Nursing, Professionalism, and Leadership for the 21st Century Health Systems

27 January 2018

1

Director, The Jockey Club School of Public Health and Primary CareHead, Division of Health System, Policy and ManagementFaculty of Medicine, The Chinese University of Hong Kong

Professor Eng-Kiong YEOH, GBS, OBE, JP

21st Century Health System: People-centered and Integrated Health Services

2WHO (2016)

Challenges for Health System• Demographic changes – life expectancy, lower fertility

• Epidemiological transition – chronic non-communicable diseases

• Social determinants of health

• Health inequalities• Preventable diseases that require lifestyle changes Advances in medical knowledge Technology transformations

• Organisational complexity

• Continuity and coordination of health services

• Collaboration and coordination of health and social care 3

Lifestyle and Chronic Diseases

• Four chronic diseases – cardiovascular disease, cancer, chronic obstructive pulmonary disease and type 2 diabetes

• Linked by common and preventable biological risk factors, high blood pressure, high blood cholesterol and overweight

• By behavioural risk factor, unhealthy diet, physical activity and tobacco use

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Lifestyle & Chronic Diseases

• Major risk factors for chronic diseases: unhealthy lifestyle

• If the major risk factors for chronic disease were eliminated– at least 80% of heart disease, stroke and diabetes would be

prevented; – 40% of cancer would be prevented

Figures quoted from WHO (http://www.who.int/chp/en/)

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Health Systems Framework for Healthy Ageing: Opportunities across the life course

WHO World Report on Ageing and Health (2015) 6

Chronic Disease Characteristics

• Emerge throughout life cycle, more prevalent in later life and associated with multimorbidity

• Multiple causes and complication with 80% life style related• Usually insidious in onset, may present acutely • Life long and persistent, requiring long term medical care• Progresses without treatment with deterioration of health• Progression and complications compromise quality of life

and functional limitations and disabilities• Preventable with life-style changes, progression delayed

and complications averted with treatments• Functional limitations improved with rehabilitation

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Needs of Patients with Chronic Disease

1. Completed medical & illness diagnosis including physical and social functioning situation and role

2. Proactive, preventive (primary and secondary) and rehabilitation interventions are important

3. Patient and the carer play important role in successful outcome of the intervention

4. Require a coordinated approach to person centred(individualized) care at all levels and types of care throughout the duration of the illness

5. Biophysical emotional, social, material, and spiritual needs and priorities of each individuals over the lifetime

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Chronic Disease Management

• Effective chronic care management requires continuity of care over the life-course to prevent deterioration, complications and disability

• 3 primary sites of fragmentation:

- between hospital, specialized, secondary and tertiary care and ambulatory, primary and preventive care

- between the public and private health sector

- between health and social care

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Healthcare Delivery System

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Primary Care

Specialty Care

SocialCare

Robust – Frail – Disabled – Dependent – End of LifeMultiple Chronic Diseases and Multiple Morbidity

Social Needs

Episodic illness

AffordabilityAcceptability

AvailabilityAccessibility

Organisation of Healthcare• Public & private Provision

• Financing

Healthcare Delivery• Types of care• Public & private

Needs and Demand for Care

Primary Care• General doctor consultation

• Health promotion• Disease prevention• Self management(Patient Empowerment)

Secondary/ Tertiary Care• Specialty care• Acute care• Sub‐acute care• Rehabilitation care• Geriatric day care• Outreach services: CNS, CGAT, etc.

Community care• Elderly centres & care support

• Day care places• Home care places

Residential Care• Nursing  home places• Care‐and attention (C&A) places

Health promotion

Disease prevention

Chronic Disease managementPalliative care

Life Course

JCSPHPC (2017)

Integrated Health Services

• Health services that are managed and delivered in a way that ensures people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, at the different levels and sites of care within the health system, and according to their needs throughout their life course

WHO global strategy on people-centred and integrated health services (2015)

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Key Elements of Integrated Care

Comprehensive assessment • Using comprehensive geriatric assessment can evaluate needs and enable care plans to be developed (Beland and Hollander 2011, Goodwin, 2014)

Discharge planning: • Personalized plans for patients aim to improve the efficiency and quality of health care surrounding the discharge process and ensure appropriate and coordinated services are in place to support the patient (Beland and Hollander 2011, Goodwin, 2014)

Case managers/ care co‐ordinators

• A named individual is identified as care coordinator/case manager, who has direct responsibility for supporting service users by coordinating care, engaging service users in their own care and providing care directly (Eklund and Wilhelmson2009, Beland and Hollander 2011, Goodwin 2014).

