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Creating a culture of connection: employee engagement at an academic medical system

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Creating a culture of connection: employee engagement at an academic medical system

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Creating a Culture of Connection:
Employee Engagement at an Academic Medical System

by

David Simpson

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 David John Simpson

ii
Acknowledgements
This study is the product of many individuals and groups, to whom I owe a debt of
gratitude. The study was completed in the midst of the COVID-19 pandemic, and in an academic
medical center that serves patients infected with the disease. Thank you to all of our caregivers in
healing humanity throughout the world. I wish to thank the clinical managers who participated in
the study. Clinical managers have wide spans of control, and ensure the safety, quality, and
access to healthcare services to all patients. Clinical managers took time to discuss the culture of
connection at DCNC and provided moving stories of how they are lifting the performance and
fulfillment of staff members, in service of patient care. Thank you, clinical managers, for your
time and your commitment to discovery and health.
I deeply appreciate and thank the outstanding cohort of learners and leaders who
motivated me, and taught me life lessons about organization change, leadership, diversity, and
accountability. Learning with accomplished scholar–practitioners in Cohort 10 was a privilege.
We learned from the venerable faculty at the University of Southern California, Rossier School
of Education, without whom, this study would not have been accomplished. I will look back on
the challenging lessons from Dr. Lynch, Dr. Ott, Dr. Combs, Dr. KK, Dr. Kim, and Dr. Phillips
with fondness and gratitude. I would also like to thank my dissertation committee, Dr. Courtney
Malloy, Dr. Kathy Stowe, and Dr. Wayne Combs, who coached me on creating the best
argument for the study and challenged me to think beyond my parochial thinking. After many
false starts and drafts, my committee chair, Dr. Malloy, gently guided me through the
dissertation process and content. Dr. Malloy taught me through feedback, helping me understand
scholarship and methodology for investigating leadership and change. Dr. Malloy, thank you for
your practicality, patience, humor, and recommendations throughout this journey.

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To my family, who quietly accepted my absences at holidays and gatherings. You
enthusiastically asked me how my studies were going when I joined you, and endured as I
discussed too many details of the study. To my mother, whose joie de vivre helped me accept
whatever life threw to me; to my wife’s father, Dr. Poppe, who was an inspirational beacon for
academic and real-world excellence; to Samantha, for encouraging me throughout the doctoral
process, as a fellow student, cheerleader, and loving daughter: thank you all. Lastly, to my wife,
Susan, who walked, sat, and worked alongside me for 3 years on weekends and nights, never
once wavering from her support of my academic pursuit: this study is dedicated to you, Susan.
Thank you for being my wise teacher.

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Table of Contents
Acknowledgements ........................................................................................................................ ii
List of Tables ................................................................................................................................ vii
List of Figures .............................................................................................................................. viii
Abstract ........................................................................................................................................... ix
Chapter 1: Introduction .................................................................................................................... 1
Introduction to the Problem of Practice ................................................................ 1
Organization Context and Mission ........................................................................ 2
Organizational Performance Status ....................................................................... 2
Related Literature .................................................................................................. 4
Importance of Addressing the Problem ................................................................. 6
Description of the Stakeholder Groups ................................................................. 8
Stakeholder Group for the Study ........................................................................... 9
Purpose of the Project and Questions .................................................................... 9
Methodological Framework ................................................................................ 10
Definitions ........................................................................................................... 11
Organization of the Project ................................................................................. 11
Chapter 2: Review of the Literature .............................................................................................. 12
Employee Engagement as a Construct ................................................................ 13
Employee Engagement Definition ............................................................ 13
External Factors Leading to Engagement .................................................. 14
Job Demands ................................................................................. 14
Job Resources ................................................................................ 15
Internal Factors Leading to Engagement ................................................... 16
Leadership Theory and Employee Engagement ................................................. 17
Transformational Leadership ..................................................................... 18
Leader–Member Exchange Theory ........................................................... 19
Relational Leadership ................................................................................ 20
Culture of Connection ............................................................................... 20
Strengths-Based Theory ...................................................................................... 21
Engagement in Healthcare .................................................................................. 23
Employee Engagement Trends in Health Care ......................................... 24
Rising Costs and Pressure to Decrease Expenditures .................... 24
Technical, Demographic, and Time Acceleration ......................... 25
Consequences of Low Engagement ........................................................... 25
Common Approaches to Increasing Engagement ..................................... 26
The Clark and Estes Gap Analytic Conceptual Framework ............................... 28
Knowledge and Skills ................................................................................ 28
Declarative Knowledge Regarding Employee Engagement, Its
Importance, and Strengths-Based Theory ..................................... 29

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Procedural Knowledge Regarding How to Use the Check-In
System ........................................................................................... 31
Metacognitive Knowledge Regarding Relationships and
Leadership Style ............................................................................ 31
Motivation ................................................................................................. 32
Purpose and Meaningfulness ......................................................... 33
Goal Orientation Theory ................................................................ 34
Organization .............................................................................................. 35
Leader Support .............................................................................. 36
Organization Support ..................................................................... 37
Psychological Safety ..................................................................... 38
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and
Motivation and the Organizational Context ........................................................ 40
Conclusion ........................................................................................................... 43
Chapter 3: Methodology ................................................................................................................ 44
Methodological Approach and Rationale ............................................................ 44
Participating Stakeholders ................................................................................... 45
Interview Sampling Criteria and Rationale ............................................... 45
Criterion 1: Department ................................................................. 45
Criterion 2: Adoption Rate ............................................................ 45
Criterion 3: Tenure ........................................................................ 45
Interview Recruitment Strategy and Rationale .......................................... 46
Interviews .................................................................................................. 46
Data Analysis ...................................................................................................... 47
Credibility and Trustworthiness .......................................................................... 49
Ethics ................................................................................................................... 52
Limitations and Delimitations ............................................................................. 54
Chapter 4: Results and Findings .................................................................................................... 56
Participating Stakeholders ................................................................................... 56
Interview Participants ................................................................................ 57
Results and Findings ........................................................................................... 60
Research Question 1 .................................................................................. 60
Knowledge Results ........................................................................ 60
Motivation Results ......................................................................... 74
Research Question 2 .................................................................................. 85
Organization Results ..................................................................... 85
Research Question 3 .................................................................................. 96
Knowledge Barriers ....................................................................... 96
Motivation Barriers ....................................................................... 97
Organization Barriers .................................................................... 98
Research Question 4 ................................................................................ 101
Recommendations ....................................................................... 101
Additional Insights ............................................................................................ 104
Check-Ins Outside of the Electronic Platform ......................................... 104
In-Group and Out-Group ......................................................................... 105

vi
Synthesis and Conclusion ................................................................................. 105
Chapter 5: Recommendations for Practice to Address KMO Influences .................................... 108
Introduction and Overview ............................................................................... 108
Knowledge Recommendations ................................................................ 108
Motivation Recommendations ................................................................. 112
Introduction ................................................................................. 112
Strategies for Improving Motivation ........................................... 114
Organization Recommendations ............................................................. 116
Introduction ................................................................................. 116
Implications for Human Capital Management .................................................. 121
Organization Change ............................................................................... 121
Accountability ......................................................................................... 123
Diversity .................................................................................................. 124
Implications for Future Research ...................................................................... 125
Privilege, Status, and Intersectionality .................................................... 125
In-Group and Out-Group ......................................................................... 126
Hidden Teams and Team Leaders ........................................................... 128
Conclusion ......................................................................................................... 129
References ................................................................................................................................... 131
Appendix A: Survey Questions ................................................................................................... 148

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List of Tables
Table 1 Knowledge Types and Influencers .................................................................................. 32
Table 2 Motivational Influences ................................................................................................... 35
Table 3 Organization Influences .................................................................................................. 39
Table 4 Respondent Check-in Adoption, Location, and Function ............................................... 57
Table 5 Tenure and Span of Control ............................................................................................ 59
Table 6 Pseudonyms of Interview Participants ............................................................................ 59
Table 7 Distribution of Factual Knowledge about Strengths, Check-ins, and Engagement ........ 62
Table 8 Value and Meaning Placed on Check-ins ........................................................................ 75
Table 9 Summary of Knowledge Influences and Recommendations ......................................... 108
Table 10 Summary of Motivation Influences and Recommendations ....................................... 113
Table 11 Summary of Organization Influences and Recommendations .................................... 117

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List of Figures
Figure 1 Conceptual Framework ................................................................................................... 41

ix
Abstract
This study applies job demands–resources (JD–R) theory, leader–member exchange
theory (LMX), and strengths–trait theory from academic literature to understand the conditions
and behaviors that support the successful adoption of the clinical manager and staff check-ins at
an academic medical center. The purpose of this study was to determine the knowledge,
motivation, and organization (KMO) influences that were assets for clinical managers who
achieved the organization goal of 60% check-in rates, as well as to identify barriers to goal
attainment, and recommendations to close the gap between performance and goal outcomes
within the organization. From a database of 400 clinical managers, KMO influences were
assessed using a maximum variation sampling approach to understand factors that influence
high-performing managers and managers who were not achieving their check-in goals. Fifteen
clinical managers were interviewed. Content analysis was employed to analyze the data.
Findings from this study confirmed KMO assets held by high-adoption managers, and KMO
needs of low-adoption managers. Knowledge of strengths and coaching to strengths were assets
for high-adoption managers. The high-adoption managers placed greater meaning and purpose
on the check-in process and sought to learn how to implement employee check-ins to improve
teamwork. High-adoption managers also enjoyed greater supervisory support to encourage
check-in adoption. This study illustrates the complexity of introducing transformational change
into organizations, which have implications for human capital management: attending to the
transformational nature of change, accountability structures, and planning for diversity and
inclusion.

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Chapter 1: Introduction
Introduction to the Problem of Practice
Abraham Maslow (1970) wrote, “What a man can be, he must be” (p. 46). Maslow, a
humanistic psychologist, influenced many future scholars from the 1960s through the 1980s,
including organization psychologist William Kahn. Kahn (1990) was one of the first scholars to
coin the phrase “Employee engagement” (p. 694). Kahn (1990) found accessing one’s “true
personal self” (p. 694) at work, allows one’s natural energy, empathic connection, and cognitive
absorption to grow and improve an individual’s effectiveness. Since Kahn published the seminal
article, scholars, consultants, and organizations have pursued strategies for improving employee
engagement in service of improved organization outcomes.
Employee engagement is a mental state that is first experienced as meaningfulness,
mutual trust, and psychological safety, which gives rise to a sense of vigor, commitment, and
flow (Csikszentmihali, 1990; Kahn, 1990; Schaufeli, Bakker, & Salanova, 2006; Schaufeli,
Salanova, Gonzalez-Roma, & Bakker, 2002). According to Gallup (2017), only 33% of
American employees say that they are engaged. In health care environments, low engagement
can lead to burnout (Bodenheimer & Sinsky, 2015; Zarei, Khakzad, Reniers, &Akbari, 2016),
which is associated with lower levels of empathy, reduced adherence to treatment plans, and a
rise in errors (Bodenheimer & Sinsky, 2015). Organizations are employing several methods for
improving employee engagement and reducing its concomitant costs, with varying levels of
success. Methods employed to improve engagement range from improved benefits and work
environment, and additional resources. (Christian, Garza, & Slaughter, 2011; Saks, 2017) This
dissertation focuses on an employee engagement strategy that an academic health system uses
with a focus on employee strengths and manager and employee relationships.

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Organization Context and Mission
The organization under study is Discovery, Compassion, and New Connections (DCNC),
a pseudonym for an academic health system. DCNC is ranked in the top 25 organizations in the
US News and World Report’s (2018) list of top hospitals in the United States. The main hospital
is located in the western United States and has expanded over the last 5 years to include four
other healthcare centers, as well as dozens of primary clinics throughout a radius of 200 miles,
and over 5,000 employees in the DCNC hospital. DCNC’s mission is to improve health through
discovery and care, and its purpose is to translate research into clinical use, prepare future
leaders of medicine, and improve health in the community.
Organizational Performance Status
In alignment with the mission and priorities of the organization, the organization’s goals
are focused on quality, patient satisfaction, employee engagement, and financial strength. Much
of the executive staff left the organization in 2017 and a new group of executives joined DCNC.
One of their first actions was to connect the goals to the mission by a widely communicated
equation: E(QxP)/C. “E” stands for employee engagement, “Q” for quality, “P” for patient
satisfaction, and “C” for cost. The employee engagement goal is a recent addition and executives
believe that engaged employees find ways to reduce cost and improve patient safety. The goals
are reported on an executive dashboard each month and performance is showcased at the DCNC
monthly meeting for all managers.
DCNC uses a short quarterly engagement survey to assess employee engagement.
Managers are expected to do one thing to improve engagement: discuss their staff members’
experience of prior week’s work, and their priorities for upcoming week. This weekly discussion
is called a “check-in,” and it is facilitated by an online platform wherein staff members answer

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six questions, and managers respond, either online or face to face. The employee engagement
goal for the organization is to achieve 60% check-in rates. Current performance levels across
DCNC is 40% each month compared to the 60% goal, resulting in a gap of up to 20% each
month. Following is a list of check-in statements.
1. Last week I contributed outstanding value to my work by . . .
2. Last week, I used my strengths every day to . . .
3. Last week, I loved . . .
4. Last week, I loathed . . .
5. Priorities for next week were . . .
6. I need the following help from my manager: . . .
(The statements are paraphrased rather than verbatim to maintain the confidentiality of the
organization.)
Before launching the engagement pulse and check-in process, employees took a strengths
assessment called “StandOut 2.0” (Buckingham, 2015), which identified two strengths for each
employee. Currently, 88% of all 13,000 employees have taken the strengths assessment (DCNC
internal presentation, 2019). Strengths, or natural talents (Buckingham & Clifton, 2001), can be
developed through awareness and effort (Biswas-Diener, Kashdan & Minhas, 2011). DCNC
leaders are expected to use their knowledge of their subordinates' strengths to provide useful
feedback when subordinates check-in weekly. Ghielen, van Woerkom, and Meyers (2018)
suggested that a leader must understand one’s strengths before moving to the next step of
encouraging strengths in others. Therefore, developing self-awareness is a vital step in the
learning process and must be developed before learners can transfer their knowledge to others

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(Higgs & Rowland, 2010). Leaders were provided training to help them develop self-awareness
of their strengths.
Team leaders receive training and online coaching tools to provide them with the
knowledge and skills to meet their 60% check-in goal. Team leaders receive a 6-hour training
course to help them to understand their strengths as well as to understand other topics such as
check-ins and engagement pulses. After training, team leaders have an opportunity to learn more
about their strengths by having a one-on-on follow up “strengths discussion” with their manager.
The electronic tool used for check-ins also provides leaders with strengths-based coaching tips.
Essential factors in this study are to understand the leaders’ understanding of their strengths, and
their experience in coaching subordinates on their strengths. As the check-in performance gap
indicates, stronger or additional interventions are needed.
Related Literature
Employee engagement has been described as a state of mind rather than a trait (Christian
et al., 2011). Scholars define engagement in terms of cognitive, emotional, and motivational
factors. The cognitive states of engagement include vigilance (Kahn, 1990) and absorption
(Schaufeli et al., 2002). Emotional states are described as elevated energy and vigor (Maslach,
Schaufeli, & Leiter, 2001). Motivational factors are described as commitment (Schaufeli et al.,
2002), involvement (Kahn, 1990), and investment (Christian et al. 2011). Antecedents to the
state of engagement include feelings of trust, meaningfulness, and an assessment of high
psychological safety (Saks, 2006). Upon experiencing engagement, employees might experience
positive feelings, a sense of fulfillment, and efficacy (Maslach & Leiter (2008); Schaufeli et al.,
2002). For this study, employee engagement is viewed as a mental state that is first experienced

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as trust, meaningfulness, and psychological safety, which gives rise to a sense of vigor,
commitment, and flow (Csikszentmihali, 1990; Kahn, 1990; Schaufeli et al., 2002).
Saks (2006) argued that engagement occurs only when employees feel a sense
meaningfulness in their work, trust their manager and colleagues, and psychological safety (Saks
2006). Meaningfulness is an important antecedent, as individuals who are more connected with
an organization’s purpose tend to be more engaged and satisfied (Judge, Bono, Erez & Locke,
2005; Kahn, 1990). Trust plays a part, in that people want to have satisfying, trusting
relationships with their manager and peers (Deci & Vansteenkiste, 2004; Edmundson, 2016). In
addition, psychological safety is the sense that one can express oneself without fear of negative
consequences to esteem or career (Edmundson, 2016; Kahn, 1990). Each of these three
characteristics leads to the core of employee engagement: vigor, commitment, and absorption, or
flow.
When individuals feel a sense of meaningfulness, trust, and psychological safety, a state
of vigor, commitment, and flow arise, which forms the core of employee engagement. Vigor is
experienced when one feels high levels of energy, allowing one to persist in the face of obstacles
(Saks, 2014). Commitment refers to being dedicated to one’s work, generating feelings of pride
and satisfaction with achievement (Saks, 2014). Flow is characterized by absorption in one’s
work, with time passing quickly, and an elevated sense of self-efficacy (Csikszentmihali, 1990;
Saks, 2014).
The job demands–resource (JD–R) theory provides a framework from which to examine
the antecedents of the states that give rise to employee engagement. When job demands (e.g.,
intricate work, sick patients, time pressure, and quality concerns) mount, high worker
engagement is achievable if a worker can access available resources (Bakker, 2017). In turn,

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high engagement acts as a mediator to job performance and outcomes. According to Halbesleben
(2010), job resources (e.g., social support, feedback, task significance, and positive supervision)
are the most salient positive predictors of work engagement. Fairhurst (1993) saw leader–
subordinate communication as an essential resource for subordinates, and high-quality
communication within this dyad produces greater trust, influence, and satisfaction.
Although the quality of leader–subordinate communication has been widely studied (Fix
& Sias, 2016), the quantity or frequency of leader–subordinate communication and its effect on
employee engagement has been less researched. Robinson, Perryman, and Hayday (2004)
demonstrated that higher levels of engagement were achieved by allowing more opportunities for
upward feedback from subordinate to leader. Treadway et al. (2006) asserted that increased
interaction frequency increases trust, and that higher quality of contact between leaders and
subordinates might also reduce uncertainty about organization change and increase subordinate’s
trust in the organization. Sias (2005) showed that higher quality relationships between leaders
and subordinates are associated with both the quantity and quality of information that employees
receive. Jian and Dalisay (2017) found that higher levels of communication frequency
significantly corresponded to high-quality relationships. However, the measure was based on the
respondent’s judgment of frequency versus a numerical indicator. This research is salient to the
current study’s focus on frequent leader–subordinate check-ins and communication.
Importance of Addressing the Problem
It is essential to examine this organization’s performance concerning its performance
goal of frequent clinical manager and staff check-ins for a variety of reasons. Perhaps most
importantly, low engagement contributes to burnout (Perlo, Balik, Swensen, Kabcenell, &
Landsman, 2017). Researchers have become alarmed about the impact of burnout on patient

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safety and cost, and have widely studied physician, surgeon, and nurse burnout over the last
decade (Lucian Leape Institute, 2013). Burnout has been conceived as a condition or syndrome
expressed by emotional exhaustion, detachment from others, loss of meaning in work, and
feelings of inadequacy or ineffectiveness (Font, Corti, & Berger, 2015; Shanafelt, Hasan, Drybe,
Sinsky, Satele, Slone, & West, 2015). Burnout is associated with lower levels of empathy and
mistakes (Bodenheimer & Sinsky, 2014), and it is critical when healthcare workers experience it,
for quality of care and patient experience of their care can decline (Zarei et al., 2016). Burnout
can contribute to suicidal thoughts; a 2016 report roughly 400 physicians commit suicide
annually (Shanafelt, Balch, Bechamps, Russell, Dyrbye, Satele, Collicott, Novotny, Sloan, and
Freischlag, 2010). Patients also bear the brunt of burned-out providers. Shanafelt et al. (2010)
found that 8.9% of surgeons had made a significant medical error in the last 3 months. The
surgeons attributed more than 70% of the cases to individual error, and the errors were strongly
related to the surgeon’s degree of burnout. Nurses too, suffer from burnout, leading to errors
causing severe harm or even death (Halbesleben, Wakefield, Wakefield, & Cooper, 2008).
In addition to the correlation between high engagement and low burnout (Perlo et al.
2017), low engagement can lead to a lack of motivation and commitment (May, Gilson, &
Harter, 2004). Work that feels meaningless or futile can lead to apathy and detachment from
work tasks and relationships (May et al., 2004). Employees with high engagement, in contrast,
tend to experience high levels of energy, commitment, and focus (Schaufeli et al., 2006). In a
correlational analysis, DCNC demonstrated (in an internal document, “Impact of check-ins on
engagement”) that DCNC staff who check-in 60% of the time also report twice the levels of
engagement as those who did not (53% vs. 26%), which suggests that frequent check-ins might
be an essential remedy to the personal and patient risks associated with low engagement.

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Description of the Stakeholder Groups
Several groups have a stake in improving employee engagement at DCNC. The three
stakeholder groups within DCNC who have the most direct effect on patient care are clinical
managers, clinical staff, and executives. The term “clinical” means that staff and managers are
directly responsible for patient care (Merriam-Webster, 2019).
Clinical managers include anyone who has responsibility for leading a team of people in
the service of patient care. Clinical managers are concerned with cost, adherence to government
and professional accrediting body requirements, patient satisfaction, and the wellbeing of
employees. Turnover significantly affects the workload of clinical managers and staff, and can
lead to mistakes and burnout (Flint, Haley, & McNally (2013). Therefore, clinical managers care
very much about creating environments that reduce turnover. Clinical managers are the unit of
analysis for this study.
Executives are held accountable by the board of directors, who originally mandated
measurement and attention to employee engagement. The chief executive officer and chief
operating officer hold the vice presidents accountable for the organization's employee
engagement goal. The chief operating officer and the chief human resources officer set the
organization’s engagement goals.
Clinical staff members include personnel who provide direct patient care. Nurses,
advanced practitioners, medical assistants, lab and radiology technicians, and patient admissions
staff are included in this population. Clinical staff members are the object of engagement
interventions, such as human resources strategies or direct manager actions.

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Stakeholder Group for the Study
DCNC’s new employee engagement strategy emphasizes the relationship between
clinical managers and staff, and presents a positive, strengths-based approach to work
relationships. The strategy relies on strengths–trait theory and leader–member exchange (LMX)
theory (Bakker, 2017; Erdogan & Bauer, 2015; Northouse, 2018). With strengths–trait theory,
Bakker (2017) suggested that leaders are most effective when using their innate strengths, while
helping their followers develop their strengths. A strength is a trait in that it is a consistent
pattern in the way one behaves, thinks, or feels (Foti, 2013). LMX theory is focused on dyadic
relationship between the team leader and team member, and is used to suggest that managers
have more favorable relationships with some staff, and less favorable relationships with others,
who are known as the “outgroup” (Erdogan & Bauer, 2015). DCNC’s strategy is used to help
clinical managers improve their relationships with more of their staff than they currently
experience.
The population of focus for this study included all team leaders within DCNC who have a
team size of three or more persons. To identify challenges to implementing check-ins and
promising practices, participants were selected from a list of clinical managers who have adopted
frequent check-ins more quickly than other clinical managers who have not yet adopted weekly
check-ins.
Purpose of the Project and Questions
The purpose of this project was to understand the conditions and behaviors that support
successful adoption of clinical manager and staff check-ins. Although an analysis would include
all stakeholders, for practical purposes this analysis focused on two groups of clinical managers:
clinical managers who have met the goal of 60% and clinical managers who are at 30% or less in

10
their check-in rates and who, therefore, have not met the goal. The following statements guided
the analysis that addressed knowledge and skills, motivation, and organization resources and for
clinical managers:
1. What are the stakeholder knowledge and motivation needs and assets related to
achieving the clinical manager check in goal of 60%?
2. What are the organizational needs and assets related to achieving the clinical manager
check in goal of 60%?
3. What are the barriers to adopting check-ins?
4. What recommendations for organizational practice in the areas of knowledge,
motivation, and organizational (KMO) resources might be appropriate for solving the
problem of practice?
Methodological Framework
The Clark and Estes (2008) gap analysis method was used to clarify goals, identify gaps
between the target performance level and actual performance, and to investigate KMO assets
contributing to actual performance, and KMO needs required to close the gap. Assumed factors
were generated using the researcher’s personal experience within the organization, and
documents within DCNC. Interviews were used for data gathering. The sampling approach was
used to obtain the maximum variation sampling to understand the factors that influence high-
performing managers and managers who have not been achieving their goals. Clinical manager
assets were studied through interviews and content analysis. The Clark and Estes (2008) method
lends itself to understanding performance gaps and generating recommendations for
improvement.

