The challenges of Allied Health Managers

5.Health Management and Organisation Interactive Session The challenges of Allied Health Managers Ka Hi (May), MAK School of Business, Western Sydney University, Sydney, Australia Dietetics Department, Liverpool Hospital, Sydney, Australia Email: 18496332@student.westernsydney.edu.au Asso. Prof. Terry Sloan School of Business, Western Sydney University, Sydney, Australia Email: T.Sloan@westernsydney.edu.au Dr. Louise Kippist School of Business, Western Sydney University, Sydney, Australia Email: L.Kippist@westernsydney.edu.au Dr. Kathy Elijiz Australian Institute of Health Service management, University of Tasmania, Sydney, Australia Email: Kathy.Elijiz@utas.edu.au

The challenges of Allied Health Managers 5.Health Management and Organisation Interactive Session ABSTRACT: Allied Health (AH) consists of sub-communities (individual disciplines), excluding medical or nursing/midwifery. It is described as one of the pillars of the patient care workforce. However, traditional medical dominance and occupational prestige remain the key challenges faced by AH professionals in establishing their roles in the healthcare system. The aim of this paper is to discuss the challenges faced by AH managers through a review of current literature on the challenges faced by other health service managers (HSM). The AH managers role are complex and full of challenges. These include managing role and identity conflict, balancing time and commitment of various tasks, meeting expectations from different sources, managing unstable and part-time workforce, exerting professional power and negotiating on resources. Keywords: Health leadership, Health professions, Professional identities In Australia, allied health (AH) makes up approximately 25% of the total workforce (Australian Institute of Health and Welfare, 2013). AH is described as one of the pillars of the patient care workforce (Philip, 2015). However, traditional medical dominance and occupational prestige remain the key challenges faced by AH professionals in establishing their roles in the healthcare system (Griffin, 2001; Kenny & Adamson, 1992; Long, Forsyth, Iedema, & Carroll, 2006; McNeil, Mitchell, & Parker, 2013; Øvretveit, 1985). For example, lower value and recognition of their clinical time, lack of autonomy in decision-making and lack of authority (Long et al., 2006; McNeil et al., 2013; Øvretveit, 1985) has led to under-utilisation of the AH workforce (Philip, 2015). Given that human capital is the key to the success of an organisation (Hambrick, 1987; Schuler & Jackson, 1987), it is important that health organisations invest in developing a strong management team. This is essential for achieving a sustainable healthcare system (Guo & Calderon, 2007; Johnson, 2005; Smith & Eades, 2003). In the Australian healthcare system, hybrid-managers are often employed to carry both clinical and managerial roles across different professional groups, such as medicine, nursing and AH (Joffe & MacKenzie-Davey, 2012; Kippist & Fitzgerald, 2009; Kippist, Hayes, & Fitzgerald, 2012). The role and position of AH managers within the healthcare organisation makes them suited to the description of middle-manager and hybrid-manager. Currently, the majority of the literature on 1

hybrid-managers relates to the medical and nursing domains. There is a lack of research on the managerial challenges faced by the hybrid-managers in AH. It is assumed that they face similar challenges as other middle and hybrid managers. However, it is important to identify whether there is some unique challenges faced by AH managers due to their role and perceived value within the organisation. The aim of this paper is to discuss the challenges faced by AH managers through a review of current literature on the challenges faced by other health service managers (HSM). The databases of the Business Source Complete (EBSCO), ProQuest Business, Emerald Insight, Scopus and Google Scholar were searched. Combinations of search terms were used to capture all the relevant articles. The key terms used were hospital, healthcare, manager, allied health, physiotherapy, dietetics, speech pathology, social work, occupational therapy, podiatry, nurse, medical, hybrid-manager, frontline-manager, and middle-manager. Reference lists of relevant journal articles were also searched for additional evidence. Other major foundation articles were also cited. The literature identified included opinion papers, quantitative, and qualitative research. BACKGROUND Hospitals are key components in the healthcare system in Australia, contributing to around 40% of the total health expenditure (Duckett, 2011, p. 186). In New South Wales (NSW), the recurrent expenditure by public hospitals is $14 billion per year, accounting for 30% of the expenditure in Australia (Australian Institute of Health and Welfare, 2015). In 2011, the Commonwealth, and the State and Territory Governments signed the National Health Reform (NHR) Agreement. The aim of this Agreement is to increase the transparency, performance and accountability of the public health service (Council of Australian Governments, 2011; National Health Funding Pool, 2015). One of the significant changes under the NHR is the governance structure. The local hospital networks (LHNs) were established to manage the hospitals and coordinate the health services in their 2

