The engagement chasm: Time for competency-based training in employee engagement for healthcare and beyond

Abstract

BACKGROUND:

Employee disengagement in healthcare and business is currently at unexceptionally high levels worldwide. Disengagement negatively impacts productivity, profitability, efficiency (waste reduction), innovation, quality, customer satisfaction and experience, staff well-being, safety, mortality, staff attendance, and turnover. Despite its serious detrimental impacts, no dedicated competency-based training curriculum exists for engagement as a competency.

OBJECTIVE:

To develop a competency-based educational curriculum for an Engagement Competency.

METHODS:

A curricular roadmap comprising the following steps was observed 1. Identifying the desired outcomes needed of trainees. These must help fulfill all the Q12 Gallup survey engagement items. 2. Explicitly defining the required Competencies, Entrustable Professional Activities, and Milestones, 3. Selecting the educational activities, and instructional methods, 4. Selecting the tools to assess progress along the milestones, and finally, 5. Designing an evaluation system to assess the outcomes of the engagement competency program.

RESULTS:

We developed an Engagement Competency Framework with 7 Entrustable Professional activities “rationally and practically” arranged. These are: Envision E1, Embrace E2, Empower E3, Enlighten E4, Empathize E5, Energize E6, and Evaluate E7 (the 7Es).

CONCLUSION:

The unfortunate global issue of disengagement in healthcare and in the business arena may be practically tackled by introducing Engagement Competency and training. It should be compulsory for all in the “leadership role". Such training may lead to remarkable performance improvement and a happier, more prosperous, and safer world.

Keywords

Competency-based education organizational change management leadership

1 Background

A highly engaged healthcare worker, or any employee for that matter, working in the right organization is literally a maverick. Such an employee is highly productive, enthusiastic, bursting with positive energy, providing high quality and safe service, innovative, and always prepared to go the extra mile to help achieve the organizational goals and aspirations. Unfortunately, epidemiological data confirm that such “highly engaged” employees are the exception, not the rule [1]. Like the quality chasm [2] that shocked the healthcare arena in the United States of America (USA) in the nineties, another chasm seems to characterize the current healthcare and business arena across not only the USA but the whole world. Currently only 21 % of the global workforce is genuinely engaged [1]. The negative financial and personal impacts are shocking, reaching billions of dollars in lost revenue [3] with worrisome figures in burnout and suicide [4, 5]. Burnout is the “employee’s state of mind, energy and behavior” that is the counterpart or the direct opposite of engagement. Figures of burnout in healthcare are at epidemic levels worldwide [4]. It is notable that just a small increase (1%) in employee engagement results in a 3% reduction in hospital acquired complications and a 7% reduction in hospital readmissions [6]. Gallup observed that the largest decline in Engagement in the USA was found among healthcare professionals [7].

Organizations with highly engaged employees have remarkably higher productivity, profitability, innovation, quality, customer satisfaction, and experience, staff well-being and less absenteeism, safety incidents, mortality, turnover, and shrinkage (theft) [8 –17]. Many of the shortcomings of current healthcare are directly related to staff disengagement or burnout, including poor safety practices, reduced service quality, increased wastage of resources, and increased mortality [8 , 10–16]. It is thus not surprising that employee engagement is widely considered 1) an essential tool or “prescription for organizational transformation” [18], 2) a “key competitive differentiator in the modern business landscape” [19], and 3) that “it unleashes the true potential of the workforce as it leads to superior staff performance” [19]. Furthermore, it 4) equates with “higher positive psychology and well-being of employees” [20].

A leading cause for poor staff engagement is a severe lack of strategic focus on staff engagement by seniors and leaders. This stems from an apparent failure of seniors and leaders to recognize the connection between employee engagement and organizational performance. Resolving this serious issue calls for a radical shift in seniors’ and leaders’ mindsets and skills. An initial step to attain this cultural and behavioral shift is likely achievable through a robust competency-based empowerment program focusing on staff engagement for all “leaders” in an organization. In healthcare, “leadership” shows itself at multiple levels-both at the macro and micro levels; the minister of health, the Chief Executive Officer of a hospital, the Chairman or Head of a Department, Division, or Section, the Consultant in a clinical team, the Senior Resident responsible for his junior team and finally the healthcare provider “engaging” their patients and co-patients. The ability or skill/competency to “engage” the “downstream” members of their team, patients, co-patients, etc., is thus indispensable for all in the “leadership” domain. Engaging and connecting with others is a critical element of leadership. An engaging as well as a transformational leadership style are considered vital drivers of employee engagement [21 –23]. Therefore, the objective of this study was to develop a competency-based, outcome-focused curriculum for a novel Engagement competency.

