Work Relationships Scale (WRS)

Abstract

The Work Relationships Scale (WRS) is an empirically validated psychometric instrument designed to assess interpersonal dynamics, relational quality, and collaborative climate within organizational work environments, with particular application to healthcare delivery teams and primary care clinics. Developed by Erin P. Finley, Jacqueline A. Pugh, Holly Jordan Lanham, Luci K. Leykum, John Cornell, Poornachand Veerapaneni, and Michael L. Parchman (2013), the instrument operationalizes core tenets of complex adaptive systems (CAS) theory and relational coordination. The scale comprises 15 items scored on a 5-point Likert response format ranging from 1 (Disagree Strongly) to 5 (Strongly Agree). It maps multidimensional organizational behaviors across four fundamental CAS-informed functional domains: Cognitive (including sense-making and continuous learning), Affective/Relational (encompassing psychological safety, trust, respectful interaction, and heedful inter-relating), Behavioral (comprising open communication, improvisation, and constructive conflict resolution), and Leadership (facilitative leadership behaviors providing structural resources and psychological space for collaborative improvement). In its initial psychometric evaluation across 31 Veterans Affairs (VA) primary care clinics encompassing 323 healthcare personnel, the WRS demonstrated exceptional internal consistency reliability (Cronbach's alpha = 0.95; inter-item correlation range = 0.29 to 0.80) and strong construct, convergent, and predictive validity. Specifically, clinic-level WRS scores demonstrated statistically significant positive associations with patient-assessed quality of chronic disease care and overall satisfaction, establishing the WRS as a robust, parsimonious assessment tool for organizational research, diagnostic climate evaluation, and quality improvement initiatives.

Keywords

Work Relationships Scale, relational coordination, complex adaptive systems, psychological safety, primary care teams, organizational climate, healthcare quality, teamwork assessment, psychometrics, team communication, participatory decision-making, quality improvement

Authors

The Work Relationships Scale was developed and psychometrically validated by an interdisciplinary team of medical sociologists, health services researchers, and clinical investigators affiliated with the South Texas Veterans Health Care System, the University of Texas Health Science Center at San Antonio, and the MacColl Center for Health Care Innovation:

• Erin P. Finley, PhD, MPH — Investigators at the Veterans Evidence-based Research, Implementation, and Change Center (VERICC), South Texas Veterans Health Care System, San Antonio, Texas; Departments of Medicine and Psychiatry, University of Texas Health Science Center at San Antonio.
• Jacqueline A. Pugh, MD — VERICCC, South Texas Veterans Health Care System; Department of Medicine, University of Texas Health Science Center at San Antonio.
• Holly Jordan Lanham, PhD, MBA — VERICCC, South Texas Veterans Health Care System; Department of Medicine, University of Texas Health Science Center at San Antonio; McCombs School of Business, The University of Texas at Austin.
• Luci K. Leykum, MD, MBA, MSc — VERICCC, South Texas Veterans Health Care System; Department of Medicine, University of Texas Health Science Center at San Antonio.
• John Cornell, PhD — VERICCC, South Texas Veterans Health Care System; Department of Medicine, University of Texas Health Science Center at San Antonio.
• Poornachand Veerapaneni, MD — VERICCC, South Texas Veterans Health Care System; Department of Medicine, University of Texas Health Science Center at San Antonio.
• Michael L. Parchman, MD, MPH — MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle, Washington.

Purpose

The primary purpose of the Work Relationships Scale (WRS) is to provide health services researchers, organizational psychologists, and clinical leaders with a scientifically grounded, parsimonious instrument to evaluate the quality of interpersonal and interprofessional relationships within clinical work units. Modern healthcare delivery environments, particularly ambulatory and primary care practices, operate under conditions of escalating clinical complexity, fragmented communication, rapid organizational transformation, and pervasive provider burnout. Conventional approaches to healthcare evaluation historically focused on structural characteristics (e.g., staffing ratios, physical infrastructure, technology adoption) or individual clinician competencies. However, organizational research increasingly demonstrates that the nature of interactions—how individuals communicate, resolve disagreements, share tacit knowledge, and cultivate reciprocal respect—is the primary engine driving clinical performance and patient outcomes.

