Love over gold and mind over matter? Identifying capabilities that preserve medical assistants' sustainable employability.

BACKGROUND: Medical assistants (MAs) are crucial for affordable, high-quality primary care, but what motivates this low-wage occupational group to stay in their job remains underexplored. This paper identifies the work aspects that MAs value ("capabilities"), and how they affect sustainable employability, which refers to employees' long-term ability to function and remain in their job. METHODS: We used structural equation modelling to assess how capabilities relate to four outcomes among MAs: burnout, job satisfaction, intention to quit, and experiencing work as meaningful. RESULTS: We find that earning a good income, developing knowledge and skills, and having meaningful relationships at work relate to the outcomes. Meaningful relationships represent a stronger predictor than salary for one's intention to quit. CONCLUSIONS: Competitive salaries are necessary but not sufficient to motivate low-wage health care workers like MAs to stay in their job. Health care leaders and managers should also structure work so that MAs can foster meaningful relationships with others as well as develop competencies.

Use it or lose it? Identifying reasons for the low use of psychosocial support by hospital staff.

BACKGROUND: Psychosocial support programs are a way for hospitals to support the mental health of their staff. However, while support is needed, utilization of support by hospital staff remains low. This study aims to identify reasons for non-use and elements that are important to consider when offering psychosocial support. METHODS: This mixed-method, multiple case study used survey data and in-depth interviews to assess the extent of psychosocial support use, reasons for non-use and perceived important elements regarding the offering of psychosocial support among Dutch hospital staff. The study focused on a time of especially high need, namely the COVID-19 pandemic. Descriptive statistics were used to assess frequency of use among 1514 staff. The constant comparative method was used to analyze answers provided to two open-ended survey questions (n = 274 respondents) and in-depth interviews (n = 37 interviewees). RESULTS: The use of psychosocial support decreased from 8.4% in December 2020 to 3.6% by September 2021. We identified four main reasons for non-use of support: deeming support unnecessary, deeming support unsuitable, being unaware of the availability, or feeling undeserving of support. Furthermore, we uncovered four important elements: offer support structurally after the crisis, adjust support to diverse needs, ensure accessibility and awareness, and an active role for supervisors. CONCLUSIONS: Our results show that the low use of psychosocial support by hospital staff is shaped by individual, organizational, and support-specific factors. These factors can be targeted to increase use of psychosocial support, whereby it is important to also focus on the wider hospital workforce in addition to frontline staff.

Through the looking glass: Confronting health care management's biggest challenges in the wake of a crisis.

BACKGROUND: The challenges brought on by the pandemic triggered a renewed scholarly focus on managing during crises. Now, 3 years on, having covered the initial crisis response, it is important to reevaluate what the crisis has taught us about health care management more generally. In particular, it is useful to consider the persistent challenges that continue to face health care organizations in the wake of a crisis. PURPOSE: The present article aims to identify the biggest challenges that currently face health care managers in order to formulate a postcrisis research agenda. METHODOLOGY/APPROACH: We employ an exploratory qualitative study, utilizing in-depth interviews with hospital executives and management to explore the persistent challenges facing managers in practice. RESULTS: Our qualitative inquiry reveals three key challenges that extend beyond the crisis and are salient for health care managers and organizations in the years to come. Specifically, we identify the centrality of human resource constraints (amidst increasing demand), the necessity of collaboration (amidst competition), and a need to reconsider the approach to leadership (utility of humility). CONCLUSION: We conclude by drawing upon relevant theories such as paradox theory to formulate a research agenda for health care management scholars that can support the creation of novel solutions and approaches to persistent challenges in practice. PRACTICE IMPLICATIONS: We identify several implications for organizations and health systems, including the need to eliminate competition and the importance of building human resource management capacities within organizations. In highlighting areas for future research, we provide organizations and managers with useful and actionable insights to address their most persistent challenges in practice.

