Abstract
Objective
To characterize the relationship between learning environments (the educational approaches, cultural context, and settings in which teaching and learning happen) and reliability enhancing work practices (hiring, training, decision making) with employee engagement, retention, and safety climate.
Data source
We collected data using the Learning Environment and High Reliability Practices Survey (LEHRs) from 231 physicians, nurses, and technicians at 67 Veterans Affairs cardiac catheterization laboratories who care for high‐risk Veterans.
Study design
The association between the average LEHRs score and employee job satisfaction, burnout, intent to leave, turnover, and safety climate were modeled in separate linear mixed effect models adjusting for other covariates.
Data collection
Participants responded to a web‐only survey from August through September 2020.
Principal findings
There was a significant association between higher average LEHRs scores and (1) higher job satisfaction (2) lower burnout, (3) lower intent to leave, (4) lower cath lab turnover in the previous 12 months, and (5) higher perceived safety climate.
Conclusions
Learning environments and use of reliability enhancing work practices are potential new avenues to support satisfaction and safety climate while lowering burnout, intent to leave, and turnover in a diverse US health care workforce that serves a vulnerable and marginalized population.
Keywords: high reliability organization, learning health system, Veterans, workforce
What is known on this topic
Health care organizations and their employees benefit from adopting learning health practices.
Learning health practices include the creation of supportive learning environments and use of reliability enhancing work practices.
The impact of learning health practices on workforce engagement and retention are not clear.
What this study adds
This study identified associations between supportive learning environments, reliability enhancing work practices, and engagement, retention, and safety climate in the largest integrated health care system in the United States.
Policy makers can use this evidence to inform program planning and decision making regarding high reliability organization and learning health system transformations.
Facility, department, and unit leaders can use the Learning Environment and High Reliability Practices Survey to provide insights into areas of strength and opportunities for improvement that can lead to meaningful change.
1. INTRODUCTION
Health care organizations and their employees can benefit from adopting learning health practices. 1 A learning health system, per the National Academy of Medicine, harnesses data and analytics to learn from every patient and return the knowledge to clinicians to implement with high reliability (i.e., error free). 2 Transforming health care organizations into learning health systems requires an understanding of learning environments and reliability enhancing work practices to realize the benefits for employees, patients, and population health. 3 , 4 Learning environments are the educational approaches (e.g., online vs. unit‐based trainings), cultural context (e.g., ways of thinking, working), and settings in which teaching and learning happen. 5 Learning environments differ from individual learning for they support individuals to collectively analyze and interpret experiences. Staff who work in supportive learning environments, the ideal learning environment, are encouraged to discuss and debate alternative ways of getting work done, share information about what does and does not work, experiment with new ways of working, and are given time for reflection and improvement. 1 , 6
Health care organizations are increasingly emulating high reliability organizations to improve safety, quality, and efficiency. High reliability organizations are guided by the following five key principles: deference to expertise, reluctance to simplify, sensitivity to operations, commitment to resilience, and preoccupation with failure. 7 High reliability in health care is achieved through a combination of specific reliability enhancing work practices to detect and adapt to unexpected events. Reliability enhancing work practices include hiring employees based on their willingness to learn new skills, the ability to work with others, and the ability to communicate. Additional practices include training programs for new hires in communication and interpersonal skills, informal education sessions, and employee forums to discuss improvements and decisions that affect work and care delivery. 6
Learning environments and reliability enhancing work practices can positively impact staff engagement, peer‐to‐peer interactions, and knowledge sharing by creating processes and forums where people feel safe to speak about concerns or new ways of working. 1 , 6 , 8 The literature has touted the benefits of learning environments and reliability enhancing work practices on quality of care, costs, and patient safety 9 , 10 , 11 , 12 , 13 , 14 , 15 However, these studies are limited to case‐study approaches, small, homogenous samples, and do not include outcomes from a diverse US health care workforce that serves vulnerable and marginalized populations.
