Motivated, Competent and

Compassionate (MCC) Training

Partcipant
Manual
Ministry of Health,
Addis Ababa

September, 2021
Table of Content
Acknowledgement ................................................................................................................................ iii
Foreword ................................................................................................................................................ v
APPROVAL STATEMENT OF THE MINISTRY ...................................................................................... vi
Acronyms ............................................................................................................................................. vii
Introduction about this manual ........................................................................................................... 1
Course syllabus ..................................................................................................................................... 2
Course schedule .................................................................................................................................... 4
Chapter 1: Motivation of Health workforce ......................................................................................... 6
Session 1: Motivation of Health Workforce .......................................................................................... 7
1.1 Basic concepts of motivation ................................................................................................ 7
1.2 Theories of Motivation ......................................................................................................... 9
2 Type of motivation ................................................................................................................. 17
3 Motivation Strategies ............................................................................................................. 22
Session 2: Self-motivation.................................................................................................................. 25
1.1 Psychology of self-motivation ............................................................................................. 26
1.2 Importance of self-motivation ............................................................................................ 27
1.3 How to foster self-motivation in the workplace .................................................................. 30
Session 3: Health Workforce Engagement in Management and Leadership........................................ 33
3.1. Basic concepts of management and leadership ...................................................................... 33
3.2 Management...................................................................................................................... 37
3.3 Differences between Leadership and Management ............................................................ 42
3.4 Leading and Managing for Strengthening HRH and Health Systems .................................... 44
Chapter 2: Competent Health Workforce.......................................................................................... 52
Session 1: Lifelong learning ................................................................................................................ 54
1.1 Concepts of lifelong learning (LLL) ...................................................................................... 54
1.2 Benefits of lifelong learning ................................................................................................ 55
1.3 Strategies to lifelong learning ............................................................................................. 56
1.4 Steps to effective lifelong learning...................................................................................... 56
Session 2: Evidence-based Practice .................................................................................................... 59
2.1. Concepts of Evidence-based Practice .................................................................................. 59
2.2. Healthcare audit................................................................................................................. 77
2.3 Principles of Effective healthcare Audit .............................................................................. 79
2.4 Process of healthcare Audit ................................................................................................ 80
 2.5 Monitoring and evaluating healthcare audit ....................................................................... 85
Chapter 3 Compassionate and respectful care ................................................................................. 87
Session 1: components of compassionate care .................................................................................. 88
1.1 Attributes of compassionate care ....................................................................................... 89
Session 2: Compassion as a foundation for Person Centered Care ............................................ 92
2.1 What is person centered care? ........................................................................................... 92
2.2 Benefits of Patient-Centered Care ...................................................................................... 94
2.3 Compassion as the foundation of patient-centered care..................................................... 96
2.4 Effective communication for PCC........................................................................................ 97
Session 3: challenges of compassionate care ..................................................................................... 99
1.5 Challenges in provision of compassionate care ................................................................... 99
1.6 Organizational characteristics ........................................................................................... 100
1.7 Compassion fatigue and burnout ...................................................................................... 100
1.8 Self-care strategies ........................................................................................................... 102
Annexes .............................................................................................................................................. 111
Reference ............................................................................................................................................ 114

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Acknowledgement

The MoH Human Resource Development Directorate has revised CRC training package
in to MCC in aligned with the HSTP II core directions and indicated as the major pillar.
This Motivated, Competent and Compassionate training package is targets all health
care workers working at different levels.

The MOH would like to acknowledge the technical working group and Health
professional Associations consortium members)for their Technical support to develop
this training package and Ethiopian Midwifery Association coordinating the development
process the packages as prime lead of health professional Associations consortium.
The Ministry would also like to extend its gratitude to the following experts and
organizations who have made major contributions to the development of this MCC
training package.

List of contributors Organization

Equlinet Misganaw Jhpiego- Ethiopia

Dr. Aschalew Worku Addis Ababa University (TASH)

Dr.Wondossen Eshetu Ministry of Health-Ethiopia

Abiyu Geta Ministry of Health-Ethiopia

Eyayalem Melesse Addis Ababa University (TASH)

Mulugeta Abate Ethiopian Public Health Association (EPHA)

Getahun Tibebu Addis Ababa University (TASH)

Tezera Tadele Ministry of Health-Ethiopia

Yohannes Assemu Jhpiego- Ethiopia

Takele Yeshiwas Ministry of Health-Ethiopia

Wotaro Balta Ethiopian Midwifes Association (EMwA)

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Mesfin Kifle Ministry of Health-Ethiopia (WHO)

Zeine Abosie Management Science for Health Ethiopia (MSH)

Tefera Mulugeta Addis Ababa University (TASH)

Fikadu Mazengia Ethiopian Midwifes Association (EMwA)

Aster Teshome Ministry of Health-Ethiopia

Ewnetu Genet Ministry of Health-Ethiopia

Fantanesh Dessalegn Ministry of Health-Ethiopia

Lidia Gebru Ministry of Health-Ethiopia

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Foreword
Delivering service with Motivated Competent and compassionate (MCC) professional is
essential to high quality healthcare and should be at the heart of our healthcare system
MCC is critical to building a sustainable, equitable and healthy future for all. An
increasing body of data shows that providing MCC improves health outcomes, enhances
patient happiness, promotes adherence to treatment, and lowers malpractice claims
and healthcare costs.

While our healthcare system has made significant health advances, there is rising
criticism about a perceived lack of Motivation in its delivery. Addressing gaps in the
provision of Motivated Competent and compassionate (MCC) care is indicated as a
major goal in the Health Sector Transformation Plan II (HSTP II), which has narrowed
its focus on a number of compassionate care, or dignity in care.

Training our health personnel on MCC is one of the efforts for the Federal Ministry of He
alth,which is primarily built on the preceding CRC, with the present focus on professiona
l motivation and competency. This program began with an assessment of our health car
e professionals' training requirements in order to better understand the knowledge, attit
ude, and skill gaps that must be filled in order to offer quality care.

The second health system transformation plan (HSTP II) refers to ensuring availability
of an adequate number and mix of quality health workforce that are Motivated,
Competent and Compassionate (MCC) to provide quality health service. Creating
motivated, competent and compassionate health workforce depends on several but
inter-related factors

As part of its implementation, our accredited CPD centers will be implemented around
the country. We as a ministry are very committed to support its implementation and
work together to guarantee that everyone is treated with Motivation, Competency and
compassion.

Assegid samuel
Human Resource Development Directorate
Director
Ministry of health- Ethiopia
Federal Democratic Republic of Ethiopia

v
 APPROVAL STATEMENT OF THE MINISTRY

The Federal Ministry of health of Ethiopia has been striving to standardize and
institutionalize in-service trainings (IST). To ensure that trainings are
implemented in a consistent way, the Ministry of Health created a national in-
service training directive and implementation guide.

Based on the responsibilities indicated in the directive the ministry of health

accredited qualified universities and professional Associations to be course and
provider accreditor and they are accredited institutions as a course provider. The
directive requires all in-service training materials fulfill the standards set in the
implementation Guide to ensure the quality of in-service training materials.
Accordingly, the ministry reviews and approves existing training materials based
on the IST standardization checklist annexed on the IST implementation guide.

As per the national continuing Professional Development implementation

process, the Motivated Competent and Compassionate (MCC) training package
has been reviewed using a standard review checklist and approved by the
ministry in March 2022.

Assegid samuel
Human Resource Development Directorate
Director
Ministry of health- Ethiopia
Federal Democratic Republic of Ethiopia

vi
Acronyms
MCC Motivated Competent and compassionate
CRC Compassionate Respectful and Caring
HSTP II Health System Transformation Plan II
CPD Continuing professional Development
IST In-Service Trainings
CEU Continuing Educational Unit
SDT Self-Determination theory
M=E*I*V Motivation = Expectancy*instrumentality*valence, M (Motivation)
VCT Voluntary counseling and testing
USAID The United States Agency for International Development
HRH Human Resource for Health
WHO World Health Organization
HCP health Care Providers
LLL Life Long Learning
EBP Evidence-Based Practice
CEO Chief Executive Officer
PICO(T) Patient, population problem, Indicator, Index, intervention,
Comparator, control strategy, Control test, Time outcome
RCT Randomized Control Trial
HSTQ Health System Quality tool
QI Quality Improvement
RHBs Regional Health Bureau and
MOH Ministry of Health
SMT Senior Management Team
TOR Term of Reference
MBI Maslach Burnout Inventory
PCC Patient Centered Care

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Introduction to the manual

The second Health System Transformation Plan (HSTP II) focuses on ensuring
availability of an adequate number and mix of quality health workforce that are
Motivated, Competent and Compassionate (MCC) to provide quality health service.
Creating motivated, competent and compassionate health workforce depends on
several but inter-related factors. These include well-regulated, high-quality pre-service
education, in-service training, and CPD to build the required number of well-qualified
professionals and managers; fair recruitment, selection, orientation, and placement;
and creation of an enabling work environment with clear roles and responsibilities,
equitable remuneration packages, and performance support (supportive supervision and
timely feedback) through strong human resources management policy and practices.

Of the 14 strategic directions in the HSTP II, five top priority areas were identified.
These include Quality and Equity of health Services, Information Revolution, Motivated,
Competent and Compassionate Health workforce (MCC), Health Financing and
Leadership.

To achieve those listed objective Compassionate and Respectful Care (CRC) is

fundamental to the practice of healthcare professionals. A growing body of evidence
has demonstrated that compassionate care has been associated with improved health
outcomes, increased patient satisfaction, better adherence to treatment
recommendations, fewer malpractice claims and reduced healthcare expenditure.
Motivated, Competent and Compassionate Health workforce (MCC), means serving
Clients, being ethical, living the professional oath, and being a model for young
professionals and students. It’s a movement that requires champions who identify with
their profession and take pride by helping people. Be compassionate and respectful for
yourself first and then you will be for others.

Core Competencies

 Provide evidence-based quality health care services with motivation, compassion,

Dignity and respect by maintaining and updating his/her competency.
Course syllabus
Course Description: This course is designed to equip health care providers with all
the necessary knowledge, attitude and skills by emphasizing on motivation of health
workforce, competence and compassionate care to enable them provide safe healthcare
service in motivating and compassionate manner.

The module is organized in three main chapters

 Chapter 1: Motivating Health workforce

 Chapter 2: Competent health workforce
 Chapter 3: Compassionate and respectful care
Course objectives

After completion of this course, you will be able to:

 Recognized the role of motivation to enhance quality health care service

provision.
 Apply lifelong learning and evidence-based practice to improve person centered
care.
 Provide person centered care with compassion.
Teaching learning approach

 Class room -based teaching (Interactive lecture and discussion, Group learning
activities (case studies, role play, discussion.)
 Health care setting (educational visit and discussion, assignment, project work ..)
 Independent study
 Demonstration and guided practice
 Reflection
Learning materials and resources

 Facilitator guide
 Participants manual
 PPT
 National MCC and CRC manuals

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  Job aids(learning guides, checklists, self-assessment tools, templates, case
scenarios)
Method of Evaluation
Formative
 Pretest
 Direct observation of performance (during and after the
training
 Oral questioning
Summative
 Post-test
 Review of work completed by learners
Course
 Daily evaluation by participants
 Daily trainer’s feedback meeting (debriefing)
 End course evaluation
Trainer
 Trainees feedback on facilitation skill
 Supervisors feedback on facilitation skill
Selection Criteria Participants are health workforce in the health system

Trainer selection criteria -  Experts who developed this training manual or

 Experts who have MCC basic training and facilitation skills
training
Certification criteria - - Participants will be certified if they fully attend the course and
score ≥70% for post training knowledge
Course Venue - - Training will be conducted at Accredited CPD training centers
Course Duration - - 05days

CEU- - 15
Suggested class size - 25-30

Trainer trainee ratio - 1: 7

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Course schedule

Time Activity Remark

Day One
8:30-9:30 AM Registration
9:30-10:00 AM Introduction to each other
10:00-10:20 AM Healthy break
10:20-12:20 PM Motivation of Health Workforce
12:20-2:00 PM Lunch
2:00- 3:00 PM Motivation of Health Workforce
continued
3:00-3:15 PM Health Break
3:15 -4:15 PM Motivation of Health Workforce
continued
4:15-515 PM Self-motivation
Day Two
8:30-9:30 Am Self-motivation continued
9:30-10:30 AM Health Workforce Engagement in
Management and Leadership
10:30-10:45 AM Healthy break
10:45-12:45 AM Health Workforce Engagement in
Management and Leadership
continued
12:30-2:00 PM Lunch
2:00-3:00 PM Health Workforce Engagement in
Management and Leadership
Continued
3:00-3:30 PM Health Break
3:30- 4:30 PM Competent Health workforce
4:30- 5:30 PM Concepts of Lifelong learning (LLL)

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Day Three
8:30-9:30 AM Concepts of Lifelong learning (LLL)
9:30- 10:30 AM Steps and strategies to effective LLL
10:30-10:45 AM Healthy break
10:45-12:00 Am Steps and strategies to effective LLL
12:00-1:30 PM Lunch
1:30-3:30 PM Concepts of Evidence based practice,
3:30-3:45 PM Healthy break
3:45-4:45 PM Steps of Evidence based practice
Day Four
8:30 -10:30 AM Steps of Evidence based practice
continued
10:30-10:45 AM Healthy break
10:45-12:45 AM Competent Health Workforce, Health
care audit
12:45-2:15 PM Lunch
2:15-4:15 PM Components of Compassionate and
respectful care
4:15-4:30 PM Healthy break
4:30- 5:30 PM Compassion as foundation for person
centered care
Day five
8:30-10:00 AM Compassion as a foundation for
Person Centered continued
10:00-10:15 AM Healthy break
10:15-12:15 PM Challenges of compassionate care
12:15-2:00 PM Lunch
2:00-3:30 PM Discussion and Reflection
3:30-3:45 PM Healthy break
3:45-5:30 PM Closing

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Chapter 1: Motivation of Health workforce
Duration: 4 hrs

Chapter Description:

This chapter is designed to enhance participants’ understanding on motivation of health

workforce. It outlines basic concept of motivation, theories and types of motivation;
describes the relevance of self-motivation and the role of motivated health workforce in
management and leadership.

Chapter objective

At the end of this chapter, participant will able to:

 Discuss motivation and theory of motivation

Enabling objectives: After completing this chapter, participants will be able to;

 Describe concepts of motivation

 Discuss theories of motivation
 Explain types of motivation
 Identify what motivates health workforce
 Describe strategies of motivation

Chapter Outline

Session 1: Motivation of health workforce

Session Content:
1.1. Basic concepts of motivation
1.2. Motivation theories
1.3. Type of motivation
1.4. What motivates health workers?
1.5. Motivation strategies
Session II: Self-motivation
Session Content
2.1. Definition of self-motivation
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 2.2. Psychology of self-motivation
2.3. Importance of self-motivation
2.4. How to foster self-motivation in the workplace
Session III: The role of motivated health workforce in management and leadership
Session Content:
3.1. Basic concepts of management and leadership
3.2. Management and leadership in health care service context
3.3. Engaging health workforce in management and leadership
Duration: 10 hrs.

Session 1: Motivation of Health Workforce

Duration: 4 hrs.

1.1 Basic concepts of motivation

ACTIVITY – I: Individual Reflection Think pair and share.

What is motivation?
8 min

Motivation is both a driver and a consequence of health worker performance.Motivated

health workers are likely to attend to their clients and provide better care, and their
improved performance affirms and drives them to achieve their goals further. This
relationship between motivation and performance is influenced further by the
organizational climate and social context within which health workers are positioned .

Worker motivation is of critical importance in the health sector: health care delivery is
highly labor-intensive and service quality, efficiency and equity is directly affected by
worker motivation. Factors such as the availability of resources and the technical
competence of health worker are not sufficient in themselves to always produce desired
work behavior. Evidence has shown that motivated workers come to work more
regularly, work more diligently, and are more flexible and willing. Increased motivation
creates the conditions for a more effective workforce, but because work motivation is

7
an interactive process between workers and their work environment, good management
and supervision are still critical factors in reaching organizational goals .

Definition
The word “motivation” comes from the Latin verb meaning “to move”. Motivation in the
work context is typically defined as the willingness to exert and maintain an effort
towards organizational goals. Motivation develops in individuals as a result of the
interaction between individual processes, immediate organizational work context and
cultural dynamics. Motivation is a complex construct, closely interrelated with the
concepts of job satisfaction, retention and performance.

A motive is a reason for doing something concerned with the strength and direction of
behavior and factors that influence people to behave in certain ways. The term
‘motivation’ can refer variously to the goal’s individuals have, the ways in which
individuals chose their goals and the ways in which others try to change their behavior.
Motivation is an internal psychological process. It is not possible to ‘motivate’ people
directly; only to create an environment conducive to high degrees of motivation.
Further, motivation itself is not an observable phenomenon; it is only possible to
observe either the result of the motivational process (such as improved performance) or
perhaps, some of the determinants of motivation.

The three components of motivation are6:

a) Direction – what a person is trying to do.

b) Effort /intensity/– how hard a person is trying?
c) Persistence – how long a person keeps on trying?

Motivating other people is about getting them to move in the direction you want them
to go in order to achieve a result. Motivating yourself is about setting the direction
independently and then taking a course of action that will ensure that you get there.
Motivation can be described as goal-directed behavior. People are motivated when they
expect that a course of action is likely to lead to the attainment of a goal and a valued
reward – one that satisfies their needs and wants. Well-motivated people engage in

8
discretionary behavior – in the majority of roles there is scope for individuals to decide
how much effort to exert. Such people may be self-motivated.

Motivation and Behavior

Motivation causes goal directed behavior. Need is the base for motivation which is a
kind of mental feeling in an individual that he needs something. This lack of something
created tension in the mind of the individual. The individual tries to overcome this by
engaging himself in a behavior through which he satisfies his needs. This is goal
directed behavior and it leads to goal fulfillment and individual succeeds in fulfilling his
needs and thereby overcoming his tension in the favorable environment. Behavior ends
the moment tension is released. However, satisfaction of one need leads to feeling of
another need, either same need after some time or different need and goal directed
behavior goes on. Thus, goal directed behavior is a continuous process. However, if the
need is not satisfying because of some reasons, the person may feel frustration which
can be defined as accumulation of tension due to non-fulfillment of needs. At this stage
the individual will try to modify his behavior to eliminate factors for non-fulfillment of
his needs. For example, putting more force need satisfactions.

