HEALTHY WORK ENVIRONMENTS: IMPROVING STAFF SATISFACTION AND
EMPLOYEE PRODUCTIVITY IN A NON-TRADITIONAL NURSING WORK
ENVIRONMENT THROUGH EMPLOYEE RECOGNITION
Charles Michael Combs II
A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in
partial fulfillment of the requirements for the degree of Doctor of Nursing Practice in the School
of Nursing.
Chapel Hill
2018
Approved by:
Rebecca Kitzmiller
Carrie Palmer
Molly O’Toole
©2018
Charles Michael Combs II
ALL RIGHTS RESERVED
ii
ABSTRACT
Charles Michael Combs II: Healthy Work Environments: Improving Staff Satisfaction
and Employee Productivity in a Non-Traditional Nursing Work Environment Through Employee
Recognition
(Under the direction of Rebecca Kitzmiller)
Background: Meaningful recognition (MR), one of the six standards outlined by the
American Association of Critical-Care Nurses for creating and sustaining a healthy work
environment, is essential for improving individual and organizational outcomes. Employee
recognition programs (ERPs), a subset of MR, are linked to improved employee performance,
job satisfaction, and employee engagement and motivation. However, little evidence is available
that specifically examines implementation of MR-based ERPs in non-traditional nursing settings
and the resultant impacts.
Purpose: The purpose of this project was to evaluate the effectiveness and feasibility of
implementing a non-monetary, MR-based ERP in a non-traditional nursing setting.
Methods: A pre-post design was used to evaluate the effectiveness and feasibility of a
three-month pilot ERP at improving job satisfaction, productivity, and the overall health of the
work environment in the BlueCross and BlueShield of North Carolina’s Medical Review
department. Recognition was given via three formats: (1) department-wide email blast, (2)
computer-generated recognition certificate, and (3) a star-shaped pin. Job Satisfaction Survey,
Healthy Work Environment Assessment Tool, and departmental productivity data were collected
and analyzed pre- and post-implementation. Employee perceptions data on the effectiveness and
meaningfulness of the ERP were analyzed post-implementation using content analysis.
iii
Results: Significant increases in job satisfaction (t = 2.39, p = 0.02), the health of the
Medical Review work environment (t = 2.16, p = 0.04), and staff productivity (t = 7.96, p = 0.02)
were noted. Participants agreed that the ERP was (1) meaningful (89.7%), (2) easy to use
(92.3%), (3) fair (89.7%), (4) beneficial to the department (87.2%), and (5) should become
permanent (76.9%). Further, 89.7% of participants reported satisfaction with the ERP and the
types of recognition given.
Conclusion: Implementation of an ERP was effective at improving job satisfaction,
productivity, and the overall health of the Medical Review work environment. Employee
recognition represents a powerful tool for leaders to utilize to motivate staff and improve their
working lives. Simple actions, such as sending an email or generating a recognition certificate,
positively impacted staff and increased departmental work performance while still improving job
satisfaction and the health of the working environment.
iv
To all those who helped make this dream possible….I thank you
from the bottom of my heart!
v
ACKNOWLEDGEMENTS
I owe this accomplishment to all my friends and family that stood by me and supported
me along this awesome journey. I wouldn’t have made it very far without your love and support.
I especially want to thank Tim Paschkewitz for always being there, listening to me, and
encouraging me along the way. Thank you for never letting me give up, even though I wanted to
numerous times. Your love and support throughout the DNP program helped me realize my
dreams and I couldn’t have done this without you! I also want to thank Tara Bass for being my
confidant and most of all my friend. You were always available to listen, bounce ideas off of,
and to tell me things would be ok. Your friendship and support throughout the DNP program and
the DNP project were invaluable to me and I can’t thank you enough for everything! I also want
to thank my friend and fellow classmate, Christine Weeks, for her friendship and support
throughout the DNP program. Lastly, I want to thank Alex Robbins and Jennifer Binkley, the
two best friends a guy could have. Thank you for always being there for me when I needed you
and for your love and support throughout this journey.
I owe a huge debt of gratitude to my DNP project committee chair, Dr. Rebecca
Kitzmiller, for her support, guidance, feedback, patience, encouragement, and faith in me
throughout both the DNP program and the DNP project. Dr. Kitzmiller was my teacher, my
adviser, my project chair, my cheerleader, and at times, even my therapist. She was there for me
during both the good and the bad and for that, I will always be truly grateful. Dr. Kitzmiller
helped me take a general idea and mold it into something I am truly proud of. I couldn’t have
done this without you! I also want to acknowledge my DNP project committee members, Dr.
vi
Carrie Palmer and Molly O’Toole. Thank you, Dr. Palmer, for stepping in during my time of
need and for your support and guidance throughout both the DNP program and the DNP project.
Thank you, Molly, for your support in continuing my education and your assistance in
facilitating the implementation of my project. I couldn’t have done this without you both.
I also want to acknowledge all the faculty and staff at the UNC School of Nursing. I
would not be here today without your guidance and support throughout the DNP program. I also
want to acknowledge my professors specifically, for teaching me, providing new learning
opportunities, and instilling in me the skills and knowledge necessary to become a nurse leader
of tomorrow. I want to thank Dr. Julee Waldrop for instilling in me a love of research and for
helping me grow my project idea into what it became. You never wavering support and kindness
were truly special to me. I also want to thank Dr. Mary Lynn for your guidance, support, and
knowledge of data analysis. The skills you instilled in me allowed me to look at data in a
different light and to understand the tools necessary for data analysis. Thank you both for
everything!
I also want to acknowledge BlueCross and BlueShield of North Carolina and my Medical
Review department family. Thank you for allowing me to implement my project and supporting
me in continuing my education. I specifically want to give a shout out to the Medical Review
management team: Bethany Archer, Aaron Hardy, Michelle Woodruff, and Tara Bass. Thank
you for your assistance and support throughout the DNP program and project. I couldn’t have
done this without you. Lastly, I want to specifically acknowledge the first Employee Recognition
Committee: Catina Hodges, Jessica Wilborne, Lisa Bell, Toyoka Davis, and Tracey Cox. Thank
vii
you for your support and assistance throughout project implementation and for acting as project
champions and helping to ensure implementation was successful. I couldn’t have done this
without you!
viii
TABLE OF CONTENTS
LIST OF TABLES ........................................................................................................................ xii
LIST OF FIGURES ..................................................................................................................... xiii
LIST OF ABBREVIATIONS ...................................................................................................... xiv
LIST OF SYMBOLS ................................................................................................................... xvi
CHAPTER 1: INTRODUCTION ................................................................................................... 1
Background ......................................................................................................................... 1
Practice Problem Statement ................................................................................................ 2
Purpose Statement ............................................................................................................... 3
CHAPTER 2: REVIEW OF LITERATURE .................................................................................. 4
Search Strategy ................................................................................................................... 4
Search Results ..................................................................................................................... 4
Healthcare Work Environments .................................................................................. 4
Healthy Work Environments ....................................................................................... 5
Recognition .................................................................................................................. 7
Meaningful Recognition .............................................................................................. 8
Employee Recognition Programs .............................................................................. 10
CHAPTER 3: CONCEPTUAL AND THEORETICAL FRAMEWORK.................................... 12
Lewin’s Theory of Change ............................................................................................... 12
Essential Points of Lewin’s Theory of Change................................................................. 12
Force-Field Analysis .................................................................................................. 13
Three Phases of Change Model ................................................................................. 14
ix
Usefulness and Limitations........................................................................................ 16
CHAPTER 4: METHODOLOGY ................................................................................................ 18
Methods............................................................................................................................. 18
Project Setting and Subjects.............................................................................................. 18
Protection of Human Subjects .......................................................................................... 19
Employee Recognition Program Design ........................................................................... 19
Program Implementation .................................................................................................. 20
Phase One: Pre-implementation ................................................................................ 20
Phase Two: ERP Implementation and Monitoring .................................................... 25
Phase Three: Post-implementation ............................................................................ 26
CHAPTER 5: DATA ANALYSIS ............................................................................................... 28
Results ............................................................................................................................... 28
Demographics Data ................................................................................................... 28
Program Results ......................................................................................................... 30
Job Satisfaction Survey.............................................................................................. 32
Healthy Work Environment Assessment Tool .......................................................... 34
Productivity................................................................................................................ 35
Employee Perceptions ............................................................................................... 37
CHAPTER 6: DISCUSSION ........................................................................................................ 45
Discussion ......................................................................................................................... 45
Job Satisfaction .......................................................................................................... 45
Healthy Work Environment ....................................................................................... 48
Productivity................................................................................................................ 51
Employee Perceptions ............................................................................................... 52
Driving and Restraining Forces ................................................................................. 53
x
Lessons Learned ........................................................................................................ 55
Sustainability ............................................................................................................. 56
Recommendations...................................................................................................... 57
Implications for Research .......................................................................................... 57
Implications for Practice ............................................................................................ 58
Limitations ................................................................................................................. 58
Dissemination ............................................................................................................ 59
Conclusion ........................................................................................................................ 59
APPENDIX A: FORCE-FIELD ANALYSIS OF THE MEDICAL REVIEW
DEPARTMENT............................................................................................................................ 61
APPENDIX B: EMPLOYEE RECOGNITION PROGRAM DESIGN ....................................... 62
APPENDIX C: DEMOGRAPHICS QUESTIONS ...................................................................... 68
APPENDIX D: JOB SATISFACTION SURVEY ....................................................................... 69
APPENDIX E: ADAPTED HEALTHY WORK ENVIRONMENT
ASSESSMENT TOOL ................................................................................................................. 72
APPENDIX F: EMPLOYEE PERCEPTION QUESTIONS ........................................................ 75
APPENDIX G: UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL’S
IRB APPROVAL .......................................................................................................................... 76
REFERENCES ............................................................................................................................. 79
xi
LIST OF TABLES
Table 1. Subject-Generated Identification Code (SGIC) and Question Set.................................. 22
Table 2. Demographic Data ......................................................................................................... 29
Table 3. Awards Received Per Team ............................................................................................ 31
Table 4. Job Satisfaction Survey – Paired Samples t-Test Results and Paired
Samples Statistics .......................................................................................................................... 33
Table 5. Healthy Work Environment Assessment Tool – Paired Samples t-Test
Results and Paired Samples Statistics .......................................................................................... 35
Table 6. The Types of Recognition were Meaningful to Me ......................................................... 37
Table 7. Overall, I was Satisfied with the Employee Recognition Program................................. 38
Table 8. The Employee Recognition Program was Easy to Use................................................... 39
Table 9. The Selection Criteria were Fair to all Participants ...................................................... 40
Table 10. The Employee Recognition Program was Beneficial to the Department ..................... 42
Table 11. The Employee Recognition Program Should Become a Permanent
Addition to the Medical Review Department ................................................................................ 43
Table 12. Mean Scores for Employee Perceptions of the Employee Recognition
Program’s Meaningfulness and Effectiveness .............................................................................. 44
Table D1. Job Satisfaction Scale .................................................................................................. 69
Table D2. Job Satisfaction Subscale Item Numbers ..................................................................... 71
Table E1. Adapted Healthy Work Environment Assessment Tool ................................................ 72
Table E2. Healthy Work Environment Assessment Tool Subscale Item Numbers ........................ 74
xii
LIST OF FIGURES
Figure 1. Average Productivity by Week ..................................................................................... 36
Figure 2. Average Productivity per Team by Week ..................................................................... 36
Figure A1. Force-Field Analysis of the Medical Review Department ......................................... 61
Figure B1. Shining Star Award Nomination Form ....................................................................... 65
Figure B2. Shining Star Award Certificate................................................................................... 66
Figure B3. Star Pin ....................................................................................................................... 67
xiii
LIST OF ABBREVIATIONS
AACN
American Association of Critical Care Nurses
BCBS NC
BlueCross and BlueShield of North Carolina
BCBSNC-MRD
BlueCross and BlueShield of North Carolina Medical Review Department
DNP
Doctor of Nursing Practice
ERC
Employee Recognition Committee
ER
Employee Recognition
ERP
Employee Recognition Program
ERPs
Employee Recognition Programs
FFA
Force-Field Analysis
HWE
Healthy Work Environment
HWEAT
Healthy Work Environment Assessment Tool
HWEs
Healthy Work Environments
IHI
Institute for Healthcare Improvement
IOM
Institute of Medicine
IRB
Institutional Review Board
JSS
Job Satisfaction Survey
MR
Meaningful Recognition
MRD
Medical Review Department
NHSR
Not Human Subject Research
PI
Primary Investigator
SGIC
Subject-Generated Identification Code
xiv
SPSS
Statistical Package for Social Sciences
UNC
University of North Carolina at Chapel Hill
UWEs
Unhealthy Work Environments
xv
LIST OF SYMBOLS
β
Beta Coefficient
M
Mean
p
P-Value (Significance)
r
Correlation Coefficient
SD
Standard Deviation
xvi
CHAPTER 1: INTRODUCTION
Background
Evidence suggests that healthy work environments (HWEs) positively impact employee
satisfaction, recruitment, productivity, retention, and engagement; and are linked to
organizational success and financial viability (Cornett & O’Rourke, 2009; Lowe et al., 2003;
Pearson et al., 2007; Raziq & Maulabakhsh, 2014; Vollers, Hill, Roberts, Dambaugh, & Brenner,
2009). In 2005, the American Association of Critical-Care Nurses (AACN) began a campaign to
improve the working environments of nurses because of the association between work
environment, nurse satisfaction and retention, and patient outcomes. The six essential elements
for creating and maintaining a HWE include: skilled communication, true collaboration,
effective decision-making, appropriate staffing, authentic leadership, and meaningful recognition
(MR) (AACN, 2005). Meaningful recognition, defined as valuing and rewarding work well done,
often occurs through formal employee recognition programs (ERPs) (e.g. supervisor and/or peer
recognition, monetary and/or non-monetary rewards) and is associated with improved
productivity, job satisfaction, and employee engagement and motivation (Akafo & Boateng,
2015; Ali & Ahmed, 2009; Darling, Arn, & Gatlin, 1997; Grochow, 2012; Lefton & Breugger,
2009; Tessema, Ready, & Embaye, 2013; Ulrich et al, 2006; Vollers et al., 2009). Despite the
positive outcomes of MR, and formal ERPs specifically, it remains one of the least researched
and utilized of the HWE standards (Tessema et al., 2013; The Maritz Institute, 2011). Further,
evidence suggests that both MR and ERPs remain underutilized in many healthcare and nonhealthcare organizations (Neckermann & Frey, 2013; Ulrich et al., 2014). Therefore, this Doctor
1
of Nursing Practice (DNP) project will examine the feasibility and effectiveness of an ERP
among staff at a non-traditional nursing work setting, BlueCross and BlueShield of North
Carolina (BCBS NC).
Practice Problem Statement
Lack of a healthy work environment (HWE), defined as safe, supportive, satisfying, and
empowering, results in increased staff turnover, worker stress, increased errors, and greater job
absenteeism (Aiken et al., 2008; Erenstein & McCaffrey, 2007; Heath et al., 2004). Virtual work
environments may further contribute to poor employee experiences due to increased feelings of
professional and social isolation and decreased employee engagement and motivation (Caillier,
2012; Felstead, Jewson, Phizacklea, & Walters, 2006; Kurland & Cooper, 2002; Sardeshmukh,
Sharma, & Golden, 2012). Nurses increasingly work in nontraditional settings, such as call
centers, telehealth, and insurance companies where virtual work is common. Because these
settings and virtual work differ dramatically from more traditional work settings (e.g.,
ambulatory or acute care), nurses may be particularly vulnerable to the negative consequences of
social isolation. Meaningful recognition (MR), one of the six standards outlined by the American
Association of Critical-Care Nurses (AACN) for creating a healthy work environment, examines
how employees are rewarded for the work they do and the value they provide to an organization
(Vollers et al., 2009). Evidence suggests that MR and employee recognition programs (ERPs), a
subset of MR, positively impact productivity, job satisfaction, and employee engagement and
motivation (Akafo & Boateng, 2015; Ali & Ahmed, 2009; Darling, Arn, & Gatlin, 1997;
Grochow, 2012; Lefton & Breugger, 2009; Tessema, Ready, & Embaye, 2013; Ulrich et al.,
2006).
