Exploring the Relationship between Human Resource Management and Organisational

Performance in the Healthcare Sector

Ian Kessler, King’s College, University of London

1. Introduction

While debate amongst policy makers, practitioners and scholars in the field of human resource

management (HRM) has often revolved around whether and how the treatment of the workforce

contributes to bottom-line corporate performance in terms of profitability and shareholder value

(Boxall and Purcell, 2011), in healthcare the organizational outcomes associated with workforce

management have assumed an altogether different form. Healthcare is one of the few sectors of an

economy in which workforce management is often quite literally a matter of life or death (Propper

and Van Reenen, 2010; West et al, 2002; West et al, 2006). Mortality is the most extreme of

potential outcomes, but it is certainly the case that the management of employees in the healthcare

sector has consequences of a distinctive order related to the quality and longevity of life and, more

specifically, to the well being of its most needy and vulnerable citizens: the acute and chronically ill.

The link between workforce management and organisational outcomes is particularly direct in

healthcare, where despite the ongoing introduction of new medical technologies service delivery

remains centred on the unmediated relationship between the worker and the service user. The

labour intensive nature of healthcare delivery in these settings is reflected in the fact that in most

developed countries labour costs constitute around two thirds of total healthcare costs (Dubois,

McKee and Nolte, 2006:13). The worker-patient relationship is enacted in three healthcare settings:

primary – where frontline care is delivered mainly by general practitioners; community - where

chronic illnesses are managed, often in the patients’ home or neighbourhood facilities; and

secondary - where acute conditions are treated in hospital. The substance of the worker-patient

relationship in all these settings ranges from the periodic assessment, diagnosis and treatment

undertaken by skilled health professionals, to the more routine but essential care provided by the

general nursing workforce and a plethora of paramedical and non-clinical support workers.

Despite the centrality of workforce management to valuable and valued individual and societal

health outcomes, the attention traditionally devoted to human resource management in the

healthcare sector by policy makers and practitioners has been patchy. Buchan (2004:1) stressed that

policy and practice, particularly in the 1980s and 90s, focused on cost control, noting that ‘The

importance of human resource management to the success or failure of health system performance

had been overlooked.’ At the same time, he acknowledged that more recently ‘getting HR policy and

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management right has been seen as core to any sustainable solution to health system performance.’

It is a shift of interest driven by the challenges faced by the sector as the emergent care needs of,

typically, aging populations with heightened expectations of service quality run-up against a

tightening resource base, especially in publicly funded healthcare systems, where government

expenditure has been reined-back post the 2008 financial crisis and its associated recession.

The research literature has reflected this uneven but growing policy interest in HRM in the

healthcare sector. Since its first issue in 1961, a leading US-based journal, Human Resource

Management, has published just seven articles with a specific focus on healthcare. However, it is

about to produce a special issue on health and social care work (forthcoming). Other HRM journals

have displayed a more sustained engagement with the healthcare sector, although this has

deepened in recent years with the International Journal of Human Resource Management (2013,

24:16) and the Human Resource Management Journal (2010, 20:4) publishing special issues on the

sector and the Industrial and Labor Relations Review is planning to do so. However, given that an

average of 10% of workforces in OECD countries is to be found in healthcare (Sermeus and Bruyneel,

2010:4), the level of interest shown by the academic HR community in the sector has fallen well

short of extravagant.

This characterisation of the mainstream literature on HRM in the healthcare sector as recently

emerging and underdeveloped relates to a number of factors. As a discipline human resource

management has usually found a home in business schools, which are more interested in exploring

the pursuit of corporate competitive advantage than in the functioning of publicly-funded, often not-

for-profit, organisations. More substantively, scope for the development of dynamic organizational

forms of HRM practice in the sector has traditionally been quite limited, with healthcare workforces

tightly regulated by the state in terms of training, performance standards and pay (Bach et al, 1999).

Moreover, with professional rather than general management systems and values historically driving

service delivery in healthcare organisations (Ackroyd et al, 1989; Ramanujam and Rousseau, 2006),

many workforce issues have been tied to specialist clinical and technical fields of expertise

addressed in other literatures such as those in nursing and healthcare studies.

In the context of such a diverse and diffuse extant research literature on HRM in healthcare, this

article focuses on a discrete but increasingly important issue for various stakeholders: the current

state of knowledge and debate on the relationship between human resource management practice

and organisational performance in the healthcare sector. A focus on the HRM-performance nexus

aligns with a central preoccupation of scholars in strategic human resource management over recent

years, but for healthcare settings, this link needs to be qualified in a number of respects. First and as

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already implied, organisational performance assumes a particular form in healthcare, suggesting

caution in theorising the link between outcomes and HRM practice in the sector. Second, debate on

workforce management issues in healthcare has been much broader than an interest in the HRM-

performance relationship. Distinctive features of the healthcare workforce have encouraged

consideration of a wide range of research issues. For example, healthcare workforces are highly

professionalised and at the same time occupationally segmented and hierarchical prompting

research on inter-occupational relations and job boundaries in the sector (Nancarrow and Borthwick,

2005; Currie et al, 2012). Moreover, as an interactive service industry, healthcare has provided

fertile ground for a consideration of service user-worker relations, with a particular focus on

emotional labour (Smith, 2012). Indeed, the gendered nature of the sector’s workforce (typically

about two-thirds of the employees are women) has generated an interest in the value (or lack of it)

placed on care work and on the (un)fairness of associated rewards (England, 2005). Some of these

alternative issues are touched on in exploring the HRM-performance connection in this article, but

they remain important research questions in their own right.

A third qualification relates to the moderation of the HRM-performance link by institutional context

(Paauwe, 2004). A detailed consideration of different national systems of healthcare delivery and

their associated HRM practices is beyond the scope of this article. In brief, however, such systems

vary along various dimensions including: sources of funding; governance; regulation; and access to

services (Johnson and Stoskopf, 2010; OECD, 2013). Roemer’s (1993) typology suggests three

healthcare models varying along these dimensions. An entrepreneurial model, found in the USA, has

traditionally provided selective healthcare coverage for the population, relying on the purchase of

private health insurance by individuals and employers. It is a model predicated on the delivery of

care by mainly privately, rather than publicly owed, providers, often driven by profit. A mandated

insurance model, characterising, for example, the German healthcare system, provides universal

healthcare coverage, funded through social insurance as bought by workers and employers. It rests

on the direct provision of care by a variety of independent, private and publicly owned

organisations, reimbursed by the government from the insurance fund for the care they deliver. The

third, a state run model, seen in Britain, also ensures universal healthcare coverage, but directly

funded through general taxation. In this model services are not only provided free at the point of the

delivery, but traditionally by publicly owned healthcare providers, controlled and run by a central

government department, the Department of Health.

These institutional differences in national healthcare systems have been remarkably durable, with a

degree of path dependence based upon a cumulative support from interested parties for their

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continuity (Pierson, 2001). The differences raise questions about whether and how they feed

through to shape national HRM policy and practice, although with a few exceptions, (Grimshaw et al

2007), these issues have not been extensively examined. Indeed, research on HRM in healthcare has

sometimes shown limited sensitivity to institutional context even within single country studies. In

reviewing the literature on the HRM-performance relationship, this article is informed by

institutional developments mainly in the British NHS, not least as a means of highlighting how the

HRM agenda in healthcare and its connection to organizational outcomes might be influenced by

broad contextual factors.

More specifically, this article explores the HRM-performance link across the healthcare sector in four

main parts. The first part examines growing pressure faced by developed countries to address the

performance of their healthcares systems and how workforce management issues have been

presented in this context by interested parties. The second part explores a stream of research which

has largely been framed by mainstream debates in the field of HRM as they relate to HRM-

performance link. The third part considers a more refined research stream, typically found in nursing

studies, which examines how staffing patterns connect to various outcomes. A final part provides an

overview discussion and draws some conclusions.