Being "low on the totem pole": What makes work worthwhile for medical assistants in an era of primary care transformation.

BACKGROUND: Primary care is undergoing a transformation to become increasingly team-based and multidisciplinary. The medical assistant (MA) is considered a core occupation in the primary care workforce, yet existing studies suggest problematic rates and costs of MA turnover. PURPOSE: We investigated what MAs perceive their occupation to be like and what they value in it to understand how to promote sustainable employability, a concept that is concerned with an employee's ability to function and remain in their job in the long term. APPROACH: We used a case of a large, integrated health system in the United States that practices team-based care and has an MA career development program. We conducted semistructured interviews with 16 MAs in this system and performed an inductive analysis of themes. RESULTS: Our analysis revealed four themes on what MAs value at work: (a) using clinical competence, (b) being a multiskilled resource for clinic operations, (c) building meaningful relationships with patients and coworkers, and (d) being recognized for occupational contributions. MAs perceived scope-of-practice regulations as limiting their use of clinical competence. They also perceived task similarity with nurses in the primary care setting and expressed a relative lack of performance recognition. CONCLUSION: Some of the practice changes that enable primary care transformation may hinder MAs' ability to attain their work values. Extant views on sustainable employability assume a high bar for intrinsic values but are limited when applied to low-wage health care workers in team-based environments. PRACTICE IMPLICATIONS: Efforts to effectively employ and retain MAs should consider proactive communications on scope-of-practice regulations, work redesign to emphasize clinical competence, and the establishment of greater recognition and respect among MAs and nurses.

Newspaper Coverage of Hospitals During a Prolonged Health Crisis: Longitudinal Mixed Methods Study.

BACKGROUND: It is important for health organizations to communicate with the public through newspapers during health crises. Although hospitals were a main source of information for the public during the COVID-19 pandemic, little is known about how this information was presented to the public through (web-based) newspaper articles. OBJECTIVE: This study aims to examine newspaper reporting on the situation in hospitals during the first year of the COVID-19 pandemic in the Netherlands and to assess the degree to which the reporting in newspapers aligned with what occurred in practice. METHODS: We used a mixed methods longitudinal design to compare internal data from all hospitals (n=5) located in one of the most heavily affected regions of the Netherlands with the information reported by a newspaper covering the same region. The internal data comprised 763 pages of crisis meeting documents and 635 minutes of video communications. A total of 14,401 newspaper articles were retrieved from the LexisNexis Academic (RELX Group) database, of which 194 (1.3%) articles were included for data analysis. For qualitative analysis, we used content and thematic analyses. For quantitative analysis, we used chi-square tests. RESULTS: The content of the internal data was categorized into 12 themes: COVID-19 capacity; regular care capacity; regional, national, and international collaboration; human resources; well-being; public support; material resources; innovation; policies and protocols; finance; preparedness; and ethics. Compared with the internal documents, the newspaper articles focused significantly more on the themes COVID-19 capacity (P<.001), regular care capacity (P<.001), and public support (P<.001) during the first year of the pandemic, whereas they focused significantly less on the themes material resources (P=.004) and policies and protocols (P<.001). Differences in attention toward themes were mainly observed between the first and second waves of the pandemic and at the end of the third wave. For some themes, the attention in the newspaper articles preceded the attention given to these themes in the internal documents. Reporting was done through various forms, including diary articles written from the perspective of the hospital staff. No indication of the presence of misinformation was found in the newspaper articles. CONCLUSIONS: Throughout the first year of the pandemic, newspaper articles provided coverage on the situation of hospitals and experiences of staff. The focus on themes within newspaper articles compared with internal hospital data differed significantly for 5 (42%) of the 12 identified themes. The discrepancies between newspapers and hospitals in their focus on themes could be attributed to their gatekeeping roles. Both parties should be aware of their gatekeeping role and how this may affect information distribution. During health crises, newspapers can be a credible source of information for the public. The information can also be valuable for hospitals themselves, as it allows them to anticipate internal and external developments.

