Impact evaluation of a five-day short course in health promotion: workforce development in action

Issue addressed: This paper reports on impact evaluation of a series of five-day Short Courses in Health Promotion that have been delivered to more than 2,000 people since 2002 as part of a statewide workforce development strategy.

Methods: A triangulated mixed methods research design was selected for the evaluation. Data were collected through a mail survey, key informant interviews, focus groups and organisational case studies. Stakeholder and participant involvement were central to the evaluation.

Results: Organisational change emerged as a key theme. Impacts of the short course were felt in relation to health promotion practice and on organisational capacity to conduct health promotion, while the development of confidence and skills of participants to engage in collaborative opportunities was a not unexpected, but important, benefit of the course.

Conclusions: A short course is effective if attention is given to quality delivery, adult learning methods, participant involvement, appropriate targeting, good planning, and adequate funding. However, respondents commonly report the need for organisational change in order for health promotion practice to be embedded into organisations and for practitioners to be supported in their efforts to re-orient services towards health promotion.

Issues in developing e-health systems: an Australian case study

Over the last few years, perceptions of the importance of eHealth have increased rapidly, together with the use of IS&T in the delivery of health and social services. Although “e” approaches to health and social services have much potential, they are not panaceas, and the use of new technologies in improving the efficiency and effectiveness of such systems cannot be considered in isolation from their wider context. eHealth systems remain complex socio-organisational systems and, as we will argue and illustrate through this case study, require that a balanced approach to feasibility and desirability analysis be taken.

The case study in this paper describes a feasibility study into the potential effectiveness of a smartdevice-based electronic data collection and payment system which was proposed for the provision of disability services. A key finding of the study was that the most significant impediment to such a system was the highly diffused, fragmented, interlocking organisational structure of the social service administration itself. Rather than raise issues specific to the implementation or diffusion of new technologies in designing e-health services, it raised issues associated with decision making and control in such an environment, and with the design of the underlying organisational system: for service provision, the level of detail required in the service data, and the locus of decision-making power among the stakeholders.

In our account we illustrate the existence of multiple, incommensurate but valid perceptions of the human service provision problem, and discuss the implications for developers or managers of information systems in the arena of e-health or governance. We examine this environment from sociological and information systems perspectives, and confirm the usefulness of socio-organisational approaches in understanding such contexts.

The influence of marketing logistics networks on organisational performance in Australia and New Zealand

Predictions concerning the influence of traditional and online marketing logistics network competency on organisational performance were tested via structural equation modelling employing a sample of Australian and New Zealand companies. The study finds a significant influence of the use of traditional marketing logistics networks on organisational performance, but that the use of the Web in this regard is yet to have such an influence.

Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research

Background: The title, Nurse Practitioner, is protected in most jurisdictions in Australia and New Zealand and the number of nurse practitioners is increasing in health services in both countries. Despite this expansion of the role, there is scant national or international research to inform development of nurse practitioner competency standards.

Objectives: The aim of this study was to research nurse practitioner practice to inform development of generic standards that could be applied for the education, authorisation and practice of nurse practitioners in both countries.

Design: The research used a multi-methods approach to capture a range of data sources including research of policies and curricula, and interviews with clinicians. Data were collected from relevant sources in Australia and New Zealand.

Settings: The research was conducted in New Zealand and the five states and territories in Australia where, at the time of the research, the title of nurse practitioner was legally protected.

Participants: The research was conducted with a purposeful sample of nurse practitioners from diverse clinical settings in both countries. Interviews and material data were collected from a range of sources and data were analysed within and across these data modalities.

Results: Findings included identification of three generic standards for nurse practitioner practice: namely, Dynamic Practice, Professional Efficacy and Clinical Leadership. Each of these standards has a number of practice competencies, each of these competencies with its own performance indicators.

Conclusions: Generic standards for nurse practitioner practice will support a standardised approach and mutual recognition of nurse practitioner authorisation across the two countries. Additionally, these research outcomes can more generally inform education providers, authorising bodies and clinicians on the standards of practice for the nurse practitioner whilst also contributing to the current international debate on nurse practitioner standards and scope of practice.

