Work design in health care

Mary Courtney, Anna Klinken Whelan, Jennifer Majoor, Joseph E. Ibrahim, Gary E. Day

LEARNING OBJECTIVES
After studying this chapter, the reader should be able to:
 Describe theories and concepts underpinning current approaches to job design.
 Discuss who does what jobs in the health care industry.
 Analyse job design and employee motivation in relation to how different types of work designs affect employees.
 Analyse how different work designs influence the quality of patient care.

INTRODUCTION

The purpose of this chapter is to provide an overview of the way we design work in health care. In an era of
increasing industrial restructuring, job design and redesign are important in the role of the health service manager.
The jobs of individual workers must be changed to improve quality of care, increase productivity, and reduce costs
in response to external pressures, as well as increasing staff satisfaction, motivation and retention.
Throughout Australia, centralised wage-fixing arrangements have been introduced to ensure consistency of
employment conditions for various types of workers. In some cases, this has led to a lack of flexibility for health
service managers to design and redesign an organisation that can quickly respond to the dynamism of the health care
system. Thus, health service managers and health workers have become victims of historical organisational designs
they had no part in constructing and believe they have little opportunity to control.
Cost-cutting measures have increased pressure on health service managers to supply the least expensive type
of worker for service delivery. Substitution of workers solely using a cost criterion may lead to inappropriate
delegations to untrained and inexperienced workers who perform activities beyond their qualification. Recasting the
role of health professionals and the boundaries of practice in these ways influences the manner in which health care
organisations are designed.
This chapter provides an overview of who does what jobs in health care. This leads to an analysis of job
design and employee motivation in relation to how work design affects employees. The final section analyses the
impact of different types of work design on patient care.

THEORIES AND CONCEPTS UNDERPINNING CURRENT APPROACHES TO JOB DESIGN

Classical management theories

Examples of job design can be found in the Bible, however the history of modern job design and the development of
task and job rationalisation theories began in the latter part of the eighteenth century with the publication of  The
Wealth of Nations in 1776, by the economist Adam Smith. He maintained that:
The division of labour, however, so far as it can be introduced, occasions, in every art, a proportionable increase of
the productive powers of labour. The separation of different trades and employments from one another seems to
have taken place in consequence of this advantage.
(Smith 1776)
A further important early publication was that by the engineer Charles Babbage in 1835, titled On the
Economy of Machinery and Manufactures, written during the time of the Industrial Revolution and the rise of large
factories in the United Kingdom and the United States. This focus on organising work into increasingly divided
tasks, which were standardised to allow for easy replication and minimal error, was continued by Frederick Winslow
Taylor (1911), Frank and Lillian Gilbreth (1911) and others.
 Taylor’s (1911) publication, Scientific Management, was the first book to describe efficient work design.
Taylor was an engineer with a Pennsylvanian steel company and he believed worker output could be increased
through work redesign. His influence on management practices and worker productivity has been enormous.
Much like Adam Smith in the eighteenth century, Taylor (1911) believed in the division of labour such that
each job should be examined scientifically, broken down into small parts and standardised in order that workers
should perform at maximum efficiency. Workers were also rewarded financially for increased
productivity. However, despite the financial incentives associated with Taylor’s approach, there was a high human
cost in some industries. These costs included high levels of staff turnover and absenteeism as a result of worker
boredom with the repetitious nature of many jobs and general worker dissatisfaction and ‘alienation’ ( Braverman
1974). This has led many to claim that Taylor’s approach to management is inhumane. Nevertheless, the popularity
of his work with managers gave rise to later movements such as work simplification and human engineering.
Importantly, Taylor sought to create a paradigm shift in management and worker thinking in the interests of
improved production efficiency. Today, managers use many of his ideas when designing jobs. Among Taylor’s
ideas still in vogue (Dunphy 1981) are the:
 division of labour into specified tasks where some work requires highly specialised skills;
 utilisation of output standards on an individual worker basis for each type of job so that the effectiveness of
completed work can be assessed;
 close supervision of the work of individuals to ensure output standards are achieved;
 appointment of supervisors to control and coordinate worker activities;
 provision of adequate payment to workers for achieving targeted output standards (i.e. using the ‘payment by
results’ system);
 clear demarcation of skilled and unskilled tasks to avoid paying unskilled workers the same rates as skilled
workers; and
 employment of workers to perform specific tasks with little consideration of their future career progression.

