Turning attention to clinician engagement in Victoria

Additional keywords: leadership, organisational culture, quality, safety.

We have all heard calls for more ‘clinician leadership’. The well-intentioned motivation behind government investment in leadership training is to find ways to catalyse healthcare improvement. Empowered individuals can and do make a difference. So why not create more of them? Yet the evidence for the value of leadership programs in terms of long-term organisational outcomes or meaningfully improved patient outcomes is limited.^1–3

One major problem is that only a small percentage of clinicians receive leadership training and opportunities. Yet the enthusiasm and effort every health professional brings to the workplace determines the outcomes we all seek: improved patient satisfaction, safer care delivered and greater support for organisational change. Analysis of the UK Health Foundation’s program evaluations found clinician engagement one of the 10 challenges to improving quality of care.⁴ We argue that instead of simply looking for leaders to train, the Australian health system should be focusing on enhancing engagement of all clinicians, at all levels.

Indeed, respondents to the recent review of Hospital Safety and Quality Assurance in Victoria⁵ suggested there was a deficiency in clinician engagement. To explore this further, in essence to ask directly whether clinician engagement in public health services was lacking, the Victorian Department of Health and Human Services (DHHS) commissioned a scoping review on clinician engagement.⁶ The DHHS took a whole-of-system view, with interest in engagement at the microsystem level of care delivery and also in the involvement of clinicians to create better state health policy. Research included review of the literature, followed by interviews and small group meetings with more than 100 clinicians and executives from the public and private hospital systems, community health services and the DHHS. Additionally, a total of 1800 people responded to surveys.

The literature review revealed that the academic study of work and employee engagement provides a behavioural perspective on employee motivation. Work engagement was originally defined as: ‘a positive, fulfilling work-related state of mind that is characterised by vigour, dedication and absorption’(Schaufeli cited in Guest).⁷ Desired behaviours performed by engaged employees are those that are discretionary or pro-social – that is outside their enforced job description (in health typically reflected in more hours worked than contracted).

There is a relationship between work engagement and job strain (burnout) – ‘the job demands–resources model’.⁸ Job demands are the physical, social, or organisational aspects of the job that require sustained effort. Job resources refer to those aspects of the job that may: (1) reduce job demands; (2) be functional for achieving work goals; or (3) stimulate personal growth, learning, and development (including autonomy and feedback). Too many demands and too few resources predict burnout^9,10 and, importantly in a healthcare setting, result in employees working less safely.¹⁰

Most engagement literature is focused on business enterprises, where maximising shareholder value is the organisational aim. Indeed, the UK government supported development work on employee engagement as one strategy to re-energise depressed British industry.¹¹ In healthcare, patient satisfaction and patient safety have been considered surrogates for the productivity and profitability measures used in business. Where clinicians are measurably engaged, there is lower staff turnover and absenteeism, decreased infection rates, increased patient satisfaction and lower patient mortality.^12,13

Yet, there are special issues in applying the general work engagement literature to clinicians. First, even when salaried employees, clinicians may still identify as independent professionals. Second, many clinicians work part-time and even full-time workers may have multiple workplaces and employers. This can be reflected in clinicians having stronger emotional allegiances to professional organisations than their employing institution.¹⁴ Third, clinicians have professional responsibilities to patients and clients. Most of their work is client-facing and they perceive their duty is first to the client rather than the employer or the broader system. Clinicians can be dedicated to patient care regardless of the status of the employee–employer relationship.

It is sometimes suggested that there is an ethical imperative to clinician engagement that is not necessarily present in other employment situations. It has been proposed that: ‘everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it’.¹⁵ However, one of those two jobs is well defined and staff have been highly trained to undertake the work. The quest for clinician engagement and leadership may sometimes be seen as an expectation that they take responsibility for change with minimal organisational support and do this extra work without compensation.¹⁶ This can be a heavy burden for an already busy clinician.

The DHHS investigation (field visits, interviews and survey responses) revealed pockets of excellence and identified problems. Responses revealed an appetite, perhaps even a hunger, for richer, more consistent engagement.⁶ A clear picture was developed of what disengagement and engagement look like at multiple system levels (Table 1).

Table 1.  The results of clinician disengagement and engagement in the health system

The solutions proposed for Victoria in the clinician engagement scoping report fall under four headings (Table 2).

Table 2.  Framework for improving clinician engagement

Victoria will seek to apply the framework described and to measure impact. We do want clinicians to flourish at work. This should be measured by staff satisfaction surveys or dedicated engagement instruments. It must be regularly reported at the board level. High involvement work practices, such as power and information sharing, training and reward for good performance can improve engagement.^7,17

However, creating a positive work environment is not enough; engagement needs to be harnessed in the form of active participation in the structures that define the nature of clinical work and the patient’s journey. For instance, if a worker enjoys coming to work, but refuses to attend unit meetings or read organisational communications, there is a problem. Healthcare is so complex that safer quality care cannot be achieved without clinicians’ attention to the broader system, beyond the patient that is sitting in front of them.

Hence the definition proposed for use in Victoria, based on definitions in use in Queensland, is focused on involvement:

Clinician engagement is about the methods, extent and effectiveness of clinician involvement in the design, planning, decision making and evaluation of activities which impact the Victorian healthcare system.⁶

Clinicians should be full participants in design, planning and evaluation and in all decisions that concern them and their patients. For clinicians, such involvement may be a prescribed part of their paid role with protected time allowed, or discretionary. For managers ensuring that such involvement occurs is not discretionary, it is central to proper performance of their paid role. The provision of opportunities to engage and the number of clinician participants being engaged form management metrics for engagement.

We believe that it is time to pay attention to the engagement of all clinicians. Development of meaningful engagement between the clinician, the employing organisation and the system will create an enhanced opportunity to improve the quality and safety of the health system for patients, their families and their carers. After all, next to the patient themselves it is the clinician who is best placed to identify needs and opportunities for healthcare improvements.

The authors have no conflict of interest.