The BlueCross and BlueShield of North Carolina Medical Review department
(BCBSNC-MRD) represents a non-traditional nursing work environment. In this productivity-
2
based environment, the majority of staff work from home with limited daily interactions. Current
BCBSNC-MRD productivity measures indicate that greater than 40% of staff are not fully
productive. Productivity directly impacts overall staff and departmental performance.
Furthermore, recent focus group and survey data (June, 2018) indicated that staff desire
increased recognition and acknowledgment for their work beyond existing monetary incentives.
Feelings of isolation and separation among BCBSNC-MRD staff may contribute to poor
productivity rates and the desire for increased recognition. Therefore, translating the HWE
Meaningful Recognition (MR) standards to this environment through the implementation of an
employee recognition program (ERP) may positively affect employee satisfaction, productivity,
and ultimately improve the overall health of the work environment.
Purpose Statement
The purpose of the project was to evaluate the effectiveness of an ERP to improve staff
satisfaction, productivity, and the overall health of the BCBSNC-MRD work environment.
Questions
Four questions guided the development of this project:
1. How does an ERP effect job satisfaction among BCBSNC-MRD staff?
2. How does an ERP effect overall work environment health within Medical Review?
3. How does an ERP effect Medical Review work productivity?
4. What facilitators and barriers impact ERP implementation at BlueCross and
BlueShield of North Carolina (BCBS NC)?
3
CHAPTER 2: REVIEW OF LITERATURE
Search Strategy
PubMed, CINAHL, Google Scholar, and Business Source Premier databases were
searched using the keywords: healthy work environment, meaningful recognition, employee
recognition program, employee productivity, and staff satisfaction. Inclusion criteria for
screening and full-text review included articles from peer-reviewed journals in the English
language. Articles examining only monetary forms of recognition were excluded. To specifically
target articles related to the AACN HWE framework and standards, a filter was applied to
identify the phrase “healthy work environment”. Keywords were combined to examine the
impacts of ERPs on the outcome measures of productivity and staff satisfaction.
Search Results
Searches produced 317 articles. Following the removal of duplicates and application of
inclusion and exclusion criteria, 62 articles were retained and read in their entirety. Of these, 44
articles met inclusion and exclusion criteria and were included in the review of the literature.
Healthcare Work Environments
Over the past two decades, the Institute of Medicine (IOM) and others focused
extensively on healthcare work environment quality. In 2004, the IOM released Keeping Patients
Safe: Transforming the Work Environment of Nurses, a hallmark report that built upon the
IOM’s earlier works, To Err is Human (1999) and Crossing the Quality Chasm, Keeping
Patients Safe (2001), and highlighted the impacts of nursing work environments on improving
patient safety and overall healthcare quality (IOM, 2004). Subsequently, the American
4
Association of Critical-Care Nurses (AACN) released the AACN Standards for Establishing and
Sustaining Healthy Work Environments: A Journey to Excellence (2016). This report, built upon
10 years of research, “responded to mounting evidence that unhealthy work environments
contribute to medical errors, ineffective delivery of care, and conflict and stress among health
care professionals” (AACN, 2016, p. 1). The AACN proposed six standards essential to creating
and maintaining a HWE: skilled communication, true collaboration, effective decision making,
appropriate staffing, MR, and authentic leadership (AACN, 2005; AACN, 2016). Although
applicable to all work environments, the majority of nurse-focused HWE research targeted
improving the healthcare work environment and increasing job satisfaction, patient care
outcomes, and staff retention in acute care settings (Huddleston, 2015). The importance of the
healthcare work environment on care quality gained further prominence when the Institute for
Healthcare Improvement (IHI) expanded the Triple Aim framework to include a fourth aim
focused on improving the healthcare work environment (Berwick, Nolan, & Whittington, 2008;
Bodenheimer & Sinsky, 2014; Sikka, Morath, & Leape, 2015) in response to “widespread
burnout and dissatisfaction” felt by many healthcare workers and the resultant negative impacts
on patient outcomes (Bodenheimer & Sinsky, 2014, p. 1).
Healthy Work Environments
Prior to 2005, the majority of healthcare research on work environments focused solely
on unhealthy work environments (UWEs). Attributes of UWEs include poor communication,
verbal and physical abuse, lack of respect, inconsistent leadership, mistrust, resistance to change,
and conflicting organizational values, vision, and mission (Heath, Johanson, & Blake, 2004).
UWEs result in increased staff turnover, higher worker stress, increased errors, and greater job
absenteeism (Aiken et al., 2008; Erenstein & McCaffrey, 2007; Heath et al., 2004). Further,
evidence suggests that higher degrees of burnout (r = -0.496, p < 0.01) and job stress (r = 0.151,
5
p = 0.016), characteristics of UWEs, significantly negatively impact productivity (Letvak &
Buck, 2008; Nayeri, 2009).
Although, the definition of a HWE varies, Shirey’s (2006) definition predominates
research. A HWE is “a work setting in which policies, procedures, and systems are designed so
that employees are able to meet the organizational objectives and achieve personal satisfaction in
their environment” (p. 258). A HWE is supportive, productive, joyful, satisfies personal needs,
and allows employees to realize their full potential (Kramer & Schmalenberg, 2008; Shirey,
2006). A HWE represents the cumulative effects of many interconnected variables related to
organization structures and processes that together combine to shape the nursing work
environment (Alspach, 2009).
Healthy work environments impact both individual and organizational outcomes
including job satisfaction, recruitment, productivity, retention, and engagement; and are linked to
the financial success and sustainability of an organization (Bai, 2015; Cornett & O’Rourke,
2009; Lowe et al., 2003; Pearson et al., 2007; Raziq & Maulabakhsh, 2014; Vollers et al., 2009).
Bai (2015) examined the impacts of HWEs on overall job satisfaction and found a statistically
significant correlation (r = 0.53, p < 0.01) between HWEs and job satisfaction. Lowe et al.
(2003) and Raziq & Maulabakhsh (2014) found that HWEs are a statistically significant
predictor of job satisfaction (r = 0.56, p < 0.01 and r = 0.363, p < 0.05 respectively).
Derived from the existing body of HWE literature (from 1990 to 2005), Shirey (2006)
identified four themes characteristic of HWEs. First, everyone is treated fairly and with respect.
Each person provides value and individual concern is apparent. Second, trust exists between
management and their employees. Employees are encouraged to grow within their position and
participate in decision-making. Employee engagement and empowerment is a primary focus.
6
Third, collaboration and communication are inherent in the organizational culture, employees are
valuable assets, and organizational decisions are not based solely on financial gains. Fourth,
HWEs encourage physical and emotional safety. The work environment is familial and
happiness results from teamwork and the organization as a whole (Shirey, 2006).
The majority of HWE research occurred in critical care settings by Ulrich and colleagues
(Huddleston, 2015). In 2006, 2008, and 2013, critical care nurses were surveyed on their
perceptions of their work environment to first gain a baseline understanding of the AACN HWE
standards in practice and then to capture trends (Ulrich et al., 2006; Ulrich et al., 2009; Ulrich et
al., 2014). The 2013 results suggested that the health of critical care nursing work environments
declined as compared to the previous year’s results (Ulrich et al., 2014). The results are
surprising based on continued HWE initiatives but provide evidence that HWEs remain relevant
and deserve attention.
Recognition
Defined as “the acknowledgment, appreciation, or approval of the positive
accomplishments or behaviors of an individual or team” (Tessema et al., 2013, p. 3), recognition
correlates with two basic human needs: the need for a sense of belonging and the need for selfesteem. Employees desire group acceptance and recognition for the work that they do. This
recognition directly supports feelings of competence and mastery of work-related skills (Carter,
2012). Further, recognition represents an essential element of morale and team cohesion (Akafo
& Boateng, 2015; Tessema et al., 2013). Organizations may utilize employee recognition as a
powerful tool for motivation, increasing performance, reducing turnover, improving employee
loyalty, and reinforcing desired behaviors (Tessema et al., 2013). Evidence demonstrates that
improved employee outcomes through recognition leads to improved overall organizational
performance and financial success (Akafo & Boateng, 2015; Tessema et al., 2013).
7
Meaningful Recognition
Meaningful recognition, an essential component of a HWE, goes beyond general
recognition in that MR acknowledges individual behaviors and the resultant impact these
behaviors have on others, ensuring that “feedback is relevant to the recognized situation, and is
equal to the person’s contributions” (Lefton, 2012, p. 331). Therefore, MR represents workplace
feedback that examines how employees’ work contributes to the organization and is rewarded
(Vollers et al., 2009). Meaningful recognition must be individualized and based on the
uniqueness of the recipient (AACN, 2016). When MR lacks congruence, it may be perceived as
disrespectful and viewed as a form of tokenism (AACN, 2016). Effective MR is a continual
process and not a single event and therefore must become engrained in the workplace culture
(AACN, 2005).
Meaningful recognition-based programs contain six elements essential for success
(AACN, 2005; AACN, 2016). First, for recognition programs to achieve effective outcomes and
to maintain sustainability, they must be formalized with detailed processes and structures.
Second, staff education must address the programmatic details and processes for participation.
Third, the MR program must include all organizational levels (from staff to executive level) and
remain consistent regardless of the recipient. Fourth, the MR program must have built-in
processes to ensure recognition methods remain meaningful. Fifth, active participation in the MR
program is expected of all employees. Sixth, the MR program includes methods for regular
evaluation and revision. Combined, these elements help to ensure that MR becomes permanently
engrained within the organizational culture (AACN, 2005; AACN, 2016).
Although understudied, MR research suggests its positive impacts on job satisfaction,
employee commitment, productivity, engagement, and team collaboration and cohesion
(Grochow, 2012; Lefton & Breugger, 2009; Ulrich et al, 2006). Gelsema, van der Doef, Maes,
8
Akerboom, and Verhoeven (2005) found a significant correlation between MR and job
satisfaction (β = 0.23, p < 0.001) and identified managerial support as a significant predictor of
job satisfaction (β = 0.12, p < 0.001) (Gelsema et al., 2005). Ajala (2012) found that MR is the
most significant (M = 3.32) predictor of employee productivity. Further, 79% of respondents
agree that MR was a motivating factor for increased productivity and greater job performance
(Ajala, 2012).
The AACN (2005) states that “recognition of the value and meaningfulness of one’s
contribution to an organization’s work is a fundamental human need and an essential requisite to
personal and professional development. People who are not recognized feel invisible,
undervalued, unmotivated, and disrespected” (p. 32). The AACN further suggests that the
majority of nurses are unsatisfied with the level of recognition they receive in their workplace.
This is of particular importance because 75% of nurse’s report that MR remains a critical
component of a HWE (AACN, 2005; AACN, 2016; Ulrich et al., 2013). Ulrich et al. (2013)
found that, from a sample of 8,444 critical care nurses, respondents reported a significant
decrease (M decrease from 2.77 in 2008 to 2.62 in 2013, p < 0.05) in the level of recognition
they receive based on the value they provide to their healthcare organization. Further, nurses
represented the least engaged of all frontline healthcare staff. Only 50% of nurses from 575
surveyed healthcare organizations agree that (1) they receive recognition for the work they do
and (2) they receive respect from executive-level leadership for the contributions of their
department (Zwickel et al., 2016). The evidence suggests that this lack of MR results from
recognition strategies that lack professional meaning and supports the idea that MR must be
individualized and unique to the person. Therefore, MR strategies must have standardized
9
processes and clear performance guidelines relavent to those being recongized (Zwickel et al.,
2016).
Employee Recognition Programs
Effective ERPs positively impact productivity, job satisfaction, and employee
engagement and motivation, and are linked to improved organizational effectiveness and overall
performance and success (Akafo & Boateng, 2015; Ali & Ahmed, 2009; Darling et al., 1997;
Manzoor, 2012; Shonubi et al., 2016; Tessema et al., 2013). Among non-healthcare employees,
employee recognition is associated with increased job satisfaction and improved motivation (r =
0.92, p < 0.01) (Ali & Ahmed, 2009). Among multinational university students, employee
recognition is a statistically significant predictor of job satisfaction (r = 0.25, p <0.001),
regardless of income level or cultural background (Tessema et al., 2013). Among temporary
employees, employee recognition, given in the form of thank-you cards, significantly increased
performance and productivity (p < 0.01), by as much as 10%, in response to the recognition. This
study highlights that simple, non-monetary forms of recognition may be successful for increasing
employee performance and productivity (Bradler et al., 2016).
Non-monetary forms of recognition are underutilized (Tessema et al., 2013), though they
represent a cost-effective means of improving job satisfaction and employee performance
(Shonubi et al., 2016). Non-financial recognition may be given more frequently, to more
recipients, with generally little or no associated cost. Survey results show that four of the five
most influential employee incentives are non-monetary and that employees rank managerinitiated forms of recognition as the most rewarding and motivating (Luthans, 2000). Simple
gestures such as a handshake or pat on the back are highly meaningful to employees (Tessema et
al., 2013). Data from recent BCBS NC focus groups and surveys (June, 2018) shows that
employees desire recognition and acknowledgment for their work (non-monetary recognition)
10
over monetary incentives. Examples of non-monetary forms of recognition include personal
congratulations, handwritten notes, recognition in public forums, and meetings that acknowledge
successes (Bradler et al., 2016; Luthans, 2000). Although the evidence clearly supports the
benefits of employee recognition, it remains largely underutilized by many organizations
including those the employ nurses (Neckermann & Frey, 2013).
Expanding on the earlier work of Nelson (1995), Luthans (2000) outlines four
characteristics of effective ERPs: timeliness, personal touch, meaningfulness, and reinforcing.
First, recognition should be timely and occur immediately after the desired behavior is noted. A
time lapse between behavior and recognition reduces the inherent value of the recognition.
Second, recognition should be personally delivered as the act of taking time out of one’s busy
schedule to provide recognition adds value in the eyes of the recipient. This is true for both peerto-peer and manager-to-employee recognition. Third, recognition should be meaningful to the
recipient. Therefore, ERPs should capture staff perceptions of value and include systematical
methods for continuing to incorporate recognition methods meaningful to staff. For ERPs to be
effective and for the desired outcomes to be achieved, recognition must be meaningful, sincere,
and valued by the recipient. Fourth, recognition should positively reinforce desired behaviors.
Recognition should not be false or given without merit (Luthans, 2000).
11
CHAPTER 3: CONCEPTUAL AND THEORETICAL FRAMEWORK
Lewin’s Theory of Change
Effective ERP implementation and sustainment require organizational change. Lewin’s
Theory of Change was selected as the theoretical framework for understanding the forces
impacting change (1947). Since change is difficult for individuals and organizations (Society for
Human Resource Management, 2018), Lewin’s Theory provides a reliable foundation for
understanding change and ensuring that change is sustainable.
Essential Points of Lewin’s Theory of Change
Grounded in social psychology, Lewin’s Theory of Change has two major elements:
force-field analysis (FFA) and Three Phases of Change Model (Miner, 2007; Sarayreh, Khudair,
& Barakat, 2013). For this project, FFA was used (1) to examine both the driving forces and
restraining forces impacting change within the Medical Review department (MRD) and (2) to
develop ERP implementation strategies that promoted the driving forces and reduced the
restraining forces of change (Shirey, 2013). Additionally, Lewin’s Three Phases of Change
Model served as the program implementation framework to promote sustainability.
Force-field analysis specifies that before change occurs, the field, or environment, is in a
state of equilibrium between the driving forces and restraining forces for change; Lewin referred
to this state as quasi-stationary social equilibrium (Lewin, 1947; Miner, 2007). Change occurs
when equilibrium is disrupted, by either adding driving forces or reducing restraining forces,
leading to the establishment of a new equilibrium (Miner, 2007). Lewin (1947) describes three
phases of change: unfreezing, moving, and freezing. Unfreezing refers to destabilizing the
12
equilibrium so that past behavior is unlearned and new behavior is accepted (Sarayreh et al.,
2013). Moving represents the transition to a more acceptable level of behavior and involves the
internal struggle to change (Burnes, 2004). Freezing refers to establishing a new equilibrium to
prevent regression back to old behaviors (Burnes, 2004).
