GRAD695 Proposal Draft 1

Running head: Employee engagement in healthcare: A pilot study 1

Employee engagement in healthcare: A pilot study 49

Employee Engagement in Healthcare: A Pilot Study

Proposal Example

Abstract

This qualitative pilot research study looked to answer which organizational strategies that inspires employees to aspire the vision, mission, and values of the organization. Studies have shown (Aziz, 2016; Granatino, Verkamp, and Parker, 2013; Ryan, 2017) that health care employees that are highly engaged are better aligned with the organizational objectives. Health care objectives are based on the mantra, “Do no harm.” And while this is the goal of the health care worker and the organization, studies have shown that patients are being harmed in the healthcare environment (Scott, 2009). One such harm is acquired hospital infections, which are often due to the misalignment of organizational objectives by employees. These infections are costly, sometimes fatal, and yet often preventable. Research has shown that engaged health care workers are more likely to follow organizational objectives (Aziz).The goal of this research is to investigate the strategies that create highly engaged employees. The sample population interviewed was from a segment of healthcare workers that interact directly with patients. This study gained information that is relevant to healthcare workers surrounding employee engagement which can help organizations construct effective strategies in the healthcare environment.

Keywords: Personal Engagement, Employee Engagement, Hospital Acquired Infections

Employee Engagement in Healthcare: A Pilot Study

Introduction

Health care organizations have struggled in delivering value to the patient on a consistent and high quality basis. Value in this sense is defined as the issues that matter most to the patient divided by the cost of delivering those outcomes (Cox, 2017). Research has shown that there are significant links between employee engagement, quality of work, and patient value and experience (Nielsen & Jørgensen, 2016). While some researchers have argued that there is more research needed to measure engagement as it relates to patient outcomes (Kanste, 2011; Boaz, Hanney, Jones, & Soper, 2015) data suggests that a positive relationship exists between the two (Gill, 2013). In the executive summary by Press Ganey, data suggests that organizations with a decidedly engaged workforce will perform better on safety, quality and patient experience (Ryan, 2017). That is, in a positive relationship, when employee engagement is high, so follows patient outcomes. In this theoretical framework, the psychological state of engagement lends to performance and compliance at high levels (Nielsen & Jørgensen). For example, an engaged health care worker is more compliant to health care practices, leading to better patient outcomes and increasing patient value. In addition, while it has been established that developing an effective employee engagement program can be costly, researchers have posit that employee engagement is vital to an effective and successful health care organization (Granatino et al., 2013). In contrast, health care workers who are less engaged are less prone to follow hospital guidelines.

In addition, when leaders make the staff feel valued and provide support, the staff becomes motivated thus engagement is created resulting in improved patient care (Aziz, 2016). On the other hand, some studies have shown that pragmatic approaches (Quality Improvement Programs) to improving quality outcomes in health care have failed to fully engage the employee, which creates apathy and resistance of health care workers (White, Butterworth, Wells, & Wells, 2017). However, other studies have demonstrated that focusing on staff engagement can lead to lower infections and decreased mortality rates (Aziz; Ryan, 2017; Scott, 2009).

While there are many key elements that drive improvements in healthcare patient safety and reducing harm are the most compelling (White et al., 2017). In the health care environment, patients have contracted Hospital Acquired Infections which have decreased patient’s values and compromised their outcomes. Infections such as catheter-associated urinary tract infections (CAUTI), central-line associated blood stream infections (CLASBI), nosocomial pneumonia and methicillin-resistant staphylococcus aureus infection (MRSA) are being transmitted by healthcare workers. Research has shown that incidents of Hospital Acquired Infections (HAI’s) have been traced to poor hygiene practice (Han et al., 2015). Hospital Acquired Infections have also shown to create longer length of stays, increased re-admission rates, and even fatalities (Rahmqvist, Samuelsson, Bastami, & Rutberg, 2016). Ultimately, patient value is diminished by non-compliance of organizational objectives which is costly, life-threatening and yet preventable (Scott, 2009).

Statement of Problem

Research has shown that health care employees that are more engaged have a higher compliance of organizational goals (Aziz, 2016). The report by Ryan (2017) states that in a cross-domain analyses, there is an important positive relationship between caregiver engagement scores and organizational performance. Increased staff engagement has also shown to be linked to effectively reducing hospital acquired infections thus improving patient care (Kleinpell, Munro, & Giuliano, 2008). The results of a 2013 British National Health Service study demonstrate that highly engaged infection prevention control practitioners along with managers can increase staff engagement, thus improving patient care (Aziz, 2016). Ultimately, the NHS study formalized a staff engagement tool that lends focus to the areas that organizations can work on in order to achieve a higher level of staff engagement.

According to the 2014 report in the New England Journal of Medicine, titled “Multistate Point-Prevalence Survey of Health Care-Associated Infections” in 2011 there were over 700,000 hospital acquired infections in acute care hospitals in the United States (Magill et al., 2014). The study points out that 75,000 patients died from hospital acquired infections ranging from catheter-associated urinary tract infections (CAUTI), central-line associated blood stream infections (CLASBI), nosocomial pneumonia and methicillin-resistant staphylococcus aureus infection (MRSA) (Magill et al., 2014). The infection rate of methicillin-resistant staphylococcus aureus infection (MRSA) and clostridium difficle (c.diff) along with other infections surpasses 300,000 annually (Longhurst, 2016). The cost associated with hospital acquired infections can be somewhere between 20-40 billion dollars in the United States annually according the study “Health Care–Associated Infection A Meta-analysis of Costs and Financial Impact on the US Health Care System” (Zimlichman et al., 2013).

