An exploration of employee engagement in medical contexts

In the mid-2000s, the construct of workplace engagement had been visible in the literature for over a decade, with no consensus on its measurement. The benefits of increasing engagement were consistently reported however measures were developed and used across different contexts, with potential underlying differences due to context remaining unaddressed. The first aim of this thesis was to investigate existing engagement measures and their comparative relevance across two contexts: business and medical. The medical context was chosen for detailed investigation because of the importance of engagement-related factors such as burnout in medical professions, and because of the lack of empirical research on engagement in this context. The second aim of the thesis was to develop an engagement measure specifically for use in medical settings. The third aim of the thesis was to explore the relationships between engagement and related constructs of interest in the literature. In the first, Pilot Study 1, items said to measure engagement were identified. In Study 2, the measures were tested for their perceived relevance to engagement with 217 business and 192 medical respondents. Results demonstrate engagement may be differentially viewed and defined in these contexts. In Study 3, data were drawn from public hospitals across New South Wales, Australia, from 392 nurses and 154 doctors. The first known measure for engagement in medical contexts was developed, a higher order construct including job satisfaction, dedication and focused time use, consistent with a consensus on engagement occurring later in the literature. A path model was developed assessing related constructs not found in other engagement models, climate, empowerment, intrinsic motivation and emotional exhaustion. The model consolidates findings and provides further evidence of differences in the way engagement operates in business and medical contexts. Engagement in medical contexts is an important aspect of current research due to a global healthcare crisis. EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS xiii EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS xiv Declaration I certify that the work in this thesis, entitled An Exploration of Employee Engagement in Medical Contexts, has not previously been submitted for a degree nor has it been submitted as part of the requirements for a degree to any other university or institution than Macquarie University. I also certify that the thesis is an original piece of research and it has been written by me. Any help and assistance that I have received in my research work and the preparation of the thesis itself has been appropriately acknowledged. In addition, I certify that all information sources and literature used are indicated in the thesis. The research presented in this thesis was approved by Macquarie University Ethics Review Committee, reference numbers: HE01APR2005-D03948, HE29APR2005-D04023 and HE27JUN2088-D05946. Signature Full name (student ID) Date EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS xv Acknowledgements Professor Julie Fitness was the principal supervisor of this PhD during most of its duration over ten years. I am deeply grateful to her for staying so engaged in this long academic voyage. Julie remained interested, encouraging and committed to the project, helping me to steer through some major challenges. Thank you, Julie, for providing much support and wise guidance during times of personal and academic turbulence that would otherwise surely have capsized this project. Associate Professor Denise Jepsen supervised the final stages of the PhD. Denise provided the rigour of an experienced organisational psychologist and structural equation modelling expert. Her contribution was critical in ensuring the thesis reached the required academic standard. Denise very quickly identified problems with the thesis and analyses due to advancements in research methodology and analyses since the commencement of the thesis since 2004. Thank you, Denise, for your academic rigour, extraordinary commitment, immense work and generosity with your time, patience and expertise. I am extremely grateful to you. I thank Dr Jane Carstairs, Dr Alan Taylor, Dr Peter Langford and Dr Alan Bull for their inspiration, support and guidance while acting as my supervisors during the early years, when the literature on engagement presented a real quandary. Thank you to all participants for generously responding to my surveys, and to the executive, administrative and ethics staff at New South Wales public hospitals. Finally, my friends, parents and aunt have been very supportive and encouraging. I thank you for understanding how important this voyage was for me. EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS 1 Chapter 1: General Introduction This chapter introduces the thesis by providing the theoretical context of the research and the problems addressed. Justification for conducting the research is presented. The structure of the studies is provided and the methodology is outlined. Finally, a summary of the results and key assumptions is provided. 