2. Performance in a Healthcare Context

2.1 Public Policy Developments

The notion of performance in a healthcare context has been contested over the years and variously

articulated in shifting socio-economic and political circumstances. In many developed countries, the

creation of publicly funded healthcare services was part of a post 1945 social settlement which led

to the creation of the welfare state (Esping-Andersen, 1990). In these countries a sizeable and

increasing proportion of GDP was devoted to healthcare expenditure, but in a period of economic

growth through to the mid 1960s and 70s, this was affordable and prompted few pressing policy

concerns about the sector’s performance. In Britain, for example, the NHS became a ‘cherished’

institution delivering free care when needed to all. As former British Chancellor Nigel Lawson noted,

the NHS was the nearest the English had to a shared religion.

A global recession in the late seventies and early eighties in the wake of the international oil crisis

prompted greater scrutiny of performance in healthcare, particularly in terms of cost efficiency, as

public expenditure came under pressure. It was a period which coincided with an ideational shift in

approaches public service delivery, captured by the notion of the New Public Management (NPM)

(Hood, 1991). As a set of prescriptive principles, underpinned by Public Choice theory (Nisakanen,

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1971), NPM challenged sheltered and bureaucratic forms of service delivery through the

introduction of market mechanisms and competitive forces. In doing so, service user or ‘customer’

choice was placed at the centre of service provision with direct implications for the workforce. Public

service workers were explicitly presented as part of the ‘problem’, with ‘producer capture’ of

services seen as undermining ‘consumer sovereignty’. In these circumstances, ways of measuring

performance and the setting of targets by which to assess comparative organisational outcomes

became a means of allowing users to make more informed choices in the ‘market place’.

While the take-up of NPM principles varied (Pollit and Bouckaert, 2004), some countries pursued

them with alacrity, particularly impacting on the management of state funded healthcare systems. In

Britain a ‘new right’ Conservative government elected in 1979 sought to apply them in an assertive

way, introducing an internal market for health and establishing hospitals as quasi autonomous

provider units ‘competing’ with one another. There were direct HRM consequences. The

government sought to weaken national systems of workforce management supporting a traditionally

integrated bureaucratic form of healthcare delivery by devolving responsibility for such issues as pay

determination to the newly created hospital trusts (Bach and Winchester, 1994). Further indicative

of the NPM approach, the Conservative government encouraged the use of private sector HRM

practice in healthcare, such as performance related pay, and introduced a cadre of general managers

as a countervailing force to the power of the healthcare professional. It is a testament to the

resilience of HRM practices in the British NHS that such attempts made limited headway (Bach,

1998; Grimshaw, 1999). But the pursuit of NPM did have a lasting impact on the delivery of

healthcare in Britain and in other countries by deepening public policy interest in the demonstrable

performance of healthcare systems defined by their sensitivity to user voice and choice.

From the 1990s, as economic growth took hold, accompanied in some countries by the introduction

of new political values and approaches, there were shifts in public policy on the performance of

healthcare systems. These should not obscure elements of continuity (Bach and Kessler, 2012). In

Britain, a ‘Third Way’ New Labour government elected in 1997 strengthened the previous

government’s target-based performance management regime as a means of continuing to facilitate

market choice for service users. A star rating system for hospitals was established which ranked

healthcare providers according to various measures, allowing users to benchmark hospital

performance (Givan, 2005). This was accompanied by the introduction of new, more intense market

forces, for instance, reflected in the outsourcing of routine elective operations to private and

independently run treatment centres and in a growing reliance on private sector funding to support

capital projects (Bach and Givan, 2010; Tailby, 2012). It was a combination of policies that

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encouraged some to characterise New Labour’s approach to healthcare as an extension of the

previous government’s neo-liberal agenda designed to commodify public services (Whitfield, 2006).

These elements of continuity were, however, qualified by important changes in practice, which

impacted on how the sector’s performance was conceived, perceived and enacted. Hospital HRM

indicators sitting alongside broader organisational financial outcomes and service measures related

to user access were developed for the first time, and covered such issues as: staff turnover and

absenteeism; the completion of individual performance appraisals; and spend on agency staff. The

inclusion of such measures was indicative of an attempt by the new government to reframe relations

with public services employees, with a move away from overt hostility to recognition that in a labour

intensive sector such as healthcare workforce support and commitment were essential to an

effective ‘modernisation’ programme.

The period was also marked by a change in how service users were conceived, with public policy

implications for the management of organisational performance. While users continued to be

viewed as an actor in the healthcare market by the New Labour government, they also came to be

seen as ‘citizens’ displaying responsibility for their own health and well being as a quid pro quo for

the receipt of care when needed (Clarke et al, 2007). These developments were accompanied by a

growing emphasis on person-centred services to be delivered in more open, integrated and perhaps

less market driven ways (Needham, 2010). Such a shift encouraged debate on the co-design and -

production of health services, with implications for healthcare workers, viewed as seeking more

collaborative relationships with the service user (Leadbeater, 2004; Kessler and Bach, 2011). A public

policy preoccupation with personalisation took root beyond Britain in continental European

countries less obviously attracted by the NPM-turn in public service delivery. It was reflected in the

European Union’s Horizon 2020 research programme calling for projects on the development of a

workforce able to deliver such personalized healthcare (European Commission, 2013:36)

From the late 1990s, an interest in improved performance in healthcare was also related to state

investment in the sector. Over recent decades, expenditure on healthcare had been increasing in

real terms across many developed nations. For example in EU countries average spend on healthcare

as a proportion of GDP rose from 6% to 10% between 1970 and 2010. In countries such as Britain,

the rise was particularly sharp, especially from the early 2000s as the government used the fruits of

economic growth to raise healthcare expenditure as a proportion of GDP to the EU average.

Between 2000-2001 and 2010-2011 real expenditure in the British NHS increased by 7% a year

compared to an annual average of 4% over the life time of the NHS (formed in 1948) (King’s Fund,

2010). Such increases in healthcare spending, particularly in state funded healthcare systems,

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prompted an interest in the improved performance of healthcare providers as an assurance that the

tax payer was receiving value for money.

2.2 New Pressures

Public policy developments, driving an interest in the performance of the healthcare sector, and

arguably constructing notions of such performance through the practices devised to define and

measure it, have been complemented by longer term pressures on healthcare systems in most

developed countries. These have mainly taken the form of demographic shifts generating new

healthcare challenges. The proportion of the world's population over 60 years is expected to double

from about 11% to 22% between 2000 and 2050. In the twenty seven countries of the European

Union those aged 65 and over will increase by 66.9 million, with the very old (85+) being the fastest

growing segment (European Commission, 2008). An aging population brings more complex

healthcare needs, not least associated with chronic conditions, most significantly dementia.

However, chronic conditions are not restricted to older people, a number being associated with life

style changes. For instance, in Britain almost two thirds of adults (61.9%) are now classified as

overweight or obese, a condition which increases the risk of type 2 diabetes, heart diseases and

certain cancers. Indeed it is striking that in Britain the number of people diagnosed with diabetes

more than doubled between 1996 and 2010 from 1.4 million to 2.9 million, with a further doubling

expected by 2025 (http://www.who.int/diabetes/facts/world_figures/en/).