2 Methods

2.1 Engagement as a competency

Engagement, or the skill of building bridges between an employer and an employee, a leader and a follower, may be envisioned as a strategic competency that needs to be mastered. Like any other competency, a curriculum for training will need to be built in reverse, with the anticipated outcomes identified first. These outcomes should logically guarantee the attainment of all the evidence-based engagement prerequisites. In this manuscript, employee, staff, and workforce are used interchangeably.

2.2 Building a competency-based curriculum

The recommended steps in building a competency-based medical education curriculum include [24]: 1) Identifying the skills needed of trainees, i.e. the desired outcomes, 2) Explicitly Defining the required Competencies, Entrustable Professional Activities, and Milestones, 3) Selecting the educational activities, and instructional methods, 4) Selecting the assessment tools to measure progress along the milestones, and finally, 5) Designing an outcomes evaluation of the program. Entrustable Professional Activity/Activities EPA is/are the specialty or discipline tasks a trainee can be trusted to perform unsupervised. Eight characteristics must be satisfied for a task to qualify as an EPA [25]. These include “having a clearly defined beginning and end, independently executable to achieve a defined outcome, is specific and focused, observable in process and measurable in outcome, clearly distinguished from other EPAs in the framework, reflects work that is essential and important to the profession, leads to recognized output or outcome of labor, is restricted to qualified personnel, requires application of knowledge, skills, and attitudes acquired through training, involves application and integration of multiple domains of competence and describes a task, not qualities or competencies of a learner.” Milestones on the other hand, are the steps or stages for successfully executing the EPA. Milestones encompass the knowledge, skills, and behavioral or attitudinal elements necessary for the successful accomplishment of the EPA.

2.3 Identifying the determinants of employee engagement

A critical step in pinpointing the new EPAs (actionable tasks) of relevance to Engagement Competency is to identify the interventions or determinants that are known to positively impact employee engagement, i.e., the outcome is an engaged employee. These interventions or determinants represent the drivers of engagement in any work setting and will qualify as tasks or EPAs if they satisfy the eight criteria above. Numerous determinants and drivers of engagement have been identified in the literature [26 –29]. The Gallup 12 questions (GQ12) are designed to measure employee engagement and identify robust drivers or interventions that contribute to it [30]. The development of the GQ12 was based on more than 30 years of accumulated quantitative and qualitative research on millions of employees of different backgrounds and professional skills [31]. Unlike another highly publicized engagement evaluation questionnaire, the Utrecht Work Engagement Scale (UWES) [32], the Gallup 12 questions encompass formative or actionable issues that drive engagement [31], with each question focusing on a different engagement action or task. They may thus be envisaged as representing different EPAs. It is therefore imperative that the Gallup Q12 questions be used to build the EPAs. However, each engagement action must be assigned a different and specific description or designation. Additionally, and like in any EPA with its milestones, essential knowledge and attitudinal-changing concepts must be highlighted and incorporated in these EPAs’ specific training program.

3 Results

Based on Gallup’s Q12, at least 7 EPAs were deemed necessary to master and practice the Engagement competency. These, “rationally and practically arranged” are Envision E1, Embrace E2, Empower E3, Enlighten E4, Empathize E5, Energize E6, and Evaluate E7 (Engagement Competency Framework, the 7Es) (Fig. 1). Table 1 depicts the 7 EPAs and their connection to the Gallup Q12 staff engagement survey items.

Fig. 1

The 7 EPAs of engagement competency.

Table 1

The 7 EPAs and their connection to the Gallup Q12 staff engagement survey items

Gallup Q12 Item	Engagement Competency Entrustable Professional Activity
1. I know what is expected of me at work.	Envision
2. I have the materials and equipment I need to do my work right.	Empower
3. At work, I have the opportunity to do what I do best every day.	Empower
4. In the last seven days, I have received recognition or praise for doing good work.	Energize
5. My supervisor, or someone at work, seems to care about me as a person.	Empathize
6. There is someone at work who encourages my development.	Energize
7. At work, my opinions seem to count.	Embrace
8. The mission or purpose of my company makes me feel my job is important.	Envision
9. My associates or fellow employees are committed to doing quality work.	Enlighten
10. I have a best friend at work.	Empathize
11. In the last six months, someone at work has talked to me about my progress.	Evaluate
12. This last year, I have had opportunities at work to learn and grow.	Empower

3.1 Envision EPA E1: Envisioning and formulating an action plan for a future state

Envisioning is a critical step in employee engagement, not least as it remedies a common cause for poor staff engagement, the unawareness of staff of the goals and cultural values of the organization as well as their specific role and importance in attaining these goals. However, this EPA’s primary aims are to envision a highly attractive future state for both the organization and the worker and to align staff thinking and behavior with these goals. This “future state” should give the organization and employees a compelling “pulling force” towards that vision. Three critical attributes help achieve this “pulling effect.” The vision must be transformative (challenges the status quo), the future state must be full of greatness (visionary, thinking big), and there is great faith and trust that it is achievable.