1.2 Theories of Motivation

ACTIVITY – II: Think pair and share.

What are the theories of motivation?

10 min

A. Maslow's Needs hierarchy Theory

The American motivation psychologist Abraham H. Maslow developed the hierarchy of
needs consisting of five hierarchic classes. According to Maslow, people are motivated
by unsatisfied needs. The needs, listed from basic (lowest-earliest) to most complex
(highest-latest) are as follows:

 Physiology (hunger, thirst, sleep, etc.)

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  Safety/Security/Shelter/Health
 Social/Love/Friendship
 Self-esteem/Recognition/Achievement
 Self-actualization/achievement of full potential/can never be fully
accomplished

Figure 1 ; A. Maslow's Needs hierarchy

The basic requirements build upon the first step in the pyramid: physiology. If there are
deficits on this level, all behavior will be oriented to satisfy this deficit. Essentially, if you
have not slept or eaten adequately, you won't be interested in your self-esteem desires.
Subsequently we have the second level, which awakens a need for security. After
securing those two levels, the motives shift to the social sphere, the third level.
Psychological requirements comprise the fourth level, while the top of the hierarchy
consists of self-realization and self-actualization. Maslow's hierarchy of needs theory can
be summarized as follows:
 Human beings have wants and desires which influence their behavior. Only
unsatisfied needs influence behaviors.
 Needs are arranged in order of importance to human life, from the basic to
the complex.
 The person advances to the next level of needs only after the lower-level
need is at least minimally satisfied.

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The further the progress up the hierarchy, the more individuality, humanness and
psychological health a person will show.

B. Herzberg's Two-factor (Hygiene –Motivation) Theory

Frederick Herzberg's two-factor theory concludes that certain factors in the workplace
result in job satisfaction, but if absent, they don't lead to dissatisfaction but no
satisfaction. He distinguished between:
 Motivators (e.g., challenging work, recognition, responsibility) which give
positive satisfaction, and
 Hygiene factors (e.g., status, job security, salary and fringe benefits) that do
not motivate if present, but, if absent, result in demotivation.
Herzberg concluded that job satisfaction and dissatisfaction were the products of two
separate factors: motivating factors (satisfiers) and hygiene factors (dissatisfies). Some
motivating factors (satisfiers) were: Achievement, recognition, work itself, responsibility,
advancement, and growth. Some hygiene factors (dissatisfies) were: company policy,
supervision, working conditions, interpersonal relations, salary, status, job security, and
personal life. The name hygiene factor is used because, like hygiene, the presence will
not improve health, but absence can cause health deterioration.

Figure 2: Herzberg hygiene and motivating factors

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C. Theory X and Theory Y
Douglas McGregor identified two different sets of assumptions about employees. The
traditional view, known as Theory X holds people have inherent dislike of work.
Although workers may view it as a necessity, they will avoid it whenever possible. In
this view most people prefer to be directed and to avoid responsibility. As a result, the
work is of secondary importance, and managers should push employees to work.
Theory Y is more optimistic. It assumes that work is as natural as play or rest. In
theory Y people want to work and can derive a great of satisfaction from work. In this
view people have the capacity to accept- even seek- responsibility and to apply
imagination, inequality, ingenuity, and creativity to organizational problems.

D. Alderfer's ERG theory

Alderfer, expanding on Maslow's hierarchy of needs, created the ERG theory. This
theory posits that there are three groups of core need — existence, relatedness,
and growth, hence the label: ERG theory. The existence group is concerned with
providing our basic material existence requirements. They include the items that
Maslow considered to be physiological and safety needs. The second group of needs is
those of relatedness- the desire we have for maintaining important personal
relationships. These social and status desires require interaction with others if they are
to be satisfied, and they align with Maslow's social need and the external component of
Maslow's esteem classification. Finally, Alderfer isolates growth needs as an intrinsic
desire for personal development. Maslow's categories are broken down into many
different parts and there are a lot of needs. The ERG categories are broader and cover
more than just certain areas. As a person grows, the existence, relatedness, and
growth for all desires continue to grow. All these needs should be fulfilled to
greater wholeness as a human being. These include the intrinsic component from
Maslow's esteem category and the characteristics included under self-actualization.

E. Self-Determination theory
Propounded by Edward L. Deci and Richard M. Ryan, this theory focuses on the degree
to which an individual’s behavior is self-motivated and self-determined. SDT
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identifies three needs that, if satisfied, allow optimal function and growth:
competence, relatedness, and autonomy. These three psychological needs
motivate the self to initiate specific behavior and mental nutriments that are essential
for psychological health and well-being. When these needs are satisfied, there are
positive consequences, such as well-being and growth, leading people to be motivated,
productive and happy. There are three essential elements to the theory:
 Humans are inherently proactive with their potential and mastering their inner
forces (such as drive and emotions).
 Humans have an inherent tendency towards growth, development and
integrated functioning.
 Optimal development and actions are inherent in humans but they do not
happen automatically
F. Goal-Setting Theory
Goal setting theory focuses on the process of setting goals themselves. According to
psychologist Edwin Locke the natural human inclination to set and strive for goals is
useful only if the individual both understands and accepts a particular goal.
Furthermore, workers will not be motivated if they do not possess goal and the skills
needed to achieve a goal. According to goal setting theory, individual is motivated when
they behave in ways that move them to certain clear goals that they accept and can
reasonably expect to attain.

Christopher Earley and Christine Shelley describe the goal setting process in terms of
four phases of a person’s reasoning:

 Establishment of a standard to be attained

 Evaluation of whether the standard can be achieved
 Evaluation of whether the standard matches personal goals.
 The standard is accepted, the goal is thereby set, and behavior proceeds
towards the goal.
Research shows that when goals are specific and challenging, they function more
effectively as motivating factors in both individual and group performance Research also

13
indicate that motivation and commitment are higher when employees participate in the
setting goals. Employees need accurate feedback on their performance

G. Victor Vroom’s Expectancy theory

Victor Vroom stated that people will be highly productive and motivated if two
conditions are met:

 People believe it is likely that their efforts will lead to successful results and
 Those people also believe they will be rewarded for their success.
People will be motivated to exert a high level of effort when they believe there are
relationships between the efforts they put forth, the performance they achieve, and the
outcomes/ rewards they receive.

There's also an equation for this theory which goes as follows: M=E*I*V or Motivation
= Expectancy*instrumentality*valence, M (Motivation) is the amount an individual will
be motivated by the condition or environment they placed themselves in; which is
based on E (Expectancy) person's perception that effort will result in performance. I
(Instrumentality), is the person's perception that performance will be rewarded or
punished. V (Valence) is the perceived amount of the reward or punishment that will
result from the performance.

H. Practical Implications of Various Theories

At lower levels of Maslow's hierarchy of needs, such as physiological needs, money is a
motivator; however, it tends to have a motivating effect on staff that lasts only for a
short period (in accordance with Herzberg's two-factor model of motivation). At higher
levels of the hierarchy, praise, respect, recognition, empowerment and a sense of
belonging are far more powerful motivators than money, as both Abraham Maslow's
theory of motivation and Douglas McGregor's theory X and theory Y (pertaining to the
theory of leadership) demonstrate. According to Maslow, people are motivated by
unsatisfied needs. The lower-level needs such as Physiological and Safety needs will
have to be satisfied before higher level needs are to be addressed. We can relate
Maslow's Hierarchy of Needs theory with employee motivation. For example, if a
manager is trying to motivate his employees by satisfying their needs; according to

14
Maslow, he should try to satisfy the lower-level needs before he tries to satisfy the
upper-level needs or the employees will not be motivated. Also, he has to remember
that not everyone will be satisfied by the same needs. A good manager will try to figure
out which levels of needs are active for a certain individual or employee. Maslow has
money at the lowest level of the hierarchy and shows other needs are better motivators
to staff. McGregor places money in his Theory X category and feels it is a poor
motivator. Praise and recognition are placed in the Theory Y category and are
considered stronger motivators than money.

 Motivated employees always look for better ways to do a job.

 Motivated employees are more quality oriented.
 Motivated workers are more productive.
The average workplace is about midway between the extremes of high threat and high
opportunity. Motivation by threat is a dead-end strategy, and naturally staff is more
attracted to the opportunity side of the motivation curve than the threat side.
Motivation is a powerful tool in the work environment that can lead to employees
working at their most efficient levels of production. Nonetheless, Steinmetz also
discusses three common character types of subordinates: ascendant, indifferent, and
ambivalent that all react and interact uniquely, and must be treated, managed, and
motivated accordingly.

An effective leader must understand how to manage all characters, and more
importantly the manager must utilize avenues that allow room for employees to work,
grow, and find answers independently. The assumptions of Maslow and Herzberg were
challenged by a classic study at Vauxhall Motors' UK manufacturing plant. This
introduced the concept of orientation to work and distinguished three main orientations:
instrumental (where work is a means to an end), bureaucratic (where work is a source
of status, security and immediate reward) and solidaristic (which prioritizes group
loyalty).

Other theories which expanded and extended those of Maslow and Herzberg included
Kurt Lewin's Force Field Theory, Edwin Locke's Goal Theory and Victor Vroom's
Expectancy theory. These tend to stress cultural differences and the fact that
15
individuals tend to be motivated by different factors at different times. According to the
system of scientific management developed by Frederick Winslow Taylor, a worker's
motivation is solely determined by pay, and therefore management need not consider
psychological or social aspects of work. In essence, scientific management bases
human motivation wholly on extrinsic rewards and discards the idea of intrinsic
rewards.

In contrast, David McClelland believed that workers could not be motivated by the mere
need for money—in fact, extrinsic motivation (e.g., money) could extinguish intrinsic
motivation such as achievement motivation, though money could be used as an
indicator of success for various motives, e.g., keeping score. In keeping with this view,
his consulting firm, McBer& Company, had as its first motto "To make everyone
productive, happy, and free." For McClelland, satisfaction lay in aligning a person's life
with their fundamental motivations.

Elton Mayo found that the social contacts a worker has at the workplace are very
important and that boredom and repetitiveness of tasks lead to reduced motivation.
Mayo believed that workers could be motivated by acknowledging their social needs
and making them feel important. As a result, employees were given freedom to make
decisions on the job and greater attention was paid to informal work groups. Mayo
named the model the Hawthorne effect. His model has been judged as placing undue
reliance on social contacts within work situations for motivating employees.

William Ouchi introduced Theory Z, a hybrid management approach consisting of both

Japanese and American philosophies and cultures. Its Japanese segment is much like
the clan culture where organizations focus on a standardized structure with heavy
emphasis on socialization of its members. All underlying goals are consistent across the
organization. Its American segment retains formality and authority amongst members
and the organization. Ultimately, Theory Z promotes common structure and
commitment to the organization, as well as constant improvement of work efficacy. In
Essentials of Organizational Behavior, Robbins and Judge examine recognition programs
as motivators, and identify five principles that contribute to the success of an employee
incentive program.
16
  Recognition of employees' individual differences, and clear identification of
behavior deemed worthy of recognition
 Allowing employees to participate
 Linking rewards to performance
 Rewarding of nominators
 Visibility of the recognition process

2 Type of motivation

ACTIVITY – III. Individual reflection

Instruction: Think individually and share your

opinion to the larger group

Do you know types of motivation? Please specify

10 min
The two types of motivation are intrinsic motivation and extrinsic motivation.

 Intrinsic motivation:
Intrinsic motivation can arise from the self-generated factors that influence people’s
behavior. It is not created by external incentives. It can take the form of motivation by
the work itself when individuals feel that their work is important, interesting and
challenging and provides them with a reasonable degree of autonomy (freedom to
act), opportunities to achieve and advance, and scope to use and develop their skills

17
and abilities. Deci and Ryan (1985) suggested that intrinsic motivation is based on the
needs to be competent and self-determining, that is, to have a choice.

Intrinsic motivation can be enhanced by job or role design. According to an early writer
on the significance of the motivational impact of job design. ‘The job itself must provide
sufficient variety, sufficient complexity, sufficient challenge and sufficient skill to engage
the abilities of the worker.’ In their job characteristics model, Hackman and Oldham
emphasized the importance of the core job dimensions as motivators, namely skill
variety, task identity, task significance, autonomy and feedback.

 Extrinsic motivation
Extrinsic motivation occurs when things are done to or for people to motivate
them. These include rewards, such as incentives, increased pay, praise, or promotion;
and punishments, such as disciplinary action, withholding pay, or criticism.

Extrinsic motivators can have an immediate and powerful effect, but will not
necessarily last long. The intrinsic motivators, which are concerned with the ‘quality
of working life’ (a phrase and movement that emerged from this concept), are likely to
have a deeper and longer-term effect because they are inherent in individuals and their
work and not imposed from outside in such forms as incentive pay (Michael Armstrong)

Table 1: intrinsic and extrinsic factors examples

Intrinsic Extrinsic

1. Participating in a sport because it’s 2. Participating in a sport in order to win a

fun and you enjoy it. reward or get physically fit.
3. Learning a new language because 4. Learning a new language because your job
you like experiencing new things. requires it.
5. Spending time with someone 6. Spending time with someone because they
because you enjoy their company. can further your social standing.
7. Cleaning because you enjoy a tidy 8. Cleaning to avoid making your partner
space. angry.

18
9. Playing cards because you enjoy the 10. Playing cards to win money.
challenge.
11. Exercising because you enjoy 12. Exercising because you want to lose weight
physically challenging your body. or fit into an outfit.
13. Volunteering because it makes you 14. Volunteering in order to meet a school or
feel content and fulfilled. work requirement.
15. Going for a run because you find it 16. Going for a run to increase your chances at
relaxing or are trying to beat a winning a competition.
personal record.
17. Painting because it makes you feel 18. Painting so you can sell your art to
calm and happy. make money.
19. Taking on more responsibility at 20. Taking on more responsibility at work in
work because you enjoy being order to receive a raise or promotion.
challenged and feeling accomplished.

1.3 What motivates health workforce

Health worker motivation is an internal psychological process, operating at the level of
an individual, while health sector reform seeks to modify entire systems. Determinants
of work motivation originate at many levels: the individual, the immediate
organizational work context, the larger health sector context, and the socio-cultural and
environmental context. The following paragraphs categorize the many determinants of
worker motivation according to the level at which they originate.

 Individual Determinants
Workers’ individual needs, self-concept, and expectations for outcomes and/or
consequences are some of the more important individual-level determinants of work
motivation. These determinants coupled with the individual worker’s technical and
intellectual capacity to perform and the physical resources at hand to carry out
the task, lead to worker performance. Also affecting the level of motivation is a
worker’s actual experience of outcomes or consequences. These consequences can be

19
observed effects of worker performance, direct feedback from supervisors or
community, or rewards or punishments for work behavior.

 Organizational and System level Determinants

Motivation is a transactional process and worker’s motivation is contingent upon the
organizational context in which the worker is situated. Figure 1 introduces
organizational and system level determinants into the picture, illustrating that
organizational structures, processes and culture, as well as information about
organizational performance and results will contribute to the motivational processes
occurring at the individual level.

It is necessary for the organization to provide complementary inputs (such as drugs

and medical supplies), as well as clear, efficient systems, in order for workers to
effectively carry out their tasks. Organizational structures and processes will affect
workers’ experience of outcomes and the nature of feedback that a worker receives
from colleagues and supervisors within the health system. This feedback loop, running
from worker performance to worker experience of outcomes, and mediated by the
organization and broader health care system is critical in affecting motivation.
Consequences experienced by the worker can be positive, to reinforce good
performance, or negative, to restrain inappropriate behavior. A particularly important
organizational system is the human resource management system which is likely
to affect both workers’ perception of their own capability and their true capability,
through such mechanisms as training, supervision, and more concrete incentives such
as remuneration, promotion, and performance review processes. Finally,
organizational work culture contributes to the individual’s level of
commitment and motivation.

20
 Worker motivation
motivation Worker Worker experience of
Worker
The internal
internal process
process performance outcomes
The

Worker capacity

Organizational factors and systems Result

structures, process, resources Organization vs system
culture level

Figure 3. Work motivation in the organizational context

 Socio-cultural, Environment, and Reform context

Outside of the immediate organizational environment, the broader social and cultural
context will also contribute to the individual’s motivational processes (Figure 2). At the
core of health service delivery is the interaction between the individual health care
worker and the client. Community members will have expectations for how services
should be delivered, (which may or may not correspond with organizational norms for
services), and they too provide feedback on health worker performance, both formally
and informally.

While the generic concepts of individual, organizational and community determinants of

work motivation described above are relevant to all country situations, the socio-cultural
context will affect the relative importance of the different determinants described and
the relationship between them. For example, in many industrialized countries, flat
organizational structures, and worker involvement are valued and are prominent
determinants of motivation. In societies that are accustomed to more hierarchical
structures and give more legitimacy to unequal distribution of power, workers may
ascribe less importance to these factors. Different cultural contexts will also shift the
balance between a worker’s competing needs. In some contexts, workers are deeply
21
embedded in their communities and social context and thus need for social validation of
their actions may be stronger than need for approval from supervisors.

Worker motivation Worker Worker experience of

The internal process performance outcomes

Worker capacity

Result
Organizational factors and systems
Organization vs system Community, client
structures, process, resources
level
culture

Health sector reforms

Socio-cultural and environment context

Figure 4. Work motivation in the larger societies

3 Motivation Strategies
ACTIVITY – IV: individual reflection , think, pair and share
Instruction: think individually and share you knowledge to
the group
What motivational strategy you apply if you are in a
position to lead your organization?
10 min
Motivation strategy should aim to increase the effective contribution of members of the
organization in achieving its objective. Motivation strategy will refer to the
performance of management and reward systems and in particular to the type
and scale of financial incentives which are to be provided. But it will also be concerned
with other process which should yield favorable attitudes including job design

22
 participation, joint objective setting career development and any other processes
relating to the individual need to achieve and maintain a sense of personal wealth and
importance. Motivation is also affected by the quality of leadership in an
organization therefore the selection, training and development of effective leaders
should be part of the strategy.

