One of the greatest challenges facing health care organisations in recent years has been how to adjust to the rapid pace of a wide variety of internal and external changes:
Role enhancement
Role enhancement involves expanding a group of workers' skills so they can assume a wider and higher range of responsibilities through innovative and non-traditional roles [
66]. Enhancing staff members' roles through new competencies gives to employees the opportunity to acquire new competencies and expand their tasks so that they can take on responsibilities traditionally carried out at higher levels [
67]. By altering the content of their work, employees are offered opportunities for individual achievement and recognition. Under this model there is greater work depth because employees are involved in tasks that increase their control or responsibility [
68]. Role enrichment is considered a vertical and upward expansion of work because it alters authority, responsibility, level of complexity and assignment specificity [
69]. In a specific health care context, role enhancement describes a level of practice that maximizes workers' use of in-depth knowledge and skills (related to clinical practice, education, research, professional development, and leadership) to meet clients' health needs [
70,
71].
Role enhancement does not entail adding functions from other professions. It occurs within a given profession's full scope of practice through the integration of theoretical, research-based and practical knowledge inherent to the development of a discipline [
72]. It can also arise from innovative professional activity, new models of health care delivery, and organisational changes that promote development of new knowledge, skills, and practices. Through experience, continued professional growth and development, and collaboration with colleagues from other disciplines, health care workers can develop new skills, abilities, and techniques they did not obtain during previous clinical preparation [
73]. In addition, as health care work expands into new settings, the situational factors that shape service provision in those environments create demands for new skills [
74].
In health care, role enhancement has been associated with the potential to increase longitudinal and personal continuity and improve patients' health outcomes by enabling one professional to cover a wider range of care needs or by enabling one patient to be cared for by fewer workers. As a result, many health care professionals such as nurses, pharmacists, and GPs have recently expanded their responsibilities beyond their traditional scope of practice to include more innovative roles. In many cases, these role expansions were initiated in order to ensure that individual professionals would be able to oversee a greater proportion of their patients' care.
Primary care and prevention are the main areas in which nurses have taken the lead in delivering expanded services, including health promotion, health screening, and discharge follow-up. Since the 1990s, nurses in UK general practices have been responsible for carrying out well-patient health checks and providing lifestyle counselling and other interventions in accordance with treatment guidelines [
75]. Nurses have also expanded their roles by specialising in practice domains and by helping people with particular conditions. Such specialist nurses can be based in either primary or secondary care, and they are particularly active in nurse-led clinics, where nurses assume responsibilities such as managing people with long-term conditions, providing health promotion advice, monitoring and informing patients, and screening for diseases (e.g., cervical screening, cardiovascular screening) [
76‐
79]. Role expansion can also be seen in nurse-led outpatient follow-ups, whereby hospital or community-based nurses oversee discharge planning and post-discharge outpatient follow-up [
80]. These examples illustrate the expansion of nursing into areas that were often unmet or inadequately addressed.
While retaining their generalist background, some GPs have also expanded their roles. In the US and the UK, GPs who hold additional qualifications or training and who focus on particular areas are sometimes known as "GPs with special interests." Such physicians can offer specialist care in the community or work as part of multidisciplinary hospital and primary care teams [
81‐
83]. Similar developments have occurred for pharmacists whose work has expanded far beyond the distribution of medications to include patient education, health promotion, counselling, medication management, health monitoring, and even, in some jurisdictions, prescribing [
84‐
86]. In England, the Medicines Management Collaborative involves 146 primary care trusts and 44 trusts, and it aims to engage all members of the pharmacy team in identifying and addressing patients' unmet pharmaceutical needs [
87].
Despite major interest in developing enhanced roles, evidence about the impact of these new roles is limited and has focussed mostly on nursing. Overall, the evidence suggests that health professionals can learn specific advanced skills that fall outside the scope of their routine practice and apply them in clinical settings. However the impact of such role enhancement remains uncertain. Some studies have found improvements associated with organisational innovations that draw on nurses with advanced skills, including nurse-led clinics or specialist nurse-led initiatives [
88‐
91]. Other studies have found fewer or no benefits [
92‐
95]. However there are variations in the nursing interventions in these studies which may lead to inconsistencies in the findings and make it difficult to draw conclusions about the effects of enhanced nursing roles on patient outcomes. We cannot be certain whether any observed differences are due to the nurses' roles or to other intervention-related factors (e.g., resource intensity, increased follow-up, access to a multidisciplinary team). Thus, although many studies have revealed connections between nurses' role enhancements and safe and effective care or improved patient outcomes, it remains uncertain whether the benefits are due to specific interventions or nurses' roles. Furthermore, the evidence regarding the opportunity costs of such service developments and marginal gains in terms of health outcomes is still scarce and often conflicting.
In addition to patient outcomes, role enhancement also likely affects professionals. Role enhancement echoes research about motivational theory and job enrichment [
96,
97]. Motivation may be a function of work factors such as responsibility, advancement, recognition and opportunity to acquire and use vertical skills including, for example, leadership and self-regulation. It has been suggested that enriched jobs that include these factors lead to satisfaction and motivation because they provide workers with more control, responsibility, and discretion over how they perform their jobs. Research on role enhancement in various sectors suggests that enriched jobs are more meaningful and less exhausting and associated with greater job satisfaction [
98‐
101]. In the health care arena, role enhancement may also have a positive effect on workforce recruitment and retention, either by providing more advanced roles with increases in pay and status or through the creation of new clinical career pathways [
102].