The performance of healthcare systems in developed countries is increasingly being assessed by

reference to these current and upcoming challenges, with growing concerns about the capacity of

the workforce to meet them. Debate in the EU has centred on workplace planning to meet future

healthcare needs, generating concerns amongst policy makers about a potential skill deficit. It has

been estimated that by 2020 across the EU there will be a shortage of some 230,000 physicians and

590,000 nurses (Sermeus and Bruyneel, 2010:11). In broader terms, Dubois et al (2006:2) reviewing

the state on the EU healthcare workforce have noted:

‘The human resources involved in the provision of healthcare have been seen as a recurring

burden rather than capital assets that represent an investment for the future. As a result

most countries (in Europe) face chronic problems caused by supply-demand imbalances,

maldistribution of health workers, skill imbalances and poor working environments,

reflecting poor human resource management and regulation.’

Such a statement begs questions as to why human resources are viewed as a ‘burden’ in a sector

such as healthcare which relies so heavily on its workforce to deliver services. Indeed the ‘poor state

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of human resource management’ is particularly surprising given a growing volume of research which

suggests that a positive relationship between HRM practices and organizational performance. In the

healthcare sector this research has assumed two distinct forms. The first has fallen within and often

been framed by mainstream HRM debates, especially those related to the use of the workforce as a

strategic resource. The second has been located much more within nursing studies and specifically

focused on staffing patterns and their connection to various outcomes. The succeeding two sections

consider, in turn, each of these streams.

3. The HRM Stream of Research

One of the key debates within the mainstream HRM literature has centred on whether and how

HRM practice relates to organisational performance. This relationship has been presented in

different, mutually exclusive, ways. One school of thought has proposed a connection between a

‘best practice’ bundle of progressive HRM practice and organizational performance. This interest in a

universal bundle of HRM practices has not precluded discussion on the nature of these practices,

variously labelled high commitment, high involvement and high performance. While such labels have

often been used loosely and synonymously (Gittell, 2009:50), some have adopted a tighter approach,

arguing that they have analytical value, privileging particular HRM practices and theorising their

relationship with organizational performance in distinctive ways (Wood, 1999: 369).

The tighter approach views the high commitment bundle as comprising HRM practices likely to

produce the attitudinal shift amongst employee needed to improve behaviours and organizational

performance in any service or product context. In contrast, the high involvement bundle places

weight on practices which facilitate employee participation, viewed as the surest means of

improving workforce and organizational outcomes (Cotton, 1993). A high performance bundle relies

on a synergy between HRM practices and work organization, or as Wood notes (1999:371) ‘the unity

of high involvement management and TQM or lean production.’ Indeed Wood also suggests that the

high performance bundle is targeted more at employee behaviours than attitudes, encouraging a

particular focus on reward and performance management practices, often designed to change such

behaviours in a direct and unmediated way.

The second school of thought, typically labelled ‘best fit’, contests any universal recipe linking HRM

practices to organizational performance, positing instead a contingent relationship between

practices and outcomes. This school has debated less the character of the HRM bundle and more the

nature of the contingencies driving the selection of such practices. Jackson and Schuler (1987) have

linked HRM practices to an organizations’ competitive strategy, while Kochan and Barocci (1985)

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have suggested that HRM practices might productively be related to the life cycle of an organization.

More recently, ‘best fit’ has been associated with the resource-based view of the firm with its

emphasis on idiosyncratic rather than more generic organizational contingencies (Barney and

Wright, 1998). Rare and inimitable employee capabilities are seen as essential to an organizations’

‘sustained competitive advantage’, encouraging HRM practices to foster and support them.

Much of the mainstream empirical research on the HRM-performance link has centred on the ‘best

practice’ model. In a not unusual research cycle, early findings from mainly quantitative studies

revealing a significant and positive relationship between such HRM practices and corporate

outcomes (for example, Huselid, 1995; MacDuffie, 1995) have progressively been challenged on

various grounds- conceptual, theoretical, methodological and empirical- prompting considerable

caution in interpreting the original results (Dyer and Reeves, 1995; Goddard, 2004).

In healthcare, an equivalent body of research, sharing many of the characteristics of the mainstream

HRM research literature has sought to relate HRM practices to various performance outcomes. Thus,

this body of work has empirically been rooted in the ‘best practice’ approach, possibly reflecting the

fact that healthcare providers, particularly in countries with state funded systems, do not pursue the

kinds of competitive, profit driven strategies often assumed by the ‘best fit’ and RBV approaches.

Moreover studies on HRM in healthcare have mimicked private sector research in largely being

based on quantitative studies correlating HRM practices to organizational outcomes, albeit

measured in clinical rather corporate financial terms.

In this section, the research literature on the HRM-performance link in healthcare is presented by

reference to three ‘best practice’ models: high-commitment; - involvement and - performance

model. A final sub section considers research cutting across these three models and focusing on

organizational climate and HRM systems.

3.1 High Commitment Practices

Following the mainstream the HRM literature, research in the healthcare sector has connected high

commitment practices to organisational outcomes. One of the most influential pieces of work, falling

within the former category, has been undertaken by West et al (2002 and 2006) in a survey of HRM

directors in British NHS hospitals. Controlling for factors such as hospital size, this study revealed a

strong relationship between a bundle of progressive HRM practices- training, team working,

appraisal - and the ‘hard’ measure of patient mortality after emergency surgery and hip fractures.

Other studies have used a wider range of high commitment practices, applying them to different

healthcare settings and linking them to alternative organizational outcomes. For example, Rondeau

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and Wager (2001) surveyed chief executives in Canadian nursing homes using a broader range of

‘progressive’ HRM practices covering communications, training, team working and compensation.

They found that the incidence of these practices was positively associated with patient satisfaction

and hard performance measures such as operating costs.

A further raft of studies has connected high commitment practices to employee, rather than

organisational, outcomes. For example, Dill et al’s (2013) surveyed frontline healthcare workers,

revealing a positive relationship between HRM practices, defined in terms of career development

and training opportunities for staff, and job satisfaction and willingness to stay. Similarly Armstrong-

Stassen and Schlosser (2010), surveying older nurses in Canada found that the availability of flexible

work options- part time working and unpaid leave- was positively related to attitudes such as

perceived organisational support and commitment, which in turn linked to intention to stay.

This focus on high commitment practices should not obscure approaches more compatible with

‘best fit’ models. In a survey of senior managers in around 130 hospitals in an Australian state,

Betram et al (2007) examined strategic HRM, as the integration of HRM practices with the

organisation’s broader strategy, finding the greater the HRM integration, the lower staff grievances,

disciplinary actions and staff turnover. Eaton’s study (2000) on workforce management in US nursing

homes, unusual in being based on qualitative data, rejects private sector bundles of HRM practices

as being insensitive to the distinctive form assumed by organisational performance in healthcare.

While not explicitly drawing upon the ‘best fit’ literature, she nonetheless proceeds to relate various

organizational approaches to patient care- ‘low quality’, ‘high quality’ and ‘regenerative’- to different

HRM practices, with different consequences for worker and patient wellbeing.

3.2 High Involvement Practices

In contrast to those adopting a high commitment approach based on a bundle of progressive HRM

practices others have privileged particular practices likely to generate the employee attitudes and

behaviours needed to improve organizational performance. As policy makers in healthcare have

displayed a growing interest in staff engagement (West and Dawson, 2012), so the HRM research

literature has sought to examine whether and how the use of high employee involvement practices

in the sector relate to various outcomes. It is a body of research which encourages consideration of

the distinctive character of staff involvement and participation in the sector. Thus forms of collective

employee voice have been especially strong in healthcare, reflected in the fact that in most

developed countries trade union density is much higher in the public than the private sector. For

example, in Australia, Germany and Britain, well over the half the public sector workforce is in a

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trade union, compared to considerably below a quarter of workers in the private sector

(Blanchflower, 2006:22). In Britain 41% of the workforce in ‘human health and social work activities’

is in a trade union, with the equivalent figure in manufacturing standing at just 19% (Department for

Business Innovation and Skills, 2013: 39). This difference largely accounted for by the strong

collective organization amongst the range of professional groups in the healthcare sector, a means

not only of safeguarding terms and conditions of employment, but also of protecting and deepening

professional identity (Larson, 1977). In Britain, most nurses belong to the Royal College of Nursing,

making it one of largest trade unions in the country with almost 400,000 members, while the British

Medical Association representing doctors has over 140,000 members.

