Engaging Teams

Elizabeth Carvelli

Simmons College

©2018, Elizabeth Carvelli

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Abstract

Employee engagement has been demonstrated to impact the productivity of the

workforce.  The healthcare climate is changing and it is becoming more important to have

engaged teams to offer the best patient experience and outcomes. Healthcare is an outcomes-

driven market, making it essential for organizations to optimize employee engagement.  Working

with teams to identify areas that are causing disengagement and working towards solutions can

result in better patient outcomes, influence motivation, and better productivity. When working

with a team that has low engagement the team may be dissatisfied with their work, have low

drive, and patient outcomes may suffer (Freeney & Tiernan, 2009). 

Purpose: The purpose of this practice improvement project was to improve employee

engagement in the Comprehensive Headache and Pain Management Center at Beth Israel

Deaconess Medical Center by utilizing a structured team building intervention.

Intervention: This intervention utilized an educational module from the Agency for

Healthcare Research and Quality TeamSTEPPS model as the initial team training; followed by

weekly team building exercises. A pre-intervention and post-intervention survey was conducted

to collect employees’ impressions of team building and training. Twenty-two staff members

participated in informal focus groups. Data obtained from the focus group answers was used to

as a baseline to inform the development of team building modules.

Results: Based on survey data, this team made moderate improvements in employee

engagement. Survey data also indicated a continued need to maintain and expand the

intervention to make further strides in engagement.

Keywords: employee engagement, team building, team training

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Acknowledgments

I wish to express my deepest gratitude to Dr. Eileen McGee. Her words of

encouragement and patience guided me through this process. I would also like to thank my other

committee member Dr. Maura Brain for her words of encouragement and editorial support.

I want to thank the entire team at the Arnold-Warfield Pain Center. They worked with

me through this project and were open to the process. A special thanks to Peter Russo and

Nathaniel Beyer who rallied the troops and kept the team moving forward.

I would like to acknowledge my family, past and present coworkers, fellow students, and

faculty members for support and encouragement. My mother encouraged me along the way with

support and love. My colleagues, Susan and Mary, who encouraged me every day and supported

me when I needed time away from work to complete schoolwork.

A special thanks to my husband, David Carvelli. He has supported me throughout my

career and education. He has encouraged me to meet all of my professional and personal goals.

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Dedication

This doctoral study is dedicated to my husband, David, sharing twenty years of

happiness, love, and laughter. Without your love and support none of this would have been

possible.

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Table of ContentsAbstract..............................................................................................................................iii

Acknowledgments..............................................................................................................iv

Dedication............................................................................................................................v

Introduction..........................................................................................................................4

Background of the Problem.................................................................................................6

Purpose Statement...............................................................................................................8

Significance.........................................................................................................................8

Review of Literature..........................................................................................................10

Employee Engagement......................................................................................................11

Culture...............................................................................................................................12

Team Building...................................................................................................................14

Conceptual Framework......................................................................................................15

Design................................................................................................................................18

Setting................................................................................................................................19

Sample...............................................................................................................................20

Methods.............................................................................................................................21

Plan....................................................................................................................................22

Do and Act.........................................................................................................................22

Study and Act....................................................................................................................23

Team Building Exercises...................................................................................................23

Data Collection..................................................................................................................25

Focus Groups.....................................................................................................................26

Team Building Survey.......................................................................................................26

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Data Analysis.....................................................................................................................27

Focus Group Analysis........................................................................................................27

Survey Results Analysis....................................................................................................27

Results................................................................................................................................27

Focus groups......................................................................................................................27

Blame.................................................................................................................................27

Communication..................................................................................................................29

Role Clarification...............................................................................................................30

Team Building Survey.......................................................................................................31

Pre-survey..........................................................................................................................32

Post-survey........................................................................................................................33

Comparison of the Survey.................................................................................................33

Limitations.........................................................................................................................33

Disscussion........................................................................................................................35

Implications for Practice....................................................................................................36

Plans for Dissemination.....................................................................................................37

Summary and Project Conclusion.....................................................................................37

Appendix A........................................................................................................................38

Appendix B........................................................................................................................39

Appendix C........................................................................................................................41

Appendix D........................................................................................................................42

Appendix E........................................................................................................................43

Appendix F........................................................................................................................44

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Appendix G........................................................................................................................45

Appendix H........................................................................................................................47

Appendix I.........................................................................................................................49

References..........................................................................................................................51

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Engaging Teams through a Targeted Process Improvement of Team Training

Introduction

Research reveals that employees who are engaged in the workplace are content and more

productive (Eldor & Harpaz, 2015). Healthcare leaders and researchers have been placing more

significance and attention on employee engagement. Airila et al. (2014) defined employee

engagement as “positive, fulfilling, work-related state of mind” (p.88). Shoaib and Kahn (2017,

p. 877) cite “the term engagement was coined by Kahn (1990, p 694) as the harnessing of

organizations members’ selves to their work roles; in engagement, people employ and express

themselves physically, cognitively, and emotionally during role performance”. Organizational

productivity is determined by employee efforts and engagement (Musgrove, Ellinger, & Ellinger,

2014).

Employee engagement measures the commitment an employee has towards an

organization.  Engagement is separate from satisfaction.  An employee can be satisfied with their

work but not use discretionary effort causing a gap between what an employee is willing to do

and actually do resulting in disengagement in the workplace (Anitha, 2014). Discretionary effort

is the amount of effort an employee would need to exhibit to exceed the minimum job

requirements; it is the feeling of wanting to do more (Morrison, Burke, & Greene, 2007). In

other words, discretionary effort is the difference in the degree of effort that one is willing to

bring to complete a job as compared to what is needed just to get the job done. Discretionary

efforts will impact outcomes not the volume of work completed in a role (Arrowood & Kelm,

2013). The willingness to use discretionary effort is a common characteristic of engaged

employees; this motivates employees to exceed expectations of employers. The use of

discretionary effort in healthcare can lead to better patient outcomes because the employee is

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driven to find solutions to problems and exceed expectations of the patient (Muha & Manion,

2010).

A satisfied employee may be pleased with conditions of the job but is unwilling to

provide discretionary effort. What this means in practical terms that the employee is performing

the basic requirements of the job, but is not fully engaged and functioning at a high level. The

employee who is merely satisfied with working conditions may deliver quality care but does not

look to make the care better, more efficient, or seek innovation in the workplace.  A critical

attribute of the engaged employee is self-motivation. In healthcare settings, the engaged

employee who possesses the trait of self-motivation displays the trait in several possible ways.

This employee is one who will seek out ways to improve both their practice and the practice of

the care setting within which they work (Eldor & Harpaz, 2015). Healthcare organizations exist

in a constant state of change. Change processes are inherently difficult and may elicit negative

responses in employees who are not fully engaged.  Failure is commonplace when trialing new

processes; the engaged employee realizes that they will have failures but uses failure

productively by learning from what went wrong and redesigns the process (Arrowood & Kelm,

2013).  

Employee engagement is a motivating factor for employee productivity, patient safety,

and job satisfaction. Teams can move between states of high and low engagement.  Staff

readiness to accept and implement change will drive their success.  Whether a team has low or

high engagement, it should be evaluated systematically; one example of a way of evaluating

team engagement is a survey.  Evaluation of employee engagement should happen on a regular

basis (Breevaart, et al., 2013). High engagement needs to be fostered by leadership to maintain

high engagement and conversely leadership needs to motivate a team with lower engagement.

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When dealing with disengaged teams employees may feel that their work is not understood or

appreciated and this can cause dissatisfaction and increased disengagement (Chen, Yen, & Tsai,

2014).