Lewin’s Theory of Change offers a step by step approach to project implementation and
the Change Model framework accounts for activities that occur during each phase of change
(Bozak, 2003). The project’s primary investigator (PI) utilized the FFA to determine the forces
impacting change and to develop both change and sustainment strategies. Lewin’s Theory of
Change has been used extensively in nursing for change implementation and is considered a
strategic nursing resource for bringing about organizational change (Shirey, 2013). McGarry et
al. (2012) utilized Lewin’s Theory of Change to promote simulation in child and adolescent
psychiatric nursing settings. Lewin’s Theory of Change has been widely used in organizational
development and ties in well with the corporate nature of the project setting (Burnes, 2004).
Lewin’s theory was selected because it adds organization and a systematic approach to change
implementation, focuses on the importance of engaging frontline staff, and helps to ensure the
project implementation is successful.
Force-Field Analysis
An assessment of BCBSNC-MRD performance metrics and feedback from staff and
management identified the following current state driving forces: decreased morale, engagement,
motivation, job satisfaction, productivity, and work quality. External departments, such as the
claims and customer service areas, are dependent on timely, high quality MRD work. These
external dependencies also serve as driving forces for change. Recognizing that work
performance might be improved through an ERP, BCBSNC-MRD management’s commitment
to the ERP project represents an additional driving force. Restraining forces for change included
13
historical patterns of staff change resistance, poor staff participation in other organizational
programs, lack of financial resources to implement and sustain an ERP, staff’s fear of the
unknown, and potential conflict between an ERP and existing corporate monetary forms of
recognition. For planned change to occur, the driving forces must outweigh the restraining forces
so that a new equilibrium state is reached (Lewin, 1947; Figure A1, Appendix A).
Force-field analysis also includes the concept of change agent, defined as any “individual
or group that undertakes the task of initiating and managing change in an organization”
(Lunenburg, 2010, p. 1). BlueCross and BlueShield of North Carolina extensively uses change
agents; therefore, incorporating a change agent within the project was congruent with current
corporate practices. A change agent promotes the driving forces for change and facilitates the
disruption of the current equilibrium (Kaminski, 2011). Change agent activities increase the
likelihood of achieving the new desired state by providing support throughout each of the three
phases of change and acting as change process experts (Kaminiski, 2011). In addition to the
project PI, change agents were selected from across the MRD teams to aid in facilitating planned
change processes as this strategy was expected to facilitate staff buy-in and promote
implementation success. These change agents served as the ERP recognition committee and
reviewed recognition submissions and selected awardees.
Three Phases of Change Model
During the unfreezing phase, the practice problem or change focus was identified
(Sutherland, 2013). In this preparatory phase, all stakeholders impacted by the change process
were determined (Bozak, 2003). For MRD, stakeholders included medical review analysts,
clinical support specialists, clinical education consultants, and the management team. In order to
build trust and ensure that staff feel secure with the change process, open and honest
communication between change agents and staff was established (Bozak, 2003). The inclusion of
14
frontline staff in planning and decision-making processes fosters empowerment and reduces
internal resistance to change and allows staff to understand that change is beneficial (Sutherland,
2013). The FFA was completed to identify the driving and restraining forces (Bozak, 2003).
Once the forces impacting change were identified, the PI devised strategies to promote driving
forces and reduce restraining forces and included involving the Medical Review staff during
each phase of program implementation, periodically informing staff about project progress,
holding frequent meetings with the staff to foster communication and encourage participation,
and communicating the BCBSNC-MRD management’s commitment to the project with the staff
(Bozak, 2003).
During the moving phase, project planning and implementation occurred. Implementation
of an ERP within the MRD required buy-in by all staff to ensure sustainability. During this
phase, change agents continued to foster group discussion and communication (Bozak, 2003).
Medical Review staff were encouraged to provide feedback on the ERP and devise specific
elements to include in the program. This helped to ensure the program remained relevant and
meaningful to staff. Specifically, staff provided encouragement to the PI and validation in the
selected aspects of ERP. Additionally, staff recommended that email blasts be kept to one per
week to prevent staff disruptions. Active involvement of frontline staff supported project
implementation by establishing a sense of ownership of the project (Sutherland, 2013). It was
crucial during this phase that change agents identified resistance to change and managed it
accordingly. This ensures that the project continued to move forward. Once the ERP was
implemented, change agents offered continued guidance and support to all participants (Bozak,
2003).
15
The freezing phase represented a “period of stability and evaluation” (Bozak, 2003, p. 84)
where project planning and implementation phases were complete. Central to this phase was
ensuring that change remained permanent (Kaminski, 2011). Change agents continued to provide
support to all stakeholders (Sutherland, 2013). Once the change process was complete and the PI
determined stability, the PI began to withdraw from the project. Change agents within the MRD
were entrusted with providing continued assistance and support (Bozak, 2003). Finally,
evaluation and dissemination of the results, successes, and challenges throughout project
implementation and future project plans were discussed (Sutherland, 2013). It is during this time
that the program was evaluated and recommendations on continuation were made.
Usefulness and Limitations
Lewin’s Theory of Change is very useful for program implementation, particularly in
change-resistant environments. It offers a framework for implementing planned change through
the three-step model and allows examination of the forces impacting change via the FFA.
Knowing the forces impacting change allows the PI to design strategies that promote the driving
forces and reduce the restraining forces. This helps to ensure that planned change is successful
and sustainable. The use of change agents helps to ensure program longevity and provides
support and guidance to staff long after the PI has withdrawn.
Four major limitations of Lewin’s Theory have been noted. First, authors argue that
Lewin’s Theory “is too simplistic and mechanistic for a world where organizational change is a
continuous and open-ended process” (Burnes, 2004, p. 992). Second, Lewin’s Theory is only
applicable to incremental or isolated change and does not encompass radical or transformational
level change (Burnes, 2004). Because an ERP is straightforward and does not require radical or
transformational changes, these limitations likely do not apply and Lewin’s Theory remains
applicable. Third, Lewin’s work fails to recognize the importance power and political struggles
16
play in many organizational cultures (Burnes, 2004). To combat this, this project recruited
change agents from across the department. This included both management and frontline staff.
Also, all staff within Medical Review were able to participate and a committee of change agents
decided who to recognize. Fourth, Lewin’s work advocates for “a top-down, management-driven
approach to change” and ignores employee-driven approaches (Burnes, 2004, p. 995). This
limitation was minimized by involving frontline staff throughout project implementation.
17
CHAPTER 4: METHODOLOGY
Methods
This DNP project examined implementation feasibility and ERP effect on job
satisfaction, productivity, and the work environment perceptions among staff from a nontraditional nursing work setting.
Project Setting and Subjects
This project was conducted in the Medical Review department at BCBS NC, a not-forprofit health insurance company headquartered in Durham, North Carolina with major operations
centers in Durham, Winston-Salem, and Fayetteville, as well as an office in Charlotte. BlueCross
and BlueShield of North Carolina served over 3.89 million members and employed over 4,700
employees (BCBS NC, 2018a). Written permission to implement this DNP project was obtained
from BCBS NC on April 26, 2018.
The Medical Review department at BCBS NC consisted of 60 staff members (at the time
of project completion), divided into five teams consisting of 11 to 16 staff members. Job titles
included medical review analysts, senior medical review analysts, dental analysts, clinical
support specialists, clinical education consultants, team leads, a senior divisional compliance
consultant, and a manager. The majority of staff worked from home and all department-wide
meetings were conducted virtually with high attendance. The management team worked both
from home and in-office and had representation in both the Durham and Winston-Salem
operation centers. The Medical Review department was responsible for post-service/pre-payment
18
claim reviews. Review types include medical necessity, pricing, dental, investigational, benefitbased, and high dollar reviews.
Protection of Human Subjects
The DNP project proposal was submitted to the University of North Carolina at Chapel
Hill’s Institutional Review Board (IRB) (IRB# 18-1163) and was classified as Not Human
Subjects Research (NHSR) on May 4, 2018 (Appendix G).
Employee Recognition Program Design
All existing recognition programs in the BCBSNC-MRD were monetary. Most forms of
monetary recognition were private and not known outside the manager and the employee and
were given infrequently (e.g. once a year). The ERP in this project utilized the four
characteristics of effective ERPs outlined by Luthans (2000) as a framework and adapted
strategies used at the University of North Carolina at Chapel Hill (UNC) and the Massachusetts
Institute of Technology’s best practices for designing and maintaining employee recognition
programs (Massachusetts Institute of Technology [MIT], n.d.; UNC, n.d.; Appendix B). These
models were selected for their clarity and detail regarding the activities that occur within each
ERP stage. Further, they represented a solid framework to build upon and adapt to fit the needs
of the MRD.
The ERP design consisted of eight stages:
1. Stage One: Identify the Program’s Purpose
2. Stage Two: Identify the Program’s Goals
3. Stage Three: Determine the Award Theme and the Selection Criteria
4. Stage Four: Form the Employee Recognition Committee
5. Stage Five: Establish Eligibility and Frequency of the Award
6. Stage Six: Define the Nomination Process
19
7. Stage Seven: Determine Recognition Type and Publicity
8. Stage Eight: Conduct Program Monitoring and Evaluation
The project utilized the following non-monetary forms of recognition to increase the
number of people being recognized: email blasts to the department, computer-generated
certificates of recognition, and mailing of small keepsakes, like a gold star pin, to the recipients
as recommended by Luthans (2000). A recognition committee was formed to review and vote on
each recognition submission and met on a weekly basis to ensure that recognition was given
timely and as soon as the desired behavior was noted. As recommended by Luthans (2000),
recognitions were delivered by departmental management and also a committee of their peers, to
enhance meaningfulness. The recognition committee reviewed each submission and assessed
merit based on the submission criteria. This was to ensure that recognition reinforced desired
behaviors and that recognition was not given falsely. Finally, during the evaluation phase,
employees were surveyed to determine if selected non-monetary forms of recognition were
meaningful to them. Based on the results, the forms of recognition may be altered upon project
completion and new forms instituted during the next iteration.
Program Implementation
Program implementation occurred in three phases: pre-implementation (May 2018),
implementation and monitoring (May-August 2018), and post-implementation (AugustSeptember 2018).
Phase One: Pre-implementation
Phase one consisted of all steps prior to ERP implementation. This included garnering
BCBS NC leadership support, change agent recruitment, program design, and gathering preimplementation data. Major milestones during this phase included (1) forming and training of the
employee recognition committee (ERC) members; (2) introducing the ERP to the entire
20
department during a virtual meeting, during which time, MRD staff received a brief overview of
HWEs, MR/ERPs and their benefits, MRD ERP processes, and how to submit the recognition
forms; (3) purchasing necessary supplies (e.g. gold star pins); and (4) collecting baseline
participant demographics, productivity, job satisfaction, and AACN HWE Assessment data
(Appendix B).
Participant Demographics. To describe project participants and explore the differences
between participants, demographics data, including BCBS NC position, length of employment
(both in Medical review and at BCBS NC), education level, and age, were collected via online
Qualtrics self-report survey (Appendix C).
Subject-Generated Identification Code. A six-element Subject-Generated
Identification Code (SGIC) was utilized to link pre- and post-implementation surveys. The SGIC
was collected via online Qualtrics self-survey (Table 1).
21
Table 1. Subject-Generated Identification Code (SGIC) and Question Set
Question Set Stem: What is the…
Example
Code
Answer
Element
First letter of your mother’s first name?
M-Mary
M
First letter of your father’s first name?
F-Frank
F
Number of older brothers (living and deceased)
01-One
01
01-One
01
Number representing the month you were born?
05-May
05
First letter of your middle name (if none, use N)?
A-Ann
A
SGIC
you have?
Number of older sisters (living and deceased) you
have?
Subject-Generated Identification Code
MF010105A
Note. Adapted from Ensuring anonymity by use of subject-generated identification codes, S. P. Damrosch
(1986) & The use of self-generated identification codes in longitudinal research, by L. A. Yurek, J.
Vasey, & D. S. Havens (2008).
Productivity. BlueCross and BlueShield of North Carolina measures employee
performance in two ways: quality of assessment of reviews (not used in this project) and
productivity or the number and complexity of completed reviews. Productivity data were
collected by MRD team leads on a weekly, monthly, quarterly, and yearly basis. Of the five
MRD teams, only three are subject to productivity. Productivity, set by MRD at 95% or greater,
was calculated based on a 6.5-hour productive day. For each 8-hour day, each staff member was
given 1.5 hours of non-productive time for lunch and other breaks and additional non-productive
time added for qualifying events such as meetings, training, etc. Next, each type of review
received a different rate per hour. Review types were divided by team and responsibilities and
included dental, high dollar, Medicare, pricing or individual consideration, investigational, and
22
medical necessity reviews. For nursing staff, a goal of 19.5 items per day or 97.5 items per week
was interpreted as 100% productive. For dental analysts and clinical support staff, a goal of 39
items per day or 195 items per week was interpreted as 100% productive. An Excel spreadsheet,
with embedded formulas was used to enter, calculate, and tabulate the productivity data. These
data were provided by BCBS NC before, during, and following implementation, and used to
assess the impact of the ERP on participants work. During the pre-implementation period,
greater than 40% of staff were not meeting the departmental productivity standard of 95%.
Example productivity calculation. John Doe was a commercial medical review analyst.
Last week, he completed 120 medical necessity reviews. John worked five days last week and
had no additional non-productive time (6.5 x 5 = 32.5 productive hours for the week). To be
100% productive, John should have completed 97.5 reviews (32.5 x 3 [productivity rate per hour
for medical necessity]). Since John completed over his goal, his productivity was 123%
(120/97.5 x 100%).
Job satisfaction. Developed by Spector (1985) for use in human service and nonprofit/public sectors, the Job Satisfaction Survey (JSS) is a widely used tool for measuring
employee satisfaction (Batura, Skordis-Worrall, Thapa, Basnyat, & Morrison, 2016; Spector,
2001). Norms from multiple disciplines (including nursing) and organization types for both
United States and non-United States samples based on research and educational studies utilizing
the JSS are available (Spector, 2011a). Reliability and validity of the JSS have been reported
(Cronbach’s Alpha = 0.91; r = 0.71) (Spector, 1985). The JSS is available for public use under
the following conditions – (1) the JSS is used for educational or research purposes and (2) the
results are disseminated to the creator (Spector, 2011b; Table D1, Appendix D).
23
Job Satisfaction Survey data was collected via an online Qualtrics self-report survey at
baseline and the conclusion of the ERP pilot period. The JSS consisted of 36 items divided into
nine subscales (Table D2, Appendix D). Subscales included pay, promotion, supervision, fringe
benefits, contingent rewards, operating procedures, coworkers, nature of work, and
communication. Participants rated each item on a six-point Likert scale ranging from disagree
very much (1) to agree very much (6). Mean scores for each subscale and the total satisfaction
score were interpreted using the scale of “dissatisfaction” (M ≤ 3.00), “ambivalence” (M = 3.014.00) and “satisfaction” (M > 4.00) (Spector, 1994).
Healthy Work Environment Assessment. Developed by the AACN in 2005 to evaluate
a work environment on the six AACN HWE standards, the Healthy Work Environment
Assessment tool (HWEAT) was used to identify specific areas for workplace improvement and
to evaluate progress towards meeting the HWE standards (AACN, n.d.). The HWEAT data was
collected via an online Qualtrics self-report survey at baseline and following implementation of
the ERP. Per the AACN, “questions and scales have been reviewed for face validity and
administered to two groups of 250 subjects each. Both samples were tested for reliability and
showed internal consistency with identical factor structures and Cronbach's Alpha scores of 0.80
or better” (AACN, n.d., para. 6). Reliability was replicated and convergent and discriminant
validity was established “using well-known surveys as benchmarks to test against the subscales”
(AACN, n.d., para.7).