A growing public policy interest in more individual forms of staff involvement, with healthcare

employers seeking to engage more directly with their staff, has weakened this collective voice,

particularly amongst the sector’s non-professional groups (Bach, 2004). In Britain, a New Labour

government set up a task force on more direct form of staff involvement in the NHS (Department of

Health, 1999) and more recently a group of NHS trusts (Foundation Trusts Network, 2013)

commissioned research on employee engagement which drew upon high profile cases and survey

data from across the public and private sector. Both reports, albeit based on mainly impressionistic

evidence, suggested a positive link between such practices and organizational performance,

implicitly encouraging the adoption of direct staff involvement practices in healthcare.

These direct employee involvement practices have taken different forms. Some have been service

centred, focusing on how employees engage in the care delivery process. For instance, Schwartz

Centre Rounds®, bringing staff together on a regular basis to talk through challenging psycho-social

workplace issues, have been adopted in over 200 healthcare sites in the US and on a selective basis

in UK. There is evidence to suggest that these rounds reduce stress and burnout amongst employees

(King’s Fund, 2011). Other forms of direct involvement in decision-making have centred on working

and employment conditions, in Britain the most striking being the introduction of annual survey of

healthcare staff in 2003. This survey has not only become a form of staff involvement, but a data

source to explore whether forms of employee engagement, examined in the questionnaire, are

associated with both HRM and patient outcomes. Such research has revealed an association

between high levels of employee engagement, lower employee absenteeism and patient mortality

and higher patient satisfaction (West and Dawson, 2012:18).

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3.3 High Performance Practices

3.3.1 Work Organisation

Recent interest in work organization, especially in an acute healthcare setting, has centred on two

main developments related to lean principles and relational job design. The application of lean

production principles, particularly drawn from car manufacturers such Toyota, to healthcare rests on

the search for ‘continuous improvement’ in the value added to the patient journey through clearly

delineated care pathways. These pathways are presented as integrated demand-pull work systems,

with process improvements introduced through the bottom-up involvement of staff responsible for

the delivery of such care (Jones and Mitchell, 2006). In Britain, lean principles were adopted in a

Department of Health ‘productive series’ seeking to improve performance in different parts of the

health care systems: acute wards, general practices, community services and operating theatres

(http://www.institute.nhs.uk/quality_and_value/productivity_series/).

This lean approach has come to be broadly defined, seemingly covering almost any attempt to

change aspects of work organisation in the sector. However research suggests that well considered

incremental changes to work processes can generate tangible improvements in organizational

performance. For example, a review of 18 studies drawn from the US, Australia and Canada on the

application of lean production techniques to emergency departments highlighted how changes to

data monitoring, staff training and communication improved a range of outcomes such as length of

stay, patient satisfaction and adverse events (Holden, 2011). In Flinders Medical Centre, Adelaide in

South Australia the application of lean principles care has been reported as allowing ’15-20 per cent

more work, with a safer service, on the same budget’ (Jones and Mitchell, 2006:6). Others have been

more cautious, calling into question the link between lean production and organizational

performance. A study by Preuss (2003) highlights a strong and positive relationship between

information quality and the performance of ‘high skilled’ hospital employees, particularly in terms of

medication errors. However, a hypothesised relationship between total quality management

practices rooted in information sharing techniques is unsupported by data in the study. More

generally, Radnor et al (2012) reveal the limited scope British hospitals have to improve work

organization within the context of the tight commissioner-provider contractual relations

underpinning healthcare delivery. Moreover, viewed as a managerial initiative seeking to reduce

costs rather than a professionally driven process designed to improve service quality, they note lean

techniques have often been viewed by hospital staff with scepticism and met with resistance.

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The second development in work organization, the relational approach to job design, was initially

conceived by Grant (2007) in a broader interactive service context. It is an approach which suggests

that positive employee attitudes and behaviours are likely to develop where jobs are designed to

ensure a close relationship between workers and the beneficiaries of a service. Gittell (2009) draws

upon this notion as the basis for her high performance healthcare model, which concentrates on

strengthening relations within and between healthcare teams through practices including: selecting

for teamwork; rewarding the team; precisely measuring team performance and establishing

boundary spanning roles. Presented in these terms, it is an approach which shares much with British

research emphasising team working as the root to improved organizational performance in a

healthcare context (Borrill et al, 2001). Gittell explores the links between relational practices and

outcomes in a distinctive way. For Grant, relational job design establishes an intimacy between

worker and beneficiary which motivates the worker and leads to pro-social behaviours. In contrast,

Gittell suggests and establishes that team-centred practices foster mutual respect and information

sharing amongst co-workers which directly connects to hard healthcare outcomes, including the

patient length of stay, satisfaction and post-operative mobility.

3.3.2 Reward and Appraisal

It has been noted that reward and staff appraisal have often been presented as high performance

practices, not least a consequence of their assumed impact on employee behaviours in a direct and

unmediated way. In drawing on human efficiency theory, Brown et al (2003a), for example,

established a positive relationship between the pay levels received by healthcare staff and patient

care outcomes in the hospitals across California, USA. It is, however, a study rooted in the US

healthcare system which allows predominantly profit-driven health providers to set pay rates for

their staff. In other national healthcare system, particularly in Europe, there is much less scope to

vary pay in this way. As Grimshaw et al (2007:603) note in examining wage setting machinery in

France, Germany, the Netherlands, Norway and Britain: ‘The ability for individual hospital employers

to negotiate distinctive, or supplementary, conditions within a wider framework is relatively weak in

all five countries.’ The individual hospitals in these countries are either tied to national agreements

which establish standard pay rates across the healthcare sector (the Netherlands Norway and

Britain) or to more broadly based arrangements cutting across the public service sector (France and

Germany). In Britain these national arrangements, presently manifest in an agreement entitled

Agenda for Change (Department of Health, 2004) have been criticized for their lack of sensitivity to

regional labour market conditions (Wolf, 2010). However, to date such national systems of pay

determination have largely prevailed, their durability residing in ongoing benefits not least to

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healthcare employers: avoiding the high transaction associated with local pay determination;

facilitating the geographical mobility of staff across the healthcare system; ensuring transparency

and sense of fairness; and establishing a affordable level playing field for hospitals as they seek to

recruit and retain their staff.

A lack of variability in pay in healthcare can also be related to the nature of the pay systems used by

healthcare providers, with attempts to link the pay of healthcare workers to performance, either

individual or organizational, proving patchy and often problematic. It is striking, for example, that in

a review of performance pay in the US healthcare system found not a single example of a financial

incentive programme for nursing staff. (http://www.rwjf.org/en/research-publications/find-rwjf-

research/2009/12/new-brief-examines-pay-for-performance-in-nursing.html). This is not to detract

from ongoing debate on the value of the linking doctors’ pay to their performance (Wall Street

Journal, 2013). Indeed, there are examples where a performance-pay link for doctors has become

established. In the Britain, the government agreed a new contract with General Practitioners in

2004, which linked a quarter of their income to the achievement of certain healthcare targets,

typically reflected in the completion of fairly routine procedures such as recording the blood

pressure of patient (Roland, 2004). Almost all GPs were able to meet these targets, with evidence

suggesting that there was very little improvement in health outcomes (Dixon et al, 2011). There has

also been longstanding merit award scheme for clinical consultants in Britain, although based on a

peer review of performance.