Teamwork and employee engagement are inextricably linked. According to Naatz

(2013), “Team building is often seen as a way to unite a group, to facilitate a team getting to

know each other and make connections on one or more fronts, and to cultivate strengths as well

as address development areas in the team as a whole” (p. 36). Strong teams have been shown to

improve outcomes and optimize resources (Ulrich & Crider, 2017).  In healthcare, teamwork and

collaboration are crucial to delivering quality care (Muha & Manion, 2010). Understanding and

building strong teams is a key to increasing employee engagement.  Teams are not always ready

to work well together; utilizing team building techniques can ready teams to efficiently work

together.  Teams that are engaged work well together and are more productive. Building strong

teams can increase job satisfaction, patient outcomes, and employee engagement. Issues

leadership faces in teams are that teams change and evolve causing fluctuation in engagement,

productivity, and satisfaction (Beck & Harter, 2015).  Without oversight of leadership, teams can

break down and become inefficient (Cronowett et al., 2007; Morrison, Burke, & Greene, 2007).

Employee engagement must be cultivated to keep the employees committed and working

towards better outcomes.  

Background of the Problem

Employee engagement is necessary for positive organizational outcomes. Meaningful

work allows for employees to feel valued and may increase levels of participation in the

workplace; this could impact employee engagement (Osbourne & Hammoud, 2017). The

employee who finds work to be meaningful is more likely to be highly engaged. “Lieff (2009)

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describes the pursuit of meaningful work as part of effective career decision making in academic

medicine and specifically addresses the importance of feeling effective, creative, and balanced in

a career. Emphasis is placed on the importance of achieving self-realization or authenticity

through meaningful career (Brown & Gundermann, 2006; Svejenova, 2005) and the benefits to

an organization when employees find meaning in their work (i.e., greater commitment to the

setting, lower intentions to leave, and higher job satisfaction; Duffy, Bott, Allan, Kik, & Torrey,

2012.” (Hinds et al., 2015; p. 212). Engagement is a challenge in many industries and

workplaces; this will continue in the future because of complexities in organizations and

challenges presented by succession planning and generational priorities (Festing & Schafer,

2014; Mishra, Boynton, & Mishra, 2014). Individuals who are members of the Millennial

generation may have different priorities and drivers than those individuals who are from the

Baby Boomer generation. Generational factors should, therefore, be considered by leaders who

are seeking to improve employee engagement. Saks and Gruman (2014) suggest that

engagement is a measurement of how much employees devote physically, cognitively, and

emotionally in completing the job. The differences in teams may work towards or against

engagement; team building can assist the team in finding commonality within the team, therefore

improving engagement.

This process improvement project addressed the problem of low employee engagement in

the Comprehensive Headache and Pain Management Center at Beth Israel Deaconess Medical

Center. The registered nurses and clinical and administrative support staff in this practice setting

underwent an initial employee engagement survey in November of 2015.  The results from the

Press Ganey Employee Engagement survey confirmed that this was a disengaged team.

Overwhelmingly the team identified the lack of role clarity and role identification as the most

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significant barrier to employee engagement and job satisfaction. Press Ganey offers solutions to

the healthcare arena via survey for patient satisfaction and employee engagement and reporting

and benchmarking for clinical quality.

Purpose Statement

The purpose of this practice improvement project was to improve employee engagement

through team building Initiatives in the Comprehensive Headache and Pain Center at Beth Israel

Deaconess Medical Center.

The specific question addressed in this process improvement project was: 

1. Will a targeted employee engagement intervention increase employee

engagement? 

The aim of this project was to increase employee engagement in this clinical setting. 

Significance

Healthcare is an outcomes-based business. Optimizing employee satisfaction and

engagement will lead to positive outcomes. Research has demonstrated that engaged employees

have higher levels of organizational commitment and job performance (Lowe, 2012). According

to Gupta (2017), “There’s a newfound realization that employees in organization make a huge

difference when it comes to innovation, competitiveness and organizational performance, thus

the emphasis on engaging employees.”(p.77). Healthcare leadership experiences increased

pressure to attain high-quality outcomes with limited resources and low cost (Tuers-Feldman,

2015). The concept of employee engagement is linked to outcomes, financial viability, and

increased productivity.      

Employee engagement is an integral part of a highly functioning clinical team (Weaver,

Dy, & Rosen, 2014).  When a team has a connection to each other and their work they tend to

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perform at a higher level because an engaged team will find meaning in work. With higher levels

of engagement, teams should experience better outcomes with patient satisfaction and culture of

safety measures. Employers must invest time and effort to increase employee engagement

(Brunges & Foley-Brinza, 2014; Hausknecht & Holwerda, 2013).  As engagement in work

increases, employees usually are more committed to their work and employers (Musgrove,

Ellinger, & Ellinger, 2014; Wagner, 2006).  Encouraging employees to do their best when

resources and tools are scarce is a struggle that most leaders face regularly.  Encouraging teams

to do more, with less, is business as usual.  Finding ways to encourage engagement as the

employees are being asked to do more is challenging.  Building emotionally intelligent and

robust teams are ways to promote engagement. 

     One tactic to increase employee engagement is team building; this will strengthen the

foundation of the team by building trust and understanding throughout the team (Agency for

Healthcare Research and Quality, n.d.).  A team that can rely on each other to offer high-quality

care will provide more discretionary effort; the team will want to do more; possibly moving a

team from great to extraordinary.  An engaged staff feels empowered at work and that their

opinion and desire for change will undergo serious evaluation by management (Duffield,

Baldwin, Roche, & Wise, 2014; Grol & Grimshaw, 2003).  Practice improvement projects are a

way to manage change (Langley et al., 2009; Lloyd, 2004).  If the staff is not engaged, it is

difficult to make the process move forward.  Utilizing frontline staff as the experts in their field

will assist in defining roles, process, and where best to make changes to have the most impact on

satisfaction and engagement.

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Review of Literature

Employee engagement is a critical attribute of a highly functioning organization. A

disengaged staff is at risk for burnout, repeated loss/replacement of personnel, and errors in

practice (Brunges & Foley-Brinza, 2014; Crawford, LePine, & Rich, 2010).  Empowered

employees are more likely to be productive and engaged (Duffield, Baldwin, Roche, & Wise,

2014).  The literature highlights studies on workforce engagement, the importance of

engagement, and suggestions to increase workforce engagement.  Feeney and Tiernan (2009) cite

that engagement in the employee's work promotes a greater sense of well-being.  Reasons to

strive for developing an engaged staff is that engaged employees report increased employee

satisfaction, less burnout, and an increase in productivity (Bakker & Sans-Vergel, 2013; Brunges

& Foley-Brinza, 2014; Wagner, 2006).  Finding the causes of disengagement and dissatisfaction

and correcting the issues may ultimately increase employee engagement.

A literature review on employee engagement and job satisfaction was implemented.  The

keywords employee engagement, employee satisfaction, staff development, team building,

motivation, and burnout were used to search in various databases.  The databases used were

CINAHL, Medline, Web of Science, and the Cochrane Library to locate studies published

between 2006 and 2018.  The initial inclusion criteria included no limitation on the date of

publication this produced over four hundred articles.  Articles were discarded that discussed

patient satisfaction.  Further review of abstracts for keywords including job culture and job

demands; finding a total of thirty-eight articles with these additional keywords.  The studies were

weighted by how many times they were cited; realizing that citation of recently published

materials is limited. 