In this study, we aim to characterize the relationship between learning environments and reliability enhancing work practices with health care employee engagement, retention, and safety climate in Veterans Affairs (VA) cardiac catheterization laboratories (cath labs). Employee engagement is conceptualized as a positive, work‐related mindset that includes feelings of vigor and dedication and absorption in one's work. 16 Engagement can be viewed as the direct opposite of burnout, for the two constructs are conceptualized as two ends of a single continuum. 16 Retention, or workforce length of employment, is a recruitment strategy, as it avoids the high costs of turnover and loss of institutional memory, provides continuity of care for patients, and contributes to unit and organizational stability. 17 Safety climate reflects team members' perceptions or attitudes about the organizational safety culture in which they work. 16 Theories and studies of engagement suggest that engaged employees have a higher probability of displaying safety‐related attitudes and behaviors that define safety climate. 18 , 19 Additional studies suggest that health care workforce engagement and retention decrease costs associated with illness and injury of patients and lost time from work. 20 , 21
In this study, we examined the 81 VA cath labs staffed by multidisciplinary teams that provide life‐saving coronary procedures to over 40,000 high‐risk and vulnerable veterans annually. In the context of cath labs, supportive learning environments are those where the interventional cardiology team or unit leaders foster psychological safety and encourage open discussion and debate during team meetings, experiment frequently with new ways of working, and provide time and structure for reflection through postprocedural briefings. Cath labs that have adopted reliability enhancing work practices are those that interview and hire staff for their procedural knowledge and their willingness to try new skills and their ability to communicate. These cath labs develop preceptor programs that teach relationship and communication skills and use daily huddles as forums for group learning, problem solving, and decision making.
Guided by the five high reliability organization principles, 7 the Learning Organization Model 10 and the Reliability Enhancing Work Practice and Patient Safety Model, 6 we administered a previously validated survey to VA cath lab staff. 22 Two hypotheses were assessed: whether learning environments that are highly supportive and use reliability enhancing work practices are (a) associated with higher employee engagement and retention and (b) are associated with higher safety climate scores.
2. METHODS
2.1. Data sources
From August through September 2020, we invited 902 physicians, nurses, and technicians at the 81 VA cath labs to participate in the web‐based Learning Environment and High Reliability Practices Survey (LEHRs), an independent survey not affiliated with the annual VA All Employee Survey. All full‐time and part‐time cath lab employees, fellows, consultants, and interventional cardiology physicians identified by cath lab management were eligible to participate. Cath lab employees that did not provide direct patient care were excluded. 22 The LEHRs consist of 27‐items from the Learning Organization Survey‐27, 1 31 items from the Reliability Enhancing Work Practices Survey, 6 10 demographic questions, and 5 employee engagement, retention, and safety climate questions. The survey items, recruitment methods, and psychometric properties of the LEHRs were pilot tested in VA cath labs in 2018. 22
2.2. Variables
The Learning Organization Survey‐27 1 items measure facets of the five high reliability organization principles. These include the supportive learning environment items which ask if people value new ideas, are open to new ways of working, and make time for reflection. The learning practices items ask if newly hired employees receive adequate training, if debriefs occur regularly, and if performance is compared to best‐in‐class organizations. The leadership items ask if management listens attentively and invites input (Data S1).
The Reliability Enhancing Work Practices Survey assesses the presence of reliability enhancing work practices, respectful interaction, mindful organizing, affective commitment, and organizational citizenship behaviors. 6 The reliability enhancing work practice items query hiring practices, communication and relationship trainings, and opportunities for decision making. The respectful interaction items query honesty, trust, and mutual respect within teams. The mindful organizing items query if teams talk openly about mistakes and ways to learn from them. The affective commitment items query feelings of emotional attachment to a team. The organizational citizenship items query behaviors helpful, but not required by an employer, such as making others more productive (Data S1).
Demographic items included age, role, education, gender, race, ethnicity, years in health care, years in VA, years in the cath lab, and supervisory status. Survey nonresponse bias was assessed by calculating the number of respondents divided by the number of staff invited to participate from the 23 Veteran Integrated Service Networks (VISN). Employee engagement was assessed through two items: “Considering everything, how satisfied are you with your job” (5‐point Likert scale, “Very dissatisfied” to “Very satisfied”) and “I feel burned out from my work” (7‐point Likert scale, “Never” to “Everyday”). Retention was assessed through one item: “If I were able, I would leave my current job” (5‐point Likert scale, “Strongly disagree” to “Strongly agree”). Turnover was assessed through one item: “We have had ____ cath lab staff leave in the last 12 months” (“Choose one: 0, 1–2, 4–6, 7+”). Safety climate was assessed through one item: “I would feel perfectly safe being treated in this cath lab” (5‐point Likert scale, “Strongly disagree” to “Strongly agree”).
