Work or review on Chapter one

R E S E A R CH B R I E F

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories

Heather M. Gilmartin PhD, NP1,2 | Edward Hess MS1 | Candice Mueller BA3 |

Brigid Connelly BA1 | Mary E. Plomondon PhD, MSPH3 |

Stephen W. Waldo MD1,3,4,5 | Catherine Battaglia PhD, RN1,2

1Denver/Seattle Center of Innovation for

Veteran-Centered and Value Driven Care,

VHA Eastern Colorado Healthcare System,

Aurora, Colorado, USA

2Department of Health Systems, Management

and Policy, University of Colorado, School of

Public Health, Aurora, Colorado, USA

3CART Program, Office of Quality and Patient

Safety, Veterans Health Administration,

Washington, District of Columbia, USA

4Department of Medicine, Cardiology Section,

Rocky Mountain Regional VA Medical Center,

Aurora, Colorado, USA

5Department of Medicine, Division of

Cardiology, University of Colorado, Aurora,

Colorado, USA

Correspondence

Heather M. Gilmartin, Denver/Seattle Center

of Innovation for Veteran-Centered and Value

Driven Care, VHA Eastern Colorado

Healthcare System, 1700 N. Wheeling Street,

Aurora, CO 80045, USA.

Email: [email protected]

Funding information

Dr Heather M. Gilmartin is supported by

Career Development Award Number

1IK2HX002587-01A1 from the United States

Department of Veterans Affairs Health

Services Research & Development Service of

the VA Office of Research and Development.

Abstract

Objective: To characterize the relationship between learning environments (the edu-

cational approaches, cultural context, and settings in which teaching and learning

happen) and reliability enhancing work practices (hiring, training, decision making)

with employee engagement, retention, and safety climate.

Data source: We collected data using the Learning Environment and High Reliability

Practices Survey (LEHRs) from 231 physicians, nurses, and technicians at 67 Veterans

Affairs cardiac catheterization laboratories who care for high-risk Veterans.

Study design: The association between the average LEHRs score and employee job

satisfaction, burnout, intent to leave, turnover, and safety climate were modeled in

separate linear mixed effect models adjusting for other covariates.

Data collection: Participants responded to a web-only survey from August through

September 2020.

Principal findings: There was a significant association between higher average LEHRs

scores and (1) higher job satisfaction (2) lower burnout, (3) lower intent to leave,

(4) lower cath lab turnover in the previous 12 months, and (5) higher perceived safety

climate.

Conclusions: Learning environments and use of reliability enhancing work practices

are potential new avenues to support satisfaction and safety climate while lowering

burnout, intent to leave, and turnover in a diverse US health care workforce that

serves a vulnerable and marginalized population.

K E YWORD S

high reliability organization, learning health system, Veterans, workforce

What is known on this topic

• Health care organizations and their employees benefit from adopting learning health

practices.

The funding organization played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the

manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of

Veterans Affairs.

DOI: 10.1111/1475-6773.13907

Health Services Research

Published 2022. This article is a U.S. Government work and is in the public domain in the USA.

Health Serv Res. 2022;57:385–391. wileyonlinelibrary.com/journal/hesr 385

• Learning health practices include the creation of supportive learning environments and use

of reliability enhancing work practices.

• The impact of learning health practices on workforce engagement and retention are not

clear.

What this study adds

• This study identified associations between supportive learning environments, reliability

enhancing work practices, and engagement, retention, and safety climate in the largest inte-

grated health care system in the United States.

• Policy makers can use this evidence to inform program planning and decision making regard-

ing high reliability organization and learning health system transformations.

• Facility, department, and unit leaders can use the Learning Environment and High Reliability

Practices Survey to provide insights into areas of strength and opportunities for improve-

ment that can lead to meaningful change.

1 | INTRODUCTION

Health care organizations and their employees can benefit from

adopting learning health practices.1 A learning health system, per the

National Academy of Medicine, harnesses data and analytics to learn

from every patient and return the knowledge to clinicians to imple-

ment with high reliability (i.e., error free).2 Transforming health care

organizations into learning health systems requires an understanding

of learning environments and reliability enhancing work practices to

realize the benefits for employees, patients, and population health.3,4

Learning environments are the educational approaches (e.g., online

vs. unit-based trainings), cultural context (e.g., ways of thinking, working),

and settings in which teaching and learning happen.5 Learning envi-

ronments differ from individual learning for they support individuals

to collectively analyze and interpret experiences. Staff who work in

supportive learning environments, the ideal learning environment, are

encouraged to discuss and debate alternative ways of getting work

done, share information about what does and does not work, experi-

ment with new ways of working, and are given time for reflection and

improvement.1,6

Health care organizations are increasingly emulating high reliabil-

ity organizations to improve safety, quality, and efficiency. High reli-

ability organizations are guided by the following five key principles:

