Concept identification and definition
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C O N C E P T A N A L Y S I S
Work engagement in nursing: a concept analysis
L. Antoinette Bargagliotti
Accepted for publication 17 September 2011
Correspondence to L. Antoinette Bargagliotti:
e-mail: [email protected]
L. Antoinette Bargagliotti DNSc RN FAAN
Professor
University of Memphis Loewenberg
School of Nursing, Memphis, Tennessee,
USA
A N T O I N E T T E B A R G A G L I O T T I L . ( 2 0 1 2 )A N T O I N E T T E B A R G A G L I O T T I L . ( 2 0 1 2 ) Work engagement in nursing: a
concept analysis. Journal of Advanced Nursing 68(6), 1414–1428. doi: 10.1111/
j.1365-2648.2011.05859.x
Abstract Aim. This article is a report of an analysis of the concept of work engagement.
Background. Work engagement is the central issue for 21st century professionals
and specifically for registered nurses. Conceptual clarity about work engagement
gives empirical direction for future research and a theoretical underpinning for the
myriad studies about nurses and their work environment.
Method. Walker and Avant’s method of concept analysis was used. Nursing,
business, psychology and health sciences databases were searched using Science
Direct, CINAHL, OVID, Academic One File, ABI INFORM and PsycINFO for
publications that were: written in English, published between 1990 and 2010, and
described or studied work engagement in any setting with any population.
Results. Work engagement is a positive, fulfilling state of mind about work that is
characterized by vigour, dedication and absorption. Trust (organizationally,
managerially and collegially) and autonomy are the antecedents of work engage-
ment. The outcomes of nurses’ work engagement are higher levels of personal
initiative that are contagious, decreased hospital mortality rates and significantly
higher financial profitability of organizations.
Conclusion. When work engagement is conceptually removed from a transactional
job demands-resources model, the relational antecedents of trust and autonomy
have greater explanatory power for work engagement in nurses. Untangling the
antecedents, attributes and outcomes of work engagement is important to future
research efforts.
Keywords: autonomy, concept analysis, nurses work engagement, trust
Introduction
Work engagement in nursing is becoming strategically
important as three important factors converge: a global
shortage of nurses who are the largest group of healthcare
providers; political resolve to restrain the growth of rising
healthcare costs in industrialized nations; and a medical error
rate that threatens the health of nations. Since nurses report
low levels of work engagement (Fasoli 2010) by scoring
lower than other hospital groups (Blizzard 2005a) on
measures of work engagement, understanding engagement
is important. While the concept of work engagement emerges
from the new ‘positive psychology’ (Luthans et al. 2007,
p. 541) that focuses on human strengths, rather than
limitations, work engagement has captured global research
attention because it is amenable to change (Luthans et al.
1414 � 2011 Blackwell Publishing Ltd
J A N JOURNAL OF ADVANCED NURSING
2007). The purpose of this concept analysis is to clarify the
concept of work engagement in nursing.
Work engagement has been studied by the disciplines of
nursing, psychology, education and business in more than
one million people. The participants for these studies have
been nurses and other professionals in the US (Mackoff &
Triolo 2008a,b, Simpson 2009b, Palmer et al. 2010), Canada
(Spence-Laschsinger et al. 2006), the Netherlands (Brake
et al. 2007), South Africa (Rothman 2008), Australia (Parker
& Martin 2009), Ireland (Freeney & Tiernan 2009), Norway
(Andreassen et al. 2007, Vinje & Mittlemark 2008), Finland
(Hakanen et al. 2008a), China (Lu et al. 2011) and Spain
(Jenaro et al. 2010).
Work engagement contributes to a distinctive body of
nursing knowledge because it theoretically underpins the
actions of nurses and nurse managers as they create a practice
environment that either supports safe and effective care or
does not. According to the IOM (2003) report, the US nurses’
work environment is a threat to patient safety. Lake’s (2007)
review of 54 nursing studies of the practice environment, and
Cummings et al.’s (2010) review of 53 studies of the effects of
nursing leadership on nursing practice attest to an enduring
nursing interest in creating a practice environment that
supports safe and effective care.
Background
Clarifying the concept of work engagement is important in
nursing because as Rafferty and Clark (2009) noted, ‘The
danger with concepts like engagement is that they can
become unwieldy, fuzzily-defined terms invoked as panaceas
for the dilemmas of workforce management’ (p. 876).
Simpson’s (2009a) nursing review of the research on work
engagement concluded that there is an essential need to
differentiate the antecedents from defining attributes because
these have been interchangeably used. This conceptual
confusion has prompted four distinctive lines of research:
personal engagement, burnout/engagement, work engage-
ment and employee engagement (Simpson 2009a).