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Employee Engagement

Wagner (2006) implied that an engaged staff finds meaning in their work.  Similar traits

found in engaged staff include close relationships with co-workers, mutually supported

relationships, a strong sense of team, and purpose and satisfaction with patient interactions

(Kompaso & Sridevi, 2010).  Dedicated and meaningful work was a substantial factor in

employee engagement (Nohira, Groysberg, & Lee, 2008). These themes were recurrent in the

research on employee engagement (Bakker & Sans-Vergel, 2013; Freeney & Tiernan, 2009).

Some behaviors may increase engagement such as clear communication from leadership, role

clarity, and striving for a motivational culture.  One study examined nurses in fourteen different

hospitals in New York State, utilizing a web-based survey.  The study suggested strong

communication from leadership and sense of team engages the staff.  The studies caution that

leadership must have oversight in maintaining the change to become part of the culture for staff

to feel loyal and engaged (Cummings et al., 2010; Pipe et al., 2012).  It is vital to measure

leadership’s engagement level as this can affect the frontline staffs’ engagement. Recently trends

highlight that leaders are becoming less engaged and this may threaten engagement of frontline

staff (Airila et al., 2014; Cummings et al., 2010).  

Measurement of job satisfaction typically measures a self-reported level of happiness

within the work role and expected workload (Brunges & Foley-Brinza, 2014; Gilmour &

Retford, 2014).  Employee satisfaction results from how the individual perceives work.  Some

factors evaluated to measure satisfaction include job security, work relationships, role definition,

and compensation (Crawford et al., 2010; Duffield et al., 2014).  Employee satisfaction measures

personal impressions of the current role.  When staff felt that their work was valued and well

defined, they were more likely to be engaged (Airila et al., 2014; Anitha, 2014).  Employee

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engagement is defined as the commitment level to an institution and includes the motivation

behind the individuals’ ability to innovate and find practical solutions to problems (Bakker &

Sans-Vergel, 2013).  The measures for employee engagement are grounded in the institutional

culture-defining work role meaning and work role importance as perceived by the

employee (Saks & Gruman, 2014).  Both employee satisfaction and engagement are essential in

the sustainability of any process improvement (Langley et al., 2009).  Crawford et al., (2010),

cited finding ways to eliminate barriers to moving work forward to increase engagement may

assist in changing the culture.  Creating a welcoming and stable culture may support satisfaction

and engagement.  Culture is difficult to change and will take the support of leadership and find

local, informal leaders to assist in the change (Freeney & Tiernan, 2009).

Culture

Culture runs deep in many workforces.  Sometimes culture is a positive force and will

boost morale, increase satisfaction, increase engagement, and support a strong sense of team

(Brick, 2012; Vestal, 2012).  Some workforces suffer from a negative culture.  Many factors

affect culture in a team.  A toxic culture can be devastating and painful to move past, causing

undue stress and an unhealthy environment (Grawitch, Ballard, & Erb, 2015).  The team needs to

feel involved and recognized.  When negative behaviors take hold in a team, it can be pervasive

and become difficult to overcome (Hartel, 2008).  When a negative attribute takes hold in a

culture managing this issue is significant as this can sabotage any changes (Bezukova, Thatcher,

Jehn, & Spell, 2012).         

Engaged employees are motivated employees.  Finding ways to increase motivation may

increase engagement.  Meeting emotional needs may assist in improving motivation.  Nohira et

al. (2008), describes motivating factors as four drives: to acquire, bond, comprehend and defend. 

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These four drives need to be met for a manager to boost morale and motivation. “To acquire” is

the need to hunt and gather for the individual, this can also be a competitive trait.  “Bond” can be

fulfilled by a strong sense of team, what is the level of commitment and trust placed on the team

members.  “Comprehend” challenges and learning motivate employees, whereas a tedious job

leaves the employee feeling disenfranchised.  Finally, the fourth driver as cited by Nohira et al.

(2008), “defend” which the employee defends self, this is similar to a fight or flight reaction.

Emotions, moods, and relationships are underlying factors in workplace culture

(McDaniel, Ngaia, & Leonard, 2015).  There are two types of toxic cultures in the workplace

based on two opposite emotional states extremely collectivist cultures and extremely

individualist cultures (Hartel, 2008).  Individualistic cultures are teams that have independent

individuals who lack a sense of team.  Collectivism culture has a team that is co-dependent upon

each other with low personal identity; these individuals are too dependent on the team.  The

similarities between the two cultures are infrequent positive emotions with persistent negative

emotion that goes unresolved (Hartel, 2008).  A healthy emotional culture exhibits a positive

emotional response, and negative emotional responses are either resolved or managed.      

Employee satisfaction and team culture are strong forces affecting employee engagement

(Hoffman & Kanzaria, 2014; Weaver & Rosen, 2013).  When a workforce is both satisfied and

engaged then innovation and forward moving thinking can happen, and outcomes will improve.

Working with the team and finding motivators that will raise engagement and satisfaction

will ultimately make the team successful (Weaver, Dy, & Rosen, 2014; Wells, Manuel, &

Cunning, 2011).  The culture in the work area must be ready for change, or it will not

occur (Menguc, Auh, Fisher, & Haddad, 2013).  

Team Building

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Team training will strengthen teams if they are ready to complete the work (Ulrich &

Crider, 2017).  Team training can improve communication, processes, and coordination of

care/tasks (Brunges & Foley-Brinza, 2014).  Building effective ways to communicate, support,

and situational awareness within the team will affect outcomes.  Providing the team and

employees with constructive feedback has been shown to increase engagement (Dent & Tye,

2016).  The importance of team building in a team with low engagement is to strengthen the

foundation.  Trying to build upon the pillars of employee engagement while the sense of team is

weak will lead to failure (Berens, 2013).

Many techniques and exercises can be used to team build.  Some evoke competition with

colleagues while others require self-reflection.  Utilizing many different modalities to build

teams may increase success ("U. S. Department of Labor," 2015).  Leaders whether formal or

informal are responsible for driving these changes, role modeling and coaching is needed to

change the culture and achieve success (Anderson, Anderson, & Mayo, 2008; Mowbray,

Wilkinson, Tse, 2014).  As with any meaningful practice improvement, failures are to be

expected and needed to accept the change wholeheartedly.   

Utilizing the strengths of the individuals in a team to support others who do not have the

same expertise or experiences can assist with team building (Buttner, Lowe, & Billings-Harris,

2014; McDaniel et al., 2015).  Identifying the unit based expert and finding ways for the expert

to disseminate their knowledge to the team builds trust and communication.  Employee

recognition as expert level sometimes is enough to increase engagement. Gaps in the literature

include limited information to small unit-based studies in healthcare; most of the research is

based on large organizations effects on employee engagement.

Conceptual Framework

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This process improvement project utilized the Jobs Demands-Resource Model. The Job

Demands- Resource Model is the dominant framework for studies reviewing employee

engagement (Osborne & Hammoud, 2017; Pipe et al., 2012; Schaufeli & Bakker, 2004).  In

2001, Demerouti first established this model in an attempt to understand the phenomenon of

employee burnout. The model was an expansion of other models; Karasek’s Job Demands-

Control model and Siegrist's Effort-Reward Imbalance model (Demerouti & Bakker, 2011).

The premise of the model is individuals will exert more efforts when job demands are high.

Upon completion of the task, the employee needs recovery time via a break from the job or

completing less demanding tasks to allow for mental and physical recovery. If the employee

does not have adequate mental and physical recovery after times of high stress, the employee

will suffer physically and emotionally and may experience burnout. The employer and employee

must find ways to balance job demands which can cause emotional and physical exhaustion such

as work overload and interpersonal conflicts; with job resources which counteract overtaxing the

employee.

