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Bailey C, Madden A, Alfes K, et al. Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.26.)

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Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature.

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Chapter 4Engagement and morale

Introduction

The focus of this chapter is on research question 2.1:

What evidence is there that engagement is relevant for staff morale?

In order to address this we have developed two subquestions:

  1. What is the evidence that engagement is relevant for staff morale within the workforce in general?
  2. What is the evidence that engagement is relevant for staff morale within the context of health?

The purpose of addressing this question is to evaluate the evidence concerning the link between engagement and morale outcomes. In particular, this chapter aims to identify which morale outcomes have been demonstrated empirically to be most significantly affected by, or at least associated with, high levels of engagement within the general workforce and within the health context specifically. To address these questions, we undertook the data extraction process described in detail in Chapter 2.

First, we review the general background and context for the research questions (next section). We then present the evidence we have assembled from our data extraction exercise in relation to the general workforce, followed by an analysis of the health context. We have included in this latter section any study that includes a sample of health-care workers, even if part of a wider sample involving a range of occupations. Finally, we bring together these findings to suggest which morale outcomes are most likely to be associated with high levels of engagement (Conclusions).

Background to morale outcomes relevant to engagement

A main concern within the prior research has been to identify which morale outcomes are associated with high levels of engagement. We have interpreted ‘morale’ in a wide sense and these morale outcome factors can be grouped under two headings:

  • well-being and health perceptions, includes measures of life satisfaction,149 general and psychological health (e.g. the 12-item General Health Questionnaire;150 Beck’s Depression Inventory151), stress/burnout (e.g. MBI152) and various other aspects such as affect,153 work ability154 and recovery155
  • work-related attitudes, including measures of organisational commitment,156,157 job or career satisfaction,158,159 occupational or career success160 and turnover intentions.161,162

In total, 35 studies examined the relationship between engagement and morale outcomes within the general workforce, and 12 studies examined the relationship between engagement and morale outcomes within the health context. Table 14 shows the breakdown of studies that satisfied the inclusion criteria, first across the two main categories, and second across the subcategories. It should also be noted that many studies examined more than one outcome (although not usually more than two or three), and a minority included outcome variables from both well-being/health perception and work-related attitude categories. Therefore the numbers in the subcategories do not add up to the numbers in the overall categories.

TABLE 14

TABLE 14

Number of studies satisfying inclusion criteria for morale outcomes

Furthermore, many studies examined the link between engagement and morale outcomes as part of a larger hypothesised model. These models tended to include a number of antecedents theorised to be related to engagement (see Chapter 6), engagement as a mediator (and, for some, other mediators such as burnout) and potential morale and/or performance outcomes (see Chapter 5). The focus for this chapter is on the specific relationship between engagement and morale outcomes; therefore, no particular details regarding any larger hypothesised model tested have been included here.

Almost all included studies have examined engagement as a psychological state experienced in relation to work in general terms (see Chapter 3, The origins and definitions of employee engagement), and have used quantitative, survey-based methods to examine how engagement relates to self-reported morale indicators. Therefore, most studies reviewed in this chapter reflect a specific and narrow research focus. Moreover, the vast majority of the studies utilised a cross-sectional, between-persons design, so causality is difficult to demonstrate.

The workforce in general

The data on morale outcomes in relation to the workforce in general are reported in Table 15.

TABLE 15

TABLE 15

Engagement and morale in the general workforce

Study considerations

Geographical considerations

Ten out of the 35 studies were conducted in Europe (representing the Netherlands, Germany, Spain, Italy, Finland, Sweden, Norway and Poland), seven in the USA or Canada, four in Africa (including South Africa and Cameroon), four in Asia (China, Japan and Malaysia), four in the UK, three in India and two in Australia or New Zealand. One was ‘international’, as it sampled teachers from Australia, Indonesia, China, Oman and Canada177 (see Appendix 18).

Measurement and analysis considerations

Twenty-seven of the studies used the UWES measure of engagement. Sixteen of these applied the 9-item version, seven applied the 17-item version and four applied an alternative: Ratnasingam et al.137 applied a 7-item version, Extremera et al.106 applied a 15-item version and Vera et al.188 applied a 16-item version. Simbula182 applied the 9-item UWES to measure general engagement and a shortened 5-item version to measure daily engagement.