deference to expertise, reluctance to simplify, sensitivity to opera-

tions, commitment to resilience, and preoccupation with failure.7 High

reliability in health care is achieved through a combination of specific

reliability enhancing work practices to detect and adapt to unex-

pected events. Reliability enhancing work practices include hiring

employees based on their willingness to learn new skills, the ability to

work with others, and the ability to communicate. Additional practices

include training programs for new hires in communication and inter-

personal skills, informal education sessions, and employee forums to

discuss improvements and decisions that affect work and care

delivery.6

Learning environments and reliability enhancing work practices

can positively impact staff engagement, peer-to-peer interactions, and

knowledge sharing by creating processes and forums where people

feel safe to speak about concerns or new ways of working.1,6,8 The lit-

erature has touted the benefits of learning environments and reliabil-

ity enhancing work practices on quality of care, costs, and patient

safety9–15 However, these studies are limited to case-study

approaches, small, homogenous samples, and do not include outcomes

from a diverse US health care workforce that serves vulnerable and

marginalized populations.

In this study, we aim to characterize the relationship between

learning environments and reliability enhancing work practices with

health care employee engagement, retention, and safety climate in

Veterans Affairs (VA) cardiac catheterization laboratories (cath labs).

Employee engagement is conceptualized as a positive, work-related

mindset that includes feelings of vigor and dedication and absorption

in one's work.16 Engagement can be viewed as the direct opposite of

burnout, for the two constructs are conceptualized as two ends of a

single continuum.16 Retention, or workforce length of employment, is

a recruitment strategy, as it avoids the high costs of turnover and loss

of institutional memory, provides continuity of care for patients, and

contributes to unit and organizational stability.17 Safety climate

reflects team members' perceptions or attitudes about the organiza-

tional safety culture in which they work.16 Theories and studies of

engagement suggest that engaged employees have a higher probabil-

ity of displaying safety-related attitudes and behaviors that define

safety climate.18,19 Additional studies suggest that health care work-

force engagement and retention decrease costs associated with illness

and injury of patients and lost time from work.20,21

In this study, we examined the 81 VA cath labs staffed by multi-

disciplinary teams that provide life-saving coronary procedures to

over 40,000 high-risk and vulnerable veterans annually. In the context

of cath labs, supportive learning environments are those where the

interventional cardiology team or unit leaders foster psychological

safety and encourage open discussion and debate during team meet-

ings, experiment frequently with new ways of working, and provide

time and structure for reflection through postprocedural briefings.

Cath labs that have adopted reliability enhancing work practices are

386 GILMARTIN ET AL.Health Services Research

those that interview and hire staff for their procedural knowledge and

their willingness to try new skills and their ability to communicate.

These cath labs develop preceptor programs that teach relationship

and communication skills and use daily huddles as forums for group

learning, problem solving, and decision making.

Guided by the five high reliability organization principles,7 the Learn-

ing Organization Model10 and the Reliability Enhancing Work Practice

and Patient Safety Model,6 we administered a previously validated survey

to VA cath lab staff.22 Two hypotheses were assessed: whether learning

environments that are highly supportive and use reliability enhancing

work practices are (a) associated with higher employee engagement

and retention and (b) are associated with higher safety climate scores.

2 | METHODS

2.1 | Data sources

From August through September 2020, we invited 902 physicians,

nurses, and technicians at the 81 VA cath labs to participate in

the web-based Learning Environment and High Reliability Practices

Survey (LEHRs), an independent survey not affiliated with the

annual VA All Employee Survey. All full-time and part-time cath lab

employees, fellows, consultants, and interventional cardiology physi-

cians identified by cath lab management were eligible to participate.

Cath lab employees that did not provide direct patient care were

excluded.22 The LEHRs consist of 27-items from the Learning Organi-

zation Survey-27,1 31 items from the Reliability Enhancing Work

Practices Survey,6 10 demographic questions, and 5 employee

engagement, retention, and safety climate questions. The survey

items, recruitment methods, and psychometric properties of the

LEHRs were pilot tested in VA cath labs in 2018.22

2.2 | Variables

The Learning Organization Survey-271 items measure facets of the

five high reliability organization principles. These include the support-

ive learning environment items which ask if people value new ideas,

are open to new ways of working, and make time for reflection. The

learning practices items ask if newly hired employees receive ade-

quate training, if debriefs occur regularly, and if performance is com-

pared to best-in-class organizations. The leadership items ask if

management listens attentively and invites input (Data S1).