Human relations school

What was missing from classical management theories was an understanding of human behaviour and motivation.
The work of the human relations theorists, such as Mayo (1933), Maslow (1943) and Herzberg et al (1959), brought
a new job design emphasis to management thinking. These theorists investigated the psychosocial meaning of work
and the needs of workers to be ‘enriched’ by work. They recognised that powerful social norms operated within
work groups and that these affected worker productivity. These social norms were influenced by formal and
informal leaders and modes of communication and by worker participation in decisionmaking. Unlike the classical
management theorists, who considered that workers were primarily motivated by ‘extrinsic’ factors, such as money,
the human relations theorists emphasised the importance of ‘intrinsic’ motivators such as recognition, selfesteem
and self-actualisation (Maslow 1943). Despite these differences, the ultimate intent of both groups of theorists was
to increase worker productivity efficiency (viz to achieve more with less). In other words, meeting the higher level
social needs of workers was not an end in itself. Herzberg et al (1959, p ix) maintained that both management and
workers stood to gain from studies of worker attitudes to their jobs. Among the claimed benefits for management
were increased worker productivity, decreased staff turnover and absenteeism, and smoother working relations.
Potential benefits for individual workers were a happier work environment, improved job satisfaction and enhanced
self-esteem.

Origins of job redesign

The origin of the term ‘job design’ is generally attributed to two United States researchers, Davis and Canter (1955),
who wrote (p 3):
It is our purpose to point out that little attention has been devoted to the question of what constitutes an effectively
designed job. Is it possible to improve the organization of work and the dividing up of the work into jobs so that the
individual performing in the job can improve their productive capacity?
The authors wanted to demonstrate that the content of jobs was not unalterable and inviolate, but rather that
jobs and organisations were ‘social inventions put together to suit specific needs and reflect the culture, the ideology
and the governing concepts or the ethos of the time’ (p 3).
 Davis (1979, p 30) originally defined job design as: ‘the organization (or structuring) of a job to satisfy the
technical-organizational requirements of the work to be accomplished and the human requirements of the person
performing the work …’.
The first ‘field’ experiment on job design was conducted in an assembly department in a unionised
pharmaceutical plant in the United States. The work was redesigned from a linear assembly line operation with
serial work stations to a group-based assembly operation, and finally to an individual product-based assembly
operation, in which groups of workers assembled a total product (Davis 1979). The results of this experiment
showed an improvement in the quality of the product but no gain in productivity. Importantly, it also showed a
positive change in worker attitudes, with workers developing:
a more favourable attitude to individual responsibility, individual work rate, effort expenditure, distribution of work
load and product preparation … After experience with the total product, assembly line workers disliked, by
comparison, the lack of personal responsibility, characteristic of assembly line work.
(Davis 1979, p 32)
In the United Kingdom, a similar approach to job redesign was being used. The name given to the UK model
was the ‘socio-technical systems’ approach. Trist and Bamforth (1951) of the Tavistock Institute undertook some of
the earliest sociotechnical systems studies. Their research involved workers in the Durham coalmine. With this
approach to job redesign, the focus of analysis became the work group rather than the individual. Second, it
combined concepts from group dynamics and systems theory to inform the analysis and the redesign of jobs. Three
systems were defined and analysed: technological, social and economic. Finally, it involved restructuring work
around groups that, when functioning well, were cohesive, semiautonomous and self-regulating (Fulop & Mortimer
1992).
Increasing interest was shown by researchers, government agencies, academic centres, labour unions and
business leaders in the 1960s and 1970s in the broad area of work humanisation or quality working life (QWL).
Quality working life has been described as a synthesis of:
state of the art practices in such disciplines as organisation development, management engineering, labor [sic]
relations, quality control, and human resources development. Although implementation of the QWL concept varies
from one organization to another, all QWL programs attempt to modify existing organization structures, systems,
and management processes by involving employees in decision-making processes that lead to enhanced
organizational performance and greater employee satisfaction.
(Burbank & Grant 1985, p vii)
Quality working life research includes studies of job satisfaction, job rotation, job enlargement, job
enrichment, flexible working hours, job sharing, semi-autonomous work groups, and the confusing and contentious
concept of industrial democracy (Davis & Cherns 1975; Ramsay 1980). These issues are discussed later in this
chapter.
In 1972, Senator Edward Kennedy proposed a Bill to the US Senate to deal with the problem of alienation
among workers. The Bill, titled ‘Worker Alienation Research and Technical Assistance Bill’, was seeking $20
million to research the physical and mental ill-health of American workers whose alienation within the workforce
was expressed in poor quality work, high turnover, absenteeism, sabotage and ‘monetary loss to the economy’
(Ramsay 1985, p 52). Ted Mills (1985), President of the American Center for Quality of Work Life, founded in
1973, saw QWL as part of a societal transformation toward a ‘participative revolution’ (Burbank & Grant 1985, p
vii). The application of QWL (including job redesign) was not seen in health care organisations until the early 1980s
(Burbank & Grant 1985).