1.1 Background to the Research The thesis challenges the belief widely held in the mid-2000s that employee engagement operates similarly in business and medical contexts. There was little research on the engagement of health professionals in medical contexts compared with a large body of research in the business domain. The thesis examines employee engagement in the different contexts and the potential need to measure engagement differently in medical contexts. The investigation of how employees engage with their work was introduced by Kahn (1990, 1992). Other researchers followed, presenting diverse and conflicting theories of engagement. Theoretical frameworks to investigate engagement were still in their infancy when the current research commenced in 2004. Engagement was considered by many researchers to overlap with well-established constructs, particularly job satisfaction (Durán, Extremera, Montalbán & Rey, 2005; Harter, Schmidt & Hayes, 2002; Newberry, 2004). However, some research suggested engagement was a distinct construct (Hallberg & Schaufeli, 2006; Wise, Chang, Duffy & Del Valle, 2004). The conceptualisation of engagement was evolving. The theoretical framework used in this thesis was formed directly from the literature in 2004 and concurs with the framework later contended by Macey and Schneider (2008). These researchers observed engagement as a higher order measure emanating from traditional job characteristics, represented by the measures of Hackman and Oldham (1980) and Smith, Balzer, Brannick, Chia, Eggleston, Gibson.Whalen EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS 2 (1987). Macey and Schneider argued engagement includes passion, enthusiasm and energy, as measured by the Utrecht Work Engagement Scale (Schaufeli, Salanova, Gonzalez-Roma & Bakker, 2002b). Macey and Schneider added that engagement included focused effort, represented in the current research by Goddard’s (1999, 2001) theory. The work of professionals, or non-business workers, and other workers has been found to be fundamentally different (Collison, 2001; Landry, 2011; Morrow & Goetz, 1988). In addition, in the medical context, health professionals face a conflict with the business imperatives of the hospitals they work in, contributing to clinician turnover (Hegland, 2008; Sorensen & Sorensen, 1974). The healthcare industry and medical profession are undergoing unprecedented change and pressure in a worldwide evolution (Klass, 2007). If it is possible to identify how professional employees engage in the medical context, how to measure this, and how engagement relates to other work constructs, benefits such as increased performance and retention may result. The next section details the research problem and questions. 1.2 Research Problem and Questions This section outlines the issues found in the engagement and medical literature in 2004 that led to the research, the problems identified and the specific hypotheses investigated. The thesis first addresses the question of how engagement is defined, investigating the theories of engagement that were evident at the time. The thesis then addresses the question of whether engagement operates differently in business and medical contexts. The need for a scale to measure medical engagement is considered. The way other related constructs operate in medical contexts and in relation to engagement is then investigated. An engagement model for these relationships is explored. Each aspect will now be addressed in turn. EMPLOYEE ENGAGEMENT IN MEDICAL CONTEXTS 3 The first major area studied in this thesis is the lack of theoretical framework for engagement in 2004. Kahn (1990) contended engagement was grounded in role theory and concerned the processes at work that led to people ‘presenting and absenting themselves’ (p. 694) during tasks. Since Kahn’s (1990, 1992) work, there has been confusion and debate about how to best conceptualise, define and measure engagement. In 2004 there was considerable debate about whether engagement was a valid and discrete construct, separate from traditional constructs such as job satisfaction and organisational commitment. Harter, Schmidt and Hayes referred to engagement as ‘satisfaction-engagement’ (2002, p. 269). Montgomery, Peeters, Schaufeli and Den Ouden referred to ‘feelings of engagement’ (2003, p. 195). Schaufeli et al. observed Maslach and Leiter (1997) had ‘assumed’ engagement was the direct opposite of burnout (2002b, p.73). Engagement was viewed inconsistently from all organisational levels: task, job, individual, team and organisation. Wide-ranging theoretical conceptualisations of engagement dominated the literature, deviating strikingly from Kahn’s (1990) founding theory, as noted by Saks (2008). These conceptualisations included time use, psychological ownership, instrumentality, burnout, job satisfaction and group work. All exisiting theories for