Fasoli (2010) characterized work engagement as the fifth
line of inquiry emerging from the American Academy of
Nursing’s Magnet study of the characteristics of hospitals
that attract and retain nurses (McClure et al. 1983). The
original MagnetTM study gave empirical evidence for what
came to be known as the essentials of magnetism (clinical
competence, RN/MD relationships, autonomy, support for
education, nurse manager support, cultural values and
adequacy of staffing). According to Fasoli (2010) the original
magnet research in the US was followed by a second wave
that shifted the focus to patient outcomes, a third wave that
compared Magnet designated hospital outcomes to their non-
Magnet cohorts, a fourth wave that focused on measuring the
professional environment and now an emerging fifth wave
focused on work engagement. Engagement moves beyond
retention to the strategic question of how to engage nurses in
their professional practice (Wagner 2006, Fasoli 2010). The
related concept of embeddedness points out why engagement
may or may not be related to retention. Embeddedness is an
enduring attachment to a job and work setting that occurs
because of the constellation of factors that keep a person in
one job. Links, person-job fit and the sacrifices that leaving
would entail are factors that grow over time to cause
embeddedness (Halbesleben & Wheeler 2008). In contrast,
work engagement is directly related to the work itself that
could be done in multiple settings.
A model of work engagement (Bakker & Demerouti 2008)
that is intuitively appealing and one that has captured
important research attention is one that is based on job
resources and demands (JD-R).
The job demands-resources model
The JD-R model (Bakker & Demerouti 2008) posits that in
all jobs, there are demands and varying resources to meet
those demands. Demands are the job requirements that
require employee effort to achieve. Resources are aspects of
the job that either enable the work to be done, ameliorate
work demands, reduce the personal cost of doing work, or
develop the work-related skill sets of the person (Demerouti
et al. 2001). The JD-R model posits that burnout occurs
when resources are inadequate and work engagement occurs
when resources are high. Subsequently, in a JD-R model, high
resource levels become the antecedent of work engagement.
The JD-R model is conceptually rooted in Lazarus and
Folkman’s (1984) transactional model of stress and coping
that describes stress as the outcome of situations where
demands (stressors) exceed available resources (coping).
However, as Hobfoll (1989) cogently noted, the inherent
flaw in all transactional or balance models of stress and
coping is the tautology that neither side of the equation
(demands or resources) has meaning without the other.
Conceptualizing the antecedents of work engagement as
personal and organizational resources that mediate or are
mediated by job demands has mixed empirical support as
noted in Tables 2 and 3. However, the JD-R model fails to
explain how work engagement occurs in adverse conditions
when demands are extraordinarily high and resources are
scarce as in an emergency or natural disaster. Moreover, this
transactional approach means that nurses’ work engagement
is solely dependent on the dubious outcome of a balancing act
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between demands/resources. Subsequently, this relegates the
dedication of nurses, a distinguishing characteristic of the
profession (Fagermoen 1997, Pask 2005, O’Connor 2007), to
being a transactional commodity that occurs because some-
one else dispenses resources. And, work engagement becomes
externally controlled.
Method
Walker and Avant’s (2010) model of concept analysis was
used. Their eight-step model includes selecting the concept
for analysis, determining the aim, identifying uses of the
concept, determining defining attributes, constructing cases,
identifying the antecedents and consequences of the concept
and defining the empirical referents for the concept.
Data sources
The Cumulative Index of Nursing and Allied Health
(CINAHL), Science Direct, OVID (Lippincott), Academic
One File, ABI INFORM and PsycINFO were systematically
searched using the keywords: work engagement, engagement,
work engagement in nursing. The inclusion criteria included:
written in English, published between 1990and 2010, and
described or studied work engagement in any setting with any
population. Because Kahn (1990) first described work
engagement in 1990, all articles between 1990 and 2010
were reviewed against the inclusion criteria of theoretical
work or empirical studies of work engagement.
Results
The results of the concept analysis include the uses of the
concept, the definitions of engagement and work engage-
ment, the attributes, three constructed cases, the antecedents,
the consequences and the empirical referents.
Uses of the concept
The Encarta World English Dictionary North American
Edition (2009) defined engagement as: ‘agreement to marry,
commitment to attend, short job, battle, and an active or
operational state’. Engagement connotes encounter when
used in the phrase the ‘rules of engagement’. For example,
Laurence (2007) described his ostracism by soldiers when his
news reports violated their ‘rules of engagement’ or unspoken
rules of conduct about reporting from a battlefield.
Nursing has used the term ‘engagement’ as engaged
scholarship, civic engagement and clinical engagement.
Engaged scholarship describes the work of faculty who
engage students as active learners in real world settings
(engaged pedagogy), collaborate with practice colleagues to
conduct community-based research and collaborate in
practice (Burrage et al. 2005). Civic engagement refers to
the political activism of nurses to shape health policy at local,
state, national and international levels (Gehrke 2008). At a
micro level, Ellefson and Kim’s (2005) qualitative study of
Norwegian nurses revealed that clinical engagement
included: nursing approaches and movements in time, space
and perspectives; involvement as in knowing the patient; and
clinical actions that were therapeutic, caring and efficient.
Definitions of work engagement
The empirical and theoretical definitions of work engagement,
as noted in Tables 1–3, have focused either on the person/
organization interaction or on the experience of the person
who is engaged in work. Tying the efforts of the person to
organizational goals can be found in two similar definitions of
work engagement: ‘the harnessing of organizational member
selves to their work roles’ as a way of self-expression in work
(Kahn 1990, p. 694) and working collegially to meet organi-
zational goals (Seymour & Dupre 2008). However, when the
focus is shifted to the experience of the person, work
engagement is defined as a ‘positive, fulfilling work-related
state of mind’ (Schaufeli et al. 2002, p. 465) and well-being at
work that is ‘characterized by vigour, dedication, and
absorption’ (Schaufeli & Bakker 2003).
