**The Future Health Workforce: Integrated Solutions and Models of Care**

Editors

**Madhan Balasubramanian Stephanie Short**

MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin

*Editors* Madhan Balasubramanian The University of Sydney Australia

Stephanie Short The University of Sydney Australia

*Editorial Office* MDPI St. Alban-Anlage 66 4052 Basel, Switzerland

This is a reprint of articles from the Special Issue published online in the open access journal *International Journal of Environmental Research and Public Health* (ISSN 1660-4601) (available at: https: //www.mdpi.com/journal/ijerph/special issues/Future Health Workforce).

For citation purposes, cite each article independently as indicated on the article page online and as indicated below:

LastName, A.A.; LastName, B.B.; LastName, C.C. Article Title. *Journal Name* **Year**, *Volume Number*, Page Range.

**ISBN 978-3-0365-1467-3 (Hbk) ISBN 978-3-0365-1468-0 (PDF)**

© 2021 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications.

The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND.

### **Contents**

### **About the Editors** .............................................. **vii**

### **Madhan Balasubramanian and Stephanie Short**

The Future Health Workforce: Integrated Solutions and Models of Care Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 2849, doi:10.3390/ijerph18062849 . . . **1**

### **Belinda O'Sullivan, Matthew McGrail, Tiana Gurney and Priya Martin**

A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 8566, doi:10.3390/ijerph17228566 . . . **5**

### **Zhanming Liang, Peter Howard, Jian Wang and Min Xu**

A Call for Leadership and Management Competency Development for Directors of Medical Services—Evidence from the Chinese Public Hospital System Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 6913, doi:10.3390/ijerph17186913 . . . **23**

### **Eid´ın ´ N´ı She,´ Deirdre O'Donnell, Marie O'Shea and Diarmuid Stokes**

New Ways of Working? A Rapid Exploration of Emerging Evidence Regarding the Care of Older People during COVID19

Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 6442, doi:10.3390/ijerph17186442 . . . **43**

### **Catherine Cosgrave**

Context Matters: Findings from a Qualitative Study Exploring Service and Place Factors Influencing the Recruitment and Retention of Allied Health Professionals in Rural Australian Public Health Services

Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 5815, doi:10.3390/ijerph17165815 . . . **59**

### **Matthew R. McGrail and Belinda G. O'Sullivan**

Faculties to Support General Practitioners Working Rurally at Broader Scope: A National Cross-Sectional Study of Their Value Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 4652, doi:10.3390/ijerph17134652 . . **87**

### **Lilian Monteiro Ferrari Viterbo, Andre´ Santana Costa, Diogo Guedes Vidal and Maria Alzira Pimenta Dinis**

Workers' Healthcare Assistance Model (WHAM): Development, Validation, and Assessment of Sustainable Return on Investment (S-ROI) Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 3143, doi:10.3390/ijerph17093143 . . . **101**

### **Luis Miguel Dos Santos**

The Challenges of Public Health, Social Work, and Psychological Counselling Services in South Korea: The Issues of Limited Support and Resource Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 2771, doi:10.3390/ijerph17082771 . . . **119**

### **Heather Krasna, Katarzyna Czabanowska, Shan Jiang, Simran Khadka, Haruka Morita, Julie Kornfeld and Jeffrey Shaman**

The Future of Careers at the Intersection of Climate Change and Public Health: What Can Job Postings and an Employer Survey Tell Us?

Reprinted from: *Int. J. Environ. Res. Public Health* **2020**, *17*, 1310, doi:10.3390/ijerph17041310 . . . **133**

### **Sandra Lofving ¨ Gupta, Katarina Wijk, Georgina Warner and Anna Sarkadi**

Readiness of Allied Professionals to Join the Mental Health Workforce: A Qualitative Evaluation of Trained Lay Trauma Counsellors' Experiences When Refugee Youth Disclose Suicidal Ideation

Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 1486, doi:10.3390/ijerph18041486 . . . **149**

### **Maria Cristina Sierras-Davo, Manuel Lillo-Crespo, Patricia Verdu and Aimilia Karapostoli**

Transforming the Future Healthcare Workforce across Europe through Improvement Science Training: A Qualitative Approach

Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 1298, doi:10.3390/ijerph18031298 . . . **165**

### **Yuki Ohara, Yoshiaki Nomura, Yuko Yamamoto, Ayako Okada, Noriyasu Hosoya, Nobuhiro Hanada, Hirohiko Hirano and Noriko Takei**

Job Attractiveness and Job Satisfaction of Dental Hygienists: From Japanese Dental Hygienists' Survey 2019

Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 755, doi:10.3390/ijerph18020755 . . . **173**

### **Rosy C. Franklin, Ryan A. Behmer Hansen, Jean M. Pierce, Diomedes J. Tsitouras and Catherine A. Mazzola**

Broken Promises to the People of Newark: A Historical Review of the Newark Uprising, the Newark Agreements, and Rutgers New Jersey Medical School's Commitments to Newark Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 2117, doi:10.3390/ijerph18042117 . . . **183**

### **Madhan Balasubramanian, Aliya Hasan, Suruchi Ganbavale, Anfal Alolayah and Jennifer Gallagher**

Planning the Future Oral Health Workforce: A Rapid Review of Supply, Demand and Need Models, Data Sources and Skill Mix Considerations

Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 2891, doi:10.3390/ijerph18062891 . . . **197**

### **James M. Oleske and John D. Bogden**

Blood Lead Concentrations in Newark Children. Comment on Franklin, R.C.; Behmer Hansen, R.A.; Pierce, J.M.; Tsitouras, D.J.; Mazzola, C.A. Broken Promises to the People of Newark: A Historical Review of the Newark Uprising, the Newark Agreements, and Rutgers New Jersey Medical School's Commitments to Newark. *Int. J. Environ. Res. Public Health* 2021, *18*, 2117. Reprinted from: *Int. J. Environ. Res. Public Health* **2021**, *18*, 2887, doi:10.3390/ijerph18062887 . . . **231**

### **About the Editors**

**Madhan Balasubramanian** is an Australian Government National Health and Medical Research Council (NHMRC) Sidney Sax Research Fellow at the University of Sydney and Kings College London. He is also a Visiting Research Fellow at the University of Adelaide. Madhan is a health services researcher, with core strengths on methodologies, health workforce, ageing, information systems and oral health. He carries specific focus on the future design and sustainable development of core health system components and developing integrated systems to address the sustainable development goals. He brings an excellent track record, relative to opportunity. He has published over 35+ scientific research articles. He has won three nationally competitive Australian Government fellowships. He has received over a million Australian dollars in nationally/internationally competitive fellowships (as CIA), in addition to scholarships and academic prizes. In addition to serving as guest editor in several journals, Madhan also serves as an editorial board member of BMC Health Services Research.

**Stephanie Short** is an established health sociologist and health policy academic at the University of Sydney. She leads the Global Health Workforce Node at the Menzies Centre for Health Policy and Economics, and convenor of HealthGov, an international research network that brings together researchers, professionals, and regulators to provide ideas and evidence to underpin good regulation, safer practice and improved access to health care. She is a member of the Editorial Committee of Health Sociology Review, the Asia Pacific Journal of Health Management and the International Journal of Health Governance. She has successfully secured approximately A\$6 million in competitive grants over the years. Professor Stephanie Short has written nine scholarly books over the last three decades. She is the co-author of the highly successful Health Care and Public Policy: An Australian Analysis, originally published by Macmillan in 1989 with the fifth edition published in 2014. She is the first co-author of the popular text Sociology for Nurses: An Australian Introduction that went into a second edition with Macmillan, and the co-editor of two scholarly collections: Goodbye Normal Gene: Confronting the Genetic Revolution published by Pluto Press, and more recently Health Workforce Governance: Improved Access, Good Regulatory Practice, Safer Patients. These books have attracted over twenty reviews in scholarly journals including Health Policy, Politics and Law, Sociology of Health and Illness, The Journal of Sociology and Health Sociology Review.

### *Editorial* **The Future Health Workforce: Integrated Solutions and Models of Care**

**Madhan Balasubramanian \* and Stephanie Short**

Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; stephanie.short@sydney.edu.au

**\*** Correspondence: madhan.balasubramanian@sydney.edu.au

The health workforce is a vital aspect of health systems, both essential in improving patient and population health outcomes and in addressing contemporary challenges such as universal health coverage (UHC) and sustainable development goals (SDGs). There is an increasing body of research that indicates that if the health workforce were to be redesigned from the ground up—based on population needs—we would see a very different configuration of the health workforce. This makes us wonder how one could design or develop innovative health workforce solution(s) for the future in order to make the health workforce more responsive to population needs.

The 21st century presents several challenges to the health workforce and the health professions that require thoughtful consideration and analysis. Health inequalities continue to exist both within and across countries, especially affecting vulnerable and disadvantaged groups. Disease patterns are changing, with a rise in chronic conditions and non-communicable diseases, the COVID-19 pandemic notwithstanding. Increased life expectancies also present us with the challenge of meeting care provisions for an ageing population. Workforce shortages, geographic maldistribution, and international migration are omnipresent.

Health workforce solutions have been diverse and generally dependent on condition, context, or country-specific scenarios. New health occupations, as well as reforming the scopes of practice of existing occupations, have been widely debated as solutions. Of importance has been how different health personnel groups can work collaboratively as a team, and at different levels of care—primary, secondary, and tertiary. Models of care specific to population groups (e.g., Indigenous peoples, children, or older people) as well as health conditions (e.g., cancer or oral health), and health strategies (e.g., rehabilitation) are emerging, with varied success.