At least three milestones help to execute this EPA successfully:

Outlining the future state of the organization and that of the employee.

Describing the program and the tools that will be employed to achieve the future state (the engagement program).

Imparting the new mindset, cognitive and behavioral skills, and cultural values the new employee must acquire to fulfill the above. Coaching employees to attain new mindsets, e.g., outcome-focused rather than process-focused, transformational thinking, believing in their abilities/unlimited potential, positive attitudes, and systems thinking, are pivotal for this EPA. Additionally, several organizational concepts such as strategic narratives, accountable engagement, people-centric business, enduring purpose, corporate ethics, strategic agility, and motivational culture must be highlighted and indoctrinated in the staff when executing this EPA.

Envisioning must be a part of everyday organizational practice and culture, e.g., incorporated into the organizational strategic narrative and culture. It should also be part of and regularly highlighted during staff and business meetings and integrated into the standard onboarding activities.

3.2 Embrace EPA E2: Embracing the workforce as partners with a voice

Embracing is about total employee involvement, employees having a voice in the everyday running of the service coupled with their direct participation in decision-making and progress towards the mutually agreed upon organizational outcomes. Milestones in the Embrace EPA include:

Communication with a language of rapport, welcoming new employees as partners, and emphasizing their “free voice” and democratic rights.

Highlighting to the employees and the practical incorporation and execution of essential embracement concepts such as Psychological Safety, Organizational Citizenship, Employee First, Customers Second (EFCS) Organizational Culture, Ideapreneurship, Autonomy, and Collective Genius (as tools for engagement, innovation, and progress).

3.3 Empowerment EPA E3: Empowering employees to reach their true potential

Empowerment guarantees employees proficiency and readiness to fulfill their duties to the highest standard despite difficulty or high job demands. It also ensures the staff’s continuous professional development and growth.

Milestones include:

Organizing and executing an “Onboarding Catalyst Program” for new employees.

Organizing and implementing a competency-based training program for the employees.

Assessing employee skills, talent profiling, and ability to shift and reorganize the services and staff as dictated by demands (Organizational Agility, Strategic Shifts, and Existential Flexibility).

Practicing the skills of systems thinking and system redesign.

Selecting and employing the “right” talent –primarily based on attitude and behavior not qualifications and skill-for the organization: skilled workforce recruitment.

3.4 Enlighten PA E4: Communicating the organizational and staff status and progress

Enlighten fosters a strategic communication program that maintains a timely, high-level employee awareness of organizational achievements and progress as well as their personal contribution towards the grand organizational plan.

Milestones in this EPA include:

Developing and executing a strategic communication program.

Establishing individualized and focused “communication channels or platforms” based on the organizational and personal needs of staff.

3.5 Empathize EPA E5: Building rapport with and insight about the workforce

Empathize upholds the humanity of the workforce while supporting them in fulfilling their social (including work-life balance), financial, and career needs and goals, etc. It allows for realizing the concept of “the Healing Enterprise.” After all, empathy for employees reflects on the customers and the organization. This is sometimes referred to as “return on kindness” rather than “return on investment”.

Milestones in this EPA include:

Establishing and executing an official program for regular leadership-employee contact within and outside the organization (staff retreats).

Demonstration of empathetic behavior and practice with employees.

3.6 Energize EPA E6: Refueling the workforce to keep giving and delivering

Energizing the workforce ensures they remain highly enthusiastic about their job, duties, and organizational goals. This is achieved through a robust recognition program and an effective reward system. Rewarding employees fosters engagement. In essence, engagement becomes a reciprocal “return of favor,” “reward,” or “pay-back” from their employer for their exemplary deeds.

As engagement is primarily “a personal choice” that cannot be imposed, drivers and rewards for different employees need to be individualized. Recognition, financial incentives, promotions, etc., may thus not work for every staff member.

Milestones for this EPA include:

Establishing a program for monitoring and recognizing staff contributions to the service and their personal achievements: “recognition program."

Establishing and executing a reward program individualized to staff needs and wishes, a recharge program, e.g., time-off, a regeneration/empowerment program, e.g., courses, conference attendance, etc., a reflection program, e.g., regular leader-staff meetings, feedback on staff contributions towards the organizational goals, etc.

3.7 Evaluation EPA E7: Monitoring the workforce’s and organization’s progress and achievements

Evaluation represents the governance part of the Engagement Competency. It is directed at assessing the Engager’s competency in engaging the workforce and its impact on the workforce and the organization. Evaluation helps realize the establishment of a “Listening Organization,” an entity that continuously aspires to listen to its employees and customers. Evaluation must be a continuous and regular process.

Milestones for this EPA include:

Establishing and executing an evaluation program.

Establishing a roadmap or system for timely corrective action.