Table 2: Motivation strategy (Armstrong, 2006)

Factors affecting motivation strategies The HR contribution
The complexity of the process of motivation Avoid the trap of developing or supporting
means that simplistic approaches based on strategies that offer prescriptions for motivation
instrumentality theory are unlikely to be based on a simplistic view of the process or fail to
successful recognize individual differences

People are more likely to be motivated if they Encourage the development of performance
work in an environment in which they are management process which provide
valued for what they are and what they do. opportunities to agree expectations and give
This means paying attention to the basic need positive feedback an accomplishment.
for recognition Develop reward systems which provide
opportunities for both financial and non-financial
rewards to recognize achievements. Bear in mind,
however, that financial rewards system is not
necessarily appropriate and the lessons of
expectancy, goal and equity theory need to
be taken into account in designing and operating
them
The need for work which provides people with Advise on processes for the design of jobs which
the means to achieve their goals, a take account of the factors affecting the
reasonable degree of autonomy, and motivation to work, providing for job enrichment
scope for the use of skills and competencies in the shape of variety, decision-making
should be recognized responsibility and as much control as possible in
carrying out the work

23
The need for the opportunities to grow by Provide facilities and opportunities for learning
developing abilities and careers. through such means as personal development
planning processes as well as more formal
training
 Develop career planning processes
 Continuous Professional Development (CPD)
The cultural environment of the Advise on the development of a culture which
organization in the shape of its values and supports process of valuing and rewarding
norms will influence the impact of any employees
attempts to motivate people by direct and
indirect means
Motivation will be enhanced by leadership  Devise competency frameworks which focus
which sets the direction, encourages and on leadership qualities and team leaders
simulates achievement, an provide support to  Ensure that leadership potential is identified
employees in their efforts to reach goals and through performances management and
improve their performance generally assessment centers
 Provide guidance and training to develop
leadership qualities

SELF ASSESSMENT QUESTIONS

1 What is motivation?
2 List down the 5 hierarchies in Maslow’s need hierarchy theory?
3 Explain the 2 factors in Herzerberg’s Hygiene Factor theory?
4 Explain Alderfer’s ERG theory?
5 What are the 3 needs in self-determination theory?
6 Define and characterize intrinsic and extrinsic motivators?
7 Mention individual and organizational determinants in motivating the health
workforce?
Session summary

 Motivation is defined as the willingness to exert and maintain an effort towards

24
 organizational goals.It is both a driver and a consequence of health worker
performance.
 The three components of motivation areDirection, Effort and Persistence.
 There are a number of theories of motivation focused on understanding what
drives a person to work towards a particular goal or outcome.
 Health worker motivation is an internal psychological process, operating at the
level of an individual, while health sector reform seeks to modify entire systems.
 Determinants of work motivation can originate at many levels.
 Motivation strategy should aim to increase the effective contribution of all
members of the organization in achieving its objective.

Session 2: Self-motivation
Duration: 2 hrs.

ACTIVITY – V, Individual reflection, think pair and

share
Instruction: Share your knowledge to the larger
group
What motivates you most?
10 min

 Self-motivation is, in its simplest form, the force that drives you to do things
(Skills You Need).
 It’s the drive you have to work toward your goals, to put effort into self-
development, and to achieve personal fulfillment.
 Self-motivation is generally driven by intrinsic motivation

25
1.1 Psychology of self-motivation
ACTIVITY – VI, Group exercise
Instruction: Be in group and discuss and share your
opinion to the larger group
How do you know if someone or yourself is self-
motivated?
Time: 5 min

 Three questions you can use to determine whether you or someone is self-
motivated:

 Can you do it? - Self efficacy

 Will it work? Response efficacy
 Is it worth? – Consequence Vs Cost
 Albert Bandura (1997) introduced a psychological construct he calls self-efficacy.
Through his research as a psychologist and researcher, he concluded that the
foundation for human motivation is not just about believing one has certain
qualities but rather that one believes he/she has power over her life. Self-
efficacy beliefs provide the basis for human motivation because unless people
believe they can affect changes in their circumstances and their lives, they have
little incentive to act or to persevere through difficult situations.
 Self-efficacy is unlike other qualities can differ greatly from one task or domain
to another. Self-efficacy judgments are not necessarily related to an individual’s
actual ability to perform a task; rather, they are based on the person’s beliefs
about that ability.
 Bandura (1997) speculates that people with high- perceived self-efficacy tend to
feel they have more control over their environmentand, therefore,
experience less uncertainty. Individuals are more likely to select tasks and
activities in which they feel competent and confident. They are apt to avoid
those in which they do not feel that way. The higher the sense of self-
efficacy, the greater the intrinsic motivation and effort people put

26
 toward their goals. They will pursue their course longer and with more
diligence than will someone who is not self-efficacious. Research also clearly
indicates that people with a highly evolved sense of self-efficacy recover from
failure and setbacks more quickly than do those who do not.
 Self–Efficacy Affects
 The choices we make
 The effort we put forth (how hard we try)
 Our perseverance (how long we persist when we confront obstacles)
 Our resilience (how quickly we recover from failure or setbacks

1.2 Importance of self-motivation

ACTIVITY – VII: group activity
Instruction: Discuss in a small 3-4 groups and share
you thinking to the larger group
What is the importance of self-motivation?
20 min

To support good performance, health care workers need clear job expectations, up-to-
date knowledge and skills, adequate equipment and supplies, constructive feedback and
a caring supervisor. Workers also need motivation, especially when some of the other
factors that support good performance are lacking. Indeed, highly motivated individuals
can often overcome obstacles such as poor working conditions, personal safety
concerns and inadequate equipment. Given the current challenges related to human
resources for health (HRH) in most developing countries (Joint Learning Initiative,
2004), helping workers to be as productive as possible in the face of such obstacles can
be an important outcome of increased motivation.
Improves Performance Level:

Motivated employees have the ability and willingness to work and improve their
performance level by obtaining relevant education and training. For example, a highly
educated employee with experience of working in abroad is employed because this

27
employee has new learning from her/his experiences to share, implement and improve
performance levels of themselves and her/his colleagues.

Indifferent Attitudes can be Changed:

Motivated employees attempt to change indifferent or negative attitudes of employees
by engaging in supporting conversations without resorting to belittling and complaining
comments, speaking up with a dismissive employee and addressing an employee’s
inability to work in a team situation. Motivated employees could also privately discuss
negative attitudes, recognize HR policies and procedures and involve HR, to make them
listen their problems and support them. With such high morale building exercises, the
possibility of conflicts and industrial disputes could be minimal.

Reduction in Resistance to Change:

Changes can be uncomfortable and require employees to think and/or act differently.
Changes in a business may seem as a sign of uncertainty that may further lead to
anxiety among employees. Accordingly, employees should be motivated in an
organization to embrace changes (if any) positively by developing transparency and
trust during the process of change in an organization. This motivation can be created by
the management along with their employees by collectively, identifying and recognizing
the benefits of possible changes.
Reduction of Employee Turnover and Absenteeism:
Employee turnover is a measurement of the term or number of years an employee
stays and/or replaced in the company. Highly motivated employees are considered to
be the most reliable and valuable assets to the organization. They are more loyal,
punctual and regular in their work schedule and stay on-job for a longer period of time
in the organization. In case of poor working conditions, lack of recognition and poor
relations with colleagues and superior’s absenteeism could increase as these conditions
demotivate employees to work harder.

28
Healthy Corporate Image:
Motivation also helps organizations in improving their image due to efficient
performance, maintenance of self-discipline and productive internal environment. It
creates a good impression and enhanced image among people outside the organization.
If the members of an organization are effectively motivated then from such motivation
the expected results are that:
 All the members will try to co-operate and co-ordinate their activities with a
view to achieve the goals which they are required to achieve.
 All the members will do their best to carry out the plans in accordance with
the policies and programs laid down by the organization.
 All the members will also try to be as efficient as possible and will try to
improve upon their skill and knowledge so that they may be able to
contribute ‘to the progress of the organization as much as it is possible.

Explaining the importance of motivation E. F. L. Brechwrites:“The problem of

motivation is the key to management actions and in its executive form; it is
among the chief task of the General Manager. We may safely lay it down that the
system of an organization is a reflection of the motivation from the top.”
Motivation is getting the members of the term to pull weight effectively, to give their
loyalty to the group and organization, to carry out properly the activities allocated and
generally to play an efficient part in the purpose or are the real assets of any
organization. Technology system and methods become ineffective in these, if the
people lack zeal and enthusiasm for work.
All administrative action loses its point unless the members of the enterprise are willing
to contribute their efforts for the fulfillment of their assigned tasks. To achieve
organism and individual goals in an economic and efficient manner,
motivation is an important tool in the hands of management to direct the behavior
of sub-ordinates in the desired and appropriate direction and thus minimize the waste
of human and other resources.

29
 1.3 How to foster self-motivation in the workplace
ACTIVITY – VIII: Group Activity
Be in 3-4 group and Discuss ways to foster self-motivation in the
workplace and share with the larger group.
Time 10 min

Workplace motivation is generally defined by modern researchers as the tendency to

initiate and sustain effort toward a goal. Even this more precise definition
suggests that we know motivation only by its outward, behavioral signs. However,
motivation is an internal state that we can’t directly observe or measure
Moreover, one cannot directly motivate others. We can’t reach inside and push the
motivation button. An organization or individual can, however, create the
conditions within which internal motivation can flourish.

Components: Modern research recognizes three main components of internal

motivation, or three main factors that will make one motivated to initiate and sustain
effort at work. They are:
i. Our perceived importance of the work (called Valance)
ii. Our perceived chances for success (called Self-Efficacy)
iii. Our expectation for personal reward (called Expectancy).
 Valance, or perceived task importance, refers to the value someone places on
the work, or tasks that they are being asked to perform. If one believes that the
value of one’s work is extremely high, one may endure great hardships, for low
pay, in order to achieve a goal. The examples of firefighters, emergency medical
technicians and missionaries come to mind. To these workers, the importance of
achieving their goals—saving lives or saving souls—drives them to work
tirelessly even in the face of many failures.
 Self-Efficacy refers to the extent to which we believe we can be successful at
our work. If we think we have no chance of success, we are unlikely to be highly
motivated to initiate and sustain a particular task. For example, taking on the
management of a project that is under-funded, under-staffed and given too

30
 short a timeline for the expected results is not a position many of us would
happily accept. The term “set up for failure” springs from the condition of low
self-efficacy. In other cases, our beliefs about self-efficacy stem from
perceptions about our own attributes. For instance, a person may pass up an
opportunity to take up the violin because of a feeling that they are “not
musical.”
 Expectancy is our anticipation of what will happen to us if the work goal is
reached. Will anyone increasing the Motivation of Health Care Workers Marc
Luoma, IntraHealth International Capacity Project knowledge sharing technical
brief September 2006 7 “There is more nonsense, superstition and plain self-
deception about the subject of motivation than about any other topic.” —
Thomas F. Gilbert notice? Will anyone care? Will we be rewarded? In all cases,
work tasks involve some effort on the part of workers. Workers expect
something in return. Motivation is likely to suffer when workers think that
nobody will notice their hard efforts or when they see workers whose
productivity is low receiving rewards equal to those who try harder.
 The interaction of the three motivation factors: As Harold Stolovich noted
during his presentation at USAID’s Performance Improvement Day workshop in
1999, a very high value of one motivation factor can offset the absence or
weakness of other factors. In most cases, however, these factors interact and
play off one another. If any of them is completely absent, employees will usually
be unmotivated to initiate effort toward a goal. For example, let’s consider a
group of clinic nurses who are asked, in addition to their regular duties, to take
on voluntary counseling and testing (VCT) for HIV. As nurses, surely their
perceived importance of VCT is high. After training they may also believe their
chances to excel at VCT are strong. But, as in many cases where such additional
tasks are added, the nurses receive no increase in salary, no additional benefits
and are not even recognized for the extra work. Indeed, their reward is simply
harder work and longer hours. How motivated might we expect the nurses to be
to perform well in VCT?

31
 Management Internal state Workplace Result
Action
Incentives Motivation Improved Performance
Workplace Climate Job Satisfaction Retention

Motivation and Job Satisfaction: - It is very important to understand that there is

a difference between motivation to perform well and job satisfaction. Indeed, a well-
developed body of literature shows that the correlation between job satisfaction and
performance is inconsistent. In her article On the Dubious Wisdom of Expecting Job
Satisfaction to Correlate with Performance, Cynthia Fisher (1980) concludes that job
satisfaction is controlled by overall workplace climate, while improved performance is
predicated more by “job facets that seem to be related to the particular situation.” If
we care about keeping health care workers in their posts, however, then we should
care very much about job satisfaction: nothing correlates more highly with retention.
With large portions of the public health workforce in developing countries leaving for
the greener pastures of private-sector work, immigrating to higher-paying countries or
exiting from the health care field entirely, retention is rightly receiving much attention
as a primary front in the battle to maintain and increase provider-to-patient ratios.
Some recent studies on applying pay and other direct incentives toward improving
retention have produced mixed results. The best methods for improving workplace
climate, job satisfaction and thereby retention are not yet well known. It is clear,
however, that motivation to improve performance and the tendency to stay in a job
are controlled by different mechanisms.
SELF ASSESSMENT QUESTIONS
 Define self-motivation?
 What are the 3 questions you ask yourself to determine your self-motivation?
 List down the importance of self-motivation?
 Mention and explain the 3 components of internal motivation?
 Explain the difference between motivation and job satisfaction?
 How can we foster self-motivation in the workplace?

32
Session summary

 Self-motivation is about achieving personal fulfillment through dedicated efforts

into self-development.
 Three important areas in self-motivate are: self-efficacy, response efficacy and
consequence. Self-motivation improves performances, reduces resistance to
change and builds healthy corporate image.

Session 3: Health Workforce Engagement in Management and Leadership

Duration: 4hrs.

3.1. Basic concepts of management and leadership

Individual activity I
What is the difference between leadership and management?

Can you identify individuals in your organization who meets the

criteria for a leader and another who meets the criteria for a
manager?
10 min

Management and leadership are often used interchangeably, but they are two distinct
and complementary processes essential to all organizations.

Good managers should strive to be good leaders and good leaders, need management
skills to be effective. Leaders will have a vision of what can be achieved and then
communicate this to others and evolve strategies for realizing the vision. They motivate
people and are able to negotiate for resources and other support to achieve their goals.

Managers ensure that the available resources are well organized and applied to produce
the best results. In the resource constrained and difficult environments of many low –
to middle-income countries, a manager must also be a leader to achieve optimum
results.

33
 3.1.1 Leadership
There are many definitions of on leadership. Leadership is the process of inspiring
people to do their best to achieve a desired result. It can also be defined as the ability
to persuade others willingly to behave differently. The function of team leaders is to
achieve the task set for them with the help of the group. Leaders and their groups are
therefore interdependent. Put simply, leadership is enabling others to face challenges
and achieve results.

Leadership is the capability to influence people, by means of personal attributes and /

or behaviors, to achieve a common goal. A leader does not necessarily have the title.
It is the process of inspiring people to do their best to achieve a desired result. It can
also be defined as the ability to persuade others willingly to behave differently. The
function of team leaders is to achieve the task set for them with the help of the group.
Leaders and their groups are therefore interdependent.

3.1.2 Dimensions of leadership

 Leadership involves not just "doing" but "being: Effective leaders have a high
level of self-awareness. Leadership involves the discipline of continually clarifying
and deepening our personal vision, of focusing our energies, of developing patience,
and of seeing reality objectively… [This discipline] starts with clarifying the things
that really matter to us, living our lives in the service of our highest aspirations"
(Senge 1994:7, 8).
 Leadership is exercised with others: Organizations that face challenges in their
environments must adapt and change. Leaders get people to face the challenge, the
change, and the learning. Solutions to adaptive challenges reside in the collective
intelligence of employees at all levels. Often the toughest task for leaders in
effecting change is mobilizing people throughout the organization to do adaptive
work (Heifetz and Laurie 1997:33).
 Leadership is responsibility. Leadership is responsibility, not rank, title, privilege,
or money… [Leaders] did not start out by asking themselves, 'What do I want?' but
'What should be done?' Then they ask themselves, 'What should I do and what must
I do to make a difference?

34
 Leadership happens at all levels. Students of management and mid-level
managers in the organizations I work with often ask me, 'How can we lead the
organization and make the changes you are talking about if we are not in the upper
ranks?' I tell them, 'You can start right where you are; it doesn't matter what your
job is. You can contribute your new judgment, new leadership, to your team or your
group'.
 Leadership and management are both necessary. "Leadership and management
are two distinctive, complementary systems of action, each having its own
characteristic practice and contributions.
 Leadership Roles
Leaders have two main roles. First, they must achieve the task. Second, they have to
maintain effective relationships between themselves and the group and the individuals
in it – effective in the sense that they are conducive to achieving the task. As
Adairpointed out, in fulfilling their roles, leaders have to satisfy the following needs:
i. Task needs. The group exists to achieve a common purpose or task. The leader’s
role is to ensure that this purpose is fulfilled. If it is not, they will lose the
confidence of the group and the result will be frustration, disenchantment,
criticism and, possibly, the ultimate disintegration of the group.
ii. Group maintenance needs. To achieve its objectives, the group needs to be held
together. The leader’s job is to build up and maintain team spirit and morale.
iii. Individual needs. Individuals have their own needs which they expect to be
satisfied at work. The leader’s task is to be aware of these needs so that where
necessary they can take steps to harmonize them with the needs of the task and
the group.
These three needs are interdependent. The leader’s actions in one area affect both the
others; thus, successful achievement of the task is essential if the group is to be held
together and its members motivated to give their best effort to the job. Action directed
at meeting group or individual needs must be related to the needs of the task. It is
impossible to consider individuals in isolation from the group or to consider the group
without referring to the individuals within it. If any need is neglected, one of the others
will suffer and the leader will be less successful. The kind of leadership exercised will be
35
related to the nature of the task and the people being led. It will also depend on the
environment and, of course, on the actual leader. Analyzing the qualities of leadership
in terms of traits such as intelligence, initiative, self-assurance and so on has only
limited value. The qualities required may be different in different situations. It is more
useful to adopt a contingency approach and take account of the variable’s leaders have
to deal with; especially the task, the group and their own position relative to the group.

