Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians.

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations and motivation to perform well. Understanding what motivates these healthworkers in their work is essential to provide an empirical base for policy decisions to improve quality of healthcare. In 2006-2007, we conducted a mixed-method study to evaluate factors affecting motivation, including reasons for varying levels of motivation, amongst these clinicians in Tanzania. Using a conceptual framework of 'internal' and 'environmental' domains known to influence healthworker motivation in low-income countries, developed from existing literature, we observed over 2000 hospital consultations, interviewed clinicians to evaluate job satisfaction and morale, then designed and implemented a survey instrument to measure work motivation in clinical settings. Thematic analysis (34 interviews, one focus group) identified social status expectations as fundamental to dissatisfaction with financial remuneration, working environments and relationships between different clinical cadres. The survey included all clinicians working in routine patient care at 13 hospitals in the area; 150 returned sufficiently complete data for psychometric analysis. In regression, higher salary was associated with 'internal' motivation; amongst higher earners, motivation was also associated with higher qualification and salary enhancements. Salary was thus a clear prerequisite for motivation. Our results are consistent with the hypothesis that non-salary motivators will only have an effect where salary requirements are satisfied. As well as improvements to organisational management, we put forward the case for the professionalization of non-physician clinicians

The governance schema of regional and rural public hospital nurses: how relevant are the dimensions of stewardship governance and trust in management?

This study broadly pertained to the issue of public health sector governance. The field of healthcare governance had been characterised as having challenges of greater intricacy and sensitivity than those found in any other sector (Philippon & Braithwaite, 2008). While increasingly regarded as important to health system performance, governance had, however, been evaluated as poorly understood in conceptual and practical terms and subject to competing ideas regarding its role and challenges (Brinkerhoff & Bossert, 2013). Specifically, the thesis elucidated frontline regional and rural hospital nurses’ cognitive schema of strategic aspects of governance practice of managers in the Western Australian Country Health Service (WACHS). It also explored the question of whether compatibility between nurses’ schema and their perceptions of governance practice increased their propensity to form the intention to leave their jobs in WACHS hospitals. Because of its heavy reliance on its nursing workforce, the Australian regional and rural health system had been described as an essentially ‘nurse-led’ healthcare context dominated by public hospitals (Bish et al., 2012). Regional and rural health reforms had also deeply affected the practice and work environments of many nurses in these areas over a long period and more change was proposed by State and Commonwealth levels of government (Department of Health and Ageing, 2010; Mahnken, 2001; WACHS, 2007, 2009). The Department of Health and Ageing had suggested an outcome of this had been that many clinicians in regional and rural areas were unhappy with strategic aspects of healthcare governance, which had led to less responsive services and the loss of opportunities to improve clinical safety and quality. Given this context, the strategic governance perspectives of frontline hospital nurses’ employed by WACHS appeared an important area of study. A core purpose of the study was to anchor the assessment of regional and rural nurses’ perspectives of strategic aspects of governance within the theoretical frames of Stewardship Governance (Travis et al., 2003) and Trust in Management (Clark & Payne, 1997, 2003, 2006). These frames had been postulated as consistent with the underpinning motives of caring professions such as nursing (Brown & Calnan, 2010, 2011; Calnan, Rowe, & Entwistle, 2006; Saltman & Ferroussier-Davis, 2000) suggesting they were likely to be apparent within the profession’s broader architecture of ‘shared mental models’ or schema of appropriate governance practice (Epitropaki & Martin, 2004; Mohammed et al., 2010). Methods suited to elucidating schema were employed in the study (Floyd & Widaman, 1995). The validity of the schema measures identified was subsequently tested with respect to their relevance and importance to the study population. This validation process was theoretically grounded in the empirically-supported cognitive process of schema ‘compatibility testing’ (Beach, 1993; Miner, 2007) and entailed the use of a turnover intention scale developed by Roodt (Jacobs & Roodt, 2007) as an outcome measure. The design features of this scale suggested it was suited to the assessment of nurse ‘compatibility testing’ of governance schema (Morrell et al., 2008). The issue of nursing turnover had also been established as a widespread and important problem for healthcare systems (Coomber & Barriball, 2007; Holtom et al., 2008; Hwang & Chang, 2008; McCarthy, Tyrrell, & Lehane, 2007; West, 2005) and had been linked with issues of management style and governance (Attree, 2005; Hayes et al., 2006; Kleinman, 2004). The stages of the research undertaken included initial interviews with 16 highly experienced clinician-managers, in which the boundaries, principles and practices of managerial governance were explored with a view to ascertaining the preferences of hospital nurses. Data from these interviews was used along with information derived from literature on the elements of Stewardship Governance (Travis et al., 2003) and Trust in Management (Clark & Payne, 1997, 2003, 2006) to construct an inventory of strategic governance practices. This inventory was then used to develop a governance questionnaire, which was further developed and evaluated in two subsequent mail surveys. Data from an initial small-scale mail survey (n=199, response rate 44%) were analysed using Exploratory Factor Analysis to check item reliability and validity, thereby guiding item deletion. The subsequent main-study survey of 1682 nurses working in WACHS regional and rural hospitals resulted in the return of 697 completed questionnaires, representing a response rate of 45%. Main-study data were interpreted using Principal Components Analysis to elucidate governance scales reflecting WACHS frontline hospital nurses’ underlying schema of strategic aspects of governance in their organisation. Scale validation was undertaken using multiple regression analyses with scores on Roodt’s Turnover Intention Scale as the dependent variable. The results supported the study hypothesis that compatibility between the governance schema of frontline regional and rural public hospital nurses employed by WACHS and their perceptions of WACHS managers’ governance practices would predict their turnover intentions. Overall, the thesis lent weight to the World Health Organization’s (WHO, 2000) claim that the concept of Stewardship Governance had relevance to health systems. Further, it supported the contentions of those like Brown, Calnan, Rowe and colleagues in relation to the relevance of trust to manager-clinician governance relationships (Brown & Calnan, 2010, 2011; Calnan & Rowe, 2008a; Calnan, Rowe, 2008b; Calnan et al., 2006). The research findings have relevance to issues of effective healthcare reform; models of nurse management and the development and support of nurse managers; and the prevention of nurse turnover in regional and rural public hospitals. The scales developed in the study may be useful in similar investigations in other regional and rural jurisdictions and to nursing research in other contexts. The scales might also have value in evaluating the impact of changes to governance in regional and rural public hospitals on frontline nurses