Table 2 depicts the 7Es and highlights their relevant concepts and skills. Table 3 lists many “enabling actions” that the organization can undertake to consolidate the 7Es in their establishment [33, 34].

Table 2
Concepts and tools relevant to each EPA

Entrustable Professional Activity Concepts and skills Tips

Envision Knowledge:

Alignment: “Do I Fit-is there a common purpose.” “Do I Trust the administration”? The Organization:

➢ Organizational culture, vision, and goals

➢ Strategic Narrative^a

➢ Engagement Program [the 7Es]

➢ People-centric Business^b [Both Employees and Customers!]

➢ Enduring Purpose^c [Just Cause]

➢ Ethical Practice/Higher Administration

➢ Strategic Agility [Change-ready], etc.

Strategic Shifts and Existential Flexibility^d, etc.

The Employee:

➢ Staff personal responsibilities/ commitment.

➢ Aligned/Accountable Engagement^e

➢ Motivational Culture^f

Skills:

Communication Skills: The Language of Envisioning!

Attitudes/Behavior:

Mindset-shift Talks:

➢ Outcome Focused

➢ Transformational

➢ Limitless Potential

➢ Positive Thinkers

➢ Systems Thinkers

Embrace Knowledge:

“Do I feel like an Owner”? ➢ Total Employee Involvement^g: Partners, not Employees!

➢ Employee First, Customers Second [EFCS] Model^h [Cultural Shift]

➢ Ideapreneurshipⁱ

➢ Organizational Citizenship^j

➢ Autonomy^k

➢ Democratizing the Workplace: Employee Voice, Psychological Safety^l

➢ Collective Genius^m

Skills:

Communication Skills

Empower Skills:

“Am I growing, developing, achieving, progressing”? ➢ Shifting the Balance of Power-Talent Profilingⁿ “Employees Reinvent Themselves”

➢ Onboarding Catalyst Program

➢ Competency training/mentoring/ Coaching [to achieve the desired organizational and personal outcomes].

➢ “Enabling Infrastructure”: Workplace Redesign [Reimagining the physical workplace], Evidence-based System-Redesign [Structures, e.g., Specialized “Action” Teams and Processes, e.g., Standardization]

➢ Skilled-workforce recruitment

Enlightening Skills: Feedback –positive and

“Am I well-informed” “Do they Listen to me”? ➢Engaging and effective organizational and personal employee Communication Strategy constructive –is a determining factor in the pursuit of greatness.

➢ Internal Marketing°

Energize Skills: Recognize Proudly and Loudly. Exceptional leaders recognize regularly and frequently.

“Is my hard work recognized” “Does the organization recognize my blood, sweat, and tears”? ➢ Employee Recognition Program

➢ Work-life balance programs

➢ Wellness programs

➢ Visible Achievements

➢ Reward system/incentivize

➢ Sustainable employability^p

Empathize Skills: Developing meaningful

“Do they care about me”? ➢ Communication skills: Empathy ➢ Stay interviews^q Relationships: regular one-on-one meetings with staff to get to know them on a personal level, their needs, negative engagement influencers, etc.

➢ Stay Interviews^q

Accommodate the needs of the employees, e.g., social needs, healthcare needs/wellness, flexible working hours, etc.

Empathetically match organizational needs with professional interests, e.g., lateral job movement, new responsibilities, etc.

Evaluate Skills:

“Are we growing, achieving, improving?” ➢ Assessment of the engagement competency, e.g., Portfolio, 360 degrees assessments, etc.

➢ Assessment of the impacts of the organizational engagement program e.g. Engagement surveys [Gallup Q12, Utrecht Work Engagement Scale], absenteeism, burnout, staff turnover, productivity, quality etc.