Despite these examples, there has been caution and at times hostility to pay for performance

amongst healthcare employees, reflected in the title of Berwick’s (1995) article ‘The Toxicity of

Performance Pay’, which critiques the use of such a system in healthcare The problems associated

with performance pay in the public services have been well rehearsed elsewhere (Dixit, 2002;

Burgess and Ratto, 2003). Suffice to say that in healthcare with its multiple stakeholders, interactions

and objectives, measuring and assessing performance for pay purposes is typically difficult.

Moreover in a service which depends so much on all the round quality of the work undertaken,

there is a danger that linking pay to specific target might narrow work effort and encourage a

concentration on rewarded outcomes rather than on what matters in deliver care.

Appraising the performance of healthcare staff has become much more integral to the management

of the healthcare workforce. However, as a general management practice, often driven by the

attempt to align individual performance with the pursuit of organizational objectives, appraisal has

been seen as in tension with the values and the authority of the powerful healthcare professions

(Perkins et al, 1997; Davies and Harrison, 2003). As Brown et al, (2003b:153) note ’senior doctors,

14

particularly consultants, have been regarded as independent or semi independent practitioners,

outside of any supervisory arrangements.’ It was just a decade or so ago, in the wake of high profile

cases of healthcare failure, which raised questions about the efficacy of self regulation of

performance quality, (Department of Health, 2001) that mandatory appraisal for medical

practitioners in 2001 and for GPs in 2002. Indeed it was only with the introduction of revalidation

and relicensing of doctors in 2012 that a quality assured appraisal framework was introduced, even

them provoking concern that the initial formative and developmental appraisal system for doctors

(London Deanery, 2012) might be assume a less welcome harder judgmental edge. As the Royal

College of Physicians noted: ‘The challenge is to ensure that by adding relicensing as an outcome of

regular appraisal, we do not undermine or devalue the usefulness and purpose of appraisal as a

supportive, reflective and formative process’ (Armitage et al, 2007).

These tensions have not inhibited the take-up of appraisal both amongst doctors and the broader

healthcare workforce, but they might well have affected the quality of its administration and impact

on staff performance (Redman et al, 2000). This is reflected in a striking paradox: the greater the use

of employee appraisal in the British NHS, the less positively it has come to be viewed by staff. The

first NHS staff survey in 2003 revealed that close to a half (40%) had not received performance

appraisals in the last twelve months, a figure that fell to only 16% by the 2013 survey

(http://www.nhsstaffsurveys.com/Page/1021/Past-Results/Historical-Staff-Survey-Results/).

However over the same period, the proportion who viewed appraisal as helping them to improve

how they did their job fell from over two third (69%) to barely over half (54%), while the percentage

left feeling valued by their organization following the process dropped from almost three quarters

(72%) to under two thirds (63%). Certainly some staff groups might gain more from the process than

others: a survey of Scottish GPs, for example, found that a third had undertaken further training as a

result of their appraisal. Indeed, there might well be national differences in how appraisal is

received, reflecting differences of practices: a survey of Norwegian nurses found that many learned

from and were highly motivated by the appraisal process. Yet the paradox of British staff survey data

does point to difficulties in administering performance appraisal (Brown et al, 2010) in the

healthcare sector.

Studies on the use and particularly the impact of performance appraisal in the sector remain scarce,

and mainly limited to small scale studies exploring staff perception of the process (Overeem et al,

2007). It might also be argued that perceived managerial difficulties associated with the effective

administration of performance appraisal are not confined to the healthcare sector (Grint, 1993). It is,

however, equally apparent that distinctive features of the healthcare workforce and the

15

employment context might deepen these difficulties. As noted, appraisal has been seen as

threatening the autonomy of the self regulating healthcare professional, leading to gaming and its

ritualistic use (McGivern and Ferlie, 2007; Chamberlain, 2010). More prosaically, in publicly funded

healthcare systems the more recent pressure on resources casts some doubt on the capacity of

healthcare providers to meet the training and career development expectations raised by the

appraisal process (Radshaw, 2008; Spence and Wood, 2007; Brown et al, 2010).

3.4 Organizational Climate and HRM Systems

The final theme from within the HRM stream is associated with organizational climate, a notion

attracting increased attention in the broader HRM research literature as a mediator in the HRM

practice-organizational performance relationship. Organizational climate has been presented by

Bowen and Ostroff (2004:205) as ‘a shared perception of what the organization is like in terms of

practices, policies, procedure, routines and rewards--what is important, what behaviours are

expected and rewarded.’ A ‘strong’ HRM system generates this shared perception through the

consistent and coherent application of a distinctive set of HRM practices.

An emphasis on organisational climate and its impacts on HRM processes and outcomes has been

manifest in the healthcare literature in three main ways. First, a climate approach places weight on

‘praxis’: on how HRM practices are implemented by line managers and experienced in situ by

employees. In healthcare, Hutchinson and Purcell (2010) have highlighted the important role played

by the ward manager in hospitals, responsible for the administering HRM practices related to

recruitment, appraisal, staffing and pay progression but often ill equipped to deliver them.

Second, organizational climate linked to HRM systems has emerged as an area of interest in relation

to group of around 40 US healthcare providers, collectively designated by the American Association

of Nursing as ‘magnet® hospitals’ (Hess et al, 2011). These hospitals are particularly adept at

attracting and retaining nurses, a capacity seen to reside in a set of ‘progressive’ organizational

practices and a rewarding working environment: a permissive form of work organisation allowing

nurse considerable control and autonomy; a flat organizational structure; and collaborative nurse-

physician relations. In Bowen and Ostroff’s terms, this appears to be a ‘strong’ HRM system, high in

distinctiveness, consistency and consensus. Since these hospitals acquired ‘magnet’ status some

twenty years ago, research has highlighted the link between this system and various positive

organizational and employee outcomes: high job satisfaction (Upenieks, 2002); high career

satisfaction (Hess, et al, 2011); and, low mortality rates (Mathews, et al 2013).

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Third, climate has become a pivotal when exploring a key aspect of organizational performance in

healthcare: patient safety. Influential reports published in the USA (Kohn et al, 2000) and Britain

(Department of Health, 2000) at the turn of the millennium exposed the scale and consequences of

adverse medical events (Tamuz and Thomas, 2006; Walshe, 2000), whether in the form of errors or

hospital acquired infections. The US report To Err is Human suggested that at least 44,000 patients

and perhaps as many as 98,000 died each year in American hospitals as a result of medical errors,

with incalculable human costs and financial costs put at between $17 and $29 billion. The British

report An Organisation with a Memory estimated that adverse events occurred in around 10% of

admissions (Department of Health, 2000: vii), a figure confirmed by more recent evidence which

indicated a similar proportion of such events in other developed countries including the US,

Australia, Germany and the Netherlands (Lu and Roughead, 2001).

In examining the cause of adverse events and in seeking to address them, both reports adopted an

organisation-centered rather than person-centered approach, with failures seen as systemic.

Failures were linked to aspects of work organisation, but more especially to a pervasive ‘blame

culture’ in healthcare systems which stifled and subverted attempts to identify and deal with safety

issues. This emphasis on organizational culture and more specifically on safety climates has, in turn,

encouraged a prescriptive narrative rooted in organisational learning--a means of allowing

healthcare providers to draw lessons from past mistakes and embed remedial action on the values,

practices and ways of working (Hughes, 2008). The research literature has provided support for

systemic and cultural influences on patient safety. Person-centered factors have not been

completely overlooked, however. For example, Faherenkopf et al (2008) found depressed hospital

residents made significantly more medical errors than their nondepressed colleagues. Differences in

safety cultures have, however, been revealed between and within countries (Wagner et al, 2013),

with implications for outcomes. For example, a survey of Dutch healthcare employees indicated that

shared perceptions of the hospital’s bundle of HRM practices were positively related to climates for

patient safety and service quality, connecting, in turn, to levels of employee commitment (Veld et al,

2010). Katz-Navon et al.’s study establishes a link between a safety climate and organizational

performance. Covering almost 50 Israeli hospitals, the study reveals a curvilinear relationship

between levels of the perceived detail of safety procedures and the number of treatment errors: too

little detail in safety procedures increases errors rate, but so does too much, as perhaps key

messages get lost in the provision of excessive information to staff.