Despite the benefits associated with role enhancement, some caution is required. First, as traditional roles and functions change, confusion and disagreements can challenge professionals' identities and engender conflicts among practitioners and occupational groups. Such conflicts can, in turn, lead to low morale and antagonistic working relationships [
103,
104].
Second, work expansion, even in a vertical direction, is not always synonymous with job enrichment or role enhancement. In the absence of an explicit professionalization project, HR management strategies designed to expand practice scopes may undermine professionals' distinctive work domains because they blur role boundaries and make the work of one profession indistinguishable from that of others. Lack of clarity about professional practice means that, in fulfilling useful, flexible, and cost-effective new roles, individuals may serve managerial, economic, and patient interests, but their roles may remain limited and lack any obvious benefits for the development of their professions. Some analysts have even suggested that the skill-mix changes that have recently gained popularity (e.g., addition of new functions to nurses' roles) are nothing more than revamped versions of rationalisation programmes, undertakings that exposed workers to a potent mix of resource constraints, heavy workloads, significant role changes, and pressures to develop a broader range of skills [
105,
106]. These increased pressures to develop new skills and reach higher educational standards may be counter-productive if they demotivate workers who feel they must take on additional work without reciprocal support [
107].
Third, it cannot be assumed that role enhancement means a general upskilling of workers. Just because staff members must perform more tasks at higher levels does not mean they have been supported by further training. Several influential reports have voiced concerns that the broad range of initiatives being implemented to expand health care workers' roles is not always combined with efforts to establish educational and training programs that are consistent with these developments [
108,
109]. While some key stakeholders, including governments and employers, have argued for the expansion of scopes of practice in health care, the pace of service development has often outstripped the ability of training programs to equip workers.
Role enlargement
Role enlargement is the horizontal accrual and diversification of employees' skills. Staff members are able to extend their activities and take on roles and functions at parallel levels (horizontal enlargement) or lower levels (downward enlargement) [
110‐
112].
In industry, role enlargement aims to change the scope of jobs in an attempt to motivate workers [
113,
114]. This practice emerged as a response to excessive specialisation in the division of industrial labour, whereby work is typically divided into small units, each of which is performed repetitively by an individual worker. Concerns about extreme specialisation and its adverse effects on workers' morale led to calls to restore some of the skill, responsibility, and variety that have been lost through work simplification [
115,
116].
In health care, role enlargement has been part of efforts to shift service delivery from a task-oriented approach towards integrated care carried out by workers who are able to meet patients' multiple and complex needs [
117]. While the rapidly shifting balance between acute and chronic health problems in industrialised countries is placing new demands on health care workers, there is a general consensus that health care professionals' skills must be expanded in order to provide effective care for people with chronic conditions [
118]. Population-based approaches to care that have been part of recent reforms in many jurisdictions move health care workers from caring for a single unit (one person seeking care) towards planning and delivering care to defined populations, to ensure that effective interventions reach all the people who need them within a given population. To meet this challenge, practitioners must assume new roles such as the ability to manage populations, to assess the health care needs of wider groups, and to plan and implement appropriate levels of health and social-care interventions.
As with role enhancement, role enlargement succeeds not by replacing one professional with another but by adding new dimensions to health care through the expansion of workers' skill repertoires. Such role enlargement has been present in many recent initiatives in which the main focus has been on practitioners' acquisition of additional, basic patient-care skills. These new skills enable practitioners to perform certain routine, frequently provided, easily trainable, and low-risk procedures (e.g., monitoring vital signs, measuring blood glucose level, carrying out venipuncture for blood sampling, measuring peak expiratory flow rate, examining for breast lumps and providing advice on health promotion) that can help bring about more integrated care.
Horizontal expansion can also be seen in increased interest in cross-training generic and nonclinical skills, such as patient/client education, technical writing and team dynamics/communication. The World Health Organisation (2005) [
119] has identified five core generic skills that transcend the boundaries of specific disciplines and apply to everyone who cares for patients with chronic conditions:
In addition to completing basic disciplinary training, professionals who care for patients with chronic conditions must acquire a broad range of skills related to programmatic activities, quality improvement, case management, systems design and management of clinical services. In several countries, this role enlargement is reflected in training efforts whereby health care workers learn to negotiate care plans with patients, to support patients' self-management, to use information systems, and to work as members of teams [
120].
Beyond its potential to reduce service fragmentation, role enlargement can also have a positive impact on staff members themselves. Studies on the effects of job-enlargement programs have generally shown that focusing on role breadth tends to increase job variety, enhance task significance, increase autonomy, and improve motivation [
121‐
123]. In one study, multi-skilled health care workers with broad practice scopes reported having more interesting jobs, greater job security, and more feelings of enhanced contribution to their hospital than did uni-skilled employees [
124].
However some research has also found that role enlargement must be undertaken cautiously because unabated expansion can eventually threaten professional identity, intensify workloads to the point of excess, and spark significant levels of demotivation and dissatisfaction. Nurses, for instance, have reported negative outcomes associated with role enlargement, primarily as a result of having to undertake more tasks. Occurring at a time of nursing shortage and often in the absence of reciprocal workload support from other occupations, these extra demands involve juggling additional functions on top of pre-existing clinical responsibilities and in more pressured environments [
125]. In such cases, staff members' resentment is fuelled by the perception that their specialist knowledge and skills are being devalued at the same time as they are being asked to take on a broader range of generic functions while less qualified personnel are taking over their traditional areas of responsibility [
125].