3.1.3 Leadership styles

Leadership style, often called ‘management style’, describes the approach managers
use to deal with people in their teams. There are many styles of leadership. Leaders
can be classified in extremes as follows:
A. Charismatic/non-charismatic. Charismatic leaders rely on their personality, their
inspirational qualities and their ‘aura’. They are visionary leaders who are
achievement-oriented, calculated risk takers and good communicators. Non-
charismatic leaders rely mainly on their know-how (authority goes to the person
who knows), their quiet confidence and their cool, analytical approach to dealing
with problems.
B. Autocratic/democratic. Autocratic leaders impose their decisions, using their
position to force people to do as they are told. Democratic leaders encourage
people to participate and involve themselves in decision taking.
C. Enabler/controller. Enablers inspire people with their vision of the future and
empower them to accomplish team goals. Controllers manipulate people to
obtain their compliance.
D. Transactional/transformational. Transactional leaders trade money, jobs and
security for compliance. Transformational leaders motivate people to strive for
higher-level goals. Goleman (2000) produced an alternative list of six leadership
styles: coercive, authoritative, affiliative, democratic, pacesetting and coaching.
We have reviewed the definition, roles and types of leadership. But what exactly do
leaders actually do to "enable work groups and organizations to face challenges and
achieve results?" To respond to this question, let us take a look at our own experiences
of leadership.

36
 Individual activity
Instructions:
 Choose a leader who you know or knew personally and who you consider a good
or even great leader. Think about what this person does or did to produce results.
 Think about this person's practices and behavior that inspired others to follow
 List the actions and behaviors of this person that, in your opinion, helped to
produce results.
10 min

3.2 Management
Small Group Activity:
Instruction: Be in group and discus types of management roles and
share with the larger groups
15 min

 Management is a set of processes that keep a complicated system of people and

technology running smoothly and efficiently.
 Management can be defined as the process of accomplishing predetermined
objectives through the effective use of human, financial, and material resources.
 We have examined in some detail the leadership practices. We have articulated
our vision for a well-led organization: such organizations adapt to changes in the
environment and develop cultures that are a source of inspiration, commitment,
and innovation, and have the capability to design and maintain the management
systems that are needed to run the organization efficiently and effectively. In an
environment of uncertainty and change, such leadership is badly needed.
Now let us take a look at the management practices. We all have an idea of what a
well- managed organization looks like. These are some of the common elements: they
have clear plans, clear reporting structures for decision-making and well-organized
systems and work processes. Personnel can carry out their assigned activities
efficiently, follow the process to the desired results step by step, and assess whether
they have been successful.

37
 3.2.1 Management style
Management style is the approach managers use to deal with people. It is also called
‘leadership style’. The following are the common management styles in practice.
’Visionary or imaginative style’’ in which this style is most proper when an organization
needs another heading. Its objective likely moves individuals towards a new set of
shared visions and goals.
Visionary leader focuses on where a group is going and doesn’t matter how it
gets there in other words the focus is on the destination, not the road, allowing
individuals to advance, explore and take risks.
Secondly, ‘’Coaching style’’ inwhich this one-on-one style centreson creating people,
showing them how to improve their performance and aligning their goals with
organization goals. coaching style works best with employees who demonstrate
activity and need more expert advancement.
However, backfire is expected if it goes towards "micromanaging" which will
cause losing self-confidence and morale for the employee.
The third style is known as an ‘’Affiliative style’’ which underlines the significance of
collaboration and makes group harmony by strengthening peoples communication. It is
specifically important when you have to enhance the balance of the team,
improve morale, and restore the broken trust and communications in the
organization. However, it has its downsides, continuous positive feedback on the
group performance might lead to poor performance to go uncorrected and
persuade that insignificance will be endured.
Another approach is a ‘’Democratic style’’ A democratic manager is a person
who solves issues or makes changes with the aid of asking crew members for their
feedback, recommendations, and ideas.
This leader can be uncomfortable with making all of the decisions themselves. This
approach can

1. Visionary or imaginative style -Visionary leader focuses on where a group is

going and not how it gets there. In other words, the focus is on the
destination, not the road, allowing individuals to advance, explore and take risks.

38
 2. Coaching style - one-on-one style, centers on creating people, showing them
how to improve their performance and aligning their goals with organization
goals. Coaching style works best with employees who demonstrate activity
and need more expert advancement.
3. Affiliative style - which underlines the significance of collaboration and makes
group harmony by strengthening peoples communication. It is specifically
important when you have to enhance the balance of the team, improve
morale, and restore the broken trust and communications in the
organization.
4. Democratic style - A democratic manager is someone who solves problems or
implements changes by soliciting comments, opinions, and ideas from the crew.
This leader may find it difficult to make all of the decisions on his or her own.
5. Pacesetting style - where the leader sets high standards for performance. He
or she is obsessive about doing things better and faster and asks the
same from everyone, this style destroys work environment, employees will
experience overwhelmed by managers needs for excellence.
6. Autocratic style - this is the style where the manager tells the employees what
to do. Consequences awaits them if they fail to fall in line, employees are
inspired generally via fear of discipline.
7. Laissez-faire style - the inverse of autocratic where workers are permitted to
settle most of the decisions, with management giving direction when required,
the manager for this situation is viewed as an adviser instead of a leader. This
style of management is mainstream in new businesses and technology
organizations, where the risk taking is supported. It works well when a group of
experts are working together and they have the success skills to achieve the
desired goals.

Most managers adopt an approach somewhere between the extremes. Some will vary it
according to the situation or their feelings at the time; others will stick to the same style
whatever happens. A good case can be made for using an appropriate style according
to the situation but it is undesirable to be inconsistent in the style used in similar

39
situations. Every manager has his or her own style but this will be influenced by the
organizational culture, which may produce a prevailing management style that
represents the behavioral norm for managers that is generally expected and adopted.
The term ‘management style’ can also refer to the overall approach an organization
adopts to the conduct of employee relations. Purcell and Sisson (1983) identified five
typical styles: authoritarian, paternalistic, consultative, constitutional and opportunist.

3.2.2 Managerial Roles

Effective managers also play certain important roles while carrying out their four
essential management practices. These are summarized and described in the table
below:
Interpersonal roles Managers as liaison officers, maintaining a web of relationships
with individuals and groups.
Informational roles Managers as monitors, continually seeking and receiving
information as a basis for action. They are disseminators,
passing factual information to supervisors, colleagues and
subordinates and transmitting value statements to guide
subordinates in making decisions. They are spokespeople,
transmitting information into their organization’s environment.
Decisional roles Managers as entrepreneurs, acting as initiators of controlled
change in the organization. Managers as resource allocators,
making choices about scheduling their own time, authorizing
actions and allocating people and finance to projects or
activities. Managers as negotiators with other organizations or
individuals
Four Management Practices
Activity: Individual Exercise:
Instruction: Choose a manager who you know or knew
personally and who you consider a good or even great
manager.
• Think about what this person does or did to produce

40
 results.
• List the actions and behaviors of this person that, in your
opinion, helped to produce results.
15 min
Effective Managers Carry out Four Essential Management Practices:
 They plan
 They organize
 They implement
 They monitor and evaluate
This is how these practices are carried out in daily life:
Plan: Health leaders who manage plan how to achieve desired results and document
these activities in a format that helps staff do their work and fulfill their responsibilities
in a timely manner. They also have to be able to plan quickly as windows of opportunity
open, and anticipate what is needed to move their programs ahead.
Organize: Health leaders who manage make sure that sufficient resources are
available to implement the planned activities, and that the necessary structures,
systems, and processes exist and run smoothly to facilitate the work. Organizing in the
context of conflict requires special attention to shifting alliances, uneven resource flows.
Implement: Health leaders who manage execute and delegate execution of planned
activities, coordinating multiple efforts to achieve desired results. This includes the
capacity to work under pressure, the ability to improvise with resources that are
available (and do without the ones that no longer are) and - in spite of conflict and
insecurity - get the work done.
Monitor and evaluate: Health leaders who manage track activities, outputs, and
results and compare them with what was planned, collecting feedback and information
from a variety of sources to see whether the intended results were obtained or not.
They fine-tune their plans and learn from errors to achieve intended results. They look
for ways to show others that results were achieved, and in doing so, motivating them to
join in or support future work. After all, results inspire!

41
 3.3 Differences between Leadership and Management
Leadership differs from management in a significant way, but not for the reasons most
people believe. Leadership isn't a magical or enigmatic concept "John Kotter, a Harvard
professor, agrees. It has nothing to do with what is frequently referred to as 'charisma,'
a nebulous trait that some people possess while others do not. Leadership is also not
dependent on unique personality traits. The world would be in peril if we had to rely on
the availability of a few exceptionally bright individuals who were born to be natural
leaders. Kotter goes on to say, "[Leadership] does not belong to a select few.
Leadership is not always superior to management or a substitute for it; the two are
distinct and complementary systems.
Leadership and management interact in two ways.

1. Firstly, leadership and management are interdependent and intricately linked social
constructs. They reinforce each other. Both roles interact in a balanced way to serve
a purpose and to achieve a desired result.
2. Secondly, there is a clear overlap between the roles of leading and managing.
Nevertheless, each of the roles is relevant. Effective leadership is a prerequisite for
effective management.
As such, leadership and management have different functions and activities, both
necessary for success in an increasingly complex setting. Not everyone has the ability to
both lead and manage equally well; some people are excellent managers but not good
leaders. Others have a great capacity for leadership but cannot be successful as
executives because they are not skilled or effective managers. Smart organizations
value both leadership and management and encourage personnel to develop their skills
in both areas.

3.3.1 Management and leadership in health care service context

As in the case of any other organization, leadership and management play a central role
also in healthcare, especially concerning reform movements, types of services provided,
quality of services and resource use. As we stated earlier, there is no universal recipe
for successful management and leadership, contextual factors like political system and
socio-economic factors play a significant part in the outcomes. Both are important

42
forthe delivery of good health services. Although the two are similar in some respects,
they may involve different types of outlook, skills, and behaviors.

Variables Managers Leaders

Functions • Cope with complexity • Cope with change
• Plan and budget • Set direction and shared values
• Organize and direct the staff • Align people with the organization &
• Control and solve problem empower them
• Motivate people
Characters • Administer • Innovate
• Maintain • Develop
• Control • Inspire
• Focus on short-term view • Long-term view
• Ask how and when • Ask what and why
• Imitate • Originate
• Accept the status quo • Challenge the status quo
• Do things right • Do the right things
Table 3 Comparison between leaders and managers (Source; Alan Murray, 2013)

Figure 5 The WHO framework for approaching leadership and management

strengthening in health.

43
 3.4 Leading and Managing for Strengthening HRH and Health
Systems

Group Activity:
Instruction: Write the eight leading and management practices
How you are doing each practice in your own organization, and put a tick
next to each practice where they think they are doing well.
20 min
Fundamental and profound changes are occurring within the health care system of
Ethiopia that directly affect and change the roles and functions of health leaders and
managers. To address these changes, the health management profession must exercise
leadership and transform itself. Since Ethiopia’s national health strategy outlines
strategic health priorities, you should link your institution’s vision to these strategic
priorities. When you connect everything, you do to these priorities, you don’t waste
time on activities that divert energy from end results.

The Leading and Managing Results Model below shows the link between the leading
and managing practices and improved health outcomes. This model of leadership
combines systems thinking, personal mastery, shared vision, and team learning to
achieve results.

People-centered health systems cannot be strengthened without good management

and leadership. Leadership and management skills are needed at all levels of the health
system. Drawing on many years of close observation of effective public health leaders
and managers, Management Sciences for Health (MSH) and its partners in the field
have distilled eight critical practices that describe the behavior of managers who lead.
These practices are: scanning, focusing, aligning and mobilizing, inspiring, planning,
organizing, implementing, and monitoring and evaluation.

The Leading and Managing for Results Model below explains these practices and how
they are linked to health outcomes. To scan, focus, align and mobilize, and inspire are
four effective leading practices; and to plan, organize, implement, and monitor and
evaluate are four effective managing practices. Working together on other building
44
blocks of a health system, these effective leading and managing practices lead to
improved health system performance, which in turn leads to better health outcomes.

Figure 6: Leading and Managing for Results Model

Question: How do management and leadership contribute to improved service delivery?

Leading practices Managing practices:

Scanning: identifying internal/external Planning: preparing a set of activities, timeline,
conditions influencing desired results resources, and accountable to meet goals
Focusing: directing attention and efforts to • Organizing: developing structures, systems
priority challenges and actions and processes to support a plan/goal
Aligning &mobilizing: uniting and • Implementing: Carrying out and adapting a
motivating internal/external stakeholders plan of action through coordinating related
to commit resources for desired results. activities
Inspiring: creating a climate of • Monitoring & evaluating: observation, inquiry
commitment and continuous improvement or assessment of organizations
Table 4 leadership and management practice attributes

45
 3.4.1 Leading and managing practices in the health sector

When applied consistently, good leading and managing practices strengthen

organizational capacity and result in higher-quality services with sustained
improvements in population health.

The Leading and Managing for Results Model serves as a road map to guide you, your
team, and your organization to improve services and better the health outcomes. By
following it, you can transform discouraged, passive employees into active managers
who lead. And once you start, one change will lead to another; you will see
improvements in team spirit, customer services, quality, and even the physical
environment in which people work. Creating these transformations is an act of
leadership that will transfer power to your team. Its members will learn by doing and
become more systematic in the way they themselves manage and lead.

3.4.2 Engaging health workforce in management and leadership

Good leadership and management are about providing direction to, and gaining
commitment from partners and staff, facilitating change and achieving better health
services through efficient, creative and responsible deployment of people and other
health resources.” (WHO/EIP/health systems/2005.1)
One of the key factors to managing a health care institution or organization is knowing
how to engage health workers. If the leaders understand the level of passion their
health workforce has for the job, they are a step ahead of the success.
As a manager, you want your employees to have pride in what they do and, in the
institution, they work for. Those who work with purpose put forth their best efforts a
practice that can only benefit the goal of your organization. It’s important to look at
every aspect of why people do the work they do and what drives them to do it.

3.4.3 Health workers Engagement

Employee engagement is more than just knowing whether someone likes their job or
not. Measuring employee engagement lets you know how committed they are to the

46
business and its success. It tells you how motivated they are and how emotionally
invested they are in the work they are doing.
For an employee to be engaged, they are motivated to work hard towards a common
goal that is in line with the organization’s vision. They will be committed to the values
their organization represents. Engaged health workers will have a clear view and
understanding of the objectives of the work they are doing.
Understanding the level of engagement is the first step in utilizing this knowledge to
your benefit. The next step is working on improving employee engagement within the
organization. As a manager, creating a workforce that is not just happy, but engaged
and motivated to provide person centered care, will clear one hurdle on the path to
success. Going beyond the basic employee engagement definition, managers should
know that there are two primary focuses of this practice. Not only should you
understand their level of engagement with the institution, but also with the managers.
The latter is a look at how these employees feel about their direct superiors and
whether they feel they are treated fairly.
Health workforce with higher levels of engagement with their superiors or leaders tend
to feel they are getting direction on the work they do, and feedback on their
performance. These employees will have a mutual feeling of respect with their
managers, which also lends to the sense of being a valued by the organization.
Organizations that implement an employee engagement strategy can most likely say
that their workforce has faith in their leadership and they believe the company acts in a
fair and respectful manner. When high levels of employee engagement are partnered
with observant and caring managers; provision of access and quality health service will
improve. It allows for an increase in service provision, elevated customer satisfaction,
and worker competency to be at an all-time high.

3.4.4 What Do Employees Need to Feel Engaged?

A few factors to consider in this area are the company and its leadership. You can’t
expect your staff to become engaged if there is no clear and decisive message for them
to embrace. Before you can start to measure their level of engagement ask yourself the
following:
 Are your organization’s goals and visions clear and concise?
47
  Do the workforce understand these goals?
 Is there a clear link between the employee’s work and the company’s goals?
 Can the employees see how their work ultimately contributes to the success of
the organization?
 Is the leadership of the organization present and able to motivate the workforce?
When all these components are in place, you can begin to look closer at how well
engaged your employees are. Taking a close look at the organization and its leadership
first can also help you further develop employee engagement strategies and practices.

