How the Best Healthcare Systems Get Employee Engagement Right

Seven months ago, Perceptyx shared new findings related to its earlier Healthcare Employee Experience in 2022: A Data-Driven Perspective report. That report, along with ongoing updates, provides data-based insights into how healthcare employee experiences are changing by studying perceptions measured nationally across more than 500 healthcare systems and 3.5 million healthcare employees.

One metric Perceptyx monitors using this database is employee engagement since engagement has a critical impact on healthcare business outcomes including safety metrics and patient advocacy. Specifically, we measure employee engagement through its four components — pride, motivation, intent to stay, and advocacy. This research provides evidence-based context to help healthcare leaders better understand the current employee experience landscape at a scale unavailable when looking only within their own organizations.

Throughout fall 2022, we consistently heard senior healthcare leaders describe the current state of their employees' experiences using positive terms such as “hope,” “optimism,” “pivoting,” and “thriving,” but does the data support this optimistic discourse? With our refreshed industry data, we sought to answer the question: does the empirical evidence continue to show improving employee experiences and engagement within healthcare?

Healthcare Engagement Is Declining Once More

As reported in our late July blog, we saw considerable reason for optimism. For most healthcare systems, engagement stopped declining for the first time since early 2020, while top-performing systems — those in the top decile — saw engagement rise sharply, surpassing even early pandemic highs. 

Unfortunately, our refreshed data through December 2022 shows that this improvement was short-lived. Indeed, all deciles have seen steep declines in engagement — reaching, on average, the lowest levels to date and representing the second steepest decline since the pandemic began.

The “best of the best” healthcare organizations reversed course, with the top decile ending almost where its average started and those in the top quartile falling well below their pre-pandemic perceptions. For most healthcare systems, engagement steeply declined once more during the last half of 2022. Across the board, these empirical data reveal that the improvements experienced in July 2022 were not sustained by most.

The ‘Why’ Behind the Declines in Healthcare Employee Engagement

Many factors contributed to these declines. Perhaps most notably, many healthcare systems are on track for their worst financial years in decades. A September report from KaufmanHall found that median hospital operating margins were cumulatively negative through the first eight months of 2022. By way of comparison, in 2020, despite losses during the initial months of COVID-19, hospitals still reported median eight-month operating margins of 2 percent — although these were in large part buoyed by federal aid.

The ‘why’ behind this historically poor financial performance can also help us understand the related decline in engagement. Labor shortages and supply chain disruptions have fueled a dramatic rise in expenses, which hospitals — limited by the annually fixed nature of payment rates — have thus far been unable to pass through to payers. At the same time, diminished patient volumes — especially in more profitable service lines — have constrained revenues.

The primary driver of rising hospital expenses is a shortage of labor — in particular, nursing labor — which could likely worsen in the future. Since the start of the pandemic, hospitals have lost more than 100,000 employees, and nursing vacancies have more than doubled. In response, hospitals have had to rely on expensive contract nurses and extended overtime hours, precipitating a perfect storm of surging wage costs and employee burnout. While these issues were worsened by the pandemic, the national nursing shortage is a decades-old problem that — with a substantial portion of the labor force approaching retirement and an insufficient supply of new nurses to replace them — is projected to reach 450,000 by 2025.

Five Barriers to Employee Engagement in Healthcare

In our 2022 healthcare report, we identified five barriers — staffing, well-being, safety, culture of listening, and optimism — that could impede the improvement of employee engagement and the overall employee experience. As the preceding data made clear, these barriers are indeed impeding engagement and leading to unwelcome business outcomes.

All is not lost, however. Even as many healthcare systems continue to face challenges, we can draw on examples from industry leaders for ideas to help us remove these barriers. Below we review specific actions from leading healthcare systems that are reversing these negative trends, helping both their people and their organization thrive.