Vinje and Mittlemark’s (2008) qualitative study of com-
munity health nurses’ work engagement defined work
engagement as ‘searching for, experiencing, and holding on
to the meaningful work that enables one to lives one’s values’
(p. 200). Alternatively, Maslach and Leiter (1997) defined
engagement as the polar opposite of burnout and Shimazu
and Schaufeli (2008) as the antithesis of burnout. Efforts to
differentiate work engagement from burnout using Warr’s
(2002) four dimensions of work well-being in a study of
South African police officers did not conceptually untangle
the two concepts (Rothman 2008). For the purposes of this
analysis, Schaufeli et al.’s (2002) earlier definition of work
engagement as a ‘positive, fulfilling work-related state of
mind’ (p. 465) is used.
Defining attributes of work engagement
The defining attributes are those characteristics of the
concept that both define and differentiate the concept
(Walker & Avant 2010). ‘‘The employment and expression
of the person’s ‘preferred self’ in task behaviors that promote
connections to work and to others, personal presence.... and
L. Antoinette Bargagliotti
1416 � 2011 Blackwell Publishing Ltd
active, full role performance’’ (Kahn1990, p. 770), being
‘emotionally connected to each other’ (Harter et al. 2002a)
and ‘cognitively vigilant’ (Harter et al. 2002a) have been
described as attributes of work engagement.
Vigour, dedication and absorption (Schaufeli & Bakker
2004) have been commonly used attributes in work engage-
ment research. When work engagement is conceptualized as
the antithesis of burnout, the attributes of work engagement
become energy, involvement and efficacy as the polar
opposites of burnout (Maslach & Leiter 1997). Vigour is
the energy and enthusiasm that the person brings to the work
setting. Dedication is being devoted, inspired and believing
that the work has a purpose. Absorption is being immersed in
the work to the extent that it is difficult to leave and time
becomes less relevant (Schaufeli & Bakker 2004).
Most recently, Vinje and Mittlemark (2008) described
three inter-related attributes of nurses’ work engagement:
having a ‘calling’ (p. 198) which provides the path to
meaningfulness; zest which happens when experiencing
meaningfulness in work; and vitality, which is the ability to
hold onto meaningfulness in work. The two most commonly
agreed on dimensions of work engagement are high levels of
energy and identification with work (Bakker et al. 2008).
Vigour, absorption and dedication (Schaufeli & Bakker
2004) were selected as defining attributes of work engage-
ment because as indicated in Table 3 they have been widely
used in work engagement research (Schaufeli & Bakker 2003,
Wong et al. 2010, Jenaro et al. 2010).
Constructed cases
Constructed cases illuminate the concept by describing the
concept’s presence in a model case, the absence of a concept
in a contrary case and the differences between the concept
and a closely associated concept in a related case (Walker &
Avant 2010).
Model case
JM, BSN, CCRN has practiced for 10 years in the intensive
care unit (ICU) of an acute care hospital that also has a Level
1 trauma centre. She excitedly tells her colleague that she had
the most wonderful day because she knew that Mr T’s tidal
volume and fluids needed to be increased before his blood
gases, blood pressure and urine output continued to deteri-
orate. Her colleagues and her manager congratulate her on
seeing what they did not see. Dr J. congratulated her on her
‘good call’ and asked how she knew. She helped Mr T’s wife
find ways to ensure her husband had some uninterrupted rest.
She was able to help a younger nursing colleague who was
Table 1 Emergence of work engagement definitions, attributes and measurement.
Kahn (1990)
Maslach and Leiter
(1997)
Schaufeli et al.
(2002)
Harter et al.
(2002a)
Vinje and Mittlemark
(2008)
Definition ‘Harnessing of
organizational
members’ selves to
work roles’ (p. 694)
Opposite end of
burnout continuum
‘Positive, fulfilling
work-related state of
mind’ (p. 465)
‘Searching for,
experiencing, and holding
on to the meaningful work
that enables one to live
one’s values’ (p. 200)
Defining
attributes
Use of ‘preferred self’
(skill, talent) in
performing tasks,
presence, and
connection to others
in fulfilling role
Energy (vs. exhaustion)
Involvement
(vs. cynicism)
Efficacy (instead of
reduced efficacy)
Vigour – high energy
levels with willingness
to persist in investing
in work even during
difficult times
Dedication – enthusiasm
and identification with
work
Absorption – deep
engrossment in work
Extended engagement
model adds personal
efficacy
Emotionally
connected
to each other;
cognitively
vigilant
Calling – a path to
meaningfulness
Zest – experience
meaningfulness
Vitality – hold onto
meaningfulness
Measurement Grounded theory that
was later ‘scored’
Maslach Burnout
Inventory (MBI-GS)
(Maslach & Jackson
1981)
Utrecht Work
Engagement
Scale (UWES)
Q-12 Phenomenology
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Table 2 Antecedents of work engagement.
