.
Need

Motivation

As shown in Table 34, two out of six assumed motivation influences were validated as
assets through survey results and interview findings. Recommendations to improve the
motivation influences that were determined to be needs will be discussed in Chapter Five.
Table 34

Assumed Motivation Influences as Assets or Needs as Determined by the Data

Assumed Motivation Influences Asset or Need
Self-Efficacy
Managers and directors are confident in their skills
to create an EEP.

Need
Managers and Directors have confidence in
building an employee engagement program.

Need
Expectancy Theory

142
Managers and directors value the goal to improve
employee engagement.

Asset
Managers and Directors have confidence that they
can impact employee engagement

Asset
Emotions
Managers and directors feel positive about
developing an EEP.

Need
Attribution
Managers and directors attribute their success or
failure of improving employee engagement to their
own efforts

Need

Organization

As shown in Table 35, one out of ten assumed organization influences were validated as
an asset through survey results and interview findings. Recommendations to improve the
organization influences that were determined to be needs will be discussed in Chapter Five.
Table 35
Assumed Organizational Influences as Assets or Needs as Determined by the Data

Assumed Organizational Influences Asset or Need
Cultural Models
Managers and directors perceive the
organization supports employee engagement.

Need
Managers and Directors perceive that the
organization values improving employee
engagement.

Need
Managers and Directors perceive there is a
culture of shared decision making

Need
Managers and directors perceive their
individual goals align with the goals of the
organization.

Need
Managers and directors perceive there is an
organizational culture of mutual respect.

Need

143
Managers and directors perceive that they have
the freedom to make decisions that affect their
ability to improve employee engagement.

Asset
Managers and directors perceive there is an
organizational culture of mutual trust.

Need
Cultural Settings
The organization organizes a number of events
to encourage employee engagement.

Need
The organization has a plan of accountability to
meet employee engagement goals.
Need
The organization supports the development of an
EEP.
Need

Chapter five will include recommendations for how to improve the assumed influences
that were not validated in the findings of this study. The proposed solutions and
recommendations will be shared with the Chief Executive Officer, Chief Financial Officer of the
medical group, and Chief Operations Officer of the USE Health System.

144
CHAPTER FIVE: RECOMMENDATIONS, IMPLEMENTATION AND EVALUATION

Purpose of the Project and Questions
The purpose of this project is to identify the problem and conduct a gap analysis to
examine the knowledge, motivation and organizational influences that contribute to USE
ambulatory service Directors and Manager’s ability to develop an employee engagement
program that encourages best practices for improving employee engagement. The analysis will
begin by generating a list of possible or assumed influences that will be examined systematically
to focus on actual or validated influences. While a complete gap analysis would focus on all
stakeholders, for practical purposes, the stakeholders to be focused on in this analysis is middle-
level managers and directors in the ambulatory practices.
There will be two questions that will guide the gap analysis:
1. What are the knowledge, motivation, and organization needs and assets that influence
Directors’ and Managers’ goal to implement an employee engagement program (EEP)
that embraces best practices for improving employee engagement in the ambulatory
setting by July 2020.
2. What are the recommended knowledge and skills, motivation, and organizational
solutions for Directors and Managers to achieve their goal?
These questions will assist in examining the causes of the performance problem for middle
management.
Introduction and Overview
The Clark and Estes (2006) assumed knowledge, motivation, and organization (KMO)
influences are reviewed in each of the following tables and determined to be needs during the

145
data collection. Each of these KMO influences are considered a high priority for achieving the
goal of increasing the managers and directors to improve employee engagement.
The tables provide details related to the assumed influence, priority, validation of the
need, and the principles, and recommendations. The recommendations are based on evidence-
based principles where learning and practice support behavior changes that assist the individuals
in achieving their goal. The recommendations will be implemented through a synchronous and
asynchronous learning program. The program includes in-classroom training, self-learning
activities, and mentoring sessions to reinforce identified critical behaviors.
The New World Kirkpatrick Model originally developed by Dr. Don Kirkpatrick used
four levels to evaluate training programs. Kirkpatrick and Kirkpatrick (2016) define these levels
as; Level 1 Reaction - measure the degree to which participants find training favorable, Level 2
Learning - acquire knowledge, skills, commitment, and confidence in training, Level 3 Behavior
- how they apply what they learned during training to their daily work activities; and Level 4
Results - how targeted outcomes occur as a result of training. The New World Kirkpatrick
Model (Kirkpatrick & Kirkpatrick, 2016) reverses these levels and starts with identifying
targeted outcomes or the desired results and ends with reaction or the degree to which
participants find training favorable. Therefore, the goal or desired outcome is the impetus to
defining critical behaviors that are necessary to achieve the goal. The New World Kirkpatrick
Model (2016) emphasizes measuring outcomes through leading indicators, defining critical
behaviors, providing the opportunity for learning and lastly, measuring the reaction to learning.

146
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations

Introduction. The four knowledge influences of factual, conceptual, procedural and
metacognitive (Krathwohl, 2011) are included as a part of the table. As shown in Table 36, only
one out of eleven assumed knowledge influences were determined to be an asset. More
specifically, the assumed influence that managers and directors know their role in improving
employee engagement is the only asset in the factual knowledge influences. Additionally,
conceptual knowledge, procedural knowledge, and metacognitive influences were determined to
be a need. For the knowledge influences that are determined to be a need, evidence-based
principles have been identified to guide context-based recommendations for improving
performance in these areas.
Table 36
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence: Cause, Need,
or Asset*

Need or Asset Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation

147
Managers and Directors
need to know what is
included in the Press
Ganey or SCORE
employee engagement
survey. (F)
Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide information on
the results of employee
engagement surveys
and a job aid
containing a glossary
of key terms, key
performance indices
found in Press Ganey
and SCORE materials.

Help individuals
identify and understand
important points.
(Schraw &
McCrudden, 2006).
Help individuals
connect new
knowledge to prior
knowledge and to
construct meaning
(Schraw &
McCrudden, 2006).
Managers and Directors
need to know the
meaning of employee
engagement. (F)

Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide information
and education -
Work with managers
and directors in
developing a
meaningful definition
of employee
engagement. Use
feedback received for
surveys and interviews
to identify past
definitions and provide
a framework for
developing a new
definition that is
relatable, actionable
and meaningful. Use
the organization
mission, values and
goals as a part of the
framework.

148
Managers and Directors
need to know their role in
improving employee
engagement. (F)

Asset Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide information
and education -
Use feedback received
for surveys and
interviews to
encourage discussion
about how they see
their role in improving
employee engagement.
Using their new
definition of employee
engagement (as
defined by them),
discuss the behaviors
that exemplify their
roles in improving
employee engagement.
Tie these new
behaviors into fitting in
the mission, values and
goals of the
organization. Work
with managers and
directors to integrate
critical behaviors into
their goals.

Help individuals
identify and understand
important points.
(Schraw &
McCrudden, 2006).

Help individuals
connect new
knowledge to prior
knowledge and to
construct meaning.
(Schraw &
McCrudden, 2006).

Managers and Directors
need to know the best
practices to foster
employee engagement.
(F)

Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide Job Aid that
includes best practices
to foster employee
engagement. Job Aid
will include a step by
step process on how to
build a program.

149
Managers and Directors
need to know the
components of an
employee engagement
program. (F)

Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide Job Aid that
includes components
of an employee
engagement program.
Job Aid will include a
step by step process on
how to build a program
and the components
required.

Managers and Directors
need to know the
consequences of
employee engagement.
(C)

Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006)

Provide information
and education from
studies that have
shown the cause and
effect of engaged and
disengaged employees.

Managers and Directors
need to know the
relationship between their
role and their ability to
impact improving
employee engagement.
(C)

Need Yes Information learned
meaningfully and
connected with prior
knowledge is stored more
quickly and remembered
more accurately because it
is elaborated with prior
learning (Schraw &
McCrudden, 2006).

Provide education from
studies that have
shown the cause and
effect of engaged and
disengaged employees
and the role of the
manager on making an
impact on employee
engagement.

150
Managers and Directors
know how to improve
employee engagement
through best practice
strategies. (P)

Need Yes Procedural knowledge is
about knowing how to
perform a task (Rueda,
2011).

To develop mastery,
individuals must acquire
component skills, practice
integrating them, and
know when to apply what
they have learned (Schraw
& McCrudden, 2006).

Feedback and modeling
increase self-efficacy
(Pajares, 2006)

Modeling to be learned
strategies or behaviors
improves self-efficacy,
learning, and performance
(Denler, Wolters, &
Benzon, 2009).

Help learners acquire new
behaviors through
demonstration and
modeling (Denler et al.,
2009).

Provide training on
how to determine best
practice and apply
them to their
ambulatory work units.

Provide training that
utilizes case studies on
applying best practices.
Develop SMART goals
that encourage
completion of the
tasks.

Provide instructional
support and build
opportunities for
practice and eventually
remove support.

Provide immediate
feedback for simple
tasks and delayed
feedback for complex
tasks.
Managers need to know
how to build an employee
engagement program. (P)

Need Yes To develop mastery,
individuals must acquire
component skills, practice
integrating them, and
know when to apply what
they have learned (Schraw
& McCrudden, 2006).

Feedback and modeling
increase self-efficacy
(Pajares, 2006)

Modeling to be learned
strategies or behaviors
improves self-efficacy,
learning, and performance
(Denler, Wolters, &
Benzon, 2009).

Help learners acquire new
behaviors through
demonstration and
modeling (Denler et al.,
Provide training on
how to build an
employee engagement
program.

Provide training that
utilizes case studies on
applying best practices.
Develop SMART goals
that encourage
completion of the
tasks.

Provide instructional
support and build
opportunities for
practice and eventually
remove supports.
Provide immediate
feedback for simple
tasks and delayed
feedback for complex
tasks.

151
2009).

Managers and Directors
know how to implement
an employee engagement
program. (P)

Need Yes To develop mastery,
individuals must acquire
component skills, practice
integrating them, and
know when to apply what
they have learned (Schraw
& McCrudden, 2006).

Feedback and modeling
increase self-efficacy
(Pajares, 2006)

Modeling to be learned
strategies or behaviors
improves self-efficacy,
learning, and performance
(Denler, Wolters, &
Benzon, 2009).

Help learners acquire new
behaviors through
demonstration and
modeling (Denler et al.,
2009).

Provide information
and training on how to
implement an
employee engagement
program.

Provide training that
utilizes case studies on
applying best practices.
Develop SMART goals
that encourage
completion of the
tasks.

Provide instructional
support and build
opportunities for
practice and eventually
remove supports.
Provide immediate
feedback for simple
tasks and delayed
feedback for complex
tasks.

152
Managers need to self-
reflect on their
effectiveness of
implementing an
employee engagement
program, and their ability
to improve employee
engagement in the
ambulatory work units.
(M)

Need Yes Higher levels of
engagement lead to
cognitive behaviors and
tactics that improve
learning such as increased
time on tasks, higher
cognitive effort, and the
use of concentrated
processing methods
(Padgett, et al., 2018).

Modeling to be learned
strategies or behaviors
improves self-efficacy,
learning, and performance
(Denler, Wolters, &
Benzon, 2009).

Help learners acquire new
behaviors through
demonstration and
modeling (Denler et al.,
2009).

Provide training on
self-reflection and their
effectiveness of
implementing an
employee engagement
program.

Provide opportunities
for learners to engage
in guided self-
monitoring and self-
assessment

Model metacognitive
process by talking out
loud and assessing
strengths and
weaknesses.

Use group
brainstorming to reveal
prior knowledge,
beliefs, associations,
assumptions and
potential
misconceptions about
employee engagement.