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Definitions
Check-ins: A check-in is performed by staff members whose responses to six questions
are then sent to the manager. Check-in rates measure the frequency with which staff members
input their responses into DCNC’s electronic engagement platform.
Clinical managers: These staff members are anyone who has responsibility for leading a
team of people in the service of patient care.
Employee engagement: This term represents a mental state that is first experienced as
trust, meaningfulness, and psychological safety, and that gives rise to a sense of vigor,
commitment, and flow (Csikszentmihali, 1990; Kahn, 1990; Schaufeli & Bakker, 2003).
Team leader: This staff member is a clinical manager to whom at least three staff
members report.
Organization of the Project
Five chapters are used to organize this study. This chapter provided the reader with the
key concepts and terminology commonly found in a discussion about employee engagement and
check-ins. The organization’s mission, goals, and stakeholders as well as the initial concepts of
gap analysis were introduced. In Chapter 2, a review of current literature surrounding the scope
of the study is provided. Topics of employee engagement, leadership, relationships between
leaders and staff, and strengths will be addressed. In Chapter 3, the assumed interfering elements
and the methodology, including choice of participants, data collection, and analysis are detailed.
In Chapter 4, the data and results are presented and analyzed. In Chapter 5, the researcher
provides solutions (from data and literature) for closing the perceived gaps, and
recommendations for an implementation and evaluation plan for the solutions.

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Chapter 2: Review of the Literature
As noted in Chapter 1, low engagement can lead to worker burnout and lower quality in
clinical care. Lower quality of care puts DCNC’s fulfillment of its mission--to improve health
through discovery and care--at risk. Creating an environment that supports high engagement is
essential to the purpose of DCNC. Therefore, DCNC’s engagement strategy is vital to the
achievement of its mission.
DCNC’s employee engagement strategy has been to encourage team leaders to establish
closer relationships with staff, to help staff use strengths, find meaning in their work, and focus
on key priorities. A process known as “check-ins” has been launched to provide a method and
electronic platform for team leaders to hold regular conversations about performance,
meaningfulness, and priorities. Managers are checking in at a rate of 30% to 55% each month
compared to the organization’s performance goal of 60%. The purpose of this study was to
examine the Kaiser-Meyer-Olkin (KMO) factors that influence a manager’s ability to close the
performance gap.
In this chapter, the researcher reviews the literature on the employee engagement
construct and theories that influence employee engagement. These theories include the JD–R
theory, the leadership theory, and the strengths–trait theory. Next, the researcher provides an
explanation of the Clark and Estes (2008) framework of KMO influences used in this study.
Definitions of types of KMO influences are examined along with the assumed influence of these
factors on DCNC team leaders. The chapter concludes with the conceptual framework that
guides this study.

13
Employee Engagement as a Construct
Employee Engagement Definition
“Employee engagement” evolved from Kahn (1990, as cited in Saks, 2017) social and
organizational psychology-based studies of workers. Kahn (1990) described engagement as a
psychological state expressed as cognitive, emotional, and physical aspects of self at work. The
author theorized that the more degrees of oneself a person brings into one’s work, the more
committed the person is and the more energetically the person works. Expressing one’s “true
self” at work allows access to one’s natural energy, empathic connection, and cognitive
absorption in service of the work one is conducting (Kahn, 1990).
Kahn’s (1990) model of engagement, the author suggested that one’s psychological
experience and state drives attitudes and behaviors, and that individual, group, and
organizational factors influence one’s psychological state. This model has been rigorously
applied in research and the construct “employee engagement” has gone through several iterations
of definition. Saks (2017) further developed Kahn’s (1990) original focus of “self-in-role” and
examined the state of engagement itself. Rothbard (2001) described engagement as one’s
psychological presence and absorption during role activities, and Crawford, LePine, and Rich
(2010) described it as a motivational concept that represents the commitment of a worker’s
cognitive, emotional, and physical energy in active role performance.
Maslach and Leiter (2008) shifted their focus on engagement to a construct representing
the opposite of burnout, while Christian et al. (2011) suggested that engagement is more of an
enduring state of mind with resources to invest personal energies in performance of work. Yet,
consistent in these definitions are the expenditure of energy, focused attention, and commitment.
Two of the most cited engagement researchers are Schaufeli, who described engagement as a

14
mental state characterized by vigor, dedication, and absorption (Schaufeli et al., 2002), and
Bakker (2017), who described it as being fully immersed, full of energy, and enthusiastic about
the work.
Employee engagement is a mental state that is first experienced as meaningfulness, trust,
and psychological safety, which gives rise to a sense of vigor, commitment, and flow
(Csikszentmihali, 1990; Kahn, 1990; Schaufeli & Bakker, 2003). Kahn’s (1990) description of
the psychological state of engagement is affected by internal factors and external factors,
resulting in positive organizational outcomes. Employee engagement arises through the
interaction between external and internal factors and outcomes.
External Factors Leading to Engagement
External factors that affect the psychological state of engagement include a supportive
relationship with the manager and job characteristics such as task variety (Bakker, 2016).
Perceived organizational support for using one’s unique strengths and the employment of one’s
strengths are also considered job resources (van Woerkom, Bakker, & Nishii, 2016). The JD–R
theory provides a framework to understand how job resources affect employee engagement. In
the JD–R theory, Bakker (2017) posited that employee engagement is highest when tasks are
challenging, nonroutine and allow for creativity and autonomy. Job demands can either generate
energy loss and burnout or, if resources are available, positive motivation and engagement
(Costa, Passos, & Bakker, 2014).
Job Demands
Factors such as workload, intricate work, emotionally demanding work are common job
demands. If these demands are too high, they can increase negative outcomes (e.g., turnover or
absenteeism; van Woerkom et al., 2016). Hence, job demands can be quantitative, meaning that

15
the amount of work represents the demand, or qualitative, reflecting emotions that are demanded
in challenging situations at work (Bakker & Demerouti, 2007). If job demands are too
demanding, they can accumulate and overwhelm, causing a person to experience what Bakker
(2017) called the “Negative Loss Cycle” (p. 68), and leading to exhaustion, lack of empathy, and
undesirable behaviors. Negative loss is exacerbated by role ambiguity, conflict, and bureaucratic
waste (van Woerkom et al., 2016). For example, imagine a nurse who wastes time resolving
problems with diagnostic tests, in an understaffed department, with critically sick patients who
require emotionally charged interactions with the nurse. The additive effects of these demands
create a spiral of lower energy to respond to future tasks, which cause further exhaustion.
Job Resources
Workers can cope with job demands when enough resources are assessable (Bakker,
2017). Job resources are the available “physical, social, psychological, or organizational aspect
of a job” (Bakker, 2017, p. 67). Therefore, job resources are generated by the individual and by
social and organizational factors. Work resources that represent external factors that influence
employee engagement include supervisory feedback and support, social support and team
helping behaviors, psychological and physical safety, and recognition (Albrecht, Bakker,
Gruman, Macey, & Saks, 2015; Hakanen, Bakker, & Schaufeli, 2006; Richardsen, Burke, &
Martinussen, 2006; Schaufeli & Bakker, 2004). Although organization culture and group
dynamics play a role in available resources, the supervisor remains an essential fixture in
providing many work resources, including coaching, respectful interactions, skill and task
discretion and decision authority (Albrecht et al., 2015). An examination of a leader’s influence
on engagement will help shed light on a critical factor in employee engagement.

16
Internal Factors Leading to Engagement
Internal factors that contribute to a sense of engagement include a sense of
meaningfulness, psychological and physical safety, and trust (Kahn, 1990). Meaningfulness is a
subjective judgment that one’s role and contribution to task completion possesses meaning or
purpose (Oades, Steger, Delle Fave, & Pasmore 2016). Dik, Duffy, and Steger (2012) identified
three stages of meaningful work. The first stage is whether the worker judges the work task as
meaningful, as opposed to worthless or trivial. The second stage arises when work is meaningful
beyond the task, and when one’s role or membership within a team goes beyond one’s
contribution to provide a deep sense that the group or organization to which one belongs is doing
meaningful work. The third phase transcends the worker’s sense of role significance, and moves
to a sense of self and team, and a belief in contribution and significance to society as a whole. At
the highest levels, meaningful work is congruent with one’s beliefs, values, and aspirations for
contributing to the greater good (Oades et al. 2016). Steger, Dik, and Duffy (2012) asserted that
workers who feel a deep sense of meaningfulness adopt prosocial and helping behaviors and
experience elevated self-efficacy, self-esteem, and positive relationships. Meaningful work
contributes to less burnout (Creed, Rogers, Praskova, & Serle, 2014), job satisfaction (Douglass,
Duffy, & Autin. 2016), and work enjoyment, vigor, and commitment (Oades et al. 2016; Steger
et al., 2012).
Trust is also an important antecedent to the psychological state of engagement, for people
want to have satisfying, trusting relationships with their manager and peers (Deci &
Vansteenkiste, 2004; Edmundson, 2016). Trust between supervisor and subordinate reflects a
willingness to be vulnerable to another person with the expectation that the person will act with
good will (Whitener, Brodt, Korsgaard, & Werner, 1998). Trust entails a positive assessment of a

17
person’s benevolence, integrity, and reliability (Mayer & Davis, 1999). Macey and Schenider
(2008) found that trust is a mediator to an employee’s level of engagement, and Wang and Hsieh
(2013) found that leaders can increase employee engagement by building trust with subordinates.
Supervisor behavior that builds trust includes consistency, integrity, sharing of control, openness,
and concern (Korsgaard, Brudt, & Whitener, 2002), fairness (Werbal & Henriques, 2009), and,
in the case of clinical staff, a willingness on the part of supervisors to come to their defense and
aid (Rodwell, McWilliams, & Gulyas, 2017). Positive leader behaviors create employee trust,
positive attitudes, and employee engagement (Wang & Hsieh, 2013).
Psychological safety, the third internal factor leading to the state of engagement, is a
belief or prediction that one will not suffer adverse consequences for actions (e.g., asking a
question, voicing a concern, or making a suggestion; Edmundson, 2004). Consequences can
range from embarrassment to harm in status or career. An individual assesses each situation and
asks oneself, “If I speak up, will I be embarrassed, poorly judged, or dismissed?” (Edmondson,
2004, p. 257). Alternatively, people feel psychologically safe when they believe that ‘‘the
benefits of speaking up outweigh the costs for the speaker’’ (Edmondson, 2004, p. 257).
Researchers have confirmed the relationship between psychological safety and engagement
(Kahn, 1990; May et al., 2004). An antecedent to psychological safety and engagement are job
resources that provide the setting and context from which employees can experience
engagement.
Leadership Theory and Employee Engagement
Managers play an important role in providing resources to employees, including
feedback, autonomy, and social support (Blomme, Kodden, & Beasley-Suffolk, 2015).
Leadership theory is far from homogenous, yet several theories focus on the relationship between

18
the team leader and team member, the dyadic joining leading to a culture of connection. Three
theories are particularly salient for the purposes of examining employee engagement:
transformational theory, LMX, and relational leadership theories.
Transformational Leadership
Transformational leadership is a relational model of leadership and first emerged as a
theory when Burns (1978, as cited in Northouse, 2018) examined the relationship between
leaders and followers. Burns (1978) proposed that leadership is much more than an exploitive or
power-based relationship with followers. Instead, effective leaders focus on motivating followers
by attending to their social and psychological needs, thereby wielding considerable influence
with workers to achieve higher output (Northouse, 2018). Transformational leadership consists
of four components: (a) communicating high expectations to followers; (b) treating each team
member as a unique contributor, with specific strengths; (c) coaching team members to grow;
and (d) encouraging followers to challenge their own, self-limiting beliefs (Northouse, 2018).
Transformational leadership behaviors improve employee engagement (Tims, Bakker, &
Xanthopoulou, 2011) because leaders focus on job meaning, psychological safety, and trust.
Leaders have an outsized influence on the work environment, and transformational leaders help
workers to make meaning of their work, by outlining clear and challenging goals (Breevaart,
Bakker, Hetland, Demerouti, Olsen, & Espevik, 2014). Trust is created when a leader uses a
transformational leadership style by acknowledging each individual’s unique strengths and by
assuming good intent in the worker’s actions (Bakker & Costa. 2014). In addition, leaders who
use transformational leadership behaviors create psychological safety by encouraging staff
members to speak up and to share their creative ideas (Bakker & Costa, 2014).

19
Transformational leaders help workers create job resources by encouraging autonomy
and by providing social support (Jena, Pradhan, & Panigrahy, 2018). For example, when nurses
invite other nurses to give input and to find solutions to improving the supply process, they will
likely feel greater autonomy and efficacy. Likewise, leaders who use transformational leadership
listen and pay careful attention to their followers, thereby, providing social support. For example,
a clinical manager might notice that a nurse is more quiet than usual, and ask them why they are
quiet and if there is anything the worker needs. Hence, leaders who employee transformational
leadership behaviors influence internal and external engagement factors and influence employee
engagement overall.
Leader–Member Exchange Theory
LMX theory is a widely researched relational approach to leadership that frames
leadership as a process and interaction between team leaders and team members (Northouse,
2018). LMX theory is unique in that the focus is on the dyadic relationship between the leader
and follower (Gregersen, Vincent-Höper, & Nienhaus, 2016). In LMX theory, leader and staff
exchanges and contacts are described on a continuum of low- to high-quality relationships
(Schyns & Croon, 2006). Leaders assess their dyadic relationship with team members according
to the team members’ commitment to work and their willingness to go above baseline
expectations (Northouse, 2018). Leaders provide more support, clear expectations, and autonomy
to staff members with whom they share high-quality relationships (Schyns & Croon, 2006). This
additional support creates more job resources for staff. High-quality relations are characterized
by growing levels of trust and mutual support (Blomme et al., 2015).
Leaders who employ an LMX style can increase the perception of meaningfulness by
delegating challenging tasks and setting clear expectations. In addition, trust can be built through

20
frequent, clear communication. LMX research is focused on how work relationships are
coconstructed through dialogue and that more frequent, accurate, and timely communication
between team members creates engagement and performance (Gittell, Logan, Cronenwett,
Foster, Freeman, Godfrey, & Vidal, 2018). In-person or even high degrees of electronic
communication between leaders and followers can result in leader–member relationships that are
more positive (Hill, Kang, & Seo, 2014).
Relational Leadership
Broadening the in-group to include more team members is essential for employee
engagement throughout the organization. Dutton and Heaphy (2003) suggested that higher
quality relationships lead to experiences of vitality, positive regard, and mutuality. Gittell and
Cochan (2017) proposed a relational leadership frame, wherein the leader helps each follower to
understand how their work connects with others, and, concurrently, helps the leader learn more
than what they could understand on their own. Organizations are too complex for any one person
to understand, and the leader who has frequent and focused conversations with team members
learns what is really happening in the workspace. This approach is aligned to humble inquiry
(Schein, 2017), wherein that team leader becomes willing to step away from the role of expert,
and to learn from others, including team members. Relational leaders work closely with all team
members, providing feedback and coaching instead of broadcasting standards and measurements
(Gittell et al., 2018). Team leaders help to create common goals (priorities), shared knowledge
(expectations), and mutual respect.
Culture of Connection
The catchphrase (from which the title of this dissertation is derived) comes from two
ideas about human behavior: (a) culture (as defined in Chapter 2, Consequences of Low

21
Engagement Section), and connection. Organizational culture is a pattern of shared assumptions
that help group members to solve problems (Schein, 2004). Culture includes observable features
(e.g., behavior, rituals, and norms), as well as deeper, hidden aspects (e.g., assumptions and
beliefs; Schein, 2004). Connection refers to the relationship between managers and staff
members. Through frequent check-ins and discussions about priorities and what help the
manager can provide to each staff member, DCNC is shifting from a hierarchical model of
authority to a relational model of authority. The emphasis on the relationship between the
manager and staff member is intended to deepen and broaden connections that staff members
feel with their manager.
The proponents of the relational model of authority theorize that the way that an authority
figure reacts to and treats their subordinates affects how the subordinates perceive the group and
themselves, and it consequently shapes their levels of engagement (Tyler & Lind, 1992). The
relational model of authority informs us that, when authorities treat subordinates more
respectfully and fairly, the subordinates feel more comfortable to engage in discretionary
behaviors (Tyler & Lind, 1992). Additionally, they will engage in behaviors that help the group
(Huo, Binning, & Molina, 2010), citizenship behaviors (Huo et al., 2010), and help seeking.
Hence, a culture of connection is one in which the norms between managers and staff encompass
frequent, respectful check-ins, and mutual offers of help.
Strengths-Based Theory
Employee engagement theory has been greatly influenced by the positive psychology
movement in an attempt to understand how positive approaches influence organization
phenomena (Gruman & Saks, 2011). One promising approach is the encouragement and use of
individual strengths at work (Bakker, 2017). Linley and Harrington (2006) defined strengths as

22
the “natural capacity for behaving, thinking, or feeling in a way that allows optimal functioning
and performance in the pursuit of valued outcomes” (p. 88). An example of using a strength is to
employ a social competence when addressing an irate customer or to use a keen sense of justice
when solving a conflict between work colleagues (Saks & Guman, 2010). In this example, social
competence might be a habit of thoughts, emotions, and behaviors that allow the person to assess
quickly a patient’s level of anxiety and to respond with an appropriate gesture to alleviate the
stress. Likewise, a sense of justice can be described as a strength when an individual has an
innate urge to resolve the issue through the habitual thought process of balancing the needs of
each staff member.
Ghielen et al. (2018) performed a meta-analysis of strengths interventions between 2011
and 2016, and found that most interventions had positive outcomes in terms of work engagement
and team outcomes. Examples of strengths interventions include reflected best-self (Roberts,
Dutton, Spreitzer, Heaphy, & Quinn, 2005), identifying strengths and using them in a new way
(Meyers & van Woerkom, 2016), and job-crafting (Berg, Dutton, Wrzesniewski, Dik, Byrne, &
Steger, 2013). With the first intervention, the reflected best-self exercise, proponents encourage
learners to think about times they are at their best, or to ask others about the times they are at
their best. Then, learners are asked to identify the context, what they were doing, and what about
their experience made them feel at their best (Cable, Lee, Gino, & Staats, 2015).
With the second intervention, employees can learn about their strengths in many ways,
although one of the most popular is by taking a strengths survey. Several instruments can be used
to identify one’s strengths, including Gallup’s (2020) Strengthfinder, Values in Action Institute
on Character’s (2020) Values in Action Profile, or Buckingham’s (2020) StandOut Strength
Roles. Thinking about one’s strengths and how they can be used helps learners to gain a more

23
profound appreciation of their unique talents. By taking this intervention a step further, learners
can imagine new ways to use their strengths through reflection or through interview, and they
can try using the strength in a new situation (Cable et al., 2015).
The third intervention is job-crafting (Berg et al., 2013), in which learners are guided
through a process of identifying their strengths and values, and comparing them with their job
tasks. If their job tasks do not allow for the expression of strengths, the learner is guided to find
ways to find tasks that require their strengths. Each of these interventions includes a mixture of
identifying one’s strengths, reflection, and finding ways to use strengths in new ways.
The use of strengths was found to facilitate engagement and proactive behavior (van
Woerkom, Oerlemans, & Bakker, 2015), and it has been linked to prosocial motivation and
flourishing (Dubreuil, Foster, & Courcy, 2014; Lyubomirsky et al., 2005; Wood, Linley, Maltby,
Kashdan, & Hurling, 2011). Kahn (1990) described one aspect of engagement as being able to
enact one’s authentic self. Schaufeli et al. (2002) found that when employees use strengths, they
can be their authentic selves, and are more likely to reach their goals. In addition, similar to
Schaufeli et al.’s (2002) definition of engagement, they experienced “a state of mind
characterized by vigor, dedication and absorption” (p. 74).
Engagement in Healthcare
With the introduction of new technical equipment, rapidly changing medical therapy
interventions, intense cost pressure, and growing morbidities experienced by an aging American
population, health care workers are experiencing increased demands in their work (Kubicek,
Korunka, & Ulferts, 2013). Associated with increases in job demands is a growing interest
throughout the healthcare industry in preventing job burnout and in increasing employee
engagement. Academics are studying the relationships among health care worker turnover,

24
burnout, and personal wellness, while health systems are increasingly investing in employee
engagement and wellness programs to stem the cost of turnover and burnout, along with
increasing the quality of patient care.
In a survey of 432 health care leaders, Cornerstone (2014) found that 75% of hospital
leader respondents claimed to measure employee engagement with a vendor survey, yet less than
20% claimed to attempt to correlate engagement results with outcomes (e.g., patient safety or
patient experience). Moreover, only 29% of respondents claimed that their organization had a
strategic approach to understanding and improving employee engagement. Although health care
entities have added employee engagement as a standard measurement or goal, a gap remains in
understanding the drivers of engagement at the organization level, and a dearth of strategic,
evidence-based approaches to improving engagement is evident.
Employee Engagement Trends in Health Care
Rising Costs and Pressure to Decrease Expenditures
Health care costs continue to rise in the United States, despite legislative, industry
innovation, and patient advocacy efforts. Healthcare costs are expected to rise to 20% of the
American gross domestic product (World Health Organization, 2019). Legislators (e.g., of the
Affordable Care Act [ACA] of 2010) assume that care can be reduced if evidence-based
treatment and standard care pathways are applied. Moreover, healthcare remains notoriously
fragmented and pressure to improve coordination of care has increased dramatically (Seick,
2017). Healthcare leaders are seeking methods to encourage the staff members who are closest to
the work to find solutions to cost control and care coordination. Teamwork and engagement are
viewed as potential contributors to the solution (Macleod & Clarke, 2014).

25
Technical, Demographic, and Time Acceleration
Kubicek et al. (2013) identified three accelerating trends that are increasing job demands
on healthcare workers. The first accelerating trend is the rapid pace of new medical technology
innovations, as well as increasing demands for electronic documentation and numerous
organization technology upgrades (e.g., new time tracking systems, billing procedures, and
quality tracking systems). The second accelerating trend is social demographics, which include
the increasing number of aged adults and their concomitant disease. Likewise, the aging
workforce demographics put pressure on health care systems to prepare to replace experienced
workers. The third accelerating trend is the acceleration of time in the workplace, wherein more
communications channels are used, communications occur more quickly with the aid of
technology, and the expectation to accomplish more done in a shorter amount of time (Kubicek
et al. (2013). Solutions that bring more resources to workers include providing scribes to relieve
the burden of electronic data record note taking, adding flexible work schedules, and investing in
wellness programs. These solutions are intended to cope with greater demands and improve
engagement (Perlo et al., 2017).
Consequences of Low Engagement
The rapid pace of work and high job demands represent significant risks to patients,
healthcare workers, and organizations (Fragoso, Holcombe, Mccluney, Fisher, Mcgonagle, &
Friebe, 2016). These risks include worker burnout, quality of care and safety, and reduced patient
satisfaction (Fasoli, 2010; Fragoso et al., 2016). Low clinical staff engagement has been found to
have an impact on each of these factors.
Nursing and physician turnover is approaching 15% (KPMG Healthcare and
Pharmaceutical Institute, 2011), creating higher costs to healthcare systems and personal costs to

26
affected workers. In addition, clinical workers are exposed to family grief, death, and intense
emotions, which put them further at risk of burnout and illness (Turnell, Rasmussen, Butow,
Juraskova, Kirsten, Wiener, & Grassi, 2016).
The quality and safety of patient care might suffer from lower engagement. Gallup (as
cited in Paller & Perkin, 2014) discovered that lower scores for nurse engagement resulted in
higher patient mortality and complication indices compared to similar, more highly engaged
nurses. Burger and Sutton (2014), in collaboration with the Loma Linda University Medical
Center, demonstrated that employee engagement and change management were the strongest
predictors of patient safety practices. The National Database of Nursing Quality Indicators
showed that dissatisfaction correlates to higher infection rates and, alternatively, increasing
satisfaction led to an 87% decrease in infection rates in health systems (Dunton, Boyle, &
Cramer, 2013).
Employee engagement might also affect the experience of hospital patients. Caldwell
(2011) at Towers Watson, a human resources consulting firm, studied 21 acute care facilities and
found that patients were 11% more likely to recommend the acute care center when employees at
that acute center were more engaged than in other centers. Burger and Sutton (2014) found that
hospitals with higher employee engagement also received higher scores in patient satisfaction
surveys.
Common Approaches to Increasing Engagement
Healthcare systems are using a variety of means to increase clinical staff engagement and
wellness. These means include process improvement, reward and recognition, and personal
wellness programs, and efforts to increase staff member control over how to complete tasks
(Abdelhadi & Drach-Zahavy, 2012; Fasoli, 2010).