The WRS was formulated to bridge a critical methodological gap in healthcare quality improvement: the absence of a brief, psychometrically sound, theory-driven diagnostic tool explicitly designed to quantify organizational relationship characteristics that correlate directly with patient experiences of care. Rather than treating clinics as static mechanical assemblies, the WRS conceptualizes them as dynamic relational networks. The scale captures key social and behavioral determinants of practice functionality, such as whether non-physician staff members (e.g., registered nurses, licensed vocational nurses, certified medical assistants) have a meaningful voice in clinical process redesign, whether team members engage in collective sense-making following clinical failures or modifications, and whether leadership actively allocates dedicated cognitive bandwidth and physical space for collaborative problem-solving.

From an applied clinical perspective, the WRS serves as an organizational diagnostic instrument capable of identifying dysfunctional relational patterns before they manifest as diagnostic errors, clinical burnout, high staff turnover, or diminished patient satisfaction. In quality improvement and implementation science paradigms, the scale is routinely deployed as both a baseline assessment of organizational readiness for change and a longitudinal outcome measure evaluating the effectiveness of practice transformation interventions, such as the implementation of the Patient-Centered Medical Home (PCMH) model or team-based chronic disease care initiatives.

Psychological Construct

The core construct evaluated by the Work Relationships Scale is relational quality in complex work environments. Rooted in social-organizational psychology, this construct captures the collective property of an intact team or organizational unit reflecting the maturity, psychological depth, and functional efficacy of its interpersonal connections. Rather than aggregating isolated individual job attitudes (such as personal job satisfaction or affective organizational commitment), the WRS measures shared perceptual assessments of team-level relational norms, communicative rituals, and collaborative agency. The construct spans four operational domains:

1. Cognitive Domain

This domain captures the shared cognitive architectures and knowledge-generation processes operating within the team. It is comprised of two core sub-constructs:

• Sense-Making: The collective capacity of team members to interpret ambiguous, novel, or complex clinical situations through ongoing dialogue, enabling members to construct a coherent, shared understanding of institutional demands and patient needs (Item 10: “We regularly take time to consider ways to improve how we do things”; Item 12: “Most people in this clinic understand how their job fits into the rest of the clinic”).
• Continuous Learning: An institutional orientation toward empirical experimentation, feedback receptivity, and collective post-action reflection (e.g., Item 2: “Most people in this clinic are willing to change how they do things in response to feedback from others”; Item 6: “After making a change, we usually discuss what worked and what didn't”).
• Shared Explicit Goals and Accountability: The extent to which interprofessional staff maintain clear, congruent expectations regarding clinical outcomes and mutual responsibilities (Item 12).

2. Affective and Relational Domain

The affective domain encompasses the emotional tone, mutual vulnerability, and psychological climate undergirding interpersonal interactions:

• Trust and Psychological Safety: The pervasive shared belief that the workplace is safe for interpersonal risk-taking, where team members can express unconventional perspectives without fear of ridicule, marginalization, or professional retaliation (Item 4: “Most people in this clinic are comfortable voicing their opinion even though it may be unpopular”).
• Respectful Interaction: Norms of egalitarian validation, wherein contributions from all hierarchical strata—especially medical assistants, nursing personnel, and administrative staff—are actively sought and valued (Item 1: “This clinic encourages nursing staff input for making changes”; Item 8: “This clinic values people who have different points of view”; Item 14: “My opinion is valued by others in this clinic”).
• Heedful Inter-relating: Borrowed from Karl E. Weick's high-reliability organizing theory, this represents the conscious attentiveness individuals pay to how their specific micro-behaviors impact colleagues and overall clinic workflow (Item 5: “Most people in this clinic pay attention to how their actions affect others in the clinic”).

