Empowering health-care managers in Australia: an action learning approach

Abstract

This paper reports on a training programme using action learning sets designed to enhance the management abilities of health-care managers. Numerous independent reports in Australia, and around the world, have related the lack of management systems and processes to substandard health-care delivery. This has suggested a need for better approaches to the education, training and ongoing development of health-care managers, and this paper reports on an action learning approach trialled over a three-year period. Participant managers reported significantly greater levels of empowerment and self-efficacy after participation in the year-long action learning sets intervention. While too early to measure the translation of these reported individual improvements into specific management practice, the literature strongly supports more effective management practice among managers who report high levels of empowerment and self-efficacy.

Introduction

Management in the public health-care sector is difficult. Managers regularly deal with conflicting policy goals, increasing demand coupled with decreasing resources, a wide range of stakeholders with disparate interests, and a highly trained, largely independent and industrially sophisticated workforce. Within most health-care systems, competent clinicians are ‘promoted’ into management positions, often without any formal management training. There is a perception that effective management skills can be learned on-the-job,¹ but recent enquiries into health system failures have consistently pointed to the lack of management systems and processes.^2–4 This has suggested a need for more effective approaches to the development of management skills among health-care managers.

Throughout the world there is a perception that, while there have been significant reforms, health-care systems have not been successful in incorporating acknowledged best practice.^5,6 In particular, there have been considerable concerns about hospital performance in patient safety and quality.^3,7–9 In Australia, the public and private enquiries that have followed patient safety crises, consistently pointed to a lack of basic management systems and processes to assure safe and effective health-care delivery,^4,10–13 and there have been similar findings in other parts of the world.^2,14,15 There has been growing recognition that the key to greater patient safety is ensuring that the health workforce develops the will, the skill and the capacity to deliver safer patient care,^3,16 and ultimately, it is the effectiveness of the management systems, practices and procedures that influence the capacity of health-care workers in delivering safer patient care.¹⁷

While it is estimated that there is in excess of 30,000 managers working in the health-care system in Australia (in government departments, hospitals, community health services, etc.), less than a quarter of these managers display the formal management qualifications required for membership in the professional associations of Australian health-care managers (that is, the Australasian College of Health Service Managers and the Royal Australasian College of Medical Administrators). There is clearly a need for effective approaches to the development of management skills among health-care managers.

In this paper, we discuss an action learning management development initiative for health-care managers. The evaluation explored the impact of this training approach on two constructs that have been identified as having an important influence on the competence of managers. First, empowerment has been seen for a long time as an important factor in workplaces. It has been found to be positively associated with job performance,¹⁸ and specifically in health care, related to quality care provision.^19–21 Specifically among health-care managers, studies have suggested a link between empowerment and organizational performance, enabling them to meet and surpass financial, operational and quality targets. For example, a study comparing high- and low-performing hospitals in the UK National Health Service found that the middle managers in the lower-performing organizations, in comparison with the middle managers of the higher-performing hospitals, reported that they were powerless and lacking empowerment.²²

Empowered individuals are confident in their ability to perform their job and their impact on outcomes that are important to the organization. It has been suggested that increased productivity results from empowered workers because they perceive that they have some control over how things are done in the organization,²³ because they have improved problem-solving skills²⁴ or because they are more likely to introduce and use measures of productivity within the organization.²⁵

The second construct is self-efficacy. Individuals derive their perceptions of their self-efficacy from their capabilities, their work task and from others in their work environment.²⁶ Empirical studies of self-efficacy have demonstrated a consistent positive relationship between levels of self-efficacy and work-related performance in a variety of industries.^26,27 There is a strong evidence base demonstrating that people with high self-efficacy generally work harder²⁸ and perform better.²⁶ That is, people who believe they can achieve, do achieve.

This paper describes a management development intervention using action learning sets. The learning sets comprised small groups of health-care managers that provided ‘communication spaces’ to assist the participants in working towards organizational solutions.²⁹ The aim of this project was to improve the empowerment and self-efficacy of managers working in public hospitals and community health services, in one state in Australia. This paper provides an evaluation of a learning set management development intervention and is one of the first papers we are aware of, that outlines the psychological mechanisms underlying the success of action learning in management development.

Given the use of learning sets in this intervention, we included the construct of psychological safety. Psychological safety is the shared belief among team members that ‘the team is safe for interpersonal risk taking’.³⁰ Team psychological safety has been positively associated with learning behaviour in teams^30,31 and would therefore be important in an effective learning set environment.