Other measures used were Britt’s102 engagement measure, May et al.’s22 psychological engagement measure, Rich et al.’s4 job engagement measure, Saks’s72 measure of job and/or organisation engagement and Soane et al.’s70 ISA engagement measure. Jenkins and Delbridge,78 who conducted a qualitative study, did not explicitly measure engagement via a self-report scale. See Chapter 3 for further details.

Fifteen of the studies used multiple regressions to test the relationships between engagement and morale, and a further nine used structural equation modelling. Five used correlations, three used multilevel/hierarchical linear modelling, one used latent path analysis, one used usability analysis and one used comparative qualitative analysis.

Only seven conducted an alternative to the between-persons cross-sectional design. Three conducted repeated-measures designs in the form of a quantitative diary. Simbula182 used a design with one measurement occasion per day for five consecutive working days and Sonnentag et al.184 used a design with two measurement occasions per day (i.e. beginning and end of day) for five consecutive working days. Sonnentag et al.183 used a design with two measurement occasions per week (i.e. beginning and end of week) for four consecutive working weeks. Two conducted time-lagged studies (i.e. independent variables measured at time 1 and dependent variables measured at time 2). Karatepe and Ngeche132 used a 1-month time lag and supervisor reports, and Halbesleben and Wheeler170 used a 2-month time lag. Two utilised a longitudinal design: Yalabik et al.191 used a cross-lagged design where the interval between time 1 and time 2 was 1 year; Shimazu et al.181 used a 7-month interval between time 1 and time 2, and calculated the change in variables between these time points.

Lastly, 23 of the studies examined engagement and morale outcomes within the scope of a larger theoretical model that linked antecedents of engagement (see Chapter 6) and outcomes of engagement (see Chapters 4 and 5) through the psychological state of engagement. Although this chapter focuses on the specific relationships between engagement and morale outcomes, it should be noted that engagement is often positioned (and found empirically) to mediate (often partially) the relationship between work/organisational factors (see Chapter 6) and morale/performance outcomes.

Sample considerations

Nine of the studies sampled a range of occupations and organisations. The majority (75%) of the studies focused on a specific occupational group and/or organisational setting. Of these, nine sampled employees from education and public service sectors (e.g. teachers/university staff, police officers, firefighters), six sampled employees from hospitality and service sectors (e.g. restaurants, hotels, retail shops, call centres), six sampled employees from professional services sectors [e.g. information and communication technology (ICT), financial, consultancy] and five sampled employees from manufacturing, production and construction industries.

Theoretical considerations

Twenty-six of the studies applied a specific theory as the main theoretical rationale. Of these, 11 applied the JD-R model192,193 (note that one uses a variant called the resources–experiences–demands model), seven applied SET194 or a related theory (e.g. procedural justice/organisational support), two applied Kahn’s21 engagement theory and one applied Fredrickson’s broaden-and-build theory.146 Five applied an alternative theory (such as self-determination or self-efficacy).

Nine of the studies did not use a specific theoretical rationale and instead either applied a general rationale based on work engagement/burnout literature or did not explicitly state an underlying theoretical basis for their hypotheses.

The relationship between engagement and well-being/health perceptions

Life satisfaction

Three studies examined the relationship between engagement (as a holistic factor) and life satisfaction as an outcome. Steele et al.185 and Shimazu and Schaufeli180 found that engagement was positively associated with life satisfaction; Shimazu et al.181 found using a time-lagged design that engagement was associated with increased life satisfaction during a 7-month period. Extremera et al.106 examined the relationship between each of the work engagement dimensions and life satisfaction, and found that only dedication (not vigour or absorption) was significantly (positively) associated with life satisfaction.

General and psychological health

Six studies examined the relationship between engagement and general/psychological health as an outcome. Shimazu and Schaufeli180 found that engagement was negatively associated with ill health, and Shimazu et al.181 found, using a time-lagged design, that engagement was associated with reductions in self-reported ill health during a 7-month period. Hallberg and Schaufeli99 found that engagement was negatively correlated with depressive symptoms, somatic complaints and sleep disturbances. Buys and Rothmann168 conducted regressions, controlling for emotional exhaustion, and found that engagement was positively associated with social functioning, but the relationships between engagement and somatic functioning and between engagement and depressive symptoms were non-significant, as these were best predicted by emotional exhaustion. Hopkins and Gardiner172 found that engagement was negatively associated with psychological distress. Simbula182 examined the relationship between engagement and mental health at both the ‘general’ and the ‘day’ level. ‘General’ engagement was positively correlated with ‘general’ mental health, and day-level engagement was positively associated with day-level mental health.