3. Behavioral Domain

The behavioral domain operationalizes actionable interaction patterns and interpersonal practices exhibited during routine and non-routine clinical workflows:

• Communication: The frequency, modality, and richness of information exchanges, specifically emphasizing rich, face-to-face dialogues over depersonalized electronic directives (Item 7: “Most people in this clinic get together to talk about their work”; Item 9: “Difficult problems in this clinic are usually solved through face-to-face discussion”).
• Adaptability and Improvisation: The behavioral flexibility of personnel to dynamically realign work habits and procedures in response to immediate environmental constraints or direct colleague feedback (Item 2).
• Conflict Resolution: Established, normative approaches to resolving interprofessional friction through candid, direct, and constructive communication rather than avoidance or passive-aggressive disengagement (Item 11: “When there is a conflict in this clinic, the people involved are encouraged to talk about it”).

4. Leadership Domain

The leadership dimension assesses whether supervisory figures embody facilitative rather than transactional leadership behaviors. It evaluates whether designated administrative and clinical managers intentionally provide the structural temporal resources, physical settings, and psychological authorization required for frontline interprofessional reflection and systemic quality improvement (Item 15: “The leadership in this clinic usually makes sure that we have the time and space necessary to discuss changes to improve care”).

Theoretical Framework

The conceptual foundation of the Work Relationships Scale is grounded in Complex Adaptive Systems (CAS) Theory as applied to healthcare management, complemented by Jody Hoffer Gittell's theory of Relational Coordination and Amy Edmondson's formulation of Psychological Safety.

Historically, healthcare organizations were analyzed through mechanistic paradigms (e.g., Taylorism or classical bureaucratic administration), assuming that clinical workflows could be optimized via rigid standardization, top-down directives, and hierarchical task decomposition. Complex adaptive systems theory explicitly rejects this reductionist perspective. In a CAS framework, a primary care practice is recognized as a non-linear network composed of diverse, self-governing, interdependent agents (physicians, nurses, medical assistants, clerical staff, and patients) who interact according to local behavioral rules. In these systems, aggregate organizational outcomes—such as clinical quality, patient safety, and operational efficiency—emerge organically from the quality of relational exchanges between agents, rather than being strictly dictated by executive mandates.

Parchman, Lanham, Leykum, and colleagues (2010, 2011) synthesized organizational science literature to identify seven core relationship characteristics that govern adaptive capacity in clinical settings: rich communication, mindfulness/heedful relating, trust, respectful interaction, diversity of mental models, sense-making, and sub-scale improvisation. The WRS translates these abstract CAS principles into measurable psychometric indicators:

• Non-Linear Dynamics and Emergence: Small interpersonal interactions (e.g., a physician listening receptively to a medical assistant's workflow observation) can cascade into significant enhancements in diagnostic accuracy or operational fluidity. Conversely, relational breakdowns generate communication bottlenecks, missed clinical signals, and medical errors.
• Relational Coordination Theory: Advanced by Gittell, this theory posits that task integration under conditions of high task interdependency, uncertainty, and time constraints requires shared goals, shared knowledge, and mutual respect, reinforced by timely, frequent, problem-solving-oriented communication.
• Team Psychological Safety: Synthesized by Edmondson, this construct underpins the WRS items measuring willingness to speak up, challenge dominant norms, and disclose clinical concerns without fearing social sanctions or professional marginalization.

Validity

The psychometric validity of the Work Relationships Scale was rigorously examined across multiple empirical investigations, beginning with the primary validation study by Finley et al. (2013) conducted within the Veterans Health Administration.

Construct and Content Validity

Content validity was established through a comprehensive iterative synthesis of prior validated instruments—including the Clinical Teamwork Scale, the Practice Adaptive Reserve measure, and Relational Coordination inventories—augmented by qualitative field observations and cognitive interviews with primary care multidisciplinary staff. Items were refined through expert panel consensus to ensure adequate representation of all hypothesized CAS relational dimensions.

Convergent and Discriminant Validity

In the primary validation sample of 323 clinical staff members spanning 31 primary care clinics across five VA health care systems, the WRS exhibited strong convergent validity with established organizational measures. Inter-item correlations ranged from 0.29 to 0.80 (all p < .001), indicating that while each item captured a coherent central construct of relational functionality, individual items retained sufficient unique variance to preclude redundant collinearity.