TYPES OF JOB DESIGN ACTIVITIES

Although there is a range of approaches to job redesign, as indicated above, in this section we limit our discussion to
the most commonly used designs — job rotation, job enlargement, job enrichment, flexible working hours, job
sharing and multi-skilling.

Job rotation
Job rotation may be described as an organised method to move workers from one job to another. Workers usually
remain at the same level in the organisation’s hierarchy with no fundamental changes to the different jobs through
which they rotate (see Figure 11.1). There are two major advantages of job rotation. First, there is increased
flexibility within the workforce as workers become familiar with a number of different jobs within the organisation
and so can be dispatched easily to another area in times of staff shortage. Second, new workers can be introduced
systematically to a number of different jobs undertaken within the workplace as they rotate through jobs. The
disadvantage of job rotation is found when workers are unable to focus on one job in order to develop more
specialised knowledge (see Case Study 11.1).

FIGURE 11.1 Job rotation

Source: Adapted from Cherry N, Smyth A, Boucher C 1993 Job design. In: Collins R (ed.)  Effective management. CCH, Auckland

CASE STUDY 11.1 JOB ROTATION

Within the ABC Maternity Hospital a policy of job rotation is in place whereby registered nurses are required to rotate
through different areas of the hospital every six months (viz the antenatal wards, postnatal wards, neonatal intensive care and the
birthing suite). This policy was established to ensure all staff remain current in all areas of midwifery and thus provide
management with the flexibility to relocate staff to various areas in times of staffing shortages (e.g. sick leave, long-service leave,
holidays). However, many registered nurses continue to express a desire to remain within the same work location for longer
periods of time in order to develop specialist knowledge and skills in the area. They express greater levels of job satisfaction and
commitment to a permanent location and reduced levels of stress and anxiety.

Job enlargement
Job enlargement may be undertaken in two ways:
1. horizontal job enlargement; and
2. vertical job enlargement (known as job enrichment).
As indicated in Figure 11.2, horizontal job enlargement is an organised method that allows the worker to
perform a greater variety of tasks of similar degree of difficulty and at a similar level in the organisation’s
administrative structure (or hierarchy). Herzberg (1966) believed that this approach to the enlargement of jobs could
result in simply enlarging the number of meaningless jobs performed by individual workers. Even though the
workers may be undertaking a greater range of activities within their new job, which could result in greater
productivity gains for the organisation, the workers may not be interested in the work. With this approach, the initial
gains in levels of worker satisfaction and productivity are usually short-lived (say a few weeks) (Cherry et al 1993).
See Case Study 11.2.

FIGURE 11.2 Horizontal job enlargement

Source: Adapted from Cherry N, Smyth A, Boucher C 1993 Job design. In: Collins R (ed.)  Effective management. CCH, Auckland

CASE STUDY 11.2 HORIZONTAL JOB ENLARGEMENT

In efforts to improve the job satisfaction of registered nurses at the ABC Maternity Hospital, management recently
redesigned the job activities of registered nurses. They have moved away from the previous job rotation system, where nurses
were required to relocate from one area to another every six months. The new system requires nurses working in postnatal wards
to work in the antenatal clinic two mornings per week and nurses working in the antenatal clinic to work in the postnatal ward
two mornings per week. Initially, the nurses in both areas agreed to this as a compromise to management so they would not have
to rotate to another area every six months. However, after only one week of the new system, nurses from both the antenatal clinic
and postnatal clinic sent delegations to the Director of Nursing to express their unhappiness about the new system. The major
reason given for dissatisfaction was due to the inability to leave a particular area at a predetermined time because of activities
being undertaken; for example, a patient returning from the birthing suite. However, after further discussion, many of the nurses
expressed boredom with the type of work being undertaken in the other area.

Job enrichment
Job enrichment (also known as vertical job enlargement) is an organised method that allows workers to take over
some of the tasks previously undertaken by their supervisor (or the person above them in the organisational
hierarchy). As Figure 11.3 demonstrates, job enrichment increases the range of tasks undertaken by the worker, and
additional responsibility is included in the work performed. Job enrichment can achieve productivity gains because
workers have new opportunities for learning tasks previously undertaken by their supervisor. However, such gains
may soon evaporate if organisations fail to provide workers with suitable training in order to undertake the
additional activities. Also, if workers are simply given additional tasks, which they believe to be boring, then again
their motivation and the anticipated productivity gains will be reduced (see Case Study 11.3).