Purpose and Goals

The purpose of this qualitative study is to examine the strategies of on organization that inspire employees to aspire to the vision, mission, and values of the organization. As earlier explained, an engaged employee has a significant impact on compliance and patient outcomes during the health care encounter.

The goals of this study are two-fold:

1. To add to the intellectual merit and broader impact of research surrounding employee engagement and as it connects to the patient’s value during their health care experience.

2. To discover new ways for organizations to effectively impact in a positive manner their employee engagement

In order to accomplish the above goals and to advance the knowledge of research, this study strives to be relevant and valid. This study utilized semistandardized interviews using nine interview questions (Berg & Lune, 2012). This study allowed the participant to use a phone to call the researcher via computer software (Zoom) as to allow the participant to remain in a comfortable setting. The aforementioned process created an efficient interview and kept the researcher as an essential instrument (Creswell & Poth, 2018). This research study followed a grounded theory approach to interpret the interviews and look for meaningful insights through contextual induction.

Research Question

This study attempts to answer the question, “What are the different types of organizational strategies that inspire employees to aspire to the vision, mission, and values of the organization?” Ultimately this aforementioned question as it relates to employee engagement, will be the cornerstone of my qualitative research. As previously stated, employees who become engaged tend to more willing to follow the organizational goals, thus creating better patient outcomes. This research gained approval from the IRB on April 2, 2018 before moving forward. The participants were health care employees, and fundamentally free to participate in the interview.

Definition of Terms

Personal Engagement: The harnessing of organizations members’ selves to their work roles (Kahn, 1990).

Employee Engagement: A workplace approach resulting in the right conditions for all members of an organization to give of their best each day, committed to their organization’s goals and values, motivated to contribute to organizational success, with an enhanced sense of their own well-being (Aziz, 2016).

Hospital Acquired Infections: A nosocomial infection is strictly and specifically an infection not present or incubating prior to admittance to the hospital, but generally occurring 48 hours after (Scott, 2009).

Literature Review

Theoretical Framework

In order to define and to understand employee engagement, a theoretical background must be examined. And while there has been much research on engagement, there has been a paucity amount dedicated to the health care employee experience within the context of the individual caregiver as it relates to the organization (Nielsen & Jørgensen, 2016). Moreover, in order to gain an improved understanding of how employees experience engagement in this context, the concept of meaning creation is examined. Subsequently, in the qualitative pilot research study, meaning creation is developed as the ways in which the participants find meaning in being engaged as they aspire to the organizational mission, vision, and goals. Earlier studies have focused on this aforementioned conceptualization that individuals can use different attributes of self, namely 1) physical, 2) cognitive, and 3) emotional as they relate to work performance (Kahn, 1990). Thus, in this original construct, employee engagement is identified as “simultaneous employment and the expression of a person’s preferred self” surrounding task behaviors with an interconnectedness between work and others, personal presence, and active complete role performance (Kahn, 1990) which is connected to the research question in the pilot study.

Moreover, engagement has been defined as a “positive, fulfilling, and affective-motivational of work-related well-being that is categorized by vigor, dedication, and absorption (Bakker, Schaufeli, Leiter, & Taris, 2008, p. 204). To expand further, engagement is categorized by a high level of energy and a strong identification with one’s work. Also, the seminal work by (Shuck & Wollard, 2010) attempts to construct a bridge between the widely disparate concepts of engagement from a historical Human Resource Development perspective. In the aforementioned viewpoint, employee engagement is described as a cognitive, emotional, and behavioral state aligned with desired organizational outcomes such as the aligning of the mission, vision, values of an organization (Shuck & Wollard, 2010).

Contrasting Thoughts

In contrast, recent research has focused on how organizational management has influenced the levels of workforce engagement (Rich, Lepine, & Crawford, 2010; Harter, Hayes, & Schmidt, 2002). In addition (Newman & Harrison, 2008) have argued that meaning creation is overly emphasized. In the aforementioned argument, meaning creation gives way to meaning of work and meaningfulness. Also, (Pratt & Ashforth, 2003) differentiate the two by suggestion that meaningfulness is subjective and is based on the amount of meaning something holds; whereas meaning of work refers to the meaning type, or an individual’s interpretation of what work brings to their life i.e. salary, higher calling. Furthermore, the researchers (Newman & Harrison, 2008) have argued that employee engagement establishes no new conceptual significance, and there exists some five-hundred original studies (David A. Harrison, Daniel A. Newman, & Philip L. Roth, 2006). On the other hand, the qualitative study by (Nielsen & Jørgensen, 2016) suggests that there are implications for future studies, and that meaning creation’s impact on employee engagement cannot be overlooked.

While some scholars (Gonzalez-Roma, Schaufeli, Bakker, & Lloret, 2006) seem to agree on the two dimension definition of engagement i.e. energy and identification, there is contrasted thought with regards to the consensus of meaning. The analysis by (Macey & Schneider, 2008) have argued that the numerous new definitions are simply “old wine in new bottles” (p. 10). In order to navigate through the theoretical framework of engagement, authors such as Hackman and Oldham (1980); Kahn (1990); McGregor (1960), have posited that engagement is reflected on a psychological disposition, i.e. “trait engagement” (Macey & Schneider, 2008). Trait engagement can be defined as the inclination to view the world from a particular vantage point (Macey & Schneider, 2008, p.5). Consequently, the disposition of the participant in the pilot study could possibly impact the response to each interview question. In this model, workplace conditions have both direct and indirect effect on state and behavioral engagement. Thus, from the early basis of folk theory to self-determination theory, work engagement has evolved and re-evolved and is a dynamic and important construct for theorists, and organizations.