The Reliability Enhancing Work Practices Survey assesses the

presence of reliability enhancing work practices, respectful interac-

tion, mindful organizing, affective commitment, and organizational cit-

izenship behaviors.6 The reliability enhancing work practice items

query hiring practices, communication and relationship trainings, and TABLE 1 Respondent demographics

N (%)

VA cath labs represented (N = 81) 67 (83)

Employees 232 (26)

Role

Nurse 146 (93)

Interventional cardiologist 27 (12)

Technician 42 (18)

Other 17 (7)

Supervisory role 58 (25)

Gender

Female 127 (55)

Male 100 (43)

Race

White 173 (75)

Asian, Pacific Islander 24 (10)

Other 18 (7)

Black 14 (6)

Native American 3 (1)

Mean (years)

Age 48

Years in health care 21

Years in VA 7

Years in current cath lab 5

Abbreviation: VA, Veterans Health Administration.

TABLE 2 Highest and lower scoring LEHR scales and example survey items

Survey scales

Example survey items (1–7 ascending Likert scale)

Mean

(SD)

Affective commitment I do feel a strong sense of

belonging to my lab

5.4 (1.4)

Supportive learning

environment

This lab engages in productive

conflict and debate during

discussion

5.3 (1.4)

Mindful organizing When a patient crisis occurs,

we rapidly pool our

expertise to resolve it

5.3 (1.3)

Respectful interaction The employees in this lab are

trustworthy

5.1 (1.4)

Organizational

citizenship

The employees in this lab help

make others more

productive

5.0 (1.5)

Leadership reinforces

learning

My supervisor listens

attentively

4.8 (1.7)

Learning processes This lab regularly conducts

postaudits, after-action

reviews, and debriefings

4.5 (1.4)

Reliability enhancing

work practices

Employees are hired based on

their ability to work with

others

4.5 (1.4)

Abbreviation: LEHRs, Learning Environment and High Reliability Practices

Survey.

GILMARTIN ET AL. 387Health Services Research

F IGURE 1 Mixed effect linear regression models: Average Learning Environment and High Reliability Practices Survey (LEHRs) score as a function of job satisfaction, burnout, intent to leave, safety climate, or turnover. Low: Average LEHRs score below the reference category (dotted line) and with confidence intervals that exclude the reference value. High: Average LEHRs score above the reference category (dotted line) and with confidence intervals that exclude the reference value. Results from five separate linear mixed effect models are presented. Each model has the average of the eight LEHRs scales as the response and includes either (A) job satisfaction, (B) burnout, (C) intent to leave, (D) safety climate, or (E) turnover as the predictor of interest plotted on the x-axis. Each model also adjusted for age, gender, race, role, supervisor status, time in VA cath lab (dichotomized at 3 years) and time in cath lab (dichotomized at 3 years) and a random intercept for site

388 GILMARTIN ET AL.Health Services Research

opportunities for decision making. The respectful interaction items

query honesty, trust, and mutual respect within teams. The mindful

organizing items query if teams talk openly about mistakes and ways

to learn from them. The affective commitment items query feelings of

emotional attachment to a team. The organizational citizenship items

query behaviors helpful, but not required by an employer, such as

making others more productive (Data S1).

Demographic items included age, role, education, gender, race,

ethnicity, years in health care, years in VA, years in the cath lab, and

supervisory status. Survey nonresponse bias was assessed by calculat-

ing the number of respondents divided by the number of staff invited

to participate from the 23 Veteran Integrated Service Networks

(VISN). Employee engagement was assessed through two items: “Con- sidering everything, how satisfied are you with your job” (5-point

Likert scale, “Very dissatisfied” to “Very satisfied”) and “I feel burned out from my work” (7-point Likert scale, “Never” to “Everyday”). Retention was assessed through one item: “If I were able, I would

leave my current job” (5-point Likert scale, “Strongly disagree” to

“Strongly agree”). Turnover was assessed through one item: “We have

had ____ cath lab staff leave in the last 12 months” (“Choose one:

0, 1–2, 4–6, 7+”). Safety climate was assessed through one item:

“I would feel perfectly safe being treated in this cath lab” (5-point

Likert scale, “Strongly disagree” to “Strongly agree”).

