It's a jungle out there: Understanding physician payment and its role in group dynamics.

Although collaboration between healthcare professionals is essential for the delivery of effective, efficient, and high-quality care, it remains an ongoing and critical challenge across health systems. As a result, many countries are experimenting with innovative payment and employment models. The literature tends to focus on improving collaboration across organizational and sectoral boundaries, and largely ignores potential barriers to collaborative work between members of the same profession within a single organization. Despite intergroup dynamics and professional boundaries having been shown to restrict patient flow and collaboration between specialties, studies have so far tended to overlook the potential effects of differentiated organizational and payment models on physicians' behaviors and intergroup dynamics. In the present study, we seek to unpack the influence of physicians' payment and employment models on their collaborative behaviors and on intergroup dynamics between specialties, adding to the current scholarship on physician payment and employment by considering how physicians' view and act in response to different structural arrangements. The findings suggest that adopting hybrid models, in which physicians are employed or paid differently within the same organization or practice, creates a bifurcation of the profession whereby physicians across different models are perceived to behave differently and have conflicting professional values. These models are perceived to inhibit collaboration between physicians and complicate hospital governance, restricting the ability to move towards new models of care delivery. These findings can be used as a basis for future work that aims to unpack the reality of physician payment and offer important insights for policies surrounding physician employment.

Electronic health record implementation and healthcare workers' work characteristics and autonomous motivation-a before-and-after study.

BACKGROUND: Technological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers' autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored. METHODS: A quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE). RESULTS: A total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation. CONCLUSIONS: Our study showed that healthcare professionals' perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers' autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers' values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

Health care professionals' motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review.

BACKGROUND: Health care professionals' work motivation is assumed to be crucial for the quality of hospital care, but it is unclear which type of motivation ought to be stimulated to improve quality. Motivation and similar concepts are aligned along a motivational continuum that ranges from (intrinsic) autonomous motivation to (extrinsic) controlled motivation to provide a framework for this mixed-methods systematic review. PURPOSE: This mixed-methods systematic review aims to link various types of health care professionals' motivation directly and through their work-related behaviors to quality of care. METHODS: Six databases were searched from January 1990 to August 2016. Qualitative and quantitative studies were included if they reported on work motivation in relationship to work behavior and/or quality, and study participants were health care professionals working in hospitals in high-income countries. Study bias was evaluated using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. The review protocol was registered in the PROSPERO database (CRD42016043284). RESULTS: A total of 84 out of 6,525 unique records met the inclusion criteria. Results show that health care professionals' autonomous motivation improves their quality perceptions and work-related behaviors. Controlled motivation inhibits voicing behavior, but when balanced with autonomous motivation, it stimulates core task and proactive behavior. Proactivity is associated with increased quality of care perceptions. PRACTICE IMPLICATIONS: To improve quality of care, policy makers and managers need to support health care professionals' autonomous motivation and recognize and facilitate proactivity as an essential part of health care professionals' jobs. Incentive-based quality improvements need to be complemented with aspects that stimulate autonomous motivation.

Two sides to every coin: Assessing the effects of moving physicians to employment contracts.

There is a growing trend of physicians becoming employees of hospital systems and employment is viewed as a mechanism to help achieve health system goals. Yet, the research is mixed on the effects of moving physicians to employment models. While the literature has traditionally placed such forms of employment relationships in opposition to professional autonomy, it has often overlooked the effects on other professional values and there is little empirical work that actually assesses how such a shift affects and is perceived by clinicians themselves. To address these gaps, we conducted a mixed method study at one hospital that recently moved all formerly self-employed physicians to employment contracts. We interviewed physicians to understand how the shift into employment was perceived to influence their work in three domains: the patient domain, the individual domain and the organizational domain. We then conducted a follow-up survey across both formerly employed and self-employed physicians to test our initial findings. We find both positive and negative effects in different domains, offering insights into the mixed results found in the current literature.

Consequences of participating in multidisciplinary medical team meetings for surgical, nonsurgical, and supporting specialties.

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors' hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

How health care complexity leads to cooperation and affects the autonomy of health care professionals.

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient's problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors.

The relationships among asymmetry in task dependence, perceived helping behavior, and trust.

Social relations analyses involving 132 working relationships among 60 individuals from 29 teams revealed that an increase in a team member's task dependence on another team member was associated with higher levels of perceived help from and interpersonal trust in that specific team member, provided the other member was highly task dependent on the focal member. The degree to which an actor perceived a relationship with a partner to be helpful partially mediated the relationship between task dependence and trust. These findings highlight the importance of attending to asymmetries in task dependence and provide valuable insights into mechanisms that can explain the development of trust in organizational work teams.

Facial disfigurement in patients with head and neck cancer: the role of social self-efficacy.

This study investigated the moderating role of social self-efficacy (i.e., the belief that one is capable of exercising control over the reactions and openness of other people) with respect to the link between facial disfigurement and psychological and n = 76) as well as their physicians. In line with the hypotheses, the results revealed that the degree of facial disfigurement, as judged by patients as well as their physicians, was positively related to psychological distress and distress in reaction to unpleasant behavior of others, but only when patients did not feel self-efficacious in social encounters. Furthermore, social self-efficacy mitigated the positive link between facial disfigurement as judged by patients and social isolation.