27
Over the past 10 years, healthcare systems have employed several process improvement
programs that were borrowed from the manufacturing industry. These methods include Total
Quality Management, Lean, and Six Sigma, with a focus on removing process inefficiencies and
obstacles to providing patient care (Abdelhadi & Drach-Zahavy, 2012). These programs focus on
teaching small teams of front-line staff how to evaluate the cause of problems and to develop
solutions. Process improvement methods focus on process inefficiencies versus assigning to
people or groups blame for mistakes or errors (Fox & Frakes, 1997). In theory, the combination
of improved processes, staff involvement, and focus on problem solving versus assigning blame
should improve employee engagement (Morgan et al., 2015). However, many health systems
have found that the data-driven method of process improvement drives attention towards visible
processes, and away from the more enigmatic areas of relationships and engagement. In addition,
clinical workers find it difficult to take time away from their clinical work to participate in
problem-solving teams (Robertson, Morgan, New, Pickering, Hadi, Collins, Arias, Griffin, &
Mcculloch, 2015).
Another common approach that healthcare organizations use is to promote personal
wellness. This approach aims to increase inner resources in response to stress. Techniques
include mindfulness meditation, relaxation, easy yoga, stretches, calming music, and focus on
the breath (Klatt, Steinberg, & Duchemin, 2015). Although Layous, Sheldon, and Lyubomirsky
(2014) showed that practices such as loving-kindness meditation increase happiness, personal
wellness outcomes are mixed (Klatt et al., 2015).
A third trend has emerged to encourage greater autonomy in clinical roles. Deci and Ryan
(2012) proposed that autonomy is the sense that one’s choices are self-generated and are not
imposed. An example of a method to increase autonomy is job crafting (Dutton & Raggins,

28
2017). Clinical workers who employee job crafting look for ways to use their strengths in the
way they approach their work and to increase the value-added tasks that help them feel vigor,
absorption, and dedication. An example is the current trend of offering documentation support
for physicians by employing clinical staff who can capture notes and can enter the information in
the electronic health systems. Scribes free physicians from work that often drains them, thus,
allowing them more time for direct patient care, teaching, and research (Sattler, Rydel, Nguyen,
& Lin, 2018).
The Clark and Estes Gap Analytic Conceptual Framework
Clark and Estes (2008) offered a framework for improving performance by analyzing
assets and needs in an organization. They suggested that, once an organization’s current
performance is compared to goals, the resulting gap could be used to guide an analysis of the
underlying, stakeholder KMO influences that support closing the gap. This dissertation is
informed by the Clark and Estes framework, and the researcher uses it to examine the challenges
and promising practices related to meeting the DCNC’s weekly check-in goal.
In the three sections that follow, the researcher will discuss the assumed KMO influences
for meeting DCNC’s weekly check-in goal for clinical managers. In the first section, the
influences affecting the knowledge and skills needed by clinical managers will be covered. In the
next session, assumed influences on motivation will be reviewed. Lastly, assumed organizational
influences on the achievement of the weekly check-in goal will be discussed.
Knowledge and Skills
Krathwohl (2002a) identified a useful taxonomy of four knowledge domains to
understand the content and objectives of knowledge required for performance and improvement.
The four knowledge domains include factual, conceptual, procedural, and meta-cognition.

29
Factual (i.e., declarative) knowledge includes the terminology and details of a discipline or
context (Rueda, 2011). Conceptual knowledge (one level up from the details of factual
knowledge) includes an understanding of how the elements of the discipline or process function
together. Understanding of theories, models, principles, and taxonomies all fit under conceptual
knowledge. Procedural knowledge helps the learner to move from understanding to action and
how to do something. Procedural knowledge includes the use of techniques, skills, and methods,
and the timing to use these skills (Rueda, 2011). Meta-cognitive knowledge is awareness of
one’s thinking or cognition (Rueda, 2011). Using one’s awareness of cognition and reflection,
one can change and adapt to navigate more successfully the environment and to achieve goal
attainment (Krathwohl, 2002a). Krathwohl’s (2002a) taxonomy is a useful tool in which to
examine the knowledge that team leaders at DCNC require to achieve their goal of 60% check-in
rates. In this section, the researcher will explore the critical knowledge content team leaders need
to achieve the performance.
Declarative Knowledge Regarding Employee Engagement, Its Importance, and Strengths-
Based Theory
Declarative knowledge is the ability to recall facts and events (Kump, Moskaliuk, Cress,
& Kimmerle, 2015). To gain this knowledge at the start of the engagement initiative, 850
managers attended a 6-hour course when the new strategy launched in July 2018. The training
was designed to provide declarative, procedural, and conceptual knowledge of employee
engagement, strengths-based theory, the check-in process, and rationale. Given that the course
was an introduction to strengths–trait leadership, several hours were spent on declarative
knowledge (e.g., the underlying principles and concepts; Clark & Estes, 1996). In essence, the
focus was on answering the question, “Why focus on strengths and frequent check-ins?”

30
The first section of the course was focused on what highly engaged and performing
people need. They need to know what is expected of them and to use their strengths every day.
These two factors were identified in a study that Buckingham and Coffman (1999) conducted
and that DCNC operationalized in its employee engagement survey. Of the eight questions on
the survey, the two factors are weighted most heavily.
Next, the course was focused on strengths theory and benefits. In the training, the
concepts of strengths were introduced along with how the cultivation of strengths could inspire
higher performance, development, and resilience. Strengths were discussed in the context of a
powerful job resource to help employees thrive in a fast-paced, emotionally charged
environment.
Lastly, the course covered Buckingham and Coffman’s (1999) study in which the authors
showed performance variance between similar retail stores in comparable demographic areas.
Buckingham and Coffman found that one manager behavior distinguished high-performing
versus low-performing stores: high-performing managers conducted frequent, strengths-based
conversations that were focused on near term work. Buckingham and Coffman called this
process a “check-in,” and their study is shared in the training to provide an underlying rationale
for conducting frequent check-ins. However, focus groups that were held 3 months after training
revealed that many team leaders struggled to explain why check-ins were essential to team
members. A gap in team leader knowledge in articulating the value of check-ins suggests a lack
of understanding of engagement and the role of check-ins at DCNC. This gap in conceptual
knowledge (Krathwohl, 2002b) might derive from a defect in the training and must be
investigated further.

31
Procedural Knowledge Regarding How to Use the Check-In System
Managers must have procedural knowledge of the electronic platform navigation and of
how the check-in process works. Procedural knowledge (e.g., how to use the electronic platform,
and when and how to perform check-ins) was covered in a short section of the training. Trainers
performed a simple evaluation of the course by surveying course participants regarding their
satisfaction with the course. However, trainers did not assess the participants on their retention or
application of knowledge after attending the course. Therefore, it is essential to know whether
this basic level of knowledge is a barrier to adoption.
Metacognitive Knowledge Regarding Relationships and Leadership Style
Team leaders require meta-cognitive knowledge to reflect on the data that they receive in
weekly check-ins to change their practice regarding engagement. Jiang, Ma, and Gao (2016)
proposed that metacognition has three variables: personal, task, and strategy. The personal
variable consists of self-knowledge, including one’s strengths and current abilities. As mentioned
in Chapter 1, understanding one’s strengths is an antecedent to helping others to understand their
own strengths (Ghielen et al., 2018; Higgs & Rowland, 2010). The task variable includes
knowledge of the task and interactions of factors that influence the task. In the case of DCNC
leaders, they should have knowledge of the check-in process and methods for teaching the
process to subordinates, and identification of successful teaching and coaching strategies. The
strategy variable refers to how one approaches tasks. For DCNC leaders, this variable shows they
know how they participate in helpful check-in conversations and awareness of when to shift
thinking strategies, depending on the subordinate’s needs. In other words, the thinking strategies
that they employ and adjust in situ represent their strategic meta-cognition.

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Table 1 provides a summary of the knowledge influences, types, and assessments
required by team leaders at DCNC to achieve their goal of regular check-ins with each of their
team members.
Table 1

Knowledge Types and Influencers
Organizational mission
Improve health through discovery and care by providing outstanding and compassionate care.
Stakeholder goal
Achieve 60% check-in rate
Manager’s need to know Knowledge type Knowledge influence assessment
Employee engagement, its importance,
and strengths-based theory.
Factual or declarative Interviews with clinical managers
who lead teams.
How to navigate and use the check-in
system.
Procedural Interviews with clinical managers
who lead teams.
Awareness of impact on team members:
the team leader must be aware of the
impact on team members when
encouraging or responding to check-ins.
Metacognitive Interviews with clinical managers
who lead teams.

Motivation
Motivation affects team member choice of work goals, persistence, and mental effort to
achieve the goals (Clark & Estes, 2008). Rueda (2011) described motivation as an activity that is
directed and sustained towards a goal. People are motivated by cognitive processes, their social
systems, and the environment around them (Bandura, 2000; Dembo, 2000; Smith, 2002;), and
the interplay between these factors. Motivation is indicated by three factors: autonomy, effort,
and persistence (Rueda, 2011). Autonomy is the freedom to choose one activity over others and
is a form of intrinsic motivation (Deci & Ryan, 2012). Intrinsic motivation is generated by one’s

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own volition and is not determined by external factors (e.g., contingent rewards or punishments).
An effort is a mental or physical activity required to learn or accomplish a task. Persistence is a
continued effort in the face of obstacles. For example, motivation would be indicated if a clinical
manager chooses to complete check-ins because it helps them to be a better leader, and to persist
over time despite the myriad tasks demanding their attention.
Motivation is multidimensional, and no single theory entirely explains motivation.
However, researchers have extensively examined several principles, and the current study
incorporates three salient principles of motivation in the context of team leaders encouraging and
performing check-ins.
Purpose and Meaningfulness
Kahn (1990) suggested that three psychological conditions serve as antecedents of
personal engagement: psychological meaningfulness, psychological safety, and psychological
availability (Saks & Gruman, 2010). Dik et al. (2012) asserted that leaders and workers who feel
a high sense of meaningfulness also adopt prosocial and helping behaviors, which are at the core
of a check-in: the helping relationship between leader and subordinate.
Intrinsic motivation arises from one’s volition and sense of choice or autonomy (Ryan &
Deci, 2017). Intrinsically motivated behaviors arise through interest and enjoyment in an
activity; the activity itself supplies the reward. The activity has a sense of meaningfulness
because it fulfills one’s need for competence, relatedness, or autonomy (Ryan & Deci, 2017).
The job characteristics model (Hackman & Oldman, 1976) contains five job dimensions that give
rise to intrinsic motivation: skill variety, task identity, task significance, autonomy, and
feedback. These dimensions lead to the psychological states of meaningfulness and commitment
(Allan, Duffy, & Collisson, 2018). Salient to this study is the dimension of task significance, or

34
one’s perception that the task helps other people (Allan et al., 2018). Task significance has been
found to generate meaningfulness at work (perceptions that work is valuable and essential), and
job performance (Duffy, Allan, & Autin, 2014). Therefore, if DCNC leaders view the task of
check-ins as having value and significance, it is reasonable to assume that leaders will be
intrinsically motivated.
Goal Orientation Theory
Goal orientation theory is a social–cognitive theory of achievement motivation
(Anderman, Anderman, Yough, & Gilbert, 2010) with a delineation of two types of goals:
mastery and orientation. Pintrich (2003) described mastery goals as self-referenced, self-
improvement goals. Individuals who hold mastery goals seek to learn and to understand content
and concepts for their own sake, and the avoidance goal is not to misunderstand the content. An
avoidance goal is an emotion, cognition, or behavior that is driven from an aversion to an
undesired outcome (Pintrich, 2003). Performance goals are focused on proving one’s ability in
comparison to one’s peers (Pintrich, 2003), and the avoidance goal is to evade the appearance of
incompetence. In addition to individuals, groups and organizations can appear to be mastery-or
performance-goal-oriented. Mastery and performance goals have both been shown to increase
performance, yet performance goals can create environments in which some people feel less than
others, leading to questions of self-efficacy, and lower motivation. If managers assume a
performance goal for check-ins, they could inadvertently reinforce the behaviors they are trying
to avoid (i.e., simply complying with the activity by asking team members to log into the
platform and check one box, without the pursuant conversation). In addition, as soon as
requirements for check-ins are lifted, managers with performance goal motivation might stop
checking in. Mastery goals on the other hand, allow team leaders and team members to adopt and

35
sustain check-ins, while deepening their connections with each other and improving
performance. The motivation types and influences are outlined in Table 2.
Table 2

Motivational Influences
Organizational mission
Improve health through discovery and care by providing outstanding and compassionate care
Stakeholder goal
Achieve 60% check-in rates
Employees need to be motivated by: Motivational influence assessment
Purpose and meaningfulness (Stegar et al., 2012). Interview
Performance vs. mastery goals clinical managers and
check-in behavior (Anderman et al., 2010)
Interviews

Organization
Examining organization culture is a useful method for identifying barriers and their
causes (Rueda, 2017). Culture gives rise to policies and procedures, systems, and accepted ways
of behaving, which might or might not facilitate goal achievement (Clark & Estes, 2008).
Organization culture is a pattern of shared assumptions that help group members solve
problems (Schein, 2004). Culture includes observable features (e.g., behavior, rituals, and
norms), as well as deeper, hidden aspects (e.g., assumptions and beliefs; Schein, 2004). A helpful
way to think about culture is the dynamic interplay between cultural models and settings.
Cultural models are the shared understandings of how the world usually works and how
to get work done (Gallimore & Goldberg, 2001). When leaders introduce change into the
organization, managers or staff might reject it if it does not conform or change underlying
beliefs. For example, if clinical managers have more than 30 staff members, they might believe

36
that it is not achievable to connect with each of their staff each week (Rueda, 2017). This belief
could be grounded in the assumption and experience that conversations with a staff member are
typically held in private and take 30 minutes or more, despite the evidence that check-ins only
take 15 minutes or less.
Cultural settings arise from cultural models. Although Schein (2017) asserted that no
organization has a monolithic cultural model, cultural models or mental models can be shared in
cultural settings where top leaders and various subcultures come together. Cultural settings are
the visible aspects of culture and they provide the work context from which structures, systems,
and policies and procedures are created (Rueda, 2017). In this section, the researcher examines
cultural models and cultural settings that support or hinder clinical manager efforts to achieve
their check-in goals.
Leader Support
Leadership support is a cultural model because it is generated by deep-seated beliefs
about how the organization and the world work. Leadership support consists of the resources,
rewards, goals, communication, and observable behaviors that senior leaders express (Kezar,
2001). Leadership support is vital to a significant organizational change (Kezar, 2001), and
without it, change can stall as new priorities emerge. Senior leaders allocate resources (e.g.,
human, funding, and time); therefore, they play an outsized role in the success of change
initiatives (Blomme et al., 2015). Organizational members are influenced by how they will be
rewarded (Schneider, Brief, & Guzzo, 1996), and they might discontinue behaviors that lack
support and subsequent rewards. Moreover, senior leaders create accountability, connecting
organization mission into organization goals (Owens, Eggers, Keller, & McDonald, 2017).

37
Senior leaders influence others to achieve their goals, and followers closely watch senior
leaders to determine their level of commitment to the goals (Blomme et al., 2015). If followers
perceive that senior leaders are treating the goal as transactional, they might strive to meet the
goal in any way possible (Blomme et al., 2015). A transaction suggests a mutual exchange of
benefits, and does not infer aligned values or aspirations. Likewise, if followers perceive that
leaders are passive in their interest in the goal unless the goal is not being met, followers might
become cynical, and experience negative emotions and stress (Bloome et al., 2015).
DCNC’s strategy to encourage weekly check-ins about past week and future work, and
team members’ strengths, represents a significant mindset shift, particularly in the clinical groups
with large spans of control. Overwhelming evidence suggests that team members rate their team
leaders as less productive when they behave in a distant manner and fail to act as part of the team
of followers (Carmeli, Brueller, & Dutton, 2009). A more effective type of leadership support
might be what Quinn and Quinn (2002, as cited in Dutton & Raggins, 2017) called “deep
contact” (p. 85) in which each person feels known and respected for their unique talents. Deep
contact helps team members to achieve better performance by cultivating high-quality, trusting
relationships (Dutton & Raggins, 2017). Therefore, the senior leaders’ active support of check-
ins is an important supporting factor for clinical managers to achieve their goals.
Organization Support
Organization support includes four essential engagement-related practices (employee
selection, socialization, performance management, and learning and development) that can
influence the organizational climate and the job demands and resources employees experienced
in their work roles (Albrecht et al., 2015). Employee selection includes the methods used to
select employees who might predictably express engaged states over long periods (Albrecht et

38
al., 2015). The tools include data analytics, interviews, assessments, and assessment centers.
Socialization is the process of introducing new employees to the organization and helping them
to learn the culture, values, and expected behaviors to become engaged and productive
employees (Albrecht et al., 2015). Performance management consists of the processes and
policies for assessing and promoting employees, helping employees to improve performance,
and creating a climate of safety and trust (Albrecht et al., 2015). Lastly, the learning and
development process and resources include training, on the job projects, feedback, and
encouraging employees to find ways to craft their job to align to their strengths (Albrecht et al.,
2015). These resources can influence clinical managers’ ability to achieve their check-in goals
successfully, and can indirectly influence work engagement, as well as the use of strengths
(Albrecht et al., 2015).
Bakker, Hetland, Kjellevold, and Espevik (2019) found that organization support for
strengths is a critical job resource, enabling employees to adapt better to work demands.
Likewise, organization-wide support of strengths use can, in some cases, substitute for team
leader behaviors, when work cohesion is high, work expectations are clear, and healthy
interdependence exists within the group (Blomme et al., 2015). Organizational context plays a
vital role in determining whether leadership efforts are successful (Blomme et al., 2015),
including the use of strengths and check-ins.
Psychological Safety
Psychological safety is a cultural setting factor that is expressed through interpersonal
behavior, and internalized by individuals. Kahn (1990) suggested one of three psychological
conditions that served as an antecedent to engagement is psychological safety (Saks & Gruman,
2010). Psychological safety is present when one feels safe speaking up or performing in front of

39
others without fear of damage to status and self-worth (Saks & Gruman, 2010), and it describes a
perception that “people are comfortable being themselves” (Edmondson, 1999, p. 354).
Psychological safety is influenced by interpersonal relationships, group and intergroup dynamics
and norms, and the leader’s style (Saks & Gruman, 2010). Carmeli et al. (2009) suggested that
psychological safety provides an important container for people to learn in work settings.
For team members to check honestly in each week with their team members,
psychological safety must be present. Likewise, team leaders must feel safe learning the process
and be willing to make mistakes as they learn to coach team members on their strengths. The
organization influences are outlined in Table 3.
Table 3

Organization Influences
Organizational global goal
Increase employee engagement as measured by the eight question quarterly pulse by 10% year over year.
Stakeholder goal
Achieve 60% check-in rates
Organizational influences Organizational influence assessment
Cultural Model Influence 1: The organization needs
to have senior leadership support.
Interviews with clinical managers that discuss
perceived senior leadership support of check-ins
Cultural Settings Influence 1: The organization
needs supporting systems to support the change.
Interviews with clinical managers that discuss the
supporting systems needed meet the check-in goal.
Cultural Settings Influence 2: The organization
needs to have psychological safety at the team level.
Interviews with clinical managers that discuss the
perceived psychological safety with their team
members, and with their direct supervisor.

40
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
A conceptual framework includes the underlying structure, theories, and concepts of the
study (Maxwell, 2013; Merriam & Tisdell, 2016). The conceptual framework informs the
researcher’s questions, design, sampling, and analysis (Merriam & Tisdell, 2016). Ultimately,
the conceptual framework informs the research problem statement and the purpose of the study.
The theory included in a conceptual framework provides a lens through which to view the
problem and interpret the data. In one sense, it provides a short cut for the researcher to make
meaning of the data and make conclusions. It can both reveal and hide meaning (Merriam &
Merriam, 2018).
Maxwell (2012) described four sources for the conceptual framework: (a) experiential
knowledge, (b) prior research, (c) the researcher’s initial assessment, and (d) thought
experiments. The conceptual framework for this study draws on prior literature and research
from the behavioral science field, including psychology, sociology, anthropology, and
organization studies, as well as the assumed KMO influences. See Figure 1 for the conceptual
framework.

41
Figure 1

Conceptual Framework

Albrecht et al. (2015) suggested that organization leadership, culture, and cultural settings
influence motivation and knowledge, and subsequent goal outcomes. Senior leadership support is
OrOr
Organization
Culture models: Senior leader support
Cultural settings: Organizational support
Cultural settings: Psychological safety
Knowledge
Declarative: Employee engagement and strengths
based theory.
Procedural: Conducting check-ins on the platform.
Metacognitive: Reflect on check-ins and adapt
approach

Motivation
Meaningfulness
Mastery or performance

Organization Goals
60% check-ins

42
vital to organizational change (Kezar, 2001) and to clinical managers’ ability to meet their
check-in goals. Organization support provides clinical leaders with the processes and resources
to conduct check-ins.
Psychological safety is strongly associated with trust, and clinical managers and staff
with low trust in their leaders might show reluctance to embrace organizational changes
(Edmundson, 2016). Staff members might also be hesitant to provide relevant information in
their check-ins if they do not trust how their manager will use the information. These factors
influence the team leader’s success in executing initiatives or contribute to performance gaps.
Clinical managers enact their role within the context of organization factors. The factors
described above influence the clinical manager’s knowledge and motivation. The primary
stakeholder in this problem of practice is the clinical managers who encourage team members to
participate in check-ins and who foster trust in a relationship wherein team members feel
comfortable sharing their assessment of their work, strengths, and priorities. To be successful,
clinical managers must have a factual and procedural understanding of employee engagement
concepts, the engagement process, and platform, as well as conceptual understanding of the
purpose of the engagement strategy and the ability to explain it to team members. Lastly, clinical
managers must have metacognitive knowledge to assess their effectiveness in conducting check-
in conversations and behaviors that are helpful or cause hindrances.
Although knowledge factors provide capability for performance, clinical managers must
be motivated to check-in consistently with their team leaders. Motivational factors include a
sense of purpose and meaningfulness in DCNC's check-in strategy and the task itself (Pink,
2009). Attribution of causes for challenges and barriers must be perceived as surmountable and
within the locus of control of clinical managers. In addition, the clinical manager mastery focus

43
versus performance focus is a motivator to learn, reflect, and improve check-in performance
rather than view check-ins as a transactional or compliance process that must be completed.
Organization, knowledge, and motivation factors influence the achievement of organization and
stakeholder goals.
Conclusion
The purpose of this study was to determine the KMO factors affecting clinical managers’
ability to achieve their check-in goal. DCNC has employed check-ins and use of strengths, for it
is the primary strategy for improving employee engagement. Employee engagement has been
examined, as well as relevant theories (e.g., JD–R theory, strengths–trait theory, and relational
leadership theories). Applications of employee engagement strategies in healthcare were
discussed, as was the Clark and Estes (2008) KMO framework designed to uncover the causes of
the existing gap between clinical manager check-in goals and actual check-in rates. The Chapter
3, the researcher will describe a methodology for understanding the KMO influences, followed
by an analysis of the data collected, and the recommendations for closing the check-in
performance gap.

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Chapter 3: Methodology
Methodological Approach and Rationale
The purpose of this project was to understand the conditions and behaviors that support
successful adoption of clinical manager and staff check-ins. Although an analysis would include
all stakeholders, for practical purposes, this analysis is focused on two groups of clinical
managers: clinical managers who have met the goal of 60% and clinical managers who have
check-in rates of 30% or less. The Clark and Estes (2008) gap analysis framework was used to
evaluate performance gaps through the analysis of KMO influences.
The following statements guided the needs analysis that addressed knowledge and skills,
motivation, and organization resources for clinical managers:
1. What are the stakeholder knowledge and motivation needs and assets related to
achieving the clinical manager check in goal of 60%?
2. What are the organizational needs and assets related to achieving the clinical manager
check in goal of 60%?
3. What are the barriers to adopting check-ins?
4. What recommendations for organizational practice in the areas of KMO resources
might be appropriate for solving the problem of practice?
This chapter contains the research design and methods used to address the above
questions. The research design includes a description of the participating stakeholders and how
they were chosen to participate. Next, data collection and instrumentation methods will be
introduced, as well as a description of how the data was analyzed. Lastly, issues of
trustworthiness and credibility of the data, and ethical considerations will be addressed.