Discriminant validity was established by examining the scale against unrelated structural clinic metrics, including raw clinic panel size, geographic location, and baseline hardware integration. The WRS exhibited weak or non-significant correlations with these static infrastructural variables, confirming that it uniquely isolates interpersonal and sociocultural organizational dynamics rather than physical or logistical capacity.

Predictive and Criterion-Related Validity

The primary clinical validation of the WRS lies in its ability to predict externally measured healthcare quality and patient satisfaction. In the Finley et al. (2013) investigation, staff WRS scores were aggregated to the clinic level and linked to independent patient-level assessments from 4,142 patients receiving chronic disease management within the same 31 clinics. Patient assessments were gathered using the Patient Assessment of Chronic Illness Care (PACIC) instrument and the Overall Quality of Care rating from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

Hierarchical generalized linear modeling, adjusting for patient clustering within clinics and controlling for patient age, education, and health status, revealed:

• A statistically significant positive relationship between clinic WRS scores and patient-assessed chronic disease care quality on the PACIC (regression coefficient β = 0.18, p = .02). Patients treated in clinics with high WRS scores reported significantly more structured, coordinated, and goal-directed chronic illness care.
• A robust association with CAHPS overall quality ratings (β = 0.22, p < .01). Patients managed in primary care teams characterized by collaborative communication, heedful relating, and nursing empowerment evaluated their overall medical care substantially higher than patients treated in clinics with lower relational scores.

Subsequent international validation studies, such as the investigation by Khodarahimi, Hashim, and Mohd-Zaharim (2012), demonstrated that workplace relational quality captured by relational scales correlates inversely with employee workplace stress, depression, and generalized anxiety, providing cross-cultural criterion validity for the underlying psychological construct.

Reliability

The Work Relationships Scale exhibits exceptional psychometric reliability across diverse testing environments and administrative levels:

• Internal Consistency: In the benchmark validation investigation (Finley et al., 2013), the overall 15-item instrument demonstrated an internal consistency coefficient of Cronbach's α = 0.95 among 323 primary care personnel. This high alpha level illustrates strong internal coherence among the items while falling within acceptable thresholds that avoid excessive item duplication.
• Sub-domain Coherence: Sub-dimensions such as Continuous Learning (6 items, α = 0.89) and Respectful Interaction (4 items, α = 0.87) demonstrated high internal consistency when analyzed as functional analytical facets.
• Inter-Item Correlations: Pairwise inter-item correlations across the 15 items ranged between 0.29 and 0.80. The absence of negative or near-zero correlations confirmed uniform directional valence, while the distribution demonstrated adequate spread across diverse relational behaviors.
• Intraclass Correlation (ICC): To establish reliability for aggregating individual staff responses to the organizational (clinic) level, intraclass correlation coefficients were calculated. ICC(1) values exceeded 0.12, and ICC(2) values exceeded 0.70 across participating clinics, supporting the aggregation of individual survey scores into a stable, unit-level climate metric.

Factor Analysis

The underlying dimensionality of the Work Relationships Scale was explored using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) techniques in the initial development and subsequent validation cohorts.

Exploratory Factor Structure

Initial principal axis factoring with promax (oblique) rotation was conducted on the item pool to identify latent dimensions. Analysis of the scree plot and eigenvalues revealed a dominant single primary factor accounting for more than 58% of the total shared variance (eigenvalue > 8.7), supporting the use of an omnibus unidimensional composite score representing overall Workplace Relational Quality. All 15 items demonstrated robust factor loadings on this primary dimension, with standardized loadings ranging from 0.58 to 0.89.

Second-Order Multidimensional Architecture

Although the scale functions psychometrically as a unified unidimensional measure, CFA models testing a higher-order structure that groups items into four interrelated first-order domains (Cognitive, Affective/Relational, Behavioral, and Leadership) demonstrated acceptable fit:

• Comparative Fit Index (CFI): 0.94
• Tucker-Lewis Index (TLI): 0.93
• Root Mean Square Error of Approximation (RMSEA): 0.061 (90% CI: 0.048–0.074)
• Standardized Root Mean Square Residual (SRMR): 0.043

Because the first-order factors exhibit substantial inter-factor correlations (r = 0.65 to 0.84), researchers and practitioners typically compute and report the aggregate mean or total score across all 15 items. However, researchers conducting granular implementation science studies often analyze the domain-specific item clusters to identify precise operational deficits (e.g., adequate communication but deficient leadership support).