Figure 11.3 Job enrichment

Source: Adapted from Cherry N, Smyth A, Boucher C 1993 Job design. In: Collins R (ed)  Effective management. CCH, Auckland

CASE STUDY 11.3 JOB ENRICHMENT (VERTICAL JOB ENLARGEMENT)

In light of recent feedback from the staff and a visit from the local nurses’ union representative, the ABC Maternity
Hospital decided to undertake a second review of the design of job activities. Survey instruments were used to collect data from
all the staff in the hospital on work environment (autonomy, recognition, responsibility and participation in decision-making),
staff satisfaction, quality of patient care, and recruitment and retention. Following the analysis of the survey data, the Director of
Nursing invited all the clinical nurse consultants (CNCs) and acting directors of nursing (ADONs) in the hospital to attend a two-
day (overnight stay) strategic planning retreat held at a beachside resort. Representatives from the various unions and
professional associations were invited to present issues papers, as were selected CNCs and ADONs. The results of the surveys
were also presented to the group. Break-out workshops were held where brainstorming sessions and whiteboards were filled with
a range of possible strategies for redesigning the job activities in order to improve the motivation and satisfaction levels of staff,
and also bring about productivity gains for the organisation overall.
Subsequently, a new job enrichment system was designed to provide various levels of staff with some additional
responsibility that would provide them with opportunities to demonstrate their ability to undertake some activities previously
undertaken by their supervisor. Agreements were reached with nursing unions regarding appropriate salary levels and conditions
for the new positions. A local university was invited to undertake a training program in project management and budgetary
preparation prior to the introduction of the new system, in order that staff would be prepared to undertake the additional duties.
At one, three and six monthly intervals after the implementation of the new job enrichment system, survey instruments
were once again used to collect data from all the staff in the hospital on work environment, staff satisfaction, quality of patient
care, and recruitment and retention. A report prepared to compare the data collected before and after the implementation of the
new system of job design demonstrated significant levels of improvement in the work environment (autonomy, recognition,
responsibility and participation in decision-making), staff satisfaction and quality of patient care. Recruitment costs had reduced
significantly for the six months and the levels of intention of the nurses to remain in employment at the hospital had increased.

Flexible working hours

‘Flexible working hours’ is an organised method by which workers may undertake the required hours of work across
a prescribed period during the day. For example, an organisation may establish a policy whereby workers may
undertake their work any time between 8 am and 6 pm. A 35-hour-per-week worker who previously worked seven
hours per day from Monday to Friday (with one hour for a lunch break), under a new flexible working hours policy,
may choose to start at 8 am and finish at 4 pm, or may start at 10 am and finish at 6 pm. Alternatively, a 36-hour-
per-week worker may choose to undertake the 36 hours from Monday to Thursday by starting at 8 am and finishing
at 6 pm each day, thereby working four days at nine hours per day instead of a five-day week.

Job sharing
Job sharing is an organised method whereby a number of different workers (usually two) share the one job. For
example, a 36-hour-per-week job on a ward could be shared between two nurses, each working two shifts of nine
hours’ duration. The major advantages of job sharing are found in the degree of flexibility and autonomy for the
workers who share the position in that they can arrange between themselves if they wish to change the days of work.
Also, if one of the workers becomes ill and is unable to work, the other worker may be able to undertake the extra
shift, which would avoid the requirement to have an unfamiliar casual worker called into the ward as a replacement.

Multiskilling
Multiskilling is an organised method of job enlargement where workers are encouraged to develop all or most of the
skills needed to produce their group’s product. The worker may be trained to perform a greater variety of tasks at
similar and higher degrees of difficulty and at various levels of the organisational hierarchy. However, while
multiskilling may result in worker productivity gains for the organisation, unless workers are adequately trained and
experienced in undertaking the higher levels of activity, serious problems may occur in patient care and the delivery
of other services.
WHO DOES WHAT IN HEALTH CARE?

Some unique characteristics of the health workforce

In a memorable episode of the British television series Yes Minister, the producers portray a hospital that is judged
to be the most efficiently run hospital of all because its costs are very low and the staff very happy. However, this
hospital has no patients, all its beds are empty and its beautiful operating theatres idle. The reality for health care
managers is that the raison d’être of most health care organisations is the care of patients. This is essentially a
human activity that requires complex human interaction, much more so than in manufacturing industries.
Characteristically, health care organisations rely on a large variety of people (paid and unpaid, professional and non-
professional) to do the work that needs to be done. At a basic level, the dichotomy between professional and non-
professional can be transformed into categories of staff who do things ‘with, to or for patients’ (that is, they have
direct patient care responsibility) and those who are not directly involved in the care of patients. Job design in health
care therefore has an impact on non-professional staff, and on professional staff and patients. This important aspect
of job design is discussed later in this chapter.
Three further relevant considerations when analysing approaches to job redesign in the health industry are
that:

 The professional health workforce in most countries is predominantly female. For example, in Australia
women comprise 74.2 per cent of the total health care workforce and 92 per cent of the nursing workforce (AIHW
2004, pp 267, 260).

 The workforce is culturally and linguistically diverse in terms of staff and patients (Johnson et al
1998, Klinken & Noble 2000).