"A manager in the minds of doctors" : a comparison of new modes of control in European hospitals

Background: Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals. Methods: The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources. Results: The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management. Conclusions: Our comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective

Developing a national dental education research strategy:priorities, barriers and enablers

Objectives: This study aimed to identify national dental education research (DER) priorities for the next 3-5 years and to identify barriers and enablers to DER. Setting: Scotland Participants: In this two-stage online questionnaire study we collected data with multiple dental professions (e.g. dentistry, dental nursing, dental hygiene) and stakeholder groups (e.g. learners, clinicians, educators, managers, researchers, academics). Eighty-five participants completed the Stage 1 qualitative questionnaire and 649 participants the Stage 2 quantitative questionnaire. Results: Eight themes were identified at Stage 1. Of the 24 DER priorities identified, the top three were: role of assessments in identifying competence; undergraduate curriculum prepares for practice; and promoting teamwork. Following exploratory factor analysis, the 24 items loaded onto four factors: teamwork and professionalism, measuring and enhancing performance, dental workforce issues, and curriculum integration and innovation. Barriers and enablers existed at multiple levels: individual, interpersonal, institutional structures and cultures, and technology. Conclusion: This priority setting exercise provides a necessary first step to developing a national DER strategy capturing multiple perspectives. Promoting DER requires improved resourcing alongside efforts to overcome peer stigma and lack of valuing and motivation

Report on Phase Three: The professional capabilities framework

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How medical students demonstrate their professionalism when reflecting on experience

Objectives:  This paper aims to examine the discourses used by students in a formal assessment of their ability to demonstrate professional values when reflecting on their experiences. Methods:  We carried out a discourse analysis of 50 randomly selected essays from a summative assessment undertaken by all five year groups of students in one UK medical school. Results:  Students were able to identify a wealth of relevant examples and to articulate key principles of professional practice. They were also able to critique behaviours and draw appropriate conclusions for their own intended professional development. Detailed textual analysis provided linguistic clues to the depth of apparent reflection: recurrent use of rhetorical language with minimal use of first-person reflections, lack of analysis of underlying factors, and simplistic views of solutions may all indicate students whose ability to learn by reflection on experience needs further development. There were also areas in which cohorts as a whole appeared to have a limited grasp of the important professional issues being addressed. Conclusions:  Assessing written reflections is a useful way of making students link their experiences with professional development. The detailed analysis of language usage may help to refine marking criteria, and to detect students and course components where reflective learning competencies are not being achieved

Coexisting Values in Healthcare and the Leadership Practices That Were Found to Inspire Followership Among Healthcare Practitioners

Healthcare delivery in the United States has a storied history that has led the American public to expect that their Health Care Practitioners (HCPs) will personally and professionally enact values such as altruism, benevolence, equality, and capability. A progressive set of events that involves the implementation of the market-based solution in the Patient Protection and Affordable Care Act has led healthcare organizations to become increasingly concerned with a conceptually different set of values. It has become more necessary for healthcare organizations to dedicate attention to market values (e.g., competition; productivity) as they operate in an environment that is commonly described as a $3.3T industry. There is significant concern that important care values are being sacrificed as the U.S. health system becomes increasingly commercialized. It is also believed that HCPs are experiencing increasing levels of demoralization and burnout as a result of their inability to realize their personal and professional care value preferences. A qualitative investigation into the experiences of a selection of HCPs served to reveal how the administration in a large health system fosters compatibility among personal, professional, and market value priorities via an application of the tenets of values-based leadership. Study outcomes also feature implications for both the servant leadership and transformational leadership constructs

Educating for Indigenous health equity: An international consensus statement

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education’s influence, for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role, and in fact may be complicit in perpetuating inequities. This article seeks to examine the factors underpinning medical education’s role in Indigenous health inequity, in order to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity. The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. In order to contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions’ responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership

Conflicting values in reflection on professional practice

Purpose – The purpose of this paper is to examine the use of reflection as a tool of enquiry within the context of higher education work based learning. The aim of the study is to investigate how reflection on professional practice brings about a review of the values underpinning that practice. Design/methodology/approach – The data were collected from a group of undergraduate students undertaking their studies by work based learning in the area of management in a Scottish University. An open-ended questionnaire was designed to learn about the participants’ views on their perceived freedom to reflect on their workplace practice in the university, their ability to challenge the organizational values and established practices in the workplace, and on their relationship with the workplace mentor. Findings – Students on work based learning programmes are subjected to demands from at least three directions: first, their own expectations, in terms of both what they want to achieve by way of their own development, second, the needs of their organization; and third, expectations of the university in ensuring that the work produced meets the standard for an academic award. These interests can sometimes coincide, but they can also conflict, and such a conflict can reveal tensions that run deeper into the culture of the organization. Research limitations/implications – This study is based on a relatively small sample of learners in one university, hence the findings are of preliminary nature. Despite the small sample size, the conclusions are indicative of a potential problem in the design of work based learning, and a larger cross-institutional study would allow the validity of these results to be verified. Practical implications – The findings emerging from this study have implications for the facilitators of work based learning in higher education. Although university work based learning programmes differ significantly from corporate learning and development efforts, this paper suggests that work based learning providers should co-operate more closely with the learners’ employing organizations towards creating an environment for learning at work. More co-operation between the university and the employer might be more beneficial for all stakeholders. Originality/value – The literature on work based learning focuses in the main on the use of reflection as a tool of enquiry into workplace practice. Drawing on the study of contemporary work organizations, this paper explores the tensions arising from reflection on the learners’ practice, and possible conflict of values that reflection exposes. Keywords Professional practice, Reflection, Work based learning, Organizational practices, Corporate learning, HE management programmes, Employees, Personal and professional development