Every occupation has its stressors.  Demerouti & Bakker (2011), break down the stressors

into job demands and job resources.  Job demands are the physical and mental skills needed to

complete tasks; these are only negative when it requires excessive demands to self to complete

the tasks.  Job resources can assist in completing tasks.  Resources encompass relationships with

co-workers, pay, and job security.  The resources to mitigate stress can be from within the

individual, someone who finds ways to relieve stress before it can manifest into a psychological

or physical symptom.  Resources can also be defined as additional ways employers assist

employees through stressful times including, for example, adding workforce or positive feedback

(Happell et al., 2013).

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Job demands can facilitate or undermine the impacts of engagement (Bakker & Sans-

Vergel, 2013).  Employees want challenges to stimulate forward thinking not barriers to prevent

innovation. Perceived barriers can negatively impact employees, and if not counteracted, this

could lead to adverse outcomes that may manifest as disengagement. If an employee motivated

and engaged in their work, and presented a challenge, the employee may use more discretionary

effort to solve the problem. Attaining this goal may be enough to fulfill the employees’ well-

being positively and prevent negative outcomes. By differentiating barriers from challenges, this

can make positive gains in employee engagement (Bakker & Sans-Vergel, 2013; Wagner, 2006).

Challenges have a positive impact while barriers have an adverse effect on employees’ attitudes

towards work. By changing the culture of a team to view work demands positively as a

challenge instead of negatively as an obstacle, this may increase engagement (Airila et al.,

2014).   

Assumptions of this model include that professions have their specific factors linked to

job-related stress (Demerouti & Bakker, 2011; Farndale & Murrer, 2015).   Categorizing factors

as job demand and job resources assists leaders with providing tools and resources needed for

success.  Job demands refer to aspects of the job that require sustained effort and skills

associated with a cost to self through physical or psychological efforts but not all job demands

have adverse effects (Bakker & Sans-Vergel, 2013; Schaufeli & Bakker, 2004). When job

demands have adverse effects, it causes job-related stress to build and may manifest physically

or psychologically. These adverse effects could manifest as exhaustion which is the energetic

component of burnout or present as withdrawal associated with low motivation and

disengagement (Nohira, Groysberg, & Lee, 2008). Employees and employers must find ways to

mitigate and prevent these negative symptoms.

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Job resources can, however, assist in meeting goals; reduce the impact of job demands,

and promotion of personal and professional growth (Crawford et al., 2010).  Job resources can be

utilized to negate the effects of job-related stress from job demands. Job resource may offer

motivation to complete tasks. Job resource offers many intrinsic values to employees including

motivation, competence, and relatedness (McDaniel, Ngaia, & Leonard, 2015).

Figure 1. Job Demand-Resources (Demerouti & Bakker, 2011) 

The dual processes of job demands and job resources are ideal for this process

improvement project because the motivational process lends to increasing employee engagement

(See Figure 1).  Job resources may motivate employees to use more discretionary effort to

complete their job, therefore, increasing employee engagement (Musgrove et al., 2014). 

Resources can assist in overcoming constant, negative job demands such as work overload. 

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Resources are available in many different ways; from an organizational level which may increase

an employee’s wage or from local leadership by fostering autonomy or giving positive feedback. 

Giving regular constructive feedback can have an overall positive outcome for employees,

causing the employee to feel valued and that the leader understands the work and role (Dent &

Tye, 2016; Tuers-Feldman, 2015). Identifying the barriers that the employees express and

finding resources to counteract these stressors is the premise of the framework. If resources

fulfill the physical and emotional needs of the employees by allowing recovery from stressful

times; this may encourage innovation, autonomy, and motivation. Innovation, autonomy, and

motivation are all factors that may increase employee engagement.

Design

This process improvement project utilized the Plan, Do, Study, Act (PDSA) model for

improvement. “The cycle promotes a trial-and-learning approach to improvement efforts, with

encouragement to test an idea rather than do extensive analysis. “The cycle is used for learning,

to develop changes, test changes and implement changes” (Langley et al., 2009, p. 23). Utilizing

the Model for Improvement principles can improve processes by reducing waste, delays, and

workarounds (Langley et al., 2009).

The benefits of PDSA are that it allows for rapid learning in the change process if the

process works. If concerns are identified, the model allows for revision of the plan and further

experimentation. In healthcare, the adaptability and flexibility of the theory are essential in the

adaptation of process changes.

Informal focus groups were utilized in this process improvement project. According to

Struebert and Rinaldi-Carpenter (2011), “a focus group is a particular form of group interview

intended to exploit group dynamics” (p.36). Informal focus groups are a useful way to elicit

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feedback from a targeted audience. In this project, it was deemed that informal focus groups

would be most helpful in encouraging participants to speak freely. An interview guide was

utilized to promote group discussion. Johnson (2015) does stress the need for a discussion guide

and the ability for the moderator to not influence participants. Developing a discussion guide

can keep the conversation moving, and ensures the inclusion of the issues in the focus group

dialogue (See Appendix C). A way to prevent influence is to occasionally remind participants

that there are no right or wrong answers, that open and honest conversation is required to identify

issues and concerns.

Setting

This DNP project took place in an Academic Medical Center in Boston.  The clinical

practice setting is the Comprehensive Headache and Pain Center at Beth Israel Deaconess

Medical Center that treats a wide range of chronic and acute pain patients.  The location of the

clinic is not on the main campus of the Medical Center but a half mile away in a Medical Office

Building. Not being located on the main campus does trigger a sense of isolation for the team.  

All of the team is located in this Medical Office Building, encompassing the work and

primary responsibilities to this space. The responsibilities for satellite sites fall on the

administrative staff and telephone triage nurses; the clinical support staff does not have

responsibility at any satellite clinics.  The clinic offers a wide array of treatment modalities form

conservative to aggressive management of pain and pain symptoms.  The pain procedures can

be for diagnostic and treatment of chronic and acute pain.  Patients are treated with narcotic and

non-narcotic medications, focusing on more adjunctive medication and therapies.  The

clinic offers mind/body treatment modalities and has a collaborative partnership with the

CHENG-TSUI Integrated Health Center.  The center is exploring the benefits of adding a Bridge

ENGAGING TEAMS 20

Clinic hours for opioid use disorder patients.  Providing a collaborative, multi-modal approach to

patients seeking relief from acute pain signs and supporting patients living with lifelong chronic

pain management is the mission of the team.  

The clinic consists of seven registered nurses and six clinical and thirteen administrative

support staff.  The nursing staff has longevity; most nurses have been part of the pain clinic team

for almost twenty years and have more than thirty years individually of diverse nursing

experience.  The support staff is an ever-changing workforce; rapid turnover is an issue.  The

faculty has grown over the past five years increasing from five attending physicians to a service

line of twelve pain specialists, a headache specialist, two pain psychologists, three nurse

practitioners, and recruiting is for an addictions specialist.  

The clinic is spread out over four distinct suites on three different levels in the Medical

Office Building; some employees float throughout the different spaces while others have

stationary offices.  The geographical location of the clinics leads to poor communication and

weakens the sense of team.  Also when certain parts of the team are isolated or assigned to one

area, this causes team members to lose appreciation for the other team members’ work and scope

of practice.

Sample

All registered nurses and clinical and administrative support staff in the clinic

were involved in this process improvement project. Staff was invited to partake in the informal

focus groups and the Pulse Employee Engagement Survey.  Participation in the survey and focus

groups was voluntary. The inclusion of the entire nursing and clinical and administrative support

staff in the targeted intervention was on a voluntary basis.