Action learning

Action learning was defined by Revans as ‘a means of development, intellectual, emotional or physical, that requires its subject, through responsible involvement in some real, complex and stressful problems, to achieve intended change’.³² It has been suggested that action learning is an effective management development approach for health-care managers.³³ In particular, learning sets provide more immediate impact on the management skills of the participants than would be attained through participation in a formal accredited management education programme. Learning sets are based on the principle that effective learning by professionals requires both action and reflection.^34,35 Learning sets are effective in assisting the members to:

Exchange experiences and learn from each other;

Give professional (and personal) support to members;

Explore options for solving problems;

Seek feedback and reflect on performance;

Test ideas for innovation and improvement.^36–38

A review of the action learning literature from 1994 to 2000, found that the greatest use of action learning was in management development,³⁹ and while there is mounting evidence of the effectiveness of action learning in this domain, there are few studies that detail how action learning might work within the participants to achieve the reported management outcomes.

Theoretical framework

Kolb's Learning Cycle (Figure 1) was used as the theoretical framework for the design of this vocational initiative. This framework suggests that the ideal learning process engages the four defined modes of concrete experience, reflective observation, abstract conceptualization and active experimentation.⁴⁰ Honey and Munford⁴¹ further adapted the learning cycle to management, suggesting the four essential components for management development were having an experience, reviewing the experience, concluding from the experience and then planning the next steps. The learning sets were designed to foster the participants' engagement with each of these modes.

Figure 1

Kolb's Learning Cycle

The focus on self-reflection within the learning sets is supported by the notion that adults need to develop capabilities to become critically self-reflective and exercise reflective judgement, and that it is the role of adult education ‘to help the learner realise these capabilities by developing the skills, insights, and dispositions essential for their practice’.⁴²

Methods

Intervention

The programme was initiated in 2007 by the Management Innovation Council with the aims of:

Equipping the participants with a range of strategies to act on challenges of organizational change;

Enhancing the capacity and confidence of the participants to deal with a range of situations, using strategic thinking and problem solving skills;

Establishing and maintaining ongoing multi-disciplinary professional peer support networks for the participants, and cross fertilization of ideas within and across the participating organizations through group learning.

The participant managers volunteered and/or were nominated by their organization to attend the programme. Each manager was assigned to a small learning group, with four to eight participants in each learning set. To preserve confidentiality and encourage open sharing of organizational situations, participants from the same organization were assigned to different groups.

The sets were not just discussion groups. Each group had a facilitator who assisted the members to work through a dynamic cycle of discussion, application of learning through action, evaluation of the action taken, rethinking and revising action if necessary, and further application consistent with the Kolb and Honey, and Munford frameworks. Action learning, addresses real problems of importance to participants in realtime. It is a quasi-experimental approach that follows a cycle of ‘problem – diagnosis – action – review – learning – action.^33,43,44 Therefore, participants were encouraged to define and analyse their issues, to develop appropriate problem solving action. The action was then evaluated for effectiveness, lessons learned were applied and further action was taken if necessary. Building this cycle into the learning set process, ensured that learning and action were central to participation, and that participants always left a meeting with a plan for testing an action in their workplace, and came to the next meeting with an evaluation of that action to discuss. It was expected that by using this approach, the learning set participants and their supervisors would see almost immediate change in the participants' capabilities within their organizations.

All teams employed a loosely structured approach to the discussion of participants' workplace issues, which largely focused on the people and organizational difficulties inherent in effecting change. Participants undertook to implement the action agreed at the set meeting, and debriefed at subsequent meetings. The discussion and action took place within a context of relevant organizational theory, and learning from others' experience.

Research questions

On completion of the learning sets would participants in the learning sets report a positive change in their levels of empowerment and self-efficacy?

Would psychological safety have a positive association with the reported levels of empowerment and self-efficacy?

Were the changes in empowerment and self-efficacy influenced by characteristics of the participants?

Evaluation measures

Participants were asked to complete a baseline questionnaire, prior to initiating the programme and an evaluative questionnaire following one year of participation in the learning set. The longer-term impact of the intervention will be tested within coming years.

