RE-THINKING OUR HEALTH ROLES

Sandra G. Leggat

Professor Health Services Management

Re-thinking our Health Roles

“Traditional conceptualisations of

medicine, nursing, physiotherapy… are unlikely to be sufficiently flexible to

address 21st century needs”. Masterson A, Humphris D. New role development: taking a strategic approach. In: Humphris D, Masterson A, editors. Developing New Clinical Roles: a guide for health professionals. London: Harcourt International; 2000.

Review of the issues

Why aren’t the proposed solutions likely to be effective?

Considerations for the future

The issues…

Skills shortages

Facilitating care across system & professional boundaries

Perceived inefficiency with waste & duplication

Potential to improve quality & safety

Potential to enhance value for money

The hospital is the “…key battleground for the various forces arrayed in the division of labour in health care”

Dingwall, R., Rafferty, A. M. & Webster, C. 1988 An Introduction to the Social History of Nursing. Routledge, London Pages.

Do we have sufficient health workers?

Region Health workers/1,000 pop’n

North America 10.9

Europe 10.4

Western Pacific 8.5

South & Central America 2.8

Middle East & North Africa 2.7

Asia 2.3

Sub-Sahara Africa 0.98

WHO 2004

Proposed solutions1. Role extension (e.g. ‘multi-skilled’

community allied health professional)

2. Role development to ‘fill the gaps’ (e.g. physician assistant)

3. Role development to combine tasks in different ways (e.g. diagnosis specific support worker)

4. Role substitution (e.g. nurse practitioner)

5. Role functional flexibility (e.g. care support worker)

‘Best practice’ work design

The research has identified 2 approaches to work design.

Job Characteristic Model (JCM) suggests that skill variety, task identity, task significance, autonomy and feedback are the important characteristics to consider in work design. (Hackman & Oldham 1976)

Sociotechnical Systems Approach (STS) provides a set of normative principles aimed at work groups that require the social and technical subsystems to be designed jointly (Cherns 1976)

JCM work design

JCM Characteristics Allied Health Doctors Nurses

Use of skills

Complete process

Impact

Autonomy

Feedback

Health roles becoming less attractive

Skill variety decreasing with ‘prescribed practice’ – e.g. Map of Medicine

Specialisation & episodic care limits task identity

Less task significance with increasing emotional management

Conflict between individual autonomy and teamwork

Decreasing feedback for some workers

STS work design

STS Characteristics Allied Health Doctors Nurses

Control/Ownership

Skill variety

Load

Security

Contact

Training

Efficiency

Quality

Flexibility

Communicate

Health system structure impedes STSSTS Health system

High technical interdependence; work should be designed at group level

Health care tends to be craft production

Greater operational uncertainty; decision making should be devolved to employees

Australian, State and Territory Governments set conflicting incentives (financial, policy, performance)

Different parts of system & organisations need different work designs

Professional bodies administer codes of conduct which complement formal regulation, or provide for self-regulation

Methods of working should be minimally specified

More than 20 bodies accredit education & training, & over 90 registration boards

Analysis of proposed solutionsExtension Fill gaps Combine

tasksSubstitution Flexibility

Use of skills + ≠ ≠ + +

Process + ≠ + ≠ +

Impact + + + + +

Autonomy + ≠ ? ≠ ≠

Control + ≠ + ≠ ≠

Load ≠ ≠ ≠ ≠ ≠

Security ≠ ≠ ≠ ≠ ≠

Social + ≠ ? ≠ +

Quality ? ≠ + ? +

Costs + ≠ + + +

Implications Health sector trends suggest our health system

will have less ability to meet work design best practice

Resulting in (continued?) reduction in the attractiveness of health professional jobs

Role extension, role development combining tasks & role functional flexibility appear to be most consistent with requirements for effective work design

Current Model New Model?

Roles are fixed in the short term

Roles are flexible in the short term

Individualistic work roles More focus on social interactions

Inflexible HR & registration processes

Personal role crafting, based on learning & privileging

Formal, inflexible siloed educational models

Accessible skill ladders, interdisciplinary learning modules

Lack of financial incentives Facilitating financial incentives

ReferencesCherns AB (1976) The principles of sociotechical design. Human Relations 29: 783-92

Duckett SJ (2005) Health workforce design for the 21st century. Australian Health Review 29(2): 201

Duckett SJ (2005) Interventions to facilitate health workforce restructure. Australia and New Zealand Health Policy 2: 14

HackmanJR & Oldham GR (1976) Motivation through the design of work. Organizational Behaviour and Human Performance 16: 250-79

Leggat SG (2007) Health professional education: perpetuating obsolescence? Australian Health Review 31(3): 325

Nadin SJ, Waterson PE & Parker SK (2001) Participation in job redesign: an evaluation of the use of a sociotechnical toll and its impact. Human Factors and Ergonomics in Manufacturing 11(1): 53-69.

Parker SK, Wall TD & Cordery JL (2001) Future work design research and practice: towards an elaborated model of work design. Journal of Occupational and Organizational Psychology 74: 413-40

Productivity Commission (2005) Australia’s Health Workforce. Commonwealth of Australia