From her early career as a nurse practitioner (NP) in Canada’s public health system to her current capacity as an influential post-doctoral healthcare academic, Dr Alison Roots has been identifying efficiencies that make healthcare workforces both more sustainable and effective.

An effective healthcare workforce with long-term impact is contingent on people working to their full scope of practice, and, according to Alison, employers with the capacity to think past short-term fiscal cycles.

Alison is an advocate for more dynamic healthcare scopes of practice outside of traditional silos, and it’s through this lens that we have our conversation today.

Could you talk about your early career and formative experiences of interdisciplinary care?

After I graduated from university with my Bachelor of Science in Nursing in the early 1980s, I moved very quickly into advanced practice, which was very much in its infancy at that time.

It was a tough road, because at that time, clinical advanced practice was certainly not very well received in lots of places, but it did give me a lot of experience and skills around how to manage change. After a few years, I became a clinical manager in a very large emergency department in a very large Canadian hospital; we’re talking more than 1000 inpatient beds. It had a huge bed shortage, because we had a very large percentage of elderly people in our geographical area.

One of the most rewarding aspects of that time was that I was part of the design, implementation, and evaluation of a program called the Quick Response Team. This was a multidisciplinary team with registered nurses, physiotherapists, occupational therapists, social workers and home support care workers, and the purpose of the team was that we could intervene within hours, and prevent an elderly person from actually becoming an acute care inpatient admission. We could use the Quick Response Team to send them home with 24-hour-a-day, live-in support for seven days.

We evaluated the program after about two years, and the program was so successful that the government expanded it to include any adult over the age of 19, and the program is still running today, 40 years later. So, it was a pretty huge change, especially considering how we were doing things at that point in time, given it was the mid-1980s. That was a pretty successful event in my career, and it had a big influence on how I moved forward from there.

Tell us about your doctoral studies  at the University of Victoria in Canada?

At the time I undertook my doctoral studies I was working for the nursing regulator to design and implement the nurse practitioner (NP) role into the provincial regulatory framework. NPs were being given the biggest scope of practice for an NP in the world at that time, basically the same as a general practitioner’s (GP) scope of practice, with the same capacity to diagnose and prescribe in the community. I chose to go to the University of Victoria to undertake my doctorate because they were heavily involved in the introduction, education  and implementation of a number of advance practice roles, including the NP role.

As a doctoral student at  the University of Victoria you were also expected to actively participate in their existing research program, which is a little different from many other places. It was sort of a given: ‘you’re here, you’re doing work with us, you’re going to be part of our program now’. I ended up completing four other research projects during the time of my doctorate. These included a study on the enablers and barriers to nursing advanced practice roles, a review of enacting scope of practice to determine if new graduates were being enabled and allowed to work to their legislated scope of practice, the three-year evaluation of the role after implementation, and the government policy review. All of these were government-funded research projects that were part of the overall project to introduce the new role.

My own doctoral work was on the outcomes related to the introduction of the NP role when they worked in collaborative practice with community-based GPs or family practice clinics. I looked at the outcomes from the perspective of GPs, the community, and the health sector. My research found some very substantial and statistically significant changes. Those findings ultimately led to the funding of an additional 200 nursing advanced practice positions across the province.

How would you define workforce planning in the context of healthcare?

Workforce planning is being able to identify your current situation, understand the factors that feed into that situation—from both the supply and demand side of things—and then use that to develop a better way to meet the goals that you need to achieve.

Everybody needs workforce planning, every sector, from health education, right through to big organisations and small businesses. Everybody needs to think more about their planning—what they’re doing, why they’re doing it, and how they need to improve it.

Historically we have been really terrible at it, in the sense that we allow each one of these groups to do it independently without thinking about how they interact with each other—we’re so tied up with meeting immediate problems.

I’ve spent the last five years working with nine jurisdictions around the world, and everybody’s got exactly the same problems, because they have not planned for the future; they work on short fiscal planning cycles, without realising that it takes pretty much a decade to produce some of the necessary healthcare professionals and then they need to support them after investing in getting them.

Do you think there is more of a willingness now to think on that kind of scale?

I think there probably is more now than there has been. I think the challenges that have occurred as a result of COVID have brought a lot of this to the forefront, the worldwide shortage of healthcare professionals—we’re looking at somewhere between 18 and 20 million in the next five years—across all professions. Obviously, it’s going to be the biggest for nursing, because they do represent more than 50% of all healthcare professionals in the world, but it is not unique to them. It’s going to be an issue that covers every allied health profession, it’s going to be an issue that covers medicine, and we’ve got to figure out a better way to go forward than where we are now.

We are incredibly siloed. We have poor planning, and we have limited understanding of the benefits of proper planning.

So what needs to change?

Well first of all, if we could understand what we want people’s scopes of practice to be, then we can educate people to that scope of practice and then get them to work to that scope of practice.