45
Participating Stakeholders
The population of focus for this study included clinical managers within DCNC who
have a team size of three or more members. The participants were selected from among clinical
managers who are meeting the 60% check in goal and clinical managers who are checking in at
less than 30%. These managers were chosen so that the researcher could learn about both the
challenges and promising practices.
Interview Sampling Criteria and Rationale
Criterion 1: Department
A maximum variation sample of respondents came from managers of clinical and patient
facing areas. Clinical managers were chosen from in-patient nursing, surgery centers, laboratory
groups, radiology departments, and clinical specialties such as cancer care, neuroscience, and
primary care clinics.
Criterion 2: Adoption Rate
Team leaders respond to team member check-ins at temporal rates (weekly, biweekly,
monthly, or not at all) and their staff members are checking in at both high and low rates. For the
purpose of this study, deviant examples of leaders whose teams have adopted check-ins at a rate
of more than 60% on average for 3 months or more were selected. In addition, leaders whose
members have adopted check-ins at a rate of less than 30% were selected.
Criterion 3: Tenure
Team leaders who were with DCNC for more than a year had an opportunity to attend the
6-hour training course, and had a chance to experience check-ins. Therefore, only team leaders
with 1 year or more of tenure at DCNC were selected.

46
Interview Recruitment Strategy and Rationale
DCNC employs 850 team leaders, and 400 of them are clinical managers. Fifteen
semistructured interviews were sought and conducted with a purposeful sample, using the three
criteria. The sample was drawn from a list of team leaders in the DCNC vendor report of check-
in and employee engagement performance. A stratified sample was taken from each of the major
clinical groups: nursing, surgery, lab, imaging, and cancer clinics. Once the respondents were
identified, the researcher used the University of Southern California (USC) email to send
introduction emails describing the purpose and scope of the study, as well as the process for
consent. Next, the researcher sent a DCNC Microsoft Outlook calendar invitation for a 1-hour
meeting, held in the participant’s office or a conference room. When in-person interviews were
not feasible because of the participant’s work schedule, a phone interview was scheduled,
whereby the researcher called the participant. When interviews had to be rescheduled, the
researcher updated the Microsoft Outlook calendar with the new time. Thirty-two clinical
managers were contacted and 15 agreed to be interviewed. Clinical managers with low-adoption
rates declined to respond at a rate of two to one compared to high-adoption leaders.
Interviews
The interview protocol was drawn from Clark and Estes’ (2008) framework, Patton’s
(2002) six types of interview questions, and Merriam and Tisdell’s (2016) ideal position and
interpretive questions. Patton (2002) provided a framework to help the interviewer explore a
subject’s broad experience, using six question types: experience and behavior, opinions, feelings,
knowledge, sensory, and background. Merriam and Tisdell (2016) suggested questions that
explore the subjects “best” experience and questions that explore the subject’s meaning making
of their experience.

47
The researcher used semistructured questions, in that the same open-ended questions
were asked of each participant, but follow up and exploratory questions were used to gain a more
in-depth understanding of participant responses and meaning making.
The researcher attempted to reduce the burden placed on clinical managers by holding the
interviews during the workweek, during work hours, and in their offices. Interviews were
scheduled according to the mutual availability of researcher and the subject. One-on-one
meetings at DCNC typically lasted an hour; therefore, the researcher abided by this norm.
Respondents were asked for consent to record the interviews, and the researcher simultaneously
captured in written notes the critical points that the subject made.
Data Analysis
Data analysis is the process that researchers use to make meaning of the data and to find
credible answers to research questions (Merriam & Tisdell, 2016). Bogdan and Biklen (2007)
recommended that researchers begin their analysis immediately after collecting new data, to
initiate the process of focusing the analysis and determine early whether the questions are
generating the intended results. Therefore, the researcher transcribed the audio recording within
24 hours after the interview. The researcher read the transcript once or twice to recall the entire
interview. Then the researcher wrote comments in the margins of the transcript that denoted
ideas, concepts, or reflections. The researcher began the analysis immediately after the first
interview.
Content analysis was employed to analyze the data. Content analysis is an inductive
approach that relies on continuously comparing data to develop categories (Merriam & Tisdell,
2016). First, the researcher identified data segments that illuminated answers to the research
questions. This step is called open coding, and the researcher identified words or phrases that

48
responded to the research questions (Merriam & Tisdell, 2016). Next, using axial coding, the
researcher compared data segments; if they were similar, the researcher clustered them into a
larger construct. A data segment can be as short as a word or a few words, and it can be
understood without any other context (Bogdan & Biklen, 2007). The researcher categorized data
segments into (a) a priori categories that the researcher anticipated finding according to the
conceptual framework, and (b) in vivo categories that emerged from the data. The researcher
searched for patterns amongst the categories, which provided the evidence from which to make
assertions that answered the research questions. Patterns are composed of categories, causes,
relationships amongst people, and theoretical constructs (Miles, Huberman, & Saldana, 2014).
All codes were identified and cataloged in a qualitative analysis software called NVivo. In
essence, NVivo was used as a codebook for the data. As coding progressed, the researcher tested
emerging themes with counterexamples or conflicts in respondent data, and the frequency with
which the respondents identified each data segment. Counterexamples and category frequency
are two methods to ensure typicality of a category (Miles et al., 2014).
Moving from axial coding to patterns to findings was an iterative process. Miles et al.
(2014) described the process as “building the chain of evidence” (p. 291). The researcher used
enumerative induction, a method for aggregating data towards the research questions, and
eliminative deduction, wherein the investigator thoroughly investigated counterexamples or
alternate explanations.
During the data collection and data analysis process, the researcher created analytic and
methodology memos immediately after the first and subsequent interviews. Memos were
recorded in a research journal noting the name, location, respondent name, and unique

49
identifying code. The memos included the researcher’s reflections about the interview, ideas for
improving the interview questions, and areas to explore further with future participants.
Credibility and Trustworthiness
Maxwell (2013) asserted that credibility is the most crucial issue in research design
because readers must be able to determine that conclusions are believable and valid, especially if
a single researcher conducts the research. Maxwell (2013) defined credibility as “the correctness
. . . of a description, conclusion, explanation, or other sort of account” (p. 122). A primary
mechanism for ensuring credibility is to identify validity threats (e.g., researcher bias) and the
ability of the researcher to identify sufficiently alternative interpretations of the data to allow the
reader to make a sound judgment of the “correctness” of the conclusions (Maxwell, 2013).
Merriam and Tisdell, 2016) described credibility as being “congruent with reality” (p. 242). In
qualitative research, the reality is a multiplicity of experiences from interviewees, and the
researcher’s role is to highlight commonality, mutual meaning making, and disparities.
Several tactics exist to improve credibility and trustworthiness. The first method is
triangulation, which is a method to validate data from more than one source (Merriam & Tisdell,
2016). In this study, triangulation was employed by interviewing clinical leaders who lead staff
members with very different roles. For example, some clinical leaders managed nurses. Others
managed radiology technicians, while still others managed lab personnel. Each of these roles is
enacted in different environments and locales; therefore, they offer a semblance of triangulation.
Another method for ensuring credibility is member checks, or respondent validation
(Merriam & Tisdell, 2016). In this study, respondents were asked to review the first themes, and
they were asked whether the researcher had missed an important theme or misconstrued a theme.
This is a crucial step to reduce researcher bias (Merriam & Tisdell, 2016). Moreover, to ensure

50
that enough data was collected, the researcher assessed how many new themes the respondents
provided after several interviews had been completed. The researcher hypothesized that the main
themes would be recurring during the final interviews. This is called data saturation (Merriam &
Tisdell, 2016).
The credibility of research is focused on the believability or validity of the findings.
Trustworthiness is about the reliability of the research process: whether it is understandable and
reasonable, and whether the findings are consistent with the data collected (Merriam & Tisdell,
2016). This is an essential distinction from quantitative reliability in which an experiment can be
replicated. For qualitative research, the goal is to ensure that the researcher has adequately
reduced bias and reactivity during the research process, thus, avoiding errant conclusions.
Bias can imbue qualitative research during research design, data gathering and analysis,
and publication (Maxwell, 2013). Interviewer bias occurs when the observer knows the status
(Panucci & Wilkins, 2010). For example, if the researcher knows a respondent is in the lower
than 30% adoption rate group, the researcher could ask fewer questions, assuming the team
leader would not know how to respond. Recall bias occurs when a respondent’s recall is
influenced by how the respondent sees themselves in the context of the study (Panucci &
Wilkins, 2010). For example, if respondents know which group they belong to before the
interview (high- or low-adoption rates), they might color their story to fit their perception of a
high or low-adoption leader. Every researcher holds unconscious bias, which can lead the
researcher to see patterns and themes that are drawn from the researcher’s mental schema and
experience (Creswell, 2014). Furthermore, the researcher resides inside the organization;
therefore, as an insider, the researcher risks influencing respondent data were based on the

51
researcher’s positionality. As an insider, the researcher is also at risk of making errors in the
analysis by taking for granted absorbed cultural norms (Buetow, 2019).
To protect against interviewer bias, the researcher read the interview question script in its
entirety with each participant. To protect against real bias, the researcher did not inform the
respondent about the two check-in adoption categories, nor which category they fell into until
after the interview. Maxwell (2013) addressed researcher bias by exhorting researchers to
identify and explain underlying theories, beliefs, or perceptual biases that they hold. This
researcher comes from a technology industry and healthcare background, and has a long work
history in operations, and leadership and team development. This researcher holds strong beliefs
about pragmatism and the development of human potential. Social construction, founded on a
Buddhist belief of emptiness, informs this researcher’s view of reality and meaning making.
Moreover, as a White, middle-class male born in the 1960s, the researcher holds values and
beliefs from a privileged class of Americans. This reflection is yet the beginning of using
reflexivity to uncover unconscious bias.
Throughout the data collection and data analysis, and the research process, the researcher
reflected on biases with the help of a research journal and field notes that captured reactions
during interviews (Merriam & Tisdell, 2016). Field notes were used to capture the perceptions
and observations that the researcher made immediately after each interview. The researcher
captured feelings, judgments, or concerns that arose within the researcher during the interview.
Using the field notes as a reference, the researcher created a research journal, assembling
thoughts and questions about the patterns that the researcher was observing, and actively
questioned underlying assumptions or experience that the researcher held that might have been
influencing the identification of patterns. This study included “thick descriptions” of the

52
interview narratives to provide readers a context and enough information to judge the credibility
of the conclusions. Thick descriptions, field notes, and a research journal helped the researcher
reflect and make unavoidable bias visible during the research and analysis phases of this study.
As an insider to DCNC, the researcher is studying his social group, which brings up the
issue positionally (Greene, 2014). Positionality is determined by the values, norms, and
organizational structure of the organization, and is determined where the participant and
researcher stand within that context (Merriam, Johnson-Bailey, Lee, Kee, Ntseane, & Muhamad,
2001). The researcher took several steps to reduce the issue of positionality. First, the invitations
to participants were sent via the researcher’s education institution, and not from the
organization’s email system. The invitation made clear that the researcher was requesting the
interview as a doctoral candidate and not as a member of the Human Resources Department. The
researcher reiterated this point at the beginning of the interview and committed not to assign or
to take any work-related action items.
Ethics
Guidelines for ethical research of human subjects have been codified by Federal
Government regulation into the Policy for the Protection of Human Subjects and are commonly
known as the “Common Rule” (USC Office for the Protection of Research Subjects [OPRS]).
This study is grounded in ethical guidelines from the Common Rule and the University of
Southern California’s Institutional Review Board (IRB). In addition, in this study, the researcher
adhered to three important principles found in the IRB guidelines, and first outlined in the
Belmont report (National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research [NCPHSBBR], 1975; USC OPRS): respect for persons, beneficence, and

53
justice. The researcher’s responsibility to uphold these principles and ethics take precedence over
the researcher’s desire to generate new knowledge (Glesne, 2011).
Respect for persons was demonstrated through the researcher’s commitment to providing
subject’s fully informed, free choice in research participation (USC OPRS). Respecting people
began with the recruitment of subjects. Subjects received an email from the researcher requesting
their participation. In the body of the email, the researcher described the study, assuring privacy
and confidentially and voluntary participation; the researcher also assured the subjects that a list
of the participants would not be published or disclosed in any way. Respect for persons
continued during the interviews by beginning the session on research ground rules, privacy, and
confidentiality (Glesne, 2011). Pursuant to USC’s IRB requirement (USC OPRS), informed
consent was discussed and reviewed with each participant, wherein the study purpose,
voluntariness, privacy, confidentially, and data handling was described.
The Belmont (NCPHSBBR, 1975) principle of beneficence assumes the maxim of “do no
harm” by minimizing risks and maximizing benefits to the subjects (USC OPRS). The research
questions present minimal psychological or emotional risk to subjects, yet the researcher is part
of the organization under study, which could present ethical dilemmas. To minimize potential
coercion of the subjects, the researcher emphasized during the informed consent discussion that
their names would not be published within the study, nor would they be revealed to their
supervisor, and that their participation or choice not to participate would not affect their
reputation or career opportunities in any way.
Subjects were treated with the Belmont principle (NCPHSBBR, 1975) of distributing
benefits of research. The subjects did not receive monetary sums or gifts to participate; therefore,
the benefit that the researcher provided was a focused, listening partner, and a promise to share

54
the data collection and analysis section of the study with them (USC OPRS). In addition, the
subjects were chosen by random sampling from the engagement reports that the engagement
platform vendor generated; therefore, convenience sampling was avoided.
The researcher works within the organization under study; therefore, potential conflicts
and biases were identified. Glesne (2011) suggested that researchers might fall into various
advocacy or exploiter roles; therefore, to avoid this difficulty, the researcher of this study was
clear during the informed consent discussion that the researcher’s role was to listen empathically,
and not seek to fix the subjects’ problems, or to take on action items beyond the presenting
study. The researcher is also involved in the engagement process at an enterprise level; therefore,
the researcher discussed the results of survey data and interpretations with the research chair,
committee, and a work colleague to avoid conformational bias. Awareness of researcher bias and
role confluence, along with transparent informed consent conversations have been used
throughout the research process to ensure privacy, beneficence, and justice to the human subjects
in involved.
Limitations and Delimitations
As the researcher developed the methodology and subsequent data collection analysis,
limitations, and delimitations affecting outcomes emerged. Limitations are factors that might
weaken this study (Bloomberg & Volpe, 2008). The limitations of this study are listed here.
• Qualitative interviews are subjective by nature and the inherent bias of the researcher
can influence them.
• Some participants knew the researcher; therefore, they could have adjusted their
comments to be more consistent with their work relationship, or respondents could
have become more guarded in their replies.

55
• More low-adoption managers declined to participate than high-participation managers
by a rate of 2 to 1. The higher decline rate is valid data, but the researcher has no way
of validating the underlying cause.
• Respondents were contacted by the researcher’s institutional email server.
Delimitations describe how the researcher narrowed the scope of the study and the effects
of the researcher’s choices (Bloomberg & Volpe, 2008). Delimitations in this study are related to
researcher choices about the sample size and clinical managers as the unit of focus for the study.
The delimitations are listed here.
• Five clinical managers with the low-adoption manager were interviewed. The
percentages reflect a high sensitivity of change from just one respondent.
• Clinical managers, as respondents and not staff members, might have had very
different perspectives on the value of check-ins.
• Clinical managers were at the extremes of performance (high and low), and not the
middle range.
• Clinical managers, and not other managers (e.g., food services and housekeeping
managers), might have brought up very different themes, including language barriers
and computer literacy skills.

56
Chapter 4: Results and Findings
In this study, the researcher sought to identify the conditions and behaviors that support
the successful adoption of clinical managers and staff check-ins. Check-ins are an essential
aspect of DCNC’s employee engagement strategy, intended to build relational strength between
team leaders and team members. Check-ins are a vital intervention to combat burnout in health
care environments and to provide a setting in which employees can thrive. A qualitative
interview method was employed to identify the clinical manager’s needs and assets that were
related to the KMO factors that led to the gap between check-in performance and goals. In this
chapter, the researcher describes the stakeholders of the study and findings. The researcher used
sought to answer the following questions in this study:
1. What are the stakeholder knowledge and motivation needs and assets related to
achieving the clinical manager check in goal of 60%?
2. What are the organizational needs and assets related to achieving the clinical manager
check in goal of 60%?
3. What are the barriers to adopting check-ins?
4. What recommendations for organizational practice in the areas of KMO resources
might be appropriate for solving the problem of practice?
Participating Stakeholders
The population of focus for this study included clinical leaders within DCNC who have a
team size of three or more staff members. For this study, 10 leaders whose teams have adopted
check-ins at a rate of more than 60% on average for 3 months or more were selected for the
sample. In addition, five leaders who have adopted check-ins at a rate of less than 30%
participated in interviews. The researcher sought to learn about both the challenges and

57
promising practices, from those managers with the highest and lowest adoption rates, that is, the
extremes. See Table 4 for a comparison of the sample criteria of high or low adoption compared
to the check-in rates within the DCNC population.
Interview Participants
Respondents came from leaders of clinical and patient-facing areas. Clinical leaders
represented in-patient nursing, laboratory groups, and clinical specialties such as cancer care,
primary care clinics, and labs. The researcher made an attempt to enroll participants from the
neuroscience and surgery units; however, no response was received from those managers. See
Table 4 for a comparison of clinical managers from various functions compared to the DCNC
population, as well as comparisons of respondent locations versus DCNC locations. Other than
the neuroscience and surgery groups’ lack of representation, respondent location and function
closely aligned with the DCNC population distribution.
Table 4

Respondent Check-In Adoption, Location, and Function
Percentage (%)
Category n Sample ALL DCNC
Check-in adoption
>60% 10 66 39
<30% 5 33 25
Location
800P 8 53 60
RWC 1 7 14
CCSB 2 13 9

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Percentage (%)
Category n Sample ALL DCNC
VC 2 13 13
Other 2 13 6
Function
Nursing 6 40 43
Oncology 3 20 18
Ambulatory 3 20 17
Lab 2 13 10
Phys therapy 1 7 1
Nuero/ED/surgery 0 0 9
Note: DCNC data from DCNC Workforce Assessment. (2017). Performed by Accenture.
School of Medicine data from School of Medicine Diversity Dashboard, 2018.
Average tenure at DCNC for current managers is 9.7 years, while the average length of
time in current role is 3.8 years. The respondents in the sample had an average tenure of 10
years, and their average time in role was 4 years. The average span of control enjoyed by clinic
managers at DCNC is 25, while the respondents in the sample managed an average of 25 staff
members. See Table 5 for a comparison of DCNC managers and sample participant tenure and
span of control.

59
Table 5

Tenure and Span of Control
Mean
Category Sample DCNC Sample range
Tenure (yrs) 10 9.7 4–20
Tenure as clinic manager (yrs) 4 3.8 1–17
Span of control (staff) 25 25.0 4–60
Note. Data from DCNC’s Human Resource Report, 2020.
The researcher has used pseudonyms for managers throughout this chapter. Pseudonyms
are listed in Table 6.
Table 6

Pseudonyms of Interview Participants
Pseudonym
Tenure at
DCNC
Tenure
managing
clinical staff
Staff
members
<60% or
>30% Location Function
Victor (HM) 20 17 60 60 VC Lab
Valorie (HM) 10 8 28 60 800P Nursing
Nancy (HM) 12 8 23 60 VC Physical therapy
Cynthia (HM) 6 6 5 60 CCSB Cancer Center
Cora (LM) 5 5 24 30 800P Cancer Center
Kristy (LM) 15 5 14 30 800P Nursing
Peter (HM) 4 4 48 60 800P Nursing
Denicia (HM) 4 4 11 60 Other Ambulatory
Cathy (LM) 8 4 4 30 RWC Ambulatory

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Pseudonym
Tenure at
DCNC
Tenure
managing
clinical staff
Staff
members
<60% or
>30% Location Function
Minnie (HM) 14 4 79 60 800P Nursing
Matt (LM) 6 3 20 30 Other Ambulatory
Sean (HM) 6 3 25 60 800P Cancer center
Bron (HM) 8 3 25 60 800P Nursing
Margareta (LM) 12 1 15 30 SBCC Lab
Eddie (HM) 15 1 24 60 800P Nursing
Note. (HM) = high-adoption manager. (LM) = low-adoption manager. Names will appear with HM or LM
throughout this chapter.
Results and Findings
This section provides the findings from the interviews. The findings provide answers to
the first two research questions, which were focused on the needs and assets related to KMO
influences. Barriers are presented, followed by recommendations from participants. The chapter
closes with a summary of the findings.
Research Question 1
What is the stakeholder knowledge related to achieving the check-in goal of 60%?
Knowledge Results
In Chapter 2, the researcher introduced knowledge factors hypothesized to influence the
achievement of the 60% check-in goal. Through interviews, three knowledge factors were
investigated and analyzed. Contrast and comparison between managers with high check-in
adoption rates and managers with low-adoption rates helped to reveal a pattern of assets and
needs that emerged from the data. The researcher was able to validate the need to understand
check-in platform navigation. The researcher also confirmed the importance of declarative

61
knowledge of one’s strengths, and the metacognitive knowledge of applying strengths when
coaching others. However, the researcher found no difference between high- and low-adoption
managers in terms of knowledge of strengths-based theory, as framed in Chapter 2.
Declarative knowledge regarding employee engagement, its importance, and
strengths-based theory. In Chapter 2, knowledge factors were identified that would likely
influence team leader check-in performance. The first influence was employee engagement, and
its importance, and strengths-based theory. Most of the respondents offered a wide variety of
definitions for engagement, and knowledge of strengths-based theory was superficial among
respondents. Therefore, the researcher cannot validate that knowledge of employee engagement
definitions and knowledge of strengths-based theory were relevant influencers for check-in
performance.
However, high-adoption leaders could describe their strengths at great lengths, and use
check-ins to coach team members to use their strengths. High-adoption leaders could also make a
connection between strengths and professional fulfillment. Knowledge of strengths was an asset
to high-adoption managers, while low-adoption managers needed to learn about their strengths
and learn how to use check-ins to help them use their strengths.
See Table 7, for the different levels of knowledge between high-adoption managers and
low-adoption managers. “Level of knowledge” represents the percentage of respondents who
identified the factor during the interview.