In this special issue of the International Journal of Environmental Research and Public Health, we have brought together research that debates and provides innovative health workforce solutions directed towards meeting population needs, mainly through integrated solutions or models of care. We have also included papers that cover challenges at an education or regulatory level. This special issue, entitled "The Future Health Workforce: Integrated Solutions and Models of Care", features a compelling range of research that spreads across the health professions, including medicine, nursing, dentistry, and allied health. This edition embraces quantitative as well as qualitative research approaches, as well as methodological pluralism and a rapid review. A hallmark of each article is methodological rigor, and we are particularly pleased to have included research conducted with health workforce groups dealing with different conditions in a range of contexts and countries including the USA, the UK, Canada, Australia, Sweden, South Korea, Japan, China, and Brazil. This special issue features 13 papers.

The first research paper, from a multidisciplinary team of researchers based in the Rural Clinical School in the Faculty of Medicine at the University of Queensland in Australia, provides a theory that assists us to understand factors that affect doctors in choosing

**Citation:** Balasubramanian, M.; Short, S. The Future Health Workforce: Integrated Solutions and Models of Care. *IJERPH* **2021**, *18*, 2849. https:// doi.org/10.3390/ijerph18062849

Received: 5 March 2021 Accepted: 6 March 2021 Published: 11 March 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

a generalist or specialist medical career [1]. Belinda O'Sullivan and colleagues' theory shows us that the decision-making process involves multi-level contextual factors that intersect with triggers that produce a career preference. Both clinical and context-specific exposures, as well as attributes, skills, norms, and the status of generalist and specialist fields affects choice. These factors combine with doctors' interests and expectations, including their professional values, and perceptions about socio-economic and lifestyle rewards. It is interesting to note too, that these factors and considerations intersected with social circumstances, most especially gender and life stage.

The second article reports research conducted with the health services management workforce in China [2]. The starting point for the study by Zhanming Liang and colleagues is the fact that the traditional recruitment approach relied on clinical performance and seniority, which provided little incentive to improve competencies. The study utilised validated management competency assessment tool that was administered to directors and deputy directors of medical services (*n* = 295) in three categories of hospitals. The survey revealed that the informal and formal education received by medical leaders in these Chinese hospitals has not been effective in developing the required medical and leadership management competencies. This provides a basis for recommendations regarding health system and higher education strategies to improve the management competencies of clinical leaders in China.

We then turn to a thematic analysis of Twitter data and newspapers extracted through a search for new forms of team work in the health and social care of older people in response to the COVID-19 pandemic [3]. The study conducted out of University College, Dublin in Ireland, identified rapid transformations in ways of working, including innovations in telehealth, and in using online platforms to facilitate team meetings. Interestingly, much of the change was attributed to goodwill as a response to the pandemic.

Catherine Cosgrave's study addresses chronic workforce shortages and unmet health care needs in rural and remote communities in Australia [4]. The findings from this qualitative study (semi-structured interviews with 74 executive staff, managers, and allied health professionals) revealed factors influencing the recruitment and retention of allied health professionals in rural public sector health services in Australia. The study emphasises the value of a 'whole-of-community approach' that supports individual allied health professionals and their families to adjust to a new place and develop a sense of belonging in a new community.

The next paper in this special issue reports a national cross-sectional study of faculties supporting general medical practitioners (GPs) [5]. Matthew McGrail and Belinda O'Sullivan report data obtained from an annual national cross-sectional survey of doctors in Australia conducted between 2008 and 2017. The survey revealed that GPs with fellowship of a rural faculty, were more likely to use advanced skills, especially procedural skills, compared with standard GPs. Membership in a rural faculty was also associated with significantly improved geographic distribution. Thus, the rural faculties were found to be critical in building and sustaining a general medical practice workforce that is better able to respond to health needs in smaller, often isolated, communities.

The following paper takes us to research conducted on an innovative model of workers' healthcare assistants by a group of Portuguese researchers in Brazil [6]. This study presented and validated the Workers' Healthcare Assistance Model (WHAM) which includes an interdisciplinary approach to health risk management. The study was conducted between 2011 and 2018 in a workers' occupational health center in the oil industry in Brazil. The study of a sample of workers (*n* = 965) showed a sustainable return on investment, covering workers with heart disease and diabetes. The study concludes that this model of workers' healthcare assistants is capable of enhancing workers' health in companies, while reducing costs for employers and improving workers' quality of life within the organisation.

Luis Miguel Dos Santos has investigated reasons behind the shortage of public health, social work, and psychological counselling professionals who can provide multilingual

services to minority groups and foreign residents in South Korea [7]. This fascinating study explored why graduates and professionals with multilingual skills in these three professions decided to leave their professional fields for the hospitality and business service sectors, particularly for those who completed their initial training at a university outside Korea. Twelve professionals were interviewed in depth, based on an approach consistent with social cognitive career theory. The results indicated that public health, social work, and psychological counselling services-related positions were not available, and that there was a lack of career development skills amongst these graduates who were working in fields such as tourism (such as a social worker working as a car valet) and marketing.

The next paper in this special issue investigated the future of careers for public-health professionals with training in climate change based on analysis of 16 years' worth of job postings and a survey with prospective employers [8]. Heather Krasna and colleagues from the Mailman School of Public Health at Columbia University in the USA conducted this study in a context where skills and competencies relevant to climate change have been incorporated into the curricula of schools of public health in Europe and Australia. They discovered that current employers value knowledge of fields such as climate mitigation and adaptation, climate-health justice, effects of climate on health, health impact assessment, risk assessment, pollution-health consequences and causes, geographic information system (GIS) mapping, communication, finance and economics, policy analysis, systems thinking, and interdisciplinary understanding. The study found that the current job market for public-health professionals with training in climate change appears small and may grow in the next 5–10 years.

Innovative health workforce solutions were needed for the Swedish mental health workforce due to the recent refugee crisis. Sandra Gupta and colleagues from Uppsala University Sweden explored the experiences of mental health workers towards new training solutions to effectively manage unaccompanied refugee minors [9]. They suggest that dealing with suicidal ideation can be challenging and feelings of helplessness can occur. They suggest that collaboration between agencies and key stakeholders as essential when targeting refugee mental health in a stepped care model to assist the mental health workforce.

The next paper from Sierras-Davo and colleagues based in Spain and Greece discusses how you can transform the future healthcare workforce across Europe through improvement science [10]. They evaluate the experience of European nursing students after an intensive one-week summer programme conducted in 2019 at the University of Alicante in Spain. Based on the findings from the study, values like compassion, respect, or empathy were identified as key elements of care. Furthermore, promoting international students' networking emerged as the key to creating a positive provision for change and the generation of improvement initiatives. They suggest that building a healthcare improvement science culture may provide future healthcare professionals with critical thinking skills and the resources needed to improve their future work settings.

Yuki Ohara and colleagues based in Japan discuss an interesting paper on job attractiveness and job satisfaction of dental hygienists based on the 2019 Japanese dental hygienists survey [11]. Using a nationally representative data set of 7869 working dental hygienists, they analyse seven items of job attractiveness, 14 items of job satisfaction, and 13 items of request to improve the working environment. They implement item response theory and structural equation modelling (SEM) in the analysis. They identify that dental hygienists preferred national qualifications more than income stability. The SEM also showed that job satisfaction consisted of two factors, 'value for work' and 'working environment', as did job attractiveness, with 'contribution' and 'assured income'. Finally, they suggest that improving job satisfaction and work environments could help to improve the employment rate of dental hygienists, which could positively influence patient care.

A very interesting commentary is featured as the penultimate article, titled Broken Promises to the People of Newark. Franklin et al [12] discuss the relationship between organised medicine, state and local leaders, and the people of Newark. The authors emphasise that among medical schools, Rutgers New Jersey Medical School's commitment to Newark is meaningfully unique. This social contract between the medical school and the people of Newark is identified through the portrayal of historical events which led to the establishment and development of the medical school.

We round out this special issue with a rapid review of contemporary techniques and practices in oral health workforce modelling, conducted by a team of researchers from England and Australia [13]. Workforce modelling is used to inform health workforce planning through examination of the current and future supply of professionals against the need and demands of a population. The rapid review included 23 studies from 15 different countries. The study identifies that dentists were the sole oral-health workforce group modelled in 13 studies; only five studies included skill-mix (allied dental personnel) considerations. Furthermore, the most common application of modelling was a workforce to population ratio or a needs-based demand weighted variant. Nearly all studies presented weaknesses in modelling process due to the limitations in data sources and/or nonavailability of necessary data to inform oral health workforce planning. Skill-mix considerations in planning models were also limited to horizontal integration within the oral health professions. This timely study identifies that planning for the future oral health workforce is heavily reliant on quality data being available for supply, demand, and needs models. Integrated methodologies that expand skill-mix considerations and account for uncertainty are essential for future planning exercises.

