Secondary Logo

It's all connected! Patient experience and healthy practice environments

Raso, Rosanne, MS, RN, NEA-BC

doi: 10.1097/01.NUMA.0000488855.08582.ce
Feature: CE Connection

Find out how clinical excellence, client satisfaction, and staff engagement intersect: Making the connection can positively impact all three of these goals.

Rosanne Raso is the editor-in-chief of Nursing Management and vice president and CNO at NewYork-Presbyterian/Weill Cornell in New York, N.Y.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 134 additional continuing education articles related to management topics, go to

Earn CE credit online: Go to and receive a certificate within minutes.



Do you have organizational goals this year to improve patient experience? How about additional “people” goals to reduce turnover and increase staff engagement scores? These goals probably have big, audacious targets and you've worked on separate action plans for both. When strategizing our approaches, it's critical to remember that these goals are completely interdependent. Avoid attempting to focus on one over the other—the principles and values for both are fundamentally the same. We're professionally obligated to both our patients and staff; it's all about people and it's all connected.

Much has been written about creating healthy work environments and its effect on nurse satisfaction and patient/clinical outcomes.1 There's also an abundance of literature on what drives a positive patient experience. When you put this research side-by-side, it's eerily similar. Let's explore the interrelatedness of these primary responsibilities of nurse leaders.

Back to Top | Article Outline

Staff engagement

Maslow's hierarchy of needs isn't only for psychology 101 courses. Several authors have used this model to describe employee engagement.2 (See Figure 1.) It's well known that basic physical and safety needs must be met first before we progress on a pyramid to the highest level of self-actualization. For staff members, basic needs include fair compensation and benefits, adequate rest and meal breaks, and the tools and resources to do their jobs. These essentials are dissatisfiers if not met; they only get us to the bottom of the pyramid and aren't motivating by themselves. If met, they may lead to basic satisfaction, but not engagement—the next level on the hierarchy. Defined as a state of emotional involvement or commitment, engagement is the goal. Even better are inspired employees, who are at the top of the pyramid.

Figure 1

Figure 1

To reach the higher levels, we must create environments of work excellence. A 2015 Harvard Business Review (HBR) article showed that employees at their highest level—inspired employees—are unstoppable, with a 225% productivity level.2 These employees are driven by meaning and purpose, find value in the organization's mission, and are enthused by their leaders. At the lower end of the spectrum, dissatisfied employees are only functioning at a 71% productivity level; almost one-third of their working time is completely nonproductive.

The Gallup Organization has researched outstanding workplaces for years.3 2014 results show a disappointing 31% engagement rate, up from 29.6% in 2013. Millennials are the least engaged in their work (28.5%). This isn't a significant difference from the aggregate total, but enough to take a leadership pause to consider how to reach this group. A large portion of the workforce (51%) may be satisfied, but they aren't engaged or at the higher levels of the pyramid. Several health systems are Gallup Great Workplace Award recipients, including Hendrick Health System (nine-time winner) and Adventist Health System (five-time winner). What are they doing differently?

Criteria include high mean employee engagement scores, as well as linkage of those scores to business outcomes. These winners show evidence that engagement and outcomes are connected. Some elements of the “secret sauce” include having leaders as role models, cultivating a no-excuses environment, making sure basics are met, relentlessly supporting teams, and connecting employees to the mission.

Press Ganey has also thoroughly studied employee engagement, uncovering the following drivers: being treated with respect; belief that the organization provides high-quality care; liking the work; basics, such as fair compensation; and resources to give the best care.4 We can visualize Maslow's pyramid providing a consistent picture of the building blocks to engagement/inspiration.

Back to Top | Article Outline

A positive workplace

The “quadruple aim” was introduced in 2015 as an expansion of our nationally mandated Triple Aim for healthcare reform: improved health, enhanced patient experience, and lower costs.5 (See Figure 2.) By adding a positive work environment to the triad, we make the connection to outcomes from the providers' perspective. Without an efficient, supportive workplace, the Triple Aim may not be achievable. It's hard to find disagreement and there's a plethora of literature supporting this concept. The quadruple aim started a firestorm of support for relieving workplace stressors in a multitude of healthcare disciplines.6

Figure 2

Figure 2

It's timely that the second edition of the American Association of Critical-Care Nurses' (AACN) seminal work on healthy work environments was recently published.1 After 10 years of research since the first edition, the AACN's six standards have been revalidated and remain intact. These standards are interrelated and continue to be the bedrock for environments of nursing excellence. Briefly, the standards are:

  1. skilled communication—respectful and open verbal and nonverbal communication
  2. true collaboration—ongoing structured and nonstructured collaboration, including equal partnership between nurse and physician leaders
  3. effective decision making—deliberate and fair processes, including the voices of nurses and patients
  4. appropriate staffing—an effective match between staff competencies and patient needs, including the use of grounded policies, processes, data, and technology
  5. meaningful recognition—ongoing and systematic recognition, including opportunities for growth and development (Recognition is considered an “accelerant for engagement” at some organizations.7)
  6. authentic leadership—organizational support and nurse leader demonstration of implementing and sustaining healthy work environment standards.