3.4.5 How to Engage Employees

1. Get to know them. Sounds simple, and it is! Spending time with your
employees and getting to know them is an easy and effective way to engage
employees. Learning about their families, backgrounds and personal goals
enables you as a manager to develop a stronger rapport with them. Find time in
the day to say hello, ask them how their families are doing or inquire about their
hobbies. This is a quick and straightforward practice that can make your
employee feel like their presence is known and that you care about them as an
individual. Research shows that employees who feel valued tend to be much
more engaged in their work and performance.
2. Provide them with the tools for success. As a manager, you should be sure
that your employees understand what they are doing. Training within their
specific job descriptions can offer them more confidence in what they’re doing.
Even if additional coaching or training is needed, providing your employees with
a strong foundation for the tasks ahead is a good step towards raising their level
of engagement.
3. Let them know how the organization is doing. They are the backbone of
the health sector, and many times its success or failure will depend on them. For
them to have a vested interest in the whether the organization does well, they
should be made aware of its successes, concerns, and struggles. Provide
employees with a briefing of not only the company’s fruitful ventures but also the
ones that didn’t work out so well. Allowing your team to know what works and

48
 what doesn’t grants them the opportunity to develop new ideas for the weaker
areas, and continue to be proactive in the sectors that are working.
4. Allow them to grow. As a manager, you need to give them the opportunity to
show off their skills and ability to do their assigned task. Give them the room to
branch out to do their jobs the best way they know how. Hovering and
micromanaging is only going to result in added stress, and that’s a condition that
no one can work well under. If an employee comes to you with a pitch or an idea
that may not be what you are looking for, choose to respond in a way that won’t
discourage them from continuing to try and develop other concepts. Offering
encouragement and appreciation for their work is important, even more so when
you may reject their first pitch.
5. Recognize your team and their hard work. A manager recognizing and
acknowledging a job well done is an essential motivator when developing
employee engagement best practices. To be a successful manager, it’s good to
understand what form of recognition works best for your staff. Words of
encouragement can go a long way in this regard. A ‘good job’ or ‘thank you’ in
regards to a task may be just what that employee needed to push forward, or to
continue do just as well on the next project.
6. Encourage teamwork among employees. Pulling workforce together to work
towards a big organizational goal can be incredibly satisfying, and allows them to
bounce ideas off each other to ultimately meet the needs of your client. It adds a
sense of cooperation, consideration, and confidence in not only each other but in
the company, itself.
7. Listen to and act on employee feedback. Listening to what your customers
have to say is important, but so is listening to your employees. Having regular
meetings to determine what areas of your workplace environment need
improvement is an important part of keeping the employees engaged with the
company.
8. Create a safe and conducive workplace.
9. Motivate, inspire and coach your employees. As a manager, you should
understand your employees’ scope of their work. Creating a positive workplace
49
 environment starts with happy employees. If you see an employee struggling
with a task, approach them to see if you can help in any way. Whether it is a pat
on the back and words of encouragement urging them to keep trying or offering
guidance on policy and procedure, they will see your willingness to help as a
concern for their state of mind, as well as the organization’s success.
10. Let them show you how well they can lead and manage. As a manager,
there will be times when you are going to have to let your team take the lead
and manage. For your employees to feel passionate about their work and strive
for only the best outcomes, they need to know that the company has faith in
them. A good way to show them that is by allowing them to display their
leadership and skills without any interference from managers or owners in the
organization.
11. Encourage their personal development and CPD opportunities.
12. Put in Place Employee Engagement Strategies
Now that you know why employee engagement is so important to your business, you
can begin to look at the strategies. The Best Employee Engagement Strategy Is From
The Bottom Up. You can watch the short movie attached
(https://youtu.be/HNr4tE74xUE)

Individual Activity
What is the right employee engagement strategy to dramatically
increase engagement in your facility or organization?
5 min

But the problem with this brainstorm-at-the-top approach is that over 70% of the
variance in engagement correlates to the manager (source: Gallup Business Journal,
April 8, 2015). In other words, who your boss is counts more than anything. Front line
leaders are the regulators of engagement.

The best way to carry on these strategies is starting with the employees, right up to the
chain of command, to the bosses themselves. First, if you want to improve something,
measure it. So you do need to conduct an employee engagement survey. Use and
50
share the information from the employee engagement survey with all the department
managers, empower them so they can take that knowledge back to their individual
teams. When the employees are made aware of the results, you can then talk to them
about their ideas for improvement. When they are part of the solution, they are less
likely to be the cause of the problems.

Self-Assessment questions
 What does leadership mean?
 Types and roles of management.
 What are the differences between leadership and management if any?
 Management Practices
 Essential Management Practices
 Differences between Leadership and Management
 Describe WHO framework for approaching leadership and management
strengthening in health
Explain leading and managing for results model

Session summary

Management and leadership are often used interchangeably, but they are two distinct
and complementary processes essential to all organizations. There are many styles,
roles and approaches used in both management and leadership. Planning, organizing,
implementing and evaluating are the four essential management practices while
scanning, focusing, aligning and inspiring are vital leadership practices. The WHO
framework for approaching leadership and management and Leading and Managing for
Results Model are recognized to enhance management and leadership in health care
service context.

51
Chapter 2: Competent Health Workforce
Duration 180 min

Chapter Description:

This chapter is designed to enhance participants’ understanding on creating competent

health workforce. It describes the relevance of Lifelong learning, Evidence-based
practice and improvement& Healthcare audit in the encasement of competency in
health care service delivery.

Chapter objectives

At the end of this chapter, participants will be able to:

 Describe the concept of competent health workforce.

Enabling objectives

 Describe practice-based learning and improvement activities that involve

investigation and evaluation of patient experiences
 Discuss healthcare audits to check for the rationality of healthcare service and
malpractice as needed
 Follow patient safety standards
 Explain the concepts lifelong learning activities
Chapter Outline

Session 1: Lifelong learning

 Explain the concepts of lifelong learning

 Explain strategies for lifelong learning
 Identify own strength and improvement of LLL by measuring personal
motivation
 Develop own continuous professional development plan

52
Session 2: Evidence-based practice and improvement
 Explain the concepts of evidence-based practice.
 Analyze health related problems through the process of EBP.
 Develop answerable problem centered questions.
 Search online databases for evidence.
 Recognize misconceptions of EBP.
Session 3: Healthcare audit
 Define healthcare audit
 Explain the principles of effective healthcare audit
 Analyze the process of healthcare audit
 Outline the monitoring and evaluation strategies for healthcare audit
Competent Health Workforce

The commitment to excelling in technical skills, ethical and legal practices and
communication skills are the foundations of competence. This requires continuous
lifelong learning (LLL) and reflection to
Evidence-based practice exceed ordinary expectations.

Another notion of competence is a

Competence commitment to ongoing quality improvement
and assurance to improve patient safety and
Lifelong learning Continous QI/QA achieve the best possible health outcomes.
In this regard, HCPs must collaboratively
develop and routinely utilize quality evaluation standards and tools. They must also
engage in the establishment and maintenance of a continuous quality improvement and
assurance (QI/QA) system.

The third aspect of competence entails the promotion of scientific knowledge and
technology. HCPs must uphold evidence-based practice through the production and
utilization of scientific standards, knowledge, and evidence.

This chapter, therefore, focuses on the three assets for competence- lifelong learning,
evidence-based practice, and healthcare audit as a key quality improvement process.
53
Session 1: Lifelong learning

Duration: 4 Hours

Activity 1 Lifelong learning scale

Assess your attitude toward lifelong learning by picking the proper scale
to characterize yourself for each of the 14 items on the lifelong learning
scale (annex 1). All items have a four point Likert scale (Strongly agree =
4, Agree = 3, Disagree =2, Strongly disagree = 1).
 Calculate the total score by summing all item scores.
 What does it mean a higher or lower score?
 What do you understand by “lifelong learning”?
Duration : 40 minutes

1.1 Concepts of lifelong learning (LLL)

Definitions of lifelong learning (LLL) vary widely around the world and there is no real
agreement on what exactly lifelong learning means. Despite these arguments, the
concept of lifelong learning is understood to cover all learning activities undertaken
throughout life for the development of competencies and qualifications. In a more
expanded definition, LLL involves a set of self-initiated activities and information-
seeking skills that are activated in individuals with the sustained motivation to learn and
the ability to recognize their own learning needs.

LLL can be summarized as the following four key terms:

Recognize Motivation Information- Self-initiated

learning needs seeking activities
skills
Activity 2
Discuss the Recognize learning needs, Motivation, Information-seeking,
Self-initiated activities used to define LLL
o What does each term refer to?
o What is the role of a healthcare provider in each area?
Duration: 30 minutes

54
 1.2 Benefits of lifelong learning
While the importance of pre-deployment initial training cannot be
underestimated, the concept of LLL recognized that learning
professional skills within a qualification through formal education and
training is no longer sufficient, and that future professional development
opportunities need to be flexible and prepare individuals to learn continuously
throughout their lives. In this regard, incorporating lifelong learning in life provides the
following benefits to the health workforce.

1. Improved self-motivation
People can become locked in routine uniform activities that they don't want to
undertake, such as going to work. Finding out the true motivates can help individuals to
control their lives and remind them that they can achieve everything they set to do.

2. Recognize personal goals and ambitions

Identifying issues that can trigger owns life can help to avoid monotony, make life more
exciting, and even offer up new chances in the future. Nobody knows where focused
personal interests and ambitions might lead to.

3. Enhanced other professional and personal attributes

While learning a new skill or gaining new knowledge, learners will develop other useful
skills that will benefit them in both their professional and personal lives. This is because
other skills are used to learn new ones. Learning to do procedural skills, for example,
necessitates decision-making. Learning to draw requires creativity. Other skills can
include problem-solving, decision-making, critical thinking, creativity, interpersonal,
reflection, leadership, adaptability, and much more.

4. Increased self-confidence
Increasing one's knowledge or expertise in a certain area can boost self-confidence in
both professional and personal lives. This self-confidence can be expressed in
professional lives as a feeling of trust in own knowledge and capacity to apply what has
been learned. On the other hand, this confidence might come from the satisfaction of

55
dedicating time and effort to learning and developing, which gives a sense of
accomplishment in one's personal life.

5. Meet regulators expectations for relicensing or recertification

Health professionals practicing in Ethiopia are required to keep a log of continuous
professional development (CPD) activities they participate in and produce evidence of
LLL to renew their practicing licenses. By promoting lifelong learning, relicense aims to
create a system of professional accountability where basic standards of care do not fall
below acceptable standards. Thus, engaging in regular LLL is a key to obtain relicense
or recertification to practice.

1.3 Strategies to lifelong learning

It is not necessary for lifelong learning to be limited to formal education. It's best
described as a self-motivated pursuit of personal fulfillment. As a result, informal or
formal education may be used to attain this goal. Most people gain new skills and
knowledge at some time during their lifetime attending formal/ informal education,
attending learning classes, reading articles and books, simply by discussing with
colleagues, or engaging in some other type of personal activities. However, in occasions
where learning the new skills is necessary for personal or professional reasons a more
ordered structure with a thorough plan is required. In this regard, the following five
steps will be useful.

1.4 Steps to effective lifelong learning

Step 1: Recognize personal desire and goals

Lifelong learning is all about self, not about what other people want. This necessitates a
reflection on one's passions as well as future ambitions, desires, and goals. E.g. if the
person’s passion is to improve leadership skills, or apply new data analysis skills, or
perform a new advanced clinical procedure or other, then there are ways to participate
in lifelong learning to accomplish these goals and aspirations.

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Step 2: Identify what should be learned or performed
Once identifying the internal motive, passion, or desire, explore the whereabouts of that
particular desire or goal. For someone with a passion for a new clinical procedure, it is
required to expand knowledge and skill on the new skill. Or perhaps the passion might
be so strong necessitating to pursue formal academic training (e.g. MSc).

Step 3: Identify how the goal and objectives will be achieved

Finding out how to get started is the first step toward achieving personal goals and
objectives. This can be facilitated by discussing with colleagues, and researching and
reading about the topic of interest and goal. Someone who wants to expand his/ her
knowledge and skill on procedural skills could watch procedural videos, observe senior
practicing professionals, attend short-term training, or even pursue formal academic
training.

Step 4: Incorporate the learning objectives and activities into the daily routine
Integrating a new learning goal and activities into an already busy schedule requires
thought and work. Learning goals won't be achieved until time and space are allocated
and it's easy to become discouraged and give up the learning completely. Plan how the
new learning activities will fit into your daily routine, or reflect on what is needed to
make them fit. For example, if learning a new procedural skill is the learning goal, set
deadlines and schedules to follow: can an hour a day be spared for it? Or do you think
15 minutes a day is more realistic?

Step 5: Make a commitment

The final and most critical step is to commit to own decision to engage in new learning
activities. If reasonable goals and activities are set with the self-motivation to follow
through, it’s critical to stick to them and don't make excuses. The implementation of the
learning plan shall be measured and verified using indicators.

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 Activity # 3 Individual exercise
 Develop action plan for five specific development areas using the
above five steps and following the continuous professional
development plan template (annex 2).
 Ensure areas involve technical and non-technical focus areas
 Refer the evaluation findings of the activity 1 (the scale rating) to
determine areas of improvement
 Finalize and submit copy of action plan to facilitators/ save your
self
Duration: 30 minutes

Self-assessment Questions
1. Define lifelong learning
2. Describe strategies for lifelong learning
3. What are the advantages of lifelong learning?

Summary

 Lifelong learning involves participation in continuing professional development

activities

 The broader concept of lifelong learning includes continuing professional

development along with developing personal, social, and managerial skills.

 The outcome of these processes may have individual, community, or system-

level effects including health workforce motivation, recognition, improvement,
satisfaction, and recertification or relicense.

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Session 2: Evidence-based Practice
The health professionals play an important role in tackling the public health challenges
present in health systems across the country. Skills that will enable staff to conduct
extensive evaluations of existing literature to improve patient care. The best available
evidence should be utilized when improving aspects of quality in health care and
enhancing evidence-based practice (EBP). This Unit provides a comprehensive overview
of EBP, and the components essential for implementation of EBP in a clinical setting.
This unit will have two sessions.

Duration: 5 Hours

2.1. Concepts of Evidence-based Practice

Duration: 2 Hours

Definition of evidence based practice (EBP)

Activity 1. Think- Pair and share on

1. What is Evidence based practice?
2. What are the steps of EBP?
3. Ask about the participant’s perception about evidence-based
practice?
Duration: 30 minutes

One of the most common definitions of evidence-based practice comes from Dr. David
Sackett. He describes EBP as:
"...the conscientious, explicit and judicious use of current best evidence in making
decisions about the care of the individual patient. It means integrating individual clinical
expertise with the best available external clinical evidence from systematic research."
Evidence-based practice is evidence from multiple sources through:

 Asking: translating a practical issue or problem into an answerable question.

 Acquiring: systematically searching for and retrieving the evidence.

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  Appraising: critically judging the trustworthiness and relevance of the evidence,
and it includes aggregating (i.e. weighing and pulling together the evidence).
 Applying: incorporating the evidence into the decision-making process.
 Assessing: evaluating the outcome of the decision taken to increase the
likelihood of a favorable outcome.

EBP has developed over time to now integrate the best research evidence, clinical
expertise, the patient's individual values and circumstances, and the characteristics of
the practice in which the health professional works.

EBP is not only about applying the best research evidence to your decision-making, but
also using the experience, skills and training that you have as a health professional and
taking into account the patient's situation and values (e.g. social support, financial
situation), as well as the practice context (e.g. limited funding) in which you are
working. The process of integrating all of this information is known as clinical
reasoning. When you consider all of these four elements (Figure .1). In a way that
allows you to make decisions about the care of a patient, you are engaging in EBP.

Figure: 1 Evidence –Based Practice involves clinical reasoning to integrate information

from four sources.

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2.1.2. Rationale for EBP

Activity 2 (Gallery walk)

1. Who are the beneficiary of EBP in your institution?
2. What is rationale/benefits of EBP to the identified
Beneficiaries?
Duration: 45 minutes

The number of research studies that strive to describe the benefits of making evidence
based decision-making standard practice in health systems is vast. Evidence on the
benefits of EBP consequently is mainly indicative. EBP has the potential to improve
quality of care and produce benefits for patients, health work force and the health-care
system, look at the benefits of evidence based practice (Table 1)

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Table 1: Benefits of Evidence Based Practice

Beneficiary …To Benefits

General population • Improved conditions for patient-centred care
• Patient preferences included in decision-making
• Consistent health services leading to better equity
• Reduction in geographic variation
• Reduction in patients’ length of stay
• Better patient outcomes
• Quality health-care services
• Increased patient safety
Health work force • Improved competency
 Increased job satisfaction
• Empowerment
• Improved skills to integrate patient preferences into practice
 To promotes an attitude of inquiry in health professionals.
 Support for professional growth
• Continuous career development through expert roles
 To evaluate research so they understand the risks or effectiveness
of a diagnostic test or treatments.
 To stay health professionals updated about new medical protocols
for patient care
Health-care systems  Improvement in the quality of care
 Better outcomes for patients
 Increased patient safety
 Reduced costs
 Stronger basis for health-care investment decisions
 Capacity-building through collaboration
Research and • Increased need for production and synthesis of robust evidence.
education • Competence development.
• Integration of nursing and midwifery expert roles in health
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systems.
 2.1.3. Sources of EBP

Before making an important decision, an evidence-based practitioner starts by asking,

‘What is the available evidence?’ Instead of basing a decision on personal judgment
alone, an evidence-based practitioner finds out what is known by looking for evidence
from multiple sources.
Activity 3: Think –share and discuss with the large group

1. The sources of EBP?

10 min

According to the principles of evidence base practice, evidence from four sources
(Figure: 2) should be taken into account:
1. The scientific literature: Findings from empirical studies published in academic
journals.
2. The organization: Data, facts and figures gathered from the organization.
3. Practitioners: The professional experience and judgment of practitioners.
4. Stakeholders: The values and concerns of people who may be affected by the
decision.

Figure 2: Sources Evidence Based Practice

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1. The scientific literature

The first source of evidence is scientific research published in academic journals. Over
the past few decades, the volume of management research has escalated hugely, with
topics ranging from evaluating merger success and the effects of financial incentives on
performance to improving employee commitment and recruitment.
2. Evidence from the organization

A second source of evidence is the organization itself. Whether this is a business,

hospital or governmental agency, organizational evidence comes in many forms.. It can
come from customers or clients in the form of customer satisfaction, repeat business or
product returns statistics. It can also come from employees through information about
retention rates or levels of job satisfaction.

Evidence from the organization can be ‘hard’ numbers such as staff turnover rates,
medical errors or productivity levels, but it can also include ‘soft’ elements such as
perceptions of the organization’s culture or attitudes towards senior management.

Evidence from the organization is essential to identifying problems that require

manager’s attention. It is also essential to determining likely causes, plausible solutions
and what is needed to implement these solutions.
3. Evidence from practitioners

A third source of evidence is the professional experience and judgment of managers,

consultants, clinical leaders and other health care practitioners.

Different from intuition, opinion or belief, professional experience is accumulated over

time through reflection on the outcomes of similar actions taken in similar situations.

This type of evidence is sometimes referred to as ‘tacit’ knowledge. Professional

experience differs from Intuition and personal opinion because it reflects the specialized
knowledge acquired by repeated experience and practice of specialized activities such
as taking vital signs or making a patient rapport.

