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. Author manuscript; available in PMC: 2024 Nov 1.
Published in final edited form as: Med Clin North Am. 2023 Jun 30;107(6):963–977. doi: 10.1016/j.mcna.2023.06.009

Healthcare worker engagement in federally qualified health centers and associations with confidence in making healthcare recommendations: Evidence from the Louisiana Community Engagement Alliance

Erin Peacock a,b, Leia Y Saltzman c, Joshua L Denson a, Sara Al-Dahir d, Michelle Wilson a,b, Alecia Cyprian e, Darie Gilliam f, Stephenie Harris g, Katie Parnell g, Diem Nguyen h, Kabrina Smith i, Shondra Williams j, Gary Wiltz k, Keith Winfrey h, LaKeisha Williams d,l, Marie Krousel-Wood a,b,m
PMCID: PMC10948011  NIHMSID: NIHMS1971744  PMID: 37806728

INTRODUCTION

In early 2020, high COVID-19-associated morbidity and mortality coupled with alarming health disparities, the changing COVID-19 landscape and guidelines, widespread uncertainty, and mis/disinformation about COVID-19 preventive strategies1 prompted an urgent need for community-engaged strategies to disseminate accurate, relevant, and timely information about COVID-19. The Community Engagement Alliance (CEAL) was funded by the National Institutes of Health to rapidly engage communities hardest-hit by the COVID-19 pandemic and provide trustworthy, science-based information through active community engagement and outreach.2 Identified early on as a “COVID-19 hotspot” area, Louisiana was one of the initial CEAL awardees and was able to engage quickly through established alliances with federally qualified health centers (FQHCs) and other state-wide community partners. Early Louisiana CEAL (LA-CEAL) efforts focused on identifying and equipping “trusted messengers” to deliver accurate and timely information to support people’s decision-making about COVID-19 vaccination and other preventive strategies.

Widespread trust in healthcare workers as a source of COVID-19 information is well-documented;3–5 yet little is known about the factors associated with healthcare workers’ COVID-19-related actions, attitudes, and recommendations. FQHCs are health centers that provide comprehensive primary care and preventive health services in a designated medically-underserved area or to a medically-underserved population.6 Like other front-line segments of the healthcare sector, FQHCs have encountered multiple challenges during the COVID-19 era, including keeping apace of changing COVID-19 information and guidelines; pivoting resources from other preventive and chronic disease care to COVID-19 testing, vaccination, and treatment; staff shortages due to COVID-19-related absence; and high staff turnover.7 In addition, healthcare workers at FQHCs experience additional stress associated with serving a patient population with poor health outcomes and high exposure to detrimental social determinants of health.8

Since the onset of the COVID-19 pandemic, there has been growing concern regarding healthcare worker burnout across health systems and its impact on health system functioning and achievement of positive patient outcomes.9,10 Using a positive deviance approach that seeks to understand why some individuals do not experience the same negative outcomes experienced by their peers,11 the purpose of this study was to determine modifiable factors associated with work engagement (i.e., lack of burnout) among employees (patient care and non-patient care) of LA-CEAL’s partner FQHCs in Louisiana. Furthermore, associations between being engaged at work and healthcare worker actions (COVID-19 booster uptake) and attitudes (self-efficacy in delivering COVID-19 vaccination information; confidence in strongly recommending adult vaccination) were explored. Differences between those in patient care versus non-patient care roles were explored for insights to inform development of interventions to improve work engagement among healthcare workers. Due to hypothesized race differences in burnout,12,13 differences across Black respondents and those who were not Black were explored.

METHODS

Study population and data collection

A cross-sectional survey was conducted among 472 employees of clinics from eight partner FQHCs throughout Louisiana between October and December 2022. In collaboration with the FQHC leadership, all FQHC employees (both patient care and non-patient care) were invited to participate via an email from the LA-CEAL research team. Questionnaires were self-administered via REDCap following validation of an organizational email address. The study was approved by the Tulane University Institutional Review Board. All human subjects procedures were in accordance with institutional guidelines. Participants provided informed consent and were compensated for participation.