networks (Australian Institute of Health and Welfare, 2014, p. 37; Willis & Parry, 2012, p. 5). The State and Territory Governments negotiate and purchase public hospital services from LHNs under a service agreement (National Health Funding Pool, 2015; Willis & Parry, 2012, p. 5). This change has lead to devolution of decision making at the local level (Bennett, 2013). The local hospital management teams are responsible for executing daily operations to ensure the LHNs provide an agreed volume of service within their allocated budget. At service delivery levels, service managers, such as medical stream managers, nurse unit managers, or AH managers, may be allocated specific and delegated responsibilities in meeting those targets. To achieve this, they are required to actively monitor their performance through key performance indicators (KPI) (NSW Health, 2012b). The introduction of ABF has increased pressure on hospital management to achieve efficient, costeffective and high quality patient care (Briggs, 2008; Briggs, Cruickshank, & Paliadelis, 2012; Briggs, Smyth, & Anderson, 2012; Leggat, 2012, p. 19). The operational responsibility of the service managers has increased. Medical managers are responsible for ensuring the department meets budget and their KPIs (NSW Health, 2012a, 2012b). The nursing structure was also restructured to work in parallel with the medical model under the clinical stream structure (Duckett, 2011). Wards are often structured based on clinical specialty, and nurse unit managers are employed with a similar management function to the medical manager. However, there is limited literature on the impact of this devolution of responsibility to AH managers. There appears to be a lack of understanding of how the AH professionals have responded to this restructure. From the author s experience and observation at various hospitals within Australia, AH is arranged as a separate division. Instead of working in parallel with the clinical stream, they operate across the different clinical stream domains. Figure 1 illustrates a common structure within a NSW hospital. Insert Figure 1 about here 3

AH is commonly described as a professional community (Boyce, 2006, p. 525) which consists of sub-communities (individual disciplines), excluding medical or nursing/midwifery (Boyce, 2006; Grimmer-Somers, Milanese, & Kumar, 2012; Turnbull et al., 2009). Core AH groups include audiology, dietetics, medical radiation science (including medical imaging, therapeutic radiography, sonography and nuclear medicine), occupational therapy, pharmacy, physiotherapy, podiatry, psychology, social work and speech pathology (Services for Australian Rural and Remote Allied Health (SARRAH), 2007). However, inconsistency in inclusion criteria exists at the stakeholder, jurisdictional, national or international level (Australian Health Workforce Advisory Committee, 2004; Grimmer & Kumar, 2005; Lowe, Adams, & O Kane, 2007; Turnbull et al., 2009). Professions such as chiropractic, optometry, orthoptics, orthotics and prosthetics, osteopathy, exercise physiologist, counselors and music therapist are also viewed as components of AH by other authors (Department of Health, 2013; Lowe et al., 2007). In addition to the inclusion criteria, the practice of registration and accreditation is inconsistent across the AH disciplines (Australian Health Practitioner Regulation Agency, 2015; Solomon, Graves, & Catherwood, 2015). Core AH professions in public settings, such as dietetics, speech pathology and social work, are excluded in the National Registration and Accreditation Scheme, while physiotherapy and occupational therapy are included (Australian Health Practitioner Regulation Agency, 2015). This inconsistency creates a difficulty in standardising professional expectations and disciplinary management across the AH professions. There is also no standardised definition of a AH manager s role and tasks. Based on the Australian and New Zealand Standard Classification of Occupations (ANZSCO), AH managers are under the health and welfare services managers. Tasks include providing overall direction and management for the services, developing, implementing and monitoring procedures, polices and standards, coordinating and administering, monitoring and evaluating resources, controlling administrative operations, liaising with other providers, advising government bodies, representing the organisation and controlling selection, training and supervision of staff (Australian Bureau of Statistics, 2013). These are similar to the roles suggested by Guo and Calderon (2007) who describe 4