Let's Talk About it: The Utility of Formalized Support for Medical Residents.

Medical residents are significantly impacted by burnout and depression. Recent events have only further increased the pressure and demands on the healthcare sector, intensifying the burden facing residents and posing a threat to residents' well-being. As a result, significant efforts are being made to provide formalized support and well-being programs. Yet, emergent evidence indicates that residents do not sufficiently utilize this form of support. Considering the organizational investment and focus on formalized support programs, we conducted a mixed-method study to investigate residents' utilization of formalized well-being support, and potential reasons for non-use. Our study was conducted during a period of increased work burden and stress for medical residents, where formalized support was specifically offered and targeted to medical staff. Our findings confirm earlier results of low support utilization and point to the importance of informal support mechanisms, in particular peer support. We conclude by discussing the role of managers and educational programs in facilitating a positive cultural shift to promote and support residents in seeking support.

Delivering High-Quality Primary Care Requires Work That Is Worthwhile for Medical Assistants.

Medical assistants are core members of the primary care team, but health care organizations struggle to hire and retain them amid the ongoing exodus of health care workers as part of the "Great Resignation." To sustain a stable and engaged workforce of medical assistants, we argue that efforts to hire and retain them should focus on making their work worthwhile. Work that is worthwhile includes adequate pay, benefits, and job security, but additionally enables employees to experience a sense of contribution, growth, social connectedness, and autonomy. We highlight opportunities during team huddles, the rooming of patients, and career development where the work of medical assistants can be made worthwhile. We also connect these components to the work design literature to show how clinic managers and supervising clinicians can promote worthwhile work through decision-making and organizational climate. Going beyond financial compensation, these components target the latent occupational needs of medical assistants and are likely to forge employee-employer relationships that are mutually valued and sustained over time.

Sweet dreams are made of this: A person-centered approach toward understanding the role of sleep in chronic fatigue.

Previous studies show that sleep is essential in preventing symptoms related to chronic levels of fatigue. In the present study, we move beyond the traditional variable-centered approach and adopt a person-centered approach by considering antecedents and outcomes of sleep profiles. Specifically, we consider job characteristics (i.e., workload, job control, and their interaction) as predictors of sleep profiles and indicators of chronic fatigue (i.e., prolonged fatigue and burnout) as outcomes. In establishing sleep profiles, we consider levels as well as the variability of the sleep dimensions across a week. Based on daily diary data from 296 Indonesian employees, the present article uses latent profile analysis to identify sleep profiles based on both weekly averages of several sleep dimensions (i.e., sleep quality, fragmentation, duration, bedtime, and wake-up time) and their intraindividual variability. Moreover, it explores the relationship between the identified profiles to prolonged fatigue and burnout 2 weeks later as outcomes, as well as to baseline workload, job control, and their interaction as predictors. We find four different profiles ("Average Sleepers," "Deep Owls," "Short Sleep Compensators," and "Restless Erratic Sleepers"). While workload, job control, and their interaction could not predict profile membership, these profiles relate differently to prolonged fatigue and burnout. As such, our study shows the importance of understanding the combination of sleep levels and variability across a week through sleep profiles, and how they differentially relate to symptoms of chronic fatigue. Our findings also highlight the need to study indicators of sleep variability alongside sleep levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Conceptual Framework for Integrating Family Caregivers Into the Health Care Team: A Scoping Review.

More than 80% of family care partners of older adults are responsible for coordinating care between and among providers; yet, their inclusion in the health care delivery process lacks recognition, coordination, and standardization. Despite efforts to include care partners (e.g., through informal or formal proxy access to their care recipient's patient portal), policies and procedures around care partner inclusion are complex and inconsistently implemented. We conducted a scoping review of peer-reviewed articles published from 2015 to 2021 and reviewed a final sample of 45 U.S.-based studies. Few articles specifically examine the inclusion of care partners in health care teams; those that do, do not define or measure care partner inclusion in a standardized way. Efforts to consider care partners as "partners" rather than "visitors" require further consideration of how to build health care teams inclusive of care partners. Incentives for health care organizations and providers to practice inclusive team-building may be required.