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Table 7

Distribution of Factual Knowledge about Strengths, Check-ins, and Engagement
% of managers who identified the component
Component High-adoption managers Low-adoption managers
Knowledge of strengths 10 2
Encourages own and others use
of strengths
9 2
Strengths and engagement 7 1
Note. Sample n = 15. For high-adoption manager, n = 10. For low-adoption manager, n = 5.
Knowledge of Strengths: Knowledge of strengths was found to be an important factor
contributing to the check-in performance gap. Knowledge of one's strengths was a significant
asset for high-adoption managers. Every high-adoption manager was able to describe their
strengths and shared colorful and detailed examples of their strengths at work. Sean (HM)
described his use of strengths at work:
For me, I love educating, and shows up for me when I do in-person rounds in the unit.
It’s the most energizing time of the day for me, being with patients, and then I get to have
conversations with staff, and teach them. Also, I love when people come to me, I love it. I
try to tell them where the resources are located to get their answer, rather than just telling
them [the answer].
Sean (HM) demonstrated that he understood his strengths and went further by describing
how he used his strengths. Minnie (HM) shared her strengths regarding thinking skills, and how
she uses problem-solving strategies that emphasize her strengths:
The creator part of me . . . likes to look at things and figure out why they are that way and
how I can come up with a plan to implement something. And it takes me time; I'm not the

63
kind of person who can just like come up with a plan and run. I like to . . .think about the
potential consequences or implications of a solution.
Only two of five low-adoption managers knew their strengths and provided examples of
their strengths in use. Cora (LM) said, “Hmmm, what am I?” Cathy (LM) said “I don’t know. I
know I should know.” Margareta (LM) was not sure either. However, Kristy (LM) and Matt
(LM) were very familiar with their strengths and provided examples of how they use their
strengths at work. Kristy (LM) said:
I’m an advisor and teacher. I’ve always enjoyed teaching, not as a career, but teaching
when precepting, being in charge, conducting discharge education, taking that time with
people to help them understand. Advising . . . also comes naturally. It’s then I’m able to
give staff time, as opposed to just tasks . . . that I feel strong.
Kristy (LM) understood her strengths, and the way that they made her feel when she used
them. Matt (LM) felt enthusiasm when using his strengths:
My StandOut roles are creator and stimulator . . . I thought “Hey, it is me,” and others
said, “Yes it’s you” . . . I’m very curious about workflows, processes, and I get creative
in how we can make things more efficient, and better. I also try to get people excited
about programs, though sometimes I get eye roles, based on my enthusiasm.
Both Kristy (LM) and Matt (LM) described their strengths in detail, yet the other three
low-adoption managers were at a loss. High-adoption managers learned their strengths and
learned how to use them; therefore, knowledge of strengths is an asset for high-adoption
managers and a need for low-adoption managers.
Encouraging Use of Strengths: Nine of ten high-adoption managers were able to help
their staff use their strengths. Only two of five low-adoption managers encouraged their team

64
members to use their strengths. The check-in process starts with strengths. To gain access to the
check-in platform, one must take a strengths assessment that is stored on the check-in platform.
One of the check-in questions is, “I used my strengths at least once every day this week.” The
DCNC engagement strategy is heavily weighted towards two behaviors: frequent check-ins and
use of one’s unique strengths, guided by strengths-based theory. When team members are asked
to enter what they love and what they loathed from the week before in their check-in, they need
to consider how they applied their strengths in invigorating ways. If neither the manager nor the
staff member knows their strengths, then the check-in is less valuable. Likewise, a focus on
strengths gives managers a touchstone to coach their employees to improve performance and pair
their strengths with others. Nancy (HM) describes how she pairs staff members according to
compatible strengths: “It’s great to be able to look at that and say, oh, here’s somebody that it
might have the strength and I might be able to use that with my strengths.” High-performance
managers encourage strengths by challenging staff members to think about their work in new
ways and to find opportunities to use them. Bron (HM) described how he encourages staff
members to use strengths beyond regular job duties:
I’ll ask, “What do you like? Do you like to teach, educate?” And for some of them,
they’ll say, “You told me I’m not ready to precept.” I’d say, “That’s true. You’re not
because of criteria you haven’t quite met. But that doesn’t mean that you can’t educate. I
mean every day we’re talking about things, so take that opportunity upon yourself. Go
talk to the person next door about what they’re doing. And, if you know, down the line,
educate them. This is where you’re gonna find fulfillment in your job.” It’s really about
empowering people to take these things and go do it. I’m not trying to hold people back
from any of it.

65
Bron (HM), Nancy (HM), and seven other high-adoption managers expressed their active
encouragement, and coached staff members to improve and use their strengths, which is an asset
for check-in adoption.
Only two of five low-adoption managers gave examples of how they encouraged staff
member use of strengths. Kristy (LM) thinks of staff member strengths when selecting staff
members for projects. Kristy (LM) said, “When we need nurses for things like committee work,
I’ve used the strengths roles to think about who would be good at a project.” Cathy (LM) tried to
accommodate staff members to take on more tasks that were aligned to their strengths:
I definitely try to understand the strengths. No one can pick and choose what they want to
do . . . but you realize there is wiggle room for people to be assigned specific tasks or
activities that aligns with their interests . . . So over time, I’ve come to accommodate that
whenever possible.
Although Kristy (LM) and Cathy (LM) did not say that they coached staff members to
use their strengths, they do consider strengths when assigning work. Encouraging staff members
to use their strengths is an important tactic within DCNC’s engagement strategy. Nine of 10
high-adoption managers actively encouraged staff members to use their strengths, and
encouraging strengths is a need for low-adoption managers.
Strengths Contribute to Engagement. In Chapter 2, the researcher hypothesized that
knowledge of strengths theory and strengths would contribute to check-in adoption. Seventy
percent of high-adoption managers were able to describe a strong connection between the words
“strength” and “engagement.” High-adoption managers described how strengths could bring
fulfillment and high achievement. Eddie (HM) said:

66
Yeah, I would say at DCNC, we use the check-in platform to assess our employees’
strengths, and then help them understand what those strengths are so that we can get help
[for] them at work, every day, to utilize those strengths so they will be happy and fulfilled
in their jobs to feel they do good work.
Eddie (HM) described the sense of fulfillment that can arise with strengths use. At
DCNC, the strengths assessment, strengths use, answering questions about using one’s strengths
in check-ins, and the quarterly engagement pulse that is used to measure engagement are
intertwined. Victor (HM) described the use of strengths in terms of achievement and motivation:
I want them to be here and that they like what they do. They like whom they’re working
with. And it motivates them to go above and beyond on their own without me having to
say.
Both Victor (HM) and Eddie (HM) described the desire to help their employees via
strengths use and check-ins to achieve more exceptional performance and fulfillment. The three
high-performance managers who were not able to describe how strengths lead to higher
engagement spoke about strengths as a means to build teamwork within the group, by celebrating
what each person uniquely brings. It is clear that knowledge of the connection between strengths
and engagement is an asset for high-adoption leaders.
Only one of five low adoption leaders could describe a connection between strengths use
and engagement. Matt (LM) described his own engagement when using his strengths:
I get fired up troubleshooting why a problem might be caused. I take it from a physical
view of space, that my staff has to work through, putting myself in their shoes. For
objective, data driven decisions, people can rely on me. That’s when the longer hours
kick in and I don’t notice the time.

67
Matt (LM) did not make an explicit connection during the interview between the staff
member strengths and check-in engagement; however, he described his own feelings of vigor
and absorption when using his strengths.
Other low adoption managers were able to offer a description of engagement that did not
include strengths or check-ins. Margareta (LM) described engagement as “being a part of
something . . . and being involved.” Cathy (LM) said that fairness was important to engagement
because people do not want to be overlooked. In addition, Kristy (LM) described engagement as
making a difference. Kristy (LM) said, “It’s when I know I’m making a difference with
something. For example, navigating a difficult discharge and helping someone go home or into
hospice to die where they want to be.” Making a contribution to the mission, belonging, and fair
treatment made up their definitions of engagement.
Seven of 10 high-adoption managers articulated the use of strengths and check-ins with
higher engagement, while only one of five low-adoption managers could do so. Low-adoption
leaders need to gain knowledge of the strengths, check-in, and engagement connection to
increase check-in rates.
Procedural Knowledge Regarding How to Use the Check-In System. Regarding how
the check-in platform was typically understood and navigated, 10 out of 10 high-adoption
managers described the four main components of the check-in platform, inferring their
knowledge of navigating the platform. The four components of the check-in platform included
(a) the mobile application, (b) the check-ins, (c) the strengths reports and coaching tips, and
(d) the engagement pulse checks. All the low-adoption leaders struggled to describe the check-in
platform, suggesting knowledge of the platform components represents a vital knowledge factor
for high adoption.

68
Eddie (HM) described the mobile application as easier to use. He said, “It just goes
‘click,’ and you put whatever your plan and goals are for the week.” When describing check-ins
on the platform, Peter (HM) focused on the navigation and features, such as sending reminders to
staff to check-in. Bron (HM) described the coaching tips on the platform as:
Clicking on the coaching things. You can understand how someone likes to be coached,
how they like to be recognized, how they like to do things and help them figure out what
is going to fulfill them that work.
Peter (HM), Eddie (HM), and Bron (HM) demonstrated that they understood how to
navigate the mobile application and check-in platform, and described how they put their
knowledge into action. Valorie went a step further by describing how she teaches staff members
to use the platform:
I also show an example of a check-in. I show them under ‘home,’ or ‘coaching’ . . .where
you can turn things on and off. I show them different aspects of it. I might even bring up
someone’s check-in and show them an example. For new people, I ask them if they’ve
done their assessment and their check-in. and if they say no, I pull up the website right
then, and we do it right then and there.
Valorie demonstrated her knowledge by describing how she taught others how to
navigate the platform. Knowledge of the check-in platform was an asset for high-adoption
managers.
Margareta (LM) described how to use the platform by logging in and looking for any
priorities entered by staff. However, when asked about functions (e.g., check-in trends and
coaching tips), she said, “Oh, where are those?” Cathy (LM) admitted that she did not use the
platform very often because only a couple of her staff members checked in on it. Although it is

69
difficult to determine whether the limited knowledge of the platform was a cause of low
adoption, or the effect of low adoption, low-adoption managers need to understand the check-in
platform components, process, and navigation steps to increase check-in adoption.
Metacognitive Knowledge About How Managers Affect Team Members When
Encouraging or Responding to Check-Ins. In terms of metacognitive knowledge, nine of 10
high-adoption managers demonstrated that they had metacognitive knowledge that was related to
how they affect team member check-ins. Among low-adoption managers, only two of five
managers expressed this kind of metacognitive knowledge. This section provides more additional
details regarding metacognitive knowledge.
Responsiveness to Team Members. When asked about how they influence check-ins,
seven of 10 high-adoption managers shared that they responded to check-ins quickly. Minnie
said, “I also have a personal thing that, if somebody checks in, I need to respond. It’s not kind to
make them feel like they have to do it and then not answer.” Denicia (HM) shared a similar sense
of responsibility, saying, “If they check in on a Friday, I’ll get back to them on a Friday. I’m a
rule follower and I know you guys say get back to them on Monday, but in a small clinic, that’s
too long.”
Minnie (HM), Denicia (HM), and five other managers described this commitment to
respond to staff member check-ins. Although the interview questions did not specifically ask
about quick response to check-ins, seven of the high-adoption managers said they attended to
check-ins quickly. Responding quickly to check-ins is an asset for high-adoption leaders. Zero of
five low performing managers identified quick response to check-ins as a consideration.
Alignment to Strengths. Regarding how check-ins were typically approached and
conducted, six out of 10 managers shared that they generally aligned their approach with their

70
strengths. For example, Bron (HM) shared that one of his strengths is energizing staff members;
hence, he typically draws on that during his check-ins:
I like getting people excited about stuff. And that comes in very handy in this role
because things are constantly changing. I think everybody is grasping for some normalcy.
I have a person on my staff having a little bit of a hard time with all the changes because
to her, the world [is] very black and white. But I tell her, “It’s okay. You have to frame
things in your mind that works for you and use your talent in a way that you can kind of
get the stuff done that you need to get done.” So you have to find ways to get people
excited and be like, okay. This is how it is. It’s going to be great.
Bron (HM) reflected on how to affect check-ins by using his own strengths. He found
that he was the most effective when he did so. Eddie (HM), who loves to use his expertise to
advise staff members when they have challenges, said,
One of the newer staff members that we just hired recently, last May, asked me in her
check-in, “How am I doing so far?” I knew there was an issue that she loathed; staying on
watch in an isolation room. She was thinking of it as a waste of time. I advised her to
have a plan set before you even step inside the room. They think of the things that you
will need to do at your initial patient contact and then do them simultaneously. Or
multitask, you know, to make the [stuff] inside that room go faster. And if that’s the only
patient that you have during that day, there’s always the anteroom where you can work.
So, I mean, those are basic things. I'm applying what I use, what I learned at the bedside
and trying to advise others and newer members of staff.

71
Bron (HM) and Eddie (HM), along with four other high-adoption managers intentionally
used their strengths during check-ins. Use of one’s strengths is an asset for high-adoption
managers, both for check-in adoption, and their own, personal engagement.
Space for Reflection. Five of the 10 high-adoption managers paused during the
interviews and discussed how check-ins help them to reflect on their past week, and their
strengths, and how they could perform better. Reflecting on their strengths and upcoming
priorities was an asset for high-performing managers. Scott (HM) said:
I think that having the opportunity to reflect on things that can become strengths I didn’t
think were strengths before. I think it’s been very beneficial. And I think that that’s one
of the key things that I’ve used with check-ins. Other than checking in with those who
will check in with me or checking in with my direct supervisor, and then just reviewing
how things go the week, it’s almost all self-reflective.
Scott (HM) recognized the valuable opportunity to pause and think about the past week
and plan for the coming week using check-ins. Another way that high-adoption managers
reflected when using check-ins was to consider the kinds of projects they would like or even
where they would like to move in their career. Minnie (HM) described how check-ins helped her
determine her next career move:
I like the understanding of the roles. It made me look a little bit more, and reflect on why
I was doing what I was doing. And I think it did help me decide that I wanted to
transition into this role because I felt like I could continue that role and do that.
High adoption managers said they did not get a lot of time in the week for reflection, and
check-ins allowed them a ‘reason’ and a timeframe during the week in which to reflect on their
performance. However, the low-adoption managers did not identify space for reflection as

72
motivating factor of check-ins. Margareta (LM) did not feel her job lent her time for reflection.
Margareta (LM) further described the time required to reflect as a barrier:
I think that's the hard part about check-ins: it really makes you dig into your emotions
and feelings. I think “Oh, God, you're gonna make me go there?” The phlebotomy labels
are pouring down and you want me to answer this?
The rapid pace of Margareta’s (LM) job makes checking in feel like a burden. Cathy
(LM) believed her staff members were not interested in reflection and direct communication and
would rather communicate indirectly, with hints and nonverbal cues. Cathy (LM) said,
Many of my staff members would just rather bring up needs and dissatisfiers with hints,
and body language signals. Check-ins are difficult for them because they have to spend a
lot of time thinking about how to communicate in a way that won’t wind up hurting them.
Both Margareta and Cathy haven’t realized the benefit of check-ins as a valuable time to reflect.
Metacognition played an important role in how managers responded more effectively
with staff and reflected on their own performance. However, while low-adoption managers may
find time to reflect on their past and future week, they did not find reflection time to be of value.
Additional Knowledge Needs. Although the high-adoption managers described how they
work with their staff on using more of their strengths, their journey was not without bumps or
challenges. The managers went through a change process, in which they had (a) to adjust to a
new way of thinking, (b) to use trial and error while balancing productivity with the tasks that
people love, and (c) to find solutions that were productive for them and their staff. Two
managers described their own experience in warming up to strengths and check-ins. They
described a process that Bridges (1986) called “transitions,” which presents a model of internal
change: loss, transition, and new beginnings. Bron (HM) described his transition:

73
I do remember when I first saw them, I was like, I don’t know if I buy into it or like agree
with it. But I think the more I did activities to try and understand it; it made sense to me
that I chose those things.
Bron (HM) made sense of the change that DCNC introduced with check-ins over time,
shifting the activity from something that he had to do, to internalizing it as something that he
wanted to do. Internalization is an essential step toward commitment (Higgs & Rowland, 2010).
Other high-adoption managers discussed the struggles that arose even after they made the mental
shift to embrace check-ins. They had to find ways to reduce the tasks that employees loathed,
while increasing the tasks that they loved. Minnie (HM) said,
It’s a struggle, too. I talk to them about their strengths, but I don’t feel I can say, “Oh, I
can take this away because you don’t like it,” you know? I mean, like, “It’s not your
strength. So you don’t have to do it.” That’s not true for any of us. You still have to do
the task, whether or not you like it.
Minnie (HM) was in the process of finding the right balance between productivity and the
use of strengths. Cynthia (HM) described her development as a manager; she saw more
opportunities to open up to encouraging strengths without losing control of focused productivity:
I try to understand their strengths. You know, when I was a manager coming in, I
thought, OK, everybody has to do the necessary levels of the job. No one can pick and
choose what they want to do. And so, I tried to implement that as a baseline. But then,
over time, you realize there is wiggle room for people to be assigned specific tasks or
activities that align with their interests. But with the understanding that all the things that
you don’t like to do are still a part of your role, but you carve out some time for things
that you are interested in because it benefits the clinic, too.

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Cynthia (HM) was farther along in the process of finding the productivity balance that
was required for intentional strengths use. High-adoption managers held greater declarative and
conceptual knowledge about strengths and check-ins than did low-adoption managers. High-
adoption managers employed frequent metacognitive knowledge when considering the check-in
task, their strategy for increasing adoption, and self-awareness of their journey through change.
Knowledge was an essential asset for high-adoption managers.
Motivation Results
In this section, the researcher introduces the motivational influences that were identified
in Chapter 2 along with the qualitative interviews. The first influence, utility and intrinsic value
of check-ins, was validated with high-adoption managers, and it represented a motivational need
for low-adoption managers. Another influence, attributing success to factors within one’s
control, was partially validated. The last motivational influence, mastery over performance
orientation, was validated for high-adoption managers. In this section, the researcher will review
further each of these three motivation influences.
Purpose and Meaningfulness. Pertaining to meaningfulness, all high-adoption managers
found that check-ins improved the relationships with staff members and inspired mutual help-
giving and prosocial behaviors. High-adoption managers identified numerous benefits from
check-ins that were aligned with both utility and intrinsic value. Managers with higher adoption
rates identified several benefits from check-ins, while managers of low-adoption groups were
less likely to identify benefits. Ten of 10 managers with higher adoption rates identified benefits
from check-ins, and only two of five managers with lower adoption rates could identify a benefit.
The most commonly identified benefits from check-ins were (a) finding meaning in check-ins,
(b) strengthening connections between manager and staff, and

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(c) structural synergy. The perceived value of check-ins was an asset for high-adoption
managers, and a need for low-adoption managers. See Table 8 for the percentage of high- and
low-adoption managers who identified benefits.
Table 8

Value and Meaning Placed on Check-ins
% of managers who identified the component
Component High-adoption managers Low-adoption managers
Finding meaning in task 9 2
Connections and relationships 10 2
Structural synergy 6 0
Sample n = 15. For high-adoption manager, n = 10. For low-adoption manager, n = 5.

Finding Meaning in Check-ins and Strengths: Nine of 10 high-adoption managers
identified a sense of meaningfulness, intrinsic satisfaction, and help-giving behaviors that arose
from check-ins. Only two of the five low-adoption managers highlighted that they found
meaning in the check-ins.
Using strengths in the context of check-ins was identified as a means of finding
fulfillment. Bron (HM) described this when discussing how he talked about check-ins and
strengths with his staff:
You guys need to be finding these things out because (maybe) your whole life . . . you
want to be happy. I say no. If you want everybody to be happy, you’re probably going to
fail because that is not life. Life is not always happy. I don’t think the human condition is
always built to be happy. However, it’s built for you to find fulfillment. And with check-

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ins, that’s what I see in it; it’s always about the fulfilling part, like finding the strengths
that make you fulfilled at work and then trying to use those things.
Bron (HM) has identified greater meaning for the check-in task and connected it to using
one’s strengths to find fulfillment. The task now has intrinsic and attainment value for him.
Feeling a sense of meaning can lead to the adoption of prosocial and helping behaviors (Dik et
al., 2012). Peter (HM) shared how he uses check-ins to help staff members when they identify
challenges or ask for help:
Nurses love working with patients and hate paperwork and forms. And it’s a cry for help
in a way. One person recently wrote [that] she loathes peer-to-peer feedback. She is
covering multiple clinics, and her physicians were delegating the peer feedback to her,
which wasn’t fair. We were able to address this because she put it in her check-in.
Peter (HM) enjoyed helping his staff members to solve problems, as did six other high-
adoption managers. Peter (HM) further described his enjoyment in responding to check-ins and
helping staff members to do what they do best:
I really enjoy the check-ins with the folks who do it . . . I look for ways to use their
strengths, connect their strengths to the work their doing. If someone likes to teach, I look
for opportunities for them to educate.
Peter (HM) felt a sense of satisfaction and pleasure in conducting check-ins; the activity
itself supplied the reward. Valorie (HM) described the intrinsic satisfaction gained from check-
ins:
I want to know how they are using their strengths and getting joy out of what they’re
doing. I love doing rounds, and this relates to how I show up as a “teacher” and
“provider.” I’ll ask the staff, for example, “How can you use your ‘connector’.” They

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might say, “I don’t know,” but I’ll push a little. I’ll ask, “What gives you energy? You’re
a teacher, and when you teach, you get energy.” Check-ins and journaling is a fantastic
method for finding strengths.
High-adoption managers found value and meaning in check-ins and strengths use. Two of
the low adoption managers found check-ins to be meaningful, albeit in ways other than
supporting fulfillment and enjoyment. Margareta (LM) found that the priorities that her staff
enter helps her to focus her attention when she receives a check-in. Margareta (LM) said,
I focus more on priorities. Because a lot of things are thrown at me. I have emails, phone
calls, questions, and meetings daily. And I honestly have a hard time juggling and time
management; making sure everything is getting looked at. So yeah, check-ins help me in
a sense, to be able to say do these three things are a priority.
Margareta (LM) believed it was helpful at times to know her staff member’s priorities.
Matt (LM) said he intends to make check-ins more meaningful:
I’ve asked people to check in the month before we meet one on one. This is more of a
recent initiative. I’m trying to connect the process of checking in and having a one-on-
one meeting. I’m also trying to focus more on recognizing staff for good work.
Although he had not yet achieved a high-adoption rate, Matt (LM) was hoping to
improve check-in rates in his unit. High-adoption managers found value and meaning in check-
ins and the use of strengths. Two of five low-adoption managers understood that check-ins could
be valuable, but they had yet to experience much value.
Connections and Relationships. Every high-adoption manager said check-ins helped
create stronger relationships with current and new staff members as well as night shift staff
whom the managers rarely see. Check-ins also gave managers a sense of how the team was doing

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emotionally. None of the low-adoption managers discussed this as a core benefit. Creating new
and stronger relationships between managers and staff was a motivational asset for high-adoption
managers.
High-adoption managers appreciated how check-ins helped them to know staff members
better. Denicia (HM) said, “I feel like I’m getting to know people, and I think check-ins are a
better tool than others – the love/loathe questions, and what are you working on, and how can I
help, questions are great.” Denicia (HM) used the responses to check-in questions to understand
staff members’ strengths, priorities, and requests for help.
In addition, check-ins were helpful to high-adoption managers to connect with staff
members who did not regularly interact with them. Sean (HM) described his newfound
relationship with one of the long-time staff members:
He’s older than me. He has more experience as a nurse than I do. However, I feel good
that he’s willing to come to me. It’s almost like a confidence booster as a leader that he’s
willing to come in and talk to me about these issues and work with me and continue to be
open, even if I don’t have the answers or can’t find the answers right away for him. I
think these are the kinds of relationships I’m developing by using stand out.
After the introduction of check-ins, Sean (HM) was able to connect with a staff member
who had more experience and had not interacted with him very often. Minnie (HM) experienced
the development of new relationships with a team member who was usually quiet and not very
interactive:
I do have one team member who uses check-ins religiously. She’s very quiet, sweet, cute,
but she won’t communicate when she’s here or face to face. But on the platform, she

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unloads it all. We can have a conversation and dialogue. What’s going well, what she’s
loathing, and her priorities. She knows it’s a safe environment.
Physical barriers present challenges to manager/staff relationships as well. Hospitals run
24 hours a day, but managers typically only work from 8:00 am to 5:00 pm. Four of 10 high-
adoption managers expressed that check-ins enhanced their ability to connect with staff on night
shifts. Minnie (HM) said, “This is a means of staying in contact with each other, a channel for
communication . . . a quick way to communicate with the staff, especially the night shift folks.
They might not feel comfortable putting things in email.” Valorie (HM) also described her
connection to night shift employees:
I have employees who work the night shift, and I try to see them once a week, but
sometimes they’re not always on the day when I’m here. It’s a good way for them to say,
“Here’s what I need.” I tell them, “I want to know how you’re doing” and “I’m so glad to
hear you’re doing that. That’s so great.” And it just reaffirms what they’re doing. So I
love it. I do.
Check-ins allowed these managers to connect with employees they might not see in ways
that were more meaningful. Managers expressed these connections as going deeper than work-
related relations go. Check-ins helped them to understand staff on a personal level and helped
them to understand that what happens outside of work can affect the work itself. Sean (HM) said:
The things they share in their check-ins are important to them. Moreover, I find that they
share not only work stuff, but sometimes personal things. I know what’s going on in their
lives outside of work, which affects how they come to work. I do think check-ins are
meaningful because they help me know what’s going on with them to connect better. I
can say, “I’m sorry that you’re going through that. What can I do to support you? Do you

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need time off? Do you need the employee assistance program,” Those kinds of things. I
do think that it’s meaningful.
Sean (HM) was able to help his staff members beyond work and demonstrate his caring,
thus deepening his relationship with them. Check-ins helped Sean (HM) understand a fuller
picture of his employee’s lives. Likewise, check-ins helped managers understand the team’s
mood beyond what they would know from their daily work. Cynthia (HM) said, “I get a sense of
what’s going on out there with check-ins. That’s helpful because they don’t always come and tell
me.” Peter (HM) echoed Cynthia (HM)’s statement, and believes that the knowledge makes him
a better manager:
I express to others that, by checking in, it’s taking a temperature of how you’re doing. It’s
another way to communicate, a discreet way. When I get participation or get others’ [to]
check-in . . . it helps me know how to improve as a manager.
By identifying the benefit of more significant connections, managers have found the
means to be more inclusive, open, and aware of the team’s challenges. Experiencing deeper
connections with staff is an asset for high-adoption managers and a critical motivation influence
in the adoption of check-ins.
Structural Synergy. Check-ins have utility value because they help managers complete
complementary tasks. Six of all 10 high-adoption respondents noted that the structure provided
by check-ins had improved the quality of their one-on-one conversations, their performance
feedback, and their evaluation of staff members. Managers spoke about the usefulness of check-
ins throughout an employee’s tenure, from hiring to ongoing appraisals. The synergy between
check-ins and other processes demanding manager attention was an asset for high-adoption

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managers. Low-adoption managers did not identify any synergies between check-ins and other
processes, as they did not use check-ins enough to realize synergies.
High potential managers found ways to use check-ins when hiring, assessing, and
improving the one-on-one conversations with staff members. Bron (HM) described how he used
strengths questions in interviews, and actively sought out candidates with complementary
strengths for his team:
When we’re going through the hiring process, people don’t yet know about check-ins or
how we use strengths. But . . . I try to . . . think about the overall thing I want. Like we
can’t hire the same person over and over. I want to hire different people. Maybe they are
really quiet, and you’re wondering about who they are as a person, but they’re very
competent, and they’re going to come in and do this job well. And you need some of
those people. You also need some of the people who have a lot to learn, but they’re
present and willing to learn. Their attitude is so uplifting. You need people like that, too. I
think about hiring a mix of different people.
Bron (HM) used what he was learning about strengths from check-ins, to consider
complementary strengths of potential new hires. Once team members are hired, managers need a
way to assess their progress. Minnie (HM) described how check-ins help her infer competency
level of new staff members:
They’ll also tell me about what they loved or loathed, which I think gives me a sense of
where they are in terms of competency. One of them wrote, “I loathed fixing an arterial
line.” And to me, that’s kind of basic. It gives me a sense that maybe we’re in the novice
region with this person.