Study measures

Engagement at work

We used the 22-item validated Maslach Burnout Inventory for Medical Personnel14,‡ measuring feelings across three subscales: emotional exhaustion (Cronbach’s alpha = 0.93 in this sample), depersonalization (Cronbach’s alpha = 0.64), and personal accomplishment (Cronbach’s alpha = 0.85). For each subscale, mean scores across subscale items were calculated and then dichotomized into high versus low using critical boundaries based on population norms.15 Participants were categorized into burnout profiles based on high versus low ratings across each subscale:

  • Engaged = low emotional exhaustion, low depersonalization, high personal accomplishment

  • Ineffective = low emotional exhaustion, low depersonalization, low personal accomplishment

  • Overextended = high emotional exhaustion, low depersonalization, personal accomplishment not specified

  • Disengaged = low emotional exhaustion, high depersonalization, personal accomplishment not specified

  • Burnout = high emotional exhaustion, high depersonalization, personal accomplishment not specified

Finally, burnout profiles were dichotomized as “engaged” versus other (i.e., ineffective, overextended, disengaged, and burnout).

Potential factors

The survey captured demographics (race, gender, age, residential zip code, work role, years in work role), mental health history, resilient coping, spirituality, social support, and organizational culture. Race was dichotomized as Black versus not Black. Residential zip codes were matched to data in the Federal Office of Rural Health Policy data files16 to determine rural versus not rural residence. Healthcare work role was collected using pre-defined categories (administrator, dentist, medical assistant, nurse, nurse practitioner, outreach staff, patient support staff, pharmacist, physician, physician assistant, other); all responses, including open-ended “other” responses, were grouped into patient care (non-provider clinical roles, e.g., nurses, medical assistants, dental assistants, pharmacy technicians; and providers, e.g., nurse practitioners, physicians, dentists, pharmacists, and licensed therapists) versus non-patient care (administrators and non-clinical personnel, e.g., front desk, billing) roles. Symptoms of depression and anxiety were measured using the 2-item Patient Health Questionnaire (PHQ-2)17 and 2-item Generalized Anxiety Disorder (GAD-2),18 respectively. Resilient coping was measured using the 4-item Brief Resilient Coping Scale19 and categorized per published scoring criteria into low/medium versus high resilient coping. Spirituality was measured using 6 items chosen from the 22-item Spirituality Scale;20 participants falling in the highest tertile of the distribution of mean scores across items were categorized as having high spirituality. Social support was measured using the 12-item Multidimensional Scale of Perceived Social Support21 and categorized into low/moderate versus high social support using published scoring guidelines. Organizational culture was measured using the 22-item Practice Culture Assessment22 across three domains: Change Culture (collaboration on quality improvement and problem resolution), Work Culture (positive and productive work environment), and Chaos (instability and disruption).

COVID-19 related actions and attitudes

Three outcomes related to healthcare workers’ COVID-19-related actions/attitudes were measured. COVID-19 booster uptake was measured using a single survey item, “Have you received at least one COVID-19 booster shot?” Self-efficacy was measured using a 5-point Likert response to de novo questions (presented in Figure 1) about confidence in delivering information about COVID-19 vaccination (e.g., engaging people in conversations about why they are hesitant to get vaccinated, answering questions about child vaccination) (Cronbach’s alpha in this sample = 0.93). A mean score across all eight items was computed and high self-efficacy was defined as the highest tertile of the distribution of summary scores. Finally, confidence in recommending the vaccine in adults was defined as a response of “somewhat” or “very” confident to the question, “How confident are you in strongly recommending to an adult that they get vaccinated against COVID-19?”