Entrustable Professional Activity	Concepts and skills	Tips
Envision	Knowledge:
Alignment: “Do I Fit-is there a common purpose.” “Do I Trust the administration”?	The Organization:
	➢ Organizational culture, vision, and goals
	➢ Strategic Narrative^a
	➢ Engagement Program [the 7Es]
	➢ People-centric Business^b [Both Employees and Customers!]
	➢ Enduring Purpose^c [Just Cause]
	➢ Ethical Practice/Higher Administration
	➢ Strategic Agility [Change-ready], etc.
	Strategic Shifts and Existential Flexibility^d, etc.
	The Employee:
	➢ Staff personal responsibilities/ commitment.
	➢ Aligned/Accountable Engagement^e
	➢ Motivational Culture^f
	Skills:
	Communication Skills: The Language of Envisioning!
	Attitudes/Behavior:
	Mindset-shift Talks:
	➢ Outcome Focused
	➢ Transformational
	➢ Limitless Potential
	➢ Positive Thinkers
	➢ Systems Thinkers
Embrace	Knowledge:
“Do I feel like an Owner”?	➢ Total Employee Involvement^g: Partners, not Employees!
	➢ Employee First, Customers Second [EFCS] Model^h [Cultural Shift]
	➢ Ideapreneurshipⁱ
	➢ Organizational Citizenship^j
	➢ Autonomy^k
	➢ Democratizing the Workplace: Employee Voice, Psychological Safety^l
	➢ Collective Genius^m
	Skills:
	Communication Skills
Empower	Skills:
“Am I growing, developing, achieving, progressing”?	➢ Shifting the Balance of Power-Talent Profilingⁿ “Employees Reinvent Themselves”
	➢ Onboarding Catalyst Program
	➢ Competency training/mentoring/ Coaching [to achieve the desired organizational and personal outcomes].
	➢ “Enabling Infrastructure”: Workplace Redesign [Reimagining the physical workplace], Evidence-based System-Redesign [Structures, e.g., Specialized “Action” Teams and Processes, e.g., Standardization]
	➢ Skilled-workforce recruitment
Enlightening	Skills:	Feedback –positive and
“Am I well-informed” “Do they Listen to me”?	➢Engaging and effective organizational and personal employee Communication Strategy	constructive –is a determining factor in the pursuit of greatness.
	➢ Internal Marketing°
Energize	Skills:	Recognize Proudly and Loudly. Exceptional leaders recognize regularly and frequently.
“Is my hard work recognized” “Does the organization recognize my blood, sweat, and tears”?	➢ Employee Recognition Program
	➢ Work-life balance programs
	➢ Wellness programs
	➢ Visible Achievements
	➢ Reward system/incentivize
	➢ Sustainable employability^p
Empathize	Skills:	Developing meaningful
“Do they care about me”?	➢ Communication skills: Empathy ➢ Stay interviews^q	Relationships: regular one-on-one meetings with staff to get to know them on a personal level, their needs, negative engagement influencers, etc.
	➢ Stay Interviews^q
		Accommodate the needs of the employees, e.g., social needs, healthcare needs/wellness, flexible working hours, etc.
		Empathetically match organizational needs with professional interests, e.g., lateral job movement, new responsibilities, etc.
Evaluate	Skills:
“Are we growing, achieving, improving?”	➢ Assessment of the engagement competency, e.g., Portfolio, 360 degrees assessments, etc.
	➢ Assessment of the impacts of the organizational engagement program e.g. Engagement surveys [Gallup Q12, Utrecht Work Engagement Scale], absenteeism, burnout, staff turnover, productivity, quality etc.

^aA strategic narrative centers on the organizational ability to articulate a focused and persuasive vision and strategy for the organization’s future. It explains why the organization exists and what makes it unique, thus inspiring employees and attracting customers. ^bA people-centric organization is defined as putting people at its heart—the people it serves [Consumers] and the people it employs [Employees]. These companies focus on their employees’ well-being, satisfaction, and specific needs. ^cAn Enduring Purpose [Just Cause] is a morally right and fair reason for action that the employee is prepared to execute, defend, or advocate. ^dStrategic agility/ Strategic Shifts and Existential Flexibility refer to an organizational ability to quickly shift and appropriately respond to changing needs or circumstances while maintaining its vision and focus. ^eAligned/Accountable Engagement-Actions primarily and specifically taken to attain the collective organizational goals, rather than just for delivering a service, thus tying commitments to agreed-upon results or outcomes. ^fA focus on the “motivational forces” that drive performance: Salary, Rewards, Work-life Balance, Wellness, Work Ethics, Transparency, Culture, Learning, Career Growth, and Communication. ^gTotal Employee Involvement-an employee-centric program that empowers them to actively get involved in the “thinking and running” of the business, thus utilizing their creative cognitive skills and physical talents to achieve the organizational objectives. ^hEmployee First, Customers Second [EFCS] Model- Staff is the most valuable asset a business can have: Human Capital. An outstanding employee experience drives both employee engagement as well as customer experience. ⁱIdeapreneurship- grassroots [rather than management-driven, employee-embraced], customer-focused innovation that empowers individual employees with the freedom and the responsibility to develop innovative solutions to organizational and customer challenges. ^jOrganizational Citizenship-is the pan-organizational involvement of the employees and their invaluable input towards their colleagues, customers, etc., that transcends job descriptions and job boundaries. ^kAutonomy in decision-making coupled with accountability drives Engagement and fulfillment of organizational goals and also promotes job mastery. ^lPsychological Safety- is the culture that reassures the employees that they will not be blamed or punished for voicing their concerns, highlighting mistakes, questioning their seniors, or suggesting new ideas. ^mCollective Genius is the bringing together of employees’ creative ideas and “slices of genius” to advance the organizational purpose. ⁿShifting the Balance of Power-Talent Profiling-the science of scrutinizing employees’ capabilities and their empowerment to take up new roles and responsibilities. It centers on the behavioral, cultural, and organizational shifts that are pivotal in empowering the users and providers of a service to transform their current [unacceptable] reality. °Internal Marketing is about viewing and approaching employees as “Internal Customers” and “Internal Marketers.” Employees are cared for as customers and trained to advocate for the organizational mission and vision. ^pSustainable employability-the capacity and capability of an employee to remain “in employment". It encompasses prerequisites such as good health, financial stability, career progress, and other job-related factors that preserve a healthy and long employee-employer contract. ^qStay Interviews- as opposed to exit interviews, are structured or standardized interviews run with employees still at work, usually highly skilled or talented staff, to gauge their satisfaction with their job and the need for any improvements or change.