Stress/burnout

Four studies examined the relationship between engagement (as a holistic factor) and stress/burnout as outcomes. Both Buys and Rothmann168 and Hallberg and Schaufeli99 found that engagement was negatively correlated with two dimensions of burnout (i.e. emotional exhaustion and cynicism, the only dimensions assessed). Both Sardeshmukh et al.179 and Simbula182 found that engagement was negatively correlated with emotional exhaustion (the only dimension assessed).

Five studies examined the relationship between the dimensions of work engagement and dimensions of burnout. These studies show mixed results. Dylag et al.136 found that each of the three dimensions of work engagement (i.e. vigour, dedication and absorption) was negatively correlated with emotional exhaustion and cynicism and positively correlated with professional self-efficacy. Extremera et al.106 found that each of the three dimensions of work engagement (i.e. vigour, dedication and absorption) was negatively associated with emotional exhaustion and depersonalisation, and positively associated with personal accomplishment. Vera et al.188 found that vigour and dedication were negatively correlated with all four dimensions of burnout (exhaustion, cynicism, depersonalisation, lack of professional self-efficacy), whereas absorption was significantly (negatively) associated only with cynicism and lack of professional self-efficacy. Høigaard et al.118 found that, when personal efficacy was controlled for (although this was a non-significant predictor of emotional exhaustion), only absorption (not vigour or dedication) was significantly (and positively) associated with emotional exhaustion. Høigaard et al.’s118 finding that absorption is positively associated with emotional exhaustion is at odds with the common hypothesis that engagement should be negatively correlated with burnout. Halbesleben’s195 meta-analysis of 53 studies found that the three dimensions of engagement (i.e. vigour, dedication and absorption) were negatively associated with three dimensions of burnout (i.e. exhaustion, depersonalisation and reduced efficacy).

Other aspects

Airila et al.164 found that engagement was positively associated with three subdimensions of work ability (current work ability generally, in relation to job demands and in relation to psychological resources), but not significantly associated with the other three subdimensions of work ability (diseases, sick leaves, own prognosis of work ability). Sonnentag et al.183 found that ‘general’ engagement was positively associated with positive affect on Friday afternoon and negatively associated with negative affect on Friday afternoon. In addition, for persons with a high level of general engagement, psychological detachment from work during off-job time was positively related to positive affect on Friday afternoon whereas, for persons with a low level of engagement, psychological detachment from work during off-job time was not significantly related to positive affect on Friday afternoon. Sonnentag et al.184 found that engagement at the beginning of the day positively predicted subsequent recovery level at the end of the workday after controlling for morning recovery level. In addition, the relationship between engagement and recovery at the end of the workday was stronger when situational constraints were low rather than high.

Lastly, Jenkins and Delbridge78 conducted a comparative qualitative study within two UK-based organisations. They found that engagement may not be universally ‘good’ for morale, as it depends on the way in which management view engagement and its purpose as well as benefits. They suggest that if engagement is pursued for purely instrumental purposes (such as for performance or competitive advantage) then it may be detrimental to morale whereas if engagement is pursued as a legitimate outcome in its own right then it may promote morale.

The relationship between engagement and work-related attitudes

Job satisfaction

Six studies examined the relationship between engagement (as a holistic factor) and job satisfaction as an outcome.72,141,137,166,177,185 All of these studies found that engagement was positively associated with job satisfaction. However, Yalabik et al.191 conducted a cross-lagged longitudinal design and found that job satisfaction may act as an antecedent rather than an outcome because engagement mediated the relationship between job satisfaction and turnover intentions. It should be noted that some studies of engagement (see Chapter 6) position job satisfaction as an antecedent rather than an outcome of engagement. Therefore it is unclear whether job satisfaction should be considered an antecedent or an outcome, although Yalabik et al.’s191 longitudinal study suggests it should be considered an antecedent.