Statistical analysis

Participant characteristics were summarized using proportions or means and standard deviations as appropriate. Design-corrected Pearson’s chi-squared and simple linear regression models with robust standard errors to account for clustering at the FQHC level were used to test for differences in participant characteristics and MBI profile across role (non-patient care versus patient care) and race (Black versus not Black). Multivariable logistic regression with robust standard errors was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for being engaged at work. Healthcare worker role- and race-stratified models, respectively, were used to identify potential differences between participants in non-patient care roles versus patient care roles, and Black participants versus those who were not Black. Separate multivariable logistic regression models with robust standard errors explored the association between being engaged at work and the three COVID-19-related actions/attitudes, overall and stratified by healthcare worker role (non-patient care versus patient care) and race (Black versus not Black). Effect modification by healthcare worker role and race was tested by including an engaged x role or engaged x race interaction term in overall models and role- and race-stratified results were presented. All analyses were done using Stata 14.2 (StataCorp, College Station, TX). Figure 2 was created using R 3.4.3 (R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

Participant characteristics

Participant characteristics are presented in Table 1. The sample was 54.2% Black, 94.7% women, and 33.8% rural, with a mean age of 42.8 years (SD 11.8). The “not Black” sample was made up of 196 participants identifying as White, 4 participants identifying as Asian, 1 participant identifying as American Indian/Alaska Native, and 5 participants identifying as having more than one race. Patient care employees made up 51.1% of the sample, including non-provider clinical roles (33.1%) and providers (17.9%), with the other 48.9% in non-patient care roles (administrators (7.5%) and non-clinical personnel (41.5%)). On average, participants had been working in their role for 10.1 years (SD 9.2) and 19.1% indicated experiencing symptoms consistent with depression or anxiety.

Table 1.

Participant characteristics, LA-CEAL Trusted Messenger survey, October-December 2022

Overall (n=472) By healthcare worker role By race
Non-patient care role
(n=229)		 Patient care role
(n=239)		 p-value Not Black (n=206)
% (n)		 Black
(n=244)
% (n)		 p-value
Black, % (n) 54.2 (244) 61.8 (134) 46.3 (106) 0.066 -- -- --
Woman, % (n) 94.7 (445) 93.9 (214) 95.4 (228) 0.477 94.2 (194) 95.0 (230) 0.727
Age, Mean (SD) 42.8 (11.8) 43.2 (12.1) 42.4 (11.6) 0.633 42.4 (11.9) 43.1 (11.8) 0.431
Rural, % (n) 33.8 (158) 37.2 (84) 31.2 (74) 0.378 40.8 (84) 29.6 (71) 0.147
Patient care role, % (n) 51.1 (239) -- -- -- 59.7 (123) 44.2 (106) 0.066
Years in work role, Mean (SD) 10.1 (9.2) 8.7 (8.3) 11.5 (9.9) 0.043 10.0 (9.8) 10.2 (8.8) 0.731
Symptoms of depression/anxiety, % (n) 19.1 (90) 21.4 (49) 17.2 (41) 0.329 22.3 (46) 15.2 (37) 0.056
High resilient coping, % (n) 37.6 (176) 37.6 (85) 37.7 (90) 0.993 27.8 (57) 45.2 (109) 0.004
High spirituality, % (n) 29.5 (139) 25.8 (59) 33.5 (80) 0.031 27.2 (56) 31.6 (77) 0.204
High social support, % (n) 75.9 (358) 72.9 (167) 78.7 (188) 0.130 81.6 (168) 70.5 (172) 0.056
Change culture score, Mean (SD) 66.9 (22.6) 70.4 (22.2) 63.5 (22.3) 0.010 65.2 (21.8) 68.3 (23.5) 0.374
Work culture score, Mean (SD) 64.1 (21.3) 66.2 (21.3) 62.0 (21.0) 0.009 62.9 (19.5) 65.3 (22.6) 0.349
Chaos score, Mean (SD) 39.2 (21.4) 37.9 (21.4) 40.7 (21.4) 0.293 42.0 (20.2) 37.3 (21.6) 0.149
Engaged, % (n) 36.9 (174) 31.0 (71) 43.1 (103) 0.005 36.9 (76) 38.1 (93) 0.756
Received COVID-19 booster, % (n) 47.6 (203) 45.6 (94) 49.8 (108) 0.455 36.8 (64) 56.2 (131) 0.009
High self-efficacy for delivering COVID-19 vaccination information, % (n) 31.1 (147) 25.3 (58) 36.8 (88) 0.011 19.9 (41) 40.2 (98) 0.015
Confidence in recommending vaccine, % (n) 44.2 (208) 38.9 (89) 49.2 (117) 0.038 35.9 (74) 51.6 (126) 0.007
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LA-CEAL – Louisiana Community Engagement Alliance; SD – standard deviation; BOLD-P<0.05

