Workforce flexibility - in defence of professional healthcare work

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care

BACKGROUND

Avoidable patient harm in hospitals is common, and doctors in training can provide underused but crucial insights into the influencers of patient safety as those working 'on the ground' within the system. This study aimed to explore the factors that influence safe care from the perspective of medical registrars, to identify targets for safety-related improvements.

METHODS

This study used enhanced critical incident technique (CIT), a qualitative methodology that results in a focused understanding of significant factors influencing an activity, to identify practical solutions. We interviewed 12 out of 17 consenting medical registrars in Scotland, asking them to recount their observations during clinical experiences where something happened that positively or negatively impacted on patient safety. Data were analysed manually using a modified content analysis with credibility checks as per enhanced CIT, with data exhaustiveness reached after six registrars.

RESULTS

A total of 221 critical incidents impacting patient safety were identified. These were inductively placed into 24 categories within 4 overarching categories: Individual skills, encompassing individual behavioural and technical skills; Collaboration, regarding how communication, trust, support and flexibility shape interprofessional collaboration; Organisation, concerning organisational systems and staffing and Training environment, relating to culture, civility, having a voice and learning at work. Practical targets for safety-related interventions were identified, such as clear policies for patient care ownership or educational interventions to foster civility.

CONCLUSIONS

This study provides a rigorous and focused understanding of the factors influencing patient safety in hospitals, using the 'insider' perspective of the medical registrar. Safety goes beyond the individual and is reliant on safe system design, interprofessional collaboration and a culture of support, learning and respect. Organisations should also promote flexibility within clinical practice when patient needs do not conform to standardised care pathways. We suggest targeted interventions within educational and organisational priorities to improve safety in hospitals.

Health workforce governance and professions: a re-analysis of New Zealand's primary care workforce policy actors

BACKGROUND

This article contributes to the health workforce planning literature by exploring the dynamics of health professions in New Zealand's Primary Care sector and deriving broad lessons for an international audience. Professions tend influence health policy and governance decisions and practices to retain their place, status and influence. Therefore, understanding their power dynamics and the positions that they have on workforce policies and issues assists workforce governance or health system reform plans.

METHODS

Using the infrequently reported health workforce policy tool, actor analysis, a reanalysis of previously collected data is undertaken using an actor-based framework for the study of professionalism. Two models were developed, (1) the framework's original four-actor model and (2) a five-actor model for the comparison of the Medical and Nurse professions. Existing workforce actor data were reclassified, formatted, and entered into actor analysis software to reveal the professions' relative power, inter-relationships and strategic workforce issue positions.

RESULTS

In the four-actor model, the Organised user actor is found to be most influential, while the others are found to be dependent. In the five-actor model, the Medical and Nurse professions are individually more influential than their combined position in the four-actor model. Practicing professionals and Organised user actors have strong converging inter-relationships over workforce issues in both models, though in the five-actor model, the Nurse profession has weaker coherency than the Medical profession. The Medical and Nurse professions are found to be in opposition over the workforce issues labelled divisive.

CONCLUSIONS

These results reflect the professions' potential to influence New Zealand's Primary Care sector, indicating their power and influence over a range of policy and reform measures. As such, the four lessons that are derived from the case indicate to policy makers that they should be aware of situational contexts and actor power, take care when encountering divisive issues and try to achieve broad-based support for proposed policies.

Staffing policy in aged care must look beyond the numbers

The COVID-19 pandemic has highlighted an aged care system struggling to meet the needs of vulnerable Australians. Staffing levels and skill mix in aged care have declined, whereas the health and social needs of an older and more clinically complex population have risen. Increasing staff and improving personal care workers' skills and education are essential steps to quality aged care in Australia, but it will not be possible without funding models that foster secure employment, development opportunities and long-term career pathways.

Fatores associados ao absenteísmo-doença de trabalhadores da saúde: revisão de escopo

Objetivo: identificar os fatores associados ao absenteísmo-doença de trabalhadores da saúde.Síntese de conteúdo: esta revisão de escopo da literatura realizada nas bases de dados Medline via PubMed incluiu 106 estudos, que totalizaram 388.381 profissionais de saúde. Foi identificado que os fatores individuais e interpessoais, relacionados ao cargo e à função, assim como os fatores ambientais e organizacionais influenciam a ocorrência do absenteísmo-doença no ambiente hospitalar.Conclusões: os fatores individuais e interpessoais, relacionados ao cargo e à função, assim como os fatores ambientais e organizacionais influenciam no absenteísmo-doença dos trabalhadores da saúde, com impacto tanto sobre a produtividade quanto sobre a continuidade da assistência prestada por esses profissionais. A ausência não programada destes leva à necessidade de contratação de outros servidores ou ao pagamento de horas excedentes para atender à demanda, o que pode agravar a situação econômica e financeira do sistema de saúde, e afetar diretamente a saúde de toda a população que depende desse sistema.

Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team

BACKGROUND

The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, "flexibility" is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team's division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly.

METHODS

The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically.

RESULTS

The roles were occupationally specialized: "Assessment and Diagnosis" tasks consumed the largest proportion of doctors' (51.1%) and NPs' (38.1%) time, and "Organization of Care" tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients' needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses.

CONCLUSION

Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to "be flexible" (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients' needs within its organizational context. The study's findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role

The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

Monitoring Viability and Sustainability in Healthcare Organizations

The paper aims to advocate the incorporating of the sustainability perspective into the management control system of healthcare organizations. The study is based on two main premises: (1) the evolution of business models towards a wide perspective of the sustainability approach; (2) the evolution of control systems in healthcare organizations towards a control-based approach to monitor the effectiveness and efficiency of the service targeted primarily to cut costs and expenses. Our methodology is developed at theoretical and conceptual level starting from: (1) a literature review on the issue, highlighting main trends and gaps and (2) the adoption of the Viable Systems Approach (VSA) as a conceptual framework oriented to integrate a wide variety of stakeholder perspectives and interests into the business model. Our findings lead us to introduce the Systems Viability Monitoring Model for Sustainability as a potential reference framework to build healthcare management control systems in which the notion of ‘systems viability,’ as defined by VSA, becomes a bridging concept by means of which the sustainability perspective can be incorporated into the management control system of healthcare organizations.