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Minnie (HM) used the check-in to help her conduct an essential clinical manager duty:
assessing clinical staff skills. Eddie (HM) built on the need to assess staff by using check-in
histories to perform performance reviews. Eddie (HM) said, “It’s easier to write their evaluations
because it’s all in there, and you don’t need to address it on a yearly basis.” Both Minnie (HM)
and Eddie (HM) connected check-ins to other processes without being trained or told; they
discovered new uses for check-ins by first adopting check-ins and then seeking synergy with
other processes.
High-adoption managers found two other uses for check-ins: improving one-on-one
meetings and helping staff members connect their work to DCNC’s mission. Three of 10 high-
adoption managers noticed that check-ins improved the quality of the conversations that they
were already having with staff members. Cynthia (HM) said, “As managers, we did one-on-
one’s, but having check-ins has made the intention of good one-on-one’s more tangible and
visible.” Peter (HM) agreed, saying, “I think it helps to have more of a casual conversation AND
have a pointed script/questions: a conversational tone, with the check-in questions to make sure I
get to the things that matter for the person.” Manager and staff member conversations occurred
before check-ins were introduced, yet they have improved for high-adoption managers like
Cynthia (HM) and Peter (HM).
Lastly, strengths and check-ins were used to help managers describe how the staff
member’s work connected to the organization’s mission and goals. Bron (HM) described a
project taken on by his assistant managers:
The other great thing about strengths and check-ins is that my assistant managers are
building them into an operational plan. One of my assistant managers has created a whole
thing on our visibility board, where she cut out little figures and made little pictures and

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faces on it. We put each person on there, and their top strengths. And then we’ve tied it
into the strategic plan, and how it affects engagement, and how engagement affects our
quality, and quality affects patient satisfaction, so that people can understand that. I want
my staff to know, “Why are we doing this?” Because it is important. Patients get better
care and better outcomes in the clinic financially. It all ties in together. That’s a good
visual representation for them to see.
Bron (HM) and his assistant managers found a way to connect strengths and check-ins
with the organization’s mission, thereby increasing the value of check-ins. Making connections
between check-ins and current structure and processes is a motivational influence for high-
adoption leaders.
Goal Orientation. Pertaining to the check-in performance goal of 60% check-in rates,
zero of 10 high-adoption managers and zero of 5 low-adoption managers could recall the goal, or
their current performance against the goal. When asked about the goal, Valorie (HM), a high-
adoption manager, replied, “Goal? I don't really have a goal. No, my goal is always to respond.”
Cora (LM), a low-adoption manager, responded, “Goal? I think this is something I could work
on.” If the managers recalled a goal, they often mixed it up with the quarterly engagement goals
of 70% participation in the survey. Bron (HM), a high-adoption manager, said, “Our goal is 70%
of the staff fills it out. And then obviously the engagement is 70% fully engaged, I think is what
it was.” Minnie (HM), another high-adoption manager, admitted that she did not have a goal for
her team, but her director had a goal for her, even though she could not recall it.
However, high-adoption leaders identified personal goals that were mastery-oriented. The
idea expressed by high-adoption managers was that check-ins were not necessarily the object for

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improvement. The objective was to use check-ins to improve their teamwork and performance
outcomes, such as patient satisfaction and quality.
Eight of 10 high-adoption managers shared how check-ins were helping them to build
teamwork and new connections throughout the team. They described using check-ins in learning
and improving teamwork, representing a form of mastery pursuit. Bron (HM) described how he
used check-ins to build his team and team culture:
I’ve always seen that when you had the foundation for teamwork and people are engaged
and working hard, everything else can stem from that. For me, it’s building the team. So,
I don’t worry too much about metrics and how other things come out over time. Yes, of
course, it’s important that we have to deep dive into what we’re missing and our gaps.
But if you’re building an engaged group and a culture that is striving for those things,
then it’ll inherently happen over time. And with strengths and check-ins, I think about
how they help the culture and engagement. We talk about it a lot in our team huddles.
Bron (HM) described how he thought about the concept of check-ins and tried to learn
more by talking with his team. He was more committed to learning and understanding than
achieving a metric goal. Peter (HM) concurred, saying, “I focus on building a team, and more
specifically building connections with team members.” Bron (HM), Peter (HM), and six other
high-adoption managers viewed the use of check-ins to achieve their goals for better teamwork
and organization outcomes.
Two of five low-adoption leaders also sought to improve teamwork. However, check-ins
were not part of their effort. Cathy (LM), a low-adoption manager, encouraged her staff to make
team decisions about scheduling and task assignments to improve teamwork. Cathy (LM), said:

85
And the same thing with flexing, where we make the assignments. We leave some room
for them to negotiate a little bit, do a bit of horse-trading. We will not do that for them for
fear of looking like one favoring one person or another. Because at the end of the day,
fairness is still very important in the clinic.
Cathy (LM) used a tactic other than check-ins to improve teamwork and reduce conflict.
Matt (LM), another low-adoption manager, described his tactic to improve teamwork as using a
“walk and talk” method. Matt (LM) said:
My goal is to use the walk and talks and ask staff members, “What do you need, who do
you want to acknowledge, and what do we need to stop/start/continue?” This will lead to
better teamwork.
Matt (LM) and Cathy (LM) had a personal goal to create teamwork. However, they were
not using check-ins as the strategy to create engaged teams. The eight of 10 high-adoption
managers who held teamwork goals described how they were learning to use check-ins as a
means to achieve this goal. High-adoption managers’ commitment to using check-ins to improve
teamwork was an asset for high check-in adoption.
Research Question 2
What is the interaction between organizational culture and stakeholder knowledge and
motivation?
Organization Results
In this section, the researcher addresses the assumed organizational influences for
implementing weekly check-ins, including a cultural model of leadership support and cultural
settings of psychological safety and support systems.

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Cultural Models: Leadership Support. Respondents described the leadership support
that they believed that they received from their immediate supervisor, and from senior leaders.
Nine of 10 high-adoption managers described high levels of support from their direct supervisor
versus zero of five low-adoption managers. Leadership support is a significant asset and
organizational influence for managers. For the purpose of this section, the direct supervisor of
the respondent, or clinical manager, will be called “direct supervisor.”
Direct Supervisors Value Check-Ins: Of the high-adoption managers, nine of 10
believed that their direct supervisor valued check-ins, whereas none of the low-adoption
managers believed that their leader valued check-ins. This finding is one of the clearest
differentiators between high-adoption and low-adoption leaders in the study. Several high-
adoption managers described their check-ins with their direct supervisor and their supervisor's
expectations. Bron (HM) said:
My leader has been my manager for a number of years; she was my boss, and now she’s
my director. I’ve been very lucky to have the same person. She does value check-ins, and
they are part of what I am held accountable.
Bron (HM) knew his direct supervisor expected check-ins from him, and that Bron (HM)
would check-in with his staff. Direct supervisors provided support by role modeling check-in
behaviors. Eddie (HM) described the support that he receives from his supervisor:
My supervisor is really good at sending his comments the day after I check in. And, if I
need help, or if I’m not sure of something, I can just ask him. And I do. When we meet
face to face, he always asks, “What do you need from me? or . . . What are your
priorities, and how can I help?”

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Direct supervisors modeled check-in behavior and were clear about their expectations of
high-adoption managers. The nine of 10 high-adoption managers described these expectations as
helpful and relational; these were not merely transactional expectations, and this support was an
asset. Low-adoption managers did not enjoy the same level of supervisor support for check-ins.
Direct Supervisor’s Active Interest in the Relationship the Manager Has With Staff: Of
high-adoption managers, six of 10 confirmed that their leader cared about their relationship with
their staff, and not just unit metrics. Active caring by direct supervisors about the manager’s
relationship with the staff was an asset. Although more high-adoption managers said their leader
cared about their relationship with staff, two of five low-adoption leaders also affirmed this
belief. High-adoption manager, Victor (HM), described their leader’s support this way: “I do feel
like my manager does care about my relationship with people.” Minnie (HM) went on to say:
I do feel like they value the relationships that I have with my staff and making sure that I
am communicating whatever concerns up to see if there’s anything that they can do from
there as well.
Other high-adoption managers echoed Victor (HM) and Minnie’s (HM) sentiments. As
described above, two of five low-adoption managers confirmed that their direct supervisor cared
about the manager’s relationship with staff. Matt (LM) said:
My manager and senior leaders care about the relationships I have with my staff and
beyond, including interactions with valet and food services.
DCNC has an internal reputation for being a relational organization; one does not
succeed without strong relationships. The two of five low-adoption managers who believed that
their supervisor cared about their relationship with staff might account for a cultural norm of
caring about positive relationships.

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Deep Connection Between Manager and Leader. A deep connection can provide safety
for trust and relational leadership (Dutton & Raggins, 2017). None of the low-adoption managers
reported a deep connection with their supervisor, although three of 10 high-adoption managers
affirmed their strong dyadic relationship and subsequent rewards or recognition. High-adoption
managers described their relationships with supervisors as “great,” “seeking ways to help each
other,” and “giving and taking constructive feedback.” Deep connections were not found to be a
significant influencing factor, yet high-adopting managers saw it as an assurance that their
manager “had their back.”
However, fractured connections or weak relationships between a manager and their direct
supervisor did lead to extinguishing check-in behavior. Two managers shared stories of fractured
connections with their supervisor, and they both stopped checking in. Victor (HM) said:
Before my new leader, each of my leaders respond in different ways. I always felt safe
saying, “My plate is full,” and that would be a sign not to give me new work. But now, I
don’t feel supported . . . and it makes me not want to check in. This week, when I
received a reminder to check-in, I chose I not to do it. And, before that, my checking-in
didn’t feel meaningful.
Victor (HM) stopped doing check-ins with his leader, even as he continued checking in
with staff. Margareta (LM), a low-adoption manager, pointed to leader turnover and confusion
over reorganizing roles that led to a hands-off approach by leaders:
I think looking back now, it was more . . . the lack of leadership. We’ve had a lot of
shifting of managers. We had leaders covering our group from remote locations, and they
didn’t get very involved. I lost interest in check-ins.

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Although the researcher cannot confirm that a deep connection is a strong influencer of
check-in behavior, it is clear that a weak or dysfunctional relationship will deter check-ins.
Mixed Senior Leadership Support. Of high-adoption managers, four of 10 believed that
senior leaders strongly supported check-ins. Strong leadership support was extrinsically
motivating to the managers because the senior leader’s behavior demonstrated caring, empathy,
and commitment. Bron (HM) described senior commitment in the way they communicated:
I think pretty much every venue I go to, whether it’s the monthly management meeting,
whatever it is, it’s always a part of it. If you’re asking me if I feel like senior leadership
thinks it’s important, I absolutely do. I mean, these are things that if they hadn’t right
then, you know, it runs the potential for it just to fall and slip away. And I think that’s one
of the big successes for it.
Bron (HM) believes check-ins are important because senior leaders believe it’s important.
Minnie(HM) had a similar assessment:
I know there is an organizational commitment to getting it done and making sure people
are in there and checking in. I know the organization says that it’s important, so it makes
me feel like it’s a priority for me.
Minnie (HM) continued on to describe senior leadership commitment in a way that
inspired her to do more with check-ins:
There was a day when we had a retreat with our nursing function. Our chief nursing
officer was there, and he talked a lot about strengths and also about professional goals
and working. “Where do you want to go and how can your strengths help get you there?”
Or “Are they predisposing you towards something that you may think is out of reach or
you wouldn’t have considered before?” Just the fact that it had been talked about more, I

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felt like with my own supervisor and directors, like the conversation was much more
open, you know. I think it definitely played a part in my commitment.
Nevertheless, four of five low-adoption managers and two of 10 high-adoption managers
believed that senior leaders could support check-ins more visibly. “I don’t think there’s a ton of
messaging around it. I don’t hear a lot of messaging,” Kristy (LM) said. Other managers
described senior leadership support in terms of numbers or metrics over concern for healthy
relationships. At the same time, they understood that this might be an easy schema for senior
leaders to take on. Kristy (LM) continued her thoughts about senior leader support:
I think in terms of senior leaders, I feel they are wrapped up in numbers. Get their quality
score up. Get up to number 3 or number 8. I think with my manager, it’s more focused on
a personal nature, but go past that, and our leaders are focused on numbers.
Another dynamic identified by managers that made senior leadership support tricky was
the fact that three different management structures operate at the clinic level. The manager leads
the nurses, medical assistants, and front office staff. The physicians report to a school of
medicine department chairs, and the advanced practitioner nurses report to a particular group
within nursing. Therefore, managers, at times, do not feel that they get the support they need
because leaders from the school of medicine or nursing might have other priorities.
The most explicit finding was that high-adoption leaders were most affected by their
leader’s view that check-ins were important, followed by a leader's concern about the manager
and staff relationships within a clinical unit. Deep relationships and senior leadership support
seemed to play an inconsistent role in check-in adoption.
Cultural Settings: Support Systems. When the researcher asked respondents about
organization support, they thought that they were getting the support they needed, until further

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prodded. The researcher asked whether there was anything in particular in the context of
organization systems and support that was going well or could improve. Most respondents shared
their views on the current state and wished for additional support. Of high-adoption leaders, three
of 10 found managing 30–50 staff members made it difficult to orient new employees to
StandOut. Another three of 10 desired more support from the training group, in the form of talks,
lessons, and job aids. A desire for more training delivered to new hires during orientation and
senior leader communications will be discussed in more detail.
Low-Adoption Manager Self-Reliance. When asked about how the organization could
better support them, high-adoption managers provided several ideas as detailed further in this
section. However, four of five low-adoption respondents believed that the responsibility for
engagement resided with the manager, and the organization had very little to do with directly
supporting engagement. Kirsty said, “You don’t need the organization . . . engagement is
between the team leader and team member.” Cathy (LM) said, “I take it as a personal
responsibility to make sure that the staff is engaged.” When asked whether the organization
could do more, Cora (LM) said, “Less is more. I’m here to engage employees and facilitate
operations. When corporate asks to do a lot of other stuff, it’s like, ‘Oh my gosh! Quit helping!’”
These low-adoption managers believed that engagement was solely their responsibility and they
did not seek more organization support. Interestingly, none of the high-adoption managers
believed that engagement fell solely on their shoulders, and they offered recommendations for
more organization support.
Desired Support. The new employee orientation that DCNC offers consists of a 6-hour
session that is largely filled with forms and compliance training to help the new hire begin work
in their unit in compliance with health care regulations. Six of 10 high adoption leaders and one

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low adoption leader expressed a desire for check-ins and strengths training to occur when new
hires join the organization. New hire training would relieve the managers of the burden of
orienting new hires and allow them to begin checking in immediately. Three of the high adoption
managers expressed a concern that they were not able to orient many new employees because
their span of control was over 50 staff members. Four of ten high-adoption managers suggested
more senior leader support for new hire training would be required.
Another four of 10 high-adoption leaders wanted senior leader support in the form of
communications and expectation setting. The messages sought by the managers were a focus on
the use of strengths and value of check-ins. One manager expressed his concern with the senior
leader focus on numbers instead of the intention of check-ins as follows:
There’s something that’s been mentioned amongst management and employees. You
know, our senior leaders wanting to know what our engagement numbers are. To be
honest, why is that being monitored? Especially if check-ins are not supposed to be
forced upon us.
If senior leaders talk about check-ins and strengths more frequently, managers and staff
will know what their senior leaders expect and might be called to account one day.
Cultural Settings: Psychological Safety. Psychological safety is present when one feels
safe speaking up or performing in front of others without fear of damage to status and self-worth
(Saks & Gruman, 2010), and it describes a perception that “people are comfortable being
themselves” (Edmondson, 1999, p. 354). Of high-adoption team managers, six of 10 felt
psychologically safe with their leader, while only two of five low-adoption managers felt safe
with their supervisor. Five of 10 of high-adoption leaders were also working on creating
psychological safety with their staff members, while two of five low-adoption leaders were

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actively focused on staff member psychological safety. Psychological safety was an asset for
high-adoption managers, a need for low-adoption managers.
Psychological Safety with Leader. Six of 10 high-adoption managers and only two of
five low-adoption managers confirmed that they feel psychologically safe with their leader when
they check in. Cora (LM), the lone low-adoption manager, said, “I feel safe checking in with my
leader and letting him know how I feel and what I need.” Minnie (HM), gave an example of a
recent check-in that made her feel safe:
I feel like I can express my disagreement with my leader. Or, the fact that I don’t like that
I have to do something, that I understand why I don’t like it, and I’m just telling her that I
don’t like it. I feel comfortable with that. My director has replied and said, “Thank you at
least for saying that. I know it’s hard, but it’s true. We have to do this and move
forward.” So, yeah, I do feel pretty comfortable saying what I need in check-ins.
Minnie (HM) expressed her ability to voice her concerns, without fear of losing status,
and was acquiescent even if her leader could not directly fix her problem. The researcher asked
respondents how they knew that they were safe when checking in. Sean (HM) described how his
leader made them feel safe. He shared the following:
I feel safe based on the experience I’ve had with my check-in comments and the rapport I
have with my leader. If it’s a serious concern, then he’s willing to take the time. He
makes it seem like it’s a priority, which I appreciate. Yeah. Articulated signals from him
that I’m safe.
The reactions managers received from their leaders informed the respondents that they
were safe when completing their check-in. Leaders listened, said “Thank you,” and made the

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manager’s concern a high priority. The low-adoption leader, who expressed that they felt
psychologically safe with their leader, described similar leader behaviors.
Staff Feel Safe with Manager. Five of 10 high-adoption managers and two of five low-
adoption managers said that they actively cultivate psychological safety with staff. The
researcher noticed a calmness in respondents when they talked about their sense of safety with
their leaders, and energy and delight when talking about cultivating psychological safety with
their staff. Valorie (HM) described how she used check-ins to cultivate trust and safety with a
new staff member:
There’s one person who just started checking in. She’s new to DCNC. She already has a
relationship with her manager, but she added me as a reviewer of her check-ins. I think
she was encouraged to check-in with me and to get to know me when she recently went
through the new grad onboarding program. When she checked in, she wrote a lot, and it
was nice to hear what she had to say. She asked for permission to write candidly and
openly. She wanted “immunity” for whatever she wrote in StandOut (concern for psych
safety and trust). I read it all and replied to her. Her response was, “Thank you for
reading everything.” One of the things she mentioned in her priorities was a desire for a
better work–life balance and a more productive work environment. She mentioned one
thing she needed and hadn’t got it. It was expensive, noise-canceling headphones. I
investigated it and was able to help her get a pair, and this has helped us build a new
relationship. She won’t report to me, but I now know her in a deeper way.
Valorie (HM) described how she listened deeply and helped the staff member problem
solve. Valorie (HM) showed she cared.

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Another benefit of psychological safety is the ability to be less than perfect, with one’s
leader and staff members. Bron (HM) described his intentional use of vulnerability with staff
members, to build trust and safety:
I’ve learned as a manager that sometimes, to be engaged, you have to be vulnerable. It’s
almost out of character for me. You have to dig deep to and think, “I’m going to be so
vulnerable right now.” Over time, I think the more vulnerable you can be, it just pays off
and creates the environment for psychological safety. And psychological safety is really
important in an environment with high stakes, stressed-out people, families not coping
well, and dealing with emotional things. People are feeling psychologically safe to
express themselves, whether it’s with other coworkers or with me; it’s really key.
Bron (HM) role-modeled psychological safety by expressing vulnerability. One low-
adoption manager, Kristy (LM), also described how she created trust and safety with her team by
role modeling kindness and help-giving behaviors:
You lead by example and walk the talk, and get your hands dirty, rolling up my sleeves
along with staff, and it builds trust. I’ve worked with these folks for years, treating them
with kindness and respect. Our housekeeper wants to stay with us when we move. She
came to me and asked if I’d send an email to her manager. Or when staff members walk
in and take candy and ask how they can help me.
Over half of all of the managers interviewed strove to create a safe and trusting
environment for their staff. However, high-adoption and low-adoption managers differed (60%
to 20% respectively) in the response rate to the question, “Do you feel psychologically safe with
your leader when you check-in?” High-adoption leaders enjoyed more psychologically safety
with their leaders, and likely, felt more value from their check-ins because they felt that they

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could bring their full range of concerns into the conversation. Psychological safety was an asset
for high-adoption managers and a need for low-adoption managers.
Research Question 3
What are the barriers to adopting check-ins?
Respondents were asked about the various barriers they faced to check-in adoption and
how those barriers might be mitigated. They identified several KMO factors that presented
barriers to check-in adoption and offered up numerous solutions as detailed below.
Knowledge Barriers
Respondents identified two knowledge barriers or gaps: lack of knowledge when new
staff members joined the unit and the manager struggled to learn how to encourage others’
strengths.
Lack of Staff Knowledge. Six of 10 high-adoption managers identified a lack of
knowledge as a barrier for new staff members. The managers were concerned that staff members
join teams without knowledge of their strengths or the check-in process. Sean (HM) said, “I
actually don’t know how they learn about check-ins.” Minnie (HM) also complained, “I feel for
my new staff who are coming on board and don’t know what it is.”
Staff members’ lack of knowledge creates higher job demand for managers to provide
training to staff, and clinical managers often do not have the capacity to deliver strengths and
check-in straining.
Struggle to Help Others Use Strengths. Three of 10 high-adoption managers described
how they struggled to help staff members use their strengths. Sean (HM) described the struggle:

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I think it’s difficult to try to create teams that work together based on their strengths. We
don’t have a lot of projects that require a group of nurses that have this just one strength
or another. The work nurses have to do is very rote; the work is very clearly identified.
Three of five low-adoption managers were not sure where to start. It was difficult for
them to imagine how nurses could take on additional tasks that were aligned to their strengths or
trade tasks with other nurses who were aligned to their strengths.
Motivation Barriers
All 15 respondents in the sample described staff members who were not open to trying
check-ins or were unwilling to find their value. Two high-adoption managers admitted that they
sometimes had difficulty imagining how a nurse would see value in check-ins. Bron (HM) said,
“For my staff of nurses, the one thing for them is that they don’t have a desk job. And so getting
them to see the value in it has always been the challenge.” For Bron (HM), a desk job
represented the leisure to reflect, access to a computer, and job variation. Sean (HM) agreed and
was not sure that a nurse would appreciate reflection time offered by a check-in:
I think if I’m a busy nurse, I’m not making the connection that if I carve time out to
reflect on my work, is it meaningful; is it useful? Do they really think they get to use
what they love to do, their strengths or think about anything they might have loathed
during the week? And “What’s my focus next week?” It’s usually the same thing, week
after week, unless they are working on a project to improve something like quality or
other metrics. If that hasn’t gotten inside of me, that it’s essential, then I’m not going to
talk much about it now.
Both Sean (HM) and Bron (HM) can empathize with the nursing role and appreciate the
inherent motivational barriers. Nevertheless, Eddie (HM), a high-adoption manager, saw the

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value in check-ins and believed that it was really an issue of personal agency, rather than an
organizational barrier:
I think the challenge is within themselves because if you really want to do something,
there’s no mountain or anything that would stand in your way. Right now, we’re in the
age of mobile phones, and everyone has one. If you would just download that app, it’s
there. So for me, it’s more mental. Not in the mechanical part, but the mental aspect.
Organizational barriers do exist; however, many managers and staff members found a
way to overcome the barriers and check in. However, more barriers need to be removed to
increase check-in adoption, as detailed in the next section.
Organization Barriers
Organization barriers include manager job demands, staff member job demands, and
round-the-clock nurse scheduling. In this section, the researcher will provide evidence to support
the validity of these barriers to check-in adoption.
Manager Job Demands. Some of the managers in the sample had more than 50 people
who reported to them. The clinical manager role has high job demands because the managers are
responsible for clinical quality, safety, patient satisfaction, and physician satisfaction in high
volume units and clinics. They have very little time to commit to training staff on check-ins.
Valorie (HM) said, “With timecards and performance reviews, check-ins are a lot (of work). I
have performance 20 reviews to complete right now.” Minnie (HM) concurred and felt that she
did not have time to help new hires understand check-ins because of their workload:
I feel like with the day to day, check-ins are hard. And especially for my new staff; I am
on them about taking the assessment. But then, I don’t have time right now to sit down
with them and talk about what it means.