Participants in patient care roles were more likely than those not in patient care roles to have high spirituality (33.5% versus 25.8%, p=0.031), to be engaged at work (43.1% versus 31.0%, p=0.005), to have high self-efficacy in delivering COVID-19 vaccination information (36.8% versus 25.3%, p=0.011), and to be confident in recommending adult vaccination (49.2% versus 38.9%, p=0.038). Compared to those in non-patient care roles, those in patient care roles also had served longer in their roles on average (11.5 years (SD 9.9) versus 8.7 years (SD 8.3), p=0.043) and had lower average Change Culture and Work Culture scores (Change Culture: 63.5 (SD 22.3) versus 70.4 (SD 22.2), p=0.010; Work Culture: 62.0 (SD 21.0) versus 66.2 (SD 21.3), p=0.009). Black participants were more likely than participants who were not Black to have high resilient coping (45.2% versus 27.8%, respectively; p=0.004), to have received a COVID-19 booster shot (56.2% versus 36.8%, respectively; p=0.009), to report high self-efficacy in delivering COVID-19 vaccination information (40.2% versus 19.9%, respectively; p=0.015), and to report confidence in strongly recommending adult vaccination against COVID-19 (51.6% versus 35.9% confident, respectively; p=0.007).

Work engagement

The mean scores for the three MBI subscales were 1.54 (SD 1.40) for emotional exhaustion, 0.66 (SD 0.91) for depersonalization, and 4.12 (SD 1.45) for personal accomplishment, translating into 16.3% of the sample with high emotional exhaustion, 4.5% with high depersonalization, and 58.3% with low personal accomplishment. Summarizing across subscales, 36.9% of the sample had an engaged profile versus 46.0% ineffective, 12.7% overextended, 0.9% disengaged, and 3.6% burnout (Table 2). Burnout profiles differed across healthcare worker role (p=0.030), with a higher percent of those in patient care roles than non-patient care roles categorized as engaged (43.1% versus 31.0%) and a lower percent categorized as ineffective (38.5% versus 52.8%).

Table 2.

Maslach Burnout Inventory‡ profiles, LA-CEAL Trusted Messenger survey, October-December 2022

Profile Emotional exhaustion Depersonalization Personal accomplishment Overall (n=472)
% (n)		 By healthcare worker role By race
Non-patient care role
(n=229)
% (n)		 Patient care role (n=239)
% (n)		 Not Black (n=206)
% (n)		 Black
(n=244)
% (n)
Engaged Low Low High 36.9% (174) 31.0 (71) 43.1 (103) 36.9 (76) 38.1 (93)
Ineffective Low Low Low 46.0% (217) 52.8 (121) 38.5 (92) 42.2 (87) 49.6 (121)
Overextended High Low High or Low 12.7% (60) 11.8 (27) 13.8 (33) 16.0 (33) 9.4 (23)
Disengaged Low High High or Low 0.9% (4) 1.8 (4) 0 (0) 0.5 (1) 0.8 (2)
Burnout High High High or Low 3.6% (17) 2.6 (6) 4.6 (11) 4.4 (9) 2.1 (5)
p-value 0.030 0.095
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‡

Copyright ©1981, 2016 by Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com

LA-CEAL – Louisiana Community Engagement Alliance

Factors associated with engagement at work

In the fully adjusted model (Table 3), those in patient care roles had higher odds of being engaged than those in non-patient care roles (aOR=1.74, 95% CI 1.22, 2.49). Those with high (versus low/medium) resilient coping, high (versus low/medium) spirituality, and high (versus low/moderate) social support had higher odds of being engaged (aOR=2.87, 95% CI 1.96, 4.22; aOR=1.60, 95% CI 1.07, 2.40; aOR=2.35, 95% CI 1.46, 3.78; respectively). Reporting symptoms of depression/anxiety was associated with lower odds of being engaged (aOR=0.50, 95% CI 0.31, 0.81). Chaos was associated with lower odds of being engaged (aOR=0.96, 95% CI 0.94, 0.99).

Table 3.