Identifying Essential Competency Areas for Occupational Therapy Education: A Scoping Review

This scoping review aims to explore the essential areas of competency in occupational therapy as the ability to acquire the necessary knowledge, skills, and values for the profession is not easily quantifiable. The objectives of this study were two-fold: (1) identify the key competency areas of occupational therapy and (2) identify assessments that measure the competency areas. The review was conducted by a team of a librarian and two independent reviewers to systematically search the peer-reviewed literature. The search yielded 296 articles and 52 articles that met the inclusion criteria. These articles were categorized under four overarching themes: (1) professional attitudes that include cultural competence and the ability to uphold ethical and legal responsibilities; (2) professional communication such as engaging in active participation with the client; (3) ability to work in collaboration with inter- and intra- professionals; and (4) provide quality service with a focus on evidence-based practices. Additional research is warranted to further build the evidence base of occupational therapy competence to improve outcomes for patients. The results of this study contribute to the ongoing collective work of researchers and practitioners who wish to continually improve a client-centered holistic approach through the recognition of these key themes. Identifying the relevant measures that assess these themes establishes the foundation needed to support the continuous effort to educate and support entry-level occupational therapists by paving the way for further development and refinement of measurement tools

Exploring Communication Between Staff and Clinicians on an Inpatient Adolescent Psychiatric Unit

This dissertation explored interdisciplinary team functioning on a long-term adolescent inpatient psychiatric unit. It compared staff perceptions (MHCs, clinicians, and nurses) of interdisciplinary coherence and unit effectiveness. This study was particularly focused on understanding MHCs perceptions of team functioning and how satisfied team members are with their level of input and involvement in team decision-making. Additionally, this study explored possible barriers to effective team functioning in this setting. Eighty-four participants in this study completed the Interdisciplinary Team Process and Performance Survey (ITPPS) to assess perceptions of team functioning. Participants answered additional questions assessing barriers to communication and collaboration and levels of satisfaction with their input in the team’s decision-making process. A one-way ANOVA was conducted to compare perceptions of team cohesion and team effectiveness across occupations. Results suggest that there is a significant difference among the three occupational groups regarding their perceptions of how their team functions, with MHCs having more negative perceptions of team processes than nurses and clinicians. This team ranked the three highest barriers to communication and collaboration: (a) Differences in accountability, payment, and rewards; (b) Hierarchy; and (c) Lack of training for MHCs. Regarding levels of satisfaction, results showed that MHCs reported the lowest levels of satisfaction, while clinicians rated the highest levels of satisfaction. With these findings, recommendations were made for ways in which long-term inpatient adolescent psychiatric hospitals can work to improve their interdisciplinary team functioning to increase job satisfaction and improve patient care

Occupational therapists\u27 attitudes toward family-centered care

The purpose of this study was to examine pediatric occupational therapists attitudes towards family-centered care. Specific attributes identified by the literature (professional characteristics, educational experiences and organizational culture) were investigated to determine their influence on these attitudes. Study participants were 250 pediatric occupational therapists who were randomly selected from the American Occupational Therapy Association special interest sections. Participants received a mail packet with three instruments to complete and mail back within 2 weeks. The instruments were (a) the Professional Attitude Scale (b) the Professional Characteristics Questionnaire, and (c) the Family-Centered Program Rating Scale. There was a 50% return rate. Data analysis was conducted in SPSS using descriptive statistics, correlations and regression analysis. The analysis showed that pediatric occupational therapists working in various practice settings demonstrate favorable attitudes toward family-centered care as measured by the Professional Attitude Scale. There was no correlation between professional characteristics and educational experiences to therapists\u27 attitudes. A moderate correlation (r=.368, p These study findings suggest that organizational culture has some influence on occupational therapists attitudes toward family-centered care (R2 =.16). These findings suggest educators should consider families as valuable resources when considering program planning in family-centered care at preservice and workplace settings