2.3 | Statistical methods

To characterize the national cross-sectional survey data, we calculated

descriptive, correlational, and reliability estimates. To assess the asso-

ciation between average LEHRs score and each of the employee

engagement, retention, and safety climate measures, a linear mixed-

effect regression model was fit with average LEHRs score as the

response variable, a given measure of interest (e.g., burnout) as the

predictor of interest, adjusting for age, gender, race, role, years in VA

cath lab, and years in cath lab, plus a random intercept for site. The

predictors of main interest were modeled categorically. The depen-

dent variable in all five models was the average LEHRs score, an aver-

age of the eight LEHRs scales (Data S1). The reference category for

job satisfaction was 3 (neutral), burnout was 1 (never), intent to leave

was 3 (neutral), turnover was 0 (no turnover), and safety climate was

3 (neutral). The overall significance of each of the five models was cal-

culated using a type II analysis of variance (ANOVA). Alpha was set at

0.05. Analyses were conducted in R version 4.0.3 (R Core Team

2020). This study was deemed an exempt, nonhuman subjects

research study by the Colorado Multiple Institutional Review Board

(17-1153).

3 | RESULTS

We received responses from 67 of the 81 (83%) VA cath labs. In total,

232 of 902 eligible employees completed surveys (26% response

rate). Of those, 146 (63%) were nurses, 42 (18%) were technicians,

27 (12%) were interventional cardiologists, and 17 (7%) were other

(e.g., fellows, electrophysiologists). A supervisory role was reported by

58 (25%) of respondents. The sample was split between females

(n = 127; 55%) and males (n = 100, 43%) and was predominantly

White (n = 173; 75%). The mean age was 48 with a mean of 21 years

in health care, 7 years in the VA, and 5 years in their current cath lab

(Table 1). The average VISN nonresponse rate was 73% (Mode: 77)

with a range from 85% nonresponse in VISN 17 (VA Heart of Texas

Health Care Network) to 41% nonresponse in VISN 20 (Sierra Pacific

Network) (Data S2).

The highest scoring survey scales across the sample was for affec-

tive commitment (mean 5.4, SD 1.4) followed by supportive learning

environment (mean 5.3, SD 1.4), mindful organizing (mean 5.3, SD

1.3), respectful interaction (mean 5.1, SD 1.4), and organizational citi-

zenship (mean 5.0, SD 1.5). The lower scoring scales were leadership

that reinforces learning (mean 4.8, 1.7), learning processes and prac-

tices (mean 4.5, SD 1.4), and reliability enhancing work practices

(mean 4.5, SD 1.4) (Table 2). These items assess themes outlined in

four of the five high reliability organization philosophies as follows:

deference to expertise, commitment to resiliency, sensitivity to opera-

tions, and preoccupation with failure.7

Overall, respondents indicated they were satisfied with their job

(mean 4.1, SD 1.1) and experienced burnout about once a month or

less (mean 3.2, 1.8). They disagreed they would leave their current job

if able (mean 2.2, SD 1.3) and reported an average of one nurse (mean

1, SD 0.8), technician and/or nonphysician having left their cath lab in

the last 12 months. On average, respondents indicated they would

feel safe being treated in their cath lab as a patient (mean 4.2, SD 1.0).

3.1 | Learning environments, reliability enhancing work practices, employee engagement, retention, and safety climate

Overall, there was a statistically significant association between the

predictors of interest (e.g., job satisfaction) and average LEHRs score.

Specifically, higher average LEHRs scores were associated with higher

job satisfaction (Chi-square 260.6, DF 4, p < 0.001), lower burnout

(Chi-square 49.2, DF 6, p < 0.001), lower intent to leave (Chi-square

85.4, DF 4, p < 0.001), lower cath lab turnover (Chi-square 23.9, DF

3, p < 0.001) in the previous 12 months, and higher perceived safety

climate (Chi-square 156.8, DF 4, p < 0.001). A regression table for the

burnout model is shown in Data S3. Results from all five models are

shown graphically in Figure 1.

4 | DISCUSSION

In this national survey study, cath lab learning environments that were

perceived as highly supportive and used reliability enhancing work

practices were associated with higher employee engagement, reten-

tion, and safety climate scores. The creation of learning environments

and use of reliability enhancing work practices are thus potential new

GILMARTIN ET AL. 389Health Services Research

avenues to support positive feelings and achievement of flow at work,

retention of valued staff, and patient safety in a diverse US health

care workforce that serve a vulnerable and marginalized population.

These findings are in alignment with research that demonstrated reli-

ability enhancing work practices, respectful interaction, and mindful

organizing can foster highly reliable performance in the form of fewer

medication errors and patient falls.6

The analysis that identified the higher and lower scoring LEHRs

items indicated that across cath labs, many staff reported considerable

personal meaning from their work, emotional attachment, and a

strong sense of belonging to their cath lab team (i.e., affective com-

mitment). The cath labs in this study also reported they engaged in

productive conflict and debate during discussion (i.e., supportive

learning environments) and rapidly pooled their expertise during crises

(i.e., mindful organizing). However, some cath labs indicated that

debriefs were not regularly conducted (i.e., learning processes), and

employees were not hired based on their ability to work with others

(i.e., reliability enhancing work practices). Suggesting there are labs

that have integrated best practices, while there are also opportunities

for improvement.