Factors associated with work engagement in federally qualified health centers, overall and by healthcare worker role and race

Overall (n=394)
Adjusted OR (95% CI)		 By healthcare worker role By race
Non-patient care role
(n=189)
Adjusted OR (95% CI)		 Patient care role (n=203)
Adjusted OR (95% CI)		 Not Black (n=189)
Adjusted OR (95% CI)		 Black (n=207)
Adjusted OR (95% CI)
Black 0.94 (0.70, 1.26) 1.49 (0.65, 3.43) 0.82 (0.48, 1.39) -- --
Woman 1.17 (0.56, 2.42) 3.49 (0.34, 35.82) 0.77 (0.33, 1.77) 0.97 (0.31, 3.00) 1.82 (0.70, 4.74)
Age 1.01 (0.98, 1.05) 1.02 (0.99, 1.05) 1.01 (0.96, 1.07) 1.02 (0.96, 1.08) 1.01 (0.99, 1.03)
Rural 1.24 (0.89, 1.71) 1.79 (0.95, 3.35) 1.09 (0.38, 3.14) 1.27 (0.66, 2.45) 1.40 (0.70, 2.81)
Patient care role 1.74** (1.22, 2.49) -- -- 2.39** (1.33, 4.29) 1.31 (0.68, 2.51)
Years in work role 0.98 (0.95, 1.02) 0.95* (0.91, 1.00) 0.99 (0.94, 1.03) 0.99 (0.93, 1.05) 0.97 (0.94, 1.00)
Symptoms of depression/anxiety 0.50* (0.31, 0.81) 0.93 (0.55, 1.58) 0.25* (0.07, 0.95) 0.55 (0.28, 1.08) 0.44 (0.15, 1.26)
High resilient coping 2.87*** (1.96, 4.22) 6.03** (2.59, 14.01) 1.81 (0.84, 3.89) 2.35** (1.35, 4.11) 3.47*** (2.15, 5.61)
High spirituality 1.60* (1.07, 2.40) 1.45 (0.60, 3.48) 1.52 (0.70, 3.32) 1.49 (0.48, 4.67) 1.69 (0.81, 3.50)
High social support 2.35** (1.46, 3.78) 1.88 (0.78, 4.55) 3.16** (1.76, 5.68) 3.31* (1.35, 8.14) 1.93* (1.14, 3.28)
Change culture score 0.99 (0.97, 1.00) 0.99 (0.98, 1.01) 0.98 (0.95, 1.02) 0.99 (0.96, 1.03) 0.98 (0.94, 1.02)
Work culture score 1.02 (1.00, 1.04) 1.03* (1.00, 1.05) 1.02 (0.98, 1.06) 1.01 (0.99, 1.03) 1.03 (0.99, 1.07)
Chaos score 0.96** (0.94, 0.99) 0.97* (0.94, 0.99) 0.96* (0.93, 0.99) 0.97 (0.94, 1.00) 0.96* (0.93, 0.99)
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OR – odds ratio; CI – confidence interval

All models included all variables listed in table (minus stratifying variable for stratified models)

***

p<0.001,

**

p<0.01,

*

p<0.05

Healthcare worker role and race-stratified models are also presented in Table 3. Chaos score was negatively associated with work engagement among those in non-patient care roles (aOR=0.97, 95% CI 0.94, 0.99) and patient care roles (aOR=0.96, 95% CI 0.93, 0.99). Additional factors associated with engagement among those in non-patient care roles were years in work role (aOR=0.95, 95% CI 0.91, 1.00), high resilient coping (aOR=6.03, 95% CI 2.59, 14.01), and work culture score (aOR=1.03, 95% CI 1.00, 1.05), while high social support was associated with higher odds of engagement (aOR=3.16, 95% CI 1.76, 5.68) among those in patient care roles. Being in a patient care role was associated with work engagement among participants who were not Black (aOR=2.39, 95% CI 1.33, 4.29). High resilient coping and high social support were associated with being engaged in participants who were not Black (Coping: aOR=2.35, 95% CI 1.35, 4.11; Social support: aOR=3.31, 95% CI 1.35, 8.14) and Black participants (Coping: aOR=3.47, 95% CI 2.15, 5.61; Social support: aOR=1.93, 95% CI 1.14, 3.28). Among Black participants, Chaos score was negatively associated with being engaged (aOR=0.96, 95% CI 0.93, 0.99).

