HEALT CARE PROFESSIONALS MOTIVATION AND ENGAGEMENT IN HEALTHCARE DEVELOPMENT

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1 HEALT CARE PROFESSIONALS MOTIVATION AND ENGAGEMENT IN HEALTHCARE DEVELOPMENT Dellve L 1, 2, Lindgren Å 2, Bååthe F 3 1 KTH Royal School of Technology, School of Health and Technology, Stockholm, Sweden 2 Occupational & Environmental Medicine, Sahlgrenska Academy, Sweden 3 Institute of Stressmedicine, Västra Götalandsregionen, Sweden lotta.dellve@sth.kth.se Health care professionals engagements in health care development processes have considerable impact on the outcomes of such processes. Particularly doctors willingness to become involved is central to success from organizational development projects in health care. The aim is to gain deeper understanding of how health care professionals view their motives and engagement in organizational healthcare developments, and it s importance for collaboration and participation in implementation of lean processes. A conceptual model of physicians engagement has been described from qualitative interviews. Thereafter an instrument has been developed to be used to assess preconditions for implementation of organizational developments. Keywords: organization development, work engagement, professional collaboration 1. Theoretical framework Due to persistent health sector problems and increasing pressure on health spending, calls for health reforms and cost reductions are tightening their grip on healthcare services. These calls have a multitude of reasons, including an increasing number of elderly, technological development, demands for a more patient-oriented approach, higher service quality expectations, increased chronic illness burden, welfare diseases, and mental health problems (McKee & Healy, 2002). This has meant that different organizational concepts applied in the industry have been adopted, most popular today is the concept of Lean production. However, when top-down or external consultant driven management concepts which promises increased efficiency are approached in hospitals, they turn out to be very slow and difficult to implement (McNulty & Ferlie 2004, Eriksson 2005, Åhgren 2007). Still, the today motives of lean are such as increased efficiency and worker performance as well as improved problem solving through closer cooperation between professionals (Mazzocato et al, 2010). The need for health care professionals active engagements and collaboration when developing healthcare has been stressed by practitioners and researchers. Since physicians have considerable impact on this process, their willingness to become involved is central. Physicians are identified as having considerable power and influence in healthcare

2 development and practices. They influence resource utilization, deliver care and influence its quality, and affect the speed and extent of healthcare change processes (McAlearney et al., 2005). The strong professional groups arguably tend towards defensiveness and passivity in reform processes, for example, due to perceived threats to their professional integrity or external financial demands (Choi et al., 2010; Degeling et al., 2003; Fulop et al., 2005). The organization reformation research tradition explains physicians poor engagement in healthcare development as part of an organizational power play. Studies have highlighted the conflicts between managerialism and professionalism (Fulop et al., 2002; Degeling et al., 2003; Choi et al., 2010). These studies point to the crash when top down decisions regarding structural changes reach clinical departments (Choi et al., 2010). The use of business logic to justify such changes has been described as increasing clinician frustration with and reluctance to embrace the changes (Choi et al., 2010). Work environment research explains physicians poor involvement in healthcare development as a result of poor working conditions and poor job satisfaction. A higher job satisfaction has been related to more positive attitudes to ongoing organizational changes and higher work engagement. The concept of work engagement is a motivational construct, with energy and involvement as the two core dimensions (Bakker et al., 2010). From this perspective, enhancing physician engagement in healthcare development activities should be recognized as a core value by the organization and its management. Engagement shortfalls may help managers identify areas in which the organization has failed to realize its espoused values (Bakker et al., 2010). The aim is to gain deeper understanding of how health care professionals view their motives and engagement in organizational healthcare developments, and it s importance for collaboration and participation in implementation of lean processes. The paper presents (a) results from a qualitative study about how physicians view their motives and engagement in organizational healthcare developments, and (b) the development of an instrument to assess health care professionals attitudes to organizational developments to be used to analyze preconditions for change. 2. Procedures The study design was a stepwise mixed method. The first step was to develop a substantive grounded theory and generate a tentative model based on empirical data from semi-structured interviews. Grounded theory as a methodological approach is commonly used to generate new hypothesis and theories in previously unexplored areas of research (Charmaz, 2006). It allows investigation of the internal motivational drives in people, since it allows them to qualitatively describe what meaning they attribute phenomena, and how they understand their positioning and behavior in relation to those phenomena. The common elements in the grounded theory method were used, i.e. is continual sampling and data analysis, and multiple comparisons of raw data with analytical findings. The aim is to bring the raw data to a higher level of abstraction and thereby creating new, empirically grounded, understanding of phenomena. The participants in the qualitative study were 25 physicians at a Swedish middle-sized hospital. To maximize data variation, physicians from in different levels of training as well as senior doctors were strategically sampled. Strategic sampling was also used to get both female and male physicians, and to include informants that were viewed among their colleagues to be both engaged and not so engaged in organization development.

