Chapter 2: Literature Review

Exploring the impact of employee engagement and patient safety GRACE SCOTT , ANNE HOGDEN, ROBYN TAYLOR, and EMILY MAULDON Australian Institute of Health Service Management, Corner of Church & Glover St, Lilyfield NSW 2040, Australia Address reprint requests to: Grace Scott, Australian Institute of Health Service Management, Corner of Church & Glover St, Lilyfield NSW 2040, Australia. Tel: +02 8572 7999; Fax: +61 3 6324 3369; E-mail: [email protected]

Abstract Background: Health service administrators are continually investigating new ways to improve the safety and quality of health services. A positive and powerful relationship between employee engagement and patient safety has been suggested in the research literature, and steps can be taken by employers to enhance engagement to improve the safety of health services, particularly considering the coronavirus disease 2019 (COVID-19) pandemic. Objective: The aim of this review was to explore the current literature on the impact of employee engagement on patient safety. Methods: A review of peer-reviewed literature relating to the impact of employee engagement on patient safety within health services between January 2015 and May 2021 was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline Complete, Scopus, Health Business Elite and Business Source Ultimate databases. A search of grey literature using the Bielefeld Academic Search Engine database was also completed. Results: Of relevant articles, 3693 were identified, of which 15 studies were included in this review. Ten articles measured employee engagement using existing, validated tools, whereas patient safety was most frequently assessed through surveys seeking staff member’s perceptions of safety or the quality of care they provide. Overall, there appeared to be a positive correlation between employee engagement and patient safety, but the strength of the relationship varied. Conclusion: Anecdotal accounts of improving employee engagement and improving patient safety abound, and the evidence reviewed appears in agreement. However, research into the impact of employee engagement on patient safety is in its early stages. As health service managers consider the best use of funding to support safe and high-quality care, evidence to support the positive impact employee engagement has on patient safety may be useful in managing the fallout from the COVID-19 pandemic. Key words: employee engagement, patient safety, quality improvement, burnout

Received 29 January 2022; Editorial Decision 29 June 2022; Revised 10 June 2022; Accepted 27 July 2022 © The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Quality in Health Care. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]

Introduction The public expect safe and high-quality health services and facilities, where systems are implemented to ensure that patient harm is prevented [1]. It is therefore vital to iden- tify factors that affect health services’ ability to deliver safe and high-quality healthcare and, where possible, modify these factors to enhance the provision of this care.

Operationally, employee engagement is a positive work- related mindset, where staff are physically, mentally and emotionally connected to work [2]. Engaged employees have strong emotional, rational and behavioural attachments to their job and their organization [3] and have been defined as a person’s connection to their organization [4]. Kahn’s theoretical model of employee engagement describes three psychological conditions that have an impact on employ- ees’ levels of engagement or disengagement: meaningfulness, safety and availability [5]. Within the healthcare environment, staff engagement can be said to primarily refer to the expe- rience of joy and meaning in the work of healthcare [6]. In addition, Kahn’s model of engagement in this environment

suggests that staff must perceive work as ‘safe’ and have ade- quate resources available, in order for them to be engaged [5].

It has been suggested that there is a positive and power- ful relationship between staff engagement and the safety and quality of the care they provide [7, 8] wherein employees engaged with their work will provide superior care to their patients. By actively engaging those healthcare workers who have the most contact with patients and their families, hospi- tals may better ensure their priorities and policies align with patient care requirements.

Increasingly within the hospital setting, there is grow- ing interest in exploring how employee engagement directly impacts patients and the quality of care they receive. In point of fact, the ‘Triple Aim’ [9]—describing how the improve- ment of healthcare systems requires simultaneous focus on improving patient experience, improving population health and reducing healthcare costs—has increasingly shifted to the ‘Quadruple Aim’, where the work life of healthcare workers should also be improved [10]. Progress towards this fourth

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2 Scott et al.

Figure 1 Literature search results and inclusions/exclusions.

goal within the Quadruple Aim can be measured through workplace engagement and workplace safety. By focusing on this goal, the workforce will be encouraged to find joy and meaning in their work, improving their experiences of provid- ing care [6]. The recent and ongoing coronavirus disease 2019 (COVID-19) pandemic has also undoubtedly affected health- care staff’s engagement, and determining the impact of this change on patient safety is timely to determine if engagement can be enhanced despite this ongoing challenge.