### **References**


International Journal of *Environmental Research and Public Health*

### *Article* **A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career**

### **Belinda O'Sullivan 1,\*, Matthew McGrail 2, Tiana Gurney <sup>1</sup> and Priya Martin <sup>1</sup>**


Received: 14 October 2020; Accepted: 17 November 2020; Published: 18 November 2020

**Abstract:** There is a lack of theory about what drives choice to be a generalist or specialist doctor, an important issue in many countries for increasing primary/preventative care. We did a realist evaluation to develop a theory to inform what works for whom, when and in what contexts, to yield doctors' choice to be a generalist or specialist. We interviewed 32 Australian doctors (graduates of a large university medical school) who had decided on a generalist (GP/public health) or specialist (all other specialties) career. They reflected on their personal responses to experiences at different times to stimulate their choice. Theory was refined and confirmed by testing it with 17 additional doctors of various specialties/career stages and by referring to wider literature. Our final theory showed the decision involved multi-level contextual factors intersecting with eight triggers to produce either a specialist or generalist choice. Both clinical and place-based exposures, as well as attributes, skills, norms and status of different fields affected choice. This occurred relative to the interests and expectations of different doctors, including their values for professional, socio-economic and lifestyle rewards, often intersecting with issues like gender and life stage. Applying this theory, it is possible to tailor selection and ongoing exposures to yield more generalists.

**Keywords:** career choice; generalist; general practice; specialist; medical training; doctors; realist evaluation; theory; experience; norms; attributes

### **1. Introduction**

Many countries are training more doctors than ever before, but a major goal is achieving enough generalists working in fields like general practice (GP) and public health compared with narrow specialty fields [1]. Achieving a critical mass of generalists is important as they support delivery of integrated, preventative and primary care services across a wide range of community needs, at lower cost, for increased life expectancy [2–5]. Although preventive and primary care services are universally needed, many countries are facing declining general practice numbers [6,7]. Current trends are producing an overabundance of non-GP specialists who focus on targeted populations or body systems, potentially increasing the geographic centralisation (city practitioners), fragmentation and inefficiencies of healthcare. A more generalist workforce could be realised if the levers underpinning the choice to become a generalist or specialist doctor, were better understood.

The existing evidence of specialty choice is limited to countries where there are strong markets for specialist services, including Australia, the United Kingdom (UK), the United States of America (USA), Canada, Germany and Japan. Some is based on medical student intentions [8–14], somewhat unreliable for informing actual choice. Other material explores preferences of junior (pre-registrar) doctors [15–21]

or trainees (registrars/residents enrolled in postgraduate vocational training) along with qualified fellows (generalist/specialist) [22–26]. However, this evidence is largely analysed by influential factors, not specifically about how these factors are activated (including for whom and when various choices might fire), which would better inform the design of interventions to produce generalists, across the long medical training pathway.

The literature highlights that choosing a specialty is a complex process with a number of identified correlates. One national survey of trainees suggested choice of a particular specialty was stimulated by *intrinsic*—appraisal of skills against specialty; intellectual content; interest in helping people; and *extrinsic* factors—work culture; flexible working hours and; hours of work [26]. Compared with other specialties, general practice trainees showed a higher regard for helping people and fitting their work to domestic circumstances [26]. General practice is also attractive because of lifestyle, continuity of care, procedural skills and work opportunities [15,16]. Primary care role models and experiences may facilitate uptake of general practice [15,24,27], although scant studies suggest general practice may have lower professional status compared with focused specialties [15,16,24]. Higher professional status is attributed to specialty fields like surgery that give a clear professional identity and tight network of inherent socio-economic capital [28].

Particular specialties may also be attractive to young and emerging doctors because of their pro-social attributes, like teamwork and caring, which reinforce expected values, norms and cultures [28]. Equally technical attributes may be a drawcard. Cardiology [25], surgery, obstetrics and gynaecology, ophthalmology, anaesthesia and emergency medicine, were attractive because of technical skills and procedural work [26].

Financial reward and medical student debt may also affect the choice to be a generalist or specialist, though the evidence is mixed. A review suggested higher medical student debt may lead to pursuing higher paying specialties in countries like the USA [29], although other USA [29–31] and Australian research [32] contradicts this.

Demographics may equally overlay choice patterns. Females show differentiated considerations of work-life balance and part-time work options when choosing specialties [11,12,25,26,33]. Females are widely demonstrated to be more likely to work in general practice, which has more flexible work options [33]. Males of older age at medical school graduation may also choose general practice to fit with the rest of their lives [32]. Apart from gender, other factors may 'prime the pump' for choosing to be a generalist or specialist, such as ethnic, family and community background as well as personal experiences, but these are under-researched.

There is minimal research specifically dichotomised to generalist or specialist choice, which accounts for the temporal dimensions impacting choice-making. Only one longitudinal study in the UK suggests general practice interest may increase over time following graduation (18% to 33%), 81% noting this related to achieving particular work conditions and 44% to fit domestic circumstances [33]. Otherwise, the decision-making process regardless of specialty is known to be multi-staged [20] and emergent [22].

In summary, complex dynamic patterns are likely to underpin specialty choices but there is minimal theory about how the choice to be a generalist or specialist doctor occurs which accounts for doctor's characteristics and their experiences over time. We aimed to develop theory about what works for whom, when and in what contexts, to yield choice to become a generalist or specialist doctor.

### **2. Materials and Methods**

### *2.1. Design*

We used a realist evaluation method guided by the RAMESES II standards because our question was realist in nature and realist evaluation is applicable for evaluating complex issues [34]. We aimed to explore how context (C) (the backdrop of the doctor's personal characteristics and experiences over time) would trigger mechanisms (M) (the things that enable or the generative force) to yield uptake of a generalist or other specialist medical career (O) [35]). The terms used in realist methods are outlined in Box 1. Realist evaluation aims to test initially hypothesised theory and develop and refine new theory about how programs achieve results, frequently expressed as C + M = O configurations (CMO). As such, the outcome of a realist evaluation is theory, depicted by one or many CMO configurations. The main author (BOS) had completed formal realist methods training and BOS and MM had previously applied the method to a program evaluation.

This study had ethical approval from The University of Queensland ethics committee 2012001171.

### **Box 1.** Definition of terms used in realist evaluations [35,36].

Context—pertains to the backdrop of conditions connected to triggering generative forces (mechanism) that modify behaviour towards the outcome. These may include conditions that change over time, such as funding, trust, experience, locations.

Mechanisms—are considered the 'triggers' or generative forces that lead to outcomes if they are 'activated' in the right conditions. It may denote cognitive or emotional reasoning of the various actors at work, challenges or successes or may be synonymous with the program's strategies such as responding to an incentive.

Outcomes—are intended or unintended resulting from the interplay of context and mechanisms and can be proximal, intermediate or final.

Context-mechanism-outcome (CMO) configurations—is a heuristic used to generate causative explanations pertaining to the data. This process draws out and reflects on the relationship of context, mechanism and outcome of interest in a particular program being evaluated. A CMO configuration may pertain to either the whole program or only certain aspects. Configuring CMO patterns is the basis for generating and/or refining theory that is the product of a realist evaluation.

### *2.2. The Environment for our Evaluation*

Our study was based in Australia which is experiencing a shortage of generalists and rural doctors related to developing a new National Medical Workforce Strategy which this evaluation can inform [37]. After completing university-based medical training, which is of 4–6 years' duration (noting Australia has a mix of under and postgraduate medical degree options), doctors work independently in hospitals as pre-registrars for a minimum of 2 years. Around this time, they are eligible to start applying/commence vocational training (spanning 3–6 years), which involves entering a competitive process for selection into one of a number of individually governed medical colleges (equivalent to 'residency' in many countries).

### *2.3. Initial Program Theory*

Realist methods require that researchers have an initial program theory, which can be tested during the realist evaluation process. This involves broadly hypothesising the potential causal patterns at play for producing generalist or specialist doctors [35]. We applied reciprocal determinism as part of social cognitive theory to our evaluation question. This theory was set out by psychologist Bandura in 1978 [38]. It notes that a person's behaviours both influence and are influenced by personal factors like cognition and the social environment such as observing other doctors. Further, the impact on behaviour may be conditioned from what is experienced/observed and the consequences of this, such as negative feedback or low financial reward. This theory aligns with the background literature about specialty choice, showing it is complex and dynamic, impacted by intrinsic and extrinsic drivers [26], an interplay of influences and mediating factors [15,28].

Moreover, that choosing a specialty involves a complex cognitive process undertaken within a personal, social and professional context particular to each individual [28,32] and over different stages [20]. The methods for exploring this further, across two phases, were chosen to firstly allow for in-depth analysis of empirical data from contemporary early career doctors about their career decisions (interviews) (phase 1: developing theory). Secondly, and broader perspectives beyond the context of the individual were collected, by checking phase 1- s findings with a wider sample of medical experts involved in this field, along with exploring other literature (phase 2: refining theory).

### 2.3.1. Phase 1: Developing Theory

To develop theory relevant to the research question, in 2019, we drew on a purposeful sample of 82 doctors who graduated from the University of Queensland (one of Australia's largest medical courses) for whom we had Email contact details. We aimed to recruit graduates between their 1st and 17th postgraduate year of work (as this is a broad period of those both entering and recently experiencing specialty training, thus capturing specialty choice decisions across diverse pathways/fields), covering a mix of genders, work locations and generalist/specialist fields to gain a breadth of perspectives of relevance to our research question.

A semi-structured interview schedule was developed and piloted by the research team of mixed qualitative and quantitative experience and explored "*the nature of medical career decision making"* including reflections (current or recent past) about specialty choice (Table 1). Participants were blinded to the research question to encourage free reflection from the perspective of their own experiences.