Association between work engagement and COVID-19 related actions and attitudes

Overall, 47.6% of participants had received a COVID-19 booster and 44.2% were confident in strongly recommending adult COVID-19 vaccination. Percent of participants confident in delivering other COVID-19 vaccination information ranged from 52.4% for answering questions about adult vaccination to 25.2% for strongly recommending to a parent that they get their child under age 5 vaccinated against COVID-19 (Figure 1). Confidence was higher among those in patient care roles versus non-patient care roles for all messages, though the difference did not reach statistical significance for the two messages related to recommending pediatric vaccination.

Figure 1. Percent of respondents at least somewhat confident in delivering COVID-19 vaccination information (n=472).

Figure 1.

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p-value from design-corrected Pearson’s chi-squared test comparing those in non-patient care versus patient care role

Having an engaged profile was associated with higher odds of being confident in recommending adult vaccination (aOR=1.64, 95% CI 1.02, 2.64) (Figure 2). The association was stronger for Black participants (aOR=2.38, 95% CI 1.36, 4.18) than participants who were not Black (aOR=1.05, 95% CI 0.38, 2.90) and for those in non-patient care roles (aOR=2.16, 95% CI 1.13, 4.14) versus patient care roles (aOR=1.29, 95% CI 0.81, 2.05). There was no association between being engaged and receiving a COVID-19 booster (Overall: aOR=0.98, 95% CI 0.53, 1.83). Being engaged was associated with having high self-efficacy in delivering COVID-19 vaccination information for Black participants only (aOR=1.91, 95% CI 1.03, 3.52).

Figure 2. Overall and subgroup associations between work engagement and COVID-19-related actions and attitudes among healthcare workers in federally qualified health centers.

Figure 2.

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OR – odds ratio; CI – confidence interval; ***p<0.001, **p<0.01, *p<0.05

All models adjusted for race, gender, age, rural residence, patient care role, time in role, symptoms of depression or anxiety minus the stratifying variable

p-interactions from overall models with engaged x patient care or engaged x race interaction term

DISCUSSION

In our sample of healthcare workers in Louisiana FQHCs, fewer than 40% of our sample were categorized as “engaged” at work (low emotional exhaustion, low depersonalization, and high personal accomplishment). Engagement was lower among those in non-patient care roles (31.0%) versus patient care roles (43.1%). Several potentially modifiable factors were associated with being engaged, including resilient coping, spirituality, and social support. Negative aspects of organizational culture (specifically, chaos in the work environment) and reporting symptoms of depression or anxiety were associated with lower odds of being engaged. The associations between symptoms of depression/anxiety and lower odds of being engaged, and between high social support and higher odds of being engaged, were stronger for those in patient care roles versus non-patient care roles, while high resilient coping had a stronger association with work engagement for those in non-patient care versus patient care roles. These findings may have insights for developing and tailoring interventions to improve work engagement for employees in patient care versus non-patient care roles. The association with being engaged for both resilient coping and social support were stronger for Black participants versus those who were not Black. Further research is needed to understand whether interventions to change these and related factors can have positive impacts on healthcare worker engagement, overall and in demographic subgroups.23–27 Notably, nearly half of the sample (46.0%) was categorized as “ineffective”, characterized by low emotional exhaustion, low depersonalization, and low personal accomplishment. What distinguishes “ineffective” from “engaged” individuals is a sense of personal accomplishment at work, raising the possibility that efforts to foster a sense of personal accomplishment in their employees, particularly among those in non-patient care roles who were more likely than those in patient care roles to be categorized as ineffective, could help FQHCs to increase engagement by their staff.