Psychological empowerment

Psychological empowerment was measured using Spreitzer's 12-item scale that comprises four components: competence, impact, meaning and self-determination. This scale has consistently demonstrated acceptable validity and reliability.^45,46 Sample items included, ‘The work I do is very important to me’ (meaning), ‘I am confident about my ability to do my job’ (competence), ‘I have a great deal of control over what happens in my job’ (autonomy) and ‘My impact on what happens in my job is large’ (impact).

Self-efficacy

Self-efficacy was measured using the 10-item general perceived self-efficacy scale of Jerusalem and Schwarzer.⁴⁷ Several studies have confirmed high reliability, stability and construct validity of this scale.^47,48 The items included, I can always manage to solve difficult problems if I try hard enough, I can remain calm when facing difficulties because I can rely on my coping abilities and I can usually handle whatever comes my way.

Team psychological safety

We wanted to make sure that the learning sets had set up appropriate conditions for the participants to meaningfully share their experiences and embrace the action learning concepts. Action learning requires a collaborative, open and supporting culture, that enables the participants to share and learn from each other's mistakes.⁴⁹ To test this, we used the team psychological safety scale³⁰ in the post-questionnaire. The scale includes seven questions with 5-point Likert scale responses, and has demonstrated high validity and reliability.³⁰ We believed that if the participants indicated high levels of psychological safety, it meant that the sets had been operating as intended.

Results

Over the three years of the learning set intervention, 137 managers participated; 133 (97% of participants) completed the pre-set evaluation questionnaire and 95 participants (69%) completed the post-set questionnaire. Of the 95 participants who completed the post-set questionnaire, 76 also completed the pre-set questionnaire. The reasons given by the participants for withdrawing from the programme included: new job/left sponsoring organization, not their favoured approach to learning, lack of time, pregnancy and difficulties with travel to the learning set destination. Table 1 provides the demographics of the pre- and post-evaluation respondents.

Table 1

Demographics of participants

	Pretraining		Posttraining*
	Male	Female	Male	Female
Age
20–39	19 (54%)	40 (41%)	8 (36%)	28 (39%)
40–59	16 (46%)	58 (59%)	14 (64%)	44 (61%)
Total	35 (100%)	98 (100%)	22 (100%)	72 (100%)

*One respondent did not complete the demographic section of the post-questionnaire

The demographics represent the health-care workforce, with a larger percentage of female employees. The distribution changed slightly between the pre- and post-surveys, with fewer males in the younger age group completing the post-questionnaire. This was the result of loss of some of the younger male participants for the reasons given above, as well as three of these participants not completing the post-survey.

All the participants had a management or project management role within the health-care system. Reflecting the structure of the system, 83% of participants worked in hospitals and 17% worked in community health services, with an almost equal split between metro (48%) and rural (52%) participants. Not surprisingly, given that the programme was targeted at middle managers in the system, 93% identified themselves as a middle manager. The largest proportion (86%) had responsibility for managing a clinical area, with only 14% managing a support service. All the managers with clinical management responsibility had a clinical background, as did 25% of the support service managers.

Strict confidentiality was maintained, as the participants did not want the government department that was funding the project to have any idea of the specific management issues faced by the hospitals and health services. The facilitators de-identified any notes recorded during the learning sets, to enable aggregation of the themes to report back to the funder. The themes were consistent throughout the three years, comprising:

How to better manage people, including managing poor performance of subordinates and fostering effective relationships with their supervisors within the organization;

How to better manage behaviours of co-workers at all levels in the organization that were not direct reports;

How to introduce new services and processes that required a change in roles and responsibilities;

How to analyse problems and develop a strategic course of action.

A separate principal components analysis was conducted for each of the three constructs and a cut-off value of 0.50 was used to indicate a satisfactory loading. The number of items that meet the loading criterion and the Cronbach's alphas for the three scales are as follows:

Empowerment: 11 of the 12 items included, with elimination of ‘I have mastered the skills necessary for my job; α = 0.86;

Self-efficacy: nine of 10 items included, with elimination of “If someone opposes me, I can find the means and ways to get what I want”; α = 0.88;

Psychological safety’ all seven items loaded satisfactorily; α = 0.98.

Impact of the action learning sets

We completed one-way repeated-measures analysis of variance (ANOVA) with empowerment and self-efficacy constructs for the 76 cases with both pre- and post-data. Following completion of the action learning sets, the participants reported significantly greater psychological empowerment (F 16.973; P < 0.001) and self-efficacy (F 8.287; P < 0.005). We explored whether characteristics of the participants influenced the change in the empowerment and self-efficacy, and found no significant effect for age, sex, type of job, rural versus metro location or organizational tenure.