**Table 1.** Interview guide used in phase 1.

Interviews of up to 40 minutes' duration were done using video and phone-meetings, by two qualitative-PhD-trained female interviewers who had no prior relationship with participants (TG and PM). Participants were not paid. Prompts (Table 1) were used to expand and deepen understanding of issues for full description [39]. Post-interviews, the researchers recorded reflective notes and discussed emerging themes with the wider research team for sense-making and informing hidden areas for further exploration [39]. Data collection ceased once saturation was reached. Interviews were recorded, transcribed verbatim and de-identified using a unique identifier.

The full de-identified transcripts were read by the whole research team. For a breadth of interpretation, the research team included academics with experience as clinicians (BOS, PM, both nonmedical), policy/program staff (BOS, PM) and mixed methods medical workforce research (all). This allowed analysis to draw on different theoretical interpretations of the data (triangulation) to reduce subjective bias [39] and be self-reflexive with respect to predilections or opinions [40,41].

The researchers highlighted and sorted CMO configurations from transcripts, building on and expanding the original program theory. These configurations were discussed at multiple meetings (iterative process), where reflective notes were recorded and shared with the team to aid depth of analysis. Thereafter, full transcripts and extracted text were re-reviewed by all authors, to check for any deviations and consider consistent CMO configurations underlying an holistic theory [39]. This process enabled internal corroboration or disconfirmation [42,43] until the research team reached consensus about a coherent phase 1 program theory.

To aid interpretation, transcripts and extracted text included notation of participant characteristics and the outcome: generalist or specialist choice (Table 2).


**Table 2.** Definition of notation used to depict participants in the text of phase 1 interviews a.

<sup>a</sup> All participants interviewed had decided on, commenced or recently completed a specialty field allowing the outcome to be measured. Rural work location was determined using official Modified Monash Model levels 2–7, which is the standard definition used by the Australian government for health policy [44].

**Table 3.** Summary of phase 1 participants (*n* = 32) a.



**Table 3.** *Cont.*

<sup>a</sup> Rural work location was determined using official Modified Monash Model levels 2–7, which is the standard definition used by the Australian government for health policy [44]. All participants interviewed had decided on, commenced or recently completed a specialty field allowing the outcome to be measured. 'Generalist' includes doctors interested, training or fellowed in general practice or public health physician. 'Specialist' included doctors interested, training or fellowed in focused fields –interviewees covering anaesthetics, ophthalmology, surgery, physician, radiology, psychiatry, dermatology.

### 2.3.2. Phase 2: Refining Theory

Inherent to the realist evaluation method, we sought to check the validity of our phase 1 theory and refine it [34]. To do this, a table of CMO configurations from phase 1 (our first stage of program theory) was sent by Email to other medical generalists and specialist experts from Australia, known for leading medical education and/or publishing in the field of medical workforce education/training. They were purposefully selected for a mix of gender, career stages, medical school of origin and Australian states. Those choosing to respond participated in an informal phone conversation about the theory, approximately one week later, (led by BOS), where the theory was explained and participants were asked to use their own experience/observations to reflect on potential refinements and missing elements. Where new or refined CMO configurations were proposed, they were explored for confirmation with further participants and considered with reference to the existing literature. Final patterns were validated or disconfirmed by in-depth discussion with the research team.

### **3. Results**

In phase 1, 32 postgraduate doctors participated, including 50% females and 38% of generalist (11 general practice and 1 public health) and 63% specialist choice (anaesthetics, ophthalmology, surgery, physician, radiology, psychiatry, dermatology) (Table 3).

In phase 2, all 17 contacted doctors responded including graduates of various Australian medical courses, including 30% who were female. Eight were generalists (seven general practice and one public health) and nine specialists (psychiatry, urology, emergency medicine, anaesthetics and three physicians and two from obstetrics and gynaecology).

Phase 1 identified theory consisting of six CMO configurations depicting six mechanisms that stimulated generalist or specialist career choice. These configurations included three mechanisms of an environmental nature: a conversion; ruling things in or out and; validation and support. Two were of a professional nature: suits desired clinical practice and; fits personality and skills. One was of a non-professional nature: work-life balance and personal sustainability. Phase 2 confirmed this theory (each of the six CMO configurations) and identified two additional CMO configurations that should be added. One was of a professional nature: status and reward and; another of a non-professional nature: suits desired economic and social position. The final refined theory consisted of eight CMO configurations, of which the mechanisms are summarised in Figure 1. The full CMO configurations underpinning the consolidated theory are summarised in Table 4 and described below, by mechanism.

**Figure 1.** Mechanisms to produce a generalist or specialist doctor. For the mechanism ruling in or out.




<sup>a</sup> Rural work location was determined using officialModifiedMonashModel levels 2–7 of the Australian government [44]. G refers to 'Generalist' and includes doctors interested, training or fellowed in general practice or as public health physicians. S refers to 'Specialist' and includes doctors interested, training or fellowed in focused fields –interviewees covering anaesthetics, ophthalmology, surgery, physician, radiology, psychiatry, oncology, dermatology.

### *3.1. Environmental*

### 3.1.1. A Conversion

Key focused clinical experiences during medical school were pivotal for choosing to be a specialist particularly if these were reinforced by further exposures in the area of interest:

*I was a medical student* ... *. I visited a surgeon* ... *who ended up doing the most comprehensive face transplant in history* ... *after that* ... *I did a student elective in [major city]—plastic surgery—that was quite good, and then I got into the nitty gritty of trying to be a Plastic Surgery Service Registrar.* (FM4\_Male\_Spec)

Some were also converted to specialist fields from a sense of belonging/comradery within a hospital Department:

*I just clicked with that department. I really enjoyed the people I worked with. I enjoyed the nature of the work, so that's how I chose anaesthetics.*(TR1\_Fem\_Spec)

For generalist choice, early experiences of connecting to a community and rural area were transformative, if reinforced:

*I did a rural health placement here [regional centre] as a student* ... *I wasn't really interested in GP probably still at that point* ... *but I was really interested in Aboriginal health* ... *I decided to apply for internship up here* ... *then when I was a Resident* ... *I did a PGPPP [general practice rotation] in [remote area]* ... *in a homeland service* ... *which was just incredible.*(FR5\_Fem\_Gen)

Phase 2 confirmed this pattern of decision-making was valid and identified that generalist conversions could also be stimulated by contact with exemplary generalist doctors [15,24,43].

### 3.1.2. Ruling Things in or Out

Choosing a specialist career involved evaluating a range of mostly postgraduate clinical experience for what was enjoyable and ruling things out.

[as a junior doctor] ... *it's just been solidified over time as I've done di*ff*erent rotations. And you rule out certain specialties.*(TM2\_Male\_Spec)

Comparatively, generalists had a degree of difficulty with choosing one area and progressively ruled things in:

[as a junior doctor] *I had trouble choosing one specific specialty* ... *I* [hoped I] *could have that opportunity to practice some primary health, some hospital health in emergency on the wards as well as some anaesthetics and giving me that wide breadth.*(TM1\_Male\_Gen)

Phase 2 confirmed this pattern of decision-making and added that a generalist choice was a way for the things that doctors 'ruled in' to be aggregated under a single role, with sufficient training [44].

### 3.1.3. Validation and Support

Receiving feedback and endorsement of focused skills, including references from a specialist, was related to choosing to become a specialist. This occurred at a stage when they were impressionable and open to new experiences.

*I think the primary motivating factor for psychiatry* ... *was driven partly by what I perceive to be reasonable success and good feedback when I worked in a junior stage. I think I was quite impressionable and so, I was quick to jump* ... (TR3\_Male\_Spec)

For generalists, validation and support came from professional role models (often supervisors) who invested in a personal connection, demonstrating lifestyle and continuity medicine as early as medical school:

[When medical student] ... *I was nursed along and shown what the joys of general practice and long-term care in a community was like.*(FR1\_Male\_Gen)

[When medical student] ... *individuals who were prepared to take me into their personal and family lives, and not just at clinic* ... *as a person, in my early 20s, that had a big impact on my ideas about the world.*(FR6\_Fem\_Gen)

Phase 2 confirmed this pattern of decision-making.

### *3.2. Professional*

3.2.1. Suits Desired Clinical Practice

Choosing to be a specialist also occurred when doctors evaluated the suitability of the components of clinical practice against professional expectations like achieving intellectual stimulation, doing procedural work and working in acute hospital care. For doctors of fixed specialty ideation at medical school entry (who knew exactly what sort of specialist they wanted to be), experiencing their preferred specialty reinforced their orientation to that particular specialist field.

*I always loved doing critical care, I was always interested in looking after sick patients. I always wanted to work in a hospital environment. That's just how I felt about it* ... *.*(FM1\_Fem\_Spec)

For doctors with malleable career ideation, postgraduate experiences aided an attraction to a particular specialist area:

*I became interested in anaesthetics when I was in my intern year* ... *I guess I really enjoy the very procedural nature of anaesthetics*(TR1\_Fem\_Spec)

Choice to be a generalist was fashioned by evaluating clinical practice against professional expectations of using a breadth of skills, being involved in holistic and longitudinal patient care improving population health. This mainly occurred in the postgraduate stage.