Barrier #1: Staffing Challenges

In a Perceptyx study of 1.5 million healthcare workers, staffing perceptions remain the least favorable with less than 2 of 5 believing there is enough staff to meet patient demands and 1 of 3 stating they work longer hours than is best for patient care. Staffing continues to be a top focus of healthcare executives. Hospital CEOs know they need to hire more skilled people and offer competitive pay but also understand that salaries must fit within their budgets. According to a recent survey from the American College of Healthcare Executives (ACHE), 90 percent of surveyed CEOs ranked shortages of registered nurses as the most pressing within the category of “workforce challenges,” followed by shortages of technicians (83 percent).

To address issues related to staffing, organizations can:

• Redesign workflows. With staffing levels continuing to be a challenge, it is incumbent upon healthcare systems to find creative ways to be “GROSS” — to “get rid of stupid stuff,” as the American Medical Association (AMA) labels it. Speaking to Becker’s Hospital Review in January 2023, Duke Health’s Chief Quality Officer Dr. Richard Shannon lent critical support to this idea, noting that, per his team’s own documentation, “we found nurses doing valuable work only about a third of the time” while “30 to 35 percent of a nurse’s time is spent documenting electronic management records.” By better understanding the current workflows, the system is able to redesign the workday to “eliminate the waste so nurses can spend more time interacting with patients and their families.”
   
  • There are many other creative solutions when it comes to workflow redesign and optimizing staff skills. NewYork-Presbyterian, for example, has leveraged technologies ranging from their internet portal to televisions, along with virtual interactions designed to enhance admissions and discharge, to keep staff moving efficiently through their daily workflow. 
    
    
  • Perceptyx’s Dialogue solution allows staff to share their own insights and feedback quickly at scale. As it relates to workflow redesign, Dialogue helps organizations crowdsource ideas from all clinical staff, efficiently listening to and prioritizing recommendations on what “stupid stuff” could be eliminated from their scope — thereby enabling them to operate at the top of their licensure more often.
    
    
• Empower flexibility with “internal staffing agencies” and innovative scheduling. Although the reliance on travel nurses is subsiding for most, many leading health systems continue to find value in leveraging “internal” staffing agencies, providing greater flexibility to move their own employees around their own system to fill staffing needs. Not only is this approach more cost-effective than the use of external agencies, but this also provides opportunities to grow your own talent, providing new experiences to team members without them having to leave your health system. Improved scheduling technology is another trend that leading health systems are embracing in order to empower their staff with more choices in when and where they work. This flexible scheduling meets the demand of today’s workforce, helping organizations retain and attract talent who desire greater empowerment over their work schedules. Flexible scheduling also helps the organization more efficiently serve the needs of patients by deploying the right talent to the right units. Overall, both internal staffing agencies and flexible scheduling help attract and retain staff desiring more flexibility while also allowing health systems to operate in a more agile, cost-effective manner that better adjusts resources to changing patient demands.
  
  
• Bring in higher-quality talent faster with panel interviews. As we wrote in July, many healthcare organizations continue to heavily invest resources in hiring new staff to alleviate staffing pressures. Unfortunately, constant hiring can significantly divert leaders’ time away from leading their current teams, negatively impacting team morale and patient outcomes. Some leading health systems leverage panel interviews to improve the speed and quality of new hires. These organizations entrust the hiring for an entire unit or even location to a panel of expert leaders who are trained and passionate about the selection process. By trusting the expert panel to hire for the entire unit or location, other leaders can focus on other mission-critical work including leading their teams effectively.
  
  
• Rethink onboarding programs to retain more new hires. Hiring new talent is only one part of relieving staffing pressures. It’s equally important to ensure new staff are quickly developed and actively retained. Invest in onboarding programs that foster a sense of belonging, communicate that new employees are valued, and enable them to be effective. Employee listening is essential here; lifecycle listening solutions like Sense from Perceptyx will enable leaders to quickly determine if onboarding programs are having the desired effects. Additionally, these solutions provide data to focus resources and actions on the areas that will improve new hire experiences, productivity, and retention the most.
  
  
• Build an early talent pipeline. Leading health systems are not only thinking about staffing needs today but are also actively growing their pipeline for the future. CoxHealth of Springfield, Missouri partnered with Ozark Public Schools to create a Health Sciences Academy that gives high school students hands-on experience and training in healthcare. While providing these students with early exposure to an in-demand sector of the economy, it also affords the healthcare system a chance to identify future top talent and create excitement about their organization. When combined with other forms of tuition and training reimbursement, investments to build excitement in healthcare among the next generation of workers could deliver a windfall of talent to healthcare systems willing to shoulder some upfront costs.

