The flexibility of healthcare teams : a mixed methods study of doctors and nurses in an emergency department

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[Background] The slow pace of reform towards a more responsive, adaptable and efficient healthcare workforce is often blamed on the ‘inflexibility’ of the healthcare professions. However, the concept of workforce flexibility is as ambiguous as it is ubiquitous. The aim of the study was to define workforce flexibility in the healthcare context by taking a division of labour perspective on a team, measuring the distribution of tasks between roles and exploring the teamwork practices and organisational factors that promote or hinder flexibility. [Study Setting and Method] The emergency department (ED) was selected as a potential exemplar of workforce flexibility. EDs are at the forefront of redesigning professional roles to increase efficiency while the unpredictable and urgent workload makes for an environment where healthcare professionals must be flexible. An explanatory sequential mixed methods design was used. Phase 1 work observations involved a time study which collected 151 hours of quantitative data to compare tasks undertaken by doctors, nurse practitioners (NPs) registered nurses (RNs) and qualitative fieldnotes which captured everyday work practices and the organisational context. In Phase 2, 19 semi-structured interviews were conducted with doctors, NPs and RNs which sought to explain the Phase 1 findings. [Results] The time study is the first to quantify how professional healthcare roles can be occupationally specialised but sufficiently multiskilled to create some overlap in the tasks they perform. The fieldnotes and interviews also generated new knowledge, in describing the teamwork of back-up behaviour between doctors and nurses. Three forms of back-up behaviour that used the team’s overlapping roles were identified: ‘task back-up’ where the team shared tasks based on the most efficient use of skills; ‘autonomy back-up’ to help a team member with less autonomy over focal medical tasks to ensure patients received timely medications and investigations; and ‘knowledge back-up’ to help teammates complete their tasks and develop as multiskilled professionals. Consistent with a growing body of evidence across healthcare settings, team members who worked together regularly were more willing and able to provide this back-up and were more effective in coordinating their specialised but overlapping roles. [Conclusion] The study’s unique insight on the work of a healthcare team highlights that workforce flexibility must be defined and evaluated from the perspective of the whole team, its patients and the organisational context. Taking this perspective revealed that healthcare professionals are more flexible than is often supposed but that individual team members, with their contextual understanding of the team, the work and the workplace are less interchangeable than current staffing practices assume. What healthcare teams need to work flexibly is stable membership. Further, the study identified that the policies that enact workforce reforms may be hindering the inherent flexibility of multiskilled, autonomous professionals.
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