I believe that we need to start with: who’s the best person to do something in a particular organisation or facility, or the private or public sector, whatever the business size? And from there, how do we then provide them with the right education? And what do we need from regulation, be it self-regulation or formal regulation from an external body?

In many cases, we have this turned upside down where we have regulators saying you can do X and an employer saying you can do a portion of that, and an educational program maybe not even teaching to the level of that. So we really do need to flip the whole thing upside down and start looking at it from the patient perspective, and what the patients or clients need, and what the community needs.

We also need to move away from having very traditional siloed approaches, and not everything has to come from medicine, we need to expand what other professions can do; I don’t think that a lot of the young doctors coming through now want it to be the way it was 20 years ago, they have different expectations than their predecessors do. We need to be able to work better together and understand how to do that better than we do now.

Which do you think is more important to educate about the need for workforce planning and how to implement it: the public sector or the private sector?

Oh, I think that we need to do this in both sectors, but clearly, we need to make much better use of the private sector in Australia. I don’t know whether we ever will, a lot of this stuff is not profitable—the private sector needs to step up to the mark and take on a bigger role, but it’s hard to know where the funding for that comes from.

Small business is also going to become an increasing player in the whole area going forward: as we keep more and more people out of hospital, ideally, we are going to need the private sector outside of the hospital to step up and take on a bigger role.

What are the main workforce challenges facing healthcare organisations?

One of the biggest workforce challenges is to recognise that pretty much every profession outside of medicine is not working to their full scope of practice.

We can do so much more with what we have, and part of that involves getting medicine to recognise that they don’t need to do everything. One of the things that came from my research and my doctorate was, because I had NPs embedded in family practice clinics working alongside GPs, one of the things that most of the GPs said is that they had no idea somebody else could do their job just as well; NPs came with a different skill set, they came with a different perspective. Working together, they could do a better job than they could in their own world as two siloed groups.

We need to be more efficient and effective about how we get people to work to their scope of practice. We need to expand and reframe people’s professional boundaries, and we need to get teams working better together.

This is a worldwide problem—every country I’ve ever had any involvement with, and that’s probably about fifteen or sixteen, has exactly the same problem.

What advice would you have for employers and managers who are looking to build a more sustainable workforce?

To think beyond their traditional boundaries and their traditional expectations, to try and remember to embrace technology where they can, but to really think outside the box, and that they can do things differently.

I think if anybody had told us—I’m going back 40 years now—that we could send these frail elderly people home with a home support person, and three times a day visits from up to three or four different types of health care professionals with their IV and their catheter and everything else that we were doing… I think people thought that we were lunatics when we proposed this.

But we did, we sent them home. What we did know is that if we admitted them to the hospital within 48 hours, they were probably never going home; just the event of being admitted into the hospital put them into a dependent state, the chances of them ever going home again were vastly reduced. By keeping them at home, they were able to function as well as they could, in a vastly improved state for them than being in a hospital and at a reduced financial cost.

How integral to a sustainable healthcare workforce are ’employee lifecycle’ concepts like attraction, recruitment, retention?

I would say in particular, recruitment and retention are paramount to a successful and sustainable workforce. You don’t want to be continuously recruiting, you want to retain.

So you need to recruit appropriately, and you need to offer appropriate attractions. Pay is one, but it is not the most important one. An environment that respects people and values and nurtures employees and the workforce is way more important than actually most of the other factors—this will probably lead to the greatest amount of retention, and people will stay because they like it, unless you’re paying terribly.

From my own research, if you have a professional colleague with whom you can share and work in a collaborative manner, it’s been shown that you can increase job satisfaction and lead to increased retention of practitioners and makes recruitment to that site easier—particularly when you’re dealing with an environment where you have a shortage of practitioners, and it is difficult to recruit.

When I did my doctoral research, one of the biggest problems was recruiting GPs to these community practices. Really hard to do, I mean it was almost impossible to recruit GPs. But when we put the NPs in there, all of a sudden, they were like, ‘hey, this has really changed my work life, whereas I wasn’t very happy before’. We had too small a sample to identify whether it helped with bringing onboard new GPs, but certainly [it helped with] retention. Almost all of them said that they were much happier to stick around, because they had a professional colleague that they didn’t have previously.

Alison, any final thoughts?

I just think that this is such an important opportunity we have. Change requires a catalyst and with everything that is currently happening, we have such an opportunity right now to make change. This is just a perfect time with the whole environment around health care and the economy and what’s happening in people’s lives to make change as best we can.

View a selection of Alison Roots’ published work on Researchgate | View Alison’s LinkedIn Profile | Alison will be co-ordinating and co-hosting ‘Develop Your Allied Health Workforce Plan In 90 Days’, a course and learning community at The Allied Health Academy.