Table 3

Enabling actions for the engagement competency EPAs

Engagement Competency EPA	Enabling actions
Envision	Show that their work is meaningful/important for the organization.
	Share your company culture with your staff.
	Develop and share a strategic narrative.
	Share the company’s enduring purpose [just cause].
	Employee First, Customer Second Model!
	Organizational citizenship.
	Create a roadmap to achieve professional goals.
	Set team goals.
	Set individual goals.
	Share company KPIs/specific goals.
	Maintain fair and ethical work practices.
Embrace	Ask for their opinions in big decisions.
	Get their feedback.
	Recognize work anniversaries.
	Make sure they feel safe and give them a strategy if they don’t.
	Allow for anonymous feedback/Q&A.
	Immediately act on feedback.
	Encourage them to take calculated risks [Autonomy].
	Make sure their basic needs are met: safety, cleanliness, etc.
	Allow employees to move laterally [change job] within the organization.
Empower	Give them the tools they need.
	Assign mentors to new hires.
	Provide ongoing coaching and employee training.
	Assess their individual strengths: Give your employees more responsibility, not just more tasks to do!
	Let employees lead meetings.
	Have completely open brainstorms!
	Make them part of the hiring process.
	Support them as they grow.
	Respond with “yes, and”: no immediate NO!-Ideapreneurship!
	Lunch & Learns [hosted by employees]
	Bring in an in-office motivational speaker
Enlighten	Open consistent lines of “transparent” communication.
	Start a newsletter.
	Keep new hires involved with the team/service.
	Be transparent about diversity/inclusive of all employees.
	Host retrospectives after big projects or each quarter.
	Put up a community board for social events, personal adverts etc.
	Share the “why” behind decisions, not just the “what”.
	Criticize privately.
	Share praise publicly.
	Invest in an employee experience platform.
Empathize	Try flexible work hours.
	Offer sick days in addition to vacation days.
	Offer a wellness/mindfulness workshop.
	Add some healthy snacks to the office/hot or cold beverages dispenser.
	Encourage work/life balance.
	Have different types of workspaces [cubicle/non-cubicle]-as per staff preferences.
	Get to know everyone on a personal level.
	Recognize the signs of burnout.
	Let them personalize their work uniform.
	Match their charitable donations.
	Provide mental health support/resources.
	Make sure they’re actually taking breaks [not just eating lunch at their desks].
	Set clear boundaries and expectations for after-work hours communication.
	Give them their own space [let them personalize it] e.g. staff lounge, overnight room.
	Treat others as you would like to be treated.
	Find out what your team members are passionate about.
Energize	Meet with your team on a regular basis: business meetings, informal etc.
	Show employees how their job advances the company’s vision.
	Recognize their hard work: Incentivize goals.
	Create an employee recognition program.
	Send tangible appreciation that shows you care e.g. email, gift etc.
	Volunteer together with your staff!
	Encourage personal projects.
	Promote from within instead of a new hire!
	Employee of the month awards!
	Have a free team lunch.
	Keep pay competitive.
	Get your health and wellness program in order.
	Offer gym and wellness discounts.
	Hold family events/ have more fun.
	Make sure they take vacation.
	Sponsored company lunch/meal.
	Give feedback more than once a year.
	Encourage individual recognition from team members, not just management.
	Give them extra time off just because “you value them”.
	Create clubs for different hobbies and interests.
	Try gamification.
	Have them write their ideal job description/new responsibilities/actions.
	Recognize any “invisible extra work” and share the mental load.
	Give them stretch goals/new projects.
	Consider profit-sharing/making them part of the company.
	Give your people “inside” information e.g. challenges, achievements etc.
	Encourage some friendly competition e.g. sales targets.
	Learn to identify toxic coworkers and have a gameplan.
	Encourage volunteering
Evaluate	Pay attention to Glassdoor reviews.
	Hold stay interviews
	Hold exit interviews.
	Send out an employee engagement surveys to get honest feedback

3.8 The 7Es in patient and family engagement

The 7Es are robustly suited to guide clinicians and healthcare providers to powerfully and effectively engage their patients [35, 36]. This will surely improve both patient experience as well as boost the quality and desired outcomes of care [35, 36]. In essence, it will help realize the requirements for value-based healthcare [37]. Table 4 is an example of employing the 7Es in engaging a patient with obesity and its comorbidities.