[As a junior doctor] ... *I can do whole of life care and get in earlier and be the first point of contact rather than just see people when they get to hospital.*(FR6\_Fem\_Gen)

For some, the desire to work in a generalist role to make an upstream difference emanated from getting burnt out by acute hospital healthcare:

[As a junior doctor] ... *I was burnt out from the hospital—you see all the sort of pointy end of things there.*(FR5\_Fem\_Gen)

Phase 2 confirmed this pattern of decision-making and expanded that choice to be a specialist was also related to desire to work in teams [28] whereas choosing to be a generalist was related to seeking more autonomous decision-making [16,32,43].

3.2.2. Fit Personality, Skills and Norms

Doctors choosing to be a specialist discussed being drawn to a field that they perceived fit their attributes, whether these were technical (knowledge of anatomy) or soft skills (communication).

[when a junior doctor] *I chose oncology* ... *I guess my communication skills are probably my strongest point and oncology is a specialty where it's based around communication.*(FR8\_Male\_Spec)

Few choosing to be a generalist noted particular personality or skills that drew them to this, except being comfortable with uncertainty. Phase 2 confirmed this pattern of decision-making and added that along with personality and skills, doctors also evaluated the fit of particular fields to desired professional norms. Those choosing to be a specialist were more likely to desire to align with professional norms [28] whereas generalists, to challenge these included integrating traditional siloes of medical care under one practice model (see *Collingrove Agreement*) [45]. Further, extending on their 'comfort with uncertainty', doctors choosing to be a generalist have attributes of enjoying problem-solving, innovation and change [43,46].

### 3.2.3. Status and Reward

Phase 2 identified a new pattern of decision-making about status and reward, which was validated through further testing and relating to the literature. This occurred in medical school and was reinforced over time. Doctors oriented to specialist choice were sensitised to the inferiority of generalists after hearing from other (hospital) doctors that generalist skills were less, commencing in medical school and reinforced over time [15,24,32]. Those with a desire to be known for doing one thing well (professional status), and to maintain income in a tightly controlled professional network and market, were stimulated to choose to choose to be a specialist [16,28]. People with healthcare power are known to be more likely to act to increase this power including by talking others down, negotiating and using coercion, to maintain this [47,48].

Status and reward influenced choice to be a generalist where doctors observed generalists with excellent skills, recognised by a professional title and well remunerated and supported to use all their skills (capacity to maintain income in a broader market and sustainable rosters and back up supports). This included observing that being able to do many things well achieved status in the community, and made a doctor useful [49]. Recognition methods necessarily have to handle the competing identities of doctors working under the generalist banner (rural and non-rural generalist practitioners is one distinction) and reconcile historical and aspirational conceptualisations of their roles [50].

### *3.3. Non-Professional*

### 3.3.1. Work-Life Balance and Personal Sustainability

Mainly at the postgraduate stage, female and male doctors chose to be a specialist in a particular field, to fulfil expectations for controlled working hours. Males mentioned this in relation to firstly, lifestyle and secondly, being older when they completed medicine and wanting to set up practice faster.

[with partner and children] *Oncology* ... *was a specialty that appealed to me* ... *for a bit of a lifestyle—not a lot of after-hours.*(FR8\_Male\_Spec)

[psychiatry] *I was very well supported in paediatrics as a PHO, but I looked at how long the training programme was at my age and what I'd have to learn and I, despite their assistance, I didn't go that way.*(FM5\_Male\_Spec)

Females did this if they had a partner and were planning children, desiring a sustainable role around personal goals.

[partner planning children, anaesthetics] ... *a career that I can spend time with my children when I have them and all that, and spend time with my partner* ... *you don't have inpatients, you don't have longitudinal care* ... *it doesn't drain you* ... . (JM1\_Fem\_Spec)

Females chose to be a generalist for work flexibility and part-time hours:

... *my own health and then also the birth of my son, yeah just helped to cement my desire for a more flexible part-time approach to clinical work.*(TR3\_Fem\_Gen)

Males chose to be a generalist if they wanted shorter times to access and greater ease to complete training thus commencing independent practice sooner. One participant who was older had considered 'Emergency medicine' but saw 'tough training' and chose to be generalist for flexibility and part-time options.

[GP] ... *allowed much more flexibility in the training and taking part-time work, for example, which any of the other specialties didn't allow.*(FR4\_Male\_Gen)

Phase 2 confirmed these decision-making patterns, including the nuanced differences by gender. Other literature identifies that female doctors favour sustainable careers [49–51] and that male doctors choose careers that allow for lifestyle interests, not restricted to having/raising children [16].

### 3.3.2. Suits Desired Economic and Social Position

Phase 2 identified a new pattern of decision-making about suiting desired economic and social position, which was validated by further testing and in relation to the literature. Doctors chose to be a specialist based on observing the positive socio-economic benefits of various fields. A perception of improved economic and social position was forged by early experience within medical families, at medical schools and reinforced over time, when doctors socialised and worked together [28]. Those with a desire to improve or uphold their socio-economic position and achieve financial security through a medical career, were attracted to specialist roles which pay more than generalist roles [52]. This desire was potentially reinforced by the level of expected rewards for the cost and effort related to training as a doctor [53] and the working hours involved in the role [54].

For doctors choosing to be a generalist, their desired economic and social position was considered in relation to broader socio-cultural values that were wider than gains to be made within the profession [55]. This could include prioritising and complementing other aspects of their socio-cultural identity formed by the values they held for family and within wider society, beyond a professional identity [24]. Other literature confirmed that generalist doctors are more motivated by benevolence, than money and power [56], suggesting that for generalists, social and cultural interests may be stronger than economic ones.

### **4. Discussion**

This is the first known study to develop theory about choosing a generalist or specialist medical career. The decision-making patterns revolved around eight mechanisms of environmental, professional and non-professional domains. These may contribute in proximal, intermediate and final ways [35], to achieving a generalist or specialist doctor, depending on the doctor's characteristics including their attributes, values and desires and how these intersect with their exposures over time.

The final theory reinforces, with some degree of nuance, elements of the original hypothesis about how choice is made, through the theory of reciprocal determinism. This includes depicting that personal cognitive, social/environmental components and conditioning plays a strong role in generalist or specialist choice [38]. Various CMO configurations have the potential to work in synchrony and nudge towards a tipping point of choice to be a generalist or specialist doctor, particularly where these may intersect and build momentum over time. No one CMO configuration within the theory is considered causal, but together these configurations contribute to the emergence of generalist or specialist choice.

Some triggers were stronger for some doctors than others. But our findings provide an understanding of a full range of ways that choice-making can be affected. This includes the context of the doctor and timing by which choice is triggered, whereby our findings have the potential to holistically inform education, training and workforce strategies for better uptake of generalist doctors and the distribution of rural doctors [7,37,57].

Although we present this theory as driving the outcome (positive direction), it can also produce negative outcomes, if patterns of generalist decision-making are suppressed, or insufficient triggers are mounted. Thus, the theory may have greatest utility if used to design holistic policies and programs that promote multiple pro-generalist decision patterns and dampen many of the pro-specialist ones.

Our initial theory was strengthened by drawing on empirical evidence from recent graduates (all of whom at chosen specialty) across a spread of specialties, genders and locations. By then gaining further input from experts spanning different medical schools, career stages and disciplines, enabled the findings and perspectives of individuals to be refined and expanded, supporting greater generalisability of the final theory. This builds on existing research showing specialty choice is multi-level [26] and multi-staged [20], by uniquely depicting the timing of various program, social-economic and cultural normative influences on driving to a generalist or specialist outcome.

The findings identify that exposures for choosing a generalist career such as connecting '*to a community*' and '*role models*', may require recurrent investment (including in medical program design) and be strong and frequent enough to override stimuli leading to specialist choice. This includes reducing the potential that some pro-specialist triggers could fire including doctors being converted by '*key focused clinical experiences*' with specialist departments in hospitals. Other research shows the value of community general practice placements for pre-registrar doctors during internship (additional knowledge and skills) [58]. Planned and regular rotations to non-hospital settings, including in rural areas, with exemplary skilled generalists, who showcase innovative practice, '*problem-solving*' and procedural aspects of their work have the potential to stimulate generalist career interest. Students and junior doctors may also be inspired if they observe the status of generalist doctors in the community, respected for their confidence and competence in a range of situations. This needs to be powerful enough to override potential professional derision of generalists by specialists who are seeking to maintain professional power and market control [15,47].

Our findings also depict that choosing to be a generalist also relies on getting '*enough experience*' of different forms of clinical medicine to '*rule things in*'. This differs from the perception that generalist doctors take this path because they aren't sure about what to do (path of least resistance). On the contrary, generalists are likely to choose this deliberately '*ruling in*' a package of skills areas that form a complementary clinical practice model that is remunerated, recognised, sustainable and allows them to focus on upstream health improvement [59]. Conceptualising viable generalist practice models may take longer for junior doctors than understanding work in more homogenous areas like hospital specialist fields that have a clear professional identity. This may underpin the need for a longer pathway and more deliberate exposure to potential models in areas of interest, to stimulate a generalist choice.