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The job demand for teaching staff about strengths and check-ins has been placed on
managers. Clinical managers in this study confirmed that they do not have the capacity to
perform this work; therefore, their current job demand is a barrier.
Multiple Shifts. In addition to job demands and large spans of control, clinical managers
in the hospital manage operations that are open 24 hours a day and must be staffed at all times.
Nurses work odd hours, and many nurses work only 2–4 days a week. Bron (HM) said:
In nursing, it is different from say, I.T., and where you have my five team members.
Every day they see each other, they do their huddle. Nurses are different. They work 3
days a week, and some of them work nights. Sometimes you only see somebody once a
month. And so to reach them with new information, it is a little bit difficult.
Bron (HM) is comparing multishift nursing work to support group work as unfavorable to
learn new, nonclinical knowledge. Merely having a one on one meeting with a staff member who
works night shifts is difficult. Minnie (HM) affirmed this barrier, and specifically called out the
difficulty in encouraging new behaviors for the night shift staff members:
I think another barrier is for me is the shift. Half of my staff is on nights, you know, and I
try to come in early or stay late, but it’s really hard for my work–life balance to do that.
And so I feel like it’s good when they check-in. Otherwise, I would not have talked to
someone at all about and issue if they didn’t send it to me via a check-in. But also being
able to push and advocate is hard because I’m not physically here to say, “Hey, do your
check-in.” I sent texts to them from my bed at night, trying to ask everyone who was
there, “Could you please fill it out?” And so they’ve been good about that and responsive,
but it’s just too hard to reach them all the time. That feels like a barrier for me because I
want to be there for them, and I want to be able to have those conversations.

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Night shift work presents a barrier to check-in adoption because managers have difficulty
training and introducing nonclinical skills to this population. The organization has not provided
training resources for night shift personnel; therefore, off-hours shifts create a barrier to check-
ins.
Nurse Job Demands. In addition to multiple shifts, nurses are challenged by jobs that
begin and end with patient care, the moment they step on the floor. Their computer use is
focused on patient notes and records. Cora (LM) said,
Ninety-five percent of the work they do is clinical. They do mandatory compliance
training. Check-ins are not mandatory, so I cannot tell them to do it. They are on the
patient floor – nurses don’t have time to fill this out as they are trying to care for our
patients.
Cora (LM) pointed out the barrier faced by nurses with high job demands: time and
access to nonclinical devices. The fast-paced nature of nurse roles also presents a challenge to
reflection time, which is inherent in the check-in process. Minnie (HM) said:
I know for staff, probably one of the barriers is just the time to sit down and write it.
Especially, if you have something that you want to say. It takes a while to formulate your
thoughts. Hmm, so they are very busy out there. I totally acknowledge that. It’s tough to
sit down at a computer and pull it up and then think, “Oh, how was my week?”
Without a specific, honored time for staff to check-in, the high work demands of nurses
presented a barrier to check-in adoption. Lastly, the primacy and overall mission of nurse work
can make checking in with a manager sometimes feel inconsequential. Sean (HM) said:
I see that sometimes the nurse is just feeling, “I don’t have time for this. I’m trying to
deal with this patient who’s dying, who has cancer. I don’t want to have to do this survey

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right this moment, or I’ll do it tomorrow.” Kind of gets pushed off, you know, I think the
priority level is reflected in the lower numbers of check-ins.
Leaders of change often look for ways to make new behaviors simple and easy to do
(Sirken, Keenan, & Jackson, 2005). The respondents identified several KMO barriers that make
check-ins appear cumbersome to some clinical workers. Without organization support to provide
protected time to conduct check-ins, training for night shift staff, and training for new hires,
organization barriers will suppress high check-in adoption.
Research Question 4
What recommendations for organizational practice in the areas of KMO resources may be
appropriate for solving the problem of practice?
In this section, the researcher introduces recommendations offered directly by the
participants. Additional recommendations from the researcher will be provided in Chapter 5.
Recommendations
High-adoption respondents provided several recommendations. The most frequently
recommended were training for new hires (six of 10) and more visible senior leader support (four
of 10). These themes were briefly covered in the Organization Support Section and will be
described more specifically in this section, along with two additional recommendations.
Training for New Hires. A challenge for new hires and managers is that clinical units
desperately need replacement workers when a nurse leaves. The pressure to recruit, select,
validate licensing, and orient the person is intense. Then, once on the job, nurses have very little
time to attend training. When managers suggested training for staff, the researcher asked how we
could accomplish the training. Six of 10 high-adoption managers declared that the training could
be part of new employee orientation before the pressure of hourly, clinical work began. Eddie

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(HM) said, “I mean logistically, it should be part of onboarding.” Bron (HM) described the depth
of training that he believed was required:
I think one way to do it is to build it [into the] new employee orientation. And it needs to
be substantial. It can’t just be an hour. It needs to be, you know, similar to what I went
through. And it was that 4–8-hour day. And you’re really getting it. You’re getting the
whole shebang about what it means. Honestly, people have fun with it. It’s fun to go
learn about those strengths, think about it, and how it relates to your job.
New employee orientation is a 6-hour day, filled with human resources forms and details.
A change will require senior leader and nurse leader, and union support. The researcher will
recommend to the human resources business partners to approach the vice presidents to sound
out their commitment to the change.
Senior Leader Support. Four of 10 high-adoption managers wanted to see more senior
leader messaging and in-person advocacy for check-ins. Eddie (HM) described how this might
be the key to full adoption throughout the organization:
Now, coming from the senior leadership after training . . . Maybe do a meeting or a
retreat, with a senior leader, or something like that. That would be like if they really want
to succeed in this venture. I mean, if we are the ones that senior management rely on to
disseminate strengths and check-in information, then it will take a long time. But if
they’re the one sponsoring it . . . and they show that they’re there, high up in the
hierarchy, then people would start doing it. Because when you have a hierarchy person
coming to present you with this topic, you know, versus like a middle management
person who is always pushing you individually to do your check-in. It’s like using a net
versus a fishing hook.

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Senior leaders visit units as part of their rounding. Rounding is a health care practice
wherein a physician visits each patient and assesses their health. For leaders, rounding is an
opportunity to visit units and observe the unit in situ. Rounds are an opportunity for senior
leaders in lending their support for check-ins and would satisfy the recommendation made by
study participants.
Charge Nurses as Change Agents. DCNC provides care around the clock, and many
staff members work between 6 pm and 6 am. It is difficult for managers to teach these staff
members to use their strengths and how to check in. Minnie (HM) thought that charge nurses, or
the most senior nurses in the unit, could become advocates for check-ins:
I think the charge nurse group is pretty good at adopting changes, like implementing a
new staffing grid or instituting new policies. But I don’t think check-ins or strengths are
on their list. Charge nurses are my early adopter group because they’re the first to know,
and they help disseminate the information to the rest of the staff, especially new nurse
staff, and sometimes they provide training. They’re good at implementing mandatory
policies, but I think I could go to them and ask what do you guys think? Can you ensure
that everybody is doing this?
When the researcher asked how the charge nurses would gain the knowledge needed to
encourage check-ins, Minnie (HM) believed training would be helpful:
If you wanted to give charge nurses training, I think you would have to ask them. I don’t
want to make that decision for them. And you don’t want to expend all that energy on
creating training, and nobody shows up (laughs).

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Although none of the other respondents mentioned this recommendation, Minnie’s (HM)
suggestion aligns to change management principles of finding trusted advocates within social
and professional groups to encourage the change (Reay, Goodrick, Waldorff, & Casbeer, 2017).
Additional Insights
During data collection and analysis, the researcher identified unexpected outcomes, as
well as suspected, but unconfirmed outcomes. The purpose of this section is to present
observations about check-in adoption that were unforeseen before the study began and might
require additional inquiry beyond this study.
Check-Ins Outside of the Electronic Platform
Two of the low-adoption managers had influential relationships with their staff. One
manager held monthly “walks” in which the manager and staff member would walk the grounds
of the hospital and discuss barriers, priorities, strengths, and support the manager could provide.
In many ways, this manager was conducting a full check-in, consistent with the intention of the
electronic check-ins, but personally, one on one. This manager’s behavior was consistent with
the DCNC intention of check-ins.
Another low-adoption manager described their maturing outlook on using strengths at
work. At first, for fear that the essential patient care work would go undone, the manager
recoiled from the idea of asking staff to find tasks that leveraged their strengths. However, as
time went on, the manager noticed some of the staff members excelled at specific tasks and
could complete the tasks much faster and with higher quality than others could. The manager’s
solution was to allow the staff to work with other staff members to trade tasks. The manager
urged staff to trade for tasks that align with their strengths in a way that encourages fairness and
performance. Check-ins that are outside of the platform represent a conundrum at DCNC; check-

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ins are measured as an indicator of staff support and performance. Perhaps questions that inquire
into the frequency of check-ins (whether they are performed in the electronic platform or not)
could be added to the quarterly engagement pulse.
In-Group and Out-Group
LMX theory was introduced in Chapter 2. An assumption that the researcher holds was
that check-ins would allow managers to connect with all staff members in new ways, thus
expanding the “in-group” of staff members who enjoyed strong relationships with managers.
However, within clinical groups, all managers expressed a concern that several staff members
were checking in. Some managers lamented that a few staff members said their union had told
them they did not have to check in. One manager expressed their view that “those who engage
me, get engagement from me.” The researcher is concerned that if check-ins are not ubiquitous
and fully adopted, new in-group and out-group formations might arise from check-in behavior.
More inquiry is needed to confirm the nature and extent of this observation.
Synthesis and Conclusion
Overwhelmingly, high-adoption managers were able to describe their strengths and the
way that they use them at work. This knowledge foundation helped them to encourage staff
members to use their strengths at work and to recognize the connection between using strengths
and attaining a sense of fulfillment. High-adoption managers were able to navigate the check-in
platform, while platform navigation appeared to present a hindrance to low-adoption leaders.
Although metacognition knowledge was found to be relevant to high-adoption managers,
managers employed metacognition primarily in how they encouraged the use of strengths and
check-ins according to the manager’s strengths and resulting style. High-adoption managers also
acknowledge the opportunity to reflect on their performance over the last week by conducting a

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check-in with their leader and reflecting on their career paths. Several of the high-adoption
leaders were also aware of their change journey as they came to grips with how best to use
check-ins. Managers gained an appreciation, and perhaps a modicum of patients with their staff,
who were slower in their adoption behaviors. Metacognition allowed these managers to improve
their strategy for encouraging the use of check-ins, and recognize the value they gained from the
act check-ins.
Respondents identified the use of strengths and check-ins as a means of providing
meaningfulness and fulfillment to work. High-adoption leaders identified several examples of
improved relationships with staff members because the manager was better able to understand
what tasks were energizing to employees. Check-ins held utility value for high-adoption leaders
because they could use the content to help them ask better interview questions, set a strength-
based tone for new hires, and simplify performance review preparation.
Most of the 15 respondents were not clear about their check-in performance versus goal.
Instead, high-adoption leaders shared their views about how check-ins were a means of
achieving other desires (e.g., creating a strong team and a healthy team climate). A few managers
articulated the inherent dilemma of a goal that relied on intrinsic motivation rather than extrinsic
mandates. Managers suggested additional support in the form of senior leader messaging, with a
focus on strengths and check-ins focused on performance rather than current senior leader
messaging about metrics and benchmarks.
An important differentiator between high-adoption and low-adoption managers was the
high value placed on check-ins by the high-adoption manager’s direct supervisors. High-
adoption managers also perceived senior leader support of check-ins that was more significant.
Low-adoption managers, who received less supervisory support, held a belief that engagement

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was primarily their responsibility, which might explain why low-adoption managers found it
difficult to identify support or desired support from the organization. However, high-adoption
managers wanted more support in the form of employee training, senior leader messaging, and
training group support for their units. In addition, although more than half of all of the
respondents tried to create psychologically safe environments with their staff; more high-
adoption managers felt safe speaking their minds in their own check-ins with supervisors than
did low-adoption mangers.
Respondents offered recommendations for improving the rate of adoption of check-ins.
The two recommendations voiced most frequently were training for new employees during
orientation, and more senior leader messaging about the importance of check-ins and using
strengths. One respondent recommended using charge nurses as change agents.

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Chapter 5: Recommendations for Practice to Address KMO Influences

Introduction and Overview
The purpose of this study was to understand the conditions and behaviors that support the
successful adoption of check-ins between clinical managers and staff members. KMO factors
were examined in the context of achieving the goal of 60% check-ins between staff and clinical
managers. This chapter presents recommendations to increase check-in rates at DCNC using the
findings and themes in Chapter 4 that were aligned to the KMO factors presented in Chapter 2.
This chapter also includes implications for human capital management, as well as
recommendations for future research.
Knowledge Recommendations
The knowledge influences in Table 9 affected the highest number of stakeholders in
achieving their goals. The researcher came to this conclusion through a literature review, prior
focus group feedback, and initial respondent interviews. In addition to the knowledge influences,
the researcher has included recommendations from theoretical principles and evidence-based
strategies to learn the required knowledge.
Table 9

Summary of Knowledge Influences and Recommendations
Knowledge influence
Validated as
a gap?
Yes, high
probability or
No
Priority
Yes, No Principle and citation
Context-specific
recommendation
Managers need to know why
employee engagement is
important and why strengths-
based theory and use improves
employee engagement. (F-C)
HP Y Modeling to-be-
learned strategies or
behaviors improves
self-efficacy,
learning, and
Provide learners a
training in which the
instructor first models an
explanation of employee
engagement and strengths

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Knowledge influence
Validated as
a gap?
Yes, high
probability or
No
Priority
Yes, No Principle and citation
Context-specific
recommendation
performance (Denler,
Wolters, & Benzon,
2009)
theory, and then asks
learners to practice.
Next, the instructor will
model how to articulate a
goal for discussing
employee engagement
and strengths with staff,
and once again, ask
learners to practice.
Managers need to be able to
be aware of their impact on
team members: the team
leader must be aware of
his/her impact on team
members when encouraging
or responding to check-ins.
(M)
HP Y The use of
metacognitive
strategies facilitates
learning (Baker,
2006).
Provide learners a
training in which the
instructor first asks
learners to consider prior
check-in conversation and
what went well and what
could have gone better.
Next, the instructor will
model check-ins in
discrete steps. Learners
will be asked to try and
then reflect on how they
can improve before
moving to the next step.
Managers need to know how
to navigate and use the
check-in platform. (P)
Y Y Provide experiences
that help people
make sense of the
material rather than
just focus on
memorization and
break down complex
tasks and encourage
individuals to think
about content in
strategic ways
(McCrudden &
Schraw, 2007).
(Information
Processing system
theory)
Provide learners a
training in which the
instructor pauses at the
four components of the
platform to have learners
make sense of the
platform rather than
memorizing how to
navigate.
Encourage individuals to
think about the content in
context of their own team
leadership.
Note. F = factual; C = conceptual; P = procedural; M = metacognitive; V = validated; Y = yes; N = no.

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Increasing Manager Knowledge of Employee Engagement and Strengths-Based
Theory. All of the participants understood that strengths use and frequent check-ins improved
employee engagement. Yet only 13% of all respondents understand the difference between the
StandOut assessment and strengths. The assessment shows that a person’s top two talents and
strengths are activities that a person enjoys and does well (Buckingham, 2011). In addition,
although 100% of high-adoption managers understood their strengths, only 40% of low-adoption
managers could name their strengths. From the data collected, it appeared that knowledge of
strengths, helped high-adoption leaders successfully help their staff use their strengths and
confidently talk about the importance of strengths and check-ins. The recommendation to
increase this knowledge for all managers is to provide a training (see recommendation in Table
9). The recommendation is grounded in social–cognitive theory. Mayer (2011) found that
learning is enhanced through observation, practicing, applying, and receiving feedback. The
recommendation is to provide learners training in which they have an opportunity to observe the
instructor modeling an explanation of employee engagement and strengths theory, and then
practice the explanation that the instructor provided. Next, learners would receive feedback from
their peers, and the instructor would ask them to create a goal to practice explaining why
employee engagement is essential and how strengths-based theory improves employee
engagement.
The goal of this training would be not only to address the underlying principles and
concepts of declarative knowledge (Clark & Estes, 1996), but also to build learners’ ability to
explain the concepts adequately to team members. Smith (2002) found that people learn from
watching behaviors that they wish to imitate. Likewise, Denler, Wolters, and Benzon (2009)
found that modeling by credible authorities improves learning retention and performance.

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Feedback from peers and instructors has also been found to improve performance (Shute, 2008).
Therefore, training that includes observations of role models, practice, and feedback can
effectively improve knowledge of managers to explain effectively engagement and check-in
concepts and benefits.
Increasing Metacognitive Knowledge of Manager Impact on Team Members When
Encouraging or Responding to Check-Ins. All of the participants affirmed that the most
critical impact they had on check-ins was to respond to them in a timely manner. However, 90%
of the high-adoption respondents observed how the way they spoke about check-ins affected the
quality or quantity of check-ins. The researcher has used information processing theory to inform
the recommendation to close this gap in metacognitive knowledge. Baker (2006) found that
metacognitive strategies facilitate learning. The recommendation is to provide learners training
in they can reflect upon prior check-in conversations and identify what went well and what could
have gone better. Next, the instructor would model check-ins in discrete steps. Learners would
be asked to try a step and then reflect on how they could improve before moving to the next step.
Baker (2006) found that metacognitive skills could be developed when learners are given
opportunities to self-assess their performance. The recommendation is to start with this
metacognitive skill practice. Next, the instructor would present the complex task of discussing a
check-in in discrete steps, which McCrudden and Schraw (2007) found to be helpful for learner
understanding and retention. The practice of new skills has been found to enhance learning
transfer (American Psychological Association, 2015); therefore, it is the final step of the training
recommendation.
Increasing the Manager’s Procedural Knowledge and Use of the Check-In Platform.
All managers understood how to retrieve a check-in and respond, and high-adoption managers

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could describe most parts of the platform. Yet, only 60% of high-adoption respondents and none
of the low-adoption respondents were unaware of the helpful guide within the platform, which
provides helpful hints from the team member’s unique talents as described in their StandOut
assessment. The researcher has used information processing theory to inform the
recommendation to close this process knowledge gap. Training transfer is more likely to occur if
learners are given experiences to make sense of the material and think about the application of
the knowledge after the training (McCrudden & Schraw, 2007). The recommendation is to
provide training in which the instructor has the learners make sense of how they can apply the
coaching tips on the platform in their future check-ins. Learners would be required to think about
the online coaching content in the context of conducting check-ins with their team.
McCrudden and Schraw (2007) proposed that information is first taken in through the
senses, and if perceived as relevant, is passed on to working memory, which acts as a temporary
memory system. If the information at this point is connected to past or existing constructs, the
information might be passed on to long term memory and integrated into the learner’s conceptual
thoughts and schema. Therefore, learners who are asked to make sense of the material in light of
their current circumstances have a better chance of remembering and applying the learning
because it has meaning and value to the learner's performance (McCrudden & Schraw, 2007).
Motivation Recommendations
Introduction
Clark and Estes (2008) presented three motivational processes that lead to higher
performance outcomes: active choice, persistence, and mental effort. They proposed that, at the
heart of these processes, lies the human desire to be effective. Personal assessment of
effectiveness is influenced by one’s culture, beliefs, and experiences (Clark & Estes, 2008), and

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the conditions that support one person’s effectiveness might not be the same conditions that
another person needs. Therefore, the interviews that the researcher conducted were intended to
identify motivation gaps that each person identified while seeking common themes. The
researcher found that the motivation influences in Table 10 affected the highest number of
stakeholders in achieving their goals. The researcher came to this conclusion through interviews,
a literature review, and prior focus group feedback. In addition to the motivation influences, the
researcher has included recommendations from theoretical principles and evidence-based
strategies.
Table 10

Summary of Motivation Influences and Recommendations
Motivation influence
Validated as a
gap?
Yes, High
Probability, No
Priority
Yes, No Principle and citation
Context-specific
recommendation
Managers need to value the
meaning and purpose of check-
ins. (Stegar et al., 2012). (EVT)
Y Y Rationales that include a
discussion of the
importance and utility
value of the work or
learning can help
learners develop
positive values (Eccles,
1983; Pintrich, 2003).
-and-
Activating personal
interest through
opportunities for
choice and control can
increase motivation
(Eccles, 1983).
Provide managers
and team members
opportunities to
discuss and identify
the value of check-
ins and how to
apply check-ins to
support their work
goals.
The initial group
settings will be
New Employee
Orientation and a
manager training.
Managers need to place master
goals ahead of performance
goals in regards to check-ins.
(Anderman et al., 2010) (GO)
HP Y Focusing on mastery,
individual improvement,
learning, and progress
promote positive
Invite managers
with high check-in
adoption rates to
convene in

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Motivation influence
Validated as a
gap?
Yes, High
Probability, No
Priority
Yes, No Principle and citation
Context-specific
recommendation
motivation (Anderman
et al., 2010).
quarterly
workshops to
discuss best
practices and
support each other’s
learning (Anderman
et al., 2010).
Note. AT = attribution theory; EVT = expectancy value theory; GO = goal orientation theory; N = no; V = validated;
Y = yes.
Strategies for Improving Motivation
Increase the meaningfulness managers place on check-ins. 100% of high-adoption
managers agreed that check-ins are valuable for their work, while only 40% of low-adoption
managers appreciated the value of check-ins. Yet, managers were unsure of the value of check-
ins held by all staff members. In other words, managers have difficulty helping team members
find value in check-ins. A solution to this motivation gap is suggested in expectancy–value
theory. Eccles (1983) found that allowing learners to discuss and examine the value of a task
helps to increase the value that the learners place on the task. This finding means that using
opportunities for stakeholder gatherings to discuss the value of check-ins would help them find
more worth in check-ins. The recommendation is to provide managers and team members
opportunities to discuss and identify the value of check-ins in group settings. New hires should
have this opportunity in orientation, and managers can have this opportunity in a manager
training during which learners would be asked to write about what is meaningful about their
work, then what is meaningful about check-ins. To conclude the exercise, learners would be
asked how best to apply check-ins that support their work.