AH (occupational therapy) managers as planners, strategic planners, leaders, problem solvers, coordinators and negotiators (Guo & Calderon, 2007). The author has recently conducted an analysis of the job descriptions of thirteen AH managers across five different disciplines in five hospitals within a LHN in South Western Sydney. The individual tasks were coded under each theme and tabulated to identify the commonality and difference. The result of the analysis found inconsistency in the job descriptions, for example creating positive workplace environment and carrying clinical load, and a significant difference in the number of job tasks, that ranged from 17 to 51. LITERATURE REVIEW The aim of this paper is to discuss the challenges faced by the AH managers. Based on the literature review, there is little research on this important topic. However, separate studies exist in investigating challenges faced by AH professions (Grimmer-Somers et al., 2012; Keane, Lincoln, Rolfe, & Smith, 2013; National Health Workforce Taskforce, 2009; Solomon et al., 2015) and hybrid- managers (Guo & Calderon, 2007; Harding, Lee, & Ford, 2014; Kippist & Fitzgerald, 2009; Leatt, 1994; Schnoor, Heyde, & Ghanem, 2015). The role and position of AH managers within the healthcare organisation makes them suited to the description of middle-manager and hybrid-manager. Being middle managers, they act as a link between the strategic (senior management) and operational levels. They often simultaneously perform managerial and specific tasks (Carney, 2006; Harding et al., 2014; Schnoor et al., 2015). Being hybrid-managers, they carry both clinical and managerial roles (Joffe & MacKenzie-Davey, 2012; Kippist & Fitzgerald, 2009; Kippist et al., 2012). These hybrid-managers can act as the knowledge brokers between the strategic and operational domains of the healthcare organisation (Burgess & Currie, 2013; Schnoor et al., 2015). However, Buchanan et al (2013) describe the role of middle and hybrid managers in healthcare as an extreme job as a result of the challenging nature of the role 5

including a fast pace, high intensity, difficult in decision-making and long hours (Buchanan, Parry, Gascoigne, & Moore, 2013). As a hybrid-manager, they also experience internal tension as a result of holding both a managerial and the clinical role (Kippist & Fitzgerald, 2009; Kippist & Fitzgerald, 2006). These complex and challenging identities often occur from the difference in their professional value and managerial responsibilities (Busari, 2013; Joffe & MacKenzie-Davey, 2012; Russell & Dawda, 2013). As a result, hybrid-managers often experience role conflict when balancing time allocated for managerial tasks, clinical work, teaching, and research responsibilities (Fulop, 2012; Leatt, 1994; Longshore, 1994; Witman, Smid, Meurs, & Willems, 2011). Role conflict is also evident when organisational decision making is required concerning resource priorities that impact on patient care, such as staffing levels (Forbes & Hallier, 2006; Leatt, 1994; Witman et al., 2011). McGivern et al. (2015) suggest the most important aspect of this transition is willingness to take on the hybrid-role. A management role is often viewed as de-skilling and raises concerns for the incumbent of loss of respect from their peers (Buchborn & Shannon, 2014; Fitzgerald, 1994; Forbes & Hallier, 2006; Llewellyn, 2001). Hybrid-managers can also be seen as traitors to their professional groups and can lose support from their subordinates (Schnoor et al., 2015; Witman et al., 2011). Professional identity remains the main barrier for medical professionals to engage in management (Doolin, 2002; Fitzgerald, 1994; Forbes & Hallier, 2006; Kippist & Fitzgerald, 2014; McGivern et al., 2015). This results in many hybrid managers focusing on delivering patient care in preference to their managerial tasks, including low visibility to their staff and a low management presence (Busari, 2013; Fitzgerald, 1994; Kippist & Fitzgerald, 2006; Llewellyn, 2001). Hence, they may not perform either task at their peak (Kippist & Fitzgerald, 2006). The challenges middle and hybrid managers experience may also be translated to AH professions. The literature suggests that additionally AH managers face some unique challenges, such as workforce 6

planning and lack of outcome measures (Grimmer-Somers et al., 2012; Keane et al., 2013; Solomon et al., 2015). The challenge of workforce planning in AH exists internationally (Fraher, Harden, & Kimball, 2011). In Australia, it was well documented that workforce retention issues and staff shortages existed in allied health workforce, particularly in rural area (Campbell, McAllister, & Eley, 2012; Keane et al., 2013; Stagnitti, Schoo, Dunbar, & Reid, 2006). Based on the literature, around 30% of allied health professionals leave the workforce within seven to eight years after graduation (Philip, 2015). This may be related to their demographics. The AH workforce is mainly made up of younger professionals. More than 85% of the workforce is under 55 years (Australian Institute of Health and Welfare, 2013; Health Workforce Australia, 2014a, 2014b). Younger professionals are found to change jobs more frequently due to extrinsic incentives, such as career progression, job conditions, resources and work-life balance (Campbell et al., 2012; Dodd, Saggers, & Wildy, 2009; Keane et al., 2013; Stagnitti et al., 2006). In addition to age, females comprise more than 90% of some AH professions, such as dietetics, speech pathology and occupational therapy (Australian Institute of Health and Welfare, 2013; Health Workforce Australia, 2014a, 2014b). Female dominance in the workforce is also a key contributing factor to staff retention. In addition to leaving work temporarily due to maternity leave, the majority of the clinicians return in a part-time capacity. A perceived association of part-time work with less available senior positions is also a reason for AH professionals leaving the position (Dodd et al., 2009). Currently, there is little research on the challenges faced by AH managers in managing this workforce, including managing a part-time workforce, ensuring stability and consistency of service provision and ensuring work-life balance for staff and managers themselves. Furthermore, the lack of information on measuring optimal staffing levels per client type (Solomon et al., 2015), creates difficulties for AH 7