Several elements of theory relate to contemporary challenges. In many countries, more doctors are emerging from postgraduate medical degrees, having incurred more time and cost to achieve two degrees to qualify as a doctor than those from undergraduate systems. Our theory might suggest that older graduates may be more likely to drive towards choosing particular specialty fields or generalist practice, based on two factors: interest in a rapid transition to independent practice (shorter training times and relative ease of training) and to manage work-life balance (leisure, children or other constraints like illness). The tipping point for this group to nominate to a specialty field is that some of these fields enable controlled hours (noted from our research, as psychiatry, anaesthetics and oncology). For this reason, a generalist choice cannot rely on controlled working hours and flexible conditions alone to attract doctors. Instead it requires multi-level strategies including emphasising the gains of organised training pathways to rapid independent practice and promoting of the gains for choosing a generalist career, such as community recognition for '*doing many things well*'. This could be strongly promoted as part of messaging within national campaigns.

Although specialists may claim legitimacy based on their lengthy professional training, expert status and certainty in one area, it may be important to counter this with evidence of generalist competence [48], trust and credibility [60] and the reward generalists may experience from contributing to social (not just professional) goals. This may be important for breaking down the assumed professional hierarchies and levels of reward enabled in specialist roles [28]. Further a structural issue to address, is reducing the gap in earnings between specialists and generalists [52].

As hours of medical work are trending down (average fall of 3.4 h per week 1999–2009 in Australia) [61], advertising generalist work through access to shorter training time frames, flexible and part-time work tailored to trainee needs (including gender-specific flexibility and maternity leave) and sustainable practice models (minimising burnout) continues to be relevant. This issue is increasingly pressing as females (wanting to build careers around children) are making up the bulk of emerging medical school graduates in many countries [62–64].

Finally, our findings also suggest that generalists may be achieved by enrolling more students into medicine who have wider values and social interests based on family, culture and community, as the basis of their identity (status), over would-be-doctors motivated by professional identity and socio-economic gain [28]. Given that values and expectations are established within a socio-cultural

context of family, ethnicity, religion and community, it may be relevant to consider these as important covariates that can affect generalist workforce outcomes.

Our study has limitations. Although we used a 2-phase process to build and refine our theory, it is possible that some elements of theory were missed. This is unlikely given that the cross-university cross-career stage experts in phase 2 largely supported the phase 1 theory, expanding only to two new patterns of decision-making that were cross-validated. Relying on phase 1 interviews across a broad single university early career cohort means there is some potential for sample and recall bias. However, participants were working independently of the university when interviewed and easily recalled their career choice process, whether generalist or specialist and, being blinded to the research question, provided genuine reflections.

The theory we propose is based on medicine in Australia and needs to be refined and validated for other disciplines, countries or career stages. This is particularly because in some countries like America and Canada, the timing of generalist or specialist career choice may occur earlier as part of filling particular pre-set generalist or specialist programs in medical schools that articulate with resident programs, which does not occur in Australia.

In our theory socio-cultural and familial influences mostly featured in relation to affecting pre-set personality, norms and skill as well as the desire for social and economic position relative to other values, but their role and timing of socio-cultural and familial influences may vary in different training sub-systems, countries and cultures. As it was based on a dichotomous outcome, out theory may also require further differentiation for choosing specific specialties and sub-specialties of medical work, including exploring whether this theory applies to further differentiating choice to be a more general (e.g., general surgeon, or more focused sub-specialist e.g., paediatric cardiologist.

### **5. Conclusions**

Our study developed new theory about the dynamics of choosing to be a generalist or specialist doctors. Within three domains: environmental, professional and non-professional, we found eight clear mechanisms linked with the patterns of decision-making to yield a generalist or specialist outcome. These represent multi-level triggers which are turned on by various exposures, relative to doctor's characteristics, at different times, to determine generalist or specialist choice. The findings provide an avenue for tailoring medical education and postgraduate work programs, as well as selecting and mentoring students and junior doctors with particular attributes, norms, values and professional orientations, to increase generalist uptake.

**Author Contributions:** Conceptualisation B.O., Methodology B.O. Data collection T.G., P.M., B.O., Validation and analysis B.O., M.M., T.G., P.M., Writing manuscript B.O., Editing and reviewing B.O., M.M., T.G., P.M. All authors contributed substantially to the work. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding. The researchers who completed this work were employed under the Australian government's Rural Health Multidisciplinary Training Program and had full independence for this project. There were no study sponsors.

**Acknowledgments:** We acknowledge the doctors who gave their valuable time to participate in this study and made this work possible.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


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International Journal of *Environmental Research and Public Health*

### *Article* **A Call for Leadership and Management Competency Development for Directors of Medical Services—Evidence from the Chinese Public Hospital System**

### **Zhanming Liang 1,\*, Peter Howard 1, Jian Wang <sup>2</sup> and Min Xu <sup>3</sup>**


Received: 25 July 2020; Accepted: 19 September 2020; Published: 22 September 2020

**Abstract:** *Background:* A competent medical leadership and management workforce is key to the effectiveness and efficiency of health service provision and to leading and managing the health system reform agenda in China. However, the traditional recruitment and promotion approach of relying on clinical performance and seniority provides limited incentive for competency development and improvement. *Methods:* A three-component survey including the use of a validated management competency assessment tool was conducted with Directors of Medical Services (*n* = 143) and Deputy Directors of Medical Services (*n* = 152) from three categories of hospital in Jinan, Shandong Province, China. *Results:* The survey identified the inadequacy of formal and informal management training received by hospital medical leaders before commencing their management positions and confirms that the low self-perceived competency level across two medical management level and three hospitals was beyond acceptable. The study also indicates that the informal and formal education provided to Chinese medical leaders have not been effective in developing the required management competencies. *Conclusions:* The study suggests two system level approaches (health and higher education systems) and one organization level approach to formulate overall medical leadership and management workforce development strategies to encourages continuous management competency development and self-improvement among clinical leaders in China.

**Keywords:** medical directors; health service management; management workforce development; management competency, Chinese hospitals

### **1. Introduction**

### *1.1. Development of Clinical Managers—The Pathway*

Healthcare systems are unique, complex and politically sensitive, not only because of their size, but because their outputs impact directly and indirectly on the health and wellbeing of the populations that they serve. Healthcare systems require management personnel who not only have the generic management competencies, but also have a good understanding of how such complex systems function, the context in which they operate, and how the large number of organizations and sectors interact. Further limitations include dealing with constant financial constraints and the pressures of the growing healthcare needs of the population. This no doubt leads to why the increasing importance of the role

of clinicians as leaders and managers and the concepts of 'clinical leadership' and 'clinician turned manager' have been well recognized [1,2].

For decades, the utilization of doctors in management roles has been common practice globally [3,4]. In more advanced and well-developed systems, healthcare is generally provided using the 'clinical directorate' concept—healthcare organizations and service provisions are managed by both clinical leaders (such as clinical directors who provide clinical leadership and manage direct service provisions) and by managing directors who may not have clinical backgrounds or qualifications and are responsible for the business and operational aspects. Very often, clinical directors carry the dual roles of heading a clinical specialty, performing management activities and maintaining their own clinical practice [4]. In a medically dominated healthcare system, clinical directors have primary control of medical practices, determine the structure and arrangements of care delivery, and manage the entire system [5]. However, this may not be the case in the less well developed and medically dominated system in China [6].

In the face of global financial downturns, a shrinking resource base and increases in demand, changing a fragmented care provision model into an integrated care model by involving clinicians, especially doctors, to manage and lead such processes, should result in the improvement of service quality, effectiveness and efficiency [2]. This makes the recruitment, selection and preparation of clinicians before and during taking on such challenging clinical management roles more critical than ever. In addition to the traditional approach of in-service training, a much more formal, systematic approach to develop clinical leaders has been recognized for decades [7].

### *1.2. Overall Health Management Workforce Development*

Studies conducted in different industries and healthcare contexts over the past 20 years suggest that management competence can be acquired and improved through targeted training programs and continuous professional development [8–11]. For example, a recent study using the UK Health and Safety Executive Management Competency Framework to train financial managers in Japan demonstrated the effectiveness of training programs in developing management competence and facilitating better work engagement between managers and subordinates [10]. A recent nursing internship program implemented at the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada confirmed the success of professional development and mentoring in developing nursing leaders' competency guided by the Canadian College of Health Leaders Framework (LEADs) (2013) [11]. A randomized control trial which tested the benefits of training programs to develop the competency of public health nurses in program planning also supported the positive linkage between management training and competency development and performance improvement [12]. However, as only a small proportion of managers have the opportunity of formal management training as a mean to advancing their management careers, even in a well-developed health system such as Australia [13], informal training and development become critical. Hence, the development of a health service management workforce requires a combination of formal education such as university degree programs focusing on health service management/administration, informal training and development with more short-term and flexible approaches to management workforce development, and in-service training, mentoring and coaching [6,9]. Participation in networking activities, seminars and conferences is also a widespread approach for professional development and skill enhancement [14]. Evidence also points at the importance of using innovative pedagogy to allow integration of competencies into practice in addition to self-reflection and improvement, such as a combined approach of briefing, discussion facilitation and virtual simulation [15,16].