Multi‐disciplinary teams • Providers from all services must work together in a flexible way to provide coordinated care and so that patients can benefit from expertise from multiple specialties (Billings 2005, Ellis et al. 2011)

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JCSPHPC (2017)

Communication • This is a vital component for all involved in care and extends to the communication between health care professional by providing integrated electronic record management (Belandand Hollander, 2011, 2005, Goodwin, 2014).

Policy and shared values

• Processes need to be facilitated through integrated systems of care so providers can work within common governance or work towards incentives (Goodwin, 2014). 

Patient‐centred care • Holistic and respectful care should be delivered with a focus on the individual and on enabling autonomy by empowering individuals to be involved in their own care (Morgan and Yoder, 2012). 

Care‐givers • Informal carers provide much of the care for older people living in the community and in order to fully integrate care, caregivers should be involved in the care plan and processes.

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Key Elements of Integrated Care (Cont’d)

JCSPHPC (2017)

(a) Type of Integration

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Type

Functional integration(Marco level)

The extent to which key support functions and activities such as financial management, human resources, strategic planning, information management and quality improvement are coordinated across operating units

Organisationintegration(Meso level)

The creation of networks, mergers, contracting or strategic alliances between healthcare institutions

Professional integration(Meso level)

Joint working, group practices, contracting or strategic alliances of healthcare professionals within and between institutions and organisations

Clinical integration (Micro level)

Extent to which patient care services are coordinated across the various personnel, functions, activities and operating units of a system

RAND Europe (2012)

Persons having Chronic Health Conditions by Age

Census and Statistics Department: Thematic Household Survey 50 (2013)

N=1,896,100

Rate of having chronic health conditions among all persons in HK is 28.1%

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Ageing with an Increase in Chronic Diseases

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Hong Kong Health System

Health Expenditure (2013/14)Total expenditure on health as % of GDP 5.7%

Public Expenditure on Health (48.9%)

Private Expenditure on Health (51.1%)

Food and Health Bureau – Hong Kong’s Domestic Health Accounts 2013/14)

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Hong Kong Health System

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Public

Service Delivery

Inpatient (Hospital beds)In 2016

Private

Outpatient(Attendances)In 2013 ‐ Refers to consultations made to Western medicine and Chinese medicine practitioners during the 30 days before enumeration

31% 69%

Inpatient data from Department of Health and Hospital Authority; Outpatient data from Census and Statistics Department Thematic Household Survey Report No. 50     

87% 13%

Hong Kong Health System

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Hong Kong elderly 65+

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No chronic diseases

At least 1 chronic diseases

Approaching end of life

Private(56.5%)

Outpatient Inpatient

Public(81.6%)

Most cannot go for outpatient due to physical problem or transportation

Public(2.9%)

Public(13.7%)

Most deaths in public hospitals

Private(0.6%)

Public(24.3%)

Both (11.7%)

Both (44.7%)

Private(59.0%)

Private(1.7%)

JCSPHPC (2017)

Conceptual integrated system model: Hospital‐Community Network

Community call centre

Care in residential/ nursing homes (CGAT)

Volunteers  & community involvement

Allied health care professionals

Palliative services

Social service centres (Neighbourhood elderly centres)

Clinic/ nursing care*Specialist clinics*Community Nursing*Day hospitals*Private clinics 

Community Hub: services  coordination team

Community Network

Private primary care

Informal caregivers

Hospital/ inpatient Network

Hospital Hub: services coordination team

A&E multidisciplinary community referral team

Inpatient assessment & discharge team

Specialist wards

General medical wards

Accident & Emergency Department

Rehabilitation / convalescent facility

Palliative beds & services

Geriatric‐care focus (i.e. cognitive impairment)       

Enabling policies

Shared medical + social services 

records

Improved  training/ education

Common goals & values

Person‐centered care

EOL policy and 

programmes

Medical‐social service connections 

Visiting medical officers

Emergency medical wards

Post‐discharge care (ICDS)

Post‐discharge care (ICDS)

Note: (1) Hubs and networks are intended as ‘virtual connections’, (2) Service lists are for illustrative purposes, and (3) manyconnections between services are encouraged, in addition to the close working connection between hospital and community hubs.