The team participating in the intervention included:

ENGAGING TEAMS 21

Seven Registered Nurses

Four Medical Assistants

Two Practice Assistants

Three Patient Service Representatives

Seven Administrative Assistants

Three Referral Specialists 

Methods

A mixed methods evaluation approach with qualitative and quantitative questions

delivered via a survey and focus groups.  The team met in two informal focus groups; one group

was administrative staff another included the clinical staff.  A series of team building exercises

and trainings were offered from AHRQ TeamSTEPPS. A TeamSTEPPS survey to elicit feelings

and beliefs towards the concept of team was administered. This survey was utilized to obtain pre

and post-training data. A pre-survey was administered prior any education and training to

understand the individuals understanding of the team.  After eight weeks of training and

education, a post-survey was conducted to evaluate if the sense of team had increased, decreased,

or remained the same.

After two informal focus groups to evaluate beliefs and impressions of the employee

engagement results the planning process for team training began; twenty-two of the twenty-

four employees participated.  The first week the team underwent TeamSTEPPS training from the

Agency for Healthcare Research and Quality to assist in understanding and setting the tone for a

concept of team.  The following six weeks the team underwent a series of team building

exercises.  At the first training, an anonymous survey was passed out to obtain baseline thoughts

and beliefs on what was the sense of team (See Appendix A).  After the final team training, a

ENGAGING TEAMS 22

post-survey was administered to see if any feelings or thoughts improved or declined in the sense

of team (See Appendix B).   

Plan

Meetings were held with the Pain Center Leadership Team and Organizational

Development to plan the process.  During the planning meetings, the responses from the informal

focus group were reviewed to identify areas of concern as cited by the staff.  The leadership team

reviewed different educational modules and as expected chose Agency for Healthcare Research

and Quality TeamSTEPPS Office-Based Care: Team Structure due to its resiliency.  The module

offers a pre and post survey which was utilized to elicit feelings and biases towards a sense of

team (See Appendix A & B).  At a follow-up meeting, the Masters' Candidate Student had

experience with team building exercises and brought different exercises that tested different

domains of team training, for example, communication and trust.  The leadership team chose the

first two team building training before starting the educational module, the training to follow will

depend on staff feedback.   

Do and Act

The employee's education started with team structure, communication, teamwork, respect

in the workplace, and role clarification.  The education was a general overview of concepts and

poignant team building exercises.  Giving staff time to reflect individually and as a group after

each session allowed for the planning of the next training. The trainings went on over eight

weeks. Feedback was elicited every other training to ensure the trainings were going as planned

and to assess if the team needed to change the types of trainings.

Study and Act

ENGAGING TEAMS 23

The Doctorate of Nursing Practice student examined and compared the pre and post

survey data.  The pre-survey (See Appendix A) evaluated the individuals' values, beliefs, and

feelings about their team and workplace.  The educational sessions explored the issues cited by

the team as barriers role identification, communication, and blame.  Team building exercises

were a weekly event, changing the teams to augment where breakdowns were noted. 

Administration of a post-survey (See Appendix B) after the final training highlighted that

approximately half of the staff had no change in attitudes or beliefs towards the team structure. 

The benefit of this cyclic process improvement process is that it allows for redirection of efforts

and finding ways to make positive change. 

Team Building Exercises

After the AHRQ TeamSTEPPS module was completed. A series of team building and

training exercises were chosen. A Master’s candidate student who is a content expert on team

training through his military background and team training teacher in his current role in the

Operating Room chose the trainings in consultation with the DNP student.

The initial team training goal was for the team to become better acquainted. This was

done through the use of an icebreaker game called “two truths and a lie”.  Teams were divided

into five groups of five, purposely mixed to force new relationships to form.  On a piece of

paper, each person in the group needed to write down two truths and one lie.  The other members

of the group needed to figure out which “fact” was a lie.  Each team then needed to nominate the

teammate who stumped the team to see if they could stump the entire team.  Team members

enjoyed this exercise, and it set a positive tone for the following weeks.

Week three the team was broke up into three groups of eight, and within these groups

further broken down into pairs.  Again the disciplines were mixed.  The goal of this intervention

ENGAGING TEAMS 24

was to build knowledge among colleagues, and this was done through an exercise called “learn

about your neighbor”.  To complete this exercise, the teams broke up into duos or trios and

interviewed each other and then had to report out to the group something interesting about the

person interviewed.  At the end of the exercise, the team discussed the facts learned.  After week

three, halfway through completing the training, staff was informally interviewed as part of the

PDSA cycle. After reviewing the PDSA cycle, the decision was made to change the type of

team building exercises towards more interactive training.

Week four divided the group into four teams of six people.  Two teams had to compete

against each other.  Individuals were partnered with colleagues whom they worked closely every

day with to complete this task.  One team went into an open area and set up an obstacle course. 

The competing team was invited in to see the obstacle course except for the team member who

would be blindfolded.  The competing team had to assist the blindfolded colleague through the

obstacle course verbally.  The training tested communication skills and teamwork within the

established teams.  Week five divided everyone into random pairs or trios for training called

blind drawing.  This module works on particular communication skills and if the team can pick

the best tool to communicate with the blindfolded individual.  Utilizing a basic picture (piglet,

cat, fish) the team sat back to back with one person trying to describe what the other person

needed to draw, without stating what the object.  A PSDA cycle was completed at the end of this

training, and the team felt that competitive, interactive trainings were effective and opted to

continue.

Week six was the most physically taxing intervention.  Teams were broken into

six groups of four.  The foursome then sat on the floor back to back and interlocked arms.  As

this armless eight-legged being the foursome needed to get into a standing position, this tested

ENGAGING TEAMS 25

teamwork. After the last intervention, the team completed the voluntary the post-intervention

survey to measure any changes in the concept of team.  The final PDSA cycle was performed for

this process improvement project. Areas identified by the team as deficient were communication

and understanding different roles.  Both were identified during the initial focus groups but

remain an area of concern post-intervention. 

Based off of the feedback during the last PDSA cycle, leadership offered two additional

interventions, a module that stresses the importance of communication and the other was “a day

in the life” which highlighted the role of one of the employees to offer a better understanding of

the job requirements.  Both interventions reviewed ineffective and effective communication. 

Going forward this PDSA cycle will continue designing new workflows and processes.

Organizational Development has agreed to work with the clinic to find formal and informal

education to boost a sense of team. 

Data Collection

For this process improvement project, a mixed methodology was utilized to review and

understand the employee's thoughts and beliefs toward team training and employee

engagement. Using quantitative data in conjunction with qualitative data provided a personalized

base of information and descriptive statistics that support the lived experience (Cairney & St.

Denny, 2014; Johnson, 2015). 

Completing the surveys and informal focus group allowed for a mixed methodology both

qualitative and quantitative data for analysis. 

Focus Groups

The Press Ganey Pulse Employee Engagement results were made available to the

leadership teams’ mid-summer of 2017. The results served as baseline information to drive the

ENGAGING TEAMS 26

informal focus group discussion.  The results of the Press Ganey Employee Engagement survey

were used to outline the discussion guide (See Appendix C). Analyzing the survey results before

meeting with the team for the scheduled informal focus groups allowed for the leadership to have

a better understanding of the results.  Trends and themes were identified and served as the

outline for the questions asked during the informal focus groups, in September 2017.  The team

did not consent to the audio recording of the focus group; this was a concern during the planning

phase of data collection which is why informal focus group was selected.  Historically this group

has had low participation in meetings, and many staff members walked out of a process

improvement meeting when the innovation team insisted on recording the discussion.