Barrier #2: Well-Being Challenges

As noted by the AMA, clinical well-being impacts the entire healthcare system. Improved clinician well-being leads to better patient care, patient outcomes, patient satisfaction, recruitment, and retention. Ongoing stress and work overload lead to increased burnout and increased intent to leave, with one study finding 37% of those burnt out indicated they will leave and a third of that acting on their intentions. To improve well-being — a barrier with a major impact on retention and patient outcomes— organizations can:

• Create a psychologically safe work environment to discuss well-being. Companies can foster a psychologically safe work environment by normalizing discussions on mental health and well-being and empowering employees to speak up and be heard when they need help. In order for this environment to truly exist, it must start at the top. For example, an executive at a large healthcare system shared his moving, personal story of mental health with the entire organization. This vulnerability from a senior leader led to other colleagues feeling safe to share their own challenges and experiences. By sharing his story, this executive created a safe space for open dialogue, reduced the stigma of mental health within that workforce, and modeled leaders’ commitment to staff well-being.

• Listen at scale for ways to truly improve employee well-being. Burnout specifically is a response to continual workplace stressors, requiring improvement in the overall work environment; well-being resources alone will not address the root causes of systemic factors that negatively impact well-being. As a result, leading health systems leverage employee listening to identify causes of workplace stress and burnout as well as actions to help alleviate these root causes. Crowdsourcing is particularly powerful for creating a psychologically safe culture through its inclusive, engaging method, which invites all employees to co-create and prioritize solutions. When it comes to well-being, inviting employees to share and prioritize what actions can improve well-being is a powerful way to gather insights for action across all employees and foster a culture where open discussion of well-being is normalized. Listening at scale during major events that can increase stress or anxiety, such as recession-driven layoffs, global pandemics, or mergers and acquisitions, provides healthcare systems with data-driven insights on the most effective actions for improving well-being while also fostering a psychologically safe culture for continued conversations on this topic.

• Optimize the use of technology. One contributing factor to job stress is the amount of work, especially administrative work, required of clinical staff. For example, one study reported eight hours of scheduled patient time equals five additional hours completing documentation in the electronic medical record (EMR) system. Some of these tasks can be delegated — which falls under the “GROSS” reworking of an employee’s scope — but the EMR itself must also be optimized. A best practice shared by a leading EMR provider is to involve frontline staff in EMR optimization or redesign. While it may seem expensive to temporarily redirect limited frontline talent away from direct patient care, leading EMR providers have found that the most successful implementations include bedside nurses in the design or redesign. By optimizing EMRs, caregivers can thereafter focus more time with their patients and alleviate stress previously caused by these administrative tasks.

• Develop more empathetic leaders.  A 2022 Medscape report on nurse career satisfaction found that nearly half of the 7,540 practicing nurses surveyed had experienced emotional abuse. RNs who experienced abuse indicated a manager or administrator was responsible 50 percent of the time. Investment in leader development, especially empathetic leaders who support employee well-being, is essential. Given the budgetary constraints now faced by most healthcare systems, organizations are leveraging artificial intelligence to provide leadership coaching at scale, such as Perceptyx’s Cultivate. This scaled coaching provides individualized, meaningful, and cost-effective developmental guidance to help all leaders better support, lead, and manage the well-being of their teams. 

Barrier #3: Safety Challenges

Team member and patient safety continue to be top priorities, with Perceptyx research finding 8 of the top 25 most declined perceptions over the last year relate to employees’ perceptions of safety. To address issues related to safety, organizations can:

• Address rising incivility: Perceptyx research from May 2022 found that 92% of healthcare workers experienced or were in close proximity to violence from a patient or patient’s caregiver in the past month. Nurses in hospitals are the most likely of all healthcare employees to be exposed to violence (physical or verbal) at work, with that same study reporting that 96% experienced an instance in the past month. The magnitude of incidents is also greater for this group: four in five hospital nurses have had to call a coworker or security because they feel unsafe — twice as many as workers in other roles.

