Preparing a 21st century workforce: is it time to consider clinically based, competency-based training of health practitioners?

Additional keywords: assistant, Massive Open Online Courses, paraprofessional, workforce flexibility.

Workforce shortages and misdistribution in Australia are well documented.^1,2 Paradoxically, workforce shortages have coincided with an increase in the duration of much of the formal training for nurses, allied health professionals and doctors, without evidence of a corresponding increase in productivity or outcomes.³ Longer training times increase training costs while reducing the flexibility and responsiveness of the workforce due to the lag times before workers are qualified.

A substantial proportion of all clinical training takes places in healthcare settings. The growth in health practitioner training is placing unprecedented pressure on clinical placement opportunities internationally. To overcome the lack of ‘real’ clinical placement opportunities, there is a growing market in simulated clinical experiences for students.⁴ In addition, Australia currently invests in substantial clinical educator infrastructure to enable students to experience rural and remote clinical practice on the expectation that they will consider rural practice on graduation.⁵ The cost of the organisation and provision of clinical placement opportunities, infrastructure and simulation is likely to be vast, but has not been calculated at a national level. These costs are also borne by students, with one study suggesting medical, nursing and allied health students experience financial hardship as a result of placements, which in turn impacts on their accumulation of debt and on their health and wellbeing.⁶ Additionally there is evidence that poorly constructed models of clinical placements actually detract from service capacity and productivity.^7,8

To help address the health workforce shortfall, there has been increasing growth in the vocationally qualified, assistant level, or paraprofessional workforce.^9–11 However, there is currently no direct pathway from a paraprofessional to a professionally qualified health worker without paraprofessionals leaving the workplace and attending university. Several ‘step-on-step-off’ programs have been introduced internationally to provide career pathways for health practitioners along a skills continuum. However, these pathways have largely failed because of the need to ‘step-off’ of vocational clinical training to attend formal university training to achieve the status of a qualified health professional.¹² This model further reduces workforce flexibility.

So we are now faced with a conundrum. Workforce shortages and misdistribution have been addressed by increasing, not decreasing, the duration of university-based training for health professionals. This coincides with a large demand for clinical placement training hours, which can deplete the services they are trying to support. In addition, there is a growing paraprofessional workforce that is unable to follow a professional health career pathway without leaving the workplace and attending university at further cost to the student and health workforce capacity.

We argue that in the 21st century, the current model of university-based training for clinicians, alongside an ‘outsourced’ model of clinical placements, needs to be reconsidered. Instead, we propose a shift to the clinic as the primary source of training, supported by an outsourced model of theoretical learning. Technology is now at the stage where all of the theoretical and some of the practical course content could be developed and delivered on a large scale, as evidenced by the rapid growth and uptake of Massive Open Online Courses (MOOC).¹³ Existing clinical education infrastructure could be mobilised and adapted to support clinical training, credentialing of trainees, and to maintain the consistency of standards. To further increase the flexibility of the approach, models of health practitioner training could be based on the achievement of specific milestones, rather than the existing time-based models.¹⁴ Career pathways could be embedded into professional training if students were credentialed to ‘step-off’ at specific stages of their training, rather than receiving a single qualification at the end of their formal training period.

This model has several potential benefits:

• Well designed and supported clinical training models build health workforce capacity and productivity.¹⁵

• Students would deliver healthcare while gaining incremental credentials and recognition for on-the-job training.¹¹

• It would potentially move resources and infrastructure away from training and into the community to support the direct delivery of healthcare.

• The creation of closer, more formalised links between universities and health providers would make the clinical setting a formal part of the university infrastructure, which could be resourced appropriately as a learning environment.

• By taking learning directly to the clinical interface it could enhance knowledge translation, service development and capacity development.

• More centralised models of theoretical learning may standardise ‘text book’ learning and reduce the need for high-cost training infrastructure, including many simulations. Instead, resources could be used to develop high-quality, remote-learning resources tailored to specific contexts.

• There would be potential to deliver health professional training directly to those areas most in need, including developing countries and rural and remote areas.

• Practitioners would develop a detailed understanding and expertise of the specific context in which they work, creating more contextually relevant practitioners.

• Clinically based learning models have the potential to provide local mechanisms for supporting, credentialing and updating practitioners who have been away from the workforce for some time, rather than having to return to university.

• Online resources could be delivered in a more centralised way, reducing the need for multiple higher education providers to deliver similar training content, and introducing efficiencies in the delivery of formal education. The downside of this for universities would be further competition and cutbacks in an already challenging higher education market.

Clearly, this approach would require some substantial changes to the current ways of thinking about health practitioner training. The challenges of clinically based training include the large burden of supervision on existing staff, the expanded role of clinical educators and increased need for technological pedagogy. It would require the development of clearly defined competencies alongside mechanisms to enable the credentialing of students at various stages of their clinical training. Clinically based training would require the mobilisation of existing clinical supervision and educator infrastructure and potentially more outsourcing of university-based staff to provide and coordinate credentialing. The nature of student peer support would change to evolve to include local and regional networks and on-line models of support.¹⁶ On-line learning and assessment would need to clearly support and accompany the clinically based learning needed to meet course accreditation requirements. The differing requirements of each profession means that no ‘one-size-fits-all’ approach could be applied to all clinician training models; however, it is likely that several of the principles already used to deliver clinically based training could be adapted and extended for each professional group. Additionally, training models would still need to ensure that students are exposed to a variety of experiences, caseloads, contexts, different ways of working (e.g. interdisciplinarity) and technical skill development. The most innovative models of rural and remote clinical training already incorporate several of these principles.¹⁷

It is time to consider the real needs of the 21st century healthcare workforce, and modernise our healthcare training accordingly to focus on the needs of patients and communities.

The authors declare there are no competing interests.