Work engagement is meant to provide ‘positive, fulfilling … work related well-being … to provide engaged, high energy work focussed staff’, broadening the view about the meaning and effects of work (Bakker, Schaufeli, Leiter & Taris, 2008, p. 187). Coaching is recognised as a supportive but challenging process in developing skills in others (Isouard, Thiessen, Stanton & Hanson, 2006) and has been identified as a key competence for healthcare leadership (Henochowicz & Hetherington, 2006). Mentoring programs enhance job satisfaction of those mentored, improving knowledge, skills and career prospects (Weng et al., 2010). Mentoring is broad-based and concentrates on developing career progression, scholarly achievement and personal development, through reciprocity and accountability over time (Mills, Francis & Bonner, 2005).

Performance management

The members of the health workforce are regularly evaluated through performance reviews based on key performance indicators, competencies, organisational objectives and the perceptions of peers and consumers, a process often referred to as 360-degree reviews. Staff are also routinely measured in service and goal orientations, and in how patients and clients generally perceive the quality of teams and services.

Managers need to focus on recruitment and retention of staff, the development of the workforce, issues of workforce substitution and the achievement of a high-performance organisation that attracts and retains the right people and provides a healthy work environment. The health sector is described as ‘people centred’ (McConnell, 2000, p. 4) and requires an understanding of organisational behaviour, culture, power and team-based bottom-up approaches (Braithwaite, 2005).

Liang, Leggat, Howard and Lee (2013) undertook research to identify core competencies important in developing the capability of health managers, identifying staff development and training needs, and the implementation and conduct of performance management systems. The core competencies described are ‘leadership; leading and managing change; operations, administration and resource management; evidence-informed decision making; knowledge of healthcare environment and the organisation; interpersonal, communication qualities and relationship management’ (Liang et al., 2013, p. 569). Competencies reflect specific skills and attributes required of a role, and capability is used to describe the capacity of individuals to successfully undertake the role and utilise the competencies. Capability goes to broader concepts of ‘knowledge, skills and personal attributes’ (Briggs, Smyth et al., 2012, p. 73).

Gender

Gender is a concept based in the beliefs of society ‘about what are appropriate roles and activities of men and women’. The debate is often around equality and equity and about opportunity to progress and receive promotion. Managers need to focus on how to ‘improve the number, distribution and skill mix of the health workforce’ (Reichenbach & Brown, 2004, pp. 792–793). Managers should also understand competing long-held beliefs and values within the workforce, including those that might be held by managers. There may also be requirements to meet institutional policies and practices on gender.

Multiple generations

The workforce now extends across four generations, described by Stanley (2010, p. 846) as ‘veterans’, ‘baby boomers’, ‘generation X’ and ‘generation Y’. Dols, Landrum and Wieck (2010, pp. 68–69) describe the generations as ‘traditionalists’, ‘baby boomers’, ‘generation X’ and ‘millennials’. The generational differences are described in terms of values, beliefs, expectations and behaviours. Managers need to develop strategies to engage and retain these groups.

Dols et al. (2010, pp. 70–73) suggest providing and rewarding effective mentors; managing high workloads and burnout; organising interventional staffing at difficult times; maintaining morale through acknowledgement, respect, praise and appreciation; recognising the ‘extra mile’; ensuring safety as the norm; building relationships and teamwork; and being a proactive leader. Wilson, Squires, Widger, Cranley and Tourangeau (2008) focus on job satisfaction and suggest implementing shared governance, self-scheduling and job-sharing. Howell, Beckett, Nettiksimmons & Villablanca (2012, p. 720) suggest that ‘enhancing and communicating career flexibility can be an effective strategy for … recruitment and retention’.

The older or ageing part of the workforce becomes more important in times of workforce shortages. In one organisation, allied health staff aged over 50 represented more than one-quarter of that occupational group, and more than half the rural health nurse workforce was over 50 (Fragar & Depczynski, 2011). Older health workers are committed productive workers affected by the impact of ageing on healthy functioning. Managing an ageing workforce requires policies and practices that are supportive and enhance their retention. Hahn’s (2011) study of multiple generations drew on the ACORN mnemonic to describe imperatives:

• Accommodate employee differences.
  
• Create workplace choices.
  
• Operate from a sophisticated management style.
  
• Respect competence and initiative.
  
• Nourish retention.

Hahn (2011) encourages the use of five strategies to address generational circumstances:

• Self-assess your managerial style.
  
• Understand generational characteristics and core values.
  
• Embrace commonalities.
  
• Create and maintain a respectful culture.
  
• Bridge the generational gap.

Generational differences can be a source of frustration for managers, who need to appreciate the differences and focus on the positives and strengths in building a positive workplace (Gursoy, Maier & Chi, 2008).