Table 4
The 7Es: Engaging a patient for a super patient experience and top-class quality of care:

Case Scenario 35-year-old, mother of 4, a housewife. A significant concern is restricted mobility because of secondary osteoarthritis of both knees. She is distraught as she can no longer enjoy her daily stride in her home garden and the nearby park. BMI is 37 Kg/m2. Other issues are pre-diabetes. Hemoglobin A1C is 6.4. Obstructive sleep apnea OSA on Continuous Positive Airway Pressure CPAP at night, dyslipidemia, and hypertension. Medications include Metformin 1000 mg BID, Atorvastatin 20 mg OD, Amlodipine 5 mg OD, and Losartan 100 mg OD.

Envision Alignment Dear Mrs. Smith, may we agree on our goals in the management plan I am going to discuss with you. We aim to help you improve your BMI to 30 within the next six months. Hopefully, this will have a very favorable impact on your OSA, hypertension, and A1C. I can imagine you having much less pain from your knees and you will be able to enjoy your regular walks in your garden again.

Embrace Patient/family-centered care-patient and family involvement and voice I would very much value your involvement in reaching a management strategy. Several interventions can help you lose weight. I need to have your decisions and preferences on the ones you feel most comfortable with.

Empower Highly empowered and educated patient I shall explain to you all the pros and cons of each. I shall also provide you with educational materials and decision-support tools, for that matter. I shall also arrange a meeting for you with our dietitian and any other relevant specialist, e.g., the endocrinologist or surgeon if needed.

Enlighten “Well-informed” “Do they listen to me” Your current weight is 120 Kg, blood pressure is 142/86, A1C is 6.4, and LDL is 2.1 mmol/l. The target weight in 6 months is 100 Kg, BP 130/80 or less with stable or improved A1C and LDL. I am happy to hear your comments and suggestions regarding these parameters.

Empathy Rapport & humane communication I very much appreciate and do understand your concerns. I can see your resolve in dealing with these health issues and shall support you. Any other matters you wish to mention or actions you want me to take?

Energize Refueling to reach goals I am optimistic you will achieve the targets above, seeing how courageous you are in facing these health issues. I am sure you will beat me in the upcoming city marathon in a few months!

Evaluate Monitoring progress I shall follow you every 4–8 weeks to monitor your progress and if any extra help is needed. Here are some contact numbers to keep me and the team posted about your progress.

Case Scenario	35-year-old, mother of 4, a housewife. A significant concern is restricted mobility because of secondary osteoarthritis of both knees. She is distraught as she can no longer enjoy her daily stride in her home garden and the nearby park. BMI is 37 Kg/m2. Other issues are pre-diabetes. Hemoglobin A1C is 6.4. Obstructive sleep apnea OSA on Continuous Positive Airway Pressure CPAP at night, dyslipidemia, and hypertension. Medications include Metformin 1000 mg BID, Atorvastatin 20 mg OD, Amlodipine 5 mg OD, and Losartan 100 mg OD.
Envision	Alignment	Dear Mrs. Smith, may we agree on our goals in the management plan I am going to discuss with you. We aim to help you improve your BMI to 30 within the next six months. Hopefully, this will have a very favorable impact on your OSA, hypertension, and A1C. I can imagine you having much less pain from your knees and you will be able to enjoy your regular walks in your garden again.
Embrace	Patient/family-centered care-patient and family involvement and voice	I would very much value your involvement in reaching a management strategy. Several interventions can help you lose weight. I need to have your decisions and preferences on the ones you feel most comfortable with.
Empower	Highly empowered and educated patient	I shall explain to you all the pros and cons of each. I shall also provide you with educational materials and decision-support tools, for that matter. I shall also arrange a meeting for you with our dietitian and any other relevant specialist, e.g., the endocrinologist or surgeon if needed.
Enlighten	“Well-informed” “Do they listen to me”	Your current weight is 120 Kg, blood pressure is 142/86, A1C is 6.4, and LDL is 2.1 mmol/l. The target weight in 6 months is 100 Kg, BP 130/80 or less with stable or improved A1C and LDL. I am happy to hear your comments and suggestions regarding these parameters.
Empathy	Rapport & humane communication	I very much appreciate and do understand your concerns. I can see your resolve in dealing with these health issues and shall support you. Any other matters you wish to mention or actions you want me to take?
Energize	Refueling to reach goals	I am optimistic you will achieve the targets above, seeing how courageous you are in facing these health issues. I am sure you will beat me in the upcoming city marathon in a few months!
Evaluate	Monitoring progress	I shall follow you every 4–8 weeks to monitor your progress and if any extra help is needed. Here are some contact numbers to keep me and the team posted about your progress.