• One tactic organizations are using to reduce the amount of incivility experienced is to use nudges such as posters, banners, and sayings on facility walls that remind patients and visitors to be kind to all. Some organizations report the success of these visual cues in reminding customers, and employees, what types of behaviors are and are not acceptable.
  
  
• Training is also a tactic used by organizations to provide staff with tools to de-escalate tense situations and mitigate potential violence, ultimately improving team member safety. Training that promotes empathy and understanding for why patients and visitors may be behaving in certain ways as well as training that provides specific actions for staff to take in order to de-escalate tense situations (“Please stop yelling at me or I won’t be able to administer your brother’s medicine”) develop employees’ skills that help protect their own safety.
  
  
• Besides training to de-escalate situations that threaten employees’ safety, other health systems have invested in training that teaches and reinforces acts of kindness in hopes of preventing patient incivility from occurring in the first place. To help reinforce the behaviors promoted in training, one leading health system uses stories of kindness to recognize and model desired behaviors across the health system. By sharing these stories publicly, staff is reminded of the importance of demonstrating kindness and see local examples for others to emulate.
  
  
• UMass Memorial Health has introduced a patient and visitor code of conduct that supports employees by holding patients and visitors accountable for inappropriate behavior. At kiosks on campuses and in offices, visitors are asked to sign an agreement to adhere to the code of conduct, which formalizes the parameters and expectations of their behavior. In just over a month following its implementation, it had more than 56,000 signed agreements for the code of conduct — and only four visitors were asked to leave during that time. Codes of conduct not only set clear expectations for how patients and visitors should behave but also signal to employees that their own safety is a top priority.
  
  
• Find new ways to measure and improve safety that are inclusive and actionable. Crowdsourcing, a feature of Perceptyx’s Dialogue product, invites employees to co-create and prioritize solutions to quickly drive meaningful action. This listening method begins by asking employees a question and inviting employees to provide ideas and solutions to solve that challenge. In the example of improving safety outcomes, this question can ask for one action to improve employees’ physical safety, employees’ psychological safety, patient safety, or more. Next, employees view ideas submitted by their peers, voting on which actions they believe are best through a pairwise voting process. From there, leaders move to action quickly by reviewing the prioritized action results. This process elevates team and localized insights, empowering leaders to make decisions and take ownership of the right actions. Due to these unique characteristics, crowdsourcing typically produces higher-quality actions that are more likely to be acted upon within organizations, resulting in improved safety outcomes.
  
  When it comes to driving safety outcomes specifically, Perceptyx research found that participation in crowdsourcing has not only a strong, positive correlation with employees’ overall perceptions of safety culture, but also meaningful relationships to patient advocacy. For example, one study found that departments in which employees were more engaged in the crowdsourcing method of listening, as demonstrated by more active participation logging in to view suggestions, providing their own improvement suggestions, and voting to help prioritize those suggestions, were also more likely to be viewed by patients as contributing to a safe and favorable patient experience overall. 

Barrier #4: Inadequate Culture of Listening

Perceptyx research finds organizations with more mature listening cultures tend to outperform peers in many metrics, including financial performance, patient satisfaction, and employee retention. This research also finds healthcare organizations tend to listen and act on employee feedback less frequently than other industries, trailing all other major industries except retail. 

To improve the culture of listening — which can also significantly improve retention — organizations can: 

• Involve employees in decision-making. Involvement in decisions is critical for improving engagement and retention but all too often decisions are made with little to no input from those most impacted. In fact, Perceptyx research finds only 50% of healthcare workers believe they are involved in decisions that impact their work. One large healthcare system reversed this trend by using Perceptyx’s Dialogue crowdsourcing product to involve nurses in identifying the traits needed in a new Chief Nursing Officer (CNO). This feedback was used to help prioritize certain traits for the selection process and provided nurses with the opportunity to have a voice in the hiring of their next leader.
  