Only 3.6% of the sample met the criteria for burnout. There is wide variability across studies in how burnout is assessed and defined,28 leading to a wide range in burnout prevalence: In their systematic review of prevalence of burnout among physicians, Rotenstein et al. documented 47 distinct definitions of burnout across the 156 studies using the MBI, and burnout prevalence ranged from 0% to 80.5% across studies. Surveys that were conducted in primary care settings in summer 202029 and August 202130 and found a prevalence of burnout of 43% and 56%, respectively, are not comparable to our survey, which was conducted later in the pandemic, used the full version of the MBI, and defined burnout according to published scoring criteria. The low level of burnout in our sample may reflect attrition over the past two years of those most likely to have experienced burnout, self-selection into the survey sample of those least likely to be currently experiencing burnout, and a reluctance among respondents to admit negative feelings about their work or their patients in their survey responses.

With respect to COVID-19-related actions and attitudes, fewer than half (47.6%) had received a COVID-19 booster shot. While higher than statewide figures for Louisiana (as of October 2022, only 23% of Louisiana residents had received a booster),31 this figure is lower than estimates from other studies of healthcare workers.32,33 Low booster uptake is particularly concerning among healthcare workers, leaving these individuals at high risk for infection given workplace exposure, further straining already overextended health systems.34 In addition, latent vaccine/booster hesitancy among healthcare workers may make them less likely to recommend vaccine/booster uptake to those who rely on them for information and advice.35,36 Provider recommendation for vaccination against COVID-19 and other vaccine preventable diseases is strongly associated with patient vaccine acceptance,37,38 highlighting the critical role healthcare workers play in promoting vaccine and booster uptake for vaccine preventable diseases.

With respect to self-efficacy in delivering COVID-19 vaccination information, confidence in delivering various COVID-19 vaccination messages ranged from a high of 52.4% confident in answering questions about adult vaccination to a low of 25.2% confident in strongly recommending childhood (under 5 years) vaccination. Not surprisingly, confidence among those in patient care roles was higher than among those in non-patient care roles, but even among those in patient care, confidence ranged from only 27% confident in recommending childhood (under 5 years) vaccination to 60% confident in answering questions about adult vaccination. Notably, respondents indicated the lowest confidence in the four items related to pediatric vaccination, revealing opportunities for engaging and equipping healthcare workers with information and resources to address this topic. Black respondents were more likely to have received a COVID-19 booster shot, to have high self-efficacy in delivering COVID-19 vaccination information, and to be confident in strongly recommending adult vaccination. Given that Louisiana FQHCs served over 460,000 patients in 2019, two-thirds of whom were categorized as racial and/or ethnic minorities, including 57% Black,39 and race concordance between healthcare workers and their patients may be associated with some positive patient outcomes,40,41 these findings are promising for maintaining the progress Louisiana achieved toward overturning race disparities around COVID-19 mortality through, in part, statewide efforts by LA-CEAL and other groups to address Black-White COVID-19 disparities by actively engaging and informing Black communities about COVID-19 preventive strategies.

This study demonstrated an overall association between being engaged at work and being confident in recommending adult COVID-19 vaccination. Other studies have demonstrated an association between healthcare worker burnout, quality of care, and other organizational and patient outcomes: a recent systematic review found associations between nurse burnout and patient safety, quality of care, nurses’ organizational commitment, nurse productivity, and patient satisfaction.42 In our sample, the association between work engagement and healthcare worker confidence in recommending adult vaccination was stronger for those in non-patient care roles versus patient care and for Black respondents than for those who were not Black. Further research is needed to explore these race and healthcare worker role differences in a larger population of healthcare workers, and to understand whether healthcare worker self-efficacy is associated with patient behaviors (e.g., vaccine/booster uptake) and outcomes.

This study has several strengths, including its timely focus on an important issue impacting the healthcare workforce and its ability to deliver quality healthcare for improved patient outcomes; a statewide diverse sample of FQHC employees; and measurement of a comprehensive set of modifiable social-behavioral factors using validated scales. Findings should be considered in the context of study limitations. Due to the cross-sectional design, causality cannot be determined; for example, rather than a positive organizational culture leading to higher work engagement, it is possible that respondents who are more engaged at work are subsequently more likely to identify positive attributes of the organizational culture. Due to self-selection into the sample and limitation of the sample to one geographic region, results may not be representative of all employees of FQHCs. Participants may have provided socially-desirable responses to some items, particularly those related to organizational culture.