The HWEAT data was collected via an online Qualtrics self-report survey at baseline and
at the conclusion of the ERP pilot. Because the HWEAT was designed for use in the inpatient
nursing setting, the 18-item tool was adapted for use in the non-clinical BCBS NC environment
(Table E1, Appendix E). The HWEAT consisted of 18 items divided into six subscales (Table
24
E2, Appendix E). The six subscales represent the AACN HWE standards: skilled
communication, true collaboration, effective decision making, appropriate staffing, meaningful
recognition, and authentic leadership (AACN, n.d.). Participants rated each item on a five-point
Likert scale ranging from strongly disagree (1) to strongly agree (6) (AACN, 2015). Mean scores
for each subscale were calculated and interpreted using the scale of “needs improvement” (M =
1.00-2.99), “good” (M = 3.00-3.99), and “excellent” (M = 4.00-5.00) (AACN, n.d.).
Phase Two: ERP Implementation and Monitoring
During phase two, the ERP was implemented and executed over a three-month period.
The ERC met weekly to review recognition submissions and voted based on the selection criteria
(Stage Five, Appendix B). Because recognition should be timely and occur as soon as possible
after the desired behavior was noted, the ERC met weekly. The time lapse between behavior and
recognition reduces its inherent value (Luthans, 2000). For each selected awardee, the following
recognition strategies were employed:
1. Email blast sent to the entire department notifying the staff of the recognition award. The
email blast included the person being recognized, the nominator, and a brief description
of the recognition reason.
2. Shining Star Award certificate was generated and emailed to the employee (Figure B2,
Appendix B).
3. Gold star pin was mailed to the employee or delivered in person (depending if worker
was in office or work-from-home) (Figure B3, Appendix B).
The ERC sent weekly reminders to department staff about the program and the recognition
process to foster participation. Additionally, productivity was monitored per departmental policy
during this phase for trending purposes.
25
Phase Three: Post-implementation
Phase three occurred at the conclusion of the three-month pilot period. During this phase,
participants completed the JSS, HWEAT, and provided perceptions about the ERP and its
meaningfulness via Qualtrics survey. Following data analysis, findings and recommendations
about the future of the program were disseminated via a virtual MRD meeting.
Subject-Generated Identification Code. A six-element Subject-Generated
Identification Code (SGIC) was utilized to link pre- and post-implementation surveys. The SGIC
was collected via online Qualtrics self-survey (Table 1).
Outcomes. Following the three-month program pilot, post-implementation data (e.g.
productivity, HWEAT, job satisfaction) was collected through Qualtrics and analyzed. The
results were disseminated to all stakeholders and recommendations were made about program
effectiveness and continuation.
Employee perceptions of the ERP. Employee perceptions of the effectiveness and
meaningfulness of the ERP were assessed using a six-item Qualtrics questionnaire. Respondents
rated each question using the same six-point Likert scale as the JSS (disagree very much [1] to
agree very much [6]) (Appendix F).
Data analysis. Demographic data were analyzed using descriptive statistics and
frequency distributions. Productivity and survey data were analyzed using descriptive statistics
and Paired t-Tests. Program evaluation data were analyzed using descriptive statistics, frequency
distributions, and content analysis. The Statistical Package for Social Sciences (SPSS) version 25
was utilized to determine:
1. Pre- and post-implementation differences in productivity, HWEAT, and employee
satisfaction using Paired t-Tests.
2. Frequency distributions of program evaluation and demographics data.
26
Dissemination and Recommendations. After data analysis, the results were
disseminated to all BCBS NC stakeholders to include both the Medical Review staff and
management. Based on the results about the effectiveness of the ERP in improving productivity,
job satisfaction, and employee perceptions of the work environment, recommendations about the
continuation of the program and opportunities to improve the ERP in advance of the next
iteration were provided. Of particular interest is the employee’s perception of the types of
recognition given and if changes to the reward selection process were required.
27
CHAPTER 5: DATA ANALYSIS
Results
Fifty-six MRD employees completed the demographic, JSS, and HWEAT preimplementation Qualtrics survey (91.8% response rate). Productivity data on 39 employees were
collected. Due to employee attrition and other factors, 56 MRD employees were eligible for postimplementation data collection. Forty completed post-implementation surveys were returned for
a response rate of 71.43%.
Demographics Data
The typical respondent was 46 years of age (M = 45.75, SD = 9.32), employed 10 years at
BCBS NC (M = 9.77, SD = 8.44), worked eight years in the Medical Review department (M =
7.94, SD = 6.39) as a Medical Review Analyst (57.1%), and possessed a Bachelor’s degree
(35.7%) (Table 2).
28
Table 2. Demographic Data
Demographic Variables
n
%
30-39
16
28.6
40-49
17
30.4
50-59
17
30.4
60-69
3
5.4
No Response
3
5.4
1-5
28
50.0
6-10
5
8.9
11-15
5
8.9
16-20
9
16.1
21-25
2
3.6
26-30
2
3.6
31+
1
1.8
No response
4
7.1
1-5
29
51.8
6-10
8
14.3
11-15
6
10.7
16-20
7
12.5
21+
2
3.6
Age
Years at BCBS NC
Years in Medical Review
29
Demographic Variables
n
%
4
7.1
Clinical Education Consultant
2
3.6
Clinical Support Specialist
4
7.1
Dental Analyst
2
3.6
Manager or Senior Divisional Compliance Consultant
3
5.4
Medical Review Analyst
32
57.1
Senior Medical Review Analyst
8
14.3
Team Lead
3
5.4
No response
2
3.6
High School Diploma
1
1.8
Associate’s Degree
16
28.6
Bachelor’s Degree
20
35.7
Master’s Degree
7
12.5
Other
10
17.9
No Response
2
3.6
No response
Position
Education Level
Note. Percentages may not total 100% due to rounding
Program Results
The ERP pilot ran for three-months from May 16, 2018 to August 14, 2018. During this
time, a total of 61 recognition awards were given (Table 3). There was a total of five teams in the
MRD. The majority of rewards (47.54%) were given by Team 4, the PI’s team. Further, the PI’s
team was the most engaged and participatory of all the MRD teams.
30
Table 3. Awards Received Per Team
Team
n
%
1
7
11.48
2
11
18.03
3
7
11.48
4
29
47.54
5
7
11.48
Recognition was given for numerous reasons. Major themes included assisting one’s peers,
managing urgent work issues and other tasks, assisting the department and other departments
within the company, commitment to one’s own team and the department overall, having
someone’s back, offering help, guidance, or support to someone, and going above and beyond
what was expected. For example, the following recognition was given to staff member XX by
their direct supervisor:
XX is instrumental to the success of the High Dollar team. In addition to completing her
daily assignments and other work functions, XX has many duties and responsibilities that
go above and beyond what is expected of her. Particularly, XX monitors the High Dollar
inventory and reports the High Dollar savings and claims volumes monthly to upper level
management. Gathering this information is very time consuming and often times, XX is
required to do this task outside her normal working hours. This involves querying a
database and cleaning raw data into a form that is usable by all. Furthermore, XX is
always willing to provide data to the leadership team and anyone else when necessary,
taking time out of her busy schedule to ensure this is managed timely. XX is truly a
Shining Star and a great asset to High Dollar, Medial Review, and the company as a
whole.
Another example of recognition was given to staff member YY by a peer on the same team:
YY is so important to the success of senior market medical review. She always makes
herself available to help with difficult reviews or questions. She keeps policies updated
and keeps us advised of changes within Medicare that impact our work. She performs
many functions "behind the scenes" that many are not even aware of and she does not
seek recognition from others. I would not be able to perform my job successfully without
YY’s knowledge and willingness to help whenever asked.
31
Job Satisfaction Survey
The JSS consisted of 36 items divided into nine subscales rated on a six-point Likert
scale ranging from disagree very much (1) to agree very much (6). Mean scores for each
subscale and the total Satisfaction score were calculated and interpreted using the scale of
dissatisfaction (M ≤ 3.00), ambivalence (M = 3.01-4.00) and satisfaction (M > 4.00) per
interpretation instructions (Spector, 1994). The nine subscales included pay, promotion,
supervision, fringe benefits, contingent rewards, operating procedures, coworkers, nature of
work, and communication. To determine if differences existed in the job satisfaction pre- and
post-implementation, a Paired Samples t-Test was performed using SPSS. Significant differences
were noted in the Contingent Rewards (t = 2.21, p = 0.04) and the Communication (t = 2.59, p =
0.02) subscales as well as the total Satisfaction score (t = 2.39, p = 0.02). Otherwise, there were
no significant differences in the remaining seven subscales (Pay, Promotion, Supervision, Fringe
Benefits, Operating Conditions, Coworkers, and Nature of Work).
Overall, the post-implementation means were higher for all subscales and the total
Satisfaction score, except the Fringe Benefits subscale score. Additionally, all mean scores
represented “satisfaction” (M > 4.00) except the pre-implementation Operating Conditions
subscale score (M = 3.84) which represented “ambivalence” (Spector, 1994). Table 4 contains
the JSS Paired Samples t-Test results and the means and standard deviations for each subscale
and the total Satisfaction score.
32
Table 4. Job Satisfaction Survey – Paired Samples t-Test Results and Paired Samples Statistics
Subscale
Pay
Promotion
Supervision
Fringe Benefits
Contingent Rewards
Operating Conditions
Coworkers
Nature of Work
Communication
Total Satisfaction
Pre/Post
M
SD
t
p
Pre
4.75
1.11
1.33
0.19
Post
4.92
1.03
Pre
4.04
1.20
0.63
0.53
Post
4.13
1.28
Pre
5.46
1.00
0.80
0.43
Post
5.57
0.95
Pre
4.54
1.08
-0.95
0.35
Post
4.41
1.10
Pre
4.28
1.02
2.21
0.04
Post
4.66
1.12
Pre
3.84
0.96
1.85
0.08
Post
4.16
0.93
Pre
5.16
0.80
1.82
0.08
Post
5.33
0.69
Pre
5.22
0.77
1.92
0.07
Post
5.38
0.74
Pre
4.55
1.12
2.59
0.02
Post
4.83
0.89
Pre
4.65
0.68
2.39
0.02
Post
4.82
0.67
Note. Mean scores >4.0 represents satisfaction, 3.1 – 4.0 represents ambivalence, ≤3.0 represents
dissatisfaction (Spector, 1994)
33
Healthy Work Environment Assessment Tool
The HWEAT consisted of 18 items divided into six subscales rated on a five-point Likert
scale ranging from strongly disagree (1) to strongly agree (6) (AACN, 2015). Mean scores for
each subscale and the total HWEAT score were calculated and interpreted using the scale of
needs improvement (M = 1.00-2.99), good (M = 3.00-3.99), and excellent (M = 4.00-5.00)
(AACN, 2005). The six subscales included: skilled communication, true collaboration, effective
decision making, appropriate staffing, meaningful recognition, and authentic leadership. To
determine if differences existed in the HWEAT pre- and post-implementation, a Paired Samples
t-Test was performed using SPSS. Significant differences were noted in the Appropriate Staffing
(t = 3.02, p = 0.01) and Meaningful Recognition (t = 3.45, p = 0.002) subscales as well as the
total HWEAT score (t = 2.16, p = 0.04). Otherwise, there were no significant differences for the
remaining four subscales (Authentic Leadership, Skilled Communication, True Collaboration,
and Effective Decision Making)
The post-implementation means were higher for all six subscales and the total HWEAT
score. Additionally, all mean scores represented “good” (M = 3.00-3.99) except the postimplementation Authentic Leadership subscale score (M = 4.02) which represented “excellent”
(AACN, 2005). Table 5 contains the HWEAT Paired Samples t-Test results and the means and
standard deviations for each subscale and the total HWEAT score.
34
Table 5. Healthy Work Environment Assessment Tool – Paired Samples t-Test Results and
Paired Samples Statistics
Subscale
Appropriate Staffing
Authentic Leadership
Skilled Communication
True Collaboration
Effective Decision Making
Meaningful Recognition
Total HWEAT
Pre/Post
M
SD
t
p
Pre
3.68
0.69
3.02
0.01
Post
3.97
0.82
Pre
3.91
0.68
1.26
0.22
Post
4.02
0.69
Pre
3.80
0.83
0.64
0.53
Post
3.87
0.92
Pre
3.62
0.76
0.31
0.76
Post
3.66
0.81
Pre
3.64
0.83
0.96
0.34
Post
3.76
0.82
Pre
3.56
0.84
3.45
0.002
Post
3.92
0.73
Pre
3.70
0.69
2.16
0.04
Post
3.86
0.73
Note. Mean =1.00-2.99 represents Needs Improvement; 3.00-3.99 represents Good; 4.00-5.00 represents
Excellent (AACN, 2005)
Productivity
Productivity was measured throughout project implementation per departmental policies
and standards. To determine if differences existed in productivity pre- and post-implementation,
a Paired Samples t-Test was performed using SPSS. Significant differences were noted in
average staff productivity pre- and post-implementation (t = 7.96, p = 0.02). Average
35
departmental productivity increased by almost 30% throughout program implementation (Pre: M
= 105.11; Post: M = 134.99) (Figure 1).
Productivity Average by Week
Post-Implementation
140.00
Productivity (%)
135.00
130.00
125.00
120.00
115.00
110.00
Pre-Implementation
105.00
100.00
0
2
4
6
8
10
12
14
16
18
Week
Figure 1. Average Productivity by Week
The Medical Review department consisted of three productivity-based teams. See Figure 2 for
the average productivity per team throughout project implementation.
Productivity Average by Team
Team 1
Team 2
Team 3
160
Productivity (%)
150
140
130
120
110
100
90
80
1
2
3
4
5
6
7
8
9
10
Week
Figure 2. Average Productivity per Team by Week
36
11
12
13
14
15
16
17
18
Employee Perceptions
Employee perceptions of the effectiveness and meaningfulness of the ERP were assessed
using a six-item Qualtrics questionnaire. Respondents rated each item using a six-point Likert
scale: disagree very much (1), disagree moderately (2), disagree slightly (3), agree slightly (4),
agree moderately (5), and agree very much (6). Employee perceptions data were analyzed by
SPSS using descriptive statistics. Additionally, qualitative data was gathered by asking staff to
explain why they selected their responses to each item on the questionnaire, these data were
analyzed through content analysis.
Was it meaningful? The first item assessed whether the staff found the ERP and the
types of recognition meaningful. Overall, 89.7% (n=35) of respondents agreed (slightly,
moderately, and very much) that the ERP and the types of recognition were meaningful (Table
6).
Table 6. The Types of Recognition were Meaningful to Me
Response
n
%
Disagree Very Much
0
0
Disagree Moderately
0
0
Disagree Slightly
3
7.7
Agree Slightly
4
10.3
Agree Moderately
10
25.6
Agree Very Much
21
53.8
No Response
1
2.6
Note. Percentages may not total 100% due to rounding
37
Staff explanation of why they selected their responses varied. Overwhelmingly, the comments
were positive (84.21%). For example, one respondent stated:
Being recognized by someone other than just the person you interacted with really made
me feel appreciated and as if I fit into the team/department. Just received email after
email saying 'congratulations' really made me smile for the rest of that day. Also,
printing the certificate out and placing my star on it was another moment of joy that
made me think 'maybe I do fit well here'.
Other common themes that arose were feeling good about oneself, being noticed, being valued,
feeling their work was important and not overlooked, and feeling that peers cared. The negative
comments (15.79% of total comments) mainly surrounded the nomination process:
I felt friends of friends were selected, so then it really didn't matter to me.
Seems the same people were always submitted and recognized.
Requirements for recognition were fairly non-specific. Would have liked more specific
documentation of what made the winners shine.
Were they satisfied? The second item assessed whether staff was satisfied overall with
the ERP. Overall, 89.7% (n=35) of respondents agreed (slightly, moderately, and very much)
they were satisfied with the ERP (Table 7).
Table 7. Overall, I was Satisfied with the Employee Recognition Program
Response
n
%
Disagree Very Much
1
2.6
Disagree Moderately
0
0
Disagree Slightly
1
2.6
Agree Slightly
4
10.3
Agree Moderately
11
28.2
Agree Very Much
20
51.3
No Response
2
5.1
Note. Percentages may not total 100% due to rounding
38
Again, staff explanation of why they selected their responses varied. Overwhelmingly, the
comments were positive (93.75%). For example, one respondent stated:
It was a pleasant surprise to get that kudos when I did something that seemed so small to
me but made a huge difference to someone else.