Engaged staff are less likely to experience burnout, which is known

to negatively impact quality and patient safety.19 Effective staff engage-

ment interventions23–25 and characteristics of engaged staff have been

identified.26 It is time for organizations to look beyond individual,

deficit-based interventions that address burnout (e.g., meditation,27

digital-based mental health interventions),23 retention (e.g., continuing

education),28 and specific patient safety issues (e.g., fall prevention pro-

grams).19 Organizations should consider systematic, learning health care-

based interventions, such as hiring and training for the five high reliability

principles,6,29 job crafting,30 relational coordination,31,32 and leadership

focused interventions (e.g., coaching).33,34 In practical terms, the individ-

ual LEHRs items provide insights into areas of strength and opportunities

for improvement that can be presented to teams to prompt discussion.

Group interventions to change a team toward learning and high reliability

could lead to increased engagement and well-being, though this requires

further research.24,29

This study should be interpreted in the context of several limitations.

First, cross sectional data show an association, not causality. Second, the

study design of only VA cath labs limits generalizability to only VA cath

labs. We do note that our sample was diverse in VA VISNs and occupa-

tions. Third, we did not analyze the impact of individual LEHRs items on

the outcomes of interest. Future work can explore these relationships in

other high-risk settings. Fifth, we received fewer responses (26%

response rate) than the previous study (40% response rate) and a lower

response rate than the 2020 VA All Employee Survey (69%). The nonre-

sponse rates across VISNs did not vary greatly. We attribute the low

response rate to the larger pool of staff invited to participate in the 2020

versus 2018 study, the absence of national support and incentives that

enhance participation in the VA All Employee Survey, and the administra-

tion of the survey during the COVID-19 pandemic. Many cath lab staff

were reassigned to other units or were preoccupied with clinical care

during COVID-19 and were not responding to research surveys.35 Last,

we used a self-reported measure of perceived patient safety versus

quantifiable patient outcomes. Though studies have demonstrated posi-

tive relationships between safety climate and outcomes at the hospital-

unit level,6,36 use of cath lab patient data would have strengthened this

outcome.

In summary, system versus individual methods that support work-

force engagement and retention are needed to ensure the well-being

of the health care workforce and patient safety. Implications of this

work include the potential for supportive learning environments and

reliability enhancing work practices to address the high rates of

employee burnout, turnover, and patient safety concerns reported

across health care settings. Moving forward, it is important to under-

stand how these environments were created, which practices were

implemented in VA cath labs, and if these findings are generalizable

across health care settings and populations. This line of inquiry holds

potential to identify tangible interventions for health care organiza-

tions and teams who seek to transform their work setting into sup-

portive learning environments within high reliability organizations and

learning health systems.

ACKNOWLEDGMENTS

We would like to thank the VA staff who participated in the survey.

CONFLICT OF INTEREST

The authors report no conflict of interest regarding this study.

AUTHOR CONTRIBUTIONS

All authors jointly designed the study, conducted data collection, and

drafted the article, reviewed, edited, and approved the final manu-

script draft.

DATA AVAILABILITY STATEMENT

Data Access, Responsibility, and Analysis: Dr Heather M. Gilmartin and

Mr. Edward Hess had full access to all the data in the study and take

responsibility for the integrity of the data and the accuracy of the data

analysis. Dr Heather M. Gilmartin and Mr. Edward Hess of the

Denver/Seattle Center of Innovation for Veteran-Centered and Value

Driven Care conducted and are responsible for the data analysis. Data

Sharing Statement: The data that support the findings of this study are

available from the corresponding author upon reasonable request,

though will be subject to the stringent data privacy rules of the VA

Healthcare System and United States Government.

ORCID

Heather M. Gilmartin https://orcid.org/0000-0002-0264-4059

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SUPPORTING INFORMATION

Additional supporting information may be found in the online version

of the article at the publisher's website.

How to cite this article: Gilmartin HM, Hess E, Mueller C,

et al. Learning environments, reliability enhancing work

practices, employee engagement, and safety climate in VA

cardiac catheterization laboratories. Health Serv Res. 2022;

57(2):385-391. doi:10.1111/1475-6773.13907

GILMARTIN ET AL. 391Health Services Research

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