Impact on psychological empowerment

To establish how the learning sets acted upon the constructs, we completed t-test analysis on the pre- and post-questionnaires for the full sample. We found significant differences between the pre-set questionnaire and post-set questionnaire responses on six of the 11 empowerment dimensions with satisfactory loading (Table 2). The italicized data illustrates those differences that can be considered to be a statistically significant reported improvement from the pre- to the post-test at P ≤ 0.05. The changes appear to relate to perceptions of increased confidence in personal capabilities and enhanced perceptions of control and influence.

Table 2

Impact on empowerment

	t	DF	Significance
Work I do is important	−1.417	216.7	0.158
Job activities are meaningful	−0.819	202.2	0.414
Work I do is meaningful	−2.913	208.5	0.004
I am confident about my ability to do my job	−2.754	224.1	0.006
I am self-assured about my capabilities	−2.524	215.6	0.001
I have autonomy	−1.478	206.6	0.141
I can decide how to do my work	−2.626	222.5	0.009
I have opportunity for independence	−1.511	214.4	0.132
My impact is large	−1.874	202.3	0.062
I have control over what happens	−3.145	187.7	0.002
I have influence	−2.215	195.0	0.028

Impact on self-efficacy

The t-test analysis also demonstrated statistically significant reported improvement in three of the nine items (Table 3). The italicized data indicates the three self-efficacy factors with a significantly more positive rating by the respondents following the learning sets, as compared with their scores at the start of the learning sets. Not surprisingly, it suggests the improvement was noted in areas related to enhanced problem-solving skills.

Table 3

Impact on self-efficacy

	t	DF	Significance
I can always manage to solve difficult problems	−0.910	174.1	0.364
It is easy to stick to my aims and accomplish my goals	−3.322	213.5	0.001
I am confident I deal efficiently with unexpected events	−1.927	191.5	0.056
Thanks to resourcefulness, I handle unforeseen circumstances	−2.184	199.5	0.030
I can solve most problems if I invest necessary effort	−2.202	201.8	0.029
I remain calm when facing difficulties because I rely on coping abilities	−1.517	208.3	0.131
When confronted with a problem, I can usually find several solutions	−1.790	205.6	0.075
If I am in trouble, I can usually think of a solution	−1.708	198.8	0.089
I can usually handle whatever comes my way	−1.312	184.9	0.191

Team psychological safety

Table 4 outlines the psychological safety scores. The results, with the reversed items with a mean of less than 2.00 (disagree), and means of 4.00 (agree) or higher for the other items, indicate that the participants reported an acceptable level of psychological safety within their learning set, suggesting the learning set process enabled a safe discussion on their issues.

Table 4

Reported team psychological safety

Variable	Mean	SD
If you make a mistake, it is held against you*	1.33	0.516
Members able to bring up problems and tough issues	4.55	0.663
Members reject others for being different*	1.52	0.882
It is safe to take a risk	4.39	0.701
It is difficult to ask other members for help*	1.55	0.738
No one would undermine my efforts	4.53	0.522
My unique skills and talents are valued and utilized	4.03	0.672

*Reversed scores

As recommended by Delaney and Maxwell,⁵⁰ we constructed a new variable to mean centre the psychological safety variable (Psychological safety score – mean score) and completed a repeated-measures ANCOVA with this variable. We found a significant effect of psychological safety (F 5.589; P < 0.05) on psychological empowerment, but no significant effect on self-efficacy (F 2.126 P = 0.15).

The learning set participants were given the opportunity to provide qualitative comments on the impact of the learning sets on their work life. Although it is not possible to prove causality, the qualitative comments of the respondents supported the quantitative results, with participants reporting greater importance and meaning in their roles, such as ‘Greater confidence in my strategies/approach.’ (2007 participant) and ‘Increased confidence in my own decision-making and position as a manager’ (2009 participant). The participants also reported greater control and influence within their workplace: ‘More able to challenge people, despite the risk of conflict’ (2007 participant); ‘To speak up and voice opinions’ (2008 participant); ‘Able to have more self control’ (2009 participant) and ‘Increased confidence in decision-making’ (2009 participant).