Other common themes included boosting morale, satisfaction with the ERP overall, fun and
enjoyable way to recognize peers, fairness to all, and being recognized no matter how big or
small the deed was. Only one negative comment was received (6.25% of total comments). It was
related to the weekly email blasts surrounding the award recipients:
On the day the awards were presented, the amount of emails congratulating winners was
somewhat disruptive.
Was it easy to use? The third item assessed whether staff believed the ERP was easy to
use. Overall, 92.3% (n=36) of respondents agreed (slightly, moderately, and very much) that the
ERP was easy to use (Table 8).
Table 8. The Employee Recognition Program was Easy to Use
Response
n
%
Disagree Very Much
0
0
Disagree Moderately
0
0
Disagree Slightly
2
5.1
Agree Slightly
1
2.6
Agree Moderately
13
33.3
Agree Very Much
22
56.4
No Response
1
2.6
Note. Percentages may not total 100% due to rounding
39
Staff explanation of why they selected their responses varied. For this item, the comments were
overwhelmingly positive (95%). One respondent stated:
The nomination form was straightforward and getting to the form was simple with the
link provided.
Another respondent stated:
Every week a link was sent out to give people an opportunity to participate and the
program tied with BCBS core values. Just a few clicks of the mouse and that's all it takes.
Very simple to submit a recommendation.
Common themes included ease of use, self-explanatory, user-friendly, straightforward, and
quick. Only one negative comment was received (5% of total comments). It was related to the
virtual work environment and not knowing their peer’s:
How can you recognize someone when you work from home, and really don't know
people?
Was it fair? The fourth item assessed whether staff believed the selection criteria of the
ERP were fair to all. Overall, 89.7% (n=35) of respondents agreed (slightly, moderately, and
very much) that the ERP was fair to all participants (Table 9).
Table 9. The Selection Criteria were Fair to all Participants
Response
n
%
Disagree Very Much
0
0
Disagree Moderately
0
0
Disagree Slightly
3
7.7
Agree Slightly
3
7.7
Agree Moderately
8
20.5
Agree Very Much
24
61.5
No Response
1
2.6
Note. Percentages may not total 100% due to rounding
40
Staff explanation of why they selected their responses varied. For this item, the comments
overwhelmingly positive (81.82%). One respondent stated:
The program allowed peers to recognize each other for jobs well done and great team
work. Everyone had equal opportunity to be nominated, if they made contributions and
their teammates recognized them.
Another respondent stated:
I feel the selection criteria was fair because it gave all staff members a chance to
recognize their coworkers whether they were on the same team or not.
Other common themes included being able to nominate anyone, fairness to all, universal criteria,
everyone having the same opportunity to be nominated, and everyone being encouraged and able
to participate. Negative comments (18.18% of total comments) surrounded the number of
nominations and awards people received. One respondent stated:
It seemed like the same people were awarded several times in a short span of time... there
should be a limit on how often a person can get awarded.
Another respondent stated that:
At some times felt like popularity contest.
Was it beneficial to the department? The fifth item assessed whether staff believed the
ERP was beneficial to the Medical Review department. Overall, 87.2% (n=34) of respondents
agreed (slightly, moderately, and very much) that the ERP was beneficial to the department
(Table 10).
41
Table 10. The Employee Recognition Program was Beneficial to the Department
Response
n
%
Disagree Very Much
1
2.6
Disagree Moderately
0
0
Disagree Slightly
2
5.1
Agree Slightly
4
10.3
Agree Moderately
11
28.2
Agree Very Much
19
48.7
No Response
2
5.1
Note. Percentages may not total 100% due to rounding
Staff explanation of why they selected their responses varied. For this item, the comments
overwhelmingly positive (94.44%). One respondent stated:
It gave the department the opportunity to recognize each other with no chance of running
out of nominations or recipients. It also allowed the recipient to accept the praise from
the entire department for 'shinning' as well as receive a physical representation of that
praise.
Another respondent stated:
I enjoyed seeing everyone participate, whether it was being recognized or congratulating
others. It's awesome to know what great things are going on in the department!
Other common themes included being able to express personal value to your peers, giving
everyone the opportunity to be appreciated and recognized, boosting morale, feeling good about
yourself, uniting the teams and the department, and allowing staff to feel like they are making a
difference. Only one negative comment was received (5.56% of total comments). This
respondent stated that:
It caused more of a divide.
42
Should the ERP become permanent? The sixth item assessed whether staff believed the
ERP should become a permanent addition to the Medical Review department. Overall, 76.9%
(n=30) of respondents agreed (slightly, moderately, and very much) that the ERP should become
permanent (Table 11).
Table 11. The Employee Recognition Program Should Become a Permanent Addition to the
Medical Review Department
Response
n
%
Disagree Very Much
1
2.6
Disagree Moderately
3
7.7
Disagree Slightly
4
10.3
Agree Slightly
4
10.3
Agree Moderately
14
35.9
Agree Very Much
12
30.8
No Response
1
5.1
Note. Percentages may not total 100% due to rounding
Staff explanation of why they selected their responses varied. For this item, the comments
overwhelmingly positive (85.71%). One respondent stated:
It was evident after the first few weeks of the program during staff/team meetings that
people were less anxious and more jovial towards each other and to management in
regards to working as a whole. I feel that when people feel recognized and rewarded,
they are happier at work and happier employees tend to be more productive employees.
Another respondent stated:
I liked the interaction that occurs weekly when nominees were announced. It's nice to see
all of the encouraging and congratulatory emails.
Other common themes included being good/beneficial for the department, a means of boosting
morale, ability to recognize peers and leaders, and allowing everyone in the department to
participate. There were three negatives comments about this item (14.29% of total comments).
43
The first stated that they prefer the current systems that were in place in Medical Review prior to
program implementation. Specifically, the respondent stated that:
I prefer the current PROPS points system and wonder if this system took away from
people giving PROPS points.
The other comments surrounded not feeling included in the program and being overlooked if no
one knows you since most staff work virtually. Specifically, one respondent stated that:
It's not inclusive. If no one knows you, you are overlooked.
Employee perceptions overall. Mean scores for each of the six items ranged from 4.66
to 5.45 (out of 6.00). The majority of items (five out of the six items) rated ‘agree moderately”
on the 6-point Likert scale (disagree very much, disagree moderately, disagree slightly, agree
slightly, agree moderately, and agree very much) except for the item asking if the ERP should
become permanent. This item rated “agree slightly” (M = 4.66) (Table 12).
Table 12. Mean Scores for Employee Perceptions of the Employee Recognition Program’s
Meaningfulness and Effectiveness
Item
M
SD
Meaningfulness
5.29
0.96
Overall Satisfaction
5.27
1.07
Ease of Use
5.45
0.80
Fairness
5.39
0.95
Beneficial
5.19
1.13
Should it Become Permanent
4.66
1.38
Note. Disagree very much (1.00-1.99), disagree moderately (2.00-2.99), disagree slightly (3.00-3.99),
agree slightly (4.00-4.99), agree moderately (5.00-5.99), and agree very much (6.00)
44
CHAPTER 6: DISCUSSION
Discussion
A quality improvement project utilizing a pre-post design evaluated the effectiveness of
an ERP at improving staff satisfaction, productivity, and the overall health of the BCBSNCMRD work environment. Specifically, this project aimed to understand the impacts of ERPs
based on non-monetary forms of recognition on staff satisfaction, productivity, and the overall
health of the work environment in a non-traditional nursing setting. Four questions guided the
development of this project:
1. How does an ERP effect job satisfaction among BCBSNC-MRD staff?
2. How does an ERP effect overall work environment health within Medical Review?
3. How does an ERP effect Medical Review work productivity?
4. What facilitators and barriers impact ERP implementation at BCBS NC?
Analysis of the JSS and HWEAT data indicated a significant improvement in the overall job
satisfaction and the health of the Medical Review work environment. Further, staff productivity
improved significantly throughout the pilot period. The results from this project support the
application of non-monetary-based recognition programs in non-traditional nursing work
environments and highlight the value of these programs in improving staff and organizational
outcomes.
Job Satisfaction
Job satisfaction is a critical predictor of organizational success and achieving
organizational outcomes. Evidence suggests a direct link between job satisfaction and
45
organizational performance and effectiveness (Bakotic, 2016). Satisfied employees are more
committed to their organization, have greater performance and productivity, and are more likely
to assist their peers and go above and beyond what is expected of them (Bakotic, 2016; Pang &
Lu, 2016). Job satisfaction is so crucial, researchers posit that employee satisfaction is the major
determinant of organizational success (Bakotic, 2016). Although, the association between job
satisfaction and employee recognition is well established, little evidence is available that
specifically inspects the impacts of employee recognition on job satisfaction within healthcare.
Further, no evidence is currently available that examines the impacts of employee recognition on
job satisfaction within non-traditional nursing work environments.
How does an ERP effect job satisfaction among BlueCross and BlueShield Medical
Review department staff? In this project, the effect of an ERP on job satisfaction in a nontraditional nursing work setting (BCBSNC-MRD) was examined. Significant differences were
noted in the total Satisfaction score (t = 2.39, p = 0.02) and the Contingent Rewards (t = 2.21, p =
0.04) and Communication (t = 2.59, p = 0.02) subscale scores of the JSS. These results suggest
that the implementation of the ERP was effective at improving job satisfaction within the
Medical Review department.
The Contingent Rewards subscale was designed to assess employee “appreciation,
recognition, and rewards” for a job well done (Spector, 2001). The Contingent Rewards subscale
consisted of four items (items #5, 14, 23, and 32 on the JSS):
•
When I do a good job, I receive the recognition for it that I should receive.
•
I do not feel that the work I do is appreciated.
•
There are few rewards for those who work here.
•
I don't feel my efforts are rewarded the way they should be.
46
Significant findings within the Contingent Rewards subscale were not surprising as the project’s
purpose was implementation of an ERP within the MRD, further increasing the available
avenues for recognition and rewards within the project setting. Further, this project was a
supplement to the already extensive rewards and recognition systems in place within BCBS NC.
The Communication subscale was designed to measure communication within the
organization (Spector, 2001). The Communication subscale consisted of four items (items #9, 18,
26, and 36 on the JSS):
•
Communications seem good within this organization.
•
The goals of this organization are not clear to me.
•
I often feel that I do not know what is going on with the organization.
•
Work assignments are not fully explained.
Significant findings within the Communication subscale were not surprising as one of the
recognition types, the departmental-wide email blasts, substantially increased communication
across the department throughout the pilot period. Prior to project implementation, many staff
members could go extended periods without speaking to their peers or management. This was
due to the nature of their work and the virtual work environment. Weekly emails blasts with the
recognition rewards allowed staff the opportunity to respond to the entire department, offering
words of congratulations and praise, and increasing their communication with their peers and the
management team.
The results of this project were congruent with studies outside of healthcare in the
education and business sectors. Ali & Ahmed (2009) noted that among non-healthcare
employees, employee recognition significantly increased job satisfaction and motivation (r =
0.92, p < 0.01). Tessema et al. (2013) examined multinational university students and noted that
47
employee recognition was a statistically significant predictor of job satisfaction (r = 0.25, p
<0.001). The importance job satisfaction and employee recognition play in achieving employee
and organizational outcomes is clearly evident. Results from this project further support that
employee recognition represents a powerful tool for management to utilize to improve job
satisfaction and ultimately ensure organizational success and the achievement of employee and
organizational outcomes.
Healthy Work Environment
A HWE is critical to the success of an organization and its employees (Shirey, 2006).
Healthier work environments are associated with improved patient, staff, and organizational
outcomes (Erickson, 2010). Meaningful recognition, one of the six AACN HWE standards,
examines employee reward based on individual value and staff contributions to their
organization (Vollers et al., 2009). Meaningful recognition and MR-based ERPs, have been
shown to positively impact job satisfaction, productivity, engagement, retention, and overall
organizational performance and success (Akafo & Boateng, 2015; Ali & Ahmed, 2009; Lefton &
Breugger, 2009; Tessema et al., 2013; Ulrich et al., 2006). Healthy work environments and MR
have been studied primarily in acute care nursing settings. Little to no evidence is available that
examines their impacts on non-traditional nursing work environments.
How does an ERP effect overall work environment health within Medical Review?
In this project, the effect of an ERP on overall work environment health in a non-traditional
nursing work setting (BCBSNC-MRD) was examined. Significant differences were noted in the
total HWEAT score (t = 2.16, p = 0.04) and the Appropriate Staffing (t = 3.02, p = 0.01) and
Meaningful Recognition (t = 3.45, p = 0.002) subscale scores of the HWEAT. These results
suggest that the implementation of the ERP was effective at increasing the overall health of the
Medical Review work environment during project implementation.
48
Appropriate Staffing was described by the AACN as staffing levels and skill mixes that
ensure “the effective match between patient needs and nurse competencies” (AACN, 2005). This
concept may be expanded more globally beyond the clinical environment to refer to the
appropriateness of the match between meeting organizational needs and the skills and
competencies of the employees (Morton, 2015). The Appropriate Staffing subscale consisted of
three items (items #3, 8, and 12 on the HWEAT):
•
Managers and team leads work with staff to make sure there are enough staff to
effectively manage the work.
•
Managers and team leads make sure there is the right mix of staff to ensure
optimal outcomes.
•
Support services are provided at a level that allows department staff to spend
their time on the priorities and requirements of work in our organization.
Significant findings in the Appropriate Staffing subscale were somewhat surprising to the PI.
Throughout the pilot period, the MRD was in an inventory backlog and many of the timeliness
obligations for work were not met. Further, most staff were working additional hours to assist
with meeting departmental and personal goals and expectations. The significant findings may be
explained because additional contract staff were hired to assist in managing the inventory. Six
additional contract staff were hired and trained during the pilot period. The addition of the
contract staff helped to significantly reduce the backlog and aging inventory. Further, permanent
staff were cross-trained to work within other areas within the department to assist with the aging
inventory. This consisted of additional training in pricing reviews and transitioning staff from
one workflow system to another.
49
Meaningful recognition was described by the AACN as recognizing others and being
recognized “for the value each brings to the work of the organization” (AACN, 2005). The MR
subscale consisted of three items (items #4, 9, and 17 on the HWEAT):
•
The formal reward and recognition systems work to make members of our
department feel valued.
•
Members of our department speak up and let people know when they've done a
good job.
•
There are motivating opportunities for personal growth, development, and
advancement.
Significant findings in the MR subscale were not surprising as the project’s purpose was
implementation of a MR-based ERP to increase the recognition provided to staff within the
MRD. Further, the project’s ERP was supplemental to the already extensive rewards and
recognition systems within place at BCBS NC. However, the significant findings in the MR
subscale was of particular importance as the ERP utilized the MR principles outlined by the
AACN as a framework (AACN, 2005: AACN 2016). Further, a MR-based ERP was shown to
effectively improve job satisfaction and performance, two of the other major outcome measures
under study within this project.
The results of this project were congruent with findings in the literature. Gelsema et al.
(2005) noted a significant correlation between MR and job satisfaction (β = 0.23, p < 0.001).
Ajala (2012) suggested that MR was the most significant predictor of employee productivity and
a major motivating factor behind increasing job performance. The importance HWEs and MRbased ERPs play in achieving employee and organizational outcomes are clearly evident. Results
from this project further support that MR-based ERPs represent a cost-effective means of
50
improving employee performance, job satisfaction, and ultimately the overall health of the nontraditional nursing work environment.
Productivity
Adequate recognition is critical to employee performance and success. Furthermore, a
productive workforce is essential for organizational success and the achievement of
organizational outcomes (Dobre, 2013). Evidence suggests a direct link between employee
recognition and increased productivity (Higginbottom, 2017). A Harvard Medical School (2011)
study revealed that employee recognition was successful at increasing employee productivity by
as much as 50%. Furthermore, this study revealed that non-monetary forms of recognition were
effective at increasing employee performance (Harvard Medical School, 2011). For
organizations to succeed and increase their performance, their employees must thrive and be as
productive as possible (Dobre, 2011). The evidence examining the impacts of employee
recognition on productivity is limited. Furthermore, little to no rigorous evidence is available that
specifically examines the impacts of employee recognition on productivity in non-traditional
nursing settings.