Job demands Job resources
Personality
characteristics
Organizational
actions
Organizational
life
Job demands are ‘physical,
social or organizational
efforts of the job that
require sustained physical
and/or mental efforts’
(Demerouti et al. 2001,
p. 501) that lead to energy
depletion and exhaustion
(Schaufeli & Bakker
2004)
Job resources are
motivational. ‘physical,
social, or organizational
aspects of the job that may:
(1) function in achieving
work goals; (2) reduce job
demands and the
associated physiological
and psychological costs;
(3) stimulate personal
growth and development’
(Demerouti et al. 2001,
p. 501)
Kim et al. (2009) study
(n = 187 Subway workers
and managers in 51 stores)
of the Big 5 personality
characteristics
[neuroticism (negative
affect), extroversion,
agreeableness,
conscientiousness and
openness to new
experiences] found that
conscientiousness
positively predicted work
engagement and
neuroticism inversely
predicted engagement
Clarity of
expectations
and basic materials
and resources are
provided
Feelings of
contribution
to the organization
Belonging to
something
beyond oneself
Workload, control over
work
Reward and recognition
(ongoing weekly
feedback)
Sense of community
(collegial social
support)
Fairness as opposed to a
lack of transparency
and promotions not
handled equitably
(Freeney and Tiernan
2009)
Bacon and Mark (2009)
study (n = 146 hospitals,
2720 patients, 3718
nurses in 286 nursing
units) found that hospitals
with >5% increase in
admission and higher
complexity were
negatively related to
work engagement
Kim et al. (2009) study
(187 Subway managers
and workers) found that
skill variety and
management position were
predictive of engagement
Buoyancy (daily resilience)
is a personal belief that
one can effectively manage
problems (Parker &
Martin 2009)
(PsyCap) composite of
self-efficacy, optimism,
hope, and resilience as
greatest contributor to
organizational
commitment (Luthans
et al. 2007) (n = 167
management college
students; n = 115
engineers and technicians
of Fortune 500 company
and n = 144 insurance
company employees)
Opportunities for
growth and
development
(Harter et al.
2002b)
Recognition,
person-job fit and
energy that comes
from being valued
in a climate that
supports employee
interests/passions.
(Kerfoot 2007)
Higher levels of support
staff and of work
engagement of nurses
were related to higher
patient satisfaction
ratings
Schaufeli and Bakker
(2004) motivational job
resources are collegial
social support,
performance feedback
and coaching
Job resources leads to
work engagement which
leads to personal initiative
that leads to work-unit
innovation that leads to
personal initiative that
leads to engagement, and
predicts future resources
(Hakanen et al. 2008a)
Job control is the job
resource that leads to
work engagement
(Mauno et al. 2007)
Personal resources of
self -efficacy
Optimism
Organizationally based
self-esteem
(Xanthopoulou
et al. 2009)
Trust (willingness to
accept vulnerability and
positive expectations) in
top management,
supervisors and co-worker
engagement has a
spiralling effect in that one
leads to more of the other.
Trust is based on belief
that trustee is competent
(knowledgeable &
capable), reliable, open
(free flow of information),
and concerned (will not
behave opportunistically
and will act in trustor’s
best interest) (Chugtai &
Buckley 2008)
L. Antoinette Bargagliotti
1418 � 2011 Blackwell Publishing Ltd
Table 3 Empirical findings about work engagement.
Investigator Sample Methods Findings
Level of
evidence *
Harter et al.
(2002a)
Meta-analysis of 42
studies (n = 36
companies, 7936
business units, 198,
514 employees
Gallup Workplace Audit r = 0Æ77 between overall satisfaction and employee engagement; 70% higher
success rate of business units above
median on work engagement than those
with below the median rates of work
engagement; 103% higher rate of success
when work engagement above/below
median was compared across companies
Level 1
Spence-Laschsinger
et al. (2006)
N = 322 nurses in
Ontario, Canada
acute care hospitals
Maslach Burnout Inventory
(MBI-GS)
Areas of Work Life (AWF)
Nurses reported greatest degrees of match
in community, value congruence and
rewards and mismatch in workload,
fairness and control. 53% reported
severe burnout; Greater control was
predictive of less onerous workloads,
greater rewards, better collegial
relationships and greater sense of
organizational fairness
Level III-3
Andreassen et al.
(2007)
N = 235 Norwegian
bank employees
Workaholism Scale
(Norwegian version)
UWES (Schaufeli &
Baker 2003) Cooper
Stress Index MBI-GS
Subjective Health
Complaints Inventory
Years worked at bank and enjoyment of
work explained 29% of the variance in
Work Engagement (R2 = 0Æ29 in 2 step model)
Level III-3
Brake et al. (2007) N = 497 Dutch
dentists
Ultrecht Work Engagement
Scale (UWES)
Maslach Burnout
Inventory –General
Survey (MBI-GS)
High levels of work engagement that
persisted across age groups; Burnout
dimensions of emotional exhaustion and
depersonalization were negatively
correlated to work engagement
Level III-3
Mauno et al. (2007) (NT1 = 735; NT2 = 623)
2 year longitudinal
study
random sample of
Finnish healthcare
workers at three
hospitals in one
healthcare district
Survey
UWES
Job Insecurity Scale
Quantitative Workload
Inventory (QWI)
Job control (time and
method) Organizational
Based Self Esteem
(OBSE) Management
quality (4 items) from the
Organizational Culture
Inventory-50
High levels of vigour and dedication were
stable over time and most predicted by
job resources (control and OBSE)
Level III-3
Hakanen et al.