3 The second step, a questionnaire was developed from the qualitative study in order to investigate prevalence and to assess preconditions for and effects of implementation of organizational developments. Central statements and substantive codes of the conceptual model of physicians motivation and attitudes to participate in organizational developments were formulated to items. These were piloted to health care professionals regarding clarity and construct validity. Thereafter the questionnaire has been distributed to all health professionals working at four selected units at two hospitals. Descriptive statistics, stratified to professional groups and univariate analysis of associations will be presented. 3. Results The qualitative interviews with physicians describe their concern when deciding to participate in organizational developments as why risk without reward or why risk professional fulfillment. The physicians described that they either could choose to be upholder of a traditional doctor role with high autonomy in relation to organization and management, clinical work serving as the main source of fulfillment. Or, were approaching a more complete employeeship-role in which organizational engagement provides a sense of fulfillment. The central motivational drives for physicians engagement in healthcare development were related to their perceptions of how and where to achieve professional fulfillment and if they believe it possible to develop health care (with lacking resources). Having loyalty to traditional roles, routines and ways of handling organizational developments were more clearly providing better opportunities for their professional development. However, the new generations of physicians were more responsive to that other professionals may have important contributions for developments of health care. Their handling of organizational developments was described in a process from sticking to traditional beliefs and opinions to taking a full employeeship role. In this process they were calculating their risks and rewards of contributing. Rewarding experiences were gained when achieving meaningful results, having impact, learning to see the greater context and fulfilling the perceived doctor role. Reinforcing organizational preconditions that facilitated physician engagement in healthcare development were: workplace continuity, such as scheduling that allowed participating in organizational developments, regularly working and meeting same people, being part of a team and feeling at home at the clinic; effective strategies and procedures in organizational developmental work, and not perceiving meaningless meetings and discussions without clear goals and follow-ups; and opportunities to gain knowledge about organization and development was reinforcing. The health professionals need role clarity regarding their participation in health care developments. Doctor s reported uncertainty about whether they were expected to participate in organizational development work or not. They also experienced a lack of organization strategies and procedures that allowed them to participate in organizational development. To be informed about the clinics aims and one s mission, to know about existing strategies and procedures, to be asked by a manager or colleague to participate in organization development activities and to be scheduled to engage in those activities were reported to facilitate engagement. Effective procedures, meaningful meetings, a clear strategy and concrete guidelines concerning doctor s time-use in clinical practice versus organization development activities was therefore regarded to be central organizational preconditions.

