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Leadership and trust: Foundations of APP engagement

Leadership and trust: Foundations of APP engagement GettyImages 1140250483

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By Milissa Eagle, MA, Director of Workforce Analytics, and Anita Opdycke, DNP, RN, APRN, PMHNP-BC, NP-C, SVP/Partner, Advisory and Consulting

In our previous blog, we discussed how advanced practice provider (APP) engagement is improving nationally, with gains across all related items. The natural next question is: Why? What drove this improvement?

The answer starts with trust. While safety culture dominates the list of engagement drivers for APPs, what distinguishes this group from many others is that confidence in senior leadership is #1. As APPs have become more central to care delivery, leadership credibility, transparency, and shared decision-making are becoming increasingly important determinants of the APP experience.

In addition to confidence in senior leadership being a top driver of APP engagement, we see other trust-related items starting to rise:

  • Confidence in senior leadership rose 0.09 points, one of the biggest positive changes across all items. It still scores 3.65 on a 5-point scale, so there’s room for improvement.
  • “There is a climate of trust in this organization” rose 0.17 points, one of the largest year-over-year improvements anywhere.
  • Senior leadership actions supporting organizational mission and values increased 0.17 points.

These findings reinforce a fundamental leadership principle: Trust outweighs the volume and frequency of communication. Trust functions as social capital—i.e., the accumulated confidence that converts communication and collaboration into coordinated action—and it depreciates quickly when decisions happen without follow-through. APPs are looking for visibility, transparency, and accountability from executive teams. They want evidence that leadership is listening, and they want to understand how decisions get made. They want confidence that organizational priorities reflect the realities they face at the bedside and in the clinic.

It’s worth asking a few questions of your own organization, and they fall into two categories: communication and shared governance. On communication: When you make a decision that affects APP practice, do your APPs know why? When they give you feedback, can they point to something that changed as a result? On shared governance: Can they exercise their voice before a decision is final, or only react once it already is?

That last question is the most important, because trust gets built when people can see what their input changed. Surveying alone won’t do it. Transparent communication, visible leadership presence, and mechanisms for two-way conversation all help, but only if action follows. Structured governance, such as APP councils, defined escalation paths, and standing seats in decision-making forums, is what turns that dialogue into a repeatable system rather than a one-time gesture.

Invest in safety, and engagement follows

One of the strongest relationships is between APP engagement and safety culture, with seven of the 10 top key drivers of APP engagement relating to safety culture. And the safety trend line is moving in the right direction. Between 2021 and 2025:

  • Overall safety culture improved from 3.81 in 2021 to 3.99.
  • Prevention and reporting improved from 3.93 to 4.08.
  • Resources and teamwork improved from 3.57 to 3.79—the largest gain of the three.
  • Pride and reputation improved from 3.97 to 4.09

APPs who trust their organization’s commitment to patient and employee safety are significantly more likely to be engaged, to be aligned, and to stay. Build a culture of psychological safety, teamwork, and trust, and you improve two things at once: the environment your clinicians work in and the safety of the patients they treat.

For executives, that changes who owns safety work. Nonpunitive reporting environments, stronger communication channels, visible leadership follow-through, and clear accountability for safety outcomes aren’t just patient safety strategies. They’re workforce strategies too. Our “State of Healthcare Safety 2026” report shows the same connection across the broader workforce.

The encouraging news is that APPs are starting to see evidence of these conditions improving, with confidence in leadership and safety culture both on the rise. But trust and safety are only part of the story.

Even as these measures move in the right direction, APPs point to persistent challenges related to staffing, workload, and the operational barriers that make it harder to deliver care efficiently. In our next blog, we’ll examine the APP practice environment itself, exploring what APPs are telling us about staffing pressures, resilience, workload, and operational efficiency.