(2008a)
3 year cross-lagged
study (n = 2,555
Finnish dentists)
Dentists’ Experienced Job
Resources Scale (DEJRS)
3 job demands (workload,
work content, and
physical work
environment)
Family/partner Support
Scale Home Demands
UWES; MBI
Burnout, Work Engagement, Depression,
and Organizational Commitment were
stable at Time 1 (T1) and Time 2 (T2)
3 years later
Home demands/home resources did not
affect well-being factors
Job resources at T1 effected work
engagement at T2. Burnout at T1 predicted depression at T2; Lack of job
resources at T1 predicted burnout at T2
Level III-3
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Table 3 (Continued).
Investigator Sample Methods Findings
Level of
evidence *
Mackoff and Triolo
(2008a)
N = 30 outstanding
nurse managers
Nurse Manager
Engagement
Questionnaire
Interview
Signature behaviours of mission drive,
generativity and/or, identification,
boundary clarity, reflection,
self-regulation, attunement, change agility,
affirmative framework were associated
with work engagement
Level III-3
Mackoff and Triolo
(2008b)
N = 30 outstanding
nurse managers
Nurse Manager
Engagement
Questionnaire
Interview
Organizational cultures of learning, regard
meaning, generativity and excellence were
associated with work engagement
Level III-3
Rothman (2008) N = 677 South African
police officers;
Stratified random
sample
Minnesota Job Satisfaction
Questionnaire
MBI-GS
UWES
Police Stress Inventory
Cynicism was related to exhaustion
(r = 0Æ59), dedication related to vigour (r = 0Æ78), lack of support was related to stressfulness of job demands
(r = 0Æ72), intrinsic job satisfaction related to extrinsic job satisfaction
(r = 0Æ61), vigour and dedication led to work engagement which is related
to work-related well-being. In a
4-factor model, job satisfaction
(r = 0Æ45) and work engagement (r = 0Æ43) were related to work-related well-being while burnout (r = �0Æ91) and occupational stress (r = �0Æ35) were not
Level III-3
Vinje and
Mittlemark (2008)
N = 11 Norwegian
community health
nurses identified as
exemplary
Qualitative analysis of
interviews
(phenomenological
interview to gather data
and hermeneutic interview
to interpret data)
Meaningfulness
Calling
Zest for work
Vitality
Level IV
Freeney and
Tiernan (2009)
N = 20 Irish nurses in
general and psychiatric
units of an acute care
hospital
Focus groups Barriers to work engagement-
Organizational life (workload, lack of
control, reward, fairness, lack of sense of
community and values conflict between
caring and hospital focus on finance
Engagement was related to intrinsic reward
of seeing patients recover, social support
from colleagues, and energy
Level IV
Simpson (2009b) N = 167
medical-surgical
RNs in 6 hospitals
UWES-9
Turnover Cognitions
Scale (TCS)
Index of Work Satisfactions
(IWS-R)
Job Search Behavior Index
(JSBI)
The combination of professional status,
interaction, and thinking of quitting
explained 46% of the variance
(P < 0Æ001) in work engagement; professional status and interaction
moderated the relationship between
thinking of quitting and work
engagement
Level III-3
L. Antoinette Bargagliotti
1420 � 2011 Blackwell Publishing Ltd
unsure about her clinical judgment, double-check her assess-
ment. She is thrilled that her task force’s work on handoffs
will be tested as a standard procedure for the hospital. She
loves nursing.
This is a model case because of the energy and enthusiasm
(vigour) JM displays in her work. Her dedication to nursing
work is exemplified by her careful attention to the condition
of her patient, her meaningful involvement of the family in
providing care, her consensual validation of a younger
nursing colleague and her work on ‘hand-offs’ to improve
nursing practice. She is absorbed in the practice of nursing.
Contrary case
TN, BSN became a nurse because her parents thought
nursing was a good profession for her. She has practiced for
2 years in a surgical unit. The unit is well staffed, she believes
her salary and benefits are excellent and she enjoys her
younger colleagues. She works nights so that she does not
have to see families or physicians and can minimally interact
with patients. She is planning to practice for only six more
months until she is married. Her job enables her to have the
time to plan and pay for her wedding.
This is a contrary case because none of the attributes of
work engagement, dedication, absorption, or vigour are
present.
Related case
AB, BSN declines the offer of another position because she
does not want to leave her current job in the ICU. She has
practiced in this unit for 5 years and knows the practice
patterns of physician and nurse colleagues. Her salary and
benefits are excellent, the hospital is close to her home and
her work schedule enables her to have the time she wants to
devote to her family. Her supervisor is not engaged in the
patient care issues of the unit because he has no background
in critical care. Nursing is a job for most of her colleagues
and she misses having colleagues who want to discuss
intriguing cases. She is dedicated to providing the best
possible care for patients but avoids asking questions that
could lead to change because that would cause problems.
Subsequently, her work is not as interesting or absorbing as
it once was.
This is a related case because it describes embeddedness, a
closely related but different concept (Walker & Avant 2010).
In this case, dedication (although limited) is the only attribute
of work engagement that is present. The excellent salary and
benefits, schedule, geographical convenience and familiarity
that anchor A.B. to this job describe embeddedness. Absorp-
tion would create questions leading to change that would
cause problems in this work setting. Enthusiasm would be
misunderstood as being too involved.
Table 3 (Continued).