Another HBR article identifies six characteristics of a positive work culture:8

  1. caring
  2. providing support, including kindness
  3. avoiding blame
  4. inspiring each other
  5. emphasizing meaning
  6. treating each other with respect.

A positive workplace is described as one that increases employee resiliency and well-being, allowing for improved organizational outcomes, including customer and staff engagement. Many of these characteristics are identical to what our patients want and need: caring, kindness, respect, and meaning. Can you see another connection developing between employee and patient needs? (See Table 1.)

Table 1

Table 1

Based on correlations with survey questions, Press Ganey research found 10 key drivers of nurse engagement, including easily recognizable basic elements of the employee hierarchy of needs and components of the higher levels:4

  1. The organization provides high-quality care.
  2. The organization treats employees with respect.
  3. I like the work I do.
  4. The environment makes employees want to go above and beyond.
  5. The pay is fair.
  6. My job makes use of my skills and abilities.
  7. I have the tools and resources needed.
  8. The organization provides career development.
  9. The organization conducts business ethically.
  10. Patient safety is a priority.

The upper-level drivers of respect, trust, belonging, pride, and recognition are, once again, clearly important. In addition, the theme of teamwork and alignment surrounding the primary goal of patient care came through in Press Ganey's work.

We see the interrelatedness of these characterizations to Maslow's pyramid. We also know that the AACN has linked the quality of practice environments to clinical excellence and patient outcomes, as have The Joint Commission and the American Nurses Association when looking at patient safety.1,9,10 Levels of staff engagement will most likely be present, with the AACN standards, HBR characteristics, Press Ganey drivers, or similar organizationally lived values in place that allow staff members to be the best that they can be.

Back to Top | Article Outline

The client perspective

Now, what do our patients and their families want? Cleveland Clinic's chief experience officer spearheaded a data-driven approach to answer this question and found three top concerns for the facility's patient population: respect, communication among staff, and happy employees.11 The results were primarily about demonstrating concern and caring, sharing information, being informed, listening, and attentiveness. They weren't about food, cleanliness, or wait times. This doesn't mean that we shouldn't address those items, only that they didn't correlate highly. Of course, we're all painfully aware that cleanliness is a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) indicator weighted equally with communication and education. On the other hand, the Gallup Organization has found in its extensive database that cleanliness is in the top tier of factors correlating with top patient HCAHPS ratings.

Back in 1993, the American Journal of Nursing published an article summarizing literature on what patients “really want from their nurses.”12 Topping the list was listening, followed by asking patients what they think, not dismissing concerns, and being treated as a person, respectfully. Last on the list was “let me know you care.” Twenty years later, patient needs remain the same: caring and concern. This isn't rocket science, yet we still struggle with these patient experience basics. Our relationship skills are just as important as our clinical skills.

We have to assume that the HCAHPS indicators developed by the Centers for Medicare and Medicaid Services years ago were based on evidence of what's important to the patient experience. As you know, the domains are nursing and physician communication (listening, respect, courtesy), pain management, medication information, responsiveness, cleanliness/quietness, transitions in care, overall rating, and willingness to recommend. The only answer of any value in public reporting and value-based reimbursement is “always.” The adult, hospital-based HCAHPS indicators have been expanded to ambulatory practices, or CG-CAHPS; pediatrics, or pedi-CAHPS; and others on the horizon, including ED-CAHPS and surgi-CAHPS. Our patients' voices are certainly being heard.

Patient engagement goes further up the pyramid than satisfaction, just as with our workforce. Principles include transparency, patient-centeredness, connectedness, sharing, relationships, access, inclusivity, and teaching self-management.13 Not coincidentally, evidence-based lists of patient satisfaction and engagement values are often thematically the same as what employees need. (See Table 1.) After all, the common denominator is that patients are people and so are our staff members. Aren't you most engaged at work when you're treated respectfully, have a mission in which you believe, feel valued, enjoy meaningful relationships, and in an environment where caring and kindness prevail? Aren't our patients most engaged when they're treated respectfully, valued, and in an environment of caring and kindness? It's all connected.

Back to Top | Article Outline

Links in the chain

So now we know the importance of a healthy work environment and employee engagement, the forces surrounding both, and that the drivers of patient experience are similar in many ways. So how do these principles, which are essentially the foundations for our leadership practice, interrelate? Christine Dempsey, CNO for Press Ganey, has compelling research using the company's 2013 data.4 The organizations with the top 20% of employee engagement scores had HCAHPS results in the 60th to 74th percentile across all domains, whereas those with the lowest 20% had HCAHPS domains in less than the 40th percentile.