Organizations and Engagement

As organizations search for a competitive advantage, employee engagement has proven to be a key driver (Collier, Fitzpatrick, Siedlecki, & Dolansky, 2016). Research (Aziz, 2016) has consistently shown that high-performing health care organizations are defined by an alignment of leadership and supportive and engaged workforce. Moreover, employee engagement is found to be linked to improving organizational components, namely 1) employee retention, 2) loyalty, 3) productivity, 4) employee turnover, and 5) patient safety (Harter, Schmidt, Killham, & Agrawal, 2009). In a special report by Press Ganey (Ryan, 2017) data suggests that health care systems with higher staff engagement had lower rates of hospital acquired infections. In the aforementioned relationship, employee engagement affects patient safety due to the employee’s positive assessment of the quality care provided by their team. Patient safety is the fundamental objective in quality healthcare. And achieving this objective demands investment of time, energy, and resources by an organization, which influences financial and patient outcomes (Ryan, 2017). While there are several strategies to improve health care worker engagement, workforce engagement is predominately determined by workplace relationships. Research has demonstrated that when employees feel connected to the mission and vision of the organization, supported by their managers and are appreciated by their colleagues tend to be more engaged than those who lack these type of associations (Weaver, Dy, & Rosen, 2014). Types of organizational relationship building strategies vary, namely 1) personal development, 2) employee recognition programs, 3) community-employee educational programs, 4) forums, 5) administrative rounding, and 6) team-building exercises (Ryan, 2017).

Hence the question, “What are the different types of organizational strategies that inspire employees to aspire to the mission, vision, and values of the organization?” Perhaps the key element in creating employee organizational buy-in is workplace relationships. Employees that feel connected to the mission, vision, and values of an organization are supported by their management teams and are appreciated by their colleagues tend to be more engaged as compared to those individuals that lack such relations (Ryan, 2017). Engaged employees, feel like they are an important part of a cohesive team which works toward shared goals, consequently leading to safer and higher quality patient care.

Healthcare and Engagement

In health care, value-based, zero harm is an ideal goal that organizations aspire. It has been noted that the quest for excellence in health care is an arduous and long journey. However when accomplished the rewards offer safe, high-quality, and coordinated patient care. Studies have shown that an engaged workforce creates an unwavering commitment to patient safety, quality, and the overall experience of health care (Ryan, 2017). A longitudinal study by Thorp et al. (2012) demonstrated that employee engagement and workplace safety have a synergistic effect on patient safety. And as previously mentioned, research has shown a significant link between employee engagement and organizational outcomes (Collier et al., 2016).

Given the aforementioned information, surprisingly health care has shown slow progress in patient safety, according to the report To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). While patient safety in health care has been slow to change, there has been some evidence that a “culture of safety” within the hospital setting does have a positive association with employee engagement (Collier et al., 2016). Furthermore, research has shown that employees that believe in the organization’s principles and values, tend to be more compliant with regards to the policies set-forth as they are more engaged (Aziz; Kleinpell et al., 2008).

Discussion

Therefore, this study focused on the research surrounding organizational strategies and its impact on employee engagement. Specifically, this study examined the factors which are utilized by an organization to improve the employee support of an organization’s strategies, i.e. mission, vision, and values. According to Granatino et al. (2013) employee engagement is vital in the development and preservation of a successful healthcare organization. In order to fully understand the goal of health care engagement, the 2017 report by Press Ganey examines the goal of health care excellence as it relates to employee engagement. In this aforementioned study, a cross-domain analyses was employed to demonstrate the important relationships between employee engagement and key drivers of quality patient outcomes, namely 1) safety, 2) quality, and 3) patient experience (Ryan, 2017).

In summary, in order to create employee and organization alignment, organizations must proactively engage their workforce by building a supportive culture. Ultimately, the aforementioned culture must be built on mutual trust and respect, open and honest communication, aligned leadership, opportunities for professional growth and development, and performance recognition.

Methodology

This qualitative pilot study employed the methodology based on the grounded theory approach, whereas the research is centered on the question, “What are the strategies that organization can utilize to inspire their employees to aspire to the goals of the organization?” In addition, this study utilized the systematic approach as described by seeking to develop a theory that explicates process, action, and interactions of the research topic (Strauss & Corbin, 1990; Strauss & Corbin, 1998). Furthermore, the information derived from data collection will be used to develop a new theory or conceptualization that which is beyond description (Strauss & Corbin, 1998). Furthermore, this pilot study utilized the qualitative data from four interviews surrounding the research questions which examines the different types of strategies that an organization can create and utilize to inspire their employees to become highly engaged. Thus by applying the methodology of grounded theory, the derived theory attempts to align distinctly to the dataset obtained from the research. In the aforementioned manner the new found theory is “grounded” in the data from the participants’ interviews, and not “off the shelf” (Strauss & Corbin). Therefore, this research study collected data by interviewing health care workers in order to find the answer to the research question, “What are the strategies that organization can utilize to inspire their employees to the goals of the organization?” Consequently, this research will not follow the initial theoretical framework and purpose as postulated by the seminal work titled Awareness of Dying by Glaser & Strauss (1967).

While most qualitative research employs recording and transcribing, the aforementioned authors posited that memoing was the foundational tool for evaluating and conceptualizing the data and events. However, in contrast (Charmaz, 2006) argues that transcribing along with coding are the better tools for theory development. Consequently, this research study utilized the methodology of audio-recording and transcribing employee interviews as proposed by Charmaz (2006) as a more sociological constructive approach. To expand the approach of grounded theory further, this study looked to discover concepts, categories, and properties and the relationships thereof. Thus as postulated by the scholars of grounded theory, the information from data sets and making comparisons of derived categories, coding will occur in three abstractions, namely 1) open, 2) axial, and 3) selective (Creswell & Poth, 2018).