3.9 Instructional methods and assessment

Like other competency-based training curricula, a learner-centered approach is desirable. A combination of instructional methods is recommended, including Lectures or Large Group Sessions, Workshops, Case Discussions and Presentations, Small Group Activities, and Guided Reflection and Coaching. Muti-source feedback, portfolios, and logbooks may help assess the acquisition of the EPAs and their milestones. Regular staff satisfaction surveys, e.g., the Gallup Q12 or Utrecht Work Engagement Scale or other indirect engagement metrics, such as absenteeism or turnover rates, assist in assessing the program’s outcomes.

4 Discussion

Engagement is a transformative tool that supports organizations in becoming agile, progressive, and innovative. Engagement sets free employees’ minds and unties their hands, unleashes their full potential, and empowers them to fulfill their duties to the customer and organization to the highest possible standard. Employee engagement is quoted as the difference that makes the difference and may make all the difference. It amounts to being unethical, depriving the workforce of the necessary engagement tools and tactics.

It is theorized that poor engagement is primarily related to a lack of fulfillment of the basic human desires and aspirations as proposed in Maslow’s Hierarchy of Needs pyramid [38]. Thus, lack of basic personal social and financial safety, poor inclusion, belonging, recognition, team spirit, and poor career progress and growth are the root causes of non-engagement. Interestingly, the 12 items of the Gallup Q12 engagement questionnaire mirror the domains of Maslow’s hierarchy, namely basic needs (questions 1 and 2), personal or individual needs (questions 3–6), teamwork (questions 7–10), and growth (questions 11 and 12) (Table 1). These are the drivers of engagement and can logically be envisaged as EPAs for a competency training curriculum and framework. These EPAs are designated the 7Es of engagement, which are logically and sequentially titled Envision, Embrace, Empower, Empathize, Enlighten, Energize, and Evaluate.

Envisioning is about creating a future image for the organization and the employee, a joint venture for both to realize. Embracing is about creating a climate for change where everyone can contribute as an owner! Empowerment supports the creation of a highly capable and responsive workforce. Enlightening creates a top-down, bottom-up communication channel and a family-like support network between staff. Empathy maintains and upholds the humanity of the whole organization. Energizing maintains momentum and keeps the mission, vision, and hopes alive. Finally, evaluation assesses progress to greatness by ensuring that “everything is going according to plan.” The 7Es are generic guiding principles for “any” engagement action. They are actionable EPAs for both employees as well as patients and families. They will also provide a guiding compendium for effective trainees’ and students ‘engagement. Many of the highlighted engagement actions for effective learning are solidly incorporated in the 7Es, e.g. setting expectations (envisioning), empowerment, competence, autonomy and relatedness, and feedback [39 –41].

It is paramount that the Engager, e.g., Chairman, Manager, Consultant Clinician, Senior Resident, etc., masters and understands what engagement is and its drivers. According to the Gartner Report, “the best organizations rely on their workforce, not executives, to lead transformational change.” Empowering “leaders” with the right EPAs, concepts, and tools of Engagement Competency is the first step in championing an engagement revolution. The whole engagement program starts and ends with the “leaders” in its broadest sense. It is imperative that chairpersons, managers, heads, consultants, senior residents, and directors of any clinical or non-clinical teams or groups be made aware of and trained in this competency!

5 Conclusion

The new Engagement Competency Framework may help in narrowing the global engagement chasm. Its seven EPAs, milestones, and concepts should help empower “leaders” with the tools and knowledge to transform their organizations and create a highly engaged, high-performing workforce. Engagement competency and training may also help resolve many serious challenges of modern health care, such as poor quality, high expenditure, burnout, poor patient experience, and loss of talent (brain drain). The 7Es have practical implications and foreseeable benefits in both the generic employee/follower successful engagement and in the specific clinical trainee, patient and family engagement domains. It is paramount that Employee Engagement becomes a strategic goal for every government or ministry of health, an action that the United Kingdom government exemplified a few years ago [42]. It is plausible that improving employee engagement will help realize a happier, more prosperous, and safer world.

5.1 Limitations

The main limitations of this review are the predominant use of qualitative data in the included articles about drivers of employee engagement and the lack of standardization for the engagement determinants highlighted in these articles. The latter made the articles difficult to compare. Our framework of EPAs is primarily based on the tasks highlighted in Gallup’s Q12 evaluation questionnaire. This may have excluded other drivers or tasks relevant to employee engagement.

Footnotes

Acknowledgments

The authors wish to acknowledge the constructive suggestions and feedback they received from the academic staff from multiple academic institutes.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Funding

The authors report no funding.

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