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4. Evidence from stakeholders

A fourth source of evidence is stakeholder values and concerns. Stakeholders are any
Individuals or groups who may be affected by an organization’s decisions and their
Consequences. Internal stakeholders include employees, CEO, Medical Directors,
Department Heads and board members.

Stakeholders outside the organization such as suppliers, patients/customers,

shareholders, the government and the public at large may also be affected. Stakeholder
values and concerns reflect what stakeholders believe to be important, which in turn
affects how they tend to react to the possible consequences of the organization’s
decisions.

It provides important information about the way in which decisions will be received and
whether the outcomes of those decisions are likely to be successful.
Steps of Evidence Based Practice

What are the steps of Evidence Based Practice?

2.2.1. Steps of evidence based practice

The EBP process has five basic steps, or 5 A’s begin and end with the patient
1. Ask patient-centered, focused questions about the care of individuals, communities
orPopulations.
2. Acquire the best available evidence relevant to your question.
3. Appraise the evidence for validity and applicability to the problem at hand.
4. Apply the evidence by engaging in collaborative decision-making with individual
patients and/or groups. Appropriate decision-making integrates the context,
values and preferences of the care recipient, as well as available resources,
including professional expertise.

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5. Assess the outcomes and disseminate results.
Because the evidence-based process informs future Questions and practice, it is useful
to imagine it as a continuous cycle (Figure 3)

Step 1: Ask Patient –centered focused questions

How do I ask well-formulated, answerable questions?

Questions are often only partly formulated, which makes finding answers in the
literature a challenge. Breaking down the question into its component parts and
restructuring it so that it is easier to find answers is an important first step in EBP. Most
clinical questions can be divided into four/five/ components, often abbreviated as PICO
(T): Look at the description below

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  1. Asking/assessing / with PICO(T)
 P- Patient, Population or Problem
 What person or group of people are you interested in?
 What is the specific clinical problem that you have in mind?
I- Intervention or Indicator
 What is the treatment strategy, exposure or test that you want to find out
about in relation to the clinical problem? This might be
 An intervention: a procedure, such as a drug treatment, surgery or diet.
 An indicator: exposure to an environmental hazard, a physical feature such
as being overweight, or a factor that might influence a health outcome.
 An index test: a diagnostic test, such as a blood test or brain scan.
C-Comparator or Control: an alternative control strategy, exposure or test.
O- Outcome: What are you or the patient most concerned about happening, or
preventing happening?
T- Time: What is the timeframe of the clinical question?
 A timeframe is often implicit in the clinical question, but it is sometimes
useful to add the timeframe explicitly.

Once you have your clinical question in PICO (T) format, there are two additional facets that you
should consider:
1. What type of question are you asking?
2. What type of study will best answer your question?
Different types of questions require different study designs. Once you have identified your question
type, you will be better able to target the specific studies that best answer your clinical question. In
each case, a systematic review of all relevant studies is preferable to an individual study (table 2)

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Question Best Question Best Study Question Best Study
Study
Therapy/ Randomized Controlled Subjects are randomly allocated to treatment
Intervention Trial or control groups and outcomes assessed
Etiology/Risk Randomized Controlled As etiology questions are similar to intervention
Factors Trial Questions, the ideal study type is an RCT.
However,
it is usually not ethical or practical to conduct
such
a trial to assess harmful outcomes.
Cohort Study Outcomes are compared for groups with and
without an exposure or risk factor: prospective
study.
Case-Control Study Subjects with and without an outcome of interest
are compared for previous exposure or risk
factor:
Retrospective study.
Frequency and Cohort Study As above.
Rate
Cross- Sectional Study Measurement of a condition in a representative
- preferably random -population sample
Diagnosis Cross- Sectional Study Preferably an independent, blind comparison
with with a gold standard test.
Random or Consecutive
Sample
Prognosis and Cohort/ Survival Study Long-term follow-up of a representative cohort
Prediction
Table 2: Study Designs

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Examples. On “How do I ask well-formulated, answerable questions?”
Activity/ Exercise

Exercise On “How do I ask well-formulated, answerable questions?”

Activity 4 Example: 1
Case scenario -Intervention question
You are presented with the following clinical problem: the parents of a
severely autistic 6-year-old boy are unhappy that no interventions have
significantly improved his lack of social communication. They were excited to
learn from the parents of another autistic child that a new treatment - the
use of intravenous secretin - has resulted in a dramatic benefit for many
children. Could this treatment help their child?
The possible answer for each question will be:
1. What are the possible questions you need to answer? Use PICO (T).
2. What is the clinical question?
3. What is the question type? Select one or the preference
4. What type of study will best answer an intervention question?
Example: 2 Case scenario - Diagnosis
Your hospital is exploring diagnostic test options in the case of a recent
COVID 19 pandemic in your area.
1. What are the possible questions you need to answer? Use PICO (T).
2. What is the clinical question?
3. What is the question type?
4. What type of study will best answer a diagnosisquestion?

Duration: 20 minutes - Use PICO (T) scheme.

Step 2: Acquire- Collect the best evidence relevant to your question

The search for evidence to inform clinical practice is tremendously streamlined when
questions are asked in PICOT format. Using the PICOT format helps to identify key

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words or phrases that, when entered successively and then combined; expedite the
location of relevant articles in massive research databases such as MEDLINE GOOGLE
SCHOLAR, PUB MED or CINAHL.
In step one you have formulated an answerable question, your next step is to acquire
the best quality evidence available to answer your question. This step begins by looking
at how to convert a well-built clinical question into a strong search strategy for your
literature search.
Constructing a well-built clinical question will lead directly to a well-built search
strategy. Note that you may not use all the information in PICO or well-built clinical
question in your search strategy, and in fact, it can often be more effective NOT to
address all of the PICO elements.
In the example below the key words are mentioned under search terms. It is used the
Clinical Query for Therapy, for the publication type, randomized controlled trial, to get
at the concept of treatment.
Example: case scenario
In patients with osteoarthritis of the knee, is hydrotherapy more effective than
traditional physiotherapy in relieving pain?
Clinical
PICO Search Terms / Strategy/
Question
 Patient, Population  Knee
 knee, osteoarthritis
(or Problem) osteoarthritis
 hydrotherapy, water therapy, whirlpool baths,
 Intervention  Hydrotherapy
aqua therapy
 Comparison or  Traditional
 Physiotherapy, physical therapy
Control (optional) Physiotherapy
 Outcome  Relief of pain  Pain
 Clinical Query – Therapy/narrow or
 Type of Question  Therapy Limit to randomized controlled trial as
document type

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  Clinical Query – Therapy/narrow or
 Type of Study - RCT Limit to randomized controlled trial as
document type

Activity/Exercise/ for Step 1 and 2 together

Step 1
1. The clinical question you need to acquire evidence is :
2. What is the PICO (T) of this question?
3. What is the question type? Answer: Etiology/Risk Factors/
4. What type of study will best answer an etiology/risk factor/ question?
Step 2: Acquire- Collect the best evidence relevant to your question
In order to build a search strategy from your clinical question, use subject headings
and synonyms to pinpoint two or three of your PICO (T) components. Combine
these components to retrieve more accurate and relevant results. You wish to
investigate whether women with asthma are at increased risk of pregnancy
complications see the table below.

PICO Clinical Question Search Terms / Strategy/

 Patient, Population
 Pregnant women Pregnancy/pregnant women
(or Problem)
 Asthma/wheeze/wheezing,
 Indicator  Asthma
wheeziness
 Comparison or
 NA  ---
Control (optional)
 pregnancy
 Outcome  Complication
complications
 a cohort study or a case-control
 Type of Question  Etiology/Risk Factors
study
 Type of Study - RCT  A randomized control trial

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  A cohort study or a case-control
study
The key words: Asthma; Pregnancy; complications and Cohort study/ case study;
then use these key words to search in the database.

Step 3: Appraise the evidence for validity and applicability

Critical appraisal is the process of carefully and systematically examining research to
judge its trustworthiness, its value and its relevance in a particular context.
Once articles are selected for review, they must be rapidly appraised to determine
which are most relevant, valid, reliable, and applicable to the clinical question. These
studies are the “keeper studies.” One reason clinicians worry that they don’t have time
to implement EBP is that many have been taught a laborious critiquing process,
including the use of numerous questions designed to reveal every element of a study.
Rapid critical appraisal uses three important questions to evaluate a study’s worth.
a. Are the results of the study valid?
This question of study validity centers on whether the research methods are rigorous
enough to render findings as close to the truth as possible. For example, did the
researchers randomly assign subjects to treatment or control groups and ensure that
they shared key characteristics prior to treatment? Were valid and reliable instruments
used to measure key outcomes?
b. What are the results and are they important?
For intervention studies, this question of study reliability addresses whether the
intervention worked, its impact on outcomes, and the likelihood of obtaining similar
results in the clinicians’ own practice settings. For qualitative studies, this includes
assessing whether the research approach fits the purpose of the study, along with
evaluating other aspects of the research such as whether the results can be confirmed.
c. Will the results help me care for my patients?

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This question of study applicability covers clinical considerations such as whether
subjects in the study are similar to one’s own patients, whether benefits outweigh risks,
feasibility and cost-effectiveness, and patient values and preferences.
After appraising each study, the next step is to synthesize the studies to determine if
they come to similar conclusions, thus supporting an EBP decision or change.
Step 4: Apply the evidence through collaborative decision-making
Integrate the evidence with clinical expertise and patient preferences and values. Then
make evidence-based recommendations for day-to-day practice.
Step 5: Evaluate the outcomes of the practice decisions or changes based on
evidence.
Review data and document your approach. Be sure to include any revisions or changes.
Keep close tabs on the outcomes of your intervention. Evaluate and summarize the
outcome.
Step 6: Disseminate EBP results.
Share the results of your project with others. Sharing helps promote best practices and
prevent duplicative work. It also adds to the existing resources that support or oppose
the practice.
2.2.2. Misconceptions of evidence-based practice

Activity 5 Think- Pair and share on

1. What are the Misconceptions about evidence-based practice?
Duration: 30 minutes

Misconceptions about evidence-based practice are a major barrier to its uptake and
implementation. For this reason, it is important that misconceptions are challenged and
corrected. In most cases, they reflect a narrow or limited understanding of the
principles of evidence based practice.
Misconception 1: Evidence-based practice ignores the practitioner’s
professional Experience.
This misconception directly contradicts our definition of evidence-based practice – that
decisions should be made through the conscientious, explicit and judicious use of
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evidence from four sources, including evidence from practitioners. Evidence based
practice does not mean that any one source of evidence is more valid than any other.
Even the professional experience and judgment of practitioners can be an important
source if it is appraised to be trustworthy and relevant. Evidence from practitioners is
essential in appropriately interpreting and using evidence from other sources. If we are
trying to identify effective ways of sharing information with colleagues, evidence from
the organization may be informative but professional experience and judgment is
needed to help to determine what practices make good sense if we are working with
professionally trained colleagues or relatively low-skilled workers. Similarly, evidence
from the scientific literature can help us to understand the extent to which our
experience and judgment is trustworthy. Research indicates that years of experience in
a technical speciality can lead to considerable expertise and tacit knowledge. On the
other hand, an individual holding a series of unrelated jobs over the same number of
years may have far less trustworthy and reliable expertise. Evidence-based practice is
hence about using evidence from multiple sources, rather than merely relying on only
one.

Misconception 2: Evidence-based practice is all about numbers and statistics.

Evidence-based practice involves seeking out and using the best available evidence
from multiple sources. It is not exclusively about numbers and quantitative data,
although many practice decisions involve figures of some sort. You do not need to
become a statistician to undertake evidence-based practice, but it does help to have an
understanding of basic statistical concepts that are useful to evaluate critically some
types of evidence. The principles behind such concepts as sample size, statistical versus
practical significance, confidence intervals and effect sizes, can be understood without
any mathematics. Evidence-based practice is not about doing statistics, but statistical
thinking is an important element.

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Misconception 3: Managers need to make decisions quickly and do not have
time for evidence-practice.
Sometimes evidence-based practice is about taking a moment to reflect on how well the
evidence you have can be trusted. More often it is about preparing yourself (and your
organization) to make key decisions well – by identifying the best available evidence
you need, preferably before you need it. Some management decisions do need to be
taken quickly, but even split-second decisions require trustworthy evidence. Making a
good, fast decision about when to evacuate a leaking nuclear power plant or how to
make an emergency landing requires up-to-date knowledge of emergency procedures
and reliable instruments providing trustworthy evidence about radiation levels or
altitude. When important decisions need to be made quickly, an evidence-based
practitioner anticipates the kinds of evidence that quality decisions require. The need to
make an immediate decision is generally the exception rather than the rule. The vast
majority of management decisions are made over much longer time periods –
sometimes weeks or even months – and often require the consideration of legal,
financial, strategic, logistical or other organizational issues, which all takes time. This
provides plenty of opportunities to collect and critically evaluate evidence about the
nature of the problem and, if there is a problem, the decision most likely to produce the
desired outcome. For evidence-based practice, time is not normally a deal breaker.
Misconception 4: Each organization is unique, so the usefulness of evidence
from the scientific Literature is limited.
One objection practitioners have to using evidence from the scientific literature is the
belief that their organization is unique, suggesting that research findings will simply not
apply. Although it is true that organizations do differ, they also tend to face very similar
issues, sometimes repeatedly, and often respond to them in similar ways. Peter
Drucker, a seminal management thinker, was perhaps the first to assert that most
management issues are ‘repetitions of familiar problems cloaked in the guise of
uniqueness’. The truth of the matter is that it is commonplace for organizations to have
myths and stories about their own uniqueness. In reality they tend to be neither exactly
alike nor unique, but somewhere in between. Evidence-based practitioners need to be
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flexible enough to consider any such similar-yet-different qualities. A thoughtful
practitioner, for instance, might use individual financial incentives for independent sales
people but reward knowledge workers with opportunities for development or personally
interesting projects, knowing that financial incentives tend to lower performance for
knowledge workers while increasing the performance of less-skilled workers.
Misconception 5: If you do not have high-quality evidence, you cannot do
anything.
Sometimes there is very little or no quality evidence available. This may be the case
with a new management practice or the implementation of new technologies. In some
areas the organizational context changes rapidly, which can limit the relevance and
applicability of evidence derived in a context different than that of today. In those cases
the evidence-based practitioner has no other option but to work with the limited
evidence at hand and supplement it through learning by doing. This means pilot testing
and treating any course of action as a prototype: systematically assess the outcome of
the decisions we take through a process of constant experimentation, punctuated by
critical reflection about which things work and which things do not.
Misconception 6: Good-quality evidence gives you the answer to the
problem.
Evidence is not an answer. It does not speak for itself. To make sense of evidence, we
need an understanding of the context and a critical mindset. You might take a test and
find out you scored 10 points, but if you don’t know the average or total possible score
it’s hard to determine whether you did well or not. You may also want to know what
doing well on the test actually means. Does it indicate or predict anything important to
you and in your context? And why? Your score in the test is meaningless without this
additional information. At the same time, evidence is never conclusive. It does not
prove things, which means that no piece of evidence can be viewed as a universal or
timeless truth. In most cases evidence comes with a large degree of uncertainty.
Evidence-based practitioners therefore make decisions not based on conclusive, solid,
up-to-date information, but on probabilities, indications and tentative conclusions.

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Evidence does not tell you what to decide, but it does help you to make a better-
informed decision.
Summary

This document is explaining what evidence-based practice was about – that it involved
decision-making through the conscientious, explicit and judicious use of the best available
evidence from multiple sources. By using and critically appraising evidence from multiple
sources, you increase the likelihood of an effective decision. The need for evidence based
practice has discussed. Evidence-based practitioners therefore make decisions not based
on conclusive, solid, up-to-date information, but on probabilities, indications and tentative
conclusions. However, the most important learning point is that evidence-based practice
starts with a critical mindset. It means questioning assumptions, particularly where
someone (including ourselves) asserts some belief as a fact. So, from now on, always ask:
‘What is the evidence for that?’, ‘How trustworthy is it?’ and ‘Is this the best available
evidence?’

2.2. Healthcare audit

Duration: 2 Hours

Healthcare audit is a quality improvement cycle that involves measurement of the

effectiveness of healthcare practices against agreed and proven standards for high
quality and taking action to bring practice in line with these standards to improve the
quality of care and health outcomes.

By following the cycle, healthcare team members will be able to see where their
practice can be improved against given benchmarks, take action, and then re-measure
and make further improvements. Whether conducted by an individual on his/her routine
work, or a healthcare team/ unit, or nationally by collaborating providers working in
different organizations, healthcare audit follows the same process. Its purpose is to
drive up standards of quality and to achieve better outcomes.

Aspects of structure (input), service provision procedure (processes), and outcomes of

care are selected and systematically evaluated against explicit standards. Following
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assessment, changes will be implemented at an individual, team, or service level, and
further monitoring is used to confirm improvement in health care delivery.

Audit vs research

Audit Research

Never involves experiments ,whether on May involve experiments on human

healthy volunteers, or patients as subjects whether patients, patients as
volunteers volunteers or healthy volunteers
Is a systematic approach to the peer review Is a systematic investigation which aims
of medical care in order to identify to increase the sum of knowledge
opportunities for improvement and to
provide a mechanism for bringing
themabout
Never involves allocating patients randomly May involve allocating patients randomly
to different treatment groups to different treatment groups

Never involves a completely new treatment May involve completely new treatment

Never involves a disturbance to the patients May involve extra disturbance or work
beyond that required for normal clinical beyond that required for normal
management clinical management

May involve patients with the same problem May involve the application of strict
being given different treatments, but only selection criteria to patients with the
after full discussion of the known same problem before they are entered
advantages and disadvantages of each into their search study
treatment. The patients are allowed to
choose freely which treatment they get

Measures against a standard Usually involves an attempt to test

a hypothesis

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 2.3 Principles of Effective healthcare Audit
Health facilities and clinical departments aspiring to conduct effective and successful
healthcare audits shall consider the following guiding principles at all times:

1. Confidentiality

Confidentiality should at all times be respected. No information regarding the health

status, treatment, or stay of a patient or client in a health facility is to be divulged
verbally or in writing without the necessary prior consent. Furthermore, patient data
entered into any computer (database) should be protected by a password, access to
such computers should be limited to authorized personnel only, and all relevant
documentation and material related to the healthcare audit must be locked away
when not attended to or not in use. Making information anonymous before it is used
in an audit could also be considered.