Participants

The goal of the sample size and participant selection is to best represent the population that is required to research the study as defined: This qualitative study is centered on the organizational strategies that can best inspire their employees to aspire to the mission, vision, and values of the organization from an employee engagement perspective. Furthermore, this research examined the relationship (if any) between employee engagement and organizational goal compliance. In this study the health care worker is the target population in which the sample is derived. Thus sampling was purposeful and criterion defined (Patton, 1990) as to meet the prespecified criterion, i.e. health care worker. Moreover, this pilot study did not achieve the ultimate criterion for the final sample size of theoretical saturation as posited by grounded theory (Strauss & Corbin, 1998).

This pilot study consisted of interviewing four health care employees, between the ages of 18-65 years of age. In addition, the participants (employees) were of both gender from a health care department in the Louisville, Kentucky region. This research was conducted at a System’s Hospital and in a department that employed healthcare workers. Thus, the Respiratory Therapy department of a system’s hospital was the choice of venue for this study.

Data Collection and Instrumentation

The qualitative research pilot study number 03142018-11 was granted IRB approval on April 2, 2018 and also gained approval from the system’s hospital executive leadership team. This qualitative research study utilized a paper-memo announcement for recruiting the participants (employees) which was placed in the breakroom bulletin board of the Respiratory Therapy department (See Appendix A). The aforesaid announcement asked for any volunteers (employees) that meet the requirements of this study, i.e. employees of Respiratory Therapy, 18-65 years of age and willing to consent and give a telephone to Zoom online interview. The interested employee was then be directed to call a phone number as to receive the consent form (See Appendix E).The consent form was explained by the researcher and signed by the employee in a face-to-face meeting to the employee for in accordance to the Institutional Review Board (IRB) guidelines. The researcher was identified on the paper-memo recruitment form as a Sullivan University PhD student who was conducting research to help employee-organizational relationships. The announcement also stated the goal of the research and the type of questions that would be asked during the interview. Also, there was full disclosure as to the outcomes of this research, i.e. academic and organizational purposes only, with emphasis on confidentiality of the participants. In addition, the announcement stated that there would be no risks to the participants and no compensation for this study. The announcement went on to state that the benefit of this study would be noted as the gift of intellectual merit and that of a broader impact to healthcare and the community it serves.

The instrument used to gather information was a telephone-online Zoom interview that took place at the participant’s choice of venue which permitted the participant to be comfortable and not fearful of being overheard or seen (Berg & Lune, 2012). This process allowed the interviewee to be able to participate in the interview in any private setting. The Zoom technology utilized, provided the ability capture and record the participants’ phone conversation with closed captioning. The interviewees were instructed to call a specified given phone followed by designated meeting id number in order to connect to the interviewer on Zoom. The audio-interview was recorded on the interviewer’s password protected laptop (not on Zoom’s data-base) as a MP4 file and verbatim transcribed. The recorded audio will not be able to be accessed by any person or entity other than the interviewer. The interview was a one-on-one, participant-to-researcher semi-structured interview design that incorporated nine qualitative questions. The nine interview questions are based on job satisfaction and how the organization assists in the overall job. In addition, within the nine questions, job passion and self-evaluation was evaluated through the kind of positive experiences within the organization. Each participant was asked same questions as to gain the participant’s thoughts, opinions, and attitude surrounding employee engagement (Berg & Lune, 2012).

The interviews were recorded using Zoom and the researcher’s password protected laptop and was downloaded and labeled on an encrypted flash drive as to maintain confidentiality of the participants. In the aforementioned design, cataloguing occurred in a specific manner i.e. P1, P2, P3, and P4. The cataloging utilized for the participants’ interviews has allowed for coding and analysis in such a way that ideas, themes, and constructs are not overlooked (Creswell & Poth, 2018). The data will be kept for a period no less than three years as to be in compliance with the Institutional Review Board (IRB).

Results and Data Analysis

The purpose of this study was to investigate the nine research question as of what types of organizational strategies inspire to the mission, vision, and values of an organization. (See Appendix B).

The participants’ response data was then coded through open coding, axial coding, and selective coding as described in the grounded theory format (Creswell & Poth, 2018). This study incorporated the qualitative computer software named ATLAS.ti8 in order to code and analyze the interviews and the associated data. In the first phase of open coding, the researcher used ATLAS.ti8 to identify twenty-three codes, namely 1) accountability, 2) acknowledgement, 3) advancement, 4) alignment, 5) communication, 6) complacency, 7) compromise, 8) education, 9) equipment, 10) example, 11) financial, 12) , 13) listening, 14) motivation, 15) patient-care, 16) perception, 17) personal development, 18) quality, 19) respect, 20) servitude, 21) staffing, 22) supplies, and 23) work-ethic (See Table 1).

The software program ATLAS.ti8 allowed the researcher to download documents (four interviewee’s transcribed responses) and was coded through the open coding process. In the aforesaid method, the researcher manually inserted the codes and was able to query as needed (See Figure 1). The strategy of identification of codes can be seen in two opposing methods i.e. abstract or concrete coding (Madison, 2005) or by writing and memos (Huberman & Miles, 1994). This pilot study utilized open coding, or substantive coding which allowed the researcher to begin to develop new concepts as to gain the potential for a new theory. The twenty-three codes are illustrated in the ATLAS.ti8 software program (See Figure 1) and are also named in Table 1 as to allow for a manual naming, and categorizing of the information from the interviews. Additionally, ATLASti.8 was able to provide the researcher an opportunity to group the four documents according to shared characteristics i.e. pilot study interviews (See Figure 2).