How does an ERP effect Medical Review work productivity? In this project, the effect
of an ERP on productivity in a non-traditional nursing work setting (BCBSNC-MRD) was
examined. Significant differences were noted in the average departmental productivity pre- and
post-implementation (t = 7.96, p = 0.02). Furthermore, the average departmental productivity
increased by almost 30% throughout program implementation (Pre: M = 105.11; Post: M =
134.99). This finding suggests that the implementation of the ERP was effective at increasing
employee productivity. Furthermore, it is the opinion of the PI that productivity increased
because overall departmental morale increased. This was evident by many of the comments from
the post-implementation survey. One of the major themes noted across surveys was improved
51
morale within the department overall. However, it is important to note that during the threemonth pilot period low-performing staff were under a performance management plan as directed
by departmental and organizational. Performance management consisted of frequent meetings
with management, one-on-one guidance and instruction from departmental educators, and
possible disciplinary action up to termination. This performance management may also explain
some of the increases in productivity as low performing staff improved their productivity or were
terminated.
The results of this project were congruent with findings in the literature. Although the
evidence is limited, Bradler et al. (2016) noted that employee recognition significantly increased
performance and productivity (p < 0.01), by as much as 10%, in response to the recognition. The
correlation between employee recognition and improving productivity is evident. Furthermore,
the literature supports that increased employee productivity improves professional and
organizational outcomes. Results from this project further support that ERPs represent an
effective organizational tool for improving employee performance and ultimately improving
organizational success and the achievement of employee and organizational outcomes.
Employee Perceptions
Overall, the support and response to the ERP were overwhelmingly positive. A six-item
questionnaire used to evaluate the ERP effectiveness and meaningfulness from the staff’s
perspective. The majority of staff agreed that the ERP was (1) meaningful (89.7%), (2) easy to
use (92.3%), (3) fair (89.7%), (4) beneficial to the department (87.2%), and (5) should become a
permanent addition to the Medical Review department (76.9%). Additionally, 89.7% of staff
reported that they were satisfied with the ERP and the types of recognition that were given.
Mean scores for each of the six items ranged from 4.66 to 5.45. The majority of items rated
52
Agree Moderately (M = 5.00-5.99) on the 6-point Likert scale except for the should the ERP
become permanent question, which rated Agree Slightly (M = 4.66) (Table 14).
Driving and Restraining Forces
Change is difficult for most individuals and organizations (Society for Human Resource
Management, 2018). For ERP implementation to be successful and sustainable, organizational
change was required. As such, it was critical to understand the forces impacting change within
the project setting (Lewin, 1947).
What facilitators and barriers impact ERP implementation at BlueCross and
BlueShield of North Carolina? Facilitators or driving forces for ERP implementation within the
MRD included decreased morale, engagement, motivation, job satisfaction, productivity, and
overall work quality. External dependencies to other areas within the organization, such as the
claims and customer service areas, and MRD’s management commitment to the ERP also served
as driving forces for change. Barriers or restraining forces for ERP implementation included the
Medical Review department’s historical resistance to change, lack of employee participation,
lack of financial resources to implement and sustain an ERP, staff’s fear of the unknown, and
conflict with existing corporate monetary forms of recognition.
Overall, staff participation in the ERP was high but at times, it was limited to certain
teams and individuals. This was noted in several staff reflections on the post-implementation
questionnaire. Of the five MRD teams, three teams submitted only seven recognition awards
(34.44% of total awards combined) while the other two teams submitted 11 (18.03%) and 29
(47.54%) respectively. Further, the PI’s team submitted 47.54% of the total number of
recognition awards given. Even though all staff were able to equally participate, this did not
occur. The Society for Human Resource Management (2017) suggests that many employees are
not motivated to participate in ERPs as they often find the types of recognition given as
53
unmeaningful. This highlights two important aspects we addressed throughout project
implementation. First, we recognized the MRD’s historical lack of motivation and engagement
with programs as a major restraining force for change. This may explain why some MRD teams
participated less than others. Although we actively and consistently engaged in evidence-based
strategies (change agents, transparent nomination processes, public communication about
awards) to promote engagement, lower numbers of award nominations as well as the MRD
members slight agreement that the ERP should continue suggest that further work is needed.
Second, that the types of recognition must be meaningful to participants. This was a major
deciding factor in designing a MR-based ERP.
A few staff members responded that they preferred the current monetary recognition
systems in place at BCBS NC and that the ERP may have negatively impacted the distribution of
monetary awards during the pilot period. The ERP was designed to supplement the current
systems in place at BCBS NC and not take away from them. This finding was very surprising as
an additional recognition means was seen by a few staff as a negative and the opposite of this
intention. One respondent stated that they didn’t see the need for anything additional as they
already had systems in place. This again may speak to the internal resistance to change within
the MRD.
The project utilized change agents throughout the development and implementation
processes and the ERC committee was formed with representation from all departmental teams
and management (Kaminiski, 2011; UNC, n.d.). This was intended to combat known barriers:
resistance to change, lack of participation, etc., and to act as facilitators for the change process.
The ERC members also met with their own work teams with the goal of increasing participation
and reducing resistance to change. During those meetings, ERC members discussed the ERP and
54
answered staff questions. Overall, this was an effective strategy for facilitating change and one
staff member noted on the post-implementation survey that the ERC was always available to
assist and answer any questions they had regarding the ERP implementation.
Another barrier was that the majority of staff work virtually, adding further challenges to
implementation and participation. To overcome the barrier created by virtual work and to
facilitate ERP implementation, frequent communications surrounding the project and
intervention were emailed to staff. Additionally, the ERP was designed to be as simple as
possible for staff to use and required very little effort or time to participate, as noted by
participant use and ease of use ratings and positive comments on the post-implementation
survey. Nevertheless, a few staff found the program challenging because, as virtual employees,
they do not really know each other that well due to working from home. This further supports
one of the core problems of virtual work environments in that they contribute to poor employee
experiences by increasing feelings of professional and social isolation and decreasing employee
engagement and motivation (Caillier, 2012; Felstead, Jewson, Phizacklea, & Walters, 2006;
Kurland & Cooper, 2002; Sardeshmukh, Sharma, & Golden, 2012). The virtual work barrier and
how to increase participation across all teams requires further research to develop evidencebased strategies that promote long-term sustainability and viability of ERPs.
Lessons Learned
The greatest lesson learned was how challenging it was to design, implement, and
manage a project from inception to completion, even with a supportive team. Ultimately, all
decisions and responsibilities fell to PI. This was very different from past project experiences
where the majority of responsibilities were shared across team members. Furthermore,
implementing a project in an almost 100% virtual setting added its own issues and challenges,
particularly, how to overcome implementation barriers and increase participation department-
55
wide. Another lesson learned was that even non-monetary forms of recognition have associated
costs, such as time costs. When developing the ERP, a major mistake was made in choosing a
star pin design that could not be mailed in a first-class, flat envelope. Each star pin required
parcel post, dramatically increasing the cost and associated time (travel to the post office) to send
to the awardee. This was rectified within the first few weeks but there were still occasional issues
surrounding the pin’s post. For example, two staff members were charged additional postage for
their star pins which had to be reimbursed. Further, three stars were returned as undeliverable
even though the addresses were correct. In one instance, a star pin was lost in the mail for four
weeks and finally delivered after a replacement had already arrived. Two other stars were lost in
the mail to be returned to the PI weeks later. In hindsight, designing a non-monetary reward that
doesn’t depend on the Postal Service may have been more productive and time and cost
effective. Although relatively inexpensive when compared to a traditional monetary-based ERP,
investment in the ERP in its current state would require a long-term financial commitment from
the MRD.
Sustainability
Overall project findings were positive, suggesting that the implementation of an ERP was
an effective means of improving job satisfaction, productivity, and the overall health of the MRD
work environment. Based on these findings, it is reasonable to expect that MRD management
will continue to support the program in some form. The ERP was relatively inexpensive to
maintain, adding further support to its longevity. Since the results were positive and participation
was high throughout, the ERP could be utilized as a framework for implementing similar
programs company-wide and may prove equally beneficial for both healthcare and nonhealthcare related areas at BCBS NC.
56
Recommendations
Due to the positive nature of the results, MRD management should consider continuing
the MRD ERP with several modifications. First, consider an alternative to the existing star pin in
order to reduce expense related to postal charges. Based on the feedback from staff in the postimplementation survey, there was no mention of the star pin in their comments. Numerous staff
members discussed the value of the department-wide email blasts and receiving the generated
certificates. Therefore, the star pin may not have equivalent value to the certificate, departmentwide email announcement, and the many peer email responses providing additional recognition
and support. This provides support that eliminating the star pin would retain the essential nature
and meaning behind the ERP as well as significantly reduce the associated time and financial
costs of the ERP.
Implications for Research
The available body of evidence examining the impacts of employee recognition on job
satisfaction, productivity, and the overall health of the work environment is limited. Further,
little inquiry into non-traditional nursing settings exists. This project may be the first to explore
the relationship between meaningful recognition, job satisfaction, work environment health, and
productivity in non-traditional nursing work settings. As more and more nurses transition away
from the bedside into non-traditional settings, further research is needed to examine the impacts
virtual work environments have on nurses. Virtual work is likely to increase as a means to reduce
costs and promote work-life-balance, therefore additional knowledge is required to understand
the resultant impacts of virtual work on such outcomes as engagement, motivation, productivity,
and job satisfaction among nurse employees.
57
Implications for Practice
The significant project findings highlight the importance employee recognition plays in
today’s work environment. Specifically, that non-monetary forms of recognition have the
potential to improve outcome measures such as productivity, job satisfaction, and overall work
environment health. Project results suggest that employee recognition may be successful in
virtual work environments where historic resistance to change and lack of participation were
present and may be applicable to both healthcare and non-healthcare organizational departments.
This is of particular importance as even though project results clearly underscore the benefits of
employee recognition, it remains currently underutilized in most organizations (Neckermann &
Frey, 2013). Additional quality improvement projects examining the impacts of employee
recognition on the work environment should be undertaken and include additional outcome
measures beyond job satisfaction and productivity. A major implication for nurse leaders is that
recognition as simple as a public email and a printed recognition certificate has great potential to
impact staff, increasing staff satisfaction with their jobs and improving staff productivity and
performance.
Limitations
A major limitation of this project was that it was designed for and implemented within a
very specific setting. The MRD represents a non-traditional nursing work environment. When
compared to other settings within the BCBS NC, almost all staff work exclusively from home
and have little daily interactions with each other. Because project results were consistent with
findings from the literature from other work environments (Ali & Ahmed, 2009; Bradler et al.,
2016; Tessema et al., 2013), such as the business and academic sectors, the ERP may be
generalizable to virtual work environments in other industries.
58
A second limitation was the decrease in response rate from the pre- and postimplementation surveys. The pre-implementation survey had a ~92% response rate compared to
the post-implementation survey with a response rate of only ~71%. Those that dropped out
between pre- and post-implementation surveys and those that chose not to respond at all may
have been significantly different from those that did respond and could potentially have impacted
the project results.
Another potential limitation was chance, particularly, in regards to the outcome measure
of productivity. Although productivity was measured weekly to provide a snapshot of an
employee’s performance, factors may have been present outside the work environment that
increased or decreased individual productivity. Having a bad day, being sick, etc. could
potentially impact productivity. Beyond productivity, job satisfaction and work environment
health may also have been potentially impacted by chance, although unlikely as the pilot was
conducted over a three-month period.
Dissemination
The dissemination plan consists of five major elements. First, the project summary was
presented to the ERC. Second, the project summary will be presented to the entire MRD. Third,
the project summary will be presented to the BCBS NC executives. Fourth, an abstract will be
submitted for conference presentation. Fifth, a manuscript will be developed for publication.
Conclusion
The purpose of this project was to evaluate the feasibility of implementing an ERP in a
non-traditional nursing work setting and to assess the effectiveness of an ERP for improving staff
satisfaction, productivity, and the overall health of the work environment within the MRD at
BCBS NC. To understand the impacts of ERPs based on non-monetary forms of recognition, the
ERP was implemented for a three-month pilot period. The results suggest that ERPs based on
59
non-monetary forms of recognition were effective at improving staff satisfaction, productivity,
and the overall health of the MRD work environment. Specifically, the results showed that (1)
there were significant improvements in total satisfaction pre- and post-implementation, (2) there
were significant improvements in MR and the overall health of the work environment pre- and
post-implementation, and (3) there were significant improvements in productivity pre- and postimplementation and that productivity increased by on average ~30%. This project provides
valuable information about a work setting that was not previously examined. The results from
this project were congruent with other studies in settings outside of healthcare. Further, the
project results add to the body of evidence involving virtual work environments, which continues
to grow and expand within most sectors and will be a hot topic of research in the future. The
project findings highlight the importance of employee recognition as a tool for leaders to
motivate staff and improve their working lives. This project demonstrated that simple actions,
such as sending an email or generating a recognition certificate, positively impacted the lives of
staff and was able to increase departmental work performance while still improving job
satisfaction and the health of their working environment.
60
APPENDIX A: FORCE-FIELD ANALYSIS OF THE MEDICAL REVIEW
DEPARTMENT
Figure A1. Force-Field Analysis of the Medical Review Department
61
APPENDIX B: EMPLOYEE RECOGNITION PROGRAM DESIGN
Stage One: Identify the Program’s Purpose
The purpose of the ERP was:
•
To recognize and reward actions and behaviors that foster the mission, vision, objectives,
and cultural values of BCBS NC, as well as the goals and initiatives within the Medical
Review department.
Stage Two: Identify the Program’s Goals
The goals of the ERP were:
•
To develop a program that is flexible, adaptable, and fair.
•
To develop a program that meets employee needs and provides the opportunity for
recognizing others for their accomplishments.
•
To maximize involvement and employee interest in the program.
•
To be transparent in the ERP processes to increase buy-in and participation.
•
To create a program that allows for participation across all levels and areas within the
department (i.e. peer to peer, manager to employee, employee to manager).
•
To make the recognition process simple, understandable, and easily accessible to all
within the department (MIT, n.d.).
Stage Three: Determine the Award Theme and the Selection Criteria
The ERP in the Medical Review department at BCBS NC was known as the Shining Star
Award. Selection criteria were based on the four cultural values of BCBS NC: Caring,
Collaborative, Committed, and Creative (the 4C’s). AT BCBS NC, the 4C’s represent key
employee attributes that allow the organization to achieve their vision of being “a consumerfocused health solutions company that leads the transformation of the health care system”
62
(BSBC NC, 2018c, para. 2). Caring refers to a customer focus. Employees that exemplify caring
are passionate about their work, team, department, and organization. Caring also represents
being a force of good both within the organization and also within your community.
Collaborative refers to having trust in your coworkers. A major attribute of Collaborative is
teamwork. It is through collaborative efforts that our greatest achievements occur. Committed
represents responsibility and accountability for the work you do and ensuring it is the highest
quality possible. Committed employees ensure professionalism in all interactions. Furthermore,
committed individuals identify problems and brainstorm possible solutions. Creative refers to
embracing change. Creative employees are innovative and constantly seeking opportunities for
improvement (BCBS NC, 2018b). An employee may exemplify one or more of the four cultural
values and each cultural value is weighted equally.
Stage Four: Form the Employee Recognition Committee
The employee recognition committee (ERC) was comprised of members from each of the
five Medical Review teams and also a member of management (six members in total). During
the first meeting, the FFA and draft ERP was presented to the committee for their feedback. No
additions or deletions were incorporated into the final ERP.
The ERC met weekly to review all employee recognition submissions and to select award
recipients. Submissions were evaluated based on how well the employee exemplified the four
cultural values of BCBS NC and were based on ERC judgement. The final award decision was at
the ERC level. In the event of a tied vote, the ERC member from the management team decided
on the submission. Committee members were allowed to serve on the ERC for a maximum of
three quarters. ERC members were selected on a volunteer basis and were in good standing
within the department and free of any performance management. Nominations were reviewed
63
weekly and as needed. A standing weekly appointment was established and based on the number
of submissions arriving, anyone from the ERC was able to schedule an as needed meeting to
address those submissions. Each submission was read in its entirety to the ERC. Voting occurred
by saying yes or no after the submission was read. If anyone was unclear or needed further
insight, a member of the ERC reviewed the selection criteria against the submission. In the event
of a tie or an abstention resulting in a tie, a member voting yes and a member voting no was
allowed to plead their case to the group. After this, another round of yes/no voting occurred. If a
tie still remained, the ERC member from the management team ultimately decided on the
submission. Each ERC member was well versed in the rules and process for voting and selection
to ensure fairness and consistency throughout.