The informal focus groups were held in two comfortable and private conference rooms

with a one-hour time limit. Each focus group utilized a moderator to introduce the questions,

probe for better understanding, and keep the conversation on track. The moderator and note

takers wrote a synopsis of the focus group expressing a level of participation, non-verbal

communication observed, and any other thoughts about the focus group.

Team Building Survey

As part of the process improvement project, an anonymous and voluntary pre and post

survey was administered to the staff to elicit bias and thoughts as it relates to the concept of

team.  The pre-survey was administered before the start of the interventions. The post-survey

was administered after the last planned intervention to elicit if any thoughts on team had changed

and to extract if the training should continue, at what frequency, and other topics of interest. 

Data Analysis

After obtaining all approvals, the informal focus groups were planned. Followed by team

building trainings and exercises; the AHRQ TeamSTEPPS training offered a survey that was

ENGAGING TEAMS 27

utilized to obtain thoughts and feelings about the sense of team. The survey from AHRQ was

used to compare the thoughts and feelings before and after the trainings and exercises.

Focus Group Analysis

Focus group data were analyzed utilizing qualitative content analysis methods. This

process involved reading and re-reading transcripts looking for commonalities. The data are

reduced, categories are created and eventually themes emerge (Johnson, 2015).

Survey Result Analysis

The form of data collection was the individuals’ thoughts and beliefs towards the concept

of team. The survey included seven scaled questions, one question on demographics, and the

post-survey asked three free text questions. The scaled questions utilized a Likert-type scale of

strongly agree, agree, neutral, disagree, and strongly disagree. The surveys were analyzed after

the pre-survey and after the post-survey; ultimately comparing responses from before the

interventions and after the interventions observing for changes in thoughts and beliefs towards

team.

Results

Focus Groups

Three themes emerged from the data. The three themes were, blame, communication and

role identity.

Blame

Teams do not work well when a culture of blame exists. Participants often expressed

pervasive feelings of negativity toward the workplace environment and these negative feelings

expressed themselves in blaming others for their unhappiness. Leadership was a frequent target

of blame. Probing questions related to engagement were often met with participants blaming

ENGAGING TEAMS 28

various people, places and processes as being the source of their lack of engagement. Underlying

this sense of blame was a feeling of deep distrust. Participants blamed leadership for a seeming

lack of transparency. When corrective disciplinary action happened, participants expressed the

belief that such actions were arbitrary. Referring to an employee termination, one participant

expressed, “Staff is just sent home, without thinking of the unit”. Participants, unaware of

corrective actions which had been on-going with a particular employee, believed that the

ultimate terminations to be “spur of the moment”. Because of the nature of the problem in this

unit, multiple employees were engaged in various stages of corrective action plans, so it seemed

to participants that people were just simply disappearing from the workplace. Blame for this was

vociferous and deeply felt.

The physician staff took a portion of the blame. In the past, the teams had forged

adversarial relationship and incidents were handled in a hierarchical and punitive manner.

Despite efforts made by leadership to improve relationships between physicians and other staff,

negative feelings of blame persist. These feelings are ingrained in the staff with longevity and are

passed on to newer staff through reliving of the tales of injustice and poor treatment. Participants

viewed physician fellows as not being team players or helping out with managing patient

concerns. One participant expressed the belief that, “Fellows still run out the door without

checking in”. Participants offered various other examples where Fellows were blamed for lack of

assistance with patient care. A belief was expressed that policies and procedures established by

physicians were ever changing and unilateral. One participant expressed, that it was “hard to

follow the rules, when the rules aren’t clear and not everyone follows the rules”. Another said,

“work isn’t standardized and they change their minds about policies all the time”. Participants

worried about the ramifications of angering physicians and cited several examples where

ENGAGING TEAMS 29

physicians had responded in angry ways to legitimate actions of nursing staff. It is clear that

pervasive feelings of blame and distrust remain on this team and much work remains to be done

to achieve the ultimate goal of an engaged workforce.

Communication

Communication processes emerged as the second theme. Many participants articulated

difficulties with communication. One employee cited that “I feel I mess up” because of poor

communication. Participants identified trends in communication and continued dissatisfaction

with break downs in communication which occur frequently. An example cited by participants

regarding communication was the issue of adding patients to the schedule and lack of

communication to the team regarding these decisions. Participants felt excluded from the

decision making and more importantly, many times are not aware that additional patients are on

the provider schedules.  Participants cited communication within the physician team as having

many barriers.  One participant cited the example that changes made by the Division Chief are

not always shared with the other physicians, thus creating a break down in communication

among all providers. Referring to this, one participant noted that the Division Chief “did not

share it with his colleagues”. This lack of communication caused participants to feel excluded

from decisions regarding patient care and marginalized as professionals.

Communication failures happened in practical ways as well. When striving for a clinic to be

patient-centered, excellent communication within the team is vital. As providers and employees

are making decisions to accommodate and tailor care to patients, if this is not communicated to

the team it causes confusion and redundancy of steps. One participant noted “patient schedules

run no later than 4:30 pm but changes are not communicated”. The issue is not that the

employees are staying to care for patients; it is that the reprioritization of the end of shift work

ENGAGING TEAMS 30

did not happen; causing employees to stay late. A Medical Assistant may close a room because

the assumption was that provider completed their schedule for the day. However, communication

about the addition of a final patient never made it to the Medical Assistant causing confusion and

lack of preparedness when the patient arrives. The lack of communication is viewed by

participants as increasing workload and decreasing engagement.

Role Clarification

The lack of understanding roles is pervasive in the department.  The lack of role clarity

will take a while to overcome as it has been an issue for many years.  The Resource Nurse is

responsible for throughput in the department.  This authority is undercut intentionally and

unintentionally most days.  The Physicians and Fellows want to micromanage the schedules,

which is understandable but not conducive to throughput.  Compounding the issue is that not

only micromanagement of the schedule to fulfill the need of that particular provider, but it will

also be done to the detriment of a colleague.  Asking for patients to be roomed into rooms

assigned to another provider that may be empty between patients. One participant “Decision

making should be included in the Resource Nurse, but she is by-passed if someone does not

agree with her decision”. If the clinician asks the Resource Nurse for an extra room and one

cannot be supplied, it is not uncommon for the clinician to then ask another team member such

as the Medical Assistant.  When asking the Medical Assistant, this is done authoritatively so that

the Medical Assistant would comply.  This was highlighted by multiple participants stating “it is

like a dictatorship” or “he is like a dictator”. The overstepping of bounds causes bottlenecks in

throughput.

The participants went on to state that they “feel overlooked”. The clinic has grown over

the past five years. Physician staff has tripled in size, Nurse Practitioner were added to the

ENGAGING TEAMS 31

provider panel. The Administrative Support team has increased to meet the needs of the

Providers and the Clinical Support staff has grown to assist in throughput of the clinic. Some

participants recognized this with these statements “the admins have been relocated into one area

and this helps a lot” and “it is nice to have our own space to get the work done”. The Registered

Nurse team has remained the same; it has not grown to support the new structure. The Nurses

feel that they are “overlooked” and “expect nurses to run the clinic with the same efficiencies”

and “instead of co-locating nurses we are spread out”. Identifying the roles and then training

staff for redundancy would allow for expansion into areas that are feeling under supported. For

example, if the Triage Nurse needed more assistance and the Recovery Room Nurses had limited

patients, the Recovery Room Nurse could assist in the triage role. Another issue is that the

Registered Nurse team has not had a new member in fifteen years causing uncertainty with

bringing on a new member. The team feels overworked in their roles but insecure about

onboarding a new team member.