2. Organizational environment
The organizationmust be supportive of healthcare audits. In practice, this means
that those who are managing health facilities should ensure policies and procedures
are in place to safeguard patient care and they should encourage professional self-
regulation, and lifelong learning.

3. A non-judgmental
The results that are produced when searching for a deviation from agreed good
practices should not be used to denigrate and condemn health care providers and
teams/ units.

4. Data-driven.
Healthcare audit can only be undertaken if enough data is available to ensure
credible results are produced. It is therefore essential that a strong relationship be
established between the health information system and the healthcare audit teams.

5. Structured program
Healthcare audit should be part of a structured programto improve the quality of
care within a facility.
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6. Participatory
Healthcare audit is participatory in nature as it involves multidisciplinary teams that
comprise health care providers and service users at any level or tier of the health
care system. Working in teams ensures that appropriate skills are pooled together
from the outset.

2.4 Process of healthcare Audit

Yet patients and the public have not lost their respect and appreciation for the caring
professions in the health service. Practitioners, patients, and the wider public all share
equally in the need to establish and maintain confidence in the quality of clinical care.

An audit is one way in which healthcare providers can work to retain trust and respect
in an increasingly critical environment. As a quality improvement tool, a healthcare
audit can demonstrate that real efforts are being made by dedicated, hard-pressed staff
to deliver high-quality professional care to all their patients. Healthcare audit is
increasingly seen as an essential component of professional practice, and we welcome
the emphasis professional bodies, regulators, and government are giving to professional
participation and leadership of audit.

Healthcare audit is a cyclical process that has five stages. Each stage of the healthcare
audit cycle must be undertaken to ensure that an audit is systematic and successful.

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 Preparing
for audit

Sustaining Selecting
environment criteria

Making Measuring
improvemen performanc
t e

Fig 1: Steps of healthcare audit/ the audit cycle

1. Planning for Audit

A healthcare audit is said to be successful if it helps to identify areas of excellence or
areas of improvement. This can be achieved through effective planning and
preparation. There are three main steps in the planning process which includes:
1. Involving stakeholders

2. Determining/selecting audit topic

 Is the topic concerned with high cost, volume, or risk to staff or users?
 Is there evidence of a serious quality problem, e.g. patient complaints or high
complication rates?
 Is good evidence available to inform standards, e.g. systematic reviews or
national clinical guidelines?
 Is the problem concerned amenable to change?
 Is there potential for involvement in a national audit project?
 Is the topic pertinent to national policy initiatives?
 Is the topic a priority for the organization?

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3. Planning the delivery of audit fieldwork

2. Determining the criteria

This is a very important step that must be given careful consideration. Subjects for
healthcare audit should be selected to improve the quality or safety of care or service
provision. The following points need to be considered while selecting a topic

Criteria and standard selection are one of the core steps in healthcare auditing after
topic selection. This is a phase whereby the healthcare audit team review available
evidence to find standards and audit criteria against which the audit will be conducted.

The choice of criteria and standards is one of the most critical points in the design of a
healthcare audit and it requires the collaboration of all participants in the audit. Indeed,
the quality of care provided (i.e., the final result of the audit) will be evaluated just
based on a comparison with these parameters.

The sources where criteria and standards can be drawn from may be international
guidelines, scientific literature, expert consensus, data obtained by other health care
facilities, and personal case studies. The stronger the evidence taken as a reference will
be, the more the results of the comparison with daily clinical practice will be reliable.
However, to design an effective healthcare audit, the standard and criteria must be
shared with colleagues before the review of the collected data, since they should not be
object of rearrangement in the course of verification, nor be changed retrospectively, in
the light of the findings derived from the audit itself.

The standards define the aspect of care to be measured, and should always be based
on the best available evidence. For Criteria to be sound and lead to improvement it
should be consistent with smart Guidance: (Specific, Measurable, Achievable, and
Relevant, Timely)

Guidance for Setting Criteria & Standard

If the selected healthcare audit topic is found in the national audit tool (HSTQ), every
audit criteria and standard mentioned in the HSTQ must be followed accordingly.

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Whereas the audit topic is new which is not in the HSTQ, then the following
recommendations should be considered.

Criteria can be classified into those concerned with:

1. Structure (what you need) Examples of criteria relating to the structure include the
numbers of staff and skill mix, the provision of equipment and physical space.

2. Process (what you do) Process criteria refer to actions and decisions taken by
practitioners and users. Examples include assessment, education, documentation,
prescribing, surgical and other therapeutic interventions.

3. Outcome (what you expect) Outcome criteria are typically measures of the physical
or behavioral response to an intervention, reported health status and level of
knowledge and satisfaction. Sometimes surrogate or intermediate outcome indicators
are used instead.

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Sourcing criteria
 Professional Associations  Statutory requirements and
 Literature regulations
 Guidelines  Clinical guidelines
 National and international  Clinical pathways
literature.  Develop
 National, and Local policies and
procedures

3. Measuring performance
Data collection must be precise and only essential data collected, i.e. only the minimum data
required by the objectives of the audit. It is strongly recommended that data that already
exists be used. To ensure only essential data are being collected, certain details about what
is to be audited must be established from the outset. This stage may be described in steps
as follows:

 Step 1: Data collection

 Step 2: Data analysis
 Step 3: Drawing conclusions
 Step 4: Presentation of results
To make sure that the data collected are precise, and that only essential data are collected,
certain details about what is to be audited must be established from the outset. These are:

 User group to be included, with any exceptions noted

 Healthcare professionals involved in the users’ care
 Time period over which the criteria apply.

4. Linking healthcare audit findings with the quality improvement

After finishing all the healthcare auditing activities, the findings of the audit must be taken to
the next level which quality improvement cycle. Each clinical department is required to refer
steps of QI cycles for them to link findings of the audit to QI activities of the hospital.

 Develop the team charter

 Set clear aim statement
 Put measures
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  Develop change ideas
 Test the change ideas
 Implement the change ideas
 Scale up the experience

5. Sustaining Improvement
The main components that should be considered when sustaining, spreading and Scaling up
change ideas:

 Monitoring the quality improvement plan

 Performance indicators
 Evaluate audit quality
 Dissemination and celebrating success
 Remember to close the loop by re-auditing
 Standardization

2.5 Monitoring and evaluating healthcare audit

Monitoring and Evaluation of a healthcare audit program should be done by all relevant
stakeholders including the institution management, RHBs and MOH. Monitoring should
basically focus on the implementation of the healthcare audit program while the evaluation
assesses the effectiveness of the programs to bring about improvement in healthcare
outcome indicators and client satisfaction.

The implementation of action plans will be monitored by the healthcare audit lead and
reported to the quality council and Senior Management Team (SMT) via a standing monthly
and quarterly report. All actions should include target dates for completion, and reporting
may therefore be by exception.

There should be an agreed process for following up any actions that have not been
implemented by the target date. The healthcare audit policy/TOR of the institution should
set out clear lines of reporting for monitoring the healthcare audit program. Each healthcare
audit project on the program would be better to have a HEALTHCARE/ CLINICAL AUDIT
LEAD that is ultimately responsible for the conduct of the audit. However to ensure that the
organization as a whole benefit from the program, it must be monitored by the Senior
Management Team (SMT).

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 Activity VI Identify audit tool
 Based on the previous reading, select a audit topic (preferably
related to the MCC area)
 Identify audit tool (criteria and standard) to measure
performance (national or international).
 Measure the performance of a healthcare facility using the audit
tool.
 Develop 3-5 change ideas to improve the identified
performance gaps
Duration: 40 minutes

Self-assessment Questions
1. Mention three differences between research
and audit.
2. What are the five stages/ steps of healthcare
audit (the audit cycle)?

Summary

Competency describes the relevance of

 Lifelong learning,
 Evidence-based practice and improvement&
 Healthcare audit in the encasement of competency in health care service delivery.

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Chapter 3 Compassionate and respectful care
Chapter Description,

Compassionate care is a fundamental component of providing quality health care service

delivery; it improves care quality, patient satisfaction, and provider efficiency. When patient-
centered practices are delivered without compassion, their very intent and value are
jeopardized. It is worth noting that patient-centered care is an oxymoron in the absence of
compassion; compassion is at the heart of any patient-centered approach. As a result,
understanding compassionate and respectful care is one of the most important skills that
health care providers should have. The chapter designed to explicit the qualities of
compassion, elements of compassion, threats/challenges of compassion, and mitigation
mechanisms of compassion threats to provide quality health care service in compassionate
manner.

Chapter objective

After the completion of this chapter, participants will be able to:

 Describe compassionate person centered care.

Enabling objectives

At the end of this chapter, participants will be able to:

 Describe the components of compassionate care respectful care

 Recognize compassion as a foundation for person centered care
 Identify threats of compassionate care
 Develop self-care strategies to prevent threats of compassionate care
 Provide person centered care with compassion
Chapter outline

 Session 1 Components of compassionate care

 Session 2 compassion a foundation for person centered care
 Session 3 challenges of compassionate care

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Session 1: components of compassionate care
Duration: 2 hours

Definition of compassion

Activity #1: Think pair and share

 discuss about individuals who you think as
compassionate in their life and practice (globally,
nationally and in your local setting)
 Time allocated: 5 minutes

Activity# 2: what do you understand from the illustration shown below?

According to the Oxford English Dictionary, the term "compassion" comes from the Latin
word "compati," which means "to suffer with." Within the medical field, Compassion is
defined as a feeling or character that promotes warmth, compassion, empathy, love, and
belongingness among individuals, service providers, and the community, and it is critical for
the delivery of high-quality, ethically acceptable health care.

Compassion can also be viewed as a result of the interaction of a multitude of physical,

affective, cognitive, attention, and embodied processes, all of which can be honed. A
mutual, reciprocal, and asymmetric interaction underpins this process. Compassion is
impossible to achieve without a healthy mix of awareness and compassion. It necessitates
altruistic desire and understanding of the self-other distinction. Compassion also entails self-
awareness and sensitivity to others.
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Compassion can also be viewed as a result of the interaction of a multitude of physical,
affective, cognitive, attention, and embodied processes, all of which can be honed. A
mutual, reciprocal, and asymmetric interaction underpins this process. Compassion is
impossible to achieve without a healthy mix of awareness and compassion. It necessitates
altruistic desire and understanding of the self-other distinction. Compassion also entails self-
awareness and sensitivity to others. In fact, it appears that the effective use of compassion
is predicated on individuals' ability to engage with and understand the thoughts of others.

1.1 Attributes of compassionate care

Specific abilities and abilities go into developing compassion; that is not something a simple
as an emotion or motivation, but rather a complex combination of attributes and qualities.
The human capacity for compassion appears to involve two different psychologies: on the
one hand for awareness and engagement, on the other for skilled intervention in action.

1.1 Motivation
The initial stage requires the motivation to be caring, supportive and helpful to others. This
is the commitment to try to do something about its aspect of compassion which can be
operate particular points of time, but also represent a set of values which define how we
would like to be in our roles and also as human beings. Motivation is the fundamental
component that shapes compassions other attributes. Individuals who are motivated to help
others rather than having ego-focused goals better social relationships, less conflict and
greater wellbeing.

1.2 Sensitivity
It is the capacity to be sensitive and to maintain open attention, enabling us to notice when
other need help. It is the opposite of ‘turning blind eye’ or being too pre –occupied to be
able to notice- or too aware that one doesn’t have time to notice’ and so gradually one
doesn’t notice.

1.3 Sympathy
Sympathy is an emotional response to distress. It is the sort of ‘emotional connectedness’
that happens when we see a child who is playing happily falling over and hurting
themselves. The spontaneous feeling of being moved to help would be familiar to most of
us. Therefore, sympathy is linked to sensitivity plus an urge to relieve suffering.

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 1.4 Distress tolerance
It is our ability to bear difficult emotions both within ourselves and others. People who feel
overwhelmed by another’s distress may feel psychologically unable to face it and so have to
turn away. Alternatively, because the suffering feels too distressing, they have to act as
rescuers under compulsion to turn off the others distress as fast as possible. Being able to
bear distress and cope with it allows us to be with distress: actively remaining present to
listen and feel able to work out with the other person what might be helpful for them.

1.5 Empathy
It is both emotional (affective) as well as cognitive (thinking) components. It necessitates
not just the ability to perceive another person's feelings, motivations, and intentions, but
also the ability to comprehend their sentiments and our own emotional responses. We have
a variety of feelings, sometimes sad, angry or anxious and sometimes joyful. However,
sometimes we are critical of our feelings, or try to run away from them, hide from or
suppress them, but when we are compassionate, we can learn to be open, tolerant,
accepting of any kind to our feelings and this helps us develop and show empathy. So, a key
aspect of compassion is learning how to tolerate and come to terms with, become familiar
with, and less frightened of, our feelings. This doesn't mean, of course, that we don't wish
to change our feelings for things, for other people or even ourselves.

1.6 Non-condemning and non-judging:

It entails not passing judgment on a person's suffering or grief, but rather accepting and
validating it. Compassion also entails being nonjudgmental, as in not passing judgment. The
distressed mind, for example, can be filled with condemning and critical thoughts of our self
or others. Giving this up is linked to becoming kind and mindful; we become more aware of
thoughts and feelings but from an observational point of view. We don't judge them, nor try
to suppress them or push them out of our minds, avoid or run away from them. Rather, we
learn to notice but not act on our feelings. Remember these abilities can be developed in
small stages, step by step. All of these are engaged with the feelings of warmth and a
genuine desire to relieve suffering and increase our growth and flourishing.

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 ACTIVITY #3: Case Study:

A mother with limited mobility brought her 3-month-old baby girl to the
outpatient clinic with a cough and fever. The health care provider was
discussing last night's football game with his colleagues when the mother
entered the examination room. He had already noticed her but had paid no
attention to her. Her child was crying, and she was attempting to soothe her.
The healthcare provider abruptly yelled at the mother to quiet her child or he
would force them to leave. The mother begged the healthcare provider to see
her child while waiting and calming her child because she was very sick and
needed urgent care. The healthcare provider told the mother that he would
see her child in five minutes while facing his friend. After waiting for 10
minutes, the healthcare provider began to examine the child and expressed
sadness about the child's condition; blamed the mother for bringing her too
late; and finally apologized to the mother for making her wait so long. The
healthcare provider gently evaluated the child, provided appropriate treatment,
reassured the mother, and the child went home feeling better.
Discussion questions
1. What compassionate characteristics did the health care provider exhibit?
2. What non-compassionate characteristics did the health care provider
exhibit?
3. What should the health care provider do differently in this case?
Time allotted: 30 minutes

Session summary

 Compassion is sensitivity to the distress of self and others with a commitment try to
do something about it and prevent it.
 Attributes of compassionate care includes motivation, empathy, sympathy, being non-
judgmental, distress tolerance and sensitivity.

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Session 2: Compassion as a foundation for Person Centered Care
Duration =1 hour

2.1 What is person centered care?

Activity #1: (picture analysis)
What do you understand from this picture?

Person-centered care is a way of thinking and doing thingsthat sees the people using health
and social services as equal partners in planning, developing and monitoring care to make
sure it meets their needs. This means putting people and their families at the center of
decisions and seeing them as experts, working alongside professionals to get the best
outcome.

Person-centered care is not just about giving people whatever they want or providing
information. It is about considering people’s desires, values, family situations, social
circumstances and lifestyles; seeing the person as an individual, and working together to

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develop appropriate solutions. There is no one definition of person-centered care. People
might also use terms such as patient-centered, family-centered, user-centered,
individualized or personalized.

Person centered care involves working with people and their families to find the best way to
provide their care. This partnership working can occur on a one-to-one basis, where
individual people take part in decisions about their health and care, or on a collective group
basis whereby the public or patient groups are involved in decisions about the design and
delivery of services.

Activity #3 : Read and answer the following questions in the table.

 Time allocated: 20min )

Write true if the statement reflects the correct PCC and false if not reflect the
right aspect of PCC, and correct the false statement accordingly
S.no Aspects of person-centered care True False Corrected answer
1 Respecting people’s values and
putting people at the center of
care
2 Taking into account more on
scientific and providers ’s
preferences than person
preferences and expressed
needs
3 The care shall be collaborative
coordinated and integrated
4 Working together to make sure
there is good communication,
information and education
5 Making sure people are
physically comfortable and safe
6 Health professional shall not
have any emotional
engagement with the patient

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 and their family
7 Making sure there is continuity
between and within services
8 Making sure people have access
to appropriate care when they
need it
9 The care shall focus on physical
comfort only
10 The presence of family
members Shall encouraged
11 Information shall share fully
and timely manner, therefore,
patient and their family
members can make informed
decision

2.2 Benefits of Patient-Centered Care

Individual reflection
Why Person Centered Care is important?
Time: 10 minutes

The primary goal and benefit of patient-centered care is to improve individual health
outcomes, not just population health outcomes, although population outcomes may also
improve. Not only do patients benefit, but providers and health care systems benefit as well,
through:

 Improved satisfaction scores among patients and their families.

 Enhanced reputation of providers among health care consumers.
 Better morale and productivity among clinicians and ancillary staff.
 Improved resource allocation.
 Reduced expenses and increased financial margins throughout the continuum of care.