Investigator Sample Methods Findings
Level of
evidence *
Jenaro et al. (2010) N = 8 nurse managers
256 RNs and 148
certified nursing
assistants (CNAs)
Modified Survey on Job
Satisfaction
(Cantera 2003)
General Health
Questionnaire (GHQ-28)
(Lobo et al. 1986)
WES (Spanish version)
13Æ3% of nurses (including CNAs) scored high on all 3 measures of work engagement.
Satisfaction with position, less social
dysfunction and less stress with patient care
explained 42% of the variance and 34Æ6% (P < 0Æ001) of the variance in vigour
Level III-3
Wong et al. (2010) N = 280 acute care
registered nurses in
Ontario, Canada
Authentic Leadership
Questionnaire (ALS)
(Avolio & Gardner 2005)
UWES-short form, Personal
identification with the
Leader (Kark et al. 2003),
Helping and Voice
Behaviors Scale (VanDyne
& LePine 1998),
International Survey of
Hospital Staffing and
Organization of Patient
Care Outcomes (Aiken
et al. 2001)
Authentic leadership directly affected trust
(b = 43, P < 0Æ001). Trust affected work engagement (b = 0Æ19, P < 0Æ001), Social identification (identification with the work
group) affected work engagement (b = 0Æ41, P < 0Æ001)
Level III-3
*National Health and Medical Research Council – Australian Government levels of evidence used.
JAN: CONCEPT ANALYSIS Engagement
� 2011 Blackwell Publishing Ltd 1421
Antecedents
Antecedents are those factors that precede the occurrence of
the concept (Walker & Avant 2010). Kahn (1990) likened
engaging in work to entering into a contract. There is
meaningfulness (a valued benefit), safety (protective guaran-
tees) and availability (resources to fulfil the contract). These
may appear to be Kahn’s defining attributes of what he
described as personal engagement (in work). However, since
Kahn’s ‘conditions’ are conditional to personal engagement
in work, they are antecedent to work engagement. As noted
in Table 2, employee personality characteristics (personal
resources) and organizational actions (job resources) have
been explored as possible antecedents of work engagement
because work engagement has been conceptualized in a job
demands/resources framework.
What must be present in the nurse’s work environment for
dedication, vigour and absorption to occur? When the
findings from work engagement studies are sifted through
the evidence about the practice environment of nurses
(Institute of Medicine 2003, Joint Commission for Accred-
itation of Healthcare Organizations 2005, Lake 2007,
Zangaro & Soeken 2007, Cummings et al. 2010), trust and
autonomy emerge as the two antecedents to the work
engagement of professional nurses.
Autonomy
Autonomy is a threshold issue for professional nursing practice
(Institute of Medicine 2003, Joint Commission for Accredita-
tion of Healthcare Organizations 2005, Chen & Johantgen
2010). The International Council of Nurses described auton-
omy as an intrinsic motivator for nurses (Manion 2009),
Fagermoen (1997) found it to be an embedded value in the
practice of Norwegian nurses (n = 6 interviews; n = 767
survey respondents), and Australian nurses ranked it as most
important in their job (Finn 2001). Zangaro and Soeken’s
(2007) meta-analysis of 31 job satisfaction studies (n = 14,567
nurses in US, Israel, England, Australia, Scotland, Canada,
Hong Kong, Sweden, Netherlands) found autonomy to have
the second highest positive effect size (ES = 0Æ30, P < 0Æ01)
with the most positive correlation (r = 0Æ39) occurring among
acute care hospital nurses.
Predictably, every grand theory of nursing is predicated on
nurses making decisions. Autonomy to make appropriate
patient care decisions is a prerequisite to having Kahn’s
(1990) availability (ability to do the job, fulfil the contract).
In the case of nurses, the contract is a social contract to give
safe and effective care. As noted by the Institute of Medicine’s
(2003, 2010) reports, the nurse’s personal availability (skill
set to do the job) has too often been stymied by organiza-
tional or systemic constraints.
From a business perspective, Drucker (1993) asserted that
autonomy and recognition of expertise are essential to
‘knowledge workers’ (p. 6) who use their specialized knowl-
edge to achieve work goals. He described teachers as the first
knowledge work professionals to emerge at the beginning of
the 20th century and nurses as the second (Drucker 2002).
The pernicious effects of diminished nursing autonomy can
be found in the results of a 2009 Gallup poll of US national
opinion leaders (n = 1500) across government, business, and
health care [Robert Wood Johnson (RWJF) 2010]. They
ranked nurses second to physicians as the most trusted source
of healthcare information in the US and next to last (patients
being last) in their influence over US healthcare reform over
the next 5–10 years (Robert Wood Johnson Foundation
2010).
Pink (2009) described autonomy as self-direction that leads
to work engagement. Autonomy requires having choice over
the ‘4-T’s’ of task, time, technique and team (Pink 2009,
p. 94). As Pink (2009) observed, management is an invented,
rather than a naturally occurring phenomenon. Management
is based on the notion that people act when prodded to do so
and stray from a circumscribed path without direction to stay
on task. Conceptually and pragmatically, prodding and
directing squelch work engagement. From a business
perspective, the outcomes of autonomy can be found in
post-it notes, a 3M product that was developed by a scientist
in his 15% ‘doodling time’; in the successes of Atlassian, a
$35 million Australian company that grew by 168% last
year, that now devotes 20% of its engineering time to
projects that are of the engineers design and choice; and in
G-mail that was developed in Google’s ‘20% free time’ as are
half of Google’s annual innovations (Pink 2009).