To date, there has been no review of existing literature regarding the impact of work engagement on patient safety outcomes or quality of care within a healthcare setting, lead- ing to the novel nature of this review. Understanding the impact of engagement on patient safety outcomes will help to determine if investment in altering engagement will lead to better outcomes for patients in a resource-constrained health system.

Aim The purpose of this review is to address the following research questions:

1. What are the indicators of employee engagement and how are they measured?

2. Which patient safety outcomes are addressed and how are they measured?

3. What is the impact of employee engagement on these outcomes?

Methods The primary investigator conducted a review of medical and business literature related to employee engagement on patient safety outcomes or quality of care within a healthcare setting.

Due to the nature of the research questions, a variety of health and medical research, as well as business and man- agement databases, were included in the search. Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline Complete, Scopus, Health Business Elite and Busi- ness Source Ultimate were searched for English language research published on or after 1 January 2015 to May 2021. The author focused on contemporaneous research to ensure that included articles were of relevance and significance to the current health environment.

A set of search strategies was developed for the follow- ing databases: CINAHL, Medline Complete, Scopus, Health Business Elite, Business Source Ultimate and, for grey litera- ture, the Bielefeld Academic Search Engine (BASE). Controlled vocabularies, synonyms and keywords were used to create search strategies for three concepts: hospital or healthcare setting, employee engagement and patient safety. The strate- gies were added together using the AND Boolean operator to identify relevant articles.

Initial searches identified 3693 articles. After duplicates were removed, the primary investigator reviewed titles and abstracts for 3680 articles. Full-text copies of articles that appeared to meet the search criteria were further reviewed by the primary investigator to determine whether they should be included. To be included, articles needed to be empirical research, include a measure of engagement as a predictor and include a measure of patient safety. Studies were excluded if they conceptualized engagement as an outcome (as opposed to an explanatory variable), as this research is focused on how employee engagement impacts patient safety, rather than whether safety culture impacts employee engagement. Studies determined to meet the inclusion criteria were reviewed by the other authors to ensure rigour.

This process resulted in 15 articles being included in the final analysis (Figure 1).

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Engagement and patient safety • Narrative Review 3

Thematic analysis, used to identify, analyse and group themes within a data set, was applied to all studies to identify themes and subthemes of the research. Studies were first coded inductively by the primary researcher, with coding and theme development directed by the content of the data set in the context of the research question. Similar codes were grouped together in a spreadsheet, and themes were generated. These were then reviewed by the research team, and either refined or discarded following team discussion and agreement. This review considered the frequency of theme occurrence, as well as the significance and contribution to the data set. The refined themes were defined, named, and explored as answers to the posed research questions.

Results The purpose of this review was to identify and synthe- size existing evidence on the relationship between employee engagement and patient safety. The resulting articles demon- strate a broad variety of literature examining the mediating role employee engagement plays in patient safety. The char- acteristics of the 15 articles identified through the literature review are summarized in Table 1.

What are the indicators of employee engagement and how are they measured? Employee engagement is not measured by any one indica- tor. A variety of tools to measure different indicators were identified in the reviewed literature. The majority of indi- cators of engagement included the assessment of employ- ees’ levels of vigour, dedication and absorption [11], which is defined as the psychological state of staff; the perfor- mance constructs of observable behaviour and a disposition or a combination of these factors [11]. This was primar- ily measured through the Utrecht Work Engagement Scale (UWES) [12]. Other validated tools such as the Gallup Q12,

the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and a validated empowerment tool developed by Spreitzer [13] were used in other stud- ies. These tools provide several questions, with responses chosen from a Likert scale. Other indicators explored through these tools included employees’ self-reported job sat- isfaction or intention to leave their role [14], as well as employees’ opinions regarding opportunities for development and support [15]. In addition to these tools, some arti- cles measured engagement through staff surveys that asked employees to report on their self-perceived levels of engage- ment at work [16, 17] or their own validated engagement tool [18].

Which patient safety outcomes are addressed and how are they measured? Similarly, there was a range of patient safety indicators used within the literature. Objective measures of safety, such as incidence of large-scale adverse events (LSAEs), which describes the frequency of serious preventable incidents, 7- day mortality, which reports the rate of deaths of patients 7 days after their admission to hospital, and frequency of medical errors were the main indicators [16, 17, 19]. Staff members’ perceptions of safety or the quality of care within their organization were used to measure patient safety [18,

20–22]. One study relied on patient perceptions of safety and quality [23], providing a more comprehensive picture of safety within health services than through staff perspectives alone. The most common tool used to measure patient safety was the Safety Attitudes Questionnaire (SAQ). This questionnaire assesses staff members’ perceptions of safety climate and was used to seek feedback on teamwork climate, safety climate and stress recognition [15, 17, 24–26]. The Hospital Survey of Patient Safety Culture (HSOPSC) was also used [18, 25], as was a research questionnaire exploring five dimensions of service quality (the SERVQUAL scale) [23].