In Australia, Canada, the U.S., U.K. and other European countries, clinicians can formally develop their management competency via the completion of postgraduate qualifications in health administration or health service management. For example, there are 13 Master of Health Administration Programs (MHA) being offered in Australia which are accredited by the Australasian College of Health Service Management (https://www.achsm.org.au/). In the U.S. and Canada, 88 programs are accredited to the Association of University Programs in Health Administration

(https://www.aupha.org/home). However, the proportion of clinicians trained by the above formal programs remains limited. There are also several specific training programs offered by medical professional institutions to foster development of doctors in leadership and management, such as the Royal Australian College of Medical Administrators (https://racma.edu.au/); the Faculty of Leadership and Medical Management in the U.K. (https://www.fmlm.ac.uk/) and the American Association of Physician Leadership in the U.S. (https://www.physicianleaders.org/).

It is argued that a cultural change in medical education is important, not only for developing medical students' clinical skills, but also introducing some leadership and management topics into the medical curriculum to develop future clinical leaders' understanding of healthcare policy, related issues and funding and financial arrangements [17]. The importance of leadership and management training needs to be recognized as there are core management knowledge and skills that cannot be leant solely based on experience [18].

Despite the increasing recognition of the importance of health service management, the implementation of consistent and large-scale health service management workforce development strategies can be challenging to achieve. For example, unlike other health professions in Australia health service management is not regulated by an accreditation board, resulting in no requirements for management qualifications. In addition, the management competency requirements have not been embedded in regular management performance appraisals resulting in inadequate incentives for continuous informal management training and development which are both time and financially consuming [18]. The lack of understanding of management competency requirements and competency development needs of health service managers in developing countries further limits the capacity of health service management workforce development, in particular leadership amongst clinical managers [19].

The international literature confirms the existence of core competency requirements across management levels and positions allowing learning and borrowing from competencies between different healthcare contexts [19,20]. However, the context sensitive nature of management competencies indicates that the importance of and required level of demonstration for core management competencies may vary between sectors, management positions and management levels [21]. An understanding of the extent of these differences will provide evidence to shape the design of management training and development for health service managers in specific healthcare contexts and positions [22].

### *1.3. Chinese Public Hospitals at a Glance—The Challenges and Management*

The population of China slightly exceeded 1.440 billion in July 2020 equivalent to 18.5% of the total world population and the most populated country in the world [23]. Among the total of 34,000 hospitals in China, 12,000 are public and 22,000 are private. However, 85% of the 6.97 million hospital beds are located in public hospitals responsible for 85% of the 8.52 billion total hospital inpatient and outpatient consultations, [24] making the public hospital system the major medical service provider in China (another 1.89 million beds are in township healthcare centers).

As of 2019, the Chinese healthcare system employs 10.10 million medical technical personnel including 3.82 million licensed doctors and licensed assistant doctors and 4.43 million registered nurses, with majority of them currently working in the public hospital system. Approximately 4.3% of these personnel are also classified as a manager and/or have taken on dual clinician and management roles [25]. The health management workforce consisting of about half million managers is crucial to leading and supervising the transformation of the current Chinese healthcare system. This planned transformation is focused on improving the quality and cost-efficiency of health service provision by shifting from a hospital-centered and fragmentation of health service delivery approach into a more primary care-centered and integrated delivery model [25,26].

The governmental agenda of developing and expanding the healthcare landscape and the rapid development in health service provision requires a health workforce of an appropriate size, skill-mix and competency levels. Recommendations for improving the competencies for hospital managers were made in the Healthy China 2030 Program Outline and *The Guidelines Opinion of Building Modern Hospital Management Systems* published by the Chinese State Council [27]. These two governmental policy documents highlighted the important role of hospital managers in the area of hospital and medical service capacity development and the expectations of improving their professionalism and managerial skills, and the management methods/tools that they used [27]. However, as argued by Linnander et al. (2017) when comparing the health service management workforce development strategies between the USA and Ethiopia, a national framework and pathway to developing the overall health service management workforce is required [28].

### *1.4. The Recruitment and Development of Clinical Leadership and Management in the Chinese Hospital System*

Similar to many developing countries, the Chinese public hospital system is still medically dominated with the vast majority of the senior hospital management positions being filled by clinicians [29,30]. A study focused on understanding the competency training needs of health executives was recently completed in three hospitals representing three different hospital categories completed in Jinan, the 19th most populated city in China with more than 4.3 million population. The study confirmed that 65% of all hospital executives are clinical directors with a medical degree with a further 28% of hospital executives (mainly Directors of Nursing) with nursing qualifications. Less than 6% of all hospital executives (mainly Directors of Administration) came from neither medical nor nursing backgrounds [6].

The senior executive positions in Chinese public hospitals, typically, Executive Directors and Deputy Directors and the Chair and Deputy Chair of the Communist Party, are appointed directly by the Provincial Health Department. The senior management positions under this executive level such as Director of Administration, Director of Clinical Services and Director of Nursing are usually selected internally based on seniority and clinical performance without specific management skills or systematic training requirements [6,29,30]. The development of managerial competency is based on experience rather than targeted management training and development [30].

Although the National Health Commission requires all health services managers to receive management training, meeting such requirements has proven challenging. Liang et al. (2020a) summed up these challenges as the following: lack of agreed management standards and requirements; irrelevance of postgraduate training in management competency development; the absence of requirement of management qualifications for management positions, and the inability of embedding the assessment of management competence and management outcomes in regular performance appraisal of hospital managers providing limited incentives for continuous management training and development [6].

In this context, a large-scale survey was conducted in three hospitals from three hospital categories in Jinan, the capital city of Shandong Province located in the northern part of China in early 2019. The study aimed to develop an understanding of hospital medical directors in terms of their education background, training received prior to and after taking up their management positions, perceived importance of management competencies to management roles, the difficulties encountered and the perceived level of management competency. The study also examined factors that may impact on the management competency development of Directors and Deputy Medical Directors. Based on the findings, the paper will discuss the proposed direction and implications for developing the health management workforce in particular the senior clinical leadership in Chinese hospitals.

### **2. Materials and Methods**

A cross-sectional, descriptive study was conducted to answer the above research questions.

### *2.1. Target Population*

The target population were Directors of Medical Services (DoMS) and Deputy Directors of Medical Services (DDoMS) working at three hospitals representing the three-tier system of hospital categorization in Jinan, Shandong, China. They were: (i) a Level 3 hospital, the First Affiliated Hospital of Shandong First Medical University, formally named Qianfoshan Hospital (QFSH), located in Jinan, the capital city of Shandong Province; (2) Lai Wu Hospital (LWH), a Level 2 hospital located in a suburb of Jinan, and (3) Xi Xian Hospital (XXH), a Level 1 hospital, located in a county area in Shandong Province. A Level 1 hospital is the equivalent to a secondary care facility based outside urban areas. Level II hospitals are equivalent to secondary care facilities based in urban areas. Level 3 hospitals are tertiary care facilities usually based in a large metropolitan center [6].

### *2.2. Questionnaire*

The survey was conducted with potential participants in the targeted positions from three hospitals in Jinan City in late 2018 and early 2019. The questionnaire was developed in English and went through translation and back translation processes and pilot tested in another Jinan hospital before the Chinese version (in Mandarin) was finalized. Each questionnaire took approximately 25 min to complete and consisted of four components:

	- C1. Evidence-informed decision-making (Evidence)—13 behavioral items
	- C2. Operations, administration and resource management (Resources)—17 behavioral items
	- C3. Demonstrated knowledge of healthcare environment and the organization (Knowledge)—11 behavioral items
	- C4. Interpersonal, communication qualities and relationship management (Communications)— 19 behavioral items
	- C5. Leading people and organizations (Leadership)—13 behavioral items
	- C6. Enabling and managing change (Change)—9 behavioral items

The validated MCAP 7-point descriptive scale (Appendix A Table A1) was used for participants to assess their own competency levels [31]. Participants were also asked to self-assess their level of competence for the 82 behavioral items for the six competencies. The results of the self-assessments of the behavioral items associated with the six competencies will be the topic of another paper.

The Qualtrics survey platform (https://www.qualtrics.com/) was used to host the online questionnaire which was distributed by one of the QFSH Deputy Executive Directors directly to the targeted management positions at each of the three hospitals and was open for a two-week period in November and December, 2018. Three reminders were sent from the Deputy Executive Directors to all potential participants during this two-week period. Due to low response rates at QFSH, after discussions a paper-based survey with the same content as the online version was distributed in February 2019 to potential participants to encourage a higher response rate. Completed paper-based surveys were collected within two weeks.

### *2.3. Data Management and Analysis*

The data were downloaded from the Qualtrics website into MS Excel format. In addition, the data from the paper-based questionnaires were entered into MS Excel. The two datasets were merged. Following error checking, the means of the six competencies and the combined competencies were

calculated. All data were then imported into IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA) for analysis.

For ease of analysis, three summary scores were calculated. The first was a summary of the number of different topics of management training experienced before participants took up their management roles. The second score summarized the number of management topics taken up by participants during their management positions. The third score enumerated the number of difficulties that the participants experienced in their current position.

Univariate analyses, including tests for normality, were carried out for all variables and separately by hospital and management level. Differences between management levels and/or hospital were tested for statistical significance by crosstabulation comparing column proportions with adjusted *p-*values (Bonferroni method) and chi square tests (exact tests where indicated) or for other continuous variables by t-tests or univariate analyses of variance.

### *2.4. Ethical Approval and Consent to Participate*

Ethics Approval was granted by the University Human Ethics Committee, La Trobe University (Application ID: HEC18071). All participants consented to participate in the study. This was achieved in the introductory pages of the online survey.