Human resources

The shifted focus of human resources still sees it as a critical component of health policy and organisational activity (Dussault & Dubois, 2003) that has a more strategic planning and developmental role. The changing context of healthcare described in this chapter requires a human resource strategic approach that:

• understands the nature of the existing workforce
  
• focuses on maximising skills utilisation in adaptive and flexible ways
  
• strategically develops the workforce in sustainable ways
  
• emphasises retention of existing staff while also preparing for succession
  
• develops a responsive, adaptive and innovative workforce.

The concepts of accountability, trust and stewardship afforded to managers are important. The extent of trust is reflected in the degree of centralisation and decentralisation allowed (Rathwell & Persaud, 2002). Ideally, leaders and managers should be located close to and accessible by those delivering care. They should be capable of managing down and out to staff, clients, patients and communities as well as being capable of managing up to higher organisational levels (Briggs, 2008).

Batalden et al. (2003) suggest that leadership and quality in clinical microsystems are important and are often group activities that involve attention to processes that build knowledge, take action, review and reflect: a consistent and continuous process. The question is how best to support, develop and increase the leadership of the microsystems, where care is actually delivered. It is important that leaders possess an understanding of leadership as something more than being concerned with hierarchies and control and goes to the core of leadership at the service delivery level, within and between professions.

Skills utilisation

Dubois and Sing (2009, p. 91) suggest a move from a focus on ‘staff-mix’ to ‘skill-mix and beyond’. These authors see the challenges as workforce shortages, societal trends towards reduced work hours, ageing and early retirement, and continued pressure on health systems over waiting times and access to services. They argue that the current focus on staff-mix is restrictive and emphasise that a focus on staff skills provides a more dynamic human resources environment that focuses effective utilisation of the available health personnel to their fullest potential.

Dubois and Singh’s (2009) focus on maximising skills requires a human resources emphasis on skills assessment, training and development so that the workforce can take on new roles and functions. This occurs through role enhancement and/or role enlargement. Altering roles should be attractive to employees because it offers opportunities, new competencies and greater achievement, recognition and motivation. Evidence in support of these types of strategies is not conclusive, however, and they might cause increased tension or confusion with traditional professional roles and be seen as convenient approaches to workforce rationalisation.

Integrated care in treating chronic conditions requires multiple skills, including management, system-planning, care-planning, negotiation and teamwork, bringing clinical and management roles into alignment. These skills are also required in direct engagement, supporting patients and clients with the capacity to self-manage their disease or chronic condition. Such approaches extend the need for skill flexibility, role substitution and role delegation. Conditions need to be created that allow the organisation to maximise human resources and to utilise them flexibly (Dubois & Singh, 2009).

The health workforce is often described in terms of activity, such as hours per day of care, or in numbers or ratios, such as nurse to patient ratios. Attempts to describe the impact of these ratios in terms of quality and safety of care are inconclusive. There are also tensions between mandating ratios and allowing management to make effective decisions around staff deployment. While the evidence about what is adequate is not conclusive, increases in nursing staff levels are generally resisted, as this occupational group is the largest profession within health, and therefore a greater expense in accounting terms for those concerned with budgets. So human resource practitioners need to understand the tension when staff are seen as a resource while at the same time being accounted for as an expense (Day, Viswasam & Briggs, 2004).

Organisational behaviour and culture

Implementing human resource initiatives in the midst of what has become constant health reform requires an understanding of the impact of culture on staff and organisations. Culture is often described in contexts of transforming and empowering people to achieve a variety of objectives. There are two main theoretical perspectives on culture: that it is descriptive of what an organisation is and that it is something that organisations have. Paying attention to culture is regarded as important in implementing reform (Davies, Nutley & Mannion, 2000).

Having a consistent and coordinated approach between the organisation and its staff as to purpose or mission and the values and behaviours ascribed is an important consideration. How management value staff and how they behave towards them are also important. This requires ‘shared beliefs, attitudes, values, and norms of behaviour’ (Davies et al., 2000, p. 112). Often within organisations this is described as ‘the way we do things around here’, mostly stated in a manner that suggests opposition to change. Leonard, Graham and Bonacum (2004, p. i89) describe resistance to change and effective behaviours as communication failures and suggest that the emphasis is on ‘correcting system flaws’, teamwork and ‘visible support from senior leadership and strong clinical leadership’. It is important to consistently practise the agreed values and behaviours so that they have real meaning within the organisation. According to Dubois and Singh (2009), an effective organisational structure for the management of human resources includes:

• relatively flat hierarchy with few supervisors
  
• worker autonomy
  
• participative management
  
• professional development opportunities
  
• relatively high organisational status for nursing
  
• collaboration.

Managing the challenge of the difficult worker

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