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4. The Staffing Stream of Research

Beyond debate in the mainstream HRM literature on the relationship between HRM practices and

organizational performance, another stream of research in healthcare has focused on the

association between patterns of staffing and a variety of outcomes. It is a stream with no obvious

counterpart in the HRM literature, and has focused mainly on the nursing workforce in acute

healthcare. Performance in the healthcare sector has been linked to four closely related but

analytically distinct aspects of nurse staffing: staffing levels; staff-patient ratios; skill mix; and staff

turnover. Each is considered in turn.

4.1 Staffing Levels

A focus on staffing levels is underpinned by the proposition that the fewer the number of nurses

employed the more negative the outcomes for the nurses themselves, for example, in terms of job

satisfaction and well being, and for the patients they care for in terms of clinical outcomes. It is a

relatively crude proposition in that these outcomes are likely to be related not only to nurse

numbers but to a range of factors including the acuity and condition of the patients. However, the

simplicity of the proposition and a surface plausibility make it attractive as the basis for policy,

practice and campaigning. In Britain, the New Labour Government at the beginning of its tenure

made a commitment to employ 20,000 more nurses (Department of Health 2002:10). More recently,

in a period of austerity and constraint on healthcare spending, the Royal College of Nursing in its

Frontline First campaign suggests a loss of almost 5,000 FTE nurses over the last three years, at the

same time raising concerns about future nurse staffing levels given a 13% reduction in the number of

pre registration training place commissioned by the government over the same period (Royal College

of Nursing, 2013a). This emphasis on nurse numbers has found some support in reports of

healthcare failure. For instance, an internal report on those trust with the highest morality rates in

England, noted ‘frequent examples of inadequate number of nursing staff in some ward areas’

(Keogh, 2013:22).

4.2 Nurse-Patient Ratios

A more nuanced view of the relationship between nurse staffing and various organizational

outcomes has centred on nurse-patient ratios. Again the proposition informing this view is that the

lower numbers of patients per nurse, the better the outcomes for both patient and nurse well being.

In certain developed countries mandatory nurse-patient ratios have been set to address this issue:

for example in California, USA, mandatory nurse-patient ratios were set at 1:5 in medical and

surgical wards in 1999, and some 15 US states have similar requirements. In Victoria, Australia

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mandatory ratios have been scaled up to 5 per 30 patients to provide more flexibility at ward level

(National Nursing Research Unit, 2012). In Britain the government has been more cautious

producing indicative ratios but viewing trusts as best placed to determine their own patient-nurse

ratios in response to local circumstance and need.

4.3 Skill Mix

The third dimension of staffing, skill mix, has attracted the most attention amongst policy makers

and practitioners, indicative of the fundamental issues raised by this practice for work organization

and for different interested parties. In broad terms, skill mix refers to the ratio between different

occupational groups within any given healthcare team. In a highly fragmented and hierarchical

workforce, skill levels vary by occupation, with organizations deciding on how they might

appropriately be blended. It is a decision made at different levels of the healthcare workforce. In

Britain, for example, skill mix was an issue at the doctor-nurse interface in the context of European

Working Time which, on implementation in the NHS in 2009, required a reduction in long hours for

junior doctors’ and a consequent delegation of some of their tasks to nurses. More typically debate

and practice have concentrated on the ratio of registered nurses to non-registered and ‘unqualified’

support workers. Nurse-support worker skill mix varies between different clinical areas, but most

hospitals in Britain will have a ‘headline’ or broadly drawn skill mix ratio for nurses and support

workers close to that recommended by the Royal College of Nursing (2013a) at 65:35.

There has been an assumption amongst stakeholders, including researchers, that the richer the skill

mix the ’better’ the employee and the patient outcomes. In Britain, this assumption has particular

resonance given the unregulated status of the HCA role. Indeed recent failures in healthcare such as

the Mid Staffordshire hospital, where during 2005-2009 between 400 and 1200 patients were

judged to have died as a result of ‘poor care’, have inter alia been related to a diluted nurse-HCA

skills mix (Francis, 2013). However, the negative relationship between diluted skill mix and care

quality needs to be addressed with caution. Skill mix has become a contested process with

stakeholders seeking to manipulate it in pursuit of their sectional interests. Skill mix dilution has

often been seen as managerial exercise designed to reduce cost in times of financial pressure or to

address periodic difficulties in recruiting registered nurses. In such circumstances, changes to skill

mix have been crude, revolving less around skill than grade (Thornley, 1996). The nursing profession

also has a stake in this process, viewing changes in skill mix with ambiguity. A richer mix protects

their numbers and ensures that they remain central to direct care delivery. However, in the pursuit

of more specialist technical expertise and roles, nurses have delegated more ‘routine’ care tasks to

support workers, in the process becoming complicit with management in the greater use of such

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support worker as a cost saving device (Kessler et al, forthcoming). Moreover, the assumption that

skill mix dilution undermines patient outcomes overlooks the possibility that a re-allocation of tasks

sensitive to the respective capabilities of nurses and support workers might well be a legitimate and

rational basis for improving care quality.

4.4 Nurse Turnover

The final aspect of staffing relates to nurse turnover, which connects to a well-established research

literature on employee turnover in the broader field of organizational studies. In common with this

wider literature, nurse turnover has been related to perceived well being (Aiken et al, 2002; and

Leiter and Maslach, 2009), the quality of working life (McCloskey, 1974; Kennington, 1999; Donner

and Wheeler, 2001; Shields and Ward, 2001; Hayes et al, 2006) and management style (Yeatt and

Seward, 2000). One of the more distinctive features of research on nurse turnover has been the

attention drawn to the moderating influence of professional commitment: the stronger the

occupational identity, the less likely the nurse is to leave the profession (Lu et al 2002).

The link between staff turnover and organizational performance is somewhat less straightforward. A

residual level of turnover has often been seen as beneficial to organizations. As Alexander et al

(1994:505) note in discussing nurse turnover, ‘at moderate levels (turnover) infuses ‘new blood’

introduces fresh ideas and keeps the organization from being stagnant.’ Indeed, the capacity of the

organization to replace nurses who leave might be viewed as having more significant consequences

than the crude level of turnover, raising broader issues associated with the supply of nurses. In

Britain, for example, a leaving rate of 8.8% amongst nurses between September 2001 and 2013

(Health and Social Care Information Centre, 2013) was more than matched by a 9.5% joining rate,

indicating indeed a net increases nurses. At the same time, a net inflow of staff into a healthcare

system should not to detract from the very real economic costs associated with the departure of

nurses: training costs are high for nurses, with little return on this investment and replacement costs

if nurses leave the healthcare system (Jones, 2005). In the USA, for example, it has been estimated

that the cost of every the lost nurse is $82,000 (Twibell et al, 2012).

In summary, it is clear that a considerable number of studies have attempted to relate aspects of

nurse staffing - levels, ratios, skill mix and turnover- to various employee and patient outcomes

(Kane et al, 2007). In the main they have been quantitative studies, taking one of these aspects of

staffing as the independent variable and correlating it with different employee and patient

outcomes. At the same time, however, the studies have varied in a number ways, including in terms

of national setting, the nature of the outcome measures and the degree to which potentially

20

confounding variables have been controlled. A number of papers have reviewed the literature on

these different relationships as they relate to: nurse staffing and nurse burnout, fatigue and medical

errors (Garrett, 2008); the cost implications of skill mix (Goryakin et al 2011); the impact of skill mix

on patient satisfaction in primary care settings (Branson et al, 2003); skills mix and changing nurse

roles and various patient outcomes (Spilsbury and Meyer, 2001) ; nurse staff levels and care quality

(Currie et al, 2005); and the causes and consequences of nurse turnover (Hayes et al, 2006).