Data presented for both employee engagement and patient safety indicators came from a variety of sources and tools. Some were objective and validated, such as the UWES [20, 23, 24] and the SAQ [17, 18, 26], which provided more rigorous results than unvalidated tools.

What is the impact of employee engagement on these outcomes? Overall, there was a positive association between employee engagement and patient safety, but the strength of this associ- ation varies. Staff members who reported being more engaged were also more likely to look favourably upon the quality of care that they, their unit or their organization provided and their attitudes towards patient safety [14, 20, 27]. Researchers also concluded that employee engagement is a predictor of patient safety. In these studies, engagement was identified as having a ‘protective role’, where employee engagement pro- tected patient safety from being diminished by external events, and higher employee engagement predicted improvements in patient safety indicators such as LSAEs, 7-day mortality and medical errors [16, 17, 19].

Other studies concluded that employee engagement is a mediator of several variables, including patient safety [21, 24]. These authors concluded that access to professional resources at work, as well as external lifestyle factors, increased staff members’ performance at work and their commitment to the organization and patient safety [24]. Another study concluded that various human resources management prac- tices provide employees with resources that lead to higher healthcare performance indicators in quality and safety via engagement [21].

Discussion Statement of principle findings To better understand the identified indicators of employee engagement, patient safety and their interrelationship, three themes were identified within this literature review. These were as follows: (i) organizational and individual resources influence employee engagement, and these resources can be manipulated; (ii) the exact nature of the relationship between engagement and safety has not been quantified and (iii) staff heterogeneity will impact the generalizability of findings.

Interpretation within the context of the wider literature These three themes are now explored in reference to the wider literature to show how these findings relate to previous research conducted on employee engagement, patient safety and their interrelationship.

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4 Scott et al.

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Engagement and patient safety • Narrative Review 5

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Organizational and individual resources influence employee engagement, and these resources can be manipulated Increasingly, health systems are being affected by resource constraints, particularly in the context of ensuring cost- neutrality or profitability, as well as patients’ care needs becoming progressively more complex [15]. A number of studies included in this review used the ‘Job Demands, Job Resources’ model to describe the relationship between resource availability and employee engagement, where increasing demands while decreasing resources creates strain on the workforce [11, 28, 29].

Resources that affect engagement include both external, organizational resources and personal, internal capability- related resources. Organizational resources include factors such as job characteristics and job crafting [20, 21, 26], organizational culture [16], staffing levels and budgets [26], available supports and controls [14] and opportunities for personal growth [21]. Personal resources include resilience [20, 21, 26], individual capability [30] and self-management [14]. These factors can be altered to affect employee engage- ment [24].

Two studies also concluded that organizational resources have an impact on internal resources [20, 31]. It was noted that constrained organizational resources, such as poor com- munication, poor managerial support and lapses in account- ability, can lead to reduced capability [30]. This in turn leads to depersonalization, impairing the quality-of-care staff pro- vide as they disassociate from care [22]. In the converse, additional or strengthened organizational resources, such as leadership involvement, can strengthen individual’s personal resources [17, 30]. Additional organizational resources lead to the growth of individual resources, which in turn is good for the organization [21, 30].

The implication that the manipulation of organizational resources and individuals impacts employee engagement, which may then impact patient safety, provides a potential strategy to improve both employee engagement and patient safety.

The exact nature of the relationship between engagement and safety has not been quantified While it has been suggested that there is a positive and power- ful relationship between staff engagement and the safety and quality of the care they provide [7, 8], it was clear from some studies that the relationship between safety and engagement has not always been considered. Safety culture describes the value, attitudes and behaviours of individuals or groups that determine the organization’s commitment to safety [32]. Two studies concluded that safety culture may not have tradition- ally considered employee engagement [15, 16] and recom- mend that this is considered in the future. When exploring how employee engagement impacts patient safety, one study suggested that engaged employees were more likely to report safety concerns and also to participate in efforts implemented to improve system weaknesses in order to improve patient safety [18].