All of the knowledge influences are important, however knowing the meaning of
employee engagement (factual knowledge) and how to improve employee engagement
(procedural knowledge) are primary considerations. Therefore, these two influences are selected
to further examine in light of supporting literature, and recommendations for performance
improvement.
Managers and directors need to know the meaning of employee engagement. The
survey results and interview findings reveal the influence that managers and directors know the
meaning of employee engagement is a need. The survey revealed 46.2% of the employees chose
the correct answer while 53.8% chose the incorrect answer. The interview findings show that
four out of five employees could describe employee engagement, however due to the small

153
sample size, to be considered an asset, both the survey and interviewed needed to meet or exceed
the threshold of 80%. Therefore, this influence is considered a need and as a priority, it is
important the managers and directors develop a working definition of employee engagement. To
that end, the recommendation is to begin by working with the managers and directors in shaping
and broadening their understanding of employee engagement by (a) defining their current
understanding of employee engagement and ask to provide observable examples; (b) reviewing
the organizational mission values to determine how and if they align with employee engagement
and provide observable examples; (c) developing a working definition that aligns with their goals
and the organizational mission, values and goals. As noted in Table 33, the recommendation is
based on the principle developed by Schraw and McCrudden’s (2006) information processing
system which states information learned meaningfully and connected with prior knowledge is
stored quickly and remembered because it elaborates with prior learning. The ability to connect
what they know about employee engagement based on their current understanding and how it
relates to the organizational mission, values and goals will help them define a working definition.
This new definition will be agreed upon by the group and therefore, a common understanding
will be achieved which will assist them in developing an employee engagement program using
best practices. Allowing the managers and directors to connect their prior knowledge with new
knowledge by using examples will reinforce their understanding of employee engagement.
Employee engagement is a complex concept. Shuck and Wollard (2010) performed an
integrative review of the definition of employee engagement and found it is inconsistently
defined resulting in a fragmented approach to developing strategies around improving employee
engagement. Simpson (2009) relates these constructs to nurse engagement in healthcare and
states to improve healthcare quality, and decrease costs, it is necessary to determine predictors of

154
performance which can help predict patient outcomes. Simpson (2009) agrees that these
predictors can be determined by addressing current methodological limitations, “the first of
which involves building upon a conceptually consistent definition [of employee engagement]
and measurement of this construct” (Simpson, 2009, p. 1002). Therefore, the review of the
literature supports the idea that there is an inconsistent definition of employee engagement, and
in order to determine predictors of performance, there needs to be a conceptually consistent
definition.
To close this gap, as noted earlier, the managers and directors will participate in a
professional development program, which will broaden and help provide a common
understanding of employee engagement The first part of the exercise will include asking the
managers and directors to define what employee engagement means to them and to provide
behavioral examples that they have witnessed or experienced. The second part of the exercise
will be to review the mission, values, and goals of the organization to understand how and if
these align with their understanding of employee engagement. The third part will engage the
managers and directors to develop a shared, working definition that is meaningful and actionable
to them. The exercise will involve reflecting on examples of their experience in working with
employees that positively support the mission, values, and goals, and those that do not. The
group will look at their past experiences to determine how they may have influenced employee
behaviors, and they will identify tactics that will help them replicate positive employee
behaviors. Recalling previous experiences and connecting it to new experiences will bring
meaning to how they influence and impact employee engagement. Furthermore, this education
will provide a base on which managers and directors engage in developing an employee
engagement program using best practices. Clark and Estes (2008) state that education provides

155
a stable but general conceptual and analytical knowledge that can bring new concepts, processes,
and theories. Educating the managers and directors on the meaning of employee engagement will
help them to understand what it is, how it relates to the mission, values, and goals of the
organization, how it relates to their role as leaders and the impact they can have on improving
employee engagement. Once they have developed a working definition of employee
engagement, a job aid will be designed by them to assure the definition “sticks.”
Managers and Directors know how to improve employee engagement through best
practice strategies. The results of the study reveal the managers and directors lack the
procedural knowledge to improve employee engagement through best practice strategies. The
managers and directors were asked to select the correct answers to the question, “Best practices
for improving employee engagement include the following: (a) Conduct a survey to determine if
the employee in my work are happy and satisfied, (b) Develop a series of parties and events that
create a positive atmosphere for the employee, (c) Seek feedback from my employees and listen
to their ideas, (e) Involve employees in making decisions about their work, (f) Have regularly
scheduled meetings and (g) Create a climate that supports and values the employee.” The
survey showed that the correct answers were selected between 71.4% and 92.9%. Since one of
the correct answers is below the threshold of 80% this is considered a need. The interview
findings showed four of the five participants could describe next steps, however since the survey
did not meet the threshold, this influence is considered a need.
Several recommendations are made based on information processing system theory,
social cognitive theory, and self-efficacy theory. Schraw and McCrudden (2006) use the
information processing system theory and state to develop mastery, individuals must acquire
component skills, practice these skills, and know when to apply what they have learned. Denler,

156
Wolters, and Benzon (2009) use the social cognitive theory to reinforce that modeling to-be-
learned strategies or behaviors improve self-efficacy, learning, and performance. Moreover,
Pajares (2006) supports this through self-cognitive theory stating feedback and modeling
increase self-efficacy. Therefore, the recommendation is to provide training that utilizes case
studies on applying best practices and develop SMART goals that encourage completion of the
tasks. Also, it will be essential to provide instructional support and build opportunities for
practice and provide immediate feedback for simple tasks and delayed feedback for complex
tasks, as noted in Table 36.
Imperatori (2017) found that managers often lack the behavioral and relational
competencies to manage their crucial roles under challenging situations effectively. He suggests
that managers often grow up in a different context and do not learn essential manager functions,
which includes planning, controlling, and organizing resources. Reina et al., (2018) supports this
and states managers must examine their behaviors as a contributor to talent loss and recognize
that their behaviors toward employees are central to employee turnover and employee
engagement. These studies support the need for managers and directors to learn how to improve
employee engagement through learning, performing and modeling, and receiving timely
feedback to reinforce behaviors. The training will provide specific “how-to” instructions and
knowledge, with the ability to practice through role-playing and modeling in a safe environment
where they can receive corrective feedback (Clark & Estes, 2008).
Motivation Recommendations
Introduction. Clark and Estes (2008) suggests there are three facets of motivated
performance. Active choice is when intention is replaced by action when pursuing a goal,
persistence is the ability to persevere in spite of distractions, and mental effort is working smarter

157
to develop new solutions. To achieve the goal of implementing an employee engagement
program that embraces best practices for improving employee engagement and identifying the
recommended knowledge, motivation and organizational solutions to achieve their goal, the
directors and managers must make an active choice, be persistent and have the mental stamina to
accomplish the goal. The motivation influences of self-efficacy, expectancy value theory,
emotions, and attribution are highlighted in Table 37 have a high probability of being validated
and have a high priority for achieving the stakeholder’s goal. Table 37 provides
recommendations for these influences which are based on theoretical principles.
Table 37
Summary of Motivation Influences and Recommendations
Assumed Motivation Influence:
Cause, Need, or Asset*

Need or
Asset
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Managers and directors are confident
in their skills to create an EEP. (SE)

Need Yes Feedback and
modeling increases
self-efficacy
(Pajares, 2006).
Provide managers
and directors with a
job aid which builds
on the skills
required to develop
an employee
engagement
program; provide
feedback and allow
the managers and
directors to practice
creating a greater
sense of confidence
in their skills on
creating an
employee
engagement
program.

Managers and Directors have
confidence in building an employee
engagement program. (SE

Need Yes Learning and
motivation are
enhanced when
learners have
positive
Provide managers
and directors the
assignment of
researching
employee

158
expectations for
success (Pajares,
2006).
engagement best
practice models and
provide the goal to
develop their own
model which will
help build self and
team confidence
and encourage
behaviors that have
functional value.

Managers and directors value the goal
to improve employee engagement. (E-
V)
Asset Yes Rationales that
include a
discussion of the
importance and
utility value of the
work or learning
can help learners
develop positive
values (Eccles,
2006; Pintrich,
2003).

Goals motivate
and direct students
(Pintrich, 2003)
Provide training on
how to develop
SMART goals and
design an exercise
that supports the
development of
goals focused on
employee
engagement that are
interesting, develop
skills, and have
utility value, while
encouraging team
building.

Managers and Directors have
confidence that they can impact
employee engagement. (E-V)
Need Yes Rationales that
include a
discussion of the
importance and
utility value of the
work or learning
can help learners
develop positive
values (Eccles,
2006; Pintrich,
2003).

Activating
personal interest
through
opportunities for
choice and control
can increase
motivation.

Provide stimulating
and interesting
tasks, activities and
materials that are
relevant and useful
and, connect to their
interest, and based
on real-world tasks.

Provide model
values, enthusiasm
and interest in the
task; models who
are credible and
similar can foster
positive values.
Managers and directors feel positive
about developing an employee
engagement program. (Em)
Need Yes Positive emotional
environments
support motivation
(Clark & Estes,
2008).
Provide an
environment that is
free of criticism and
promotes creativity
and positivity which
allows managers

159
and directors to feel
positive about their
contributions to the
development of an
employee
engagement
program.

Provide a
collaborative group
environment that
encourages
creativity and
autonomy in
designing an
employee
engagement
program.

Managers and directors attribute their
success or failure of improving
employee engagement to their own
efforts. (Attr)
Need Yes Provide feedback
that stresses the
process of
learning, including
the importance of
effort strategies,
and potential self-
control of learning
(Anderman &
Anderman, 2009).
Provide feedback
throughout the
process of
developing an
employee
engagement
program so that
learning is
enhanced.

Provide a
supportive and
caring personal
relationship in the
community of
learners.

Three of the most influential psychological constructs of motivation are value, self-
efficacy and emotion (Clark and Estes, 2008). In this study, value was determined to be an asset,
while self-efficacy, emotion and positivity, were determined to be needs. As such, self-efficacy,
confidence, emotion and positivity are the influences selected to further examine in light of
supporting literature, and recommendations for performance improvement.
Managers and Directors have confidence in building an employee engagement
program. The survey results and interview findings reflected a conflict between the results; the
survey was determined to be a need while the interview findings showed an asset. However, due

160
to the small sample size, both the survey and interview results needed to meet or exceed the
threshold of 80%. Since the survey results did not meet the threshold of 80%, this influence is
considered a need and therefore, the managers and directors do not feel confident in building an
employee engagement program. Pajares (2006) suggests that learning and motivation are
enhanced when the learner has high self-efficacy and positive expectations for success. This
suggests that the managers and directors will benefit from a motivational exercise that increases
their self-efficacy. Thus, it is recommended that the managers and directors are guided through
an exercise where they engage in researching employee engagement program best practices,
designing and implementing an employee engagement program, developing monitoring tools and
metrics that will show progression towards meeting their goal. The exercise will be a team
exercise where they can build individual and group self-confidence while engaging in behaviors
that have functional value. The intended outcome of this exercise is for the managers and
directors to build self-confidence in a supportive, encouraging atmosphere which will lead to an
increase in self-confidence and self-efficacy.
An empirical study by Luthan and Peterson (2002) investigated the relationship between
a manager's psychological state of self-efficacy and the relationship between their employee's
level of engagement. Specifically, the study proposes that the manager's self‐efficacy may be
related to employee engagement because as the employees become more engaged in their work,
the manager acquires confidence and belief in her/his ability to create and build an engaged
team. The findings revealed emotional and cognitive engagement of employees are related to
their manager's self‐efficacy, and that the manager's self‐efficacy was related to their own
perceived effectiveness as evaluated themselves, their peers, and their subordinates. Moreover,
the findings revealed that the manager's self‐efficacy was a partial mediator of the relationship