In general terms, this substantial body of research has produced findings which provide some

support for the proposition presented above: in other words, the higher level of nurse staffing, the

lower the patient: nurse ratio, the richer the skill mix, and the lower the nurse turnover the more

positive the employee and patient outcomes. As Griffiths (2009) has noted, ‘There is now

considerable evidence of a positive correlation between nurse staff levels and patient outcomes’.

However, Griffiths goes on to note that these relationships are not always strong or consistent,

raising concerns about the value of this evidence as the basis for policy and practice. It is to these

issues and others related to the quality and use of research data on human resource management

practice and staffing in healthcare that attention turns in the final section.

5. Discussion and Conclusions

This final section has three purposes: to evaluate the streams of research on the HRM- and staffing-

performance link in the healthcare sector; to assess how this research has informed public policy

and practice; and to consider future research on HRM in the healthcare sector.

5.1 Evaluating the Research Streams

The HRM and staffing streams of research in healthcare have been conceptualized in somewhat

different ways. In the main, the HRM stream draws upon established models from the strategic

human resource literature. These are based on ‘best practice’ recipes which emphasise high-

commitment high-involvement or high-performance HRM practices, used singly or in combination.

The staffing stream is rooted in the assumption that more qualified nursing staff, whether in

absolute terms or relative to patients or non qualified support workers, is likely to yield better

outcomes for employee and patient well being.

Despite a myriad of studies, both streams have been far from conclusive in establishing a causal link

between the three alternative HRM approaches on the one hand and staffing practices and

outcomes on the other. This is partly a methodological issue: many of the surveys have been cross

sectional and used a variety of different measures for similar variables, inhibiting comparison

21

between these studies and the cumulative validation of findings. It also relates to a lack of

conceptual precision and consistency in the use of key terms. As Hayes et al (2006: 238) noted in

reviewing the literature on nurse turnover: ‘The definition of turnover and accuracy of the reasons

for turnover are often inconsistent, making it difficult to compare or generalize across studies’. In

addition the theorisation of the link between practices and outcomes in the respective streams has

not been particularly strong. It might be argued that with frontline staffing so crucial to patient well

being, the nurse staffing-outcome link is more plausible than the one based on the relationship

between a set of generic HRM practices and clinical outcomes. However, the emphasis on staff

numbers in this stream of research still leaves open questions about the management and use of

staff (Skills for Health, 2012).

A focus on how variation in the use of certain HRM and staffing practices relates to employee and

organizational outcomes also runs the risks of overlooking descriptive data on the incidence of such

practices and their operation. Studies highlighting the negative consequences of diluted skill mix

should not obscure the fact that in Britain over the last decade, skills mix has actually become richer

(Kessler et al, 2012). The weight placed on staff involvement as positively associated with various

outcomes should not overlook evidence which suggests that the take-up of employee engagement

practices still remains limited in healthcare providers. One survey report notes that while most

hospitals in Britain have systems in place to engage their staff, ‘rather less encouragingly only 54%

formally canvass the opinions of their staff more frequently than annually’ (Foundation Trust

Network 2013:8).

5.2 Research and Public Policy

In general, studies from within both the HRM and staffing streams of research in healthcare have

displayed limited sensitivity to the policy or institutional context (Boselie et al, 2003). It has been

noted that upstream shifts in public policy on the delivery of healthcare often have important

downstream consequences for substantive HRM practices. This is reflected in the link between NPM

approaches to public service delivery and attempts to introduce of new HRM practices, often drawn

from the private sector. Equally significant have been national differences in the regulation of

healthcare workforce, likely to produce variations in HRM and staffing and their performance

outcomes. In a country such as Britain where the nursing workforce is relatively weakly regulated,

allowing non-qualified nurse support workers to take on a wide range of patient-centred nursing

tasks, skill mix dilution might well be expected to have more significant consequences for outcomes

than in countries such as the USA where nursing roles are tightly regulated (Kessler et al, 2012).

22

This range of concerns about research on the link between workforce practice and outcomes raises

questions about the value of the findings from the respective research streams for policy and

practice. As one review of the literature noted:

A number of studies suggest richer skill mix may be associated with better outcomes and

fewer adverse events for patient. The evidence however is highly limited by practical

limitations and methodological shortcomings. While many studies have reported positive

impacts from enriching skill mix, they do not offer clear guidelines about ideal threshold in

terms of person/patient ratios or the proportion of different categories of staff members

(Skills for Health, 2012:20)

Doubts about the practical value of the research do not sit particularly easily with policy

developments, especially on Britain, where in the wake of various high profile instances of

healthcare failures, a growing emphasis has been placed on evidence-based approaches to the fixing

of safe and adequate staffing levels in healthcare providers. The British government has

commissioned work to ‘develop accredited staff tools against evidence based guidance on safe

staffing’ to be used by healthcare providers (Department of Health, 2013). However, if the evidence

base does not readily lend itself to such guidance, developing such tools might well be problematic.

As research on the workforce practice-outcome link in healthcare has increased so has its

relationship to and policy and practice become fluid and iterative. While pressures on healthcare

systems have driven a research agenda on workforce management and performance, the resultant

research has, in turn, increasingly been used by healthcare providers to justify changes in HRM

practices. For example, many hospitals in Britain now have a strategy of staff involvement, often

framed by academic research on its positive organizational benefits. In language which would appear

to come straight out of a strategic HRM textbook, one such hospital strategy notes ‘Employee

engagement and empowerment are driving forces for any high performing organization. Research

demonstrates that staff engagement leads to measurable improvement in performance’

(Leicestershire Partnership NHS trust, 2013:3). It appears that research evidence on workforce issues

is increasingly becoming a mechanism for legitimizing changes in HRM practice, with limited regard

to its relevance or meaning.

5.3 Future Research

5.3.1 Addressing Past Limitations

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Turning to the future direction of research on human resource management in the healthcare

sector, there is scope both to address past limitations- methodological and substantive- and to

recalibrate interest as new organizational pressures and workforce issues emerge in a shifting policy

context. Methodologically, it has become clear that the search for a link between HRM and staffing

practices and organizational performance in healthcare has heavily relied on quantitative research

techniques, rarely sensitive to organizational context, contingency or complexity. Healthcare

providers, particularly hospitals, are often highly ‘balkanized’ organizations covering diverse clinical

specialties and reflecting a variety of managerial style and practice at ward level. In taking the

hospital as their unit of analysis, broadly based surveys run the risk of generalising and overlooking

such diversity. For example, a survey seeking information on staff training using a few generic

organizational measures is likely the overlook the variation in employee development as different

clinical areas devise their own staff training programmes to meet their particular needs.

A reliance on survey techniques which seek to correlate HRM practice and organizational

performance also weakens the capacity of researchers to explore how and why HRM practices

develop and affect employee and attitudes and behaviours. This neglect of process or ‘black box’

issues, shared with much HRM research in the private sector, is partly a methodological issue with

greater scope to use qualitative approaches to examine the relationship between HRM practices and

their consequences especially at the ward or workplace level. There is strong tradition of

ethnographic research centring on hospitals and healthcare work. For example, Becker at el’s (1951)

ethnography Boys in White, provides a rich insight into the socialization of doctor trainees in a US

medical school, but attempts to develop ‘thick descriptions’ remain rare within the mainstream HRM

healthcare literature.