To Uncertainty and Beyond: Identifying the Capabilities Needed by Hospitals to Function in Dynamic Environments.

Hospitals operate in increasingly complex and dynamically uncertain environments. To understand how hospital organizations can cope with such profound uncertainty, this article presents a multiple case study of five hospitals during the COVID-19 crisis in a heavily hit region of the Netherlands. We find that hospitals make adaptations in five key categories, namely: reorganization, decision-making, human resources, material resources, and planning. These adaptations offer insights into the core capabilities needed by hospitals to cope with dynamic uncertainty. Our findings highlight the need for hospitals to become more flexible without sacrificing efficiency. Organizations can accomplish this by building in more sensing and seizing capabilities to be better prepared for and respond to environmental change. Furthermore, transforming capabilities allow organizations to be more resilient and responsive in the face of ongoing uncertainty. We make recommendations on how hospitals can build these capabilities and address the core challenges they face in this pursuit.

There and back again. Examining the development of employee commitment during a prolonged crisis.

To effectively function and adapt in crises, healthcare organizations rely on the skills and commitment of their workforce. Yet, our current understanding of how employees' workplace commitment is affected by and evolves throughout the course of a crisis remains limited. In this paper, we explore the commitment of hospital staff to an important workplace target, the COVID-19 crisis response, and show how this commitment develops over time. We report on an exploratory case study of hospital staff in a heavily hit region of the Netherlands. We conducted interviews with hospital executives, management, medical and support staff to uncover the issues hospitals faced in recruiting staff to provide COVID-19 care throughout the first and second wave of the crisis. Our findings suggest that while staff initially exhibited high levels of commitment to aiding in the crisis effort, staff were perceived to exhibit lower levels of commitment in the second wave, complicating the provision of COVID-19 care. We unveil three contributing factors to this shift, namely: competing demands, energy depletion and a lack of support and appreciation. Our findings suggest that while staff were initially willing to dedicate themselves and take responsibility for the crisis effort, as their other more stable commitments became more salient in the second wave, their willingness to dedicate limited resources to the crisis effort decreased. In our discussion, we examine the implications of our findings for the literature on workplace commitment, and advance our understanding of employee workplace commitment during crises.

We're Not Gonna Fall: Depressive Complaints, Personal Resilience, Team Social Climate, and Worries about Infections among Hospital Workers during a Pandemic.

Maintaining hospital workers' psychological health is essential for hospitals' capacities to sustain organizational functioning during the COVID-19 pandemic. Workers' personal resilience can be an important factor in preserving psychological health, but how this exactly works in high stakes situations, such as the COVID-19 pandemic, requires further exploration. Similarly, the role of team social climate as contributor to individual psychological health seems obvious, but how it exactly prevents workers from developing depressive complaints in prolonged crises remains under investigated. The present paper therefore applies conservation of resources theory to study the relationships between resilience, team social climate, and depressive complaints, specifically focusing on worries about infections as an important explanatory mechanism. Based on questionnaire data of 1126 workers from five hospitals in the Netherlands during the second peak of the pandemic, this paper estimates a moderated-mediation model. This model shows that personal resilience negatively relates to depressive complaints (ß = -0.99, p < 0.001, 95%CI = -1.45--0.53), partially as personal resilience is negatively associated with worries about infections (ß = -0.42, p < 0.001, 95%CI = -0.50--0.33) which in turn are positively related to depressive complaints (ß = 0.75, p < 0.001, 95% CI = 0.31-1.19). Additionally, team social climate is associated with a lower effect of worries about being infected and infecting others on depressive complaints (ß = -0.88, p = 0.03, 95% CI = -1.68--0.09). These findings suggest that resilience can be an important individual level resource in preventing depressive complaints. Moreover, the findings imply that hospitals have an important responsibility to maintain a good team social climate to shield workers from infection related worries building up to depressive complaints.