In addition, the analysis software package ATLAS.ti8 allowed the interviews to be examined under the analyze tab. The researcher was able to select the participants’ downloaded and coded interview by opening in network editor. The next step is to import neighbors, namely 1) code, 2) quotation, 3) common, and 4) group (See Figure 3). In turn, the researcher was able to select the layout which has several types, i.e. tree, orthogonal tree, perpendicular and others (See Figure 4). The ATLAS.ti8 software package also has the ability to create a word cloud (spiral and typewriter format) (See Figure 5), and word list (length and count) (See Figure 6). Furthermore, the researcher can perform a code co-occurrence analysis from the choice of three displays, namely 1) code co-occurrence explorer, 2) open code co-occurrence table, and 3) code document table. By using the qualitative software package, the researcher can select the specific analytics needed to visualize the contextual characteristics of the data in holistic terms. Twenty-three open codes created tentative labels for the chunks of data, which were based on the participant’s responses (See Tables 1-9).

In subsequent fashion, categories or properties emerged from the open coding process which circled back to the study’s original research question, “What are the different types of organizational strategies that inspire employees to aspire to the vision, mission, and values of the organization?” This pilot study followed the grounded theory approach and revealed categories and the associated properties from the fracturing of data (Strauss & Corbin, 1990) which are namely, 1) showing and receiving appreciation, giving recognition, 2) setting the example, creating a strong work standard 3) creating teamwork, everyone makes a contribution no matter how small, 4) providing good patient experiences, 5) need supplies, needing updated equipment, need additional equipment 6) understaffed, overworked, 7) increase workflow efficiency, 8) management not interested, 9) reaching a settlement, 10) improving communication, listening and responding by management, 11) identifying supply chain issues, 12) cleaning of equipment, 13) specifying roles and responsibilities, making a commitment, 14) providing quality care, serving the community and patients, working to improve patient care, 15) checking exams prior to reading, 16) providing strategic organizational and employee alignment, 17) striving to become a better employee, striving to be your best, creating perception of self, 18) developing the individual , pursuing educational advancement, creating the opportunity for changing positions, making the opportunity to move into different fields, 19) establishing respect, 20) creating teamwork, helping co-workers, building a supportive team, and 21) seeking a monetary reward, seeking a paycheck, reaching for a financial reward (See Tables 1-9).

The study applied the second phase of coding, namely axial coding, which is defined as a set of procedures whereas data are put back together in new ways after the initial open coding, by creating connections between categories (Strauss & Corbin, 1990; Strauss & Corbin, 1998). Axial coding is based upon the open coding and the process of the relation of those codes either by properties or categories, by developing core themes. In the aforementioned construct, axial coding helps to answer the question, “What are the connections between the codes?” In the axial coding process, the researcher identified five axial codes or themes, namely 1) seeking external validation, 2) creating a positive work environment, 3) improving the patient experience, 4) individual improvement, and 5) identifying hurdles (See Table 10).

The participants in this study providing statements that help support the themes as described by candid statements. In the first theme described as seeking external validation, three participants expressed appreciation in receiving cards, cash vouchers, and coupons that showed appreciation of a job well done. The participant stating “That a month later you’ll get a really nice gift card or a small gift of gratitude” is very descriptive. Another participant stated that “We receive five dollar vouchers for lunch” helps to show that employees seek and appreciate acknowledgement. The underlying message here is that the organization supported this form of acknowledgement and helped to develop it. In addition, external validation is established by giving and providing respect as described by the participants. In this example one participant exclaimed that “People give respect” and was eager to share their story behind the reasons why. Also, the first theme was supported by two participants in terms of a monetary paycheck. While this on the surface may sound different in terms of external validation methods, paycheck is nonetheless external validation and is substantiated in several seemingly important ways.

The second theme, creating a positive work environment hinges on employees that want to set an example as in the one participant’s interview, “And I try to do that all time even when things are good or bad so I make me as example and set an example.” This participant also stated the following, “Every day I come to work I try to be…ah… and like an example.” Teamwork and accountability were also found to be important in this interview process as one participant states, “Yes I'm really proud of the team we have, we are very efficient, I work in a department where we tend to have people come in and they see multiple areas in this department and we work really well together.” Another participant put the importance of teamwork in these words, “So I really love that our team works together.” Accountability is mentioned indirectly in terms of one participant in this way, “I think absolutely I think so and that kind of stems back to everybody has their place and their responsibilities.” While the aforesaid does not mention the word accountability, it is implied. Moreover, communication and alignment play a role in creating a positive work environment as stated by a participant in this way, “We have monthly meetings for our department.” In this statement, the researcher gains insight and understanding that meetings are important organizational formats for the delivery of information.

Interview question number six helps sets the tone for this research study, “Does the mission of this organization create importance in your job?” Organizational and employee alignment was described by one participant as “Yes I feel like [HOSPITAL NAME] has a very clear vision of taking care of their patients and they definitely stress that to us as employees on how they want to us to make sure people are taken care of.”

In contrast to what an organization can do build a positive work environment, one participant state that the following, “Not really. I have not viewed the organization's goals or beliefs, it’s anything that just strives pushes me to do a better job, I do a better job of what I'm supposed to do you know, the only thing that drives me forward is you know grand internal moral compass and you know how I was raised and everything, be the organization changed their beliefs to something that it does set with mine… no, may not stay with an organization that did that, you know, you picked something that is aligned with what you want to do.” However, as one participant states, “Absolutely and I mean it's what we're here to do every day is provide great care and treat everybody with respect and the mission and value the [HOSPITAL NAME] puts forth, something we need to practice every single day” sets the example of the majority of the responses to interview question six.