2.3. Statistical methods
To characterize the national cross‐sectional survey data, we calculated descriptive, correlational, and reliability estimates. To assess the association between average LEHRs score and each of the employee engagement, retention, and safety climate measures, a linear mixed‐effect regression model was fit with average LEHRs score as the response variable, a given measure of interest (e.g., burnout) as the predictor of interest, adjusting for age, gender, race, role, years in VA cath lab, and years in cath lab, plus a random intercept for site. The predictors of main interest were modeled categorically. The dependent variable in all five models was the average LEHRs score, an average of the eight LEHRs scales (Data S1). The reference category for job satisfaction was 3 (neutral), burnout was 1 (never), intent to leave was 3 (neutral), turnover was 0 (no turnover), and safety climate was 3 (neutral). The overall significance of each of the five models was calculated using a type II analysis of variance (ANOVA). Alpha was set at 0.05. Analyses were conducted in R version 4.0.3 (R Core Team 2020). This study was deemed an exempt, nonhuman subjects research study by the Colorado Multiple Institutional Review Board (17‐1153).
3. RESULTS
We received responses from 67 of the 81 (83%) VA cath labs. In total, 232 of 902 eligible employees completed surveys (26% response rate). Of those, 146 (63%) were nurses, 42 (18%) were technicians, 27 (12%) were interventional cardiologists, and 17 (7%) were other (e.g., fellows, electrophysiologists). A supervisory role was reported by 58 (25%) of respondents. The sample was split between females (n = 127; 55%) and males (n = 100, 43%) and was predominantly White (n = 173; 75%). The mean age was 48 with a mean of 21 years in health care, 7 years in the VA, and 5 years in their current cath lab (Table 1). The average VISN nonresponse rate was 73% (Mode: 77) with a range from 85% nonresponse in VISN 17 (VA Heart of Texas Health Care Network) to 41% nonresponse in VISN 20 (Sierra Pacific Network) (Data S2).
TABLE 1.
Respondent demographics
| N (%) | |
|---|---|
| VA cath labs represented (N = 81) | 67 (83) |
| Employees | 232 (26) |
| Role | |
| Nurse | 146 (93) |
| Interventional cardiologist | 27 (12) |
| Technician | 42 (18) |
| Other | 17 (7) |
| Supervisory role | 58 (25) |
| Gender | |
| Female | 127 (55) |
| Male | 100 (43) |
| Race | |
| White | 173 (75) |
| Asian, Pacific Islander | 24 (10) |
| Other | 18 (7) |
| Black | 14 (6) |
| Native American | 3 (1) |
| Mean (years) | |
|---|---|
| Age | 48 |
| Years in health care | 21 |
| Years in VA | 7 |
| Years in current cath lab | 5 |
Abbreviation: VA, Veterans Health Administration.
The highest scoring survey scales across the sample was for affective commitment (mean 5.4, SD 1.4) followed by supportive learning environment (mean 5.3, SD 1.4), mindful organizing (mean 5.3, SD 1.3), respectful interaction (mean 5.1, SD 1.4), and organizational citizenship (mean 5.0, SD 1.5). The lower scoring scales were leadership that reinforces learning (mean 4.8, 1.7), learning processes and practices (mean 4.5, SD 1.4), and reliability enhancing work practices (mean 4.5, SD 1.4) (Table 2). These items assess themes outlined in four of the five high reliability organization philosophies as follows: deference to expertise, commitment to resiliency, sensitivity to operations, and preoccupation with failure. 7
TABLE 2.