161
between the emotional and cognitive engagement of their subordinates and their perceived
managerial effectiveness. Therefore, as the managers and directors go through the process of
researching, building, and implementing their own employee engagement program, their
perceived level of self-efficacy and effectiveness will increase, which will support building the
emotional and cognitive engagement of their employees. To help the managers and directors
understand this concept, a self-reflection exercise will be developed that will assist in learning
about self-efficacy. The focus of this exercise will be on learning about themselves and
understanding how they model employee engagement by sharing, listening, learning, being
transparent, persistent, and involving employees in the change process while identifying learning
opportunities (Tucker, 2017). It will be imperative that through the process of researching an
employee engagement program, the managers and directors also learn how to share, how to be
transparent, how to listen, and how to be persistent. These components are paramount in building
a relationship with their employees. The concept of modeling also applies to the leadership that
sponsors the program. Providing a model of being engaged is essential during this process and
modeling these behaviors will support an engaged culture throughout the organization.
Managers and directors feel positive about developing an employee engagement
program. The survey results reveal that 76.92% of the managers and directors feel positive
about developing an employee engagement program while the interview findings show 80%
express positive feelings about developing an employee engagement program. However, given
the small sample size, to be considered an asset, both the survey and interview results should
meet or exceed the 80% threshold. Therefore, this influence is a need. Clark and Estes (2008)
state that a positive emotional environment supports motivation. Therefore, as the managers and
directors go through the process of developing an employee engagement program, it is important

162
they feel positive about the project and an environment that is free of criticism and promotes
creativity and positivity envelopes them and their efforts. This will allow the managers and
directors to feel encouraged about their contributions to the development of an employee
engagement program. Furthermore, it is crucial to ensure a collaborative group environment that
encourages teamwork and mastery, and not competition.
Reina, et al., (2018) performed an empirical study that looked at the effects of
inspirational appeal and how it is associated with employee emotional engagement. They
hypothesized that emotional engagement or disengagement might play a vital role in transmitting
the effects of leader influence tactics on employee engagement. The study involved two
electronic questionnaires; the first survey asked the employee to respond to items regarding their
managers' use of influence tactics related to their job satisfaction, and the second survey asked
employees to report their emotional engagement in their jobs. Twelve months later the
researchers collected voluntary turnover data from the surveyed employees. The findings suggest
that inspirational, emotional appeal may contribute to employee loyalty and increased employee
engagement. In other words, what managers project and how they choose to influence employees
to perform may affect the employees' decision to engage in an organization. As such, emotional
engagement (i.e. positivity) can predict employee engagement and employee retention.
Therefore, the managers and directors must be able to project a positive, inspirational attitude, as
well as provide a positive work environment.
Positive emotions, such as happiness, support work commitment (Clark & Estes, 2009).
Bower (as cited in Clark, 2003) provides the following recommendations in providing a positive
work environment: a) investing in an upbeat environmental design, (b) letting people decorate
their workspace as long as it follows organizational policy, (c) allowing music, (d) the

163
elimination of rules that do not support an encouraging work environment, and (e) promote
enthusiasm. The organization designs medical office buildings and outpatient practices with
some of these concepts in mind, and as a result, the employees benefit from working with design
elements such as open spaces with natural light, and soft, calming music. Although it may not be
possible to implement all of Bower’s (1995) suggestions, there are tactics the managers and
directors can implement that will enhance a positive work environment.
Organizational Recommendations

Introduction. As shown in Table 38, all of the assumed organization influences
were determined to be a need during data collection. More specifically, the organizational
influences of cultural settings, and cultural models are areas of need in which improvement is
necessary. For these influences that remain classified as needs, evidence-based principles have
been identified to guide context-based recommendations for improving performance in these
areas.
Table 38
Summary of Organization Influences and Recommendations
Assumed Organization Influence:
Cause, Need, or Asset*

Need or
Asset
Priority
Yes, No
(Y, N)
Principle and
Citation

Context-Specific
Recommendation
Managers and directors perceive the
organization supports employee
engagement.
Need Yes Effective change
efforts are
communicated
regularly and
frequently to all key
stakeholders (Clark
& Estes, 2008).

Effective change
efforts ensure that
everyone has the
resources
(equipment,
personnel, time,
Provide managers
and directors with
communication and
assurance from
organizational
leaders that
employee
engagement is a
priority and assure
managers and
directors that they
will have the
resources to support
them in their pursuit

164
etc.) needed to do
their job, and that if
there are resource
shortages, then
resources are
aligned with
organizational
priorities (Clark &
Estes, 2008).

to increase their
skills and knowledge
to build and design
an employee
engagement
program.
Managers and Directors perceive the
organization values improving
employee engagement.
Need Yes Effective
organizations ensure
that organizational
messages, rewards,
policies and
procedures that
govern the work of
the organization as
aligned with or are
supportive of
organizational goals
and values (Clark &
Estes, 2008).
Provide managers
with evidence on
how the organization
values improving
employee
engagement through
the review of
personnel policy and
procedures that
consistently supports
an engaged
workforce while
discourages
employee
disengagement
through disciplinary
process.
Managers and Directors perceive there
is a culture of shared decision making.
(CM)
Need Yes Effective change
efforts ensure that
all key stakeholders’
perspectives inform
the design and
decision-making
process leading to
the change. (Clark
& Estes, 2008).

Effective leaders
share power
appropriately. They
consider equity in
the process of
allocating resources
(Johnson, 2006).

Organizational
culture is created
through shared
experience, shared
learning and
stability of
membership. It is
Provide managers
and directors with
access to
organizational
leaders that can
provide suggestions
to guide them design
an employee
engagement
program.

Organizational
leadership needs to
support a
collaborative work
environment and
promote shared
decision making
while eliminating
top-down
communication.

165
something that has
been learned. it
cannot be imposed
(Schein, 2004).
Managers and directors perceive their
individual goals align with the goals of
the organization
Need Yes 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 &
Estes, 2008)

Focusing the work
on the school’s
vision was
correlated with
improvements in
student learning
outcomes (Waters,
Marzano &
McNulty, 2003).

Accountability is
increased when
individual roles and
expectations are
aligned with
organizational goals
and mission,
incentives and
rewards systems
need to reflect this
relationship.
Design of incentive
structure and use of
incentives are more
important than the
type of incentives
used (Elmore,
2002).
Provide managers
and directors with
clear, measurable
goals around
employee
engagement ensuring
alignment with the
mission and values
of the organization.

Provide support
through
accountability;
measure efforts of
meeting the goal and
holding them
accountable through
regular checks and
feedback.

Provide an incentive
bonus program to
managers and
directors which is
linked to their ability
to meet the goal.
Managers and directors perceive there
is an organizational culture of mutual
respect.
Need Yes Effective change
efforts ensure that
all key stakeholders’
perspectives inform
the design and
decision-making
process leading to
Provide managers
and directors with
commitment to
consistent, clear,
structured
communication plans
to assure managers

166
the change (Clark &
Estes, 2008).

The more a leader
acts in a way that
followers feel is
appropriate ethical
leader behavior, the
more a leader will
be trusted (Van den
Akker, Heres,
Lasthulzen & Six,
2009).
and directors are
heard, barriers are
removed, and they
feel supported by the
organization to meet
their goal to increase
employee
engagement. Use
DICE to provide a
framework for
communication plan.

Provide managers
and directors with
visible support by
committing to being
involved,
participating in
meetings, removing
barriers, listening, by
holding the team
accountable.
Managers and directors perceive that
they have the freedom to make
decisions that affect their ability to
improve employee engagement.
Asset Yes Effective change
begins by
addressing
motivation
influencers; it
ensures the group
knows why it needs
to change. It then
addresses
organizational
barriers and then
knowledge and skill
needs (Clark &
Estes, 2008).
Organizations with
high levels of
cultural trust tend to
produce high quality
products and
services at less cost
because they can
recruit and retain
highly motivated
employees. These
employees are more
likely to enjoy their
work, take the time
to do their jobs
correctly; make
their own decisions;
take risks; innovate;
Provide an
organizational
atmosphere of trust
and vulnerability;
involve all
stakeholders
including employees,
and organizational
leaders to discuss
why employee
engagement is
important, reinforce
commitment to the
goal and how they
share and can meet
the goal together.
Managers and
directors will be
encouraged to work
with their employees
to determine what
they need to achieve
full engagement

167
embrace the
organization's
vision, mission and
values and display
organizational
citizenship behavior
(e.g., helping a
coworker in
need).(Colquitt,
Scott & LePine,
2007).

Managers and directors perceive there
is an organizational culture of mutual
trust.
Need Yes Organizational
effectiveness
increases when
leaders are
trustworthy and in
turn, trust their
team. The most
visible
demonstration of
trust by a leader is
accountable
autonomy.
Organizational
effectiveness
increases when
leaders behave with
integrity. The most
powerful teaching
tool a leader has is
leading by example,
which is occurring
all the time, whether
intended or not,
conscious or not.
(Clark & Estes,
2008)
The more a leader
acts in a way that
followers feel is
appropriate ethical
leader behavior, the
more a leader will
be trusted (van den
Akker, Heres,
Lasthulzen & Six,
2009).
Provide managers
and directors with
commitment to
consistent, clear,
structured
communication plans
to assure managers
and directors are
heard, barriers are
removed, and they
feel supported by the
organization to meet
their goal to increase
employee
engagement. Use
DICE to provide a
framework for
communication plan.

Provide managers
and directors with
visible support by
committing to being
involved,
participating in
meetings, removing
barriers, listening, by
holding the team
accountable

168
The organization organizes a number of
events to encourage employee
engagement.

Need Yes Effective change
begins by
addressing
motivation
influencers; it
ensures the group
knows why it needs
to change. It then
addresses
organizational
barriers and then
knowledge and skill
needs (Clark &
Estes, 2008).

Provide the
managers and
directors with
knowledge and learn
communication on
the current status of
employee
engagement
programs, first by
providing survey
results with
explanations of what
the survey results
mean, and what is
needed for change.
Provide the
managers and
directors with a
forum to share ideas
with leadership and
work with them to
develop a solid plan
on how they plan to
build an employee
engagement program
with timelines,
milestones and
measurable goals.

The organization has a plan of
accountability to meet employee
engagement goals.

Need Yes The organization
ensures that
organizational
messages, rewards,
policies and
procedures that
govern the work of
the organization are
aligned with or are
supportive or
organizational goals
and values (Clark &
Estes, 2008).
Different types of
benchmarking
contribute data to
improve
organizational
performance (Bogue
& Hall, 2003).
Provide education to
managers and
directors of past
performance scores
and work with them
to decide if these are
reasonable
benchmarks that can
be used for goal
development.
Assure all
stakeholders are
comfortable with
goal setting exercise.
Identify any
necessary changes in
workflow and
develop policies and
procedures to
support changes that
can be hard-wired to
support employee
engagement. Work

169
with managers and
directors to find
other observable and
measurable ways to
determine an
increase in employee
engagement (e.g.
Press Ganey Patient
Satisfaction Scores).
The organization supports the
development of an employee
engagement program.

Need Yes Effective change
begins by
addressing
motivation
influencers; it
ensures the group
knows why it needs
change. It then
addresses
organizational
barriers and then
knowledge and
skills (Clark &
Estes, 2008).
Provide the
managers and
directors with
support from
organizational
leadership to remove
obstacles and
barriers that may
prevent their ability
to develop an
employee
engagement plan;
and then address by
providing training
classes that provide
them with
knowledge and skills
to develop an
employee
engagement plan.