4 A conceptual model of physicians engagement has been described from the qualitative interviews (further described in Lindgren et al 2012). Thereafter an instrument was developed to be used to assess preconditions for and effects of implementation of organizational developments. Central statements, of the conceptual model were formulated in items. The items were compared to substantive codes in raw data (interviews) and tested among a group of health professionals (physicians and nurses) regarding clarity and concept validity. Eleven statements (attitudes) regarding organizational developments are included (table 1). One single item of their own beliefs about the possibility of developing health care was formulated: Do you believe it is possible to develop health care service without adding more resources?. Descriptive results from the quantitative assessment will be reported. Table 1: Examples of index and items included in the questionnaire Health care professionals engagements in organizational development processes INDEX ITEMS At my hospital, engaging in organizational developments means: workplace continuity To have influence and be a part of a process effective strategies and procedures To invest energy in something that risk being meaningless To participate in a systematic process, driven with continuity and evaluations opportunities to gain knowledge To gain understanding and knowledge about organization role clarity regarding participation To do my work 4. Discussion To be effective, healthcare development needs physician engagement in its practices and processes. Structural and financial changes have threatened traditional professional roles, highlighting the importance of developing new roles for physicians in healthcare development. Sandberg and Targama argue (2009) that an alternative managerial approach to a rationalistic management perspective is to focus on how professionals understand their work and also that management could be redirected to managing understanding. Interviewees expressed feeling left outside the strong, workplace-based community of other professionals, while they themselves tended to shift between workplaces and workgroups due to the scheduling practices of their profession. This experience of lack of workplace continuity and sense of being left out of the organization could cast light on previous findings that problematize the various cultures of collaboration among physicians compared with nonphysicians (Stoller, 2004). Experiencing professional fulfillment from participation in healthcare development is crucial for sustainable professional engagement in such activities as lean. For physicians to strive for professional fulfillment from participation in healthcare development processes as well, these experiences arguably need to differ qualitatively from the fulfilling experiences of clinical practice. The need for experiences of involvement, development alongside other professionals, and recognition by oneself and others as a small but efficient partner in the larger community of healthcare development, is suggested by the present results. Without the benefits of a collaborative workplace community, physician experience of organizational homelessness might encourage them to uphold an autonomous doctor role, formed and reinforced by their professional community.

5 In conclusion, for a rewarding sense of professional fulfillment to arise from participation in healthcare development, health care professionals stressed the importance of results, impact, efficiency, and learning. The findings suggest the provision of effective organizational structures and procedures that let all health care professionals be active throughout the workplace and its development processes. 5. References Arnetz B Psychosocial challenges facing physicians of today. Social Science and Medicine 52, Bakker AB, Schaufeli W, Leiter MP & Taris TW Work engagement: An emerging concept in occupational health psychology. Work & Stress 22, Charmaz K Constructing grounded theory. A practical guide through qualitative analysis. SAGE Publications: Thousand Oaks. Choi S & Brommels M Logics of pre-merger decision-making processes: The case of Karolinska University Hospital, Journal of Health Organization and Management 23, Choi S, Holmberg I, Löwstedt J & Brommels M Executive management in radical change The case of the Karolinska University Hospital merger. Scandinavian Journal of Management. DOI: /j.scaman Degeling P & Carr A Leadership for the systematization of health care: the unaddressed issue in health care reform. Journal of Health Organization and Management 18, Degeling P, Maxwell S, Kennedy J, Coyel B Medicine, management, and modernisation: a dance macabre? British Medical Journal 326, Edwards N Doctors and managers: building a new relationship. Clinical Medicine 5, Eriksson N Friska vindar I sjukvården: Stöd och hinder vid förändringar vid professionella organisationer (PhD-thesis). Förvaltningshögskolan, Göteborgs Universitet. Fulop N, Protopsaltis G, King A, Allen P, Hutchings A, Normand C Changing organisations: a study of the context and processes of mergers of healthcare providers in England. Social Science & Medicine 60, Glouberman S, Mintzberg H Managing the Care of Health and the Cure of Disease Part I: Differentiation. Health Care Management Review 26, Lindgren Å, Bååthe F & Dellve L. Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development. Submitted manuscript McAlearney AS, Fisher D, Heiser K, Robbins D & Kelleher K Developing effective physician leaders: changing cultures and transforming organizations. Hospital Topics: Research and perspectives on health care 83,

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