Team Building Survey  

In the pre and post survey, most staff did not enter demographics; this entailed circling

their role administrative, clinical support, or nurse.  This simple act signifies the lack of trust

within the team. In the pre-assessment survey (See Appendix A), two participants did not

answer one question each.  The two questions were “Staff within my office share information

that enables timely decision making by the direct patient care team” and “My team makes

efficient use of resources (e.g., staff, supplies, equipment, and information).”  In the post-

assessment survey (See Appendix B), one person did not answer “Staff within my office share

information that enables timely decision making by the direct patient care team,” but it was not

the same participant who did not answer in the pre-assessment.  Five participants only answered

ENGAGING TEAMS 32

a pre or post assessments, resulting in the data removal from the project.  The lack of

comparative surveys could have been a result of turnover or choice not to complete this

voluntary survey.   

Pre-survey

The pre-survey was an anonymous, voluntary survey.  Two participants opted not to

answer one question each; the questions addressed decision making and resource usage.  The

pre-assessment survey supported the observed behaviors of poor teamwork (See Appendix G). 

The question “Staff within my office share information that enables timely decision making by

the direct patient care team” had both the highest negative responses in the survey with 19% of

respondents disagreed, while 58% agreed that they were involved in timely decision making. 

When reviewing all questions, very few responses 2% were in the strongly disagree

category while 18% of responses registered a strongly agree response. The majority of

responses, 41%, were in the “agree” category.  Three questions addressed communication,

blame, and role clarity. The question that addressed role clarity response rate was highest in the

neutral response at 40%; this further strengthened the stance on role confusion; the question was

“Staff understands their roles and responsibilities.”  The question that addresses blame “Staff are

held accountable for their actions” had 10% of responses stating “strongly agree”; this may have

been due to the staff observing staff turnover due to poor performance within the team. The

disconnect between the focus group results and the team building survey results may have been

due to “blame” When blame was discussed during the focus group, the team included

individuals beyond the team in the focus groups. In the focus groups the team took into account

the entire team administrative support, clinical support, nurses, providers, and fellows. Whereas,

the TeamSTEPPS survey only addressed the immediate team; support staff and nurses. The

ENGAGING TEAMS 33

team highlighted poor communication in the highest negative response rate; 19% as

disagreeing, “Staff within my office share information that enables timely decision making by

the direct patient care team.”       

Post-survey

During the post-survey, one participant did not answer the question about decision

making, and it was not the same participant who did not answer it during the pre-survey.  The

highest and lowest scoring questions are different. The highest scoring question was at 63%

agreed that roles and responsibilities are understood, this is very good because in the focus

groups lack of role identification was a strong negative theme.  The lowest score, only 21% of

the participants felt that skills overlapped to sufficiently share work.  The feeling that they did

not have these skills could be because of the turnover, and unintentional removal of overlapping

of skills.  Follow-up questions were asked to inquire if the training was deemed helpful in team

building; overwhelmingly the team agreed that it should continue. 

Comparison of the Survey 

The purpose of the pre and post survey was to establish the baseline sense of team within

the participants. The thought was that the team did not have a sense of cohesion as discussed

during the focus group and noted during performance. After the exercises and educational

offerings were completed a post-survey was administered. Ultimately the answers between the

two surveys were compared to measure any increase, decrease, or no change in thoughts and

feelings towards team.  The sense of team is an essential tenet of employee engagement.  If the

foundation of teamwork is at all fractured, it is challenging to promote engagement. Only

seventeen surveys were eligible for comparison; this data will not be statistically significant.

Table 1

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Comparison of answers between pre and post survey

Variable Frequency %

Scored higher or remained at “Strongly Agree” 42 36

Scored remained the same at “Agree” or below 54 45

Scored lower 23 19

Note: N=17

Due to turnover, the results included only seventeen surveys for the pre and post-survey

comparison results.  During the overall comparison of answers, the data collected pre and post

survey 45% of the respondents did not change their position on their thoughts and beliefs of the

team.  In that 45%, it does include nine responses that initially rated “strongly agree” this is the

highest scoring answer and could not increase. All “strongly disagree” responses did improve

from pre and post survey.  19% of the participants scored some question as lower than their pre-

survey answer.  Not making timely decisions was the question that went the lowest with 23% of

the participants scoring this lower than their previous survey.  Whereas four questions scored

higher, these included accountability, timely decision making, resource management, and roles

and responsibilities.

Limitations

Qualitative findings are not generalizable. In addition to this, focus groups in this project

were limited by the participant’s unwillingness to be audio-taped. This greatly impacted the

quality of the data to be analyzed. Trust and toxic culture were the two biggest behavioral

limitations with this team. The team could not trust that the surveys and focus groups would be

ENGAGING TEAMS 35

anonymous. The years of hierarchal blame has paralyzed this team. Constantly reliving events

from the past and storytelling to new team members perpetuates the toxic culture.

Discussion

The focus of this practice improvement project intended to bolster team dynamics which

could lead to increased employee engagement.  Teams will fluctuate through times of

engagement and non-engagement usually due to different drivers in their workspace.  Giving

teams the tools and resources they need to come together and work through times of low

engagement will foster a healthy workspace (Musgrove et al., 2014). The starting point of this

process improvement was dealing with a team who were disengaged. It was hoped that as a

result of various team building initiatives that engagement would increase. Responses from the

focus group and surveys provided insight into barriers and strengths of this team’s engagement.

The findings suggest that the team still has more work to complete to reach cohesion.  A follow-

up Press Ganey Employee Engagement Survey was administered in April of 2018, with results

coming available in early summer 2018. Anecdotally, the team is exhibiting characteristics

aligning with higher engagement but the formal survey results will either agree with the changed

behaviors or offer more areas in which the team should work to increase engagement. Finding

ways to foster communication, encourage a culture of safety, and clarifying roles will work

towards increasing engagement.  Teams with low engagement are resistant to change (Anitha,

2014; Berens, 2013; Eldor & Harpaz, 2015).  The team exhibits resiliency; the team is willing to

look at processes and make changes as needed.  Ultimately the team should feel empowered to

make changes that will better patient outcomes (Sanchez & Cralle, 2012).  

Implications for Practice

ENGAGING TEAMS 36

Studies have shown that team building can increase employee engagement (Arrowood &

Kelm, 2013; Dollard & Bakker, 2010; Kompaso & Sridevi, 2010).  Understanding the teams'

views on their workplace will offer continued cyclical process improvement abilities.  Engaging

frontline staff in continuous improvement projects will allow for improved efficiency with the

results.  Utilizing continuous PDSA allows for parts of the process that are impactful remain in

place while implementing countermeasures to change outcomes that are not adding benefit

(Langley et al., 2009; Lloyd, 2004). 

The results from the informal focus groups support the theory of Job Demands-Resources

model.  The Job Demands-Resource provides a framework that allows leaders to examine the

demands placed on employees and resources in place to mitigate the undue stress placed on the

employee (Demerouti & Bakker, 2011; Happell et al., 2013).  Finding ways to increase the sense

of team, improve communication, clarify roles, and move towards a blame-free culture may

increase employee engagement.  The employees can learn this through formalized training as

used during this initiative.  Alternatively, through informal training which could be examining

actual clinic events during staff meetings, identifying what went well and where improvement

could have changed outcomes.