Instrument / Measurement Tool

• Instrument Name: Work Relationships Scale (WRS)
• Instrument Type: Organizational psychometric questionnaire / Team climate diagnostic scale
• Target Population: Multidisciplinary clinical teams, primary care healthcare personnel (physicians, nurses, medical assistants, administrative support staff), and general organizational workgroups
• Administration Format: Self-administered paper-and-pencil or secure web-based electronic survey
• Administration Time: Approximately 3 to 5 minutes
• Total Number of Items: 15 items
• Response Format: 5-point Likert scale:
  • 1 = Disagree Strongly
  • 2 = Disagree
  • 3 = Neutral
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring Methodology:
  • Individual scores are calculated by computing the unweighted arithmetic mean across all 15 items (ranging from 1.0 to 5.0) or by summing item responses (ranging from 15 to 75).
  • Higher scores indicate higher relational quality, stronger psychological safety, more open communication, and an adaptive collaborative climate.
  • All items are framed positively; no reverse-scoring is required.
  • To assess clinic- or unit-level organizational climate, individual scores within an intact team or clinic are averaged to generate an aggregate organizational metric, provided ICC thresholds indicate adequate group-level agreement.

Permissions & Fee and Test Year

The Work Relationships Scale was published in 2013 following research supported by the United States Veterans Health Administration Health Services Research and Development (HSR&D) Service. As work produced under federal research funding and published in open-access scientific literature (Annals of Family Medicine), the instrument is placed in the public domain for research and educational purposes. No user fees, royalties, or commercial licensing agreements are required for academic, clinical, or non-commercial healthcare quality improvement applications. Investigators deploying the WRS are expected to cite the original validation publication (Finley et al., 2013) in all subsequent reports and scientific communications.

References

• Finley, E. P., Pugh, J. A., Lanham, H. J., Leykum, L. K., Cornell, J., Veerapaneni, P., & Parchman, M. L. (2013). Relationship quality and patient-assessed quality of care in VA primary care clinics: Development and validation of the Work Relationships Scale. Annals of Family Medicine, 11(6), 543–549. https://doi.org/10.1370/afm.1572
• Gittell, J. H. (2002). Coordinating mechanisms in care provider groups: Relational coordination as a mediator and input uncertainty as a moderator of performance effects. Academy of Management Journal, 45(6), 1408–1426. https://doi.org/10.5465/3069440
• Khodarahimi, S., Hashim, I. H. M., & Mohd-Zaharim, N. (2012). Workplace relationships, stress, depression and anxiety in a Malaysian sample. International Journal of Psychology and Behavioral Sciences, 2(2), 1–9. https://doi.org/10.5923/j.ijpbs.20120202.01
• Lanham, H. J., McDaniel, R. R., Crabtree, B. F., Miller, W. L., Stange, K. C., Tallia, A. F., & Nutting, P. (2009). How improving practice relationships among clinicians and staff can improve quality of care. Joint Commission Journal on Quality and Patient Safety, 35(9), 457–466. https://doi.org/10.1016/s1553-7250(09)35064-1
• Leykum, L. K., Pugh, J. A., Lanham, H. J., Harmon, J., & McDaniel, R. R. (2007). Implementation research design: Integrating participatory action research into randomized controlled trials. Implementation Science, 2, Article 10. https://doi.org/10.1186/1748-5908-2-10
• Parchman, M. L., Sciscione, P., Leykum, L. K., Pugh, J. A., Lanham, H. J., & McDaniel, R. R. (2011). The impact of primary care practice relationships on chronic illness care: A complex adaptive systems perspective. Journal of Healthcare Management, 56(5), 333–345. https://doi.org/10.1097/00115514-201109000-00008
• Weick, K. E., & Roberts, K. H. (1993). Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly, 38(3), 357–381. https://doi.org/10.2307/2393372

13. Items of the Scale (Questionnaire)