In addition, Press Ganey found that components of a healthy practice environment, such as staffing and meal breaks, also correlated with outcomes. This held up in both the nurse listening and responsiveness HCAHPS indicators and clinical outcomes, including unassisted falls, central line-associated bloodstream infections, and stage 2 hospital-acquired pressure ulcers. So, again, we see the clinical excellence aspect of our work related to our workforce efforts.

Further evidence of connectedness is found within the transformative Relationship-Based Care (RBC) model, which has been implemented in numerous organizations with positive clinical, patient, and workforce outcomes.14 The RBC model focuses on the power of relationships among the team, patients, families, and self, and includes infrastructure and a powerful leadership paradigm. Caring practices are the exemplars, inclusive of management, staff, and patients/families.

Another important body of research is within Magnet®-recognized organizations. Magnet recognition symbolizes nursing excellence and an organizational culture of patient-centered collaborative care in which nurses have a strong voice. A standard for nurse satisfaction has to be met to qualify. So how do Magnet organizations fare on the HCAHPS survey? A recent study of 212 Magnet hospitals and 212 non-Magnet hospitals showed that patients in Magnet hospitals reported more frequent positive nurse communication experiences and higher overall ratings.15 Also pertinent is a recently published study, which found that differences in nursing work environment, staffing, and educational levels explained outcome differences in mortality and failure-to-rescue.16 We see that the supportive environment of a healthy workplace yields remarkable results.

Back to Top | Article Outline

Make the connection

The most important point is that the work we do in the traditional buckets of clinical excellence, patient experience, and staff engagement is completely connected. It's the same work. Although different goals may appear on your dashboard, they go together and your interventions can be designed to work for all three. Improving the care environment positively affects patient experience and clinical outcomes—clearly a place to start. Improving systems that result in better patient safety outcomes positively affects the practice environment. Focusing on cultivating relationships helps both the patient experience and the work environment. For example, addressing a clinical concern using a staff-led approach, which includes interventions to foster patient engagement, is a win-win-win in all three areas: employee engagement, patient experience, and clinical excellence.

Authentic leadership is the key. This is your practice and you own it. Enthusiastic and inspirational actions, guidance, and role modeling propel staff members up the pyramid of employee needs. Of course, the environment also has to be healthy for leaders; this isn't always within your circle of control, but certainly within your circle of influence.

If you're truly leading based on the drivers and values outlined here, your scores will follow. Keeping our work connected for patients and staff reaps benefits in outcomes for our workforce and our patients. You can't have one without the other.

Back to Top | Article Outline

INSTRUCTIONS It's all connected! Patient experience and healthy practice environments


  • Read the article. The test for this CE activity is to be taken online at
  • You will need to create (its free!) and login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Williams & Wilkins online CE activities for you.
  • There is only one correct answer for each question. A passing score for this test is 13 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
  • For questions, contact Lippincott Williams & Wilkins: 1-800-787-8985.
  • Registration deadline is August 31, 2018.
Back to Top | Article Outline


Lippincott Williams & Wilkins, publisher of Nursing Management, will award 1.5 contact hours for this continuing nursing education activity.

LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours, the District of Columbia, Georgia, and Florida CE Broker #50-1223. Your certificate is valid in all states.

Payment: The registration fee for this test is $17.95.

Back to Top | Article Outline


1. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016.
2. Garton E, Mankins MC. Engaging your employees is good, but don't stop there.
3. Adkins A. Majority of U.S. employees not engaged despite gains in 2014.
4. Dempsey C. Compassionate connected care for the caregiver: improving the patient experience by improving the caregiver experience. Presentation at AONE 2016, March 2016.
5. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider.
6. Raso R. To the triple aim...and beyond. Nurs Manage. 2015;46(7):6.
7. Proccacino A. Everyday amazing. Presentation at New York Presbyterian Hospital, March 2016.
8. Seppala E, Cameron K. Proof that positive work cultures are more productive.
9. The Joint Commission. Improving worker and patient safety: opportunities for synergy, collaboration and innovation.
10. Pecci AW. ANA to launch “culture of safety” campaign.
12. Messner RL. What patients really want from their nurses. Am J Nurs. 1993;93(8):38–41.
13. Barello S, Graffigna G, Vegni E, Bosio AC. The challenges of conceptualizing patient engagement in health care: a lexicographic literature review.
14. Koloroutis M, Manthey M, Felgen J, et al. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2004.
15. Stimpfel A, Sloane D, McHugh M, Aiken L. Hospitals known for nursing excellence associated with better hospital experience for patients.
16. McHugh MD, Aiken LH, Eckenhoff ME, Burns LR. Achieving Kaiser Permanente quality. Health Care Manage Rev. 2016;41(3):178–188.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.