Family Medicine/ primary care community care centres (HA)

Elderly health centres (DOH)

Hub/ patient coordinators

21JCSPHPC (2017)

Primary care● General Out Patient Clinic● Private Doctors

Community care● Department of Health Elderly Health Centres (health promotion, disease prevention & screening)

Sub‐acute care ● Rehab hospital● Integrated Care Discharge Support 

Community services●Meal delivery● Home care visits● Non‐government organisations

Long‐term care●Community Geriatric Assessment Service (CGAS) in Residential Care Homes for the Elderly (RCHE)● Community Nursing Service

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Intensity

 of care ne

eds

Social service centres● Neighbourhood/ district elderly centres

Post‐hospital discharge/ high intensity needs

Occasional acute illness, otherwise stable

Requires regular additional support

Stable chronic disease/Generally ‘well elderly’

Clinic/ nursing care● Specialist Out Patient Clinic● Community Nursing Service 

‘Medical’ services ‘Social’ services

Enabling policies

Linked budgets

Improved  training/ education

Common goals & values

Information sharing/ 

communication

EOL policy and 

programmes

Harness volunteer potential

Public‐private 

partnership

Commitment to change

An integrated medical-social service network for providing needs-matched care and support

Note: services listed are illustrative rather than definitive 

Patient‐CenteredCare

JCSPHPC (2017)

Profession

• “Profession” as “The occupation which one professes to be skilled in and to follow. a) A vocation in which professed knowledge of some department

of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it

b) In a wider sense: any calling or occupation by which a person habitually earns his living.”

Oxford English Dictionary

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“Professes”

• “Professes” represents a public commitment to a set of values i.e. the Hippocratic Oath or its modern equivalent.

• Knowledge is applied in serving others, professions are seen as altruistic and value based

Cruess, Cruess & Johnston (2000)

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Profession

• Knowledge base• Skills and competencies• Attributes• Values and attitudes• Vocation and duties• Unique service and occupation• Societal recognition

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Professional –Sociological Perspectives1. Possession of specialised knowledge and training that

enable professionals to know what to do in particular circumstances, to be able to provide a rational explanation for their actions, and to undertake the action safely

2. Dedication to public service3. Socially approved self-governance

McDonald (1995)

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Professional –Professional Perspectives• Traditionally, professionals had a broader concept of

professionalism goes beyond sociological description to include a complex of virtues and ideals involving habits of mind and character

Benatar (1997)

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Professionals

• Professionals only have duties – they do not have privileges. The have duties over and above the duties of being a citizen.

Sir Ian Kennedy (20 May 2005)

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Professionalism

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Professionalism

[Professionalism] is based around standards, and the starting point is that it is not just about standards that the individual acquires, but they are [also] in the context of the institution. By standards we are talking not just about clinical standards, but about behaviour and values.

Sir Nigel Crisp (20 May 2005)

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Professionalism

While a body of knowledge is clearly essential, it is the interpretation of knowledge, the engagement with new knowledge, the acknowledgement of uncertainty about knowledge, the sharing of knowledge, not the holding of knowledge, that are the characteristics of modern medicine.

Harry Cayton (12 November 2004)

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Professionalism:Behaviour and Systems View• Specific behaviours required multidimensional

competencies• A practiced skill• Profoundly influenced by organization and environmental

context• External forces need to be harnessed to support, not

inhibit

Lesser et al. (2010)

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Systems View of Professionalism

Lesser et al. (2010)

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Professionalization• Process through a person becomes socialized into a

profession (Chitty KK, 2001)• A process “by which a person acquires the knowledge, skills,

and sense of occupational identity characteristic of a professional and involves the internalization of the values and norms of a professional group” (Jacox A, 1978)

• Professional socialization – begins during the foundational education programs when nurses

internalize the knowledge, skills, attitudes and professional standards– continues as the nurse practices