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ACTIVITY #1: Case Study: Patient-centered care in the OPD

Scenario 1
The care provider team inthe hospital outpatient department (OPD) served a
patient with the following manners:-Assess comprehensively with Empathy,
two-way communication, eye-to-eye contact, were all demonstrated well by the
health care providers. Peer support programs, social workers, financial
counselors, mental and emotional health providers, transportation and daily
living assistance, and, language interpretation provided to the patient by health
care team. They also assisted the patient using a technology-based tools to
assist the patients in taking his medicine appointments, get information about
their condition and care instructions, review lab results and pay bills at their
convenience outside the hospital
Discussion question
Identify and list components that make the care PCC
Time allotted: 30 minutes (15m for group work and 15 for reflect)

ACTIVITY #4: Case Study: Patient-centered care in the Hospital

Scenario #2
In hospital X, patients are given the authority to decide who can
and cannot visit them and when. Family members (as
defined by the patient and not limited to blood relatives) are
invited to visit during rounding and shift changes so they can
participate in discussions and care decisions as part of the
care team. When they are not in the room with the patient,
they are kept up to date on their loved one's progress via
direct and timely updates.
Discussion questions are:
1.Identify person centered care practices
2.Discuss the value of those person centered care practices to
patient healing process and satisfaction of beloved ones

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 2.3 Compassion as the foundation of patient-centered care

Activity # 1:Think, pair share

Think about the definition of PCC given in the previous session;
“Providing care that is respectful of, and responsive to, individual patient preferences,
needs and values, and ensuring that patient values guide all clinical decisions”
What is missing in PCC definition, in regard to meet the patient need?
________________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________.

Compassionate care is an important and frequently overlooked component of patient-

centered care. It addresses the emotional and psychosocial aspects of the patient
experience and the patient’s innate need for human connections and relationships. At its
core, it means recognizing the concerns, distress and suffering of patients and their families
and taking action to relieve them. It is based on active listening, empathy, strong
communication and interpersonal skills, knowledge of the patient as a whole person
including his or her life context and perspective, and the ability to work together to relieve
distress.

When patient-centered practices are delivered in the absence of compassion, their very
intent and value is undermined. It is worth that patient-centered care in the absence of
compassion is an oxymoron; compassion is at the heart of any patient-centered approach.

For example, If a patient asking to know their condition is made to feel as if they are being
‘difficult’ or feels patronized, the opportunity to forge a meaningful patient–caregiver
relationship has been squandered. Indeed, such attitudes could cause the patient to avoid
asking questions or making their needs known in the future, negatively impacting upon
caregivers’ abilities to deliver patient-centered care. Similarly, having a 24-h, patient-directed
visitation policy to promote the presence of family defeats the purpose if family members
are made to feel that they are an inconvenience or a disruption to staff.

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 2.4 Effective communication for PCC
Communication skills needed for patient-centered care include eliciting the patient’s agenda
with open-ended questions, especially early on; not interrupting the patient; and engaging in
focused active listening. Understanding the patient’s perspective of the illness and
expressing empathy are key features of patient-centered communication.

Patient-centered approach to care is based on these three goals;

 Eliciting the patient’s perspective on the illness,

 Understanding the patient’s psychosocial context and
 Reaching shared treatment goals based on the patient’s values.
Patient-centered care builds on discussions and decisions that involve shared information,
compassionate and empowering care provision, sensitivity to patient needs, and relationship
building. In contrast to a disease-focused biomedical approach, patient-centered care
considers patient preferences, needs, and values, ensuring that they guide all medical
decisions in tandem with scientific evidence.

Table 1: Basic skills in patient centered communication

Basic skills in patient Suggested Example/Phrases

centered communication
Introduce and build rapport All persons present at the visit should be introduced. In
non-urgent situations, positive remarks about nonmedical
issues, such as the weather, generalities about the day, or
nonspecific encouraging observations, can help build
rapport.
Elicit the patient’s agenda Use phrases such as “How may I help you today?” or “What
can I do for you today?” to bring the focus to the purpose
of the visit.
Start discussing the patient’s “Tell me more about…” “Would you like to talk more
concerns with open-ended about…?”
questions
Elicit the patient’s perspective Feelings “Tell me more about what was worrying you.”
Ideas “Do you have any thoughts on what might
be causing this?”
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 Concerns “What do you worry about regarding your
health?”
Impact “How has your illness affected your daily life?”
Expectations “Is there anything else you need from us
today?”
Summarize “So, from what you have told me so far, you…”
“Let me summarize what we have discussed so far.”
“You have told me a lot of things. Let me just say it out
loud, so you know that I have heard you correctly.”

Activity 4: (Think pair and share)

1. Think individually for 1 minute about any experience that encountered a
communication between patient and health care provider/s that surprised you
2. Identify and list the strength of the communication between them.
3. Identify and list the weak areas that should be improved during their
communication.
4. Share the story to the larger groups.

Activity 5: (role play)

A 65-year-old male patient came from a rural area to a referral hospital's outpatient clinic.
He works as a farmer and is the father of five children. He recently lost his partner and
presented to the hospital with the primary complaint of shortness of breath and fatigability.

Role of a client: sick looking, blunt affect, causal dressed, come with his elder child (grade
12)

Healthcare provider: sitting in the overcrowded Outpatient clinic, hospital, physicians

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Task
Provide PCC with compassion for this client
Discussion question
Did the health care provider;
 Established rapport?
 Demonstrated empathy?
 Elicit patient concern?
 Use appropriate non-verbal behavior
 Elicit perspective of and his accompanied family

Summary
 Compassion is the foundation for provision of patient center care and effective
communication skills mediates the provision of person-centered care with
compassion.

Session 3: challenges of compassionate care

Duration =1hour

1.5 Challenges in provision of compassionate care

Introduction

Compassionate care is considered a foundation of health care service provision in Ethiopia,

research indicates that compassion is often lacking in hospitals.

Individual reflection

What do you think are the challenges to provide a

compassionate care?

Time 10 minutes

There are factors preventing compassion and compassionate behavior for individual
members of staff, teams and units and hospital. Most research discusses compassion at the
individual level. In general, the most common challenges for compassionate care are:

 Organizational characteristics and

 Burnout and compassion fatigue

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 1.6 Organizational characteristics
Many studies indicated that compassionate care depends not only on the individual clinician
but also on…the organizational context within which he or she practices.

Activity # 6; Identify your organizational challenges

The followings are common organizational challenge to provide compassionate care. Read
the mentioned challenges and mark  if the challenge exists in your health care setting and
mark X if the challenge doesn’t exist in your health care setting.

No Among organizational characteristics that encourage less compassionate

care
1 Poor staff–to-patient ratios

2 Clinicians facing large numbers of distressed patients

3 demand for long hours of work

4 clinicians are increasingly pressured to meet performance goals and

achieve service efficiencies
5 Expectation on clinicians to do more with less resource.
6 The single-minded focus on wringing ever-greater service efficiencies out
of clinicians.

Write additional challenges you think which is not mentioned above

1.7 Compassion fatigue and burnout

Compassion fatigue can strike the most caring and dedicated health care providers. These
changes can affect both their personal and professional lives with symptoms such as
difficulty concentrating, intrusive imagery, and loss of hope, exhaustion and irritability. It can
also lead to profound shifts in the way helpers view the world and their loved ones.
Additionally, helpers may become dispirited and increasingly cynical at work; they may make
clinical errors, violate client boundaries, lose a respectful stance towards their clients and
contribute to a toxic work environment. It has been shown that, when we are suffering from
compassion fatigue, we work more rather than less. What suffers is our health, our
relationship with others, our personal lives and eventually our clients.

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What is it? What do I need to know about it?

1. Burnout “…is a psychological syndrome Who: Anyone in human services

of emotional exhaustion, depersonalization
and reduced personal Symptoms: Depression, anxiety, sleep
accomplishment.”(E.J. Gentry, 2017) disturbance, headaches, cardiovascular
2. Compassion Fatigue “…a natural disease, feelings of dread about going to
consequence of working with those who work, excessive boredom, feelings of
have experienced a trauma or another flatness or tiredness, pessimism about
stressful event.” (C. Joinson,1992) the future.
3. It is a combination of secondary
traumatization and burnout precipitated Warning signs: Frequent absences or
by the care delivery that brings health- tardiness, chronic fatigue, or evidence of
care professionals into contact with the poor client care may indicate that it’s time
suffering.” (B. Szabo, 2006 for a vacation, but if symptoms persist
4. Secondary trauma is “…a stress coming after implementing some time off it may
from helping or wanting to help reflect more serious burnout.
traumatized or suffering individuals. (C.
Joinson, 1992

Case study

Situation:

You are the head nurse on a busy ward. It's been a year since you became a ward leader.
You've noticed this week that one particular hardworking, punctual, and motivated nurse
arrived at work later, just after morning medication administration time. The nurse arrives
late for the next two days, looking depressed, tired, and irritable, as well as dressed
inappropriately. The nurse complains about a headache the next day and requests anti-pain
medication. You're becoming concerned and wondering what's causing it.

Discussion question

1. What syndrome does the nurse have based on the above case scenario? WHY?
2. What if the nurse show sleep disturbance because of an intrusive memory of a sad
history she heard from a patient in the outpatient clinic? Why?

Time allowed:20

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 1.8 Self-care strategies
Activity 1. Reflection question

 What activities do you do during your long annual leave? Why?

 Share your experience to the larger group
 What possible organizational care do you propose?
Time: 10 minutes

Building a Self-Care Plan

When it comes to self-care plans, there is no one-size-fits-all option. We all have different
needs, strengths, and limitations. The following four-step process will help you to build a
plan that’s just right for you

Step 1: Evaluate Your Coping Skills

Examining your own habits is an important first step in developing a self-care plan. How do
you typically deal with life’s demands? Can you identify when you need to take a break?
When faced with challenges, we can use either positive coping strategies or negative coping
strategies. Below are a few examples of each. Which strategies do you use?

Positive Negative
 Deep breathing  Yelling
 Stretching  Acting aggressively
 Meditation  Overeating
 Listening to music  Drinking excessive amounts of
 Exercising alcohol
 Reading  Smoking
 Going for a walk  Pacing
 Taking a bath  Biting your fingernails
 Socializing with friends  Taking drugs
 Sitting outside and relaxing  Skipping meals
 Engaging in a hobby  Withdrawing from family and friends
 Dangerous driving

102
Step 2: Identify Your Self-Care Needs

We are all faced with unique challenges and no two people have the same self-care needs.
Take a moment to consider what you value and need in your everyday life (daily self-care
needs) versus what you value and need in the event of a crisis (emergency self-care needs).
Remember that self-care extends far beyond your basic physical needs: consider your
psychological, emotional, spiritual, social, financial, and workplace well-being.

Step 3: Barriers and Areas for Improvement

 Reflect
Reflect on the existing coping strategies and self-care tools you have outlined in the previous
activities. What’s working? What isn’t working? Keep the helpful tools, and ditch the stuff
that doesn’t help you.

 Examine
Are there barriers to maintaining your self-care? Examine how you can address these
barriers. Start taking steps toward incorporating new strategies and tools that will benefit
your health and well-being.

 Replace
Work on reducing, and then eliminating, negative coping strategies. If you find yourself
using negative strategies, then begin by choosing one action you feel is most harmful and
identify a positive strategy to replace it.

Step 4: Create Your Self-Care Plan

Once you’ve determined your personal needs and strategy, write it down. Your self-care plan
can be as simple or complex as you need it to be. You may choose to keep a detailed plan at
home and carry a simplified version in your wallet, in your purse, or on your phone.

Activity

What are you doing to support your overall well-being on a day-to-day basis? Do you
engage in self-care practices now? Are you more active in some areas of self-care than
others? You can use the table below to help you determine which areas may need more
support.

103
Self-Care Plan

Area of Self-Care Current Practices Practices to Try

Physical
(e.g. eat regular and healthy
meals, good sleep habits, regular
exercise, medical check-ups, etc.
Emotional
(e.g. engage in positive activities,
acknowledge my own
accomplishments, express
emotions in a healthy way, etc.)
Spiritual
(e.g. read inspirational literature,
self-reflection, spend time in
nature, meditate, explore spiritual
connections, etc.)
Professional
(e.g. pursue meaningful work,
maintain work-life balance, positive
relationships with co-workers, time
management skills, etc.)
Social
(e.g. healthy relationships, make
time for family/friends, schedule
dates with partner/spouse, ask for
support from family and friends,
etc.
Financial
(e.g. understand how finances
impact your quality of life, create a
budget or financial plan, pay off
debt, etc.
104
Psychological
e.g. take time for yourself,
disconnect from electronic devices,
journal, pursue new interests,
learn new skills, access
psychotherapy, life coaching, or
counseling support

Burnout Self-Test Maslach Burnout Inventory (MBI)

The Maslach Burnout Inventory (MBI) is the most commonly used tool to self-assess
whether you might be at risk of burnout. To determine the risk of burnout, the MBI
explores three components: exhaustion, depersonalization and personal achievement.
While thistool may be useful, it must not be used as a clinical diagnostic technique,
regardless of the results. The objective is simply to make you aware that anyone may be
at risk of burnout.
For each question, indicate the score that corresponds to your response. Add up your
score for each section and compare your results with the scoring results interpretation at
the bottom of this document.

105
 A Few A Few
A Few Once
Never Times Once a Times
Times a Every
Questions: per Month per
per Week Day
Year Week
Month

Section A: 0 1 2 3 4 5 6

I feel emotionally drained by

my work.
Working with people all day long
requires a great deal of effort.
I feel like my work is breaking
me down.

I feel frustrated by my work.

I feel I work too hard at my job.

It stresses me too much to work

in direct contact with people.

I feel like I’m at the end of my

tether.

Total score – SECTION A

106
 A Few A Few A Few
Once
Times Once a Times Times Every
a
Questions: Never per Month per per Day
Week
Year Month Week
Section B: 0 1 2 3 4 5 6
I feel I deal with my team/
colleagues impersonally, as if
they are objects.
I feel tired when I get up in
the morning and have to face
another day at work.
I have the impression that
my team/ colleagues make
me responsible for some of
theirproblems.
I am at the end of my patience
at the end of my work day.
I really don’t care about what
happens to some of my
team/colleagues.

I have become more insensitive

to people in the workplace.
I’m afraid that this job is making
me uncaring.

Total score – SECTION B

107
 A Few
A Few
Times Once Every
Questions: A Few Once a Times
per a Day
Never Times Month per
Month Week
per Week
Year

Section C: 0 1 2 3 4 5 6
I accomplish many worthwhile

things in this job.

I feel full of energy.

I am easily able tounderstand

what my team/colleaguesfeel.
I look after my team/colleagues
problems very effectively.
In my work, I handle emotional
problems very calmly.
Through my work, I feel that
I have a positive influence on
people.
I am easily able to create a
relaxed atmosphere with my
team/colleagues.
I feel refreshed when I
have been close to my
team/
colleagues at work.
Total score – SECTION C

108
SCORING RESULTS – INTERPRETATION

Section A: Burnout

Burnout (or depressive anxiety syndrome): Testifies to fatigue at the very idea of work,
chronic fatigue, trouble sleeping, physical problems. For the MBI, as well as for most
authors, “exhaustion would be the key component of the syndrome.” Unlike depression,
the problems disappear outside work.
Total 17 or less: Low-level burnout

Total between 18 and 29 inclusive: Moderate burnout

Total over 30: High-level burnout
Section B: Depersonalization

“Depersonalization” (or loss of empathy): Rather a “dehumanization” in interpersonal

relations. The notion of detachment is excessive, leading to cynicism with negative
attitudes with regard to colleagues, feeling of guilt, avoidance of social contacts and
withdrawing into oneself. The professional blocks the empathy they can show to their
colleagues.
Total 5 or less: Low-level burnout
Total between 6 and 11 inclusive: Moderate burnout
Total of 12 and greater: High-level burnout
Section C: Personal Achievement

The reduction of personal achievement: The individual assesses themselves negatively,

feels they are unable to move the situation forward. This component represents the
demotivating effects of a difficult, repetitive situation leading to failure despite efforts. The
person begins to doubt their genuine abilities to accomplish things. This aspect is a
consequence of the first two.
Total 33 or less: High-level burnout
Total between 34 and 39 inclusive: Moderate burnout
Total greater than 40: Low-level burnout

109
A high score in the first two sections and a low score in the last section may indicate
burnout.
Note: Different people react to stress and burnout differently. This test is not intended to
be a clinical analysis or assessment. The information is not designed to diagnose or treat
your stress or symptoms of burnout. Consult your medical doctor, counselor or mental
health professional if you feel that you need help regarding stress management or dealing
with burnout.
Annexes

Annex 1: Jefferson Scale of Lifelong Learning

Strongly Disagree

Strongly Agree
Instructions: Please indicate the extent of your agreement with each of

Disagree
the following statements by circling the appropriate number.

Agree
1. Searching for the answer to a question is, in and by itself, rewarding 1 2 3 4
2. Lifelong learning is a professional responsibility of all health care 1 2 3 4
providers

3. I enjoy reading articles in which issues of healthcare/medicine are 1 2 3 4

discussed

4. I routinely attend professionals study groups 1 2 3 4

5. I read healthcare/medical literature in journals, websites or text books 1 2 3 4

at leastOnce every week

6. I routinely search electronic resources to find out about new 1 2 3 4

developments in health care/ medicine

7. I believe that I would fall behind if I stopped learning about new 1 2 3 4

developmentsIn healthcare/medicine

8. One oftheimportant goals of health professions’ education is to 1 2 3 4

develop students’ lifelong learning skills

9. Rapid changes in health science/medicine require constant updating of 1 2 3 4

knowledge and development of new professional skills.

10. I always make time for learning on my own, even when I have a busy 1 2 3 4
workschedule and other obligations

11. I recognize my need to constantly acquire new profession 1 2 3 4

acknowledge

12. I routinely attend optional sessions, such as professional meetings,

1 2 3 4
guest lectures, or clinics where I can volunteer to improve my
knowledge and clinical skills

13. I take every opportunity to gain new knowledge/skills that are 1 2 3 4

important toMy discipline
14. My preferred approach in finding an answer to a question is to 1 2 3 4
consult a credible resource such as a textbook or electronic resource

©2007JeffersonMedical College.Allrightsreserved.
Annex 2: Continuing Professional Development Plan

What I would Specific What I will do By when Review of

like to objectives objectives
(Date)
develop (How? By
whom?)

e.g. Improve e.g. Perform a e.g. Attend short e.g. 30th e.g. Training
my patient care new procedural term training August 2021 certificate
skill in skill (mention provided by a Medical reports
performing specifically) professional and records on
association my performance
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