A Configurational Approach to the Relationship between High-Performance Work Practices and Frontline Health Care Worker Outcomes

Frontline health care workers (FLWs), ranging from nursing assistants and patient care technicians to mental health counselors and respiratory therapy technicians, comprise over 50 percent of the health care workforce and provide a wide range of direct patient care and supportive services across health care settings (Schindel et al. 2006). Traditionally, health care organizations have seen investment in FLWs as less worthwhile because the low threshold to entry means these workers can be easily replaced (Lepak and Snell 2002). However, as the U.S. population ages and demand for health care continues to rise, organizations are increasingly relying on FLWs as a more cost-effective method of meeting basic service demands and expanding primary care services (Brownstein et al. 2011). Consequently, workforce management and work redesign strategies have increasingly emerged as critical to health care organizations’ efforts to recruit and retain skilled workers and improve service quality without raising costs (e.g., Standing and Chowdhury 2008). High-performance work practices (HPWP), also referred to as high involvement or high commitment work systems, seek to increase worker satisfaction and improve organizational performance through investment in human capital (Pfeffer 1996; Burke 2006). HPWP are typically implemented as synergistic “bundles” of policies and practices that emphasize worker training, socialization, and rewards such as team-building, performance-based incentives, job rotation or multiskilling, and participative decision making (Appelbaum et al. 2001; Sullivan 2004). In the health care sector, the effects of HPWP have primarily been studied among physicians or nurses and have been broadly associated with increased worker commitment and reduced health care errors (Harmon et al. 2003; Gowen, McFadden, and Tallon 2006; West et al. 2006). Specific HPWP such as team-based work practices and pay-for-performance have also received considerable attention as strategies for engaging staff and improving quality of care (Fried, Topping, and Rundall 2000; Pearson et al. 2008). However, although research suggests that FLWs’ response to workforce management and redesign efforts can significantly impact the success of these strategies (Dickson et al. 2009; Petrova et al. 2010), few studies have examined the effects of HPWP on this group of workers. In addition, although HPWP are conceptualized as most effective when implemented as “bundles” of policies and practices (McAlearney et al. 2011), few studies have tested this assumption or assessed the relative effectiveness of different combinations of HPWP. Current research on HPWP has tended to either operationalize HPWP as a single-factor construct or examine the isolated net effect of individual practices on outcomes. Except for a single qualitative study on nursing homes conducted by Eaton (2000) that highlighted the need for a configurational approach to this type of research, the few studies that have examined additive or interactive effects of HPWP on outcomes have not been conducted in the health care sector (MacDuffie 1995; Barnard and Rodgers 2000; Macky and Boxall 2007). The current study contributes to the literature by applying both multivariate regression and fuzzy-set qualitative comparative analysis (QCA) techniques to identify different configurations or “bundles” of HPWP associated with high job satisfaction and perceived quality of care among FLWs. Data for this study are drawn from a sample of 661 FLWs located within 13 large health care employers within the United States. The framework for this study is based on a conceptual model developed by Garman et al. (2011) following an extensive review of the literature, and it focuses specifically on HPWP policies and practices designed to engage and empower frontline staff as a means of improving worker satisfaction and quality of care.