Trust
Trust, the second antecedent of work engagement in nursing,
is salient for nurses because integrity is legally demanded and
central to the ethical comportment of nurses. Subsequently,
trust is a fundamental expectation that nurses have of their
practice setting. However, Altuntas and Baykal’s (2010)
study of Turkish acute care hospital nurses (n = 482) found
that nurses minimally trusted the hospital while highly
trusting their managers and colleagues. Since trust in the
institution moderately correlated (r = 52, P = 0Æ000) with
the civic virtue (concern and active involvement in the life of
the organization) of these nurses, Altuntas and Baykal’s
(2010) findings suggest why institutional trust is also impor-
tant to the organization.
L. Antoinette Bargagliotti
1422 � 2011 Blackwell Publishing Ltd
Jameton (1984) underscored the salience of trustworthy
practice environments to nurses when he asserted that nurses
experience moral distress ‘when one knows the right thing to
do, but institutional constraints make it nearly impossible to
pursue the right course of action’ (p. 6). When nurses practice
in healthcare systems where the mission to give safe, effective
care is subverted for financial gain, nurses find themselves as
the only trustworthy actors in an untrustworthy environ-
ment. The IOM (2003) study found a wide spread loss of
trust among American nurses in hospital organizations
because nurses believed that efficiency initiatives had over-
shadowed patient safety. Canadian nurses (random sample
n = 388) reported that their highest intensity of moral distress
was working with unsafe RN levels (Pauley et al. 2009). At
the heart of contemporary nurses’ concerns is that financially
driven healthcare shreds the nursing safety net and erodes the
enduring social contract that nursing has with its public.
Australian nurses described the substitution of RNs in the UK
with healthcare technicians as a crisis that placed patients at
risk (Shields & Watson 2008). This central concern of nurses
is echoed by 60% of the American public who ‘do not trust
hospitals to do the right thing for patients’ (King & Moran
2006, p. 3) and who believe hospitals ‘place economics ahead
of patient care’ (p. 5). Freeney and Tiernan’s (2009)
qualitative study of Irish nurses found that the values conflict
between patient care and organizational financial constraints
was a barrier to work engagement.
For the purposes of this concept analysis, trust is the
willingness to be vulnerable to another because the other is
‘competent, reliable, open and concerned’ (Mishra 1996,
p. 265). In Mishra’s (1996) definition of trust, the willingness
to trust or be vulnerable to another is conditional upon the
other acting in competent, reliable, open and concerned
ways. Work engagement requires creating a culture of trust at
all organizational levels (Chugtai & Buckley 2008, Macey
et al. 2009).
Trustworthy organizations act reliably when they make
decisions that support the stated mission. They act compe-
tently to improve the organization, are open in their processes
and demonstrate concern by acting in the best interest of
employees and following-through on promises (Gardner et al.
2005, Denham 2006, Chugtai & Buckley 2008, Wong &
Cummings 2009). Trustworthy managers are competent and
act reliably when they give good advice and guidance. They
act fairly and impartially to all employees, are available to all,
are open to the uninhibited flow of ideas and act in the best
interests of employees (Chugtai & Buckley 2008). Wong
et al.’s (2010) study of Canadian nurses (n = 280) found that
trust in the manager directly affected work engagement.
Wong et al.’s (2010) finding that social identification
(identification with the work group) had the greatest effect
on the work engagement of nurses underscores the vital
importance of trusting collegial relationships.
In trusting collegial relationships, colleagues are compe-
tent. Vital information can be openly shared because it will
not be misused in harmful ways. Colleagues demonstrate
concern for each other by working together through difficult
times (Chugtai & Buckley 2008, Freeney & Tiernan 2009).
Collegial supportive relationships among nurses that value
individual contributions is one of the prescribed characteris-
tics of professional nurses in the American Association of
Critical Care Nurses (AACN) Synergy Model (Hardin 2009)
of nursing practice at the bedside.
All these dimensions of trust (organizational, managerial
and collegial) are reflected in four of the five factors in
Olson’s (2010) Hospital Ethical Climate Survey (HECS):
‘peers willingness to listen to concern about patients’ care, ....
managerial support, shared sense of mission, and trust’
(p. 345). Trust is an antecedent of work engagement for
nurses because it frees intellectual capital to be directed
towards work, rather than towards protecting self from the
effects of poor decisions by others.
Consequences
There are organizational and personal consequences of the
work engagement of nurses. A Gallup study of outcomes in
more than 200 hospitals found that the work engagement of
Registered Nurses was the primary predictor (P < 0Æ05) of
mortality variance among hospitals and patient complication
rates (Blizzard 2005b).
Increased levels of personal initiative (PI) that extend
beyond the formal requirements of work have been found to
be an outcome of work engagement. In a study of 2555
Finnish dentists, PI predicted perceptions of work-unit
innovativeness suggesting the contagiousness of work engage-
ment (Hakanen et al. 2008a). Personal initiative differs from
absorption, an attribute of work engagement, because
personal initiative means taking an innovative or new action
or approach. Absorption refers to being immersed in a
subject, in this case, nursing practice.
