Managers shaping the service triangle: Navigating resident and worker interests through work design in nursing homes

Managers play a key role in shaping the service triangle and navigating stakeholder interests within this. In healthcare, labor shortages are prompting consideration of the consequences of care delivery for service users and staff. Here we consider how senior nursing home managers tasked with balancing resident and worker interests manage tensions using work design. Findings identify a five-cluster typology, reflecting variations in how managers from twenty Flemish nursing homes operationalize the same resident-centred care model. Managers purposively shape a different service triangle in each operationalization, variously prioritizing benefits for residents, seeking the golden mean or attempting to suppress tensions

Reframing and reacting to employees' responses to change: A focus on resistance

Background A hallmark of a leader is their ability to manage change—an ever-present feature of organisational life. Indeed, all improvement requires change, and in this context navigating employees’ responses to progress change is a key part of leadership. To support this, research and leadership development have historically focused on how leaders can reduce resistance to change. This review highlights the value of reframing classic conceptions of resistance to change as something negative. Result Widening understanding of non-acceptance responses to change supports the provision of broader, yet more meaningful advice to leaders and managers about how to engage with employees in ways that can support improvement. To do this, the article identifies why resistance is important in the contemporary context and then outlines three current broad views within research on resistance to change identified by Robyn Thomas and Cynthia Hardy. These influence how resistance is seen and therefore how it is approached. The article considers what leaders can learn and do to more effectively navigate employees’ responses to change, and how reframing resistance applies to the specific context of healthcare

From bipartite to tripartite devolved HRM in professional service contexts: evidence from hospitals in three countries

This article explores the devolution of HRM in a hospital context. Based on secondary data and 128 interviews conducted in nine hospitals across three European countries (Ireland, the Netherlands and UK), we examine roles and responsibility for HRM under devolution and coordination between those delivering it. Findings challenge bi-partite conceptions of devolution, identifying a tripartite model with: (1) HR practitioners, (2) line managers and, (3) senior professionals (managers and specialists) implementing HRM. Involving senior professionals in HRM reflects longstanding concern regarding managerial legitimacy in overseeing professional work. In the tripartite relationship each party has scope to contribute to people-management: HR practitioners to formulate a strategic framework, HR practices, and provide advisory services; line managers to implement HR practices and interface between HR and front-line professionals and; senior professionals to act as line managers’ advocates and provide expert knowledge and credibility to inform people-related decision-making. However, lack of role clarity and tensions in coordination relate to the differing goals of, and distance between, the HR function, line managers and senior professionals. Our theoretical reframing of devolution notes potential for tripartite relational involvement to enhance HR performance in professional service contexts, the contingencies affecting this and potential implications for the HR architecture

Performance management in context: formative cross-functional performance monitoring for improvement and the mediating role of relational coordination in hospitals

Recent research suggests that to fully realise its potential, performance management should be bespoke to the social context in which it operates. Here we analyse factors supporting the use of performance data for improvement. The study purposively examines a developmentally oriented performance management system with cross-functional goals. We suggest that these system characteristics are significant in interdependent work contexts, such as healthcare. We propose and test that (a) relational coordination helps employees work effectively to resolve issues identified through formative and cross-functional performance monitoring and (b) that this contributes to better outcomes for both employees and patients. Based on survey data from management and care providers across Irish acute hospitals, the study found that perceptions of relational coordination mediated the link between formative cross-functional performance monitoring and employee outcomes and partially mediated the link between formative cross-functional performance monitoring and patient care respectively. Our findings signal potential for a more contextually driven and interdependent approach to the alignment of management and human resource management practices. While relational coordination is important in healthcare, we also note potential to identify other social drivers supporting productive responses to performance monitoring in different contexts

Hospital doctors in Ireland and the struggle for work–life balance

Ireland has a high rate of doctor emigration. Challenging working conditions and poor work–life balance, particularly in the hospital sector, are often cited as a driver. The aim of this study was to obtain insight into hospital doctors’ experiences of work and of work–life balance. In late 2019, a stratified random sample of hospital doctors participated in an anonymous online survey, distributed via the national Medical Register (overall response rate 20%; n = 1070). This article presents a qualitative analysis of free-text questions relating to working conditions (n = 469) and work–life balance (n = 314). Results show that respondent hospital doctors, at all levels of seniority, were struggling to achieve balance between work and life, with work–life imbalance and work overload being the key issues arising. Work–life imbalance has become normalized within Irish hospital medicine. Drawing on insights from respondent hospital doctors, this study reflects on the sustainability of this way of working for the individual doctors, the medical workforce and the Irish health system. If health workforce planning is about getting the right staff with the right skills in the right place at the right time to deliver care, work–life balance is about maintaining doctor wellbeing and encouraging their retention