• Goal of professional socialization – Development of professionalism

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Nursing Professional – Theoretical Framework

Person

Body Pathology

Three interlocking circles Core circle – social, emotional, spiritual, and intellectual needs of the family, community, and world and the therapeutic use of self

Cure circle – functions collaboratively with healthcare team members

Care circle – bodily care

Hall’s Care, Cure, and Core Theory (1969) 35

Prime Feature of Nursing Professionalism

• Relationship between the nurse and the patient (Volp K, 2006)

• Demonstrate certain professional attributes– Knowledge and skills– Accountability– Interpersonal skills and professional attitudes including

communication, empathy and courtesy

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Wheel of Professionalism in Nursing

Copyright ©1984 Barbara Kemp Miller 37

Nursing Professionalism

4 properties:1. High degree of systematic and public knowledge,

2. awareness about the interests of society rather than the personal interest

3. High degree of self-control in behavior through moral codes

4. existence of a reward system as a sign for success

Barber (1965)

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Nursing Professionalism

Defined codes of professional behavior:1. Respecting the dignity, value, and beliefs of the patients

2. Maintaining patients’ trust, making informed decision

3. Provision of competent and safe care, maintaining standards of activities

4. Presenting the image of nursing, having a harmony with the law in action

Lui (2007)

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Nursing Professionalism 1. Continuum in the professional socialization process

2. 5 groups of antecedents of nursing professionalization:

(i) Demographic: ethnic differences, gender differences

(ii) Experience: years of experience, previous experiences, maturity in professional experiences

(iii) Education: membership in professional organizations, specialized certification, educational readiness, training and socialization

(iv) Position: gap between education and clinical practice, expectations & type of organization, workload

(v) Value: professional satisfaction organizational commitment, professional freedom and independence, motivation, belonging, knowing, acknowledging, support and guidance, responsibility, altruism, professional identity, belonging to a team, valuing the work.

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Nursing Professionalism –beginner – expert continuum

5 levels: Beginner

Advanced

Competent

Proficient

Expert

Represent progressive stages of acquired skills and experience

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Concept map of the Professional Value

DignityUniqueness

Right to PrivacyConfidentialityProtection fromIncompetencyResponsibilityCompetence

Informed JudgementProfession’s Body of 

KnowledgeStandards of Care

Conditions of EmploymentCollaboration

Protection of the Public

Unique Body of Knowledge Autonomy 

Strong OrganizationAltruism 

High Education Service

ProfessionalValues

ANA Co

de 

of Ethics

Characteristics 

of Professions

ANA = American Nurses AssociationAACN = American Association of Colleges of Nursing

Kubsch (2008)42

Perceived Professional Values

• Nursing education• Leadership position• Professional organization membership• Age• Baccalaureate registered nurses in first 2 years of

employment

Kubsch (2008)

Correlated with:

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Nursing Professionalism –

Professional vales embodied by the more experienced and older nurses through years of work, insight, and rewards of nursing care that is empathetic, altruistic, holistic, ethical, nutritive, generative, and protective in nature

Kubsch (2008)

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Nursing Professional Development –Clinical Nursing Model – Building

and Enabling Environment

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Hospital Authority Dr Eric Chan (2014)

Career Progression Model for Nurses in HA

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CGMNGMN

DOM/SNONurse

ConsultantDepartment OperationsManager

WM/NS/NO/NE

AdvancedPracticeNurse

Nurse Unit Manager

RN Specialty Nurse

Practice Nurse (pre‐specialty level)

Practice Nurse (perceptive level)

EN

Nursing Service Department , HAHO (2008)

Framework of model

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Tier 5 Servicemanager

Manageservice operation & development

Tier 4 Team manager Manage team operation & development

Tier 5 Specialty /Subspecialtyleader

Lead professionaldevelopment of the specialty/subspecialty

Tier 4 Specialty /Subspecialtypractitioner 

Lead a team provide complex care independently for specialty/subspecialty

Tier 3 Specialty practitioner Provide complex care independently for general specialty

Tier 2 Practitioner Provide general patient care independently Complex/ difficult case under supervision

Tier 1 Entrant practitioner License to practiceProvide service under supervision

Management  Clinical

Nursing Service Department , HAHO (2008)