Simbula182 examined the relationship between engagement and job satisfaction at both the ‘general’ and ‘day’ levels. They found that ‘general’ engagement was positively correlated with ‘general’ job satisfaction, and that day-level engagement was positively associated with day-level job satisfaction. Vincent-Höper et al.189 used subjective occupational success (i.e. career satisfaction, social and career success) rather than job satisfaction as an outcome and found that engagement was positively associated with subjective occupational success.

In addition, three studies examined the relationship between the dimensions of work engagement and job satisfaction. These studies showed mixed results. Vera et al.188 found that all three dimensions (vigour, dedication and absorption) were correlated with job satisfaction. Wefald et al.101 found that vigour and dedication, but not absorption, were significantly (and positively) associated with job satisfaction, whereas Høigaard et al.118 found that only dedication was significantly (and positively) associated with job satisfaction after self-efficacy was controlled for. These inconsistencies highlight the issue of analysing the dimensions rather than the composite whole of engagement.

Organisational commitment

Six studies examined the relationship between engagement (as a holistic factor) and organisational commitment as an outcome.72,141,168,166,167,173 All found that engagement was positively associated with organisational commitment. Wefald et al.101 examined which dimensions and measures of engagement were most associated with organisational commitment. They found that vigour and dedication (but not absorption) of the UWES and the physical strength dimension of Shirom’s84 vigour construct were significantly (positively) associated with organisational commitment. Britt et al.’s190 measure of engagement was not significantly associated with organisational commitment.

Turnover intentions

Fourteen studies examined the relationship between engagement (as a holistic factor) and turnover intentions as an outcome.70,72,99,104,132,163,165,170,173,174,177,185,187,191 All found that engagement was negatively associated with turnover intentions. Of these, four are particularly noteworthy. Juhdi et al.174 examined organisational engagement72 rather than job or work engagement, and Yalabik et al.191 utilised a cross-lagged longitudinal design. Both Halbesleben and Wheeler170 and Karatepe and Ngeche132 used a time-lagged study and found that the relationship between engagement and turnover intentions may be influenced by job embeddedness: ‘the combined forces that keep a person from leaving his or her job’ (p. 159).196 For Halbesleben and Wheeler170 engagement was negatively correlated with turnover intentions, yet, when both engagement and job embeddedness were included in a usefulness analysis, engagement did not explain any unique variance in turnover intentions whereas job embeddedness did. However, they did not conduct any further analysis to examine whether or not job embeddedness may mediate the relationship between engagement and turnover intentions. Karatepe and Ngeche132 did conduct a mediation analysis and found that the relationship between engagement and turnover intentions was partially mediated by job embeddedness.

In addition, three studies examined the relationship between dimensions of engagement and turnover intentions as an outcome. These show mixed results. Mendes and Stander178 found that dedication, but not vigour and absorption, was significantly (negatively) associated with turnover intentions, whereas Høigaard et al.118 found that, when personal efficacy was controlled for, absorption, but not vigour and dedication, was significantly (positively) associated with turnover intentions. Høigaard et al.’s118 finding that absorption is positively associated with turnover intentions is at odds with the common hypothesis that engagement should be negatively correlated with turnover intentions. Wefald et al.101 found that, when job satisfaction and organisational commitment were controlled for, neither the UWES nor Britt et al.’s190 measure of engagement explained any additional variance in turnover intentions. They conclude that the relationship between engagement and turnover intentions is likely to be mediated by organisational commitment and/or job satisfaction. Relating this to the findings of Karatepe and Ngeche,132 it seems that the relationship between engagement and turnover intentions may be mediated by work-related attitudes.

The health context

The data relating to morale outcomes in the health context are reported in Table 16.

TABLE 16

TABLE 16

Engagement and morale in the health context

Study considerations

Geographical considerations

Three out of the twelve reported on data from samples in Europe (representing Finland, Belgium and Germany), two from samples in Australia, two from samples in Canada, two from samples in China, one from a sample in Scotland and one from a sample in Ireland, as well as one198 that took samples from mixed sites: the USA and Australia (see Appendix 18).