Even Superheroes Need Rest: A Guide to Facilitating Recovery from Work for Health-care Workers during COVID-19 and beyond.

The COVID-19 pandemic burdens health-care workers (HCWs) worldwide. Amid high-stress conditions and unprecedented needs for crisis management, organizations face the grand challenge of supporting the mental health and well-being of their HCWs. The current literature on mental health and well-being primarily focuses on improving personal resilience among HCWs. However, this puts the responsibility for coping with COVID-19-related stress almost fully on the individual. This chapter discusses an important alternative framing of this issue - how health-care organizations (HCOs) can facilitate recovery from work processes (i.e., returning to a baseline level by engaging in nonwork activities after work) for their workers. Based on a narrative review of the occupational health psychology literature, we provide practical strategies for supporting the four key recovery experiences of detachment, control, mastery, and relaxation, as well as present general recommendations about how to promote recovery. These strategies can help HCOs facing the grand challenge of sustaining worker well-being and functioning during the COVID-19 pandemic, as well as during future pandemics and for workers facing high work pressure in general.

Addressing evolving patient concerns around telehealth in the COVID-19 era.

With a rapid shift to telehealth during the coronavirus disease 2019 (COVID-19) pandemic, clinicians, health care organizations, and policy makers must consider and address patients' evolving needs, concerns, and expectations.

Improving measurement models in clinical epidemiology: time to move beyond the inherent assumption of an underlying reflective measurement model.

OBJECTIVES: The nature of a construct's measurement model, most decisively being predominantly reflective or formative, is essential for its development, validation, and use. Differentiating between these types of measurement models cannot be done based on statistics alone, but has to rely on expert judgment, preferably guided by checklists and theoretical assumptions. However, consideration and substantiation of the choices of the measurement models is lacking in most studies describing the validation of measurement instruments in the field of clinical epidemiology. STUDY DESIGN AND SETTING: A convenience sample of 96 clinimetric studies, published from 2017 up until May 17th, 2018 was scored on model use and (mis)specification. RESULTS: In over 50% of the identified studies in this sample, formative measurement models are considered and/or analyzed as reflective. CONCLUSION: Misspecification of formative measurement models as reflective was found to be more rule than exception. It is therefore recommended that model selection and considerations on the theoretical nature of the measurement model should be classified, motivated, and discussed, for example, by using available checklists. Hereby, it can be ensured that the appropriate measurement models and corresponding statistics are used.

Measuring the Unmeasurable : The Psychometrics of Life History Strategy.

Within evolutionary biology, life-history theory is used to explain cross-species differences in allocation strategies regarding reproduction, maturation, and survival. Behavioral scientists have recently begun to conceptualize such strategies as a within-species individual characteristic that is predictive of behavior. Although life history theory provides an important framework for behavioral scientists, the psychometric approach to life-history strategy measurement-as operationalized by K-factors-involves conceptual entanglements. We argue that current psychometric approaches attempting to identify K-factors are based on an unwarranted conflation of functional descriptions and proximate mechanisms-a conceptual mix-up that may generate unviable hypotheses and invites misinterpretation of empirical findings. The assumptions underlying generic psychometric methodology do not allow measurement of functionally defined variables; rather these methods are confined to Mayr's proximate causal realm. We therefore conclude that K-factor scales lack validity, and that life history strategy cannot be identified with psychometrics as usual. To align theory with methodology, suggestions for alternative methods and new avenues are proposed.

Handling the reflective-formative measurement conundrum: a practical illustration based on sustainable employability.

OBJECTIVES: Constructs capturing health or functioning can have reflective and/or formative measurement models. Although a construct's measurement model has extensive implications on the