Clark and Estes (2008) suggest that organizational culture has the most influence on
organization performance. They further suggest that cultural conflicts are demonstrated by
individual’s differing beliefs in the goal and how to achieve the goal. Thus, unless the
organization culture is aligned, the desired outcomes will not come to fruition. Therefore, the
influence that the organization values improving employee engagement and culture of mutual
respect are of high priority and consequently were selected to be examined more closely using
the literature.
Managers and Directors perceive the organization values improving employee
engagement. The managers and directors were asked if the organization values employee

170
engagement. The survey results revealed 69.23% the managers and directors believe the
organization values employee engagement, while the interviewed findings showed 80% believed
the organization values employee engagement. This influence is considered a need since the
survey did not meet the threshold that both the survey and interview needed to meet or exceed
the threshold by 80%. Over half of the managers and directors believe the organization values
improving employee engagement, however the interview findings express the desire for
executive leadership to be visibly supportive of their daily activities and challenges which
includes personnel management. Dixon (1994) speaks about the types of support necessary for
organizational change, two of which specifically apply to this influence. One of these is
leadership must be continually involved in the improvement process, while another is leadership
must have clear vision, goals and ways to measure progress. Furthermore, Clark and Estes
(2008) posit that effective organizations ensure organizational messages, rewards, policies, and
procedures that govern the work of the organization align with organizational goals and values.
The managers and directors acknowledge that the employee of the month, and employee
of the year rewards, lunches with the CEO, and holiday celebrations are examples of
organizational efforts to engage employees. However, the managers and directors also want the
organization to be supportive in their daily challenges such as consistent policies to manage
employees. For instance, if the organization values employee engagement, the organization
needs to have policies and procedures that support valuing engaged employees and disciplining
disengaged employees. Managers and directors feel there is a lack of support to terminate
employees that are detrimental to the organization. The director's state challenging employees
make it difficult to change the culture, and disciplinary policy and procedures are vague and
inconsistent. Therefore, having clearly defined disciplinary policies and procedures will assure

171
appropriate employee boundaries and allow the managers and directors to take action to counsel
and discipline as defined through the policy. Therefore, the recommendation is to commit to the
managers and directors that the organization will review policy and procedures that support an
engaged workforce and discipline and discourage employee disengagement.
Schein (2017) states making deliberate changes to the rewards and punishment systems
are the most difficult to bring about, but also the quickest and easiest way to change overt
behavior and initiate cultural changes in the organization. Furthermore, the rewards and
punishment systems of an organization, as well as assumptions about authority, forms cultural
assumptions of how people in the organization relate to each other, react to anxieties, and give
meaning to their daily interactions which is a part of the cultural DNA (Shein, 2017). Therefore,
reviewing the rewards and punishment systems, whether policy and procedures or the
celebratory events, both are equally important in establishing a shared value in employee
engagement.
Managers and directors perceive there is an organizational culture of mutual
respect. The survey results show 69.23%of the managers and directors feel there is an
organizational culture of mutual respect, while only 60% of the interview participants agree there
is a culture of mutual trust. Since both the survey and interview findings are less than the
threshold of 80%, this influence is a need. A comment by one of the interview participants was,
“I don’t feel disrespected, but they probably don’t know what I'm doing over here.”
Peter Schein (2017) states underlying assumptions are values in a culture that creates
actions within the culture. Some of these assumptions are not necessarily discussed, but are
composed of unconscious thoughts, beliefs, perceptions and feelings (Schein, 2004). Since these
assumptions are not discussed openly, they cannot be addressed and consequently, organizational

172
problems may arise. The feeling that the organization does not know what the managers and
directors are doing, may be an underlying assumption that is contributing to the feeling of lack of
respect. Clearly, this is an indication that change is essential.
Organizational change theory states that change occurs when the perspective of all
stakeholders is considered in the design and decision-making process (Clark and Estes, 2008).
Respect can be a critical byproduct of trust; therefore, the lack of mutual trust and respect can
have a significant impact on the ability of the managers and directors to improve employee
engagement. Hence, it is paramount for organizational leadership to provide a message of
commitment, consistency, and acknowledgment to support the efforts necessary to improve
employee engagement. These elements will be designed into the professional development
training program and will feature executive leaders as speakers that model these characteristics
and the values of the organization. The more a leader acts in a way that followers feel is
appropriate ethical leader behavior, the more a leader will be trusted (Van den Akker, Heres,
Lasthulzen & Six, 2009) which will lead to a culture of mutual respect.
The professional development training program will encompass the DICE framework
(Sirkin, Keenan & Jackson, 2005) to ensure change is effective. DICE is an acronym that
describes a process which takes into account duration (D) which is the time between the review
of the review of the project; integrity (I) which represents the integrity of the project team;
commitment (C ) of organizational leadership and project participants and, effort (E) of the
project participants required to support and sustain change. Fostering mutual respect between
the organization, and the managers and directors will motivate them to achieve their goal to
improve employee engagement and will ultimately establish a culture of mutual respect.

173
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The Kirkpatrick Model developed by Dr. Don Kirkpatrick used four levels to evaluate
training programs. Kirkpatrick and Kirkpatrick (2016) define these levels as; Level 1 Reaction,
Level 2 Learning, Level 3 Behavior and Level 4 Results. Each of these levels measure the
degree to which participants find training favorable, acquire knowledge, skills, commitment, and
confidence in training, how they apply what they learned during training to their daily work
activities, and how targeted outcomes occur as a result of training. The New World Kirkpatrick
Model (Kirkpatrick & Kirkpatrick, 2016) is significantly different in that it reverses these levels
in the planning of the evaluation and starts with identifying targeted outcomes or the desired
results and ends with reaction or the degree to which participants training favorable. The
emphasis of the New World Kirkpatrick Model is to understand the desired outcomes through
leading indicators, determine critical behaviors that will achieve the desired outcomes, provide
the opportunity for learning and lastly, measure the reaction to learning.
Organizational Purpose, Need and Expectations

USE is an academic medical center that emphasizes excellence in clinical care, teaching
and research. Employee engagement is linked to promoting a culture of exceptional person-
centered care, building a system of integrated care to meet patients’ needs across the continuum
of care, and to drive innovation in clinical information technology to enhance patient care.
Furthermore, a cross-cutting goal that applies throughout the health system includes a
commitment to a supportive work environment ensuring an atmosphere of trust and respect.
Although the organization does not have a specific goal focused on increasing employee
engagement, it is implied. Furthermore, the literature supports, patient and employee satisfaction

174
is dependent on employee engagement (Lowe, 2012; Peltier et al., 2009; Pech & Slade, 2006;
Scotti, et al., 2007). Thus, it would seem reasonable that the aspirational goal is to have 100%
engaged employees. Therefore, the desired outcome for this project is to improve employee
engagement by providing the managers and directors with the necessary knowledge and skills,
motivation and organizational support to implement an employee engagement program that
embraces best practices for improving employee engagement in the USE ambulatory work units.
Level 4: Results and Leading Indicators

Level 4 is described as the result of training; more important, it is the connection and
contribution to desired results (Kirkpatrick & Kirkpatrick 2016). Leading indicators are the
short-term observations that demonstrate critical behaviors are targeted to reach the desired
results (Kirkpatrick & Kirkpatrick, 2016). Table 39 provides the leading internal and external
indicators, and the metrics and methods for how they will be measured and observed. These
leading indicators will inform USE leadership as to whether the goal of designing and
implementing an employee engagement program in the USE ambulatory units is successful.
Table 39
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased patient satisfaction Increase scores in patient satisfaction
survey results, specifically in the
domains of “Helpful and Courteous
Office staff,” and “Recommend this
Provider office”
Report monthly CGCAHPS survey
results to stakeholders and executive
leadership.
Increased new patient volume 15% Increase in new patients Report monthly to stakeholders and
executive leadership
Increased in outside physician
referrals

10% increase in referrals from outside
physicians by end of fiscal year
Report monthly physician referral
volumes

175
Internal Outcomes
Increased employee satisfaction Annual employee satisfaction survey
results, specifically by 4% points
Report SCORE employee satisfaction
results annually to stakeholders and
leadership
Increased employee retention Increase employee retention by 3% on
a yearly basis
Report to stakeholders monthly and
yearly
Increased the number of
employee engagement activities
Number of employee engagement
activities and the number of employees
that participate
Report on engagement training, and
engagement activities
Decreased union enrollment
and activities
Union activities decrease, number of
practices joining the union decreases or
ceases.

Level 3: Behavior

Critical behaviors. Level 3: Behavior is defined as the degree to which participants
apply what they learned during training when they are back on the job (Kirkpatrick &
Kirkpatrick, 2016). It is essential to define the critical behaviors that will have significant
impact on desired results to meet the organization and stakeholder goal (Kirkpatrick &
Kirkpatrick, 2016). Table 6 demonstrates three critical behaviors that the managers and directors
must demonstrate in order to achieve their performance goals.
First, the managers and directors need to understand how their role, what they model and
how they treat their employees is a primary step in understanding employee engagement.
Employee engagement increases when leaders are trustworthy, and they trust their team. Rath
and Conchie (2009) state the four characteristics followers describe in the “best” leader are trust,
compassion, stability and hope. Therefore, these are critical behaviors these leaders must
display. These are observable and measurable behaviors. These behaviors must be consistent
and performed reliably to have the biggest impact on the desired outcomes (Kirkpatrick &
Kirkpatrick, 2016).

176
The second critical behavior is the managers and directors ability to create an employee
engagement program. The knowledge and skills to build a program that embraces best practices
for improving employee engagement are the tactical skills the managers and directors must be
able to display. The training sessions for the manager and directors will include a conceptual
map and framework on how to develop an employee engagement plan. The managers and
directors will receive job aids and coaching on developing their program. The ability to develop
a program is a critical behavior that can be observed during training and post training.
Furthermore, implementation of the program is a critical behavior that is the key to achieving
change in the organization.
The third critical behavior is the ability to self-monitor their plan with motivation and
commitment to increasing employee engagement. The ability to develop a program can be
observed and monitored through weekly, monthly meetings with leadership and their coach or
mentor. In summary the critical behaviors begin with understanding leadership, having the
knowledge and skills to design and implement an employee engagement program, and lastly,
accountability to themselves and the organization to monitor their plans, meet or exceed desired
results and achieve the goal to increase employee engagement. An important critical behavior
that is outside of the individual behavior is that of the organization. The managers and directors
can only be successful if the organization supports the program by providing monetary and
human resources. Organizational commitment is also demonstrated by monitoring the program,
reinforcing performance, encouraging, listening and being available to resolve problems and
removing obstacles. Finally, rewarding the managers and directors for good performance is
essential. The specific metrics, methods, and timing for these critical behaviors can be found in
Table 40 below.

177
Table 40

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s) Method(s) Timing
1. Managers and
directors understand
their role as leaders and
display trust,
compassion, stability
and hope.
Number of behaviors
observed. Managers and
directors display behavior
of commitment to their
employees by doing what
they say; they do not
micromanage and allow
staff to reach goals
displaying confidence in
their abilities.
Observe behaviors during
huddles and meetings and
provide feedback to the
director/manager on
behavior. Pulse survey staff
on their ability to accomplish
tasks with autonomy. Look
for consistency in how tasks
are managed.
Review behaviors
ongoing and provide
consistent feedback.
Coach to provide advice
and feedback on
leadership style during
monthly mentoring
sessions.
2. Managers and
Directors
can develop and
implement an employee
engagement program
using framework and
job aids provided
during training.
Number of program
components completed.
Managers and directors
will provide a framework
of employee engagement
programs; they will be able
to speak about their
program and implement
the program.
Observation during training
sessions, observations post
training
Framework will be
complete during training
sessions; follow up on
plan will be bi-weekly
with Directors for their
work units, monitoring
of plan and goal
achievement will be
monthly with a mentor.
3. Managers and
directors will develop a
self-monitoring
program that will keep
them accountable to
achieving their goal.
Number of behaviors
observed. Managers and
directors will be able to
provide a self-monitoring
program which will be
developed during training
sessions. They will be able
to demonstrate behaviors
that they can monitor the
achievements of their plans
and goals.
Observation during training
session to build a self-
monitoring plan, observation
post training that they
continue to self-monitor
towards goal achievement.
Plans will be completed
during training class, bi-
weekly meeting with
CAO to review metrics,
and review metrics with
coach/mentor on a
monthly basis.
4. Organization will
support the program by
providing time, staff,
and monetary
resources.
Organization will show
support by being engaged
and active in monitoring
the program, reinforcing
performance by providing
feedback, providing time
for mentorship program
Observation of commitment
throughout the program
Start of program -
support the development
of training programs
through monetary
resources, through the
life of the program by
providing mentors,
commitment and
support.