Wellbeing, job satisfaction and commitment among Australian community health workers: the relationship with working conditions

The Australian community health sector has undergone extensive organisational reform in recent times, and, in the push to enhance efficiencies and contain costs, there are indications that these changes may have undermined the wellbeing of community health personnel and their ability to provide high quality illness-prevention services. The aim of this study was to examine the working environments experienced by community health service employees and identify conditions that are predictive of employee stress. The study was guided by a tailored version of the demand-control-support model, whereby the generic components of the model had been augmented by more situation-specific stressors. The results of multiple regression analyses indicated that job control, and, to a lesser extent, social support, were closely associated with the outcome variables (psychological health, job satisfaction and organisational commitment). The more situation-specific stressors also accounted for significant proportions of explained variance. Overall, the results suggest that working conditions, particularly job control, social support and specific job stressors, offer valuable opportunities for protecting and enhancingthe wellbeing of community health service personnel.

A role for workforce competencies in evidence-based health promotion education

Education programs should be based on research about the knowledge and skills required for practice, rather than on intuition or tradition, but there is limited published curriculum research on health promotion education. This paper describes a case study of how workforce competencies have been used to assist evidence-based health promotion education in the areas of curriculum design, selection of assessment tasks and continuous quality assurance processes in an undergraduate program at an Australian university. A curriculum-competency mapping process successfully identified gaps and areas of overlap in an existing program. Previously published health promotion workforce competencies were effectively used in the process of selecting assessment items, providing clear guidelines for curriculum revision and a useful method to objectively assess competency content in an evidence informed framework. These health promotion workforce competencies constituted an additional tool to assess course quality. We recommend other tertiary institutions consider curriculum-competency mapping and curriculum based assessment selection as quality and evidence based curriculum review strategies.

Health promotion and evaluation - a programmatic approach

Health promotion has evolved significantly in the past twenty years. Its emphasis has shifted from relatively simple monocausal models focused on behavioural risk factors to a greater emphasis on broader social determinants of health. Single method, single risk factor interventions have increasingly been replaced with multiformat, multiple risk factor interventions and extended campaigns, with whole-of-govemment implications. Health promotion structures have developed from ad hoc single shot activity to large dedicated agencies with continuing responsibilities and a wide ambit.

The development of health promotion research and evaluation has followed these trends. The early epidemiology studies linked behavioural risks such as smoking, diet and physical activity with systemic conditions such as cancer and cardiovascular disease. A raft of small and large scale intervention studies aimed at demonstrating that these behavioural risk factors could be modified and that modification would lead to improved health outcomes followed with mixed results.

More recent evidence suggests that behavioural risks are not the onIy social factors that influence health outcomes. There is now strong evidence that social determinants such as income, education and employment have highly significant direct effects on health outcomes, which are not mediated by behavioural risks, and that behavioural risks are also correlated with these broader determinants.

Health promotion now operates in a variety of ways at different scales and different levels of the health system (and the wider social system). The goals of health promotion, and the measures that assess whether a project, campaign, or general strategy has met its goals, differ accordingly.

Arguably, where local, state and federal governments begin to coordinate their efforts systematically across settings, intervention strategies, health action areas and population groups, health promotion becomes more
programmatic, sustainable and effective. A programmatic approach also integrates knowledge generation, the development of health promotion capacity, practice and evaluation together.

However, programmatic approaches to health promotion are comparatively new. Only recently have governments begun to develop and resource
comprehensive and sustained health promotion programs that address a range of health issues using multiple intervention strategies. The scope of a more programmatic approach and its functions and purposes is still developing.

Although evaluation has a key role to play in this respect, the development of programmatic strategies for health promotion has generally outpaced evaluation theory and practice. While we now have reasonable technologies for measurement of behavioural risks and individual attitudinal and cognitive influences on them, strategies to evaluate organisational and community interventions are still emerging.