The third theme defined as improving the patient experience places emphasis on servitude, quality, and patient-care. In the example of servitude, one participant explains, “We are coming to do every day is very important and helping out the community and people that need healthcare we're going to provide that for them.” Another participant provides the following the following tempered response, “To provide the best care for patients and to pay my own bills.” However, this participant went on to say, “Just you know I know I do a good job and people get better” which helps to explain the servant aspect of the health care employee. Quality extends over several categories and can best be projected by one participant, “Then I hope make sure that they're doing what they need for our patients it gives me satisfaction see that down the line for me going down everybody's taking care of and is providing great care and does a good job.”

The fourth theme is listed as individual improvement and is built upon advancement, education, personal development, motivation, work-ethic, and perception. Personal development was pointed out by one participant as, “And I know that those are there for me at any moment but I know that if and when I'm ready to do something different and try a new avenue they're there for me.” This aforesaid statement provides a basis as an organizational strategy that meets the employee need to aspire to the mission, vision, and values of the organization. Education and advancement are supported by statements such as, “I definitely see down the road pursuing further education,” and “A lot of people will go into management or into teaching or kind of branch off in other fields within Respiratory.” Motivation, work-ethic, and perception were conveyed by one participant’s statement in the following way: “Well I mean there's so many different reasons first and foremost because you have people relying on you… you know you have your coworkers relying on you and working at [Hospital Name] where they don't put people on call if you don't come to work you're really putting them in a bind and I actually at my other job we do put people on call and so if you call in you're kind of giving your coworker the short end of the stick. And it makes a bad name for yourself.” In contrast, another participant eludes the following, Does the organizational put in place strategies to help motivate? The answer is yes, strategies such as attendance and performance guidelines and policies as to maintain hospital staffing efficiencies as well as hospital standards (Cox, 2017).

The fifth theme is defined as the identification of hurdles in the health care employment arena. In this theme supplies, equipment, and staffing are mentioned as hurdles for not maximizing work efforts. One participant states the following surrounding equipment, “Obviously new and nicer equipment we've got really nice equipment here there's only like a couple more things that I would like to have for our staff and next generation X ray room ah another nice new portable.” Another participant goes on to say, “At this time probably my wish list would be to get a new set of halters and which would include even more than the current stash that we have right now.” The aforesaid mention of halter monitors represented half of the participants’ request as in the following example, “More Halter monitors. Probably or more work stations that could read the Halter. That's really the only thing that I can think of for my actual job.” Thus for equipment needs, the halter monitor is a sub-theme of equipment. Staffing is surrounded by several statements and begins with the following participant’s response, “And then also I think that a lot of times in health care people are a little overworked maybe their patient load is big enough that you can't get your work done.” Another response substantiates the aforesaid comment, “Yeah, I understand that its hard in health care because it's kind of all or nothing you know either you are so busy that you don't have time to stop at all or it kind of seems that when you are adequately staffed that's when it's pretty slow and you just never know when it's going to get busy at the hospital.” While healthcare organizations put into place strategies to maintain staffing (Cox, 2017), this theme had several responses to suggest otherwise. Supplies complete this fifth theme and provides statements such as, “I think that sometimes it's hard to find the supplies that you need occasionally.” And in one instance supplies were complicated by an inventory process such as, “I was working the E.R. one day and a one year old came in that needed to be intubated it and although we had vents down there we had no pediatric circuits we had no pediatric endotracheal tubes we had no supplies down there really to do that and because we don't do it that often and there was a time lapse of putting a vent together for a baby and so after that situation I had the idea let's just keep the vent in the ER with the pediatric circuit on it and so we did that and although we haven't had to use it since then it's nice to know what they are already ready to go. No, no more surprises.” In this aforesaid example, the participant was able to work with management and the organization as to make a corrective change, thus creating an alignment and improved engagement.

The third and final element of coding was selective coding, which occurred after identifying the core variable. The core variable identified in this pilot study was determined to be the improvement of an employee within an organization which helped to explain the behavior of the participants as they look for resolution of their key issues. In this step the researcher formulated a hypothesis based on the modeling of interrelated categories, derived from the coding and data (Creswell & Poth, 2018). The theory-derived hypothesis is stated as follows: Organizational strategies are effective when they are aligned with the needs of the employee.

The four employees in this pilot study interview provided insight in what matters most to the employee in terms of solutions brought forth by the nine interview questions. This research study suggests that the employees do have insightful ideas and valid concerns, which are meaningful. The data from this pilot study suggests that more data is needed to determine significance as a population of health care workers. However this pilot study does offer a look at the items that are significant to the small sample size with regards to resources needed, i.e. supplies, equipment, and staffing. This study also identified the importance of teamwork, and being an example as they relate to the organization’s success. Organizational strategies that center on teamwork have shown to reflect a high rate of adoption and perceived effectiveness (Ryan, 2017). This qualitative pilot research study also provided key themes that an organization can focus on in order to improve employee engagement such as employee recognition, accountability, personal development, communication, and listening.

Ethical Considerations

The protection of the participant is first and foremost in any research that involves human beings, thus this study required and gained written approval from the Sullivan Institutional Review Board (IRB), This IRB approved research study, required a signed letter of consent from each participant. The consent was in accordance to the format of the Institutional Review Board and contain sections, namely 1) study description, 2) risks and benefits, 3) and the participant’s protection of anonymity and confidentiality. Furthermore, the consent explained that the participants could discontinue the interview at any time.

Reducing Coding Problems

Qualitative data collection and data analysis can occur concurrently or asynchronously, however the goal of the researcher is to develop a plan built on a cycle of data collection and analysis (Wilkin, 2018). And while the qualitative researcher does not numerically measure data, they must be concerned about validity and the reliability of the data that is collected. According to (Leedy & Ormrod, 2015) the data collected qualitatively must be both 1) reasonably accurate with regards to characteristics and dynamics of the entities or situation being studied (validity), and 2) consistent in the patterns and dynamics that they reflect (reliability).