SUMMARY

Among Louisiana FQHC employees, resilient coping, spirituality, and social support were associated with being engaged at work. FQHC employees with symptoms of depression/anxiety (versus without) and those indicating a more chaotic work environment were less likely to have an engaged profile. Being engaged at work was associated with confidence in COVID-19 adult vaccine recommendation. Depressive/anxiety symptoms and social support were more salient factors associated with work engagement for those in patient care versus non-patient care roles, while resilient coping was more salient for those in non-patient care versus patient care roles. More research is needed to understand if interventions that foster resilient coping and social support among healthcare workers and improve organizational culture can increase work engagement by healthcare workers as trusted messengers for COVID-19 and other health issues.

CLINICS CASE POINTS

  • Since the onset of the COVID-19 pandemic, there has been growing concern regarding healthcare worker burnout across health systems and its impact on health system functioning and achievement of positive patient outcomes.

  • This study took a positive deviance approach to explore factors associated with work engagement (i.e., lack of burnout) among FQHC employees. Resilient coping, spirituality, and social support were associated with being engaged at work. FQHC employees who reported symptoms of depression or anxiety, or who perceived more chaos in their work environment were less likely to be engaged at work.

  • Depressive/anxiety symptoms and social support appear to be more salient factors associated with engagement for those in patient care versus non-patient care roles, while resilient coping appears to be more salient for those in non-patient care versus patient care roles.

  • Being engaged at work was associated with confidence in strongly recommending adult COVID-19 vaccination.

  • Further research is needed to develop interventions that change these factors and test if they have positive impacts on healthcare worker engagement and patient outcomes.

Key Points.

  • Healthcare workers are reported to be the most trusted source of information and advice about COVID-19; yet little is known about the factors associated with healthcare workers’ work engagement and its association with COVID-19-related actions, attitudes, and recommendations.

  • Throughout the COVID-19 pandemic, there have been numerous demands on healthcare workers, leading to impacts on work engagement and burnout, which can affect healthcare delivery and patient outcomes.

  • Using a positive deviance approach that seeks to understand why some individuals do not experience the same negative outcomes experienced by their peers, this study aimed to identify potentially modifiable factors associated with work engagement (i.e., lack of burnout) among healthcare workers in federally qualified health centers. In this sample, resilient coping, spirituality, and social support were associated with being engaged at work.

  • Employees with symptoms of depression or anxiety and those perceiving a more chaotic work environment were less likely to be engaged at work.

  • The associations between symptoms of depression/anxiety and lower odds of being engaged, and between high social support and higher odds of being engaged, were stronger for those in patient care roles versus non-patient care roles, while high resilient coping had a stronger association with work engagement for those in non-patient care versus patient care roles.

  • Work engagement was associated with being confident in recommending adult COVID-19 vaccination.

  • Further research is needed to develop and test interventions to improve work engagement to optimize healthcare delivery.

Synopsis.

Throughout the COVID-19 pandemic, there have been numerous demands on primary care practices and providers impacting work engagement and burnout, which can affect healthcare delivery and patient outcomes. We determined potentially modifiable factors associated with work engagement among employees of FQHCs throughout Louisiana. Resilient coping, spirituality, and social support were associated with being engaged at work. FQHC employees perceiving a more chaotic work environment and those with depressive or anxiety symptoms were less likely to be engaged at work. Being engaged was associated with confidence in COVID-19 vaccine recommendation for adults.

Sources of Funding:

Research reported in this NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities publication was supported by the National Institutes of Health under Award Number OT2 HL158287. The authors also receive NIH funding from R01 HL133790 (Krousel-Wood – Multi-PI; Peacock – Study Manager), R01 HL153750 (Krousel-Wood – PI; Peacock – Co-Investigator), R33 AG068481 (Krousel-Wood & Peacock – Co-Investigators), K12 AR084224 (Krousel-Wood – PI; Peacock – Scholar), U54 GM104940 (Krousel-Wood), U54 TR001368 (Krousel-Wood), and 5U54MD007595–14 (Williams). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Disclosure Statement: The authors have nothing to disclose.

‡

Copyright ©1981, 2016 by Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com

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