Similarly, while new approaches to evaluate small scale community and organisational interventions have been developed, comprehensive models to monitor and evaluate health promotion programs and strategies across multiple intervention sites over extended periods have not yet emerged. Nor have we resolved the methodological problems of teasing out the relative contribution of different intervention strategies to observed change in health outcomes.

More programmatic approaches to health promotion require a more programmatic approach to health promotion evaluation. This paper represents an issues based examination of the evidence base for a more programmatic health promotion and the evaluation issues that arise

Reviewing the learning organisation model in a child and adolescent mental health service

From 1995 onwards, a child and adolescent mental health service (CAMHS) applied Senge's learning organisation model. This review compared service performance with that of peer services 5 years later and explored whether any differences were associated with the application of this model. The comparison methodology used quantitative analysis of external data from the Department of Human Services, together with qualitative analysis of material including interviews with CAMHS directors and service managers. Results showed high evaluation activity and high quality, efficiency and efficacy of care compared with other services. Several restraints to the optimal application of the model were identified, including inadequate training of new managers, service overload, major external organisational change and limited investment in information systems. Other outcomes are discussed.

Rethinking policies for the retention of allied health professionals in rural areas : a social relations approach

Objective: Retaining allied health professionals in rural areas is a recognised problem. Generally the literature has concentrated on three elements: practitioner needs, community needs and organisational needs. There has been little attempt to focus other types of social relations in which health practitioner retention and recruitment takes place. The aim of this paper is to question the present dominant hierarchical approach taken in relation to the retention of allied health professionals in rural localities.

Methods: The data derives from a survey in Southwest Victoria, Australia. The sample was purposive rather than representative as it was intended to be exploratory in nature rather than definitive.

Results: The data indicates that there is a greater tendency for allied health professionals in private practice to be retained in rural areas than those in the public sector.

Conclusion: The paper concludes by raising some questions about the pertinence of present models for regional health initiatives since they are locked into a bureuacratic model where relationships are hierarchical and asymmetrically controlled.

Cultural racism, language prejudice and discrimination in hospital contexts : an Australian study

This article explores the idea that racial and ethnic disparities in healthcare may be expressive of unacknowledged practices of cultural racism. In conducting this exploration, the researchers identify, describe and discuss the practice of language prejudice and discrimination by health service providers, discovered serendipitously in the context of a broader study exploring cultural safety and cultural competency in an Australian healthcare context. The original study involved individual and focus groups interviews with 145 participants recruited from over 17 different organisational and domestic home sites. Participants included health service managers, ethnic liaison officers, qualified health interpreters, cultural trainers/educators, ethnic welfare organisation staff, registered nurses, allied health professionals, and healthcare consumers. Participants self-identified as being from over 27 different ethnocultural and language backgrounds.

Analysis of the data revealed that English language proficiency, like skin colour, was used as a social marker to classify, categorise, and negatively evaluate people of non-English speaking backgrounds (NESB) in the contexts studied. Negative evaluations, in turn, were used to justify the exclusion of NESB people from healthcare relationships and resources. Further data analysis revealed that underpinning the negative attitudes and behaviours in hospital domains concerning people who spoke accented English or who did not speak English proficiently were a dislike of difference, fear of difference, intolerance of difference, fear of competition for scarce healthcare resources, repressed hostility toward difference, and ignorance.

Highlighting the implications of language prejudice for the safety and quality care of NESB people, the researchers call for further internationally comparative research and debate on the subject.