Required drivers. To support reaching desired outcomes, there are processes and
systems that reinforce, monitor, encourage, and reward critical behaviors (Kirkpatrick &

178
Kirkpatrick, 2016). Required drivers fall into two categories; support and accountability.
Support is essential post training to reinforce what was learned during training. The ability to
refer to a job aid, or to provide mentoring or coaching and recognition for improving
performance, are support drivers that reinforce behaviors. Accountability reinforces behaviors
through monitoring key performance indicators, observations, interviewing and self-monitoring.
Table 41 lists the recommended drivers that support critical behaviors of the managers and
directors to implement an employee engagement program that embraces best practices for
improving employee engagement.
Table 41
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Job aids will be provided during and
post training that support increased
leadership skills, self-efficacy and
confidence.
Face to Face Training full day
sessions; monthly on-line learning
1, 2, 3
Job aids which include a framework
for developing employee
engagement programs, and a
checklist to support monthly
monitoring.
Face to face full day training;
Monthly
2, 3
Organization supports program by
providing leadership mentors that
can support and reinforce the
managers and directors with critical
behaviors, and monitoring.
Monthly 2, 3
Encouraging
Mentoring program is developed for
managers and directors to support
encouraging and sustaining
behavior.

Monthly 1, 2, 3
Rewarding

179
Develop a program that rewards
when critical behaviors are
successfully displayed by managers
and directors.
Quarterly 1, 2
Develop a reward program when
managers and directors successfully
meet key performance indicators
.
Monthly, Yearly 1, 2, 3
Develop a reward program when
managers and directors meet or
exceed defined internal and external
metrics.
Monthly, Yearly 1, 2, 3
Monitoring
Managers and Directors will report
on key performance indicators.
Monthly, Yearly 1, 2, 3
Managers and Directors will report
on patient satisfaction survey results
monthly.
Monthly 1, 2, 3
Manager and Directors will report
on employee engagement results
yearly and action plans monthly.
Bi-Weekly, Monthly, Yearly 1, 2, 3

Organizational support. Executive leadership plays an essential role in supporting the
managers and directors in meeting the goal of implementing an employee engagement program
that embraces best practices for improving employee engagement. First, leadership must
commit to continuing to measure patient and employee satisfaction as they are key measures that
will provide objective evidence of employee engagement. Second, leadership will commit to
the program by supporting the development of a training program, providing resources, funding,
and holding the managers and directors accountable for reaching their goals. The organization
will support increasing employee engagement by developing policy and procedures that reward
engagement and discourage employee disengagement. Lastly, the organization will support the
managers and directors by rewarding their accomplishments through special events or monetary
rewards that reinforce and encourage critical behaviors.

180
Level 2: Learning

Kirkpatrick and Kirkpatrick (2016) describe Level 2: Learning as “The degree to which
participants acquire the intended knowledge, skills, attitude, confidence, and commitment based
on their participation in training.” (Kirkpatrick & Kirkpatrick, 2016, p. 42).
Learning goals. The following learning goals are recommended solutions based on
the required knowledge and skill, motivation and organization influences. Upon completion of
the learning goals the managers and directors will have the confidence to perform the following:
1. Managers and directors will (a) describe employee engagement meaning and surveys,
(b) baseline metric and organizational goal to increase employee engagement scores; and,
(c) the manager's role and responsibility in developing and implementing an employee
engagement program that embraces best practices for improving employee engagement.
(Factual Knowledge)
2. Managers and directors will explain the relationship between employee engagement
and providing the knowledge and tools to the managers and directors to implement an
employee engagement program. (Conceptual Knowledge)
3. Managers and directors will apply the strategies to develop an employee engagement
program. The framework will include training, job aids, mentoring and coaching which
is intended to increase procedural knowledge of how to build an employee engagement
program. (Procedural Knowledge)
4. Managers and directors will self-reflect on their progress and will have the confidence
and competence to understand what to measure, monitor, and make appropriate changes
to gain significant results. (Metacognitive Knowledge)

181
5. Managers and directors will be confident that they can improve employee
engagement and achieve their goal to develop employee engagement practices using best
practices. (Self-efficacy)
6. Managers and directors will value goals to accomplish the task of implementing an
employee engagement program with metrics, key performance indicators, and
identification of critical behaviors that instill confidence and competence in their abilities.
(Expectancy-value theory)
7. Managers and directors and leadership will be positive about promoting an
atmosphere of positivity to encourage positive emotions about developing an employee
engagement program. (Emotions)
8. Managers and directors will attribute successful outcomes to their own appropriate
implementation of strategies. (Attribution Theory)
Program. The program name is GEN!UINE (Miguel-Johnson, 2019), which is an
acronym for “Get Engaged Now! You Initiate New Experiences.” The GEN!UINE program will
focus on increasing the skills and knowledge of the managers and directors to build an employee
engagement program while increasing their self-efficacy and confidence to be influential leaders
in the organization that can impact employee engagement. The program is in four parts. Part
One: “About You - It Starts with Me” will focus on how the managers and directors see
themselves as leaders, their role, their goals, and how they contribute to the mission, values, and
goals of the organization. They will participate in group and individual exercises that will teach
them how to use reflection as a tool to learn about themselves and improve their leadership
skills. They will also learn about trust, compassion, stability, and hope (Rath & Conchie, 2009)
as cornerstones to leadership. Part Two - “Employee Engagement - Where do we start?” will

182
focus on building a shared understanding of the term employee engagement, review of past
survey results, and an understanding of what the survey results mean. The group will review the
mission, values, and goals of the organization and identify how their goal to increase employee
engagement aligns. Part Three - “Building a Framework for Employee Engagement” will
provide the managers and directors with tools and job aids to help them build an employee
engagement program. The employee engagement survey results will be used to teach how to use
past survey results to improve employee engagement. They will identify critical behaviors that
they want to see from their employees, develop key performance indicators and metrics that they
will use to measure employee engagement. They will be guided through a process where they
will determine the knowledge and skills they need to build a program. They will also develop
solutions and determine how the organization can support them through the process. Part Four -
“It Starts and Ends with Me” brings the learning process back to the beginning; what they
learned about themselves at the beginning, what they learned through the program, a review of
the employee engagement plan, leading indicators, and how they are meeting the key metrics.
Part Four emphasizes self-reflection and identification of the motivating factors that will help
them reach their goals.
GEN!UINE is a synchronous and asynchronous learning program that will take place
through two full-day face-to-face sessions, and self-exercises outside the classroom. In addition,
for six months post training, the managers and directors will be paired with a leader in the
organization that will provide coaching, mentoring, and hold them accountable to their personal,
professional and organizational goals.
Although the objective of the program is to increase employee engagement and increase
patient satisfaction, the proximate goal is: (a) to teach the managers and directors about

183
confidence, self-efficacy and the value of self-reflection, (b) to teach the managers and directors
how to use past results to build an employee engagement program that they understand,
appreciate and value, and (c) build an organizational culture of learning, trust and mutual respect.
The effectiveness of the program will be measured by turnover metrics, an increase in critical
behaviors, an increase in patient satisfaction, and an increase in employee engagement scores.
Evaluation of the components of learning. Table 42 below lists the methods and
activities that will be used to evaluate the declarative knowledge, procedural skills, attitude,
confidence, and commitment of the managers and directors to build an employee engagement
program using best practices for improving employee engagement and help them identify the
knowledge, motivation and organizational solutions that will help them achieve their goals.
Table 42
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Managers and directors can confidently describe self-
reflection processes; can demonstrate the ability to
build an employee engagement program and
determine what is needed from the organization to
support solutions.
During training
Managers and directors will demonstrate learning
through group activities which include role playing
and demonstration of behaviors.
During training
Pre and post assessment - Knowledge will be
determined by using questions from the research
survey to learn about pre-training knowledge. Same
survey will be provided to determine post-training
knowledge.
Before and after training.
Procedural Skills “I can do it right now.”
Observe group and individual dynamics to determine
level of engagement, confidence and competence.
During training, post training

184
Observe group and individual employee engagement
plans using the framework checklist provided during
class.
During training, post training
Provide feedback on employee engagement plans
developed by participants.
During training and post training
Feedback will be provided by mentors/coaches on
employee engagement and goal achievement.
During six-month post training
Attitude “I believe this is worthwhile.”
Survey managers and directors pre-training using
research questions regarding the value of employee
engagement.
Pre, during and post training survey
Discussion about the value and relevance of
the training.

Pre, during and post training survey
Confidence “I think I can do it on the job.”
Discussion about challenges and barriers to
implement new knowledge and skills.
During and post training discussion
Discussion with coaches/mentors on their ability to
accomplish the goal
Post training
Commitment “I will do it on the job.”
Development of employee engagement plan with
SMART goals.
Post training
Coaches/mentors will meet with participants to assure
goals are being monitored and achieved.
Post training

Level 1: Reaction

Level 1: Reaction is the degree to which participants find the training favorable, engaging
and relevant to their jobs (Kirkpatrick & Kirkpatrick, 2016). Level 1 is a quick way to determine
whether the training and trainer are effective. Formative evaluation methods is the process of
seeking immediate feedback during training while summative evaluation is usually a survey post
training (Kirkpatrick & Kirkpatrick, 2016). Table 43 below lists the methods that will be used
to determine whether the training program is effective and relevant.

185
Table 43
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Instructor observation and second observer. During each training session.
Active interaction during group activities. During each training session.
Asking meaningful questions. During each training session.
Relevance
Summative Survey Immediately after training
Pulse Survey During the training, Immediately after training
Customer Satisfaction
Summative Survey Immediately after training
Online Training Events Pulse Survey after each online training event

Evaluation Tools

The Kirkpatrick Model focuses on the outcomes of learning, rather than the mechanism
used to accomplish those results (Kirkpatrick & Kirkpatrick, 2016). Therefore, success is not
about the intervention program; it is about behavior changes that result in achieving targeted
outcomes. However, the intervention program should be designed to provide knowledge and
motivation, inspiring a catalyst towards change. Thus, the need to evaluate the training program
pre-training, during training, immediately after the training intervention and a determined time
post-training, are important aspects of measuring the success of the training intervention
The Blended Evaluation Approach (Kirkpatrick & Kirkpatrick) is a methodology which
uses immediate and delayed evaluation tools to assess data about the effectiveness of a training
program. The purpose of immediate evaluation tools is to assess Levels 1 Reaction and Level

186
Learning, while Level 3 Behavior and Level 4 Results evaluations are focused on behaviors that
result in the application and outcomes.
Immediately following the program implementation. Using the Blended Evaluation
Approach (Kirkpatrick and Kirkpatrick, 2016), the Level 1 assessment will include questions
related to the participants confidence and commitment to apply what was learned, and questions
related to anticipated application and outcomes. Since the classroom training takes place over a
two-day period, the survey will be administered electronically at the end of each day. The
blended evaluation will assess the participants engagement, satisfaction and relevance of training
and materials (Level 1), and their knowledge, skills, attitude, confidence and commitment (Level
2). The immediate evaluation tool will be an electronically administered survey, with questions
using rating scales.
Delayed for a period after the program implementation. Kirkpatrick and Kirkpatrick
(2016) suggest focusing delayed evaluations on how training graduates have applied what they
learned on the job including the support they are receiving (Level 3) and the results they have
accomplished (Level 4). Additionally, delayed evaluations also reexamine the effectiveness of
the training by measuring the reaction (Level 1) and learning (Level 2) of the program once
again (Kirkpatrick & Kirkpatrick, 2016). There will be two types of delayed evaluations. The
participants will be provided an electronic survey three times post the training event. The survey
questions will be open ended and rating scales which will test knowledge, skills, confidence,
attitude and commitment. Additionally, the evaluation will be performed through action plan
monitoring and observation which will be completed by the mentor/coach after each monthly
meeting with the participant. These data will be used to evaluate the participants' engagement,
their ability to apply what they have learned, as well as the effectiveness of the training event.