The reverse of the research question was also suggested— that is, that the stronger the patient safety culture, the more engaged the employees [23]. It is possible that high- performing teams motivate the employees in these teams to be more engaged [3]. Similarly, poor safety culture may lead to

disengagement [18], or clinicians that cannot provide quality care may feel exhausted [22].

Staff heterogeneity will impact the generalizability of findings Multiple studies described the heterogeneity of the work groups across the health care setting [17, 21, 23, 31]. Due to the complexity of healthcare organizations, the organi- zation will employ staff across multiple work groups, from specialized physicians to administrative staff to management. These work groups’ differences will affect their engagement with work and their impact on patient safety. For exam- ple, nursing staff and allied health professionals ‘belong’ to a professional group, and this belonging may increase their engagement at work [21]. These differences may be less apparent in specific health services, such as Veterans Health Administration-funded facilities, where the choice of an employer may increase the homogeneity of staff [16].

Staff heterogeneity was repeatedly highlighted to indicate that results applicable to one group may not be applicable to another [14, 17, 21, 23, 30]. Some studies focused on partic- ular work groups. For example, one study explored physician engagement’s impact on patient safety, noting that physicians can be weak team players based on their training and differ- ences between expectation and reality [31]. This implies that strategies that are implemented to affect employee engage- ment may need to be tailored for the work group it is targeted for. In addition, it was also suggested that improvements in one group’s engagement may impact another group’s engage- ment. Improving physician engagement was found to improve staff engagement, and efforts to improve engagement at the clinical work unit level may also result in efforts to improve provider engagement [18].

This indicates the need for results generated from indica- tors of employee engagement to be reported for each separate work group, rather than being homogenized. This is also important to better measure the impact of strategies that are implemented to affect employee engagement due to the heterogeneity of each staff group.

Implications for policy, practice and research The results of this review highlight the need for more method- ologically rigorous research to identify directions for future practice change within health services. It is recommended that, in future studies, both employee engagement and patient safety are measured using existing validated, objective tools. As research in this area matures, future reviews may be able to use a more rigorous quality assessment process to evaluate the quality of the research [15]. In addition, stud- ies that explore both qualitative and quantitative impacts of engagement on patient safety should be further explored, as there are a multitude of indicators that can be harnessed to determine whether patient safety is truly affected. It is also recommended that, if perceptions of patient safety are being explored, it would be wise to seek feedback from those potentially most affected by engaged employees—our patients.

An empirical gap in research exploring the relationship between employee engagement and patient safety is therefore evident. This gap requires further investigation, as this rela- tionship may identify valuable areas for further investment in a resource-constrained health system to produce significant improvements in patient safety. Further investigation into this

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Engagement and patient safety • Narrative Review 7

relationship within the Australian healthcare system, using validated employee engagement and patient safety measures, is therefore warranted.

Strengths and limitations This review focused on exploring the relationship between employee engagement and patient safety within the health- care setting. Only 15 articles met the inclusion criteria. The inclusion of only English language studies limited the number of studies eligible to be included in the review and may result in language bias. Indeed, most articles included were based on studies conducted in either European or American healthcare systems. Publication bias may result in studies, where authors identified that there is a relation- ship between employee engagement and patient safety being over-represented in the literature identified. Additionally, the studies included in the review featured heterogeneity in their design and metrics assessed, making direct comparability dif- ficult. Finally, most studies reviewed were designed to assess single hospitals or individual inpatient clinical units, poten- tially limiting the generalizability of their findings.

To increase the strength and holistic nature of this review, the search used five databases for peer-reviewed research, the grey literature search engine BASE and reference lists of included papers to identify potential studies within this field for inclusion within this literature review. The search also included both quantitative and qualitative measures of patient safety and employee engagement and included a rig- orous review of outcome measures and reporting. The articles reviewed explored employee engagement from a variety of employees’ perspectives, including non-clinical staff. While it cannot be disputed that clinical staff have a significant impact on the quality of care that patients receive, non- clinical staff also play a role in patients’ care quality and experiences [3].

Conclusions While studies investigating relationships between employee engagement and patient safety exist, high-quality peer- reviewed evidence regarding the definitive impact of employee engagement on patient safety remains in its early stages. Fur- ther investigation is warranted to identify potential resource investment areas for health service managers to consider in the constant battle to improve patient safety. As health ser- vice managers consider the best use of funding to support safe and high-quality care among the significant challenges of COVID-19, research into employee engagement may assist in identifying strategies to manage the impact of this pandemic on our healthcare staff.

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