Ethical, economic and efficient sector : is it a gamble? The case of New Zealand Health

The New Zealand public sector has gone through major reform as a result of fiscal deficit in 1984 (KettI, 1997; Schwartz, 1997), resulting in shift of emphasis from quality service provision to establishing financial supremacy (Kettl, 1997). This raises concern as to how public sector employees are attaining balance between their service objectives with financial ones and how is the ethics negotiated in this process. Following this concern, this paper focuses on determining the organisational variables consisting of organisational policies in the District Health Boards (DHBs) and hospitals of New Zealand on ethical behaviours of managers and the ethical climate of these departments. The aim of this study is to increase our understanding of the ethical climate of the public health. Our findings suggest that little emphasis has been provided to the aspect of ethics in New Zealand health sector. There is no reward for employees who exhibit exemplary ethical behaviour, no hot line to consult/report about ethics, any detailed guidelines and policies, and not enough ethics-related training provided to staff.

Skill shortages in health : innovative solutions using vocational education and training

Introduction: This article reports findings of a project funded by the Australian National Council for Vocational Education Research. The project explores solutions to current and projected skills shortages within the health and community services sector, from a vocational education and training perspective. Its purpose is to locate, analyse and disseminate information about innovative models of health training and service delivery that have been developed in response to skill shortages.

Methods: The article begins with a brief overview of Australian statistics and literature on the structure of the national health workforce and perceived skill shortages. The impact of location (state and rurality), demographics of the workforce, and other relevant factors, on health skill shortages is examined. Drawing on a synthesis of the Australian and international literature on innovative and effective models for addressing health skill shortages and nominations by key stakeholders within the health sector, over 70 models were identified. The models represent a mixture of innovative service delivery models and training solutions from Australia, as well as international examples that could be transposed to the Australian context. They include the skill ecosystem approach facilitated by the Australian National Training Authority Skill Ecosystem Project. Models were selected to represent diversity in terms of the nature of skill shortage addressed, barriers overcome in development of the model, healthcare specialisations, and different customer groups.

Results: Key barriers to the development of innovative solutions to skills shortages identified were: policy that is not sufficiently flexible to accommodate changing workplace needs; unwillingness to risk take in order to develop new models; delays in gaining endorsement/accreditation; current vocational education and training (VET) monitoring and reporting systems; issues related to working in partnership, including different cultures, ways of operating, priorities and timelines; workplace culture that is resistant to change; and organisational boundaries. For training-only models, additional barriers were: technology; low educational levels of trainees; lack of health professionals to provide training and/or supervision; and cost of training. Key enhancers for the development of models were identified as: commitment by all partners and co-location of partners; or effective communication channels. Key enhancers for model effectiveness were: first considering work tasks, competencies and job (re)design; high profile of the model within the community; community-based models; cultural fit; and evidence of direct link between skills development and employment, for example VET trained aged care workers upskilling for other health jobs. For training only models, additional enhancers were flexibility of partners in accommodating needs of trainees; low training costs; experienced clinical supervisors; and the provision of professional development to trainers.

Conclusions: There needs to be a balance between short-term solutions to current skill shortages (training only), and medium to longer term solutions (job redesign, holistic approaches) that also address projected skills shortages. Models that focus on addressing skills shortages in aged care can provide a broad pathway to careers in health. Characteristics of models likely to be effective in addressing skill shortages are: responsibility for addressing skills shortage is shared between the health sector, education and training organisations and government, with employers taking a proactive role; the training component is complemented by a focus on retention of workers; models are either targeted at existing employees or identify a target group(s) who may not otherwise have considered a career in health.

New work ethics? The corporate athlete's back end index and organisational performance

Drawing on Michel Foucault’s later genealogies of the Self the paper will illustrate particular dimensions of the increasingly powerful individualizing and normalizing processes shaping the lifeworlds of worker-citizens in a globalizing risk society. Processes that require those who wish to be positively identified as professional, entrepreneurial, resilient, effective, athletic to do particular sorts of work on themselves. Here the paper argues that we can identify the emergence of what we call New Work Ethics. We illustrate this more general argument via an analysis of the ways in which a large Information Technology (IT) organization seeks to produce—via a workplace health and fitness program—employees who imagine themselves as embodying the behaviours and dispositions that mark the person as a corporate athlete. Knowledge of the Self in these terms can, it is promised, enhance the performance of the Self, and the organization.