      Through the initiative, it became evident that addressing the other pillars of employee

engagement would further enhance the outcome.  Although the team training is not complete and

will require ongoing training and maintenance; addressing communication and role identity are

the next steps.  Building a strong foundation may eliminate some of the struggles this team

faces.  Without a stable foundation, any attempts at increasing employee engagement will be

fragile and difficult to maintain (Eldor & Harpaz, 2015; Lowe, 2012; "U. S. Department of

Labor," 2015).       

ENGAGING TEAMS 37

Plans for Dissemination  

The dissemination of the results of this process improvement project will include.  A

presentation of the project at Simmons College to the faculty and DNP students.  The

Comprehensive Headache and Pain Center will continue with the work the cyclic nature of the

process improvement.  More team building/training exercises will continue on at least a quarterly

basis.  Another Press Ganey Employee Engagement survey was administered in April 2018; the

survey results will highlight the success or failure of the training formally and allow for further

process improvement projects that will address new issues. 

Summary and Project Conclusion

The focus of this practice improvement project intended to bolster team dynamics which

could lead to increased employee engagement.  Employee engagement is a characteristic found

in successful, innovative teams (Lowe, 2012).  Responses from the focus group and surveys

provided insight into barriers and strengths of this team’s engagement.  The themes further

strengthened previous studies on employee engagement and finding ways to (a) build teams, (b)

improve communication, (c) clarify roles, and (d) move towards a blame-free culture.  The

findings suggest that the team still has more work to complete to reach cohesion.  Finding ways

to foster communication, encourage a culture of safety, and clarifying roles will work towards

increasing engagement. 

ENGAGING TEAMS 38

Appendix A

This is an anonymous survey; please do not put your name on this paper. A number will be assigned randomly.

Number: _________ Pre-assessmentPlease circle the best descriptor of your role:

Administrative Clinical Support Nurse

Team Structure Strongly Agree

Agree Neutral Disagree Strongly Disagree

1 The skills of staff overlap sufficiently so that the work can be shared when necessary.

2 Staff are held accountable for their actions.

3 Staff within my office share information that enables timely decision making by the direct patient care team.

4 My team makes efficient use of resources (e.g., staff, supplies, equipment, information).

5 Staff understand their roles and responsibilities.

6 My team has clearly articulated goals.

7 My team operates with high efficiency.

ENGAGING TEAMS 39

Appendix B

This is an anonymous survey; please do not put your name on this paper. A number will be assigned randomly.

Number: _________ Post-assessment

Please circle the best descriptor of your role:

Administrative Clinical Support Nurse

Team Structure Strongly Agree

Agree Neutral Disagree Strongly Disagree

1 The skills of staff overlap sufficiently so that the work can be shared when necessary.

2 Staff are held accountable for their actions.

3 Staff within my office share information that enables timely decision making by the direct patient care team.

4 My team makes efficient use of resources (e.g., staff, supplies, equipment, information).

5 Staff understand their roles and responsibilities.

6 My team has clearly articulated goals.

7 My team operates with high efficiency.

ENGAGING TEAMS 40

Did you find this helpful?

Would you like to continue doing these activities?

Any other topics you would be interested in covering?

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Appendix C

EMPLOYEE ENGAGEMENT SURVEY: WORK UNIT RESULTS

UNIT Arnold-Warfield Pain Center

# OF RESPONSES 8

ENGAGEMENT SCORE

4.40

TIER 3

STRENGTHS 1. BIDMC conducts business in an ethical manner.

2. BIDMC provides high-quality care and service.

3. I feel like I belong at BIDMC.4. I feel BIDMC is a diverse and inclusive work

environment.5. BIDMC makes every effort to deliver safe,

error-free care to patients.

CONCERNS 1. I am involved in decisions that affect my work.

2. My work unit is adequately staffed.3. This organization makes employees in my

work unit want to go above and beyond.4. The person I report to is a good

communicator.5. My job makes good use of my skills and

abilities.

FOR DISCUSSION- What do you think of these results?- Any Surprises? Any Thoughts?- Is there anything missing that you thought

you’d see on our Strengths or Concerns lists?- What questions do you have about the

results?

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Appendix D

Figure 2. BIDMC IRB approval letter

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Appendix E

ENGAGING TEAMS 45

Appendix F

Figure 4. Email invitation for the Department of Anesthesia to partake in the engagement survey 

ENGAGING TEAMS 46

Appendix G

Table 1

Pre-Intervention Data

Variable Frequency %

Skills overlap sufficiently Strongly agree 3 15

Agree 8 40

Neutral 5 25

Disagree 3 15

Strongly disagree 1 5

Staff held accountable for actions Strongly agree 2 10

Agree 9 45

Neutral 5 25

Disagree 2 10

Strongly disagree 2 10

Share information for decision making Strongly agree 3 16

Agree 11 58

Neutral 3 16

Disagree 2 19

Strongly disagree 0 0

No answer 1

Team makes efficient use of resources Strongly agree 6 32

ENGAGING TEAMS 47

Agree 7 37

Neutral 5 26

Disagree 1 5

Strongly disagree 0 0

No answer 1

Understand roles and responsibilities Strongly agree 4 20

Agree 5 25

Neutral 8 40

Disagree 3 15

Strongly disagree 0 0

Team has clearly articulated roles Strongly agree 3 15

Agree 9 45

Neutral 7 35

Disagree 1 5

Strongly disagree 0 0

Team operates with high efficiency Strongly agree 4 20

Agree 8 40

Neutral 7 35

Disagree 1 5

Strongly disagree 0 0

Note: N=20

ENGAGING TEAMS 48

Appendix H

Table 2

Post-Intervention Data

Variable Frequency %

Skills overlap sufficiently Strongly agree 1 5

Agree 8 48

Neutral 5 26

Disagree 4 21

Strongly disagree 0 0

Staff held accountable for actions Strongly agree 1 5

Agree 8 42

Neutral 7 37

Disagree 2 11

Strongly disagree 1 5

Share information for decision making Strongly agree 3 17

Agree 10 56

Neutral 4 22

Disagree 1 5

Strongly disagree 0 0

No answer 1

Efficient use of resources Strongly agree 5 26

Agree 10 54

ENGAGING TEAMS 49

Neutral 4 21

Disagree 2 11

Strongly disagree 0 0

Understand roles and responsibilities Strongly agree 1 5

Agree 12 63

Neutral 4 21

Disagree 2 11

Strongly disagree 0 0

Team has clearly articulated goals Strongly agree 3 16

Agree 11 58

Neutral 4 21

Disagree 1 5

Strongly disagree 0 0

Team operates with high efficiency Strongly agree 4 21

Agree 4 21

Neutral 10 53

Disagree 1 5

Strongly disagree 0 0

Note: N=19

ENGAGING TEAMS 50

Appendix I

Table 3

Comparison Data

Variable Frequency %

Skills overlap sufficiently Scored higher* 8 47

Scored same** 7 42

Scored lower 2 11

Staff held accountable for actions Scored higher* 8 47

Scored same** 7 42

Scored lower 2 11

Share information for decision making Scored higher* 7 42

Scored same** 6 35

Scored lower 4 23

Efficient use of resources Scored higher* 7 42

Scored same** 7 42

Scored lower 3 16

Understand roles and responsibilities Scored higher* 7 42

Scored same** 4 23

Scored lower 6 35

Team has clearly articulated goals Scored higher* 1 6

Scored same** 13 76

Scored lower 3 18

Team operates with high efficiency Scored higher* 4 23

ENGAGING TEAMS 51

Scored same** 10 59

Scored lower 3 18

Note: N=17.

*=scored higher or remained “strongly agree”

**=scored the same but below “strongly agree”

ENGAGING TEAMS 52

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