Moreover, there is a need to re-visit the substantive focus of research on HRM in the healthcare

sector. Often this research has been narrowly pre-occupied with the management of the specific

occupational groups, particularly the qualified nurse workforce. The neglect of other healthcare

groups is reflected in Thornley’s (1997) description of the long established nurse auxiliary role as

performed by ‘invisible workers’, with the management of such groups as doctors and allied health

professions also under-researched. Of particular interest to the HRM scholar, the role of specialist

HRM function in healthcare has, with some exceptions (Bach, 1994), been overlooked by

researchers. The function faces major challenges, required to compete with a range of powerful

actors, in particular the nursing and medical professions, also with an interest in workforce

management, and arguably with greater clinical control over and insight into the technical issues

associated with it. The specialist HRM manager often has executive director status in healthcare

24

provider organizations, along with the nursing and medical director (Truss, 2003), but how these

relationships play-out and their relative contribution to strategic and workforce issues remains

unclear.

A narrow research focus has further been reflected in the emphasis placed on workforce

management in secondary or hospital care, to the relative neglect of HRM in community and

primary healthcare settings. These latter two settings involve a different range of work roles--

occupational therapists, district nurses, health visitors, general practitioners–and a distinctive set of

staffing issues. For example, community based workers require a distinctive skill set associated with

care delivery to patients in their own homes, often in collaboration with family members. How do

HRM policies and practices contribute to the development of such capabilities and healthcare

outcomes in these settings? Community and primary healthcare workforce members are also more

dispersed as employees work with considerable autonomy and with less direct supervision. How is

the performance of such a fragmented workforce managed?

Most striking, a shift of interest to the community healthcare encourages a focus on new

organizational forms and their HRM implications. For example, in Britain, public policy has

increasingly been directed towards facilitating the integration of health and social care, the former

traditionally delivered by the NHS and the latter delivered by municipal government. Such moves

have been accompanied by the search for much closer, co-ordinated working across these sectors,

not least in multi-disciplinary teams. However, bringing health and social workforces together raises

a range of HRM challenges: the respective workforces are covered by different terms and conditions

of employment and subject to contrasting sets of values, routines and practices (Skills for Care,

2013). In such circumstances, how and with what effect are shared working cultures and HRM

systems developed?

The relative neglect by HRM scholars of workforce management in community healthcare assumes

particular significance as this setting becomes increasingly important as the site for service provision

in many countries (RCN, 2013b). It is a development driven by various factors: patients prefer care as

close to home as possible (Health Foundation, 2011); such care is often seen as more cost efficient

that hospital care; new technologies are facilitating the delivery of care in the home; and the scale

and type of care required by aging populations is likely to be delivered most effectively in the

community. Indeed, in a broader sense, these influences might be viewed as shaping the future

HRM-performance research agenda in healthcare, with a need to focus on: patient voice and choice;

resource constraints; new technologies; and demographic trends.

25

5.3.2 A New Research Agenda

The public policy emphasis on patient voice and choice is particularly challenging for the healthcare

professional. Professional status has traditionally rested on worker autonomy and an assumed

passivity on the part of patients who assume that health care professionals will act in the patients’

‘best interest’ (Friedson, 2001). Challenging these assumptions, the personalisation agenda in health

is likely to accelerate and deepen as service users, particularly with chronic conditions, seek a

greater say in their treatment and care delivery. In Britain, for example, this trende is reflected in the

introduction of individual healthcare budgets that give those with ‘complex medical conditions and

substantial and ongoing care needs’ control over allocated sums of money (Forder et al, 2012).

Rising patient expectations of choice and engagement generate new challenges for healthcare

professionals, particularly in times of resource constraints. What capabilities are needed to address

such challenges? How might HRM policies and practices support the development of such

capabilities? To what extent will worker performance be assessed according to how such challenges

are met?

The emergence of new attitudinal and behavioural challenges is not confined to the professions in

the healthcare. Growing concern about the quality of care delivered to the increasing number of frail

elderly patients has prompted policy makers to re-evaluate performance across the healthcare

workforce and to develop new capabilities centred on compassion (Chief Nursing Officer, 2012;

Willis, 2012). The provision of compassionate care suggests a tempering of the traditional reliance

on hard, typically accredited technical competencies with softer, values-based experiential skills. It is

an approach already affecting HRM practices, reflected in Britain, for instance, where values -based

recruitment for nursing staff, placing less weight on formal qualifications and more on the

applicant’s orientation and commitment to care work, is being encourged (Cavendish, 2013:34).

Indeed increasingly worker and organizational performance will be judged not solely according to

single clinical outcomes measures, but ‘softer’ outcomes associated with the quality of life for older

people and others with chronic conditions and co-morbidities. How and to what extent can HRM

policies and practices support the delivering of care with compassion and dignity, particularly to the

frail elderly?

Finally, a future HRM research agenda is opened up by the development of new technologies to

deliver healthcare: technologies directly related to the diagnosis and treatment of healthcare

conditions as well as to the collection and sharing of patient information. In terms of workforce

organization, there are examples of technologies breaking down job barriers and re-distributing

tasks. An Australian study notes how the capacity to perform remote X-rays has allowed practice

26

nurses and GPs to provide this service where a radiographer is not available (Smith and Jones, 2007).

In Britain new breast screening technology can now be used by unregistered assistant practitioners,

freeing-up registered nurses to perform other tasks (Skills for Care, undated: 7). New technologies

are affecting aspects of workforce management, particularly in relation to employee development as

simulation training through interactive DVDs replace more traditional forms of training delivery (Gill,

2007).

The impact of these new technologies on employee performance in healthcare remains an open

question. They might well improve the quality of working life, generating enriched work experience

and feeding through to positive employee attitudes and behaviours. It is equally plausible to suggest

that new technologies lead to new pressures, for example, on workers to acquire and continually

update their capabilities. The current evidence provides support for both lines of argument. A study

by Yassi and Miller (1990) reveals employee stress following the introduction of new technologies

into clinical laboratories across four US teaching hospitals while other research has highlighted

increased job satisfaction through the better communication and enhanced responsibilities

associated with new technologies in healthcare (Lavoie-Tremblay et al, 2010). These competing

findings imply there is still considerable scope to explore the contingencies that influence how new

technologies impact on the healthcare workforce and its performance (Skills for Health, undated).

How will such technologies impact on the workforce organisation, management and performance?

Will they have a positive impact on the well being of healthcare workers?

It is difficult to recall a period post 1945 when employee and organizational performance in the

healthcare sector has faced such an array of challenges or been under such intense scrutiny. As

increasing user demand and expectation confront a shrinking resource base, the future performance

of national health systems will depend upon fundamental structural and operational changes. In a

sector where service delivery is rooted in the unmediated relationship between user and worker,

these changes are likely to have profound implications for human resource management. This article

has suggested that the research literature has made at best faltering steps towards deepening our

understanding of the link between HRM policy and practice and employee and organizational

performance. A patchy mainstream HRM literature centred on a best practice models and a more

vibrant but narrowly focused literature on nurse staffing has displayed a shared set of flaws: a lack of

conceptual precision; an overreliance of quantitative, survey methods; an under theorisation of the

relationship between practices and outcomes; and a narrow concern with the nursing workforce in

an acute healthcare setting. Indeed, this is a somewhat fragile basis for the development of

evidence-based policy and practice, although this has not deterred policy makers and practitioners

27

from using it to legitimize their actions. It has been argued that a future HRM agenda in the

healthcare sector needs to address these shortcomings not least by: broadening its focus to

encompass the diversity of occupational groups and healthcare settings; exploring whether and how

HRM practice can support the development of new employee capabilities needed to deliver more

compassionate care; and examining how employees might optimise their performance in new, often

more integrated organisational forms and through the use of new healthcare technologies.

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