professionals when weighing up the policy debates (Fraher et al., 2011). This contributes to their ability when bargaining for limited organisational resources. A lack of appropriate or available outcome measures and clinician support have been described as the barrier in routine outcome and performance evaluation in AH (Duncan & Murray, 2012; Lizarondo, Grimmer, & Kumar, 2014). The AH task pattern is further complicated by the differences and complexity in the patient group, stakeholder, operation, outcomes and quality measures (Grimmer- Somers et al., 2012). With increased accountability under the ABF, measuring efficiency and effectiveness is an essential task for managers. However, there is limited literature describing how AH managers respond to such performance measures. This potentially impacts their ability to demonstrate the importance of AH professions in contributing to a sustainable healthcare services. Hence, lack of evidence in negotiating about resources. DISCUSSION At present, there is limited research investigating the challenges faced by AH managers. Based on the context of the healthcare system and the AH position within the healthcare organisation structure, it is expected that AH managers face similar challenges as other hybrid managers within healthcare. Medical dominance and occupational prestige remain evident in healthcare. AH professionals appear to have difficulty in establishing a more powerful and influential status in the healthcare system (Griffin, 2001; Kenny & Adamson, 1992; Long et al., 2006; McNeil et al., 2013; Øvretveit, 1985). As a result, AH managers struggle to exercise the same professional power as their medical counterparts. Ability to exercise power is an important attribute to ensure the department is adequately resourced (Griffin, 2001). Similar to other hybrid-managers, AH managers experience internal and role conflicts in decision-making. They are required to meet varying expectations from senior management, the staff and the patients. The results of the analysis of AH managers job descriptions demonstrate their tasks include: provide direct patient care, ensure governance of clinical practice (updating policy and procedure), ensure evidenced based practice (conducting clinical audit, participating in accreditation, managing complaint), manage human resource (recruitment, performance management, supervision, orientation, 8

monitoring of attendance), provide education (staff, other healthcare provider and university students), provide advocacy (represent the professions, allied health, hospital and LHD), manage finance (purchasing, budget monitoring) and comply the legislative responsibility (OH&S, work covers, environment audit). The above results illustrate the mulit-dimensional nature of the AH manager s job. Hence it could be concluded that AH managers experience similar struggles with time management as other hybrid-managers. As discussed in the literature review, workforce planning is difficult among AH professions. Due to the young, female dominance in the workforce, there is a high proportion of part-time and locum staff. This creates challenges for AH managers in managing their workforce, for example, ensuring continuity in patient care, managing carer and sick leave and managing multiple staff sharing a caseload. From the author s experience, AH managers also take on the role of counseling staff regarding work-life balance and setting up realistic expectations of part-time role capacity. Due to the lack of optimal staffing to patient ratio, it is difficult for AH managers to negotiate recruitment when staff are on paid maternity leave. Since the majority of AH professions are female, it is common to have three to four staff on maternity leave at one point. Without replacement of these staff, there is a significant impact on service provision, particularly for small groups, such as dietetics or speech pathology. This can ultimately lead to burn-out and low morale among staff. CONCLUSION Despite AH making up of a quarter of the healthcare workforce, there is limited research in understanding the management of AH. The AH managers role are complex and full of challenges. These include managing role and identity conflict, balancing time and commitment of various tasks, meeting expectations from different sources, managing unstable and part-time workforce, exerting professional power and negotiating on resources. These challenges are based on the author s interpretation of the literature through her own experiences. Therefore, it is important to properly investigate the challenges through interviewing existing or past AH managers. This will allow a better understanding this group, and help in identifying most appropriate competency and training for AH managers. 9

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Figure 1: Common organisational structure within a NSW hospital General Manager Diirector of Medicine Director of Surgery Director of Financial Services Dirrector of Human Resources Director of Coporate Services Director of Allied Health Director of Nursing and Midwifery Services Director of Medical Services Opeartional Nurse Managers Surgical units directors or managers, such as trauma, general surgery, Allied health department managers, such as dietetics, physiotherapy Various wards and clinical units managers (medical units) Medical units directors or managers,such as cancer therapy centre, Various wards and clinical units managers (surgical units) 17