Building an Evidence-Based, Ireland-Specific Framework for Employee Engagement in the Healthcare Sector

Abstract

Ireland�s health system is currently facing acute challenges in engaging and retaining its workforce. Widespread staff burnout, organisational inefficiencies, limited career progression, and psychosocial stressors have contributed to declining morale, particularly among frontline workers. Although employee engagement is widely recognised as a key determinant of workforce resilience, service quality, and organisational sustainability, there is currently no validated, context-specific framework in the Irish health sector for systematically assessing and enhancing engagement at both the individual and organisational levels. This doctoral research addresses this critical gap by developing, validating, and operationalising a comprehensive multidimensional framework for measuring employee engagement in the Irish healthcare system. Grounded in pragmatist philosophy and guided by an explanatory sequential mixed-methods design, the study integrates theory-driven quantitative analysis with qualitative insights into healthcare workers' lived experiences. The overarching aim is to generate a robust, empirically grounded model that is both statistically valid and practically relevant to policymakers, healthcare leaders, and human resource professionals. The study began with a scoping review of the international literature on healthcare employee engagement. This review mapped the conceptual and theoretical landscape, highlighting fragmentation in definitions, inconsistencies across measurement tools, and a lack of comprehensive frameworks tailored to healthcare settings. Drawing on this evidence and using the Nienaber and Martins model as a theoretical foundation, an initial multidimensional engagement framework was developed, incorporating both organisational-level factors (e.g. leadership, teamwork, performance recognition) and individual-level factors (e.g. health and wellbeing, my role in my organisation, and training and opportunities). The quantitative phase of the study involved secondary analysis of the HSE�s �Your Opinion Counts� (YOC) staff survey data. Mirza et al.�s (2019) reflective validation framework was applied to structure the validation process. Principal Component Factor Analysis (PCFA) and Confirmatory Factor Analysis (CFA) confirmed the internal structure of the proposed framework, resulting in eight dimensions and 20 subdimensions of engagement. Structural Equation Modelling (SEM) and path analysis were used to explore the relationships between dimensions and overall engagement, while mediation and moderation analyses examined the influence of factors such as workplace bullying, discrimination, age, gender, job role, and years of experience. To move beyond generalised, sample-level engagement measures, a novel Employee Engagement Score (EES) was developed at the individual level. The EES integrated: (1) direct scores from the validated dimensions, (2) indirect effects via mediators (e.g. bullying and discrimination), and (3) moderation effects shaped by demographic and occupational characteristics. The final score was normalised using min-max scaling and transformed into a percentile rank, enabling meaningful interpretation, subgroup comparison, and policy-relevant benchmarking. Findings revealed considerable engagement disparities, with younger staff, women, frontline workers, and those in high-pressure environments reporting lower scores, highlighting the need for targeted interventions. The qualitative phase complemented the quantitative findings by exploring the lived experiences of healthcare staff through interviews and focus groups. Using reflexive thematic analysis (RTA), themes such as employees need to feel recognised and valued, ineffective leadership and organisation�s strategy, lack of health and wellbeing, and the need of systemic and structural changes were found to undermine engagement. NVivo software was used to facilitate coding, and researcher reflexivity was embedded throughout the process to ensure analytic rigour. Quantitative and qualitative findings were integrated through the Pillar Integration Process (PIP), resulting in a revised, validated engagement framework that reflects both statistical evidence and the lived experiences of healthcare workers. The final framework recognises employee engagement as a dynamic, multidimensional construct, shaped by the intersection of organisational design, leadership culture, workplace experiences, and individual characteristics. This thesis makes several original contributions. First, it offers a rigorously validated healthcare- specific engagement framework for Ireland, which addresses the theoretical and practical limitations of generic models. Second, it introduces a personalised engagement scoring system that captures indirect and moderated effects, advancing current practices in workforce analytics. Third, it integrates qualitative insights into the institutional, social, and psychological dimensions of engagement, producing a model with both explanatory power and operational relevance. In the short term, the results of this study offer actionable insights for health service managers, Human Resources departments, and policymakers seeking to improve engagement, retention, and staff wellbeing. In the longer term, the validated engagement score and framework have the potential to inform national workforce strategy and support longitudinal tracking of engagement over time. Ultimately, this thesis contributes to international scholarship on healthcare workforce engagement and provides a scalable, evidence-informed blueprint for strengthening workforce resilience in complex and high-pressure health systems.