Stage Five: Establish Eligibility and Frequency of the Award
All medical review employees were eligible to participate in the ERP, including
permanent and contract employees. There were no requirements based on length of service or
employment status. The only requirement was that the employee has exemplified the cultural
values of BCBS NC. Members of the ERC were able to be nominated for the award but
abstained from voting. There was no limitation on how frequently an employee may be
nominated or how frequently an employee may receive the award.
Stage Six: Define the Nomination Process
A nomination form was created using Survey Monkey (Figure B1). The link to the form
was published via email to the Medical Review department. The nomination form and ERP were
only for Medical Review department use. As such, the recognition form was password protected.
The nomination process was confidential and not be shared outside the ERC. The nomination
process was confidential instead of anonymous to prevent abuse and possible self-voting. All
64
fields on the nomination form were mandatory. Mandatory fields included (1) name of the
nominator, (2) the employee being nominated, (3) the cultural values exhibited, and (4) a
description of how the employee demonstrated the cultural values with detailed examples
provided. Any departmental employee was able to submit a nomination. This includes both
permanent and contract staff. Employees were not able to nominate themselves. Any selfnomination submission was rejected. All nominations were submitted electronically through the
recognition form.
Figure B1. Shining Star Award Nomination Form
retrieved at https://www.surveymonkey.com/r/W6XWSBD
65
Stage Seven: Determine Recognition Type and Publicity
Recognition occurred via three formats. First, an email blast was sent to the entire
department notifying the staff of the recognition award. The email blast included the person
being recognized, the nominator, and a brief description of the recognition reason. Second, a
Shining Star Award certificate was generated and emailed to the employee (Figure B2). Third, a
gold star pin was mailed to the employee or delivered in person (depending if the worker was in
office or work-from-home) (Figure B3).
Figure B2. Shining Star Award Certificate
66
Figure B3. Star Pin
retrieved from
http://www.jonesawards.com/Shop/Details/1327/?sc=WGP&gclid=Cj0KCQjw2KHWBRC2ARI
sAJD_r3dzSZygoM2RzMlDUOQBZOo7Ex5RbnZXRR5i3MRQO5UAuGpr8YkbmwsaAgNkE
ALw_wcB
Stage Eight: Conduct Program Monitoring and Evaluation
The ERP was monitored and evaluated on an ongoing basis. During this DNP project, the
evaluation and monitoring occurred in conjunction with PI and the ERC. The ERC sent weekly
reminders reminding staff of the program, the recognition process, and the link for the
recognition submission form. Furthermore, ERC members discussed the ERP during all team
meetings and answered any questions that arose. At the completion of the DNP project, program
evaluations were sent to the entire department. The purpose was to elicit feedback into the forms
of recognition and to evaluate program effectiveness and if it was meeting the staff’s needs. This
also provided valuable data for the department leadership to use for program continuation upon
the withdrawal of the PI as the project lead.
67
APPENDIX C: DEMOGRAPHICS QUESTIONS
1. What is your current position?
a. Medical review analyst, senior medical review analyst, dental analyst, clinical
support specialist, clinical education consultant, team lead, senior divisional
compliance consultant, or manager
2. What is your highest level of educational preparation?
a. High school diploma, Associate’s Degree, Bachelor’s Degree, or Master’s Degree
3. What is your current age?
a. ____
4. How long have you worked at BCBS NC?
a. ____
5. How long have you worked in Medical Review at BCBS NC?
a. ____
68
APPENDIX D: JOB SATISFACTION SURVEY
Table D1. Job Satisfaction Scale
JOB SATISFACTION SURVEY
Paul E. Spector
Department of Psychology
University of South Florida
Copyright Paul E. Spector 1994, All rights reserved.
PLEASE CIRCLE THE ONE NUMBER FOR EACH QUESTION THAT COMES
CLOSEST TO REFLECTING YOUR OPINION ABOUT IT.
1
I feel I am being paid a fair amount for the work I do.
1
2
3
4
5
6
2
There is really too little chance for promotion on my job.
1
2
3
4
5
6
3
My supervisor is quite competent in doing his/her job.
1
2
3
4
5
6
4
I am not satisfied with the benefits I receive.
1
2
3
4
5
6
5
When I do a good job, I receive the recognition for it that I
should receive.
1
2
3
4
5
6
6
Many of our rules and procedures make doing a good job
difficult.
1
2
3
4
5
6
7
I like the people I work with.
1
2
3
4
5
6
8
I sometimes feel my job is meaningless.
1
2
3
4
5
6
9
Communications seem good within this organization.
1
2
3
4
5
6
10
Raises are too few and far between.
1
2
3
4
5
6
11
Those who do well on the job stand a fair chance of being
promoted.
1
2
3
4
5
6
12
My supervisor is unfair to me.
1
2
3
4
5
6
13
The benefits we receive are as good as most other
organizations offer.
1
2
3
4
5
6
14
I do not feel that the work I do is appreciated.
1
2
3
4
5
6
15
My efforts to do a good job are seldom blocked by red tape.
1
2
3
4
5
6
16
I find I have to work harder at my job because of the
incompetence of people I work with.
1
2
3
4
5
6
17
I like doing the things I do at work.
1
2
3
4
5
6
18
The goals of this organization are not clear to me.
1
2
3
4
5
6
69
19
I feel unappreciated by the organization when I think about
what they pay me.
1
2
3
4
5
6
20
People get ahead as fast here as they do in other places.
1
2
3
4
5
6
21
My supervisor shows too little interest in the feelings of
subordinates.
1
2
3
4
5
6
22
The benefit package we have is equitable.
1
2
3
4
5
6
23
There are few rewards for those who work here.
1
2
3
4
5
6
24
I have too much to do at work.
1
2
3
4
5
6
25
I enjoy my coworkers.
1
2
3
4
5
6
26
I often feel that I do not know what is going on with the
organization.
1
2
3
4
5
6
27
I feel a sense of pride in doing my job.
1
2
3
4
5
6
28
I feel satisfied with my chances for salary increases.
1
2
3
4
5
6
29
There are benefits we do not have which we should have.
1
2
3
4
5
6
30
I like my supervisor.
1
2
3
4
5
6
31
I have too much paperwork.
1
2
3
4
5
6
32
I don't feel my efforts are rewarded the way they should
be.
1
2
3
4
5
6
33
I am satisfied with my chances for promotion.
1
2
3
4
5
6
34
There is too much bickering and fighting at work.
1
2
3
4
5
6
35
My job is enjoyable.
1
2
3
4
5
6
36
Work assignments are not fully explained.
1
2
3
4
5
6
Note. Scale: (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree slightly,
(5) Agree moderately, and (6) Agree very much
70
Table D2. Job Satisfaction Subscale Item Numbers
Subscale
Item Numbers
Pay
1, 10, 19, 28
Promotion
2, 11, 20, 33
Supervision
3, 12, 21, 30
Fringe Benefits
4, 13, 22, 29
Contingent Rewards
5, 14, 23, 32
Operating Conditions
6, 15, 24, 31
Coworkers
7, 16, 25, 34
Nature of Work
8, 17, 27, 35
Communication
9, 18, 26, 36
Total Satisfaction
1 - 36
71
APPENDIX E: ADAPTED HEALTHY WORK ENVIRONMENT ASSESSMENT TOOL
Table E1. Adapted Healthy Work Environment Assessment Tool
1. Members of our department (managers, team leads, analysts, etc.) maintain frequent
communication to prevent each other from being surprised or caught off guard by
decisions.
2. When making important decisions, managers and team leads involve staff to the
appropriate degree.
3. Managers and team leads work with staff to make sure there are enough staff to
effectively manage the work.
4. The formal reward and recognition systems work to make members of our department
feel valued.
5. Most members of our department have a positive relationship with their leaders (team
lead, managers, directors, etc.).
6. All members of our department (managers, team leads, and staff) make sure their
actions match their words -they "walk their talk."
7. All members of our department (managers, team leads, and staff) are consistent in their
use of data-driven, logical decision-making processes to make sure their decisions are
the highest quality.
8. Managers and team leads make sure there is the right mix of staff to ensure optimal
outcomes.
9. Members of our department speak up and let people know when they've done a good
job.
10. Staff members of our department feel able to influence the policies, procedures, and
bureaucracy around them.
11. The right departments, professions, and groups are involved in important decisions.
12. Support services are provided at a level that allows department staff to spend their time
on the priorities and requirements of work in our organization.
13. Leaders (team leads, managers, directors, etc.) demonstrate an understanding of the
requirements and dynamics of work and use this knowledge to work for a healthy work
environment.
14. Members of our department (managers, team leads and staff) have zero-tolerance for
disrespect and abuse. If they see or hear someone being disrespectful, they hold them
accountable regardless of the person's role or position.
72
15. When team leads and managers speak with staff, it’s not one-way communication or
order giving. Instead, they seek input and use it to shape decisions.
16. Members of our department are careful to consider the needs of the team and the needs
of the organization whenever they are making important decisions.
17. There are motivating opportunities for personal growth, development, and
advancement.
18. Managers and team leaders are given the access and authority required to play a role in
making key decisions.
Note. Scale: Strongly Disagree (1), Disagree (2), Neutral (3), Agree (4), and Strongly Agree (5)
73
Table E2. Healthy Work Environment Assessment Tool Subscale Item Numbers
Subscale
Item Numbers
Skilled Communication
1, 6, 14
True Collaboration
2, 10, 15
Effective Decision Making
7, 11, 16
Appropriate Staffing
3, 8, 12
Meaningful Recognition
4, 9, 17
Authentic Leadership
5, 13, 18
Total HWEAT
1 - 18
74
APPENDIX F: EMPLOYEE PERCEPTION QUESTIONS
1. The employee recognition program was easy to use.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
2. The selection criteria were fair to all participants.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
3. The types of recognition given were meaningful to me.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
4. The employee recognition program was beneficial to the department.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
5. The employee recognition program should become a permanent addition to the Medical
Review department.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
6. Overall, I was satisfied with the employee recognition program.
a. (1) Disagree very much, (2) Disagree moderately, (3) Disagree slightly, (4) Agree
slightly, (5) Agree moderately, or (6) Agree very much
75
APPENDIX G: UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL’S IRB
APPROVAL
To: Charles Combs
School of Nursing
From: Office of Human Research Ethics
Date: 5/04/2018
RE: Determination that Research or Research-Like Activity does not require IRB Approval
Study #: 18-1163
Study Title: Healthy Work Environments: Improving Staff Satisfaction and Employee
productivity through Employee Recognition
This submission was reviewed by the Office of Human Research Ethics, which has determined
that this submission does not constitute human subjects research as defined under federal
regulations [45 CFR 46.102 (d or f) and 21 CFR 56.102(c)(e)(l)] and does not require IRB
approval.
Study Description:
•
•
•
Purpose: The purpose of this quality improvement project is to evaluate the effectiveness
of an employee recognition program (ERP) to improve measures of healthy work
environment, job satisfaction, and productivity.
Background: Published evidence suggests that healthy work environments and job
satisfaction are contingent on meaningful recognition of work effort and contribution to
the organization. In turn, these variables impact job performance and productivity.
Methods: This pre-/post- project will recruit subjects from the Medical Review
department of BlueCross and BlueShield of North Carolina (n=70) to participate in an
employee recognition program for a 90-day period. The following data will be collected
pre/post ERP implementation: productivity, job satisfaction, and healthy work
environment assessment. In addition, demographic variables and evaluation criteria will
be collected at one time point. Paired t-Tests analyses will be used to determine
differences pre/post.
76
Please be aware that approval may still be required from other relevant authorities or
"gatekeepers" (e.g., school principals, facility directors, custodians of records), even though IRB
approval is not required.
If your study protocol changes in such a way that this determination will no longer apply, you
should contact the above IRB before making the changes.
CC:
Rebecca Kitzmiller, School of Nursing
Lisa Miller , School of Nursing Deans Office
77
78
REFERENCES
Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital
care environment on patient mortality and nurse outcomes. The Journal of Nursing
Administration, 38(5), 223-229. https://doi.org/10.1097/NNA.0b013e3181aeb4cf
Ajala, E. M. (2012). The influence of workplace environment on workers’ welfare, performance
and productivity. The African Symposium, 12(1), 141-149. Retrieved from
http://africanresearch.org/africansymposium/archives/TAS12.1/TAS12.1Ajala.pdf
Akafo, V., & Boateng, P. A. (2015). Impact of reward and recognition on job satisfaction and
motivation. European Journal of Business and Management, 7(24), 112-124. Retrieved
from http://www.iiste.org/Journals/index.php/EJBM/article/view/25095/25961
Ali, R., & Ahmed, M. S. (2009). The impact of reward and recognition programs on employee’s
motivation and satisfaction: An empirical study. International Review of Business
Research Papers, 5(4), 207-279. Retrieved from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.472.8630&rep=rep1&type=pdf
Alspach, G. (2009). Craft your own healthy work environment: Got your bff? Critical Care
Nurse, 29(2), 12-21. https://doi.org/10.4037/ccn2009931
American Association of Critical-Care Nurses. (2005). AACN standards for establishing and
sustaining healthy work environments: A journey to excellence. American Journal of
Critical Care, 14(3), 187-197. Retrieved from
http://ajcc.aacnjournals.org/content/14/3/187.full
American Association of Critical-Care Nurses. (2015). AACN healthy work environment
assessment: Team assessment results. Retrieved from
https://www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-workenvironment/hwesampleassessment.pdf?la=en
American Association of Critical-Care Nurses. (2016). AACN standards for establishing and
sustaining healthy work environments: A journey to excellence, 2nd edition. Retrieved
from https://www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-workenvironment/execsum.pdf?la=en
American Association of Critical-Care Nurses. (n.d.). AACN Healthy Work Assessment Tool.
Retrieved from https://www.aacn.org/nursing-excellence/healthy-workenvironments/aacn-healthy-work-environment-assessment-tool
Bai, J. (2015). Does job satisfaction mediate the relationship between healthy work environment
and care quality. British Association of Critical Care Nurses, 21(1), 18-27.
https://doi.org/10.1111/nicc.12122
Bakotic, D. (2018). Relationship between job satisfaction and organizational performance.
Economic Research-Ekonomska Istraživanja , 29(1), 118-130.
https://doi.org/10.1080/1331677X.2016.1163946
79
Batura, N., Skordis-Worrall, J., Thapa, R., Basnyat, R., & Morrison, J. (2016). Is the job
satisfaction survey a good tool to measure job satisfaction amongst health workers in
Nepal? Results of a validation analysis. BMC Health Services Research, 16(1), 1-13.
https://doi.org/10.1186/s12913-016-1558-4
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost.
Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759
BlueCross and BlueShield of North Carolina. (2018a). About Us. Retrieved from
https://www.bluecrossnc.com/about-us
BlueCross and BlueShield of North Carolina. (2018b). Life at Blue Cross NC. Retrieved from
https://www.bluecrossnc.com/about-us/careers/life-blue-cross-nc#culture
BlueCross and BlueShield of North Carolina. (2018c). Mission & vision. Retrieved from
http://mediacenter.bcbsnc.com/overview/mission-vision
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires
care of the provider. Annuals of Family Medicine, 12(6), 573-576.
https://doi.org/10.1370/afm.1713
Bousquet, J. F. (n.d.). Fill in the blank certificates. Retrieved from http://www.baymall.net/stores/diplomas/fillinblanks.html
Bozak, M. G. (2003). Using Lewin’s force field analysis in implementing a nursing information
system. Computers, informatics, nursing, 21(2), 80-85. Retrieved from
http://vb3lk7eb4t.scholar.serialssolutions.com/?sid=google&auinit=MG&aulast=Bozak&
atitle=Using+Lewin%E2%80%99s+force+field+analysis+in+implementing+a+nursing+i
nformation+system&id=pmid:12802948
Bradler, C., Durr, R., Neckermann, S., & Non, A. (2016). Employee recognition and
performance: A field experiment. Management Science, 62(11), 3085-3099.
https://doi.org/10.1287/mnsc.2015.2291
Burnes, B. (2004). Kurt Lewin and the planned approach to change: A reappraisal. Journal of
Management Studies, 41(6), 977-1002. https://doi.org/10.1111/j.1467-6486.2004.00463.x
Caillier, J. G. (2012). The impact of teleworking on work motivation in a U.S federal
government agency. American Review of Public Administration, 42(4), 461-480.
https://doi.org/10.1177/0275074011409394
Carter, S. (2012). Recognizing the extraordinary work of UC Irvine healthcare nurses.