### **3. Results**

A total of 295 DoMS/DDoMS out of a target population of 303 (97%) participated in the survey from the three targeted hospitals. Table 1 provides the characteristics of the participants by hospital. The distribution of management levels was significantly different across hospital levels. DoMS: Level 1 hospital 68.2% versus Level 3 hospital 42.6% (Chi square = 11.009, df = 2, *p* = 0.004).

### *3.1. Demography and Employment Details*

The average male and female gender ratio was 1.78:1 ranging from 1.47:1 to 3.0:1 across hospitals and management levels. Overall, the mean age of participants was 47.2 years. DoMS were significantly older than DDoMS (49.4 years versus 45.1 years, t = 5.883, df = 293, *p* < 0.0005). DoMS had been employed at their current hospital significantly longer than DDoMS (26.5 years versus 20.9 years, t = 5.367, df = 293, *p* < 0.0005). DoMS had been employed as a manager significantly longer than DDoMS (12.7 years versus 7.2 years, t = 6.591, df = 293, *p* < 0.0005). DoMS had been employed in their current management role significantly longer than DDoMS (8.6 years versus 5.0 years, t = 5.893, df = 293, *p* < 0.0005).

### *3.2. Qualifications and Disciplines*

Table 1 also shows the highest levels of education by hospital level. The most frequent highest level was a doctorate (*n* = 115, 39%), followed by a bachelor's degree (*n* = 102, 35%). The next highest level was a master's degree (*n* = 54, 18%). Finally, 8% of participants had only achieved a technical college education. The participants of this last category were usually older DoMS at the Level 1 hospital. Amongst the 169 directors with postgraduate qualifications, five of them were from LCQH (Level 2 hospital), the rest (164, 97%) worked at QFSH (Level 3 hospital). The distributions of education levels were significantly different between hospitals (Fisher's Exact Test = 166.291 *p* < 0.0001).


\* Level 1—Xi Xian Hospital (XXH); Level 2—Lai Wu Hospital (LWH); Level 3—Qian FoShan Hospital (QFSH). The proportions shown are based on a comparison of columns. The compare column proportions option computes pairwise comparisons of column proportions and indicates which pairs of columns (for a given row) in the crosstabulation table are significantly different. The column proportions test assigns a subscript letter to the categories of the column variable. For each pair of columns, the column proportions (for each row) are compared using a *z test*. If a pair of values is significantly different, the values have different subscript letters assigned to them.

There were also significant differences in the distribution of education levels between management levels (data not shown). Deputy directors had significantly higher levels of education compared to directors (Chi-Square = 21.632, df = 3, *p* < 0.0001). More deputy directors of medical services had completed a doctorate compared to directors (48.0% versus 29.4%). Moreover, directors had a higher proportion of technical college education compared to deputy directors (13.3% versus 2.6%).

Out of the 295 participants, 245 (83.1%) had degrees in medicine. Seven participants (2.4%) held a degree in nursing; 13 (4.4%) held a degree in management and 30 (10.2%) held a degree in another discipline. Only nine of the 169 postgraduate qualifications (≈5%) were management related.

### *3.3. Informal Training*

Hospital managers had opportunities to participate in different types of informal training which may include management or non-management related training organized internally by the hospitals or externally by other organizations. Table 2 indicates that more managers participated in management training organized internally than externally (72% vs. 41%) for more than 10 h annually. There were no significant differences between management levels.


**Table 2.** Proportion of participants undertaking different types of informal training for more than 10 h annually by management level, and proportion undertaking

About 22% of participants committed to no less than ten hours in self-study of management related topics annually in the past three years. Table 2 indicates the self-study commitment by DoMS and DDoMS by hospital. Significantly more directors (65.6%) completed self-study compared to deputy directors (34.4%) (Chi square = 8.417, df = 1, *p* = 0.004).

### *3.4. Informal Management Related Training*

Overall, between 37% and 54% of managers from the three hospitals participated in some form of management related training before taking up their current management positions and between 51% and 77% of the managers from the three hospitals participated in some form of management related training after taking up their current management positions. There was an increase in management training participation amongst managers after taking up current management positions across the three hospitals. The participation rate increased between 13% and 29% (Table 3); the increase being greatest amongst managers from XXH.


**Table 3.** Frequency and proportion (*n* (%)) of participants taking part in management related training before taking up and during their current management positions by hospital, and mean scores of training types completed by hospital.

\* Level 1—Xi Xian Hospital (XXH); Level 2—Lai Wu Hospital (LWH); Level 3—Qian FoShan Hospital (QFSH).

### *3.5. Participation in Training Focusing on Di*ff*erent Management Related Topics*

Sixteen management related training topics were provided to participants for multiple selection. Table 3 details the mean scores for training types undertaken before and during current management role by hospital. Managers at QFSH attended significantly more management training types both before taking up and during their management positions compared to the other two hospitals but the differences were not statistically significant. Across all hospitals, managers completed more training types after taking up the management roles compared with before. The increases were greater amongst managers at QFSH and XXH than managers at LWH but the differences were not statistically significant.

Of all the management training topics, (1) conflict resolution, (2) employee relationships, (3) safety training, (4) performance management, (5) leadership, (6) human resource management, and (7) communications were the seven areas which attracted the highest participation (26–37%) before taking up the management positions. After taking up their management roles, an additional five topics (time management, decision-making, resource management, quality control and policy and procedure) also attracted higher participation rates (27–35%).

### *3.6. Di*ffi*culties Encountered in the Management Position*

A list of 15 difficulties for multiple selection were provided for participants to indicate those that they had encountered while in their current management position. There was considerable variation between hospitals. Participants at QFSH tended to report more difficulties than the other hospitals. Table 4 shows the mean difficulties scores by hospital and management level. The mean scores of QFSH managers were significantly higher than the managers at XXH (3.85 versus 2.74). The mean scores of directors of medical services were higher than those of deputy directors (3.89 versus 3.36). In a univariate model of difficulty scores both hospital and management level were significant predictors (hospital: Type III Sum of Squares = 59.206, df = 2, Mean Square = 29.603, *p* = 0.013); management

level: Type III Sum of Squares = 34., df = 1, Mean Square = 34.391, *p* = 0.024). Figure 1 illustrates these results.

**Table 4.** Mean difficulty scores and difficulties experienced (percentage of managers) by hospital and management level.


\* Level 1—Xi Xian Hospital (XXH); Level 2—Lai Wu Hospital (LWH); Level 3—Qian FoShan Hospital (QFSH). # DoMS—Director of Medical Services; DDoMS—Deputy Directors of Medical Services. Bolded percentages identify difficulties experienced by more than 25% of managers from all three hospitals. Italicized percentages indicate difficulties experienced by more than 25% of managers from two hospitals. Those bolded and italicized identify difficulties experienced by more than 25% of both DoMS and DDoMS.

**Figure 1.** Marginal means of difficulties scores by hospital and management level. Level 1—Xi Xian Hospital (XXH); Level 2—Lai Wu Hospital (LWH); Level 3—Qian FoShan Hospital (QFSH).

Table 4 also shows the percentage of managers selecting specific difficulties by management level and hospital. Patient conflict and employee performance were the difficulties selected by no less than 25% of directors from all three hospitals (bolded). Other difficulties that were selected by no less than 25% of directors from at least two hospitals included peer conflict, decision-making and change, new skill acquisition, expected work quality and management outcomes expectations (italicized). In addition, more than 25% of directors from QFSH also encountered the difficulties of team conflict, innovative teamwork and team skill building. There were few significant differences in the selection of difficulties by management level. Those selected by more than 25% of directors and deputy directors (bolded and italicized) included: peer conflict, patient conflict, innovative teamwork, employee performance, decision making and change, new skill acquisition and expected work quality.

### *3.7. Perceived Importance and Self-Assessment of Management Competencies*

Participants were asked to indicate the importance of each of the six core management competencies to their current management role. Using a 5-point Likert importance scale, the vast majority of the managers (ranging from 88% to 98%) confirmed the six competencies as important or very important.

Participants were also asked to what extent they had acquired these competencies prior to taking up the current management position using another 5-point Likert scale as detailed in Table 5. The 'cumulative percentage' column indicates the percentage of participants (ranging between 14.6% and 38.1%) who had not fully acquired or acquired most of the competency.


**Table 5.** Proportions of managers acquiring competencies before taking up their current management position.

### *3.8. Overall Competency Level—Self-Assessment*

Participants were asked to rate their own competency level of the six 'overall' competencies using the validated MCAP management competency assessment descriptive scale [25]. According to the description of MCAP Likert scale (Appendix A Table A1), a competency score of five (5.0) or greater indicates that participants could demonstrate the competency in their role independently without guidance. Table 6 provides details of the mean scores for the six competencies and the combined competencies by management level and hospital. None of the competencies received a mean score greater than five for both management levels. DoMS (range 4.33 to 4.84) scored themselves higher than DDoMS (range 3.94 to 4.57), the differences being statistically significant for competencies 2 (t = 2.350, *n* = 279, *p* = 0.019), 3 (t = 2.089, *n* = 279, *p* = 0.038), 6 (t = 2.126, *n* = 279, *p* = 0.034) and combined competencies (t = 2.128, *n* = 279, *p* = 0.034).



\* Level 1—Xi Xian Hospital (XXH); Level 2—Lai Wu Hospital (LWH); Level 3—Qian FoShan Hospital (QFSH).