Summary

This qualitative research study has attempted to search and examine the organizational strategies that engage the health care employee. And while there are different views of the concept and outcomes of employee engagement, (Kahn, 1990; W. A. Kahn, 1992; Rothbard, 2001) this study focused on employee engagement and organizational goal alignment in the health care arena.

This qualitative pilot research study had preliminary findings i.e. themes, that suggest that employees are willing to discuss their concerns, and provide relevant and important information as to help organizations create strategies that can improve the employee’s work environment. This study attempted to answer the question, “What are the different types of organizational strategies that inspire employees to aspire to the vision, mission, and values of the organization?” The alignment of organizational strategies and employee’s concerns, could possible provide the inspiration needed for the employee to aspire to the mission, vision, and values of the organization.

The researcher recognizes the limitations of this pilot study, i.e. small sample size, a single employee population type, researcher’s bias, researcher’s skills (first qualitative study), possible Hawthorne effect along with others. Regardless of the limitations listed, the study looked to gain qualitative information that will add to the body of knowledge in this field of study. Future work will be focused on meeting theoretical saturation, procuring a broader population, and a deeper understanding of qualitative methodology, i.e. coding, and analysis. Moreover, in future studies with a larger sample size and deeper analysis could suggest a broader impact and improved intellectual merit surrounding this research.

In summary, research has shown that highly engaged health care workers are linked to high performance and effective organizational strategies (Robertson-Smith & Makwick, 2009). The importance of this research lends prudence to the fact that every health care worker plays an important role in patient outcomes. Thus organizations become successful when engaged employees are aligned with the vision and aims of the organizations (“NHS Staff Engagement Toolkit,” 2013).

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Meaning creation and employee engagement in home health caregivers. Scandinavian Journal of Caring Sciences, 30(1), 57–64. https://doi.org/10.1111/scs.12221 Patton, M. Q. (1990). Qualitative evaluation and research methods. Newbury Park, Calif: Sage Publications. Retrieved from http://proxyiub.uits.iu.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cat00016a&AN=inun.143264&site=eds-live&scope=site Pratt, M. G., & Ashforth, B. E. (2003). Fostering meaningfulness in working and at work. In Positive organizational scholarship : foundations of a new discipline (pp. 309–327). Retrieved from http://proxyiub.uits.iu.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edszbw&AN=EDSZBW688376045&site=eds-live&scope=site Rahmqvist, M., Samuelsson, A., Bastami, S., & Rutberg, H. (2016). Direct health care costs and length of hospital stay related to health care-acquired infections in adult patients based on point prevalence measurements. 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The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Economist. Retrieved from https://libraries.indiana.edu/ Shuck, B., & Wollard, K. (2010). Employee engagement and HRD: A seminal review of the foundations. Human Resource Development Review, (1), 89. Retrieved from https://libraries.indiana.edu/ Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Retrieved from https://libraries.indiana.edu/ Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage. Retrieved from https://libraries.indiana.edu/ Thorp, J., Baqai, W., Witters, D., Harter, J., Agrawal, S., Kanitkar, K., & Pappas, J. (2012). Workplace engagement and workers’ compensation claims as predictors for patient safety culture. 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Tables

Table 1. Open Coding Research Question 1: Please provide an example when someone expressed appreciation for the work you do.
Open Code	Properties	Participant’s Words
Acknowledgement	Showing and receiving appreciation Giving recognition	People express appreciation Get a really nice card Small gift of gratitude Got a gift card Nice to be recognized We receive five dollar vouchers I've received several of those over the years I see those many times over the years When I came in today for my shift there was a five dollar coupon for me for helping another department out with their rounds last week when they were short staffed That’s the usual go to Like thank you reward from managers
Example	Setting the example	A picture of a leader out in front of all employees A leader that leads by example

Table 2. Research Question 2: Please explain how your work contributes to the success of the organization.
Open Code	Properties	Participant’s Words
Teamwork	Creating teamwork Everyone makes a contribution, no matter how small	Everybody's work contributes to the success of the organization Small part of a huge corporation We need everybody to kind of to make it work
Example	Setting the example	Every day I come to work I try to be an example I make me as example and set an example Stay as calm as possible and treated with respect
Servitude	Providing good patient experiences	If I take care of patients then they're more likely to recommend that their family member come here or more likely to come back We give them a good experience We provide the doctors with the information they need to get the diagnosis and treatment for the patient

Table 3. Research Question 3: What is your “wish list” of resources required to do your job?
Open Code	Properties	Participant’s Words
Supplies	Need supplies	It's hard to find the supplies that you need occasionally
Staffing	Understaffed Overworked	In health care people are a little overworked More staff would always be great You just don't have the time to go in there and do anything Maybe it would be helpful to have more hands sometimes More people, Yeah. Yeah Patient load is big enough that you can't get your work done It's kind of all or nothing you know either you are so busy that you don't have time to stop You just never know when it's going to get busy at the hospital
Equipment	Needing updated equipment Need additional equipment Increase workflow efficiency	Obviously new and nicer equipment Like to have for our staff and next generation X ray room ah another nice new portable My wish list would be to get a new set of halter monitors Having twenty on hand would be more efficient We're having times where we run into time having to wait Having new equipment having enough equipment to take care of those issues More Halter monitors More work stations