Highest and lower scoring LEHR scales and example survey items
| Survey scales | Example survey items (1–7 ascending Likert scale) | Mean (SD) |
|---|---|---|
| Affective commitment | I do feel a strong sense of belonging to my lab | 5.4 (1.4) |
| Supportive learning environment | This lab engages in productive conflict and debate during discussion | 5.3 (1.4) |
| Mindful organizing | When a patient crisis occurs, we rapidly pool our expertise to resolve it | 5.3 (1.3) |
| Respectful interaction | The employees in this lab are trustworthy | 5.1 (1.4) |
| Organizational citizenship | The employees in this lab help make others more productive | 5.0 (1.5) |
| Leadership reinforces learning | My supervisor listens attentively | 4.8 (1.7) |
| Learning processes | This lab regularly conducts postaudits, after‐action reviews, and debriefings | 4.5 (1.4) |
| Reliability enhancing work practices | Employees are hired based on their ability to work with others | 4.5 (1.4) |
Abbreviation: LEHRs, Learning Environment and High Reliability Practices Survey.
Overall, respondents indicated they were satisfied with their job (mean 4.1, SD 1.1) and experienced burnout about once a month or less (mean 3.2, 1.8). They disagreed they would leave their current job if able (mean 2.2, SD 1.3) and reported an average of one nurse (mean 1, SD 0.8), technician and/or nonphysician having left their cath lab in the last 12 months. On average, respondents indicated they would feel safe being treated in their cath lab as a patient (mean 4.2, SD 1.0).
3.1. Learning environments, reliability enhancing work practices, employee engagement, retention, and safety climate
Overall, there was a statistically significant association between the predictors of interest (e.g., job satisfaction) and average LEHRs score. Specifically, higher average LEHRs scores were associated with higher job satisfaction (Chi‐square 260.6, DF 4, p < 0.001), lower burnout (Chi‐square 49.2, DF 6, p < 0.001), lower intent to leave (Chi‐square 85.4, DF 4, p < 0.001), lower cath lab turnover (Chi‐square 23.9, DF 3, p < 0.001) in the previous 12 months, and higher perceived safety climate (Chi‐square 156.8, DF 4, p < 0.001). A regression table for the burnout model is shown in Data S3. Results from all five models are shown graphically in Figure 1.
FIGURE 1.
Mixed effect linear regression models: Average Learning Environment and High Reliability Practices Survey (LEHRs) score as a function of job satisfaction, burnout, intent to leave, safety climate, or turnover. Low: Average LEHRs score below the reference category (dotted line) and with confidence intervals that exclude the reference value. High: Average LEHRs score above the reference category (dotted line) and with confidence intervals that exclude the reference value. Results from five separate linear mixed effect models are presented. Each model has the average of the eight LEHRs scales as the response and includes either (A) job satisfaction, (B) burnout, (C) intent to leave, (D) safety climate, or (E) turnover as the predictor of interest plotted on the x‐axis. Each model also adjusted for age, gender, race, role, supervisor status, time in VA cath lab (dichotomized at 3 years) and time in cath lab (dichotomized at 3 years) and a random intercept for site
4. DISCUSSION
In this national survey study, cath lab learning environments that were perceived as highly supportive and used reliability enhancing work practices were associated with higher employee engagement, retention, and safety climate scores. The creation of learning environments and use of reliability enhancing work practices are thus potential new avenues to support positive feelings and achievement of flow at work, retention of valued staff, and patient safety in a diverse US health care workforce that serve a vulnerable and marginalized population. These findings are in alignment with research that demonstrated reliability enhancing work practices, respectful interaction, and mindful organizing can foster highly reliable performance in the form of fewer medication errors and patient falls. 6
The analysis that identified the higher and lower scoring LEHRs items indicated that across cath labs, many staff reported considerable personal meaning from their work, emotional attachment, and a strong sense of belonging to their cath lab team (i.e., affective commitment). The cath labs in this study also reported they engaged in productive conflict and debate during discussion (i.e., supportive learning environments) and rapidly pooled their expertise during crises (i.e., mindful organizing). However, some cath labs indicated that debriefs were not regularly conducted (i.e., learning processes), and employees were not hired based on their ability to work with others (i.e., reliability enhancing work practices). Suggesting there are labs that have integrated best practices, while there are also opportunities for improvement.