What’s the future?Current Issues Opportunities for Nursing

Ageing population

Primary Health Care

Non‐communicable diseases

Hospital accreditation

Health care financing & insurance

Health system pressure – waiting list and waiting time

Professional advancement –academy

Tertiary education for nurses

Prevention/ early prevention: health maintenance

Enhancing care in the community

Independent practice

Enhanced scope of practice and credentialing

Refine and redefine of health professional boundaries – service needs and pressure from patients

Relevancy of nursing education and practice – basic and post basic

48Dr Eric Chan (2014)

Professional Regulation

Main purposes

• Ensure that minimally acceptable standards of care are being provided

• Provide accountability and reassure patients and payers that medical professionals are deserving trust; and

• Improve quality of care by providing guidance about best practice and fostering improvements in performance through measurement and feedback

Sutherland and Leatherman (2006)

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Integrated Mechanisms for Regulation

• Personal regulation• Team-based regulation• Organisational regulation• National professional regulation system• Meta-regulation• Patient and public assurance

Department of Health of UK (2009)

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8 Myths in Leadership

52Source: https://www.elsevier.com/connect/8‐myths‐of‐leadership‐by‐a‐stem‐leader

Myth #1: Leadership is a rare skillMyth #2: Leaders are born, not madeMyth #3: Leaders are charismaticMyth #4: Leadership exists only at the 

top of the organizationMyth #5: The leader controls, directs, 

prods and manipulatesMyth #6: How you behave outside of 

work and online does not affect your ability to lead

Myth #7: Leaders have all the answersMyth #8: Your team is there to serve you

Leaders, Leading and Leadership: Confusions in Application• Leaders

– Formally position defined role

– Informal (charismatic/heroic)

"As we look ahead into the next century, leaders will be those who empower others“ (Bill Gates)

• Leadership also refers to “leading” towards achievement of a goal.

• Leadership– Noun: to describe people who lead

– Adjective: to describe quality of leaders or leading

– Adverb: refers to the process of leading

53Source 1: https://www.forbes.com/sites/kevinkruse/2013/04/09/what‐is‐leadership/2/#709fbdd541f0Source 2: http://www.nwlink.com/~donclark/leader/leadled.html

Leadership

Leadership is a dynamic process ofsocial influence towards achievement of a goal

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Health System

• Healthcare leadership takes place at multiple levels and involves multiple professionals

• Requires organisations to redistribute leadership power to wherever expertise, capability and motivation within organisations.

• It calls for collective and shared leadership with the health system and a healthcare organization

• The leadership emphasis is shifted to building relationships, networking, trusts, commitment and social capital

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Psychology 101 for Leaders?• Leadership is about understanding, changing and enhancing human

behavior• Good knowledge of how humans operate in an organization helps the

leadership process – Role of Motivation – People dynamics, how self, groups and organizations behave and

interact– Relationships building and Conflict management, – Building commitment and group identity– Adapting influencing behavior to increase effectiveness– Understanding and influencing culture– Understanding psychodynamic processes

A process of influence that occurs within relationships between leaders and their stakeholders establishing shared vision and generating motivation and inspiration.

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Harnessing Health Professionalism for Clinical Excellence

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Leader

ManagerHealth 

Professional

Self ManagementEmotional intelligence

TraitsStyles

Behaviours

RegistrationClinical Governance

Credentialing

Influencing(clinical excellence)

Psychodynamics Process

ContextTask 

CultureSituation

Power (instrument of influence): PositionalPersonalSocietal

Clinician

Health ProfessionalManager

Motivation (Individual, group)

NeedsExpectancy

InstrumentalityValenceGoals

Professionalism:Values

BehavioursRelationship

Dynamic Dynamic Temporal Temporal

Relationship RelationshipEnvironment Environment JCSPHPC (2017)

Philosophy of Science, Theory and Knowledge Relating to Nursing and Professionalism

“Philosophy, knowledge and theory are intrinsically linked”

“…explore the nature of the philosophy of science, knowledge and theory and their interrelationships, with particular reference to professionalization by considering where nursing has come from and consequently the way forward to ascertaining professional status.”

Rutty (1998)

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Thank you!

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