Press Ganey national data, based on responses from 1.4 million employees across 4,000 provider organizations, shows signs that workforce engagement is stabilizing after a multiyear downward trend that began prior to the pandemic. Yet despite these gains, and the inherent rewards of a career in healthcare, many organizations are hard-pressed to attract and retain skilled staff. Addressing workforce issues continues to be the #1 priority among health system CEOs, given current and expected labor shortages.
Underlying the aggregate data is a large gap in engagement between top and bottom performers—a gap that has widened over the last three years. The top decile of performance is now higher than it was before COVID hit, while bottom-decile performance is worse. Important lessons emerge from both ends of the curve—and clear evidence that, with the right approach, it is possible to improve engagement in today’s challenging environment.
Average scores on engagement and intent to remain differ significantly by role, with the lowest scores concentrated among front-line caregivers. Despite modest gains in 2023, nurses, APPs, licensed technical staff, and physicians are consistently at the low end of the engagement curve each year.
Where to focus: Drivers of physician and caregiver engagement
Sustaining high performance on caregiver and provider experience is no accident. A key driver analysis of organizations that have maintained high engagement despite the industry’s macro pressures reveals common strengths, as perceived by their caregivers and providers.
These center on themes of respect, senior management behavior and actions, and commitment to quality and safety—all key facets of trust and social capital. Notably, while compensation and staffing are correlated to engagement, they are not among the top 10 drivers of engagement. Fair pay and adequate staffing are table stakes, but they’re not among the aspects of workforce experience that drive engagement and contribute to the creation of social capital.
Top 10 drivers of employee engagement
Treating employees with respect
Senior management’s actions support the organization’s mission and values
A commitment to quality improvement
Conducting business in an ethical manner
Employees’ perspectives factored into decision-making
The organization’s work climate promotes patient safety
Confidence in senior management’s leadership
Satisfaction with job security
Caring about customers
Caring about employee safety
Safety culture is reported as a composite score, but the correlations between engagement and the subscales—resources and teamwork, prevention and reporting, and pride and reputation—illustrate powerful relationships. Simply put, when a healthcare organization prioritizes safety by fostering a culture of safety, its employees are more able to be fully invested in their work.
Prior to the pandemic, national aggregate safety culture scores were on the rise—and safety events were on the decline. But the stress of COVID on the healthcare system eroded national performance across all measures. In 2021, organizations redoubled efforts around safety, and results in 2022 brought gains in the prevention and reporting subscale, followed by gains across all subscales in 2023.
Notably, it is among employees in front-line roles where we saw the greatest improvement in perception on questions related to resources and teamwork and prevention and reporting. Safety culture is a rising tide measure: Organizations that continue to invest in this area will realize gains across patient, caregiver, and business outcomes.
Organizations with the strongest safety cultures have multiple attributes and practices in common. These include highly visible leadership, tiered safety huddles, leader rounding, transparency around issue identification and resolution, and high reliability communication behaviors for leaders, managers, and front-line staff. They also involve front-line staff in improvement initiatives—with the dual benefit of faster improvement cycle time and fostering better engagement.
Analysis of survey results shows the critical impact of organizational culture on engagement and retention: In addition to a commitment to safety, equity, respect, and a sense of belonging are highly correlated with employee retention across all roles. And they have a well-understood link to safety outcomes: If staff members don’t feel respected, valued, and included, they are less inclined to speak up and raise concerns, putting patients and the organization at substantial risk.
Key driver analysis reveals nurses are more likely to stay with an organization when they feel a strong sense of inclusion and belonging and believe their job is the right fit for them. For physicians, feeling aligned with their organization—having respectful relationships with leadership, being part of decision-making processes, and sharing a common vision for the organization’s mission—plays a significant role in retention and engagement.
Onboarding: Modern onboarding programs recognize that building engagement starts on day one. Unlike orientation programs, robust onboarding programs focus on connecting new employees to the organization more broadly—its mission, vision, and values—to their unit or department, and, finally, to ongoing opportunities for their own professional development. Fostering a sense of belonging is key to success.
Front-line leader development: Nurse managers are the linchpins of inpatient acute care, but they often don’t get adequate training for the role. A standard, enterprise approach to leader development and coaching yields significant ROI, including higher nurse engagement, improved resilience among nurse managers, reduced nurse turnover, better clinical outcomes, and productivity.
Safety as a core value: Organizations that commit to zero harm and high reliability organizing (HRO) principles achieve gains in employee and patient safety—including psychological safety. In a period of transformation, leading health systems make it a priority to review, refresh, and recommit to enterprise behavior standards, as well as reconfirm mechanisms for accountability, learning, and improvement. They are paying close attention to safety culture, with a particular focus on violence and incivility experienced by caregivers.
Fix broken systems: A poor workforce experience is frequently due to inefficient systems and processes. Lasting solutions come from listening to front-line employees, whose direct experience provides essential insights. When these employees feel their voices are valued and understood, they’re more inclined to consistently offer useful feedback, fostering a positive feedback loop. To gather employee insights on a larger scale, top organizations are turning to innovative technologies, including AI-powered platforms, virtual focus groups, and crowdsourcing.
Future-proofing the workforce: The straightforward, but hard, work of cultural transformation
Change is constant in healthcare. And organizational culture ultimately determines which organizations weather the storm and emerge stronger following major change efforts. Culture is how values are expressed through formal elements of strategy, priorities, and policies, as well as through informal aspects of customs and behaviors. Organizations on the leading edge of the engagement curve have certain things in common across the formal and informal elements of culture. They are: an environment that fosters respect, inclusion, and safety; a commitment to consistently executing on best practices; and a willingness to redesign the work being done. These traits emerge in three principal areas:
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