187
The objective of involving the coach/mentor in the evaluation process is to engage them in the
success of the program while holding them accountable in supporting the manager or director in
their development.
Data Analysis and Reporting

The Kirkpatrick Model emphasizes that obtaining data about the program is not a
byproduct, but an integral part of the process. Gathering and analyzing data should happen
throughout the program in order to maximize results. The gathering of data should answer three
questions, “Does it meet expectations? If not, why? If so, why?” (Kirkpatrick & Kirkpatrick,
2016).
The data analysis questions will center around the four levels; Level 1 Reaction, Level 2
Learning, Level 3 Behavior, and Level 4 Results (Kirkpatrick & Kirkpatrick, 2016). Level 1 will
focus on the participant’s engagement during the program, whether what they learn is relevant to
their job responsibilities and their satisfaction of the program. Level 2 will address what they
learned, and knowledge obtained, how they demonstrate their skills and how their attitude,
confidence and commitment to applying the knowledge they gained from the program. Level 1
and 2 will be obtained during the program and immediately after the program. Level 3 Behavior,
will be obtained every month for six months post training. The mentor or coach assigned to the
participant will complete the delayed survey which addresses observation of critical behaviors.
The feedback data from the coaches and mentors will be used to reinforce what was learned, to
encourage critical behaviors, monitor their progress, and reward the achievement of their goals.
Level 4 Results will involve a focus group of participants that will be asked about their
experience and whether the program helped them reach their goals and coaches and mentors will
be asked if the program is helping the organization meet the targeted outcomes.

188
Communicating the results will not be about the program, but about the success of the
participants because of the observable changes in performance. Propagating positive findings
from the training program and positive findings on the job, will peak interest from others and
will provide feedback to program facilitators on what can make the program impactful.
Data from the research surveys will be compared to the survey results following the
program event, and critical behavior feedback after the six months of coaching and mentoring.
Results will be displayed using meaningful charts which will depict improvement in confidence,
commitment, knowledge and motivation. In addition, patient satisfaction scores and employee
engagement scores will be displayed to show correlation in scores. A graduation event will be
planned to celebrate completion of the course at which time participants of the course will
educate the audience on the program, survey data and the participant’s success.
Summary of the Implementation and Evaluation

The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) will be used to
plan, implement, and evaluate the effectiveness of the training program which is designed to
provide managers and directors the knowledge, motivation and organizational support to develop
and implement an employee engagement program that embraces best practices.
The Kirkpatrick’s four levels of training and evaluation model will be used to maximize
learning, which is intended to improve critical behavior, and subsequently lead to positive
organizational results. The four levels of the New World Kirkpatrick Model (Kirkpatrick &
Kirkpatrick, 2016), is used to measure and determine whether the training program is successful
and whether the managers and directors are engaged in the program, whether they find it
relevant, and whether they are able to transfer skills learned during the program to on the job. In
other words, did the managers and directors find the training favorable, engaging, and relevant to

189
their jobs (Level 1), did they acquiring the intended knowledge, skills, attitude, confidence, and
commitment based on their participating in the training (Level 2), did they apply what they
learned on the job (Level 3), and did targeted outcomes occur as a result of the training (Level 4).
Strengths and Weaknesses of the Approach
The strengths of the Clark and Estes (2008) KMO framework are several; first, it frames
the problem of practice by systematically addressing performance gaps, and second, it
encourages the development and implementation of training and education solutions for each
identified need. Furthermore, the professional development training and education program can
be replicated for different stakeholder groups, thus effecting cultural change throughout the
organization. However, the professional development program comes at a cost upwards of
$400,000/year which includes personnel, facilities, time and equipment. To help executive
leadership understand the value of the program it will be compared to the cost of employee
turnover.
Several assumptions are made to calculate the turnover rate and costs of turnover.
Ballou-Nelson (2019) states turnover rates for employees in a physician’s office range from
9.92% to 20% depending on the position. Therefore 15.25% which represents an average of
these rates was used for this calculation. The costs of turnover per employee range from 20% -
30% of annual salary which averages $12,133.33. Therefore, based on 1000 employees, the
average cost of turnover can be in excess of $1.8M per year as noted in Table 44.

190
Table 44
Costs of Turnover
Positions Turnover Rate
Business operations support staff turnover: 9.92%
Clinical support staff turnover: 15.83%
Front office support staff turnover: 20.00%
Turnover Blended Average 15.25%
Turnover Costs Turnover Cost
(20% of annual pay; $72800 x 20%) $ 14,560.00
(30% of annual pay; $72800 x 30%) $ 21,840.00
Blended Cost of Turnover $ 12,133.33
Cost of Turnover (based on 1000 employees) $ 1,850,333.33
Note. Based on 1000 employees

Therefore, the cost for a professional development program is less and the benefits
outweigh the employee turnover costs. As such, the Clark and Estes (2008) gap analysis
framework which emphasizes education and training, is applicable to the problem of practice and
appropriate for this study.
Limitations and Delimitations
The strength of the KMO framework is also its weakness. A delimitation is the study is
focused on a specific stakeholder group and the recommended solutions are based heavily on the
education and training. This study is focused on the manager and director stakeholder group,
yet there are other stakeholders that can directly affect the success of this group. For instance,
executive leadership and the employees are identified stakeholders that can create intentional or

191
unintentional interruptions preventing success. Each group of stakeholders has accountability
and responsibility to support the managers and directors in meeting performance goals.
Furthermore, the research study is based on one organization. Ideally, to validate the findings, it
would be beneficial to study other academic ambulatory practices. Another delimitation is the
inability for this researcher to conduct the interviews due to the influence of position in the
organization. The inflections in voice and body language are key to understanding when to
probe to get additional information or clarification.
A limitation of the study was the sample size of the survey and interviews. A total of 57
surveys were sent with three reminders over three weeks. The survey yielded 13 responses,
which represents a 22% response rate, and only five individuals volunteered for the interview.
The small sample size of the survey and interview was affected by the 2020 Covid-19 worldwide
pandemic. The survey administration occurred two weeks before California issued the “Stay at
Home” order, and the managers and directors immediately shifted their focus on the safety of
their employees, faculty physicians, and patients. A larger sample size would have been
preferred; however, to mitigate the small sample size, a high threshold was set.
Future Research
This study only begins to scratch the surface of employee engagement. First, Chapter
One describes only one aspect of the problem, yet there are many facets of employee
engagement that can be explored independently. For instance, in an academic setting, the
complicated relationship between the hospital leadership, the faculty physicians, and medical
school create a situation nuanced by politics, competing priorities, and misaligned goals. Each
of these stakeholders can justifiably make a case of how employee engagement and
disengagement affect performance and the ability to meet goals.

192
Second, there are opportunities to further explore the comments made during the
interviews. Specifically, in the section discussing underlying assumptions and the influence of
mutual respect, it would be interesting to explore the comment, “They don’t know what we do.”
These comments can describe a desire to be heard, acknowledged, and recognized, or it can
describe apathy which destroys motivation. A study understanding the psychological and social
processes that begin and sustain motivation is a topic deserving of further research. Moreover,
one of the assets discovered in the study is a culture of autonomy. Going back to the comment,
“They don’t know what we do,” can denote autonomy, which could be considered an asset, yet
in the aspect of respect, it was considered a need. Therefore, an understanding of autonomy,
trust and respect deserves deeper examination.
Last, the limitation presented by the 2020 Covid-19 pandemic introduces a host of
research topics. The research was limited by the small sample size, which was a consequence of
the 2020 Covid-19 pandemic. It would be interesting to understand if the same survey
administered in the future would yield different results. Additionally, overnight the healthcare
industry was overwhelmed with changes that provided opportunities to highlight engaged
employees. Employee engagement in healthcare has been recognized, appreciated, and
celebrated. When the nation needed healthcare workers, they were present, and they performed.
Furthermore, their courage and strength to confront and battle Covid-19 is exemplary,
commendable, and a demonstration of the ultimate engaged employee. However, there are also
many healthcare workers that refused to potentially subject themselves to Covid-19 and refused
to come to the workplace. As such, a study to understand what happened during the crisis, and
the motivating factors that influenced those employees who nonetheless walked into potential
harm, and those that chose not to, could possibly redefine the characteristics of an engaged

193
employee. The crisis of the 2020 Covid-19 pandemic will be a fascinating research study for
future ages.
Conclusion
This case study examines the factors that influence employee engagement in ambulatory
practices in a specific healthcare organization. The purpose is to research the role of the
managers and directors and their ability to increase employee engagement. Using the Clark and
Estes (2018) conceptual framework, the focus was on the knowledge, motivation, and
organization needs and assets that influence the directors and managers to implement an
employee engagement program, and the recommended knowledge, motivation and
organizational solutions for directors and managers to achieve their goal. The findings reveal the
ambulatory care units at this organization have the potential for change that involves all
leadership levels, specifically the managers and directors of the ambulatory work units. The
research highlights employee engagement requires attention, consistency, and commitment.
The proposed solution is a professional development program called GEN!UINE, which
is an acronym for "Get Engaged Now! U Initiate New Experiences (Miguel-Johnson, 2019).
GEN!UINE is a learning program that highlights leadership development through knowledge
and skill-building exercises, and mentoring and coaching by executives who will reinforce the
program's objectives and hold the individuals accountable for meeting their goals. The objective
of the program is to increase employee engagement and increase patient satisfaction. However,
the proximate goal is: (a) to teach the managers and directors about confidence, self-efficacy and
the value of self-reflection, (b) to teach the managers and directors how to use past survey results

194
to build an employee engagement program that they understand, appreciate and value, and (c) to
build an organizational culture of learning, trust, and mutual respect.
This research study started with the case of a nurse who was unengaged and distracted by
an unrelated event, resulting in the patient's death. The other side of the story is that people are
saved each year because of fully engaged healthcare workers. The 2020 Covid-19 pandemic is an
example of a motivated, engaged healthcare workforce that will sacrifice their health for others'
health. The research and findings in this study show that a strong middle-management leadership
team can contribute to the organization's success by having the knowledge, motivation, and
organization support to prevent medical errors, increase patient satisfaction and increase
employee engagement.