  
• Round with clear follow-up. Connecting directly with employees is a great way for leaders to learn about firsthand ideas, barriers, challenges, and opportunities to improve day-to-day experiences. Although leader rounding is a common practice for many healthcare organizations, it is important that leaders follow up their listening with meaningful action. For example, Atrium Health’s Enterprise Chief Experience Officer and Market CHRO Vishal Bhalla shared a leader rounding strategy that includes clear expectations for leaders to follow up 4 weeks later using a stoplight approach: green for actions taken, yellow for actions in which help or more information is needed, and red for ideas in which action will not be taken at this time. Red is critical because it provides transparency about what is and is not being acted on, as well as ensures that employees know they have been heard. This approach clarifies how employee feedback is being used.
  
  
• Listen to truly understand and measure what matters. An employee survey is a powerful way to listen to employees at scale, providing insights and actions to help both staff and the business thrive. When it comes to the use of employee surveys, healthcare organizations must remember to ask questions that matter today to their employees and leaders. Although its helpful to ask questions that have been asked previously to measure changes in perception or to ask questions other healthcare organizations are asking to see how you compare, failing to ensure the questions you ask are also relevant and important to your organization today will limit the usefulness of your employee listening effort.
  
  Ask yourself and other stakeholders: What data do leaders need to make better decisions today? This isn’t necessarily about comparing one healthcare system to another, but about getting the insights needed to solve problems and make faster and better decisions. If a healthcare system is simply tracking an engagement metric and tying it to administrative decisions, it might wind up missing broader experience insights and continuous opportunities to improve. This is where a people insights platform backed by professional expertise can make a considerable difference in driving world-class business outcomes.

Barrier #5: Lack of Optimism

Employees want to believe they are part of a successful organization and that they can achieve success within that organization themselves. Unfortunately, optimism in the future is another area Perceptyx research has found that continues to decline within healthcare, with employees reporting less confidence in the future, less understanding of why changes are occurring, and less belief that the healthcare organization is competing effectively in the marketplace.

To increase optimism — yet another key driver of retention — organizations can:

• Reconnect with purpose and the role of meaningful work. Employees want to hear a meaningful vision for the future articulated by leaders — and need to know how their work fits into this bigger picture. Many organizations that are experiencing rising engagement are clearly communicating a meaningful purpose, describing why employees’ work matters, and sharing how employees’ actions contribute to the greater good. Reconnecting employees with meaningful work is necessary to build higher engagement and retention. 
  
  
• Improve employee optimism by providing clear career pathways for the future. As described in our Fall 2021 report, The New Factors Driving Employee Experience Now, employees need to have a clear sense of the company’s direction, an indication of specific ways they personally contribute to that direction, and the management support to get there. Future career growth was the number one attractor for new joiners, with nearly half placing it in the top three reasons they selected their new role. Recent Perceptyx research found that when recent job-changers were asked about the top reasons for leaving their immediate last job, the top selection was an opportunity to grow or develop in their career, with compensation way down the list. To help employees see an optimistic future for themselves, many healthcare systems are defining and communicating clear career pathways, visually showing employees different paths for career development. Since many roles require specific licenses, many healthcare systems are continuing to invest in education support, helping employees financially so they can realize these career opportunities.
  
  
• Hire a retentionist. Employee engagement rises when individuals can anticipate a successful future for themselves within the organization. While communicating career pathways is a necessary first step, that alone may not help employees take advantage of new opportunities. To better align employees with career opportunities, many organizations are leveraging “retentionist” roles: dedicated HR professionals who proactively connect individuals with growth opportunities within their organization. For a variety of reasons, conversations about career growth with managers and leaders can be difficult. A dedicated retentionist can work with employees to find places for them within the organization, helping individuals continue to advance their careers while also retaining individuals within the health system.

Perceptyx Can Help Your Healthcare Organization Learn from the Best

Perceptyx helps healthcare organizations create listening programs that will facilitate all these best practices in employee experience and engagement. From crowdsourcing insights to developing always-on listening models, we provide organizations with crucial resources to help your people and organization thrive. To learn more, schedule a demo today.