Noteworthy Nursing, 8(1), 3. Retrieved from
http://www.healthsciences.uci.edu/nursing/docs/newsletters/nursing-jan2012.pdf
Cornett, P. A., & O’Rourke, M. W. (2009). Building organizational capacity for a healthy work
environment through role-based professional practice. Critical Care Nursing Quarterly,
32(3), 208-220. https://doi.org/10.1097/01.CNQ.0000356819.47395.a4
80
Damrosch, S. P. (1986). Ensuring anonymity by use of subject-generated identification codes.
Research in Nursing & Health, 9(1), 61-63. https://doi.org/10.1002/nur.4770090110
Darling, K., Joseph, A., & Gatlin, R. (1997). How to effectively reward employees. Industrial
management, 39(4), 1-4. Retrieved from https://search-proquestcom.libproxy.lib.unc.edu/docview/211629905/fulltextPDF/6B96607C61A54539PQ/1?ac
countid=14244
Dobre, O. (2013). Employee motivation and organizational performance. Review of Applied
Socio-Economic Research, 5(1), 53-60. Retrieved from
ftp://ftp.repec.org/opt/ReDIF/RePEc/rse/wpaper/R5_5_DobreOvidiuIliuta_p53_60.pdf
Erenstein, C. F., & McCaffrey, R. (2007). How healthcare work environments influence nurse
retention. Holistic Nursing Practice, 21(6), 303-307.
https://doi.org/10.1097/01.HNP.0000298615.25222.de
Erickson, J. I. (2010). Overview and summary: Promoting healthy work environments: A shared
responsibility. The Online Journal of Issues in Nursing, 15(1).
https://doi.org/10.3912/OJIN.Vol15No01ManOS
Felstead, A., Jewson, N., Phizacklea, A., & Walters, S. (2006). Opportunities to work at home in
the context of work‐life balance. Human Resource Management Journal, 12(1), 54-76.
https://doi.org/10.1111/j.1748-8583.2002.tb00057.x
Gelsema, T. I., Van der Doef, M., Maes, S., Akerboom, S., & Verhoeven, C. (2005). Job stress in
the nursing profession: The influence of organizational and environmental conditions and
job characteristics. International Journal of Stress Management, 12(3), 222-240.
Retrieved from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.542.170&rep=rep1&type=pdf
Grochow, D. (2012). Health work environment: Meaningful recognition. Noteworthy Nursing,
8(1), 1. Retrieved from
http://www.healthsciences.uci.edu/nursing/docs/newsletters/nursing-jan2012.pdf
Harvard Medical School. (2011). In praise of gratitude. Retrieved from
https://www.health.harvard.edu/newsletter_article/in-praise-of-gratitude
Heath, J., Johanson, W., & Blake, N. (2004). Healthy work environments: A validation of the
literature. The Journal of Nursing Administration, 34(11), 524-530. Retrieved from
http://vb3lk7eb4t.search.serialssolutions.com.libproxy.lib.unc.edu/?sid=Entrez:PubMed&
id=pmid:15586074
Higginbottom, K. (2017). Employee appreciation pays off. Retrieved from
https://www.forbes.com/sites/karenhigginbottom/2017/03/03/employee-appreciationpays-off/#5ec0dd7d6ddc
81
Huddleston, P. (2015). Measuring direct care nurses’ and nurse leaders’ perceptions of a
healthy work environment within acute care settings (Doctoral dissertation). Available
from ProQuest. (UMI No. 3709734)
Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC:
National Academies Press.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st
century. Washington, DC: National Academies Press.
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of
nurses. Washington, DC: National Academies Press.
Jones School Supply. (2018). Star chenille pin. Retrieved from
http://www.jonesawards.com/Shop/Details/1327/?sc=WGP&gclid=Cj0KCQjw2KHWBR
C2ARIsAJD_r3dzSZygoM2RzMlDUOQBZOo7Ex5RbnZXRR5i3MRQO5UAuGpr8Yk
bmwsaAgNkEALw_wcB
Kaminski, J. (2011). Theory applied to informatics - Lewin’s change theory. Canadian Journal
of Nursing Informatics, 6(1). Retrieved from http://cjni.net/journal/?p=1210
Kramer, M., & Schmalenberg, C. (2008). Confirmation of a healthy work environment. Critical
Care Nurse, 28(2), 56-63. Retrieved from http://ccn.aacnjournals.org/content/28/2/56.full
Kurland, N. B., & Cooper, C. D. (2002). Manager control and employee isolation in
telecommuting environments. Journal of High Technology Management Research, 13(1),
107-126. https://doi.org/10.1016/S1047-8310(01)00051-7
Lefton, C. (2012). Strengthening the workforce through meaningful recognition. Nursing
Economic$, 30(6), 331-355. Retrieved from
https://www.nursingeconomics.net/necfiles/news/ND12_Lefton.pdf
Lefton, C., & Breugger, R. (2009). Literature review on meaningful recognition in nursing.
Retrieved from
https://www.daisyfoundation.org/system/files/Literature%20Review%20on%20Meaningf
ul%20Recognition%20in%20Nursing%20-1.pdf
Letvak, S., & Buck, R. (2008). Factors influencing work productivity and intent to stay in
nursing. Nursing Economic$, 26(3), 159-165. Retrieved from
http://vb3lk7eb4t.search.serialssolutions.com.libproxy.lib.unc.edu/?sid=Entrez:PubMed&
id=pmid:18616053
Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science;
social equilibria and social change. Human Relations, 1(1), 5-41.
https://doi.org/10.1177/001872674700100103
82
Lowe, G. S., Schellenberg, G., & Shannon, H. S. (2003). Correlates of employees’ perceptions of
a healthy work environment. American Journal of Health Promotion, 17(6), 390-399.
https://doi.org/10.4278/0890-1171-17.6.390
Lunenburg, F. C. (2010). Managing change: The role of the change agent. International Journal
of Management, Business, and Administration, 13(1), 1-6. Retrieved from
https://naaee.org/sites/default/files/lunenburg_fred_c._managing_change_the_role_of_ch
ange_agent_ijmba_v13_n1_2010.pdf
Luthans, K. (2000). Recognition: A powerful, but often overlooked, leadership tool to improve
employee performance. The Journal of Leadership Studies, 7(1), 31-39. Retrieved from
http://journals.sagepub.com.libproxy.lib.unc.edu/doi/pdf/10.1177/107179190000700104
Manzoor, Q. (2012). Impact of employee’s motivation on organizational effectiveness. European
Journal of Business and Management, 3(3), 36-44. Retrieved from
http://www.iiste.org/Journals/index.php/EJBM/article/viewFile/265/150
Massachusetts Institute of Technology. (n.d.). Best practices for designing and maintaining a
program. Retrieved from http://hrweb.mit.edu/rewards/best-practices/designing-andmaintaining-program
Miner, J. B. (2007). From Kurt Lewin’s social psychology to change processes and goal setting.
In Organizational behavior 4: From theory to practice (pp. 29-35). New York, NY:
Routledge.
Morton, P. G. (2015). Creating and sustaining healthy work environments. Journal of
Professional Nursing, 31(3), 165-167. https://doi.org/10.1016/j.profnurs.2015.04.002
Nayeri, N. D. (2009). Burnout and productivity among Iranian nurses. Nursing & Health
Sciences, 11(3), 263-270. https://doi.org/10.1111/j.1442-2018.2009.00449.x
Neckermann, S., & Frey, B. S. (2013). And the winner is. . .? The motivating power of employee
awards. The Journal of Socio-Economics, 46, 66-77.
https://doi.org/10.1016/j.socec.2013.06.006
Nelson, B. (1995). Motivating employees with informal awards. Management Accounting, 77(5),
30-34. Retrieved from
http://vb3lk7eb4t.search.serialssolutions.com.libproxy.lib.unc.edu/?ctx_ver=Z39.882004&ctx_enc=info%3Aofi%2Fenc%3AUTF8&rfr_id=info%3Asid%2Fsummon.serialssolutions.com&rft_val_fmt=info%3Aofi%2Ff
mt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Motivating+employees+wit
h+informal+awards&rft.jtitle=Management+Accounting+%28USA%29&rft.au=Nelson
%2C+Bob&rft.date=1995-1101&rft.pub=Institute+of+Management+Accountants&rft.issn=00251690&rft.volume=77&rft.issue=5&rft.spage=30&rft.externalDBID=IAO&rft.externalDo
cID=17905248&paramdict=en-US
83
Pang, K., & Lu, C. (2016). Organizational motivation, employee job satisfaction and
organizational performance: An empirical study of container shipping companies in
Taiwan. Maritime Business Review, 3(1), 36-52. https://doi.org/10.1108/MABR-03-20180007
Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., Tucker, D., & Long, L. (2007).
Comprehensive systematic review of evidence on developing and sustaining nursing
leadership that fosters a healthy work environment in healthcare. International Journal of
Evidence-Based Healthcare, 5(2), 208-253. https://doi.org/10.1111/j.14796988.2007.00065.x
Raziq, A., & Maulabakhsh, R. (2014). Impact of working environment on job satisfaction.
Procedia Economics and Finance, 23, 717-725. https://doi.org/10.1016/S22125671(15)00524-9
Sanderson, R. (2004). Survey findings of the effectiveness of employee recognition in the public
sector. Public Personnel Management, 33(3), 255-275. Retrieved from
http://journals.sagepub.com.libproxy.lib.unc.edu/doi/pdf/10.1177/009102600403300302
Sarayreh, B. H., Khudair, H., & Barakat, E. A. (2013). Comparative study: The Kurt Lewin of
change management. International Journal of Computer and Information Technology,
2(4), 626-629. Retrieved from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.404.636&rep=rep1&type=pdf
Sardeshmukh, S. R., Sharma, D., & Golden, T. D. (2012). Impact of telework on exhaustion and
job engagement: a job demands and job resources model. New Technology, Work and
Employment, 27(3), 193-207. https://doi.org/10.1111/j.1468-005X.2012.00284.x
Shining star award nomination form. (n.d.). Retrieved from
https://www.surveymonkey.com/r/W6XWSBD
Shirey, M. R. (2006). Authentic leaders creating healthy work environments for nursing practice.
American Journal of Critical Care, 15(3), 256-267.
Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. The Journal of
Nursing Administration, 43(2), 69-72. https://doi.org/10.1097/NNA.0b013e31827f20a9
Shonubi, O. A., Abdullah, N., Hashim, R., Hamid, N. B., Jaya, H. T., & Jaya, H. T. (2016). The
psychological impact of recognition and appreciation on job satisfaction and job
performance among IT employees: Review. The Social Sciences, 11(21), 5222-5227.
Retrieved from http://docsdrive.com/pdfs/medwelljournals/sscience/2016/5222-5227.pdf
Sikka, R., Morath, J. M., & Leape, L. (2015). The quadruple aim: Care, health, cost and meaning
in work. BMJ Quality & Safety, 24(10), 608-610. https://doi.org/10.1136/bmjqs-2015004160
84
Society for Human Resource Management. (2017). Managing employee recognition programs.
Retrieved from https://www.shrm.org/resourcesandtools/tools-andsamples/toolkits/pages/employeerecognitionprograms.aspx
Society for Human Resource Management. (2018). Managing Organizational Change. Retrieved
from https://www.shrm.org/resourcesandtools/tools-andsamples/toolkits/pages/managingorganizationalchange.aspx
Spector, P. E. (1985). Measurement of human service staff satisfaction: Development of the job
satisfaction survey. American Journal of Community Psychology, 13(6), 693-713.
Retrieved from http://shell.cas.usf.edu/~pspector/scales/ajcp85-jss.pdf
Spector, P. E. (1994). JSS scale: Original English. Retrieved from
http://shell.cas.usf.edu/~pspector/scales/jsspag.html
Spector, P. E. (2001). Job satisfaction survey, JSS. Retrieved from
http://shell.cas.usf.edu/~pspector/scales/jssovr.html
Spector, P. E. (2011a). Job satisfaction survey norms. Retrieved from
http://shell.cas.usf.edu/~pspector/scales/jssnorms.html
Spector, P. E. (2011b). Sharing results for researchers who use my scales. Retrieved from
http://shell.cas.usf.edu/~pspector/scales/share.html
Sutherland, K. (2013). Applying Lewin’s change management theory to the implementation of a
bar-coded medication administration. Canadian Journal of Nursing Informatics, 8(1).
Retrieved from http://cjni.net/journal/?p=2888
Tessema, M. T., Ready, K. J., & Embaye, A. B. (2013). The effects of employee recognition,
pay, and benefits on job satisfaction: Cross country evidence. Journal of Business and
Economics, 4(1), 1-12. Retrieved from
https://pdfs.semanticscholar.org/d999/306d685a85cbe2232a844f8415a689e985f0.pdf
The Maritz Institute. (2011). The human science of giving recognition: Creating true connections
between humans in the workplace. Retrieved from
https://www.maritz.com/~/media/Files/MaritzDotCom/White%20Papers/Motivation/Whi
te_Paper_The_Science_of_Giving_Recognition1.pdf
The University of North Carolina at Chapel Hill. (n.d.). Employee recognition handbook.
Retrieved from https://www.med.unc.edu/fbo/files/2018/08/employee-recognitionhandbook.pdf
TJinsite. (2012). Employee recognition boost their productivity. Retrieved from
http://content.timesjobs.com/tjinsite/employee-recognition-boost-theirproductivity/articleshow/57896948.cms?utm_source=jb&utm_medium=referral&utm_ca
mpaign=jobbuzz
85
Ulrich, B. T., Lavandero, R., Hart, K. A., Woods, D., Leggett, J., Friedman, D., ... Edwards, S. J.
(2009). Critical care nurses’ work environments 2008: A follow-up report. Critical Care
Nurse, 29(2), 93-102. https://doi.org/10.4037/ccn2009619
Ulrich, B. T., Lavandero, R., Hart, K. A., Woods, D., Leggett, J., & Taylor, D. (2006). Critical
care nurses’ work environment: A baseline status report. Critical Care Nurse, 26(5), 4657. Retrieved from http://ccn.aacnjournals.org/content/26/5/46.long
Ulrich, B. T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care nurse work
environments 2013: A status report. Critical Care Nurse, 34(4), 64-79.
https://doi.org/10.4037/ccn2014731
Van Saane, N., Sluiter, J. K., Verbeek, J. H., & Frings-Dresen, M. H. (2003). Reliability and
validity of instruments measuring job satisfaction—a systematic review. Occupational
Medicine, 53(5), 191-200. https://doi.org/10.1093/occmed/kqg038
Vollers, D., Hill, E., Roberts, C., Dambaugh, L., & Brenner, Z. R. (2009). AACN’s healthy work
environment standards and an empowering nurse advancement system. Critical Care
Nurse, 29(6), 20-27. https://doi.org/10.4037/ccn2009263
Yurek, L. A., Vasey, J., & Havens, D. S. (2008). The use of self-generated identification codes in
longitudinal research. Evaluation Review, 32(5), 435-452.
https://doi.org/10.1177/0193841X08316676
Zwickel, K., Koppel, J., Katz, M., Virkstis, K., Rothenberger, S., & Boston-Fleischhauer, C.
(2016). Providing professionally meaningful recognition to enhance frontline
engagement. Journal of Nursing Administration, 46(7/8), 355-356.
https://doi.org/10.1097/NNA.0000000000000357
86