Engaged staff are less likely to experience burnout, which is known to negatively impact quality and patient safety. 19 Effective staff engagement interventions 23 , 24 , 25 and characteristics of engaged staff have been identified. 26 It is time for organizations to look beyond individual, deficit‐based interventions that address burnout (e.g., meditation, 27 digital‐based mental health interventions), 23 retention (e.g., continuing education), 28 and specific patient safety issues (e.g., fall prevention programs). 19 Organizations should consider systematic, learning health care‐based interventions, such as hiring and training for the five high reliability principles, 6 , 29 job crafting, 30 relational coordination, 31 , 32 and leadership focused interventions (e.g., coaching). 33 , 34 In practical terms, the individual LEHRs items provide insights into areas of strength and opportunities for improvement that can be presented to teams to prompt discussion. Group interventions to change a team toward learning and high reliability could lead to increased engagement and well‐being, though this requires further research. 24 , 29
This study should be interpreted in the context of several limitations. First, cross sectional data show an association, not causality. Second, the study design of only VA cath labs limits generalizability to only VA cath labs. We do note that our sample was diverse in VA VISNs and occupations. Third, we did not analyze the impact of individual LEHRs items on the outcomes of interest. Future work can explore these relationships in other high‐risk settings. Fifth, we received fewer responses (26% response rate) than the previous study (40% response rate) and a lower response rate than the 2020 VA All Employee Survey (69%). The nonresponse rates across VISNs did not vary greatly. We attribute the low response rate to the larger pool of staff invited to participate in the 2020 versus 2018 study, the absence of national support and incentives that enhance participation in the VA All Employee Survey, and the administration of the survey during the COVID‐19 pandemic. Many cath lab staff were reassigned to other units or were preoccupied with clinical care during COVID‐19 and were not responding to research surveys. 35 Last, we used a self‐reported measure of perceived patient safety versus quantifiable patient outcomes. Though studies have demonstrated positive relationships between safety climate and outcomes at the hospital‐unit level, 6 , 36 use of cath lab patient data would have strengthened this outcome.
In summary, system versus individual methods that support workforce engagement and retention are needed to ensure the well‐being of the health care workforce and patient safety. Implications of this work include the potential for supportive learning environments and reliability enhancing work practices to address the high rates of employee burnout, turnover, and patient safety concerns reported across health care settings. Moving forward, it is important to understand how these environments were created, which practices were implemented in VA cath labs, and if these findings are generalizable across health care settings and populations. This line of inquiry holds potential to identify tangible interventions for health care organizations and teams who seek to transform their work setting into supportive learning environments within high reliability organizations and learning health systems.
CONFLICT OF INTEREST
The authors report no conflict of interest regarding this study.
AUTHOR CONTRIBUTIONS
All authors jointly designed the study, conducted data collection, and drafted the article, reviewed, edited, and approved the final manuscript draft.
Supporting information
Data S1. 2020 Learning Environment and High Reliability Practices Survey in VA Cardiac Cath Labs.
Data S2. Survey nonresponse by VA Veteran Integrated Service Network.
Data S3. Regression Model: Effect of average Learning Environment and High Reliability Practices Survey (LEHRs) scores on burnout.
ACKNOWLEDGMENTS
We would like to thank the VA staff who participated in the survey.
Gilmartin HM, Hess E, Mueller C, et al. Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Health Serv Res. 2022;57(2):385-391. doi: 10.1111/1475-6773.13907
Funding information Dr Heather M. Gilmartin is supported by Career Development Award Number 1IK2HX002587‐01A1 from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development.
The funding organization played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.
DATA AVAILABILITY STATEMENT
Data Access, Responsibility, and Analysis: Dr Heather M. Gilmartin and Mr. Edward Hess had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Heather M. Gilmartin and Mr. Edward Hess of the Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven Care conducted and are responsible for the data analysis. Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request, though will be subject to the stringent data privacy rules of the VA Healthcare System and United States Government.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. 2020 Learning Environment and High Reliability Practices Survey in VA Cardiac Cath Labs.
Data S2. Survey nonresponse by VA Veteran Integrated Service Network.
Data S3. Regression Model: Effect of average Learning Environment and High Reliability Practices Survey (LEHRs) scores on burnout.
Data Availability Statement
Data Access, Responsibility, and Analysis: Dr Heather M. Gilmartin and Mr. Edward Hess had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Heather M. Gilmartin and Mr. Edward Hess of the Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven Care conducted and are responsible for the data analysis. Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request, though will be subject to the stringent data privacy rules of the VA Healthcare System and United States Government.