In the Gallup meta-analysis of 955,905 respondents in the
US and 23 other nations, work engagement accounted for
78% of the variance in profitability across 17,339 business
units (Harter et al. 2009). Those business units with higher
levels of work engagement had a 94% higher success rate in
their own organization and a 145% higher success rate across
organizations (Harter et al. 2009). Harter et al. (2009) found
that work engagement/disengagement ratios of 9Æ57:1 are
found in the most successful companies in comparison to the
JAN: CONCEPT ANALYSIS Engagement
� 2011 Blackwell Publishing Ltd 1423
ratio of 1Æ83:1 that occurs in average companies. Gallup
estimated that a consequence of disengagement is a produc-
tivity loss in the US alone of $300 billion annually.
Empirical referents
Empirical referents are the processes that can be used to
measure the concept (Walker & Avant 2010). All the mea-
sures of work engagement are self-reported survey instru-
ments. The Ultrecht Work Engagement Survey (UWES)
(Schaufeli & Bakker 2003) has a 17-item long form, a 9-item
short form available in 22 languages and a student form
available in three languages that measures vigour, dedication
and absorption.
The Q12, originally referred to as the Gallup Workplace
Audit (GWA), is a 12-item instrument (Harter et al. 2002b)
that measures dedication, absorption, vigour and collegial
and managerial support, autonomy and essential resources
(Harter et al. 2002b).
Discussion
A limitation of this concept analysis is that the empirical
work was not limited to studies of nurses, who may have
differing levels of professional commitment than do other
professionals or occupational groups. History is also an
important limitation of this analysis as the climate for nursing
practice is in flux as economic conditions change.
The use of concept analysis as a methodology, specifically
Walker and Avant’s (2010) model, is a limitation of the study
(Morse 1995, Paley 1996, Penrod & Hupcey 2005, Duncan
et al. 2007, Beckwith et al. 2008, Risjord 2009). However, as
Simpson (2009a) noted, it is the lack of conceptual clarity
about work engagement that has resulted in multiple lines of
inquiry with mixed results.
Understanding work engagement in nurses, the largest
health professional group in all nations, is critically impor-
tant. Underscoring the pragmatic urgency of this issue are the
error rates in care reported by sicker adults who had received
health care in the past 2 years: Australia (n = 702, error
rate = 27%); Canada (n = 752, error rate 30%); New
Zealand (n = 704, error rate = 25%); the UK (n = 1770,
error rate = 22%); the US (n = 1527, error rate = 34%); and
Germany (n = 1503, error rate = 23%) (Schoen et al. 2005).
The IOM (2003) reported that the work environment of US
nurses was ‘a threat to patient safety’ with ‘threats [that] are
found in all four of the basic components of all organizations-
organizational management practices, workforce deployment
practices, work design, and organizational culture’ (Execu-
tive Summary, p.3).
When the definition of work engagement is combined with
its antecedents and consequences, a formal definition of work
engagement emerges. In nursing, work engagement is the
dedicated, absorbing, vigorous nursing practice that emerges
from settings of autonomy and trust and results in safer, cost
effective patient outcomes. From this definition, work
engagement can be developed as an explanatory middle
range theory that conceptually captures the concerns that
nurses have about their work environment. The assumptions
that underlie work engagement, the linkages between the
antecedents of autonomy and trust and the relationship of the
antecedents of trust and autonomy to the closely related
concepts of transformational and authentic leadership styles
are some of the remaining areas to be developed in a middle
range theory.
A middle range theory of work engagement could explain
the dedication, absorption and vigour of nurses that are
What is already known about this topic
• Work engagement is the important question for all professionals.
• Nurses’ levels of work engagement are lower than those for other hospital groups.
• The enduring shortage of nurses, growing political pressures to stem healthcare costs, and medical error
rates create a climate that underscores the importance of
work engagement.
What this paper adds
• The attributes of work engagement are vigour, dedication and absorption.
• Trust (organizationally, managerially and collegially) and autonomy are the antecedents that have
explanatory power for work engagement in adverse
situations.
• The outcomes of work engagement are higher levels of personal initiative, decreased hospital mortality rates
and higher financial profitability for organizations.
Implications for practice and/or policy
• The work engagement of nurses is enhanced in trustworthy practice settings that value the autonomy of
nurses.
• The antecedents for work engagement are relational ways of behaving and being, rather than resources that
can be transacted.
• Safe patient care requires the engagement of nurses in their practice.
L. Antoinette Bargagliotti
1424 � 2011 Blackwell Publishing Ltd
strategically important to the profession and to the patients
who seek nursing care. The antecedents of work engagement,
trust and autonomy, are amenable to change and highly
congruent with intrinsically held professional nursing values.
Conclusions
Creating practice environments that fully engage nurses in
their practice is a central issue for the nursing profession, a
safety issue for patients, and an important economic issue for
all the nations. Since the antecedents of work engagement are
relational rather than transactional, they have no financial
costs. These antecedents shed important light on the direction
that healthcare organizations, nurse managers and nurses can
take to create a work environment that supports the work
engagement of nurses.
This concept analysis provides a clearer direction for future
research in the work engagement of nurses and a theoretical
underpinning for the myriad studies of the work environment
and MagnetTM forces.
Conflicts of interest
No conflict of interest has been declared by the author.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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JAN: CONCEPT ANALYSIS Engagement
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