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Wigfield and Eccles (2001) found that individual beliefs about utility affect motivation.
Utility value is associated with the belief in the relevance the task or goal has to their work goals
or work life. Hulleman, Thoman, Dicke, and Harackiewicz (2017) found that when students were
asked about how a course related to their lives, learners found greater relevance and value in the
course and higher expectations of personal success in the course. Staff member motivation can
be improved by providing forums for managers and staff to discuss the value of check-ins in
context of their work goals, and to make the choice in how to apply check-ins in their work
context.
Increase Goal Orientation Motivation to Master Check-Ins. Increase motivation to
master check-ins versus simple check-in adoption rates. Forty percent of respondents
(hypothesis) were unsure of their goal for check-ins. They were not clear about the check-in
adoption rate, neither did they have a mastery goal. The motivational challenge posed by a lack
of a clear goal can be addressed by a solution that is rooted in goal orientation theory. Anderman
et al. (2010) described goal orientation theory as having two types of goals. The first goal is a
mastery goal in which the learner attempts to learn and master the subject and compares success
against prior efforts. The second goal is a performance-oriented goal, wherein the learner is
focused on performing in competition and comparison with others. Learners can hold both types
of goals, and in some cases, it is beneficial to performance. Learners apprehend goal types from
leaders and teachers. They can discern whether the emphasis is on improvement and learn how to
complete the task thoroughly, or whether they will achieve the best outcome in comparison with
others. The solution is to provide an organizational structure and consistent communications to
support learning mastery of check-ins and performance conversations in addition to performance
goals. This can be achieved through training and organization-wide communication structures

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that emphasize both types of goals. In addition, human relations staff members would provide a
forum for managers with high check-in adoption rates to convene quarterly. Managers would
discuss best practices and support each other's learning.
Ryan and Deci (2000) asserted that the need for competence is one of three basic needs,
including the need for competence, relatedness, and autonomy. The need for competence refers
to the desire to master and be competent in interactions with the environment. For example,
students were found to persist in the face of challenging tasks and to process information more
deeply when they adopted mastery goals rather than performance goals. Anderman et al. (2010)
also found that mastery and tracking learning progress promotes future motivation to succeed.
Dweck (1999) advanced goal theory by describing a growth mindset as one that is open to
learning new concepts and tasks, without fear of poor performance. Therefore, training and
convening managers to support their learning mastery would provide them with both
performance goals against a check-in goal of 60% and mastery goals of performing high quality,
meaningful check-ins.
Organization Recommendations
Introduction
In addition to knowledge and motivation, Clark and Estes (2008) identified
organizational work processes and resources as a third factor for performance. Clark and Estes
(2008) further asserted that organizational cultural influences work processes and resources
because culture represents the values, beliefs, and action that leaders and staff apply when
allocating resources and enacting work processes. Therefore, the researcher applied the construct
of cultural models and cultural settings, while collecting data from respondents (Rueda, 2011).
Cultural models are the shared understanding of how the world works within the organization,

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and cultural settings are the observable behavior and artifacts used to get the work done (Rueda,
2011). The researcher found that the organizational influences in Table 11 affected the highest
number of stakeholders in achieving their goals. The researcher came to this conclusion through
interviews, a literature review, and prior focus group feedback. In addition to the organizational
influences, the researcher has included recommendations from theoretical principles and
evidence-based strategies.
Table 11

Summary of Organization Influences and Recommendations
Organization influence
Validated as a
gap?
Yes, High
Probability, No
Priority
Yes, No Principle and citation
Context-specific
recommendation
Senior Leaders need to
support and encourage
managers to adopt check-ins
(cultural model)
HP Y Adults are more
motivated to participate
(and learn) when they
see the relevance of
information, a request,
or task (the “why”) to
their own
circumstances. They are
goal oriented (Knowles,
1980).
Human Resources
(HR) to provide
senior leaders with
compelling talking
points, based on the
findings of this
research study, and
for HR business
partners work one on
one with the leaders
they support to plan
their
communications. HR
business partners will
report progress to the
chief HR officer.
Managers require supporting
systems to help them adopt
check-ins throughout their
teams
(cultural settings)
Effective change efforts
ensure that everyone
has the resources
(equipment, personnel,
time, etc) needed to do
their job, and that if
there are resource
shortages, then
resources are aligned
with organizational
Incorporate check-in
training into new
employee orientation.
Ask new employees
to commit to a time
of day on Fridays to
complete their check-
ins.

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Organization influence
Validated as a
gap?
Yes, High
Probability, No
Priority
Yes, No Principle and citation
Context-specific
recommendation
priorities (Clark and
Estes, 2008). Update new hire
checklist to include
first check-in between
managers and team
members.
Managers need to foster
psychological safety with
their team members.
(cultural settings)
Creating positive
relationships with one’s
staff is correlated with
gains in student learning
outcomes in schools
(Waters, Marzano &
McNulty, 2003)
Shift corporate
communication from
HR about check-ins
to include trust
building behaviors on
the parts of managers
and tips for building
psychological safety.
Note. AT = attribution theory; EVT = expectancy value theory; GO = goal orientation theory; HR = human
relations; N = no; V = validated; Y = yes.
Enlist Senior Leaders to Support and Encourage Managers. Twelve team leaders
with high check-in adoption rates reported high levels of encouragement, trust, and
psychological safety from their managers. Three team leaders who were in the 30% and lower
response rate had little encouragement from their manager to adopt check-ins. The researcher
used leadership theory to develop a recommendation to close the gap. Knowles (1980) found that
adults are more likely to engage when they understand why the change improves their situation.
Knowles’ finding suggests that senior leaders play an essential role in describing why check-ins
contribute to DCNC’s mission. The recommendation is for human resources staff members to
provide senior leaders with compelling talking points from the findings of this research study,
and for human relations business partners to work one on one with the leaders whom they
support to plan their communications. Human relations business partners would report progress
to the chief human relations officer.

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Cultural models are generated by deep-seated beliefs about how the organization and the
world works, and leaders can greatly influence organizational beliefs and mindsets (Clark &
Estes, 2008). Leadership support includes communication, goals setting, rewards, and resources,
and leader’s support is vital for the success of large-scale change (Kezar, 2001; Sirken et al.,
2005). Leaders who are competent in communicating why organizational change matters to
managers and staff have a better chance of organizational change success (Hattaway, & Henson,
2013; Strebel, 2009). The literature, combined with this researcher’s findings, support the
recommendation to prepare leaders to deliver consistent communications focusing on how
check-ins help DCNC achieve its mission.
Provide Managers the Support Systems to Help Them Adopt Check-Ins
Throughout Their Teams. Six of the 15 respondents were concerned about the lack of training
and education that new staff members received on the purpose and process for check-ins. They
felt that the responsibility to train them was a burden, and they admitted that they often did not
provide adequate training because their focus was to help clinical staff complete their clinical
orientation. Clark and Estes (2008) asserted that successful change efforts have the required
resources to achieve work goals. Managers of this study have confided they do not have the
personal resources to train their team members adequately to complete check-ins. Therefore, the
recommendation is for the human relations staff to incorporate check-in training into new
employee orientation and to update the new hire checklist to include the first check-in between
managers and team members. The new hire checklist would also be updated with a job aide for
managers to conduct debriefs of the strengths assessment that new employees would complete.
The strengths assessment would provide important cues to help new staff members identify their
strengths and to reference their strengths in check-ins.

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Organizational support includes practices such as socialization and training for new
employees, which can influence the organizational climate and job demands that employees
experienced in their work roles (Albrecht et al., 2015). Learning and development processes and
resources would include training, on-the-job projects, feedback, and encouraging employees to
find ways to craft their job to align with their strengths (Albrecht et al., 2015). These resources
could influence the clinical managers’ ability to achieve their check-in goals successfully and
indirectly influence work engagement, as well as the use of strengths (Albrecht et al., 2015).
These findings support the recommendation to provide training and onboarding resources to
team members, thereby increasing their readiness to conduct check-ins during their first month of
employment.
Managers Need to Foster Psychological Safety With Their Team Members. Eleven
of the 12 respondents with high-adoption rates described trusting, psychologically safe
relationships with their managers. They believed that they could openly express themselves in
their check-ins without repercussions. However, two of the three respondents with low-adoption
rates had expressed concerns about psychological safety with their manager. Moreover, one of
the respondents with high-adoption rates reported they recently began reporting to a new
manager who responded punitively when they checked in. The respondent was not sure whether
they would continue checking in in the future. In Edmondson’s (1999) theory of psychological
safety, the author describes how team learning and actions are positively affected if people “feel
comfortable being themselves” (p. 354) without fear of embarrassment or damage to their
careers. When staff members or managers fear that what they say in their check-ins will be used
against them, their desire to participate fully is suppressed. The recommendation is to make this

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finding known to senior leaders and to include trust-building behaviors on the parts of managers
along with tips for building psychological safety.
Psychological safety is a cultural setting factor that is expressed through interpersonal
behavior and that individuals internalize. Interpersonal relationships, group and intergroup
dynamics and norms, and the leader’s style also influence psychological safety (Nembhard &
Edmondson, 2006). Waters et al. (2003) found that creating positive relationships among staff
members correlated with gains in student learning outcomes. Carmeli et al. (2009) suggested that
psychological safety provides an essential container for people to learn in work settings. Check-
ins supplement relationships between managers and team members and they support their mutual
learning. The research and findings from this study support the recommendation to create a
heightened awareness of how to build psychological safety and trust between managers and team
members.
Implications for Human Capital Management
This study illustrates the complexity of introducing transformational change into
organizations, which have implications for human capital management. In this section, the
researcher presents three salient organization change issues: attending to the transformational
nature of change, accountability structures, and planning for diversity and inclusion.
Organization Change
As described in Chapter 1, DCNC introduced check-ins when the DCNC Board of
Directors asked for an employee engagement survey. DCNC bundled the survey with a simple
strategy to increase employee engagement: conduct weekly check-ins and emphasize strengths.
The clinical leaders, in particular, were attracted to this solution because the weekly check-ins
reminded them of “standard work” or work that is done weekly, the same way every time.

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DCNC leaders assumed the introduction of the change would be transactional because the
organization was familiar with engagement surveys and standard work. Fulop and Mark (2013)
pointed out that leaders often assume that a change can be ordered along mechanistic, or
“Newtonian” lines, which can lead to errors in planning and roll-out if the change represents a
transformational shift in mindset or culture.
In DCNC’s case, a minor guiding principle, championed by human resources midway
through implementation, represented a required seismic shift in thinking to ensure success. To
ensure that managers and staff would not manipulate their responses to receive a reward
according to their engagement score, reporting on check-in rates and engagement scores were
limited to each team member. Managers were to be trusted with their data, shielded from a
demand from above to increase their score.
However, this small change represented the tectonic shift between transactional change to
transformational change. As one respondent said, “How does an organization that is used to
managing by numbers and hierarchical accountability achieve high adoption if the new behavior
is not mandatory and is to be intrinsically motivated?” Vice presidents use metrics to demand
performance and improvement. DCNC, like many academic medical systems, has a high degree
of hierarchical accountability for essential metrics. Hierarchy and compliance are critical to
ensure the quality and safety of patient care. However, when vice presidents were asked to talk to
their directors about their engagement scores and success with check-ins, instead of receiving
reports with adoption rates, the vice presidents were slow to respond. The shift from a
transactional to a transformational change happened quickly. DCNC managers were not aware of
the shift until adoption stalled. DCNC leaders held disparate mental models of the change:
transactional vs. transformational (Weller, Boyd, & Cumin, 2014). The lesson for practitioners is

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that changes can shift in complexity if the changes are counter-cultural. If not identified early,
senior leaders, who thought they were on the same page, could quickly become misaligned.
Accountability
In Chapter 4, two respondents referred to the challenge of achieving high adoption of
check-ins when they were not mandatory. Just as one respondent in Chapter 4 called out the
motivation challenge inherent in a voluntary organizational initiative with high-adoption
aspirations, another respondent revealed the nursing union confirmed to employees that check-
ins were optional and might have advised against check-in participation. Senior leaders created a
DCNC organization-wide goal in an attempt to create some level of goal-oriented motivation. A
DCNC goal of 60% of all employees checking-in regularly was set. However, senior leaders did
not cascade the goal assignment to the functions or clinical units, and more importantly, at
DCNC, check-ins rates were not included in manager bonus goals. The lack of unit-level goals
has thrown off many leaders, from vice presidents to unit-level supervisors. They are familiar
with “programs” with mandatory requirements and goals for compliance because of the
organizational culture present at DCNC. However, without the usual mandate from senior
leaders, many employees declined to check-in, and some team leaders delayed check-ins given
multiple priorities.
When DCNC launched the employee engagement strategy, a certain degree of hope and
humanistic optimism might have prevailed, given that engagement is mostly a natural feeling of
commitment, vigor, and discretionary effort (Saks, 2017). After all, could engagement be
mandated? Perhaps the muscular focus of the engagement initiative to stimulate intrinsic
motivation on the part of team leaders and team members would suffice to encourage check-ins?
However, given the performance gap in check-in rates, it is clear that accountability structures

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play a significant role. In a setting that is hierarchical and compliance-driven, voluntary
initiatives might feel more like communities of practice, or affinity groups, than widespread
adoption and achievement of the organization’s mission. Practitioners are in a unique position to
advise and to question accountability structures early in the planning stages of transformational
change. The accountability structure for check-ins at DCNC lacks the managerial, professional,
and external accountabilities that motivate behaviors. It appears that accountability is trumping
intrinsic motivation at this stage of DCNC’s implementation.
Diversity
Healthcare leaders often come from the ranks of physicians or administrators. They
reside in a world of privilege and might not see how hidden system structures affect team
dynamics and personal motivation within clinical units. They reside in a world of computer
literacy and access to electronic tools. People self-select into different professions and
specialties, perhaps according to similar worldviews or thinking styles, and privileged classes
have much more access and ability to enter into medical and business schools, which reinforces
the sense of in-groups and out-groups (Weller et al., 2014). Stereotyping goes beyond the
professional realm to include in-group and out-group views that are determined by race,
economic class, and even whether one speaks English with an accent. As individuals self-
categorize themselves, they create a positive distinctiveness and create differentiation from the
“other,” which can quickly deteriorate into stereotyping or assumptions of superiority or
inferiority. The feedback from focus groups (i.e., that lower level employees lacked electronic
tools and education) could reflect bias and not merely financial decisions.
Diversity and inclusion in the workplace have emerged as a priority in organizations
(Downey, Werff, Thomas, & Plaut, 2015). Diversity research has also been on the rise, yet little

125
research into diversity initiatives and their impact on engagement has been conducted. In
addition, diversity initiatives were treated separately from employee engagement (Downey et al.,
2015). How can diversity and inclusion issues be incorporated into employee engagement
initiatives, and what kind of interventions will succeed? For practitioners, the challenge will be
to encourage senior leaders to incorporate diversity and inclusion considerations from the
beginning of engagement strategy planning.
Implications for Future Research
This study was focused on the KMO factors that influence clinical managers’ adoption of
check-ins. Three dynamics were discovered that warrant further research: (a) the interaction of
frequent manager and employee check-ins and the quality of communication, (b) managing
informal teams in a formal structure, and (c) the creation of new in-group and out-group settings
because of an organizational change.
Privilege, Status, and Intersectionality
In this study, the researcher did not examine identity, race, gender, power, and
intersectionality in terms of how they influenced the context wherein staff members are asked to
check in, or the overall impact on check-in rates and quality of conversations. Of the participants,
eight were White, and while it did not have bearing to this study, we do not know how
perceptions of identity, race, gender, power, and intersectionality relate in the context wherein
staff members are asked to check in, or overall impact on check-in rates and quality of
conversations.
Intersectionality is a view that race, gender, and identity act as coconstructing
phenomena, which in turn create social inequities (Collins, 2015). Weller, et al. (2014) further
contended that professional identities might contribute to intergroup conflict that has its basis in

126
in- group expectations about respect, and how work is to be done. Stereotyping goes beyond the
professional realm, to include in-group/out-group views based on race, economic class, and even
whether one speaks English with an accent (Burford, 2012). A cognitive frame of deficit
(Bensimon, 2005) can arise wherein the leaders or physicians can attribute differences in position
as evidence of inferiority or lack of intelligence. DiTomaso, Post, and Parks-Yancy (2007) used
status construction theory as an explanation for how people in high status are thought of by
others as being more competent and worthier, and those who are higher in status, act more
confidently or assertively than others. Hierarchically, the dominant person in a healthcare
environment is the physician or administrator who is primarily responsible for creating a sense of
psychological safety, wherein all team members feel comfortable speaking up (Edmondson,
2016). The researcher did not investigate these issues.
In-Group and Out-Group
In the previous section, the researcher referenced the “in-group and the out-group.” This
phrase can apply to diversity, but it also can also apply to the relationships that a manager holds
with each employee. Employees who are in the in-group tend to receive more resources and
attention. DCNC’s strategy of encouraging high adoption of check-ins presents an opportunity
for managers to expand the in-group to include employees who might otherwise not interact
frequently with the manager. However, as revealed in Chapter 4, new in-groups and out-groups
could develop because of check-in frequency and quality.
LMX theory explains the development of varying degrees of relationship between the
team leader and each staff member (Erdogan & Bauer, 2015). Team dynamics might be affected
by some team members checking-in and others not doing so. Most of the clinical staff members
belong to a union, which means that they have protections and clear job roles. Fairness is an

127
issue that frequently emerges in clinical teams, for example, when staff members decry that the
manager has “favorites” (Rodwell & Munro, 2013). If staff members are checking in, and
thereby enjoy more considerable attention, do they experience negative repercussions from team
members?
Do check-in behavior and potential in-group and out-group reconfiguration affect the
coordination of care for patients? Li and Liao (2014) found that when a working unit is split into
two social groups, coordination might suffer. More research could be conducted to investigate
manager-to-staff, and staff-to-staff relationships in clinical care units.
A common criticism of strong manager and staff member relationships is that the
manager might rely more on the staff member, and the staff member might become
overburdened and stressed with workload (Erdogan & Bauer, 2015). The examples that
respondents provided were primarily focused on manager helping and problem-solving behavior.
However, neither the respondents nor the researcher investigated subsequent delegating of work
to the staff member. Do staff members view close relationships with managers as suspect
because they might receive more work or more accountability for their work? In a medical union
environment, accountability for nurses is prescribed by the union contract and management
oversight. A closer relationship with the manager might mean more work. The dynamic
relationship between union labor and high-quality LMX would benefit from future research.
Quality of Check-Ins
DCNC’s primary focus on check-in is frequency. The goal is to have 60% of employees
checking in at least once a month. Little is said about the quality of check-ins and check-in
conversations in organizational communications regarding check-ins. It certainly becomes
comfortable at the organization level to report check-in numbers that meet the goal without

128
concern for the quality of conversation. Hill, Kang, and Seo (2014) studied the role of electronic
communication in employee empowerment and work outcomes, and found that a higher degree
of electronic communication between leaders and followers resulted in more positive leader–
member relationships.
However, high-adoption respondents reported high levels of psychological support and
confidence in expressing their full selves in check-ins. Burgoon, Pfau, Parrott, Birk, Coker, and
Burgoon (1987) found that positive affect and relational communication affected mutual respect
and trust, as well as psychological safety. Communication messages with receptivity, similarity,
and nondominance were likely to produce the most satisfaction between managers and staff
members (Burgoon et al., 1987). Losada and Heaphy (2004) defined relational connectivity as a
degree of openness to discuss new information. When the manager and staff members have a
high degree of connectivity, they each can feel at ease to be themselves, become engaged in the
task at hand, and speak freely and respectfully without fear of retribution. What remains
unknown is whether frequent check-ins inspire increased performance, or if the quality of the
check-ins, as expressed by high connectivity, acts as a mediating factor. More research is needed
to investigate the manager and staff member’s communication frequency and quality.
Hidden Teams and Team Leaders
Check-ins are completed in an electronic platform organized by the hierarchical team
leader and staff members. However, healthcare is enacted by disparate teams in various
professional roles and widely separated geographies (Weller et al., 2014). Teamwork in medicine
extends beyond the boundary of the hierarchical administrative or physician structure. Even the
leader of the medical care team can sometimes be the physician and, at other times, a nurse
leader or technical lead. Moreover, although care coordination and team care are becoming more

129
prevalent in healthcare settings, the hierarchical structures have yet to catch up. The
administrative manager rarely directly manages all care team members who care for a patient. In
medicine, informal or “shadow” teams exist that do not show up on human resource organization
charts. Costa et al. (2014) suggested that “team” engagement occurs when team members
strongly identify themselves with the team and bring their full physical, affective, and cognitive
self to the work of the team. In high-engagement, team environments, team members will
encourage each other to do more work in-service towards the goal (Costa et al., 2014). In the
case of clinical team members, staff members might feel allegiance to the team that provides
patient care rather than the hierarchical team (Gulati, 2007). The hierarchical team might be
broader and include team members who are not directly responsible for patient care Although the
dynamics of medical teamwork have been somewhat studied in the last decade, little research has
been devoted to leader/follower dynamics in medical teams where formal and informal leaders
play a significant role. Further research is also needed to identify human resource structure
models that account for the hidden teams in health care and align more fluidly with the
coordination structure focused on patients.
Conclusion
The purpose of this study was to determine the KMO influences that were assets for
clinical managers who achieved the organizational goal of 60% check-in rates, as well as to
identify barriers to goal attainment, and recommendations to close the gap between performance
and goal outcomes within the organization. The researcher examined influences using LMX,
strengths–trait, and JD–R theory, and data collected from high-adoption and low-adoption
managers. Differences in KMO support experienced by high-adoption and low-adoption
managers were identified. Recommendations presented in this study were developed by

130
participants and the researcher, and could help the organization close the gap between the goal of
check-in adoption and actual performance. Moreover, these findings have implications for
increasing engagement and reducing burnout in healthcare settings, ultimately improving patient
care. As noted, low worker engagement contributes to burnout and negatively affects patient
safety and cost (Lucian Leape Institute, 2013; Perlo et al., 2017). Additionally, employees with
high engagement tend to experience high levels of energy, commitment, and focus (Schaufeli et
al., 2006). In fact, in 2019, the DCNC human resources team conducted its own correlational
analysis that showed DCNC staff who checked-in 60% of the time reported twice the levels of
engagement on its annual 2020 survey as those who did not check in (53% vs. 26%). Those
findings, coupled with the results from this study, suggest that frequent check-ins might be an
essential remedy to mitigating the potentially catastrophic risks to patient safety associated with
burnout and low engagement.

131
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Appendix A: Survey Questions
1. Tell me about your background. How long have you worked at DCNC?
2. How long have you managed clinical staff___?
3. To begin, let’s talk about StandOut strengths. What are your top two strengths and how
do you use them at work? Can you give an example?
4. How, if at all, has your view of using strengths at work changed over the last year?
5. How has the organization’s emphasis on strengths affected your leadership style?
Building on this, how would your team leaders describe your leadership style?
6. Think about your experience when you talk to a team member about their check-in.
Describe what happens. What kinds of feelings come up for you?
7. Imagine I’m a new team member…how would you describe check-ins? Is there anything
you would change to make your description even better?
8. How confident do you feel in the quality of your check-ins, or conversations with your
staff?
9. Tell me about times when you feel your work is meaningful. How might check-ins and
attention be meaningful?
10. Have you encountered barriers to implementing check-ins? What parts of the barriers do
you have the ability to overcome?
11. What is your goal with check-ins?
12. Do you feel you team leader and/or senior leaders support your relationship with your
team members? In what ways?

149
13. How does the organization processes, training, and systems to support your check-ins?
What support from your function, HR, IT, or other groups would help you adopt check-
ins, and develop deeper trust with your team members.
14. Do you feel safe saying whatever you want in your own check in to your team leader? If
not, why not?
15. How do you feel about the engagement strategy? How do you feel about the check-in
process?
16. What advice would you give to a new manager who is going to implement these check
ins? What would you tell them to do?

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Asset Metadata

Creator Simpson, David John (author)

Core Title Creating a culture of connection: employee engagement at an academic medical system

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 08/02/2020

Defense Date 06/17/2020

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

Tag academic medical center,check-ins,employee engagement,gap analysis,health care,job demands-resources,KMO,Knowledge,leader-member exchange,Motivation,OAI-PMH Harvest,organization,qualitative,strengths,strengths-trait theory,transformational change

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Malloy, Courtney (committee chair), Combs, Wayne (committee member), Stowe, Kathy (committee member)

Creator Email davesimp@usc.edu,djsotter@outlook.com

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