Discussion

Participants in the action learning sets reported higher levels of empowerment and self-efficacy

In support of previous research,^33,43,51,52 following participation in the action learning set, the participants reported higher levels of empowerment and self-efficacy in completing their jobs. The result was obtained with t-test analysis on the data for all participants who completed the questionnaires, and a repeated-measures ANOVA for the 76 participants who completed both the pre-set and post-set questionnaire. The respondent participants reported that their work was more meaningful; they were more confident about their ability to do their job and solve problems; they were more self-assured about their capabilities; and they had greater opportunity to decide on how to do their work. They reported perceptions of greater control and influence within their workplaces. The participants also reported greater self-efficacy on three of the self-efficacy components of accomplishing goals, handling unforseen circumstances and solving problems.

The participants indicated that they perceived the learning sets to be psychologically safe, which suggested that the learning sets were effective as an intervention, with safe participation. We also found that psychological safety had an effect on the improvement in empowerment, but no effect on self-efficacy. This is related to the nature of the two constructs. Self-efficacy relates to their personal beliefs of competence and it is unlikely that having a safe place to discuss workplace issues and solutions, would have an impact on self-efficacy. Whereas, discussion on workplace issues in the learning sets could actually be disempowering, as participants realised that they shared organizational and health system barriers to achievement of their management goals. However, the use of the learning set to contemplate strategies to address these barriers and the accountability to act and report back to the set, were mechanisms to empower the participants. The link between psychological safety and empowerment appears to support this. When participants felt their sets afforded them the psychological safe opportunity to work through and act upon their issues, there was a stronger effect on their perceptions of empowerment. This is consistent with findings that researchers who encourage an action learning approach assist participants to increase their competence in handing change.⁵³

This study found that the outcomes were not influenced by age, sex, type of job, rural versus metro location or organizational tenure. There were also no effects found for managers with a clinical background and those without. This suggests that all types of health service managers will benefit from an action learning approach to management development. These are important outcomes for managers in the difficult world of health-care management, as empowerment and self-efficacy are essential to management competence.^22,54

Implications for management development in health care

The majority of the set members had not previously experienced this approach to learning, and a key theme of their discussions was the increase in feelings of personal and professional empowerment – particularly when the action they had discussed and agreed during the set meeting was successful. The participants were positive about the very act of taking action, supported by their learning set colleagues. This is consistent with the suggestion that ‘… learning is thinking generated by and tested against the experience of the consequences of action’.^{55; 114} This balance between acting and learning is important and further empirical study is required to explore whether this is an optimal balance that positively influences learning outcomes.

This study illustrates the significant improvement in empowerment and self-efficacy reported by the participants before and after their learning set programme. Several authors have remarked that the general lack of employer-supported education within the health-care sector has negative implications for the performance and potential for improvement of the sector.^1,2,4,56 Given the consistent links of empowerment with positive workplace outcomes reported in the literature, the learning sets appear to be an effective and relatively efficient mechanism for management development in the health-care sector. Based on the results of our study, policy-makers in public health care should consider the potential for improvement in management competence leading to enhanced system performance that can be attained with the provision of action learning management development.⁵⁷

Limitations

The post-set evaluation was completed as the year of learning sets concluded. It will be important to follow up the participants to see if the improvements in empowerment are maintained. It is reasonable to assume that the positive effects of the learning sets would diminish over time, and based on the recommendations of the project and feedback from the participants, the sponsoring agency has established an ongoing support initiative that brings together all of the learning set participants twice a year, to further support their development. The quantitative evaluation was based on self-reports from the participants, using validated scales. An important further component to the evaluation would be the determination as to whether the empowerment observed, was translated to better performance on the job. The preliminary qualitative evaluation of both the participants and their supervisors confirmed this visible translation, but further evaluation will be required.

Conclusions

Our results suggest that action learning through a learning sets process is an effective way to empower health-care managers in their roles. The action learning approach is supported by previous study that emphasizes the importance of experimentation,⁴⁰ action⁵⁵ and reflection⁴² in learning. Participant respondents indicated that following the learning sets, they perceived that their work was more meaningful, they were more confident about their ability to do their job, they were more self-assured about their capabilities and they had greater opportunity to decide how to do their work. They also reported more positively on their impact, control and influence within their organizations. These are important outcomes for managers in the difficult world of health-care management.

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