Measurement and analysis considerations

The UWES was used in all of the studies, with the 9-item version applied in the majority of cases. Two-thirds used structural equation modelling to test the relationships between engagement and morale. The remainder used multiple regressions, except Van Bogaert et al.,208 who used multilevel/hierarchical linear modelling, as the individual was nested within the clinical unit. Only one was longitudinal in design.202 This used a three-wave design with a 3-year interval between time 1 and time 2 and a 4-year interval between time 2 and time 3. Lastly, around three-quarters of the studies tested the relationship between engagement and morale indicators within a larger theoretical model that linked antecedents and outcomes via the psychological state of engagement.

Sample considerations

Sample sizes ranged from just over 100 to just under 2000 individuals. Just under half of the studies reported bias towards females, and just under half reported some bias towards younger age groups due to the population targeted, for example early-career health professionals. Just over half of the studies sampled employees from a particular occupational group within the health sector. Three of these sampled only nurses; the remaining four sampled one occupational group representing surgeons, midwives or dentists/dental nurses.

Theoretical considerations

Two-thirds applied the JD-R model192,193 as the main theoretical rationale, one applied conservation of resources theory209,210 and one applied SET.194 The remaining two did not specify a particular theory.

The relationship between engagement and well-being/health perceptions

Life satisfaction

One study examined the relationship between engagement and life satisfaction as an outcome. Hakanen and Schaufeli202 found that engagement positively predicted life satisfaction from time 1 to time 2 (3-year interval) and from time 2 to time 3 (4-year interval) in a sample of dentists.

General and psychological health

Three studies examined the relationship between engagement and general/psychological health as an outcome. Freeney and Fellenz201 found that engagement was positively associated with general health in a sample of midwives. Hakanen and Schaufeli202 found that engagement negatively predicted depressive symptoms from time 1 to time 2 (3-year interval) and from time 2 to time 3 (4-year interval) in a sample of dentists. Poulsen et al.205 found that engagement was positively associated with subjective well-being in a sample of cancer workers.

Stress/burnout

One study examined the relationship between engagement and stress/burnout as outcomes. Fong and Ng199 found that engagement was negatively associated with both stress and burnout in a sample from Chinese elderly care settings. However, the association was weak for the former relationship.

Other aspects

Mache et al.204 found that engagement was positively associated with work ability (i.e. ‘the sum of factors enabling an employed person in a certain situation to manage his/her working demands successfully’; p. 317).

The relationship between engagement and work-related attitudes

Job satisfaction

Two studies examined the relationship between engagement and job satisfaction as an outcome. Both Spence Laschinger206 and Van Bogaert et al.208 found that engagement was positively associated with job satisfaction. The former study also found a positive association between engagement and career satisfaction.

Organisational commitment

Three studies examined the relationship between engagement and organisational commitment as an outcome.197,198,203 All found a positive association between engagement and organisational commitment.

Turnover intentions

Seven studies examined the relationship between engagement and turnover intentions as an outcome.197,198,200,203,206208 All found that engagement was negatively associated with turnover intentions (note: Van Bogaert et al.208 used a positive valence scale representing intention to stay). Spence Laschinger206 also found a positive association between engagement and career turnover intentions. Both Albrecht and Andreetta197 and Brunetto et al.198 also included organisational commitment as a mediator within this relationship and found that organisational commitment partially mediated the engagement–turnover intentions relationship. Relating this to Wefald et al.’s101 conclusions (see The workforce in general, The relationship between engagement and work-related attitudes), the relationship between engagement and turnover intentions may probably be mediated by organisational commitment.

Conclusions

A total of 47 studies had examined the relationship between engagement and at least one morale outcome (35 related to the general workforce; 12 to the health context).

Of these, 21 tested the associations between engagement and at least one well-being/health indicator. The most robust finding identified was the positive association between engagement (as a holistic factor) and life satisfaction (four out of four studies). Of these studies, two were longitudinal: one in the health context202 and one in the general workforce.181 Having longitudinal evidence was a key element for identifying ‘robust’ findings.

The other consistent finding identified was that engagement (as a holistic factor) was negatively correlated with burnout measures (five out of five studies). However, these studies relied solely on correlations and cross-sectional designs, and many measured burnout with only one or two dimensions (e.g. emotional exhaustion and/or cynicism). There is still debate regarding whether burnout and engagement are independent or overlapping constructs. The meta-analysis by Cole et al.92 suggests that ‘employee engagement, as gauged by the UWES, overlaps to such an extent with job burnout, as gauged by the MBI, that it effectively taps an existing construct under a new label’ (p. 1574).