Table 4. Research Question 4: What happens when you express an opinion about your work process to your supervisor?
Open Code	Properties	Participant’s Words
Complacency	Management not interested	They hear you out but it's not anything that they haven't heard a hundred times
Compromise	Reaching a s Listening and responding by management settlement	If you give a little bit here and you got to take a little bit in another area As far as the way things are ran it is what it is. I've had ideas that have been rejected for one reason or another you know regardless of its benefits Maybe I don't see the whole picture whereas there are other seeing the whole department in another areas I think squarely more than I do
Listening	Listening and responding by management	I feel like they you know take into account what I have to say Maybe down the road we can get it My direct supervisor she listens to it She considers it She says yeah let's see how everybody else feels about it She'll send out an email and say let's try this workflow instead of previous workflow and trying to make things a little bit better It's usually really taken in and thought about mulled over if it's a good idea I've had some ideas accepted and taken and you know that appreciative input

Table 5. Research Question 5: Provide an example of a time when you developed a better idea to improve a work process.
Open Code	Properties	Participant’s Words
Supplies	Identifying supply chain issues in low volume patient specific areas	We had no pediatric circuits We had no pediatric endotracheal tubes We had no supplies down there I had the idea let's just keep the vent in the ER with the pediatric circuit on it No more surprises It stays down there I overhauled and created a new inventory process for keeping track of equipment as well as the sign-in and check out for the distributing the equipment drop Checking-in and checking-out
Quality	Checking exams prior to reading	Some of our Radiologists call to complain about how we perform our DEXA’s. I told the staff to run any kind of DEXA scan to me and let me check them off and make sure they're O’K before they go out for the Radiologist
Equipment	Cleaning of equipment	We were checking all the machines during the day time cleaning all of them on the weekend and we kind of shifted that now to where we're checking machines, if there there's a little bit less work and not cleaning on the weekend when there's only one person here I suggested moving it off moving the cleaning the machines off the weekend and then we kind of decided as a group on when to check changing checking the machines
Communication	Improving communication	We have monthly meetings for our department and so we talked about when would it be best to

Table 6. Research Question 6: Does the mission of this organization create importance in your job?
Open Code	Properties	Participant’s Words
Accountability	Specifying roles and responsibilities	Everybody has their place and their responsibilities When a patient is on an vent and something going on with that then they need to call Respiratory Department Know what we're supposed to do and let us take care of our job. It's what we're here to do every day
Quality	Providing quality care	Provide great care and treat everybody with respect
Alignment	Providing strategic organizational and employee alignment	Yes I feel like [Hospital Name] has a very clear vision of taking care of their patients and they definitely stress that to us as employees on how they want to us to make sure people are taken care of. Not really. I have not viewed the organization's goals or beliefs, it’s anything that just strives pushes me to do a better job You picked something that is aligned with what you want to do.
Motivation	Striving to become a better employee	I do a better job of what I'm supposed to do The only thing that drives me forward is you know grand internal moral compass

Table 7. Research Question 7: Explain your opportunities for professional development.
Open Code	Properties	Participant’s Words
Advancement	Creating the opportunity for changing positions Making the opportunity to move into different fields	To go after another position and a lot of people do People will go into management or into teaching or kind of branch off in other fields within Respiratory There's different areas that you can kind of branch off to
Education	Pursuing educational advancement	Like going back to school to get further education I definitely see down the road pursuing further education I've been encouraged to get certification As well as information to pursue other degrees that would allow me to move up within the organization but they would allow me to stay within my own department
Personal Development	Developing the individual	We have a workforce development team and I've met with them before And I know that those are there for me at any moment And when I'm ready to do something different and try a new avenue they're there for me

Table 8. Research Question 8: What aspects of your work make you proud to be employed here?
Open Code	Properties	Participant’s Words
Respect	Establishing respect	Hospital is reputable and well known People give respect
Teamwork	Creating teamwork Helping co-workers Building a supportive team	Every time I can do something to help my employees and make their work experience better I feel like I'm succeeding I kinda start with the employees and then from there I work for the patients Yes I'm really proud of the team we have we are very efficient We work really well together So I really love that our team works together
Patient-Care	Working to improve patient care	Providing great care I know I do a good job and people get better
Work-Ethic	Striving to be your best	I'm a hard worker You do the job to the best of your ability provided to me all the standards that you are supposed to meet
Financial	Seeking a monetary reward	At the end of the day the jobs that provide you with the money and the means be the same thing that you truly love outside of work

Table 9. Research Question 9: Why is it important to come to work every day?
Open Code	Properties	Participant’s Words
Accountability	Making a commitment	First and foremost because you have people relying on you If you don't come to work you're really putting them in a bind It is always important to show up for work When you're understaffed like if you have people calling out all the time you wind up being understaffed
Financial	Seeking a paycheck Reaching for a financial reward	Obviously the paycheck is nice To pay my own bills
Servitude	Serving the community and patients`	We are coming to do every day is very important and helping out the community and people that need healthcare Sometimes what I do is just listen to what's going on with patients and I think that that makes a big difference To provide the best care for patients
Work-Ethic	Creating a strong work standard	I mean that's organization doesn't run without employees here doing hard work
Perception	Creating perception of self	It makes a bad name for yourself

Table 10. Axial codes and selective codes based on open codes:
Open Codes	Axial Codes -Themes	Selective Codes
Acknowledgement Respect Financial	Seeking external validation	Improving as an employee within an organization
Example Teamwork Communication Accountability Alignment	Creating an positive work environment
Servitude Quality Patient-Care	Improving the patient experience
Motivation Advancement Education Personal Development Work-Ethic Perception	Individual improvement
Supplies Staffing Equipment	Identifying hurdles

Figures

Figure 1. ATLAS.ti8 Open Coding

Figure 2. Atlas.ti8 Document Grouping

Figure 3. ATLAS.ti8 Network Build

Figure 4. ATLAS.ti8 Layout Tree

Figure 5. ATLAS.ti8 Word Cloud

Figure 6. ATLAS.ti8 Word Count and Length

Appendix A

Appendix B

Appendix E