Hybrid healthcare governance for improvement? Combining top-down and bottom-up approaches to public sector regulation

Improving healthcare governance is an enduring challenge for policy-makers. We consider two national healthcare regulators adopting novel ‘hybrid’ regulatory control strategies in pursuit of improvement. Hybrids combine elements usually found separately. Scotland and Ireland’s regulators combine: (1) top-down formal regulatory mechanisms deterring breaches of protocol and enacting penalties where they occur (e.g. standard-setting, monitoring, accountability); and (2) bottom-up capacity building and persuasive encouragement of adherence to guidance by professional self-determination, implementation and improvement support (e.g. training, stimulating interventions). We identify socio-historical contextual factors constraining and enabling regulatory hybridity, whether and how it can be recreated, and circumstances when the approaches might be delivered separately. Using our findings, we develop a goal-oriented governance framework illustrating distinct, yet complementary, national and local organizational roles: (1) ensuring the adoption and implementation of best-practice, (2) enabling and (3) empowering staff to adapt and add to national mandates and (4) embedding cultures of improvement

Primary Care Physicians’ Experiences With and Adaptations to Time Constraints

Importance The primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees’ experiences and outcomes of work. Objective To examine how time constraints affect primary care physicians’ work experiences and careers. Design, Setting, and Participants Between May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians’ reflections on implications for their careers. Main Outcomes and Measures Thematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey). Results Interviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients. Conclusions and Relevance These findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians’ withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians

How the organisation of medical work shapes the everyday work experiences underpinning doctor migration trends: The case of Irish-trained emigrant doctors in Australia

Medical migration is a global phenomenon. In Ireland, hospital doctor emigration has increased significantly in recent years, with Australia a destination of choice. With work and employment conditions cited as a driver of these trends, this article explores how health system differences in the organisation of medical work shape the everyday experiences of hospital doctors which underpin migration decisions. Drawing on 51 semi-structured interviews conducted in July-August 2018 with Irish-trained hospital doctors who had emigrated to work in Australia, the findings highlight doctors’ contrasting experiences of medical work in the Irish and Australian health systems. Key system differences in the organisation of medical work manifested at hospital level and related to medical hierarchy; staffing, support and supervision; and governance and task coordination. Findings indicate that retention of hospital doctors is as much about the quality of the work experience, as it is about the quantity and composition of the workforce. At a time of international competition for medical staff, effective policy for the retention of hospital doctors requires an understanding of the organisation of work within health systems. Crucially, this can create working contexts in which doctors flourish or from which they seek an escape

Tissue Glucocorticoid Metabolism in Adrenal Insufficiency:A Prospective Study of Dual-release Hydrocortisone Therapy

Background: Patients with adrenal insufficiency (AI) require life-long glucocorticoid (GC) replacement therapy. Within tissues, cortisol (F) availability is under the control of the isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD). We hypothesize that corticosteroid metabolism is altered in patients with AI because of the nonphysiological pattern of current immediate release hydrocortisone (IR-HC) replacement therapy. The use of a once-daily dual-release hydrocortisone (DR-HC) preparation, (Plenadren®), offers a more physiological cortisol profile and may alter corticosteroid metabolism in vivo.Study Design and Methods: Prospective crossover study assessing the impact of 12 weeks of DR-HC on systemic GC metabolism (urinary steroid metabolome profiling), cortisol activation in the liver (cortisone acetate challenge test), and subcutaneous adipose tissue (microdialysis, biopsy for gene expression analysis) in 51 patients with AI (primary and secondary) in comparison to IR-HC treatment and age- and BMI-matched controls.Results: Patients with AI receiving IR-HC had a higher median 24-hour urinary excretion of cortisol compared with healthy controls (72.1 µg/24 hours [IQR 43.6-124.2] vs 51.9 µg/24 hours [35.5-72.3], P = .02), with lower global activity of 11β-HSD2 and higher 5-alpha reductase activity. Following the switch from IR-HC to DR-HC therapy, there was a significant reduction in urinary cortisol and total GC metabolite excretion, which was most significant in the evening. There was an increase in 11β-HSD2 activity. Hepatic 11β-HSD1 activity was not significantly altered after switching to DR-HC, but there was a significant reduction in the expression and activity of 11β-HSD1 in subcutaneous adipose tissue.Conclusion: Using comprehensive in vivo techniques, we have demonstrated abnormalities in corticosteroid metabolism in patients with primary and secondary AI receiving IR-HC. This dysregulation of pre-receptor glucocorticoid metabolism results in enhanced glucocorticoid activation in adipose tissue, which was ameliorated by treatment with DR-HC