Other well-being/health perceptions, such as depressive symptoms, were consistently related to engagement, as a holistic factor (eight out of nine studies), yet this covered a range of different aspects of well-being/health where many were only examined by one study, such as psychological distress, and did control for burnout. Although the meta-analysis by Halbesleben195 found that engagement is positively associated with health outcomes (yet little detail is given about which these are), the meta-analysis by Cole et al.92 indicates that engagement may not explain any unique variance in health complaints above that of burnout. Indeed, the study by Buys and Rothmann168 also supports this finding. Taken together, it could be suggested that engagement may be specifically related to positive well-being/health experiences rather than negative well-being/health experiences.

Out of the 46 studies, 31 tested the associations between engagement and at least one work-related attitude. The most robust finding identified was the positive association between engagement (as a holistic factor) and organisational commitment (nine out of nine studies). However, all but one utilised a cross-sectional design, so causality cannot be established. Despite this, the findings are supported by two meta-analyses: Halbesleben195 found that engagement was positively associated with organisational commitment and Cole et al.92 found that the dimensions of engagement accounted for a small to moderate amount of unique variance (beyond that of the burnout dimensions) in organisational commitment.

Engagement (as a holistic factor) was consistently found to be positively associated with job satisfaction when job satisfaction was deemed the outcome (nine out of nine studies). However, all of these studies were cross-sectional. Nevertheless, this association is supported by Cole et al.’s92 meta-analysis, which found that the dimensions of engagement (as measured by the UWES) accounted for a small to moderate amount of unique variance (beyond that of the burnout dimensions) in job satisfaction. Yet, in the only longitudinal study, Yalabik et al.191 found that job satisfaction may, in fact, be an antecedent rather than an outcome of engagement. Therefore, further longitudinal research is needed to confirm this finding.

Although there is consistent evidence to show that engagement (as a holistic factor) is negatively associated with turnover intentions (22 out of 22 studies), which is supported by the meta-analytic findings of Halbesleben,195 four of these studies also found that this relationship may be mediated by other work-related attitudes, specifically organisational commitment and job embeddedness.101,132,197,198 However, 19 studies utilised cross-sectional designs and only three utilised time-lagged designs, so causality cannot be fully established.

A particular issue arose during the course of this evidence review. It was found that when engagement was examined not as a holistic factor, but as three subfactors (i.e. representing vigour, dedication and absorption dimensions of work engagement), findings became less consistent and more complex. However, dedication seems to be consistent in its (significant) association with morale indicators (9 out of 10 studies). This is supported by Cole et al.’s92 meta-analysis, which found that dedication was the most significantly related to job satisfaction and organisational commitment. The issue of examining individual dimensions is particularly important, as engagement has been widely conceptualised and defined as a holistic yet multidimensional construct. The finding that subdimensions of engagement are more inconsistently related to morale outcomes than is a composite single factor of engagement is important, as it indicates that the latter is more appropriate than the former when examining the relationship between engagement and morale outcomes.

In summary, although the findings are far from conclusive, four consistent links between engagement and specific morale outcomes were identified. The first, and most conclusive, is that high levels of engagement are related, and may lead to higher levels of life satisfaction, as demonstrated by consistent findings across three cross-sectional and two longitudinal studies. The second is that high levels of engagement are associated with low levels of burnout, as demonstrated by consistent findings across five cross-sectional studies. However, concern is still warranted over whether or not the two are completely independent and linked in a causal rather than intercorrelated way. The third and fourth are that high levels of engagement are associated with high levels of organisational commitment and weak intentions to leave the organisation, as demonstrated by consistent findings across 9 and 22 studies, respectively, of which four were longitudinal. A tentative proposition is that the relationship between engagement and turnover intentions is mediated by organisational commitment and/or by job embeddedness, as demonstrated by three cross-sectional studies and one that was time-lagged. Another tentative proposition is that, although engagement and job satisfaction are positively related, job satisfaction may act as an antecedent rather than an outcome of engagement, as demonstrated by Yalabik et al.’s191 longitudinal study.

In the next chapter, we consider the evidence relating to the association between engagement and performance outcomes.

Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Bailey et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK299339

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