195
References
Akker, L. V., Heres, L., Lasthuizen, K., & Six, F. E. (2009). Ethical leadership and trust: It's all
about meeting expectations.
Aller, B. (2019). Vanderbilt Failed To Report Unnatural Patient Death.
https://hospitalwatchdog.org/vanderbilt-med-center-cover-up/.
Altman, J., (2017). How much does employee turnover really cost? Huffington Post
https://www.huffingtonpost.com/entry/how-much-does-employee-turnover-really-
cost_us_587fbaf9e4b0474ad4874fb7
Andel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics of health
care quality and medical errors. Journal of health care finance, 39(1), 39.
Anderman, E. & Anderman, L. (2006). Attributions.

http://www.education.com/reference/article/attribution-theory

Anderman, E., & Anderman, L. (2009). Attribution theory. Education. com, 23.

Anderson-Miles, E. (1994). Benchmarking in healthcare organizations: An introduction.
Healthcare Financial Management, 48(9), 58-61.
Argyris, C., & Schon, D. Organizational learning. 1978. S, 18(24), 26-27.
Bakker, A.B., Demerouti, E., (2007). The job demands–resources model: state of the art. Journal
of Managerial Psychology 22 (3), 309–328.
Bakker, A. B., Schaufeli, W. B., Leiter, M. P., & Taris, T. W. (2008). Work engagement: An
emerging concept in occupational health psychology. Work & Stress,22(3), 187-200.
doi:10.1080/02678370802393649

196
Ballou-Nelson, P. (2019). Employee Turnover – how do you compare? Medical Group
Management Association. https://www.mgma.com/resources/resources/human-
resources/employee-turnover-how-do-you-compare
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, N.J: Prentice-Hall.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Freeman.

Baradarani, S., & Kilic, H. (2018) Service innovation in the hotel industry: culture, behavior,
performance, The Service Industries Journal, 38:13-14, 897-924, DOI:
10.1080/02642069.2017.142017
Bogue, E. G., & Hall, K. B. (2003). Quality and accountability in higher education: Improving
policy, enhancing performance. Greenwood Publishing Group.
Business Reports, (2013). https://www.businessreport.com/article/the-breaking-point-employee-
burnout-and-disengagement-are-on-the-rise
Center for Medicare and Medicaid (2017). https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network
MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf
Center for Medicare and Medicaid (2018). https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Repors/NationalHealthExpendData/NationalHealthAccountsHistorical.html
Clark, R. E. (2003). Fostering the work motivation of individuals and teams. Performance
Improvement, 42(3), 21-29. doi:10.1002/pfi.4930420305
Clark, R.E., & Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions. Charlotte, NC: Information Age Publishing, Inc.

197
Clark, R. E., & Effort, M. M. (2004). What works in distance learning: Motivation strategies.
What works in distance learning: Guidelines. Greenwich, CT: Information Age
Publishers, 89-110.
Clinician and Group Consumer Assessment of Healthcare Providers, (2018).
https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/
Colquitt, J. A., Scott, B. A., & LePine, J. A. (2007). Trust, trustworthiness, and trust propensity:
A meta-analytic test of their unique relationships with risk taking and job performance.
Journal of applied psychology, 92(4), 909.
Creswell, J.W., & Creswell, J.D., (2018). Research design: Qualitative, quantitative, and mixed
methods approaches. Thousand Oaks, CA: Sage Publications.
Czarnowsky, M. (2008). Learning’s role in employee engagement: An ASTD research study.
Alexandria, VA: American Society for Training and Development.
Elflein, J. (2019). Ages of U.S. physicians 2019. Statista.
https://www.statista.com/statistics/415961/share-of-age-among-us-physicians/
Daud-Gallotti, R. M., Morinaga, C. V., Arlindo-Rodrigues, M., Velasco, I. T., Arruda Martins,
M., & Tiberio, I. C. (2011). A new method for the assessment of patient safety
competencies during a medical school clerkship using an objective structured clinical
examination. Clinics, 66(7), 1209–1215. http://doi.org/10.1590/S1807-
59322011000700015
Denler, H., & Wolters, C. Benzon, (2006). Social cognitive theory. The Gale Group.
Department of Health and Human Services. Adverse events in hospitals: national incidence
among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.

198
Dixon, J. Robb, 1994. Business process reengineering: Improving in new strategic directions.
California Management Review 36: 93-108.
Ebrahim, A. (2016). The Many Faces of Nonprofit Accountability. The Jossey‐Bass
Handbook of Nonprofit Leadership and Management, 102-123.
Eccles, J. (2006). Expectancy-value motivational theory.
http://www.education.com/reference/article/expectancy-value-motivational-theory/
Elmore, R. F. (2002). Bridging the gap between standards and achievement: The imperative for
professional development in education. Secondary lenses on learning participant book:
Team leadership for mathematics in middle and high schools, 313-344.
Erez, M., & Gati, E. (2004). A Dynamic, Multi‐Level Model of Culture: From the Micro Level
of the Individual to the Macro Level of a Global Culture. Applied Psychology, 53(4),
583–598. https://doi.org/10.1111/j.1464-0597.2004.00190.x
Firestone, W. A., & Riehl, C. (2005). A new agenda for research in educational leadership. New
York: Teachers College Press.
Gallimore, R., & Goldenberg, C. (2001) Analyzing cultural models and settings to connect
minority achievement and school improvement research. Educational Psychologist,
36(1), 45-56.
Gallup. (2013). State of America Workplace.
http://www.elicitingexcellence.com/documents/State%20of%20the%20American%20Wo
rkplace%20Report%202013.pdf
Gebauer, H., Edvardsson, B., Gustafsson, A., & Witell, L. (2010). Match or Mismatch: Strategy-
Structure Configurations in the Service Business of Manufacturing Companies. Journal
of Service Research, 13(2), 198–215. https://doi.org/10.1177/1094670509353933

199
Gidwani, R., Nguyen, C., Kofoed, A., Carragee, C., Rydel, T., Nelligan, I. (2017). Impact of
scribes on physician satisfaction, patient satisfaction, and charting efficiency: A
randomized controlled trial. Annals of Family Medicine, 15(5), 427–433.
https://doi.org/10.1370/afm.2122
Glesne, C. (2011). Becoming qualitative researchers: An introduction, 4th ed. Boston, Mass:
Pearson.
Harrington, L., Heidkamp, M., (2013). The aging workforce: challenges for the healthcare
industry workforce. The NTAR Leadership Center. Retrieved from
www.dol.gov/odep/pdf/HTAR-AgingWorkforceHealthCare.pdf
Harter, J. K., Schmidt, F. L., & Hayes, T. L. (2002). Business-unit-level relationship between
employee satisfaction, employee engagement, and business outcomes: a meta-analysis.
Journal of applied psychology, 87(2), 268.
Harter, J.K., Schmidt, F.L., Keyes, C.L.M., 2003. Well-being in the workplace and its
relationship to business outcomes: a review of the Gallup studies.
Hatch, M., & Schultz, M. (2002). The Dynamics of Organizational Identity. Human Relations,
55(8), 989–1018. https://doi.org/10.1177/0018726702055008181
Imperatori, B. (2017). Engagement and disengagement at work: drivers and organizational
practices to sustain employee passion and performance. Cham, Switzerland: Springer.
https://doi.org/10.1007/978-3-319-51886-2
Institute for Healthcare Improvement, (2018).
http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

200
Institute of Medicine (US) Committee on the Future Health Care Workforce for Older
Americans. (2008). Retooling for an aging America: Building the health care
workforce. Washington DC: National Academies Press (US). doi:10.17226/12089.
Johnson, G. (2014). Research methods for public administrators. Routledge.
Johnson, L. (2006). “Making Her Community a Better Place to Live”: Culturally Responsive
Urban School Leadership in Historical Context. Leadership and Policy in Schools, 5(1),
19–36. https://doi.org/10.1080/15700760500484019
Kahn, W. A. (1990). Psychological conditions of personal engagement and disengagement at
work. Academy of Management Journal, 33(4), 692.
Kahn, W.A., 1992. To be fully there: psychological presence at work. Human Relations 45 (4),
321–349.
Kaiser Foundation, (2017). Total Health Care Employment https: kff.org
Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick's four levels of training evaluation.
Association for Talent Development.
Kohn, L. T. (1999). To err is human: building a safer health system. Washington: National
Academy Press.
Krathwohl, D.R. (2002). A revision of Bloom’s taxonomy: An overview. Theory into Practice,
41(4), 212-218.
Krosgaard, M. A., Brodt, S. E., & Whitener, E. M. (2002). Trust in the face of conflict: The role
of managerial trustworthy behavior and organizational context. Journal of Applied
Psychology, 87(2), 312-319. doi:10.1037//0021-9010.87.2.312
Lowe, G. (2012). How employee engagement matters for hospital performance. Healthcare
Quarterly, 15(2), 29-39

201
Lu, D. W., Dresden, S., McCloskey, C., Branzetti, J., & Gisondi, M. A. (2015). Impact of
burnout on self-reported patient care among emergency physicians. Western Journal of
Emergency Medicine, 16(7), 996–1001. http://doi.org/10.5811/westjem.2015.9.27945
Luthans, F., & Peterson, S. (2002). Employee engagement and manager self-efficacy. Journal of
Management Development, 21(5), 376–387. https://doi.org/10.1108/02621710210426864
Macey, W., & Schneider, B. (2008). The Meaning of Employee Engagement. Industrial and
Organizational Psychology, 1(1), 3–30. https://doi.org/10.1111/j.1754-9434.2007.0002.x
Makary, M. A., Daniel, M. (2016). Medical error-the third leading cause of death in the US.
BMJ: British Medical Journal (Online), 353 doi:http://dx.doi.org./10.1136/bmj.i2139
Mallak, L. A., Lyth, D. M., Olson, S. D., Ulshafer, S. M., & Sardone, F. J. (2003). Culture, the
built environment and healthcare organizational performance. Managing Service Quality,
13(1) doi:http://dx.doi.org.libproxy2.usc.edu/10.1108/09604520310456690
Markos, S., & Sridevi, M. (2010). Employee engagement: The key to improving performance.
International Journal of Business Management, 5(12), 90-96.
Maslach, C., Leiter, M., (1997). The Truth About Burnout. Jossey- Bass, San Francisco
Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual review of
psychology, 52(1), 397-422.
Matziari, A., Montgomery, A.J., Georganta, K., & Dougouleri, K. (2017). The Relationship
Between Organizational Practices and Values with Burnout and Engagement, Current
Psychology (2017) 36: 276.
Maxwell, J.A. (2013). Qualitative Research Design. Thousand Oaks, CA: Sage Publications.

202
May, D. R., Gilson, R. L., & Harter, L. M. (2004). The psychological conditions of
meaningfulness, safety and availability and the engagement of the human spirit at work.
Journal of occupational and organizational psychology, 77(1), 11-37.
Mayer, R. E. (2011). Applying the science of learning. Boston, MA: Pearson/Allyn & Bacon.
McCrudden, M. T., Schraw, G., & Hartley, K. (2006). The effect of general relevance
instructions on shallow and deeper learning and reading time. The Journal of
Experimental Education, 74(4), 291-310.
Merton, R. (1957). The Role-Set: Problems in Sociological Theory. The British Journal of
Sociology, 8(2), 106-120. doi:10.2307/587363
Merriam, S. B., & Tisdell, E. J. (2017). Qualitative research: A guide to design and
implementation. Vancouver, B.C.: Langara College.
Miguel-Johnson, L. (2019). GEN!UINE. Unpublished manuscript. Keck Medicine of University
of Southern California.
National Library of health Institute of Health. (2010).
Padgett, J., Cristancho, S., Lingard, L., Cherry, R., & Haji, F. (2018). Engagement: What is it
good for? The role of learner engagement in healthcare simulation contexts. Advances in
Health Sciences Education. doi:10.1007/s10459-018-9865-7
Pajares, F. (2006). Self-Efficacy theory. http://www.education.com/reference/article/self-
efficacy-theory/
Parsons, T. (1961). Theories of society foundations of modern sociological theory.
Pech, R., Slade, B. (2006). “Employee disengagement: is there evidence of a growing problem?”
Handbook of Business Strategy, 7(1), 21-25.

203
Pekrun, R., Goetz, T., Frenzel, A., Barchfeld, P., & Perry, R. (2011). Measuring emotions in
students’ learning and performance: The Achievement Emotions Questionnaire (AEQ).
Contemporary Educational Psychology, 36(1), 36–48.
https://doi.org/10.1016/j.cedpsych.2010.10.002
Peltier, J., Dahl, A., Mulhern, F. (2009). The relationship between employee satisfaction and
hospital patient experiences. In Forum: For People Performance Management and
Measurement.
Physician Shortage and Projections. (n.d.).
https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.ht
ml
Pintrich, P. R. (2003). A motivational science perspective on the role of student motivation in
learning and teaching contexts. Journal of educational Psychology, 95(4), 667.
Press Ganey (2018). http://www.pressganey.com/docs/default-source/default-document-
library/the-key-to-a-high-performing-workforce.pdf?sfvrsn=0
Rath, T., & Conchie, B. (2009). Strengths based leadership.
Reina, C., Rogers, K., Peterson, S., Byron, K., & Hom, P. (2018). Quitting the Boss? The Role of
Manager Influence Tactics and Employee Emotional Engagement in Voluntary Turnover.
Journal of Leadership & Organizational Studies, 25(1), 5–18.
https://doi.org/10.1177/154805181770900
Rubin, H.J., & Rubin, I.S. (2012). Chapter 6: Conversational partnerships. In Qualitative
interviewing: The art of hearing data(3rded.) (pp. 85-92). Thousand Oaks, CA: SAGE
Publications.

204
Rueda, R. (2011). The 3 dimensions of improving student performance. New York: Teachers
College Press.
Saks, A. M. (2006). Antecedents and consequences of employee engagement. Journal of
managerial psychology.
Savič, B., & Pagon, M. (2008). Individual involvement in health care organizations: differences
between professional groups, leaders and employees. Stress and Health., 24(1), 71–84.
https://doi.org/10.1002/smi.1164
Schein, E. H. (1985). Defining organizational culture. Classics of organization theory, 3(1), 490-
502.
Schein, E. H. (2004). Organizational culture and leadership. San Francisco: Jossey-Bass.
Schein, E.H., Schein, P. (2017). Organizational culture and leadership, 5th edition. San Francisco:
Jossey-Bass.
Schön, D., & Argyris, C. (1996). Organizational learning II: Theory, method and practice.
Reading: Addison Wesley, 305(2).
Schunk, D. H. (1991). Self-efficacy and academic motivation. Educational psychologist, 26(3-4),
207-231.
Schwandt, D. R., & Marquardt, M. J. (2000). Organizational learning: From world-class
theories to global best practices. Boca Raton, FL: St. Lucie Press.
Scherer, K. R. (2009). The dynamic architecture of emotion: Evidence for the component
process model. Cognition and emotion, 23(7), 1307-1351.
SCORE Survey (2016). www.swscn.org.uk/wp/wp-content/.../Safety-Culture-
information_final_10Feb16.pdf

205
Scotti, D., Harmon, J., & Behson, S. (2007). Links among high-performance work environment,
service quality, and customer satisfaction: An extension to the healthcare sector. Journal
of Healthcare Management/American College of Healthcare Management/American
College of Healthcare Executives, 52(2),109-124.
Seijts, G. H., & Crim, D. (2006). What engages employees the most or, the ten C’s of employee
engagement. Ivey Business Journal, 70(4), 1-5.
Senge, P. M. (1990). The leaders new work: Building learning organizations. Cambridge, MA:
Sloan Management Review.
Sherman, E. (2019) U.S. Health Care Cost Skyrocketed to $3.65 Trillion in 2018. Fortune.
http://fortune.com/2019/02/21/us-health-care-costs-2/
Sherwood, R. (2013). Employee engagement drives health care quality and financial returns.
Harvard Business Review. https://hbr.org/2013/10/employee-engagement-drives-health-
care-quality-and-financial-returns
Shuck, B., & Wollard, K. (2010). Employee engagement and HRD: A seminal review of the
foundations. Human Resource Development Review, 9(1), 89-110.
Simpson, M. R. (2009). Engagement at work: A review of the literature. International journal of
nursing studies, 46(7), 1012-1024.
Simon, M. (2011). Assumptions, limitations and delimitations.
Sirkin, H. L., Keenan, P., & Jackson, A. (2005). The hard side of change management. HBR’s 10
Must Reads on Change, 99.
Steinbrook, R. (2009). Health Care and the American Recovery and Reinvestment Act. The New
England Journal of Medicine, 360 (11), 1057–1060.
https://doi.org/10.1056/NEJMp0900665

206
Tax Policy Center. (2020). https://www.taxpolicycenter.org/briefing-book/how-much-does-
federal-government-spend-health-care
Tompkins, C.P., Higgins, & A.R., Ritter, G.A., (2009). Measuring outcomes and efficiency in
Medicare Value-Based Purchasing. Health Affairs 8 (2): Stimulating Health IT.
doi.org/177/hlthaff.28.2.w251.
Tracy, S. K. (2013). Qualitative research methods: Collecting evidence, crafting analysis,
communicating impact. Chichester: Wiley-Blackwell.
Tucker, E. (2017). Engaging employees: Three critical roles for managers. Strategic HR Review,
16(3), 107-111.
U.S. Bureau of Labor Statistics (2014). https://www.bls.gov/careeroutlook/2014/spring/art03.pdf
U.S. Bureau of Labor Statistics (2019) https://www.bls.gov/emp/tables/employment-by-major-
industry-sector.htm
Vance, R. J. (2006). Employee engagement and commitment. SHRM foundation, 1-53.
Vespa, J., Armstrong, D., & Medina, L. (2018). Demographic Turning Points for the United
States: Population Projections for 2020-2060.
Waters, T., Marzano, R. J., & McNulty, B. (2003). Balanced leadership: What 30 years of
research tells us about the effect of leadership on pupil achievement. A working paper.
Weiner, B. (1985). An attributional theory of achievement motivation and emotion.
Psychological Review, 92, 548-573.
West, M., & Dawson, J. (2012). Employee engagement and NHS performance. The King’s Fund
1, 23

207
Wood, R.E., Bandura, A., & Bailey, T. (1990). Mechanisms governing organizational
performance in complex decision-making environments. Organizational Behavior and
Human Decision Processes, 46, 181‑201. https://doi.org/10.1016/0749-5978(90)90028-8

208
Appendix A
Immediate Evaluation Tool
Participant Evaluation

Date _________________

Instructions
For questions 1 – 5, please use the following rating scale:

0 Strongly disagree 10 Strongly agree

Please circle the appropriate rating to indicate the degree to which you agree with the statement
and provide comments to explain your answer.
Rating
Strongly disagree Strongly agree

0 1 2 3 4 5 6 7 8 9 10 1. I took responsibility for being
involved in the program.
Comments

0 1 2 3 4 5 6 7 8 9 10 2. This program held my interest.
Comments

0 1 2 3 4 5 6 7 8 9 10 3. The presentation style of the facilitator
contributed to my learning experience.

209
Comments

0 1 2 3 4 5 6 7 8 9 10 4. The information in this program is
applicable to my work.
Comments

For questions 6 - 10, please use the following rating scale:

1 2 3 4 5
None or Very Very High Level
Low Level

Please circle the appropriate rating before the training and now (after the training) and please
provide comments to explain your ratings.

Before the
Training
After the Training
1 2 3 4 5 5. Understanding of employee engagement and
why it is important.
1 2 3 4 5
Comments
1 2 3 4 5 6. How to build an employee engagement
program.
1 2 3 4 5

210
Comments
1 2 3 4 5 7. My confidence level in building an employee
engagement program.
1 2 3 4 5
Comments
1 2 3 4 5 8. My role and how I impact employee
engagement.
1 2 3 4 5
Comments
1 2 3 4 5 9. How my goals align with the mission, values
and goals of the organization.
1 2 3 4 5
Comments
1 2 3 4 5 10. My understanding of how the organization
supports my efforts and my accountability to meet
my goals.
1 2 3 4 5
Comments
1 2 3 4 5 11. There is a culture of mutual trust to support
my efforts in developing an employee
engagement program.
1 2 3 4 5
Comments

211
Appendix B

Delayed Feedback

Please indicate if Mentee has displayed these behaviors by checking the appropriate box.
Y - Yes Observed; P - Partial Observation; N- Not Observed
Critical Behavior Y P N Comments/
Feedback/Goals for next session
Manager or Director has developed an
employee engagement plan with goals
and targeted outcomes.

Manager or Director is able to verbalize
the mission, value and goals of the
organization and can describe how their
goal to build an employee engagement
program aligns with the overall goals of
the organization.

Manager or Director has developed
processes that reinforce, monitor and
reward employee engagement.

Managers and Directors are confident in
their ability and skills to develop, and
implement an employee engagement
program and meet the targeted outcomes.

Managers and Directors understand self-
reflection and can verbalize what they are
learning from the training event and
activities post the training event.

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Winning the organizational leadership game through engagement: a gap analysis

PDF

Role ambiguity and its impact on nonprofit board member external responsibilities: a gap analysis

PDF

The successful implementation of diversity and inclusion efforts: a study of promising practice

PDF

Exploring mindfulness with employee engagement: an innovation study

PDF

Improving veterans employment outcomes through increasing enrollment in vocational rehabilitation and employment program

PDF

The role of middle manager alignment in achieving effective strategy execution: an evaluation study

PDF

Mitigating low employee engagement through improved performance management: an evaluation study

PDF

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

PDF

The moderating role of knowledge, motivation, and organizational influences on employee turnover: A gap analysis

PDF

Enhancing socially responsible outcomes at a major North American zoo: an innovation study

PDF

Increasing engagement and avoiding burnout of counselors of at-promise youth: a gap analysis approach for supervisors

PDF

Case study in improving staff engagement and job satisfaction in a school of business

PDF

Achieving high levels of employee engagement: A promising practice study

PDF

Employee engagement and leadership collaboration: a gap analysis of performance improvement teams in healthcare

PDF

Analyzing the implementation of a learning management system into a post-merger & acquisition organization and its effects on sales performance (improvement model)

PDF

Leadership education and development that incorporates e-leadership: the “e” factor in leading in an electronic (virtual) work environment

PDF

One to one tablet integration in the mathematics classroom: an evaluation study of an international school in China

PDF

Addressing service recovery with radiation oncology frontline managers to improve the patient experience: an evaluation study

PDF

Transportation security officer engagement in the Transportation Security Administration: a study of a promising practice

PDF

Developing and retaining employees: exploring talent management initiatives for enlisted women

Asset Metadata

Creator Miguel-Johnson, Laurie M. (author)

Core Title Middle-management's influence on employee engagement in the ambulatory practices

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 07/16/2020

Defense Date 06/22/2020

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

Tag ambulatory employee engagement,employee engagement,healthcare disengaged employees,healthcare employee engagement,OAI-PMH Harvest,patient satisfaction

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth (committee chair), Sparangis, Themistocles (committee member), Tobey, Patricia (committee member)

Creator Email huladiver@aol.com,Laurie.Johnson@med.usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-331440

Unique identifier UC11665955

Identifier etd-MiguelJohn-8686.pdf (filename),usctheses-c89-331440 (legacy record id)

Legacy Identifier etd-MiguelJohn-8686.pdf

Dmrecord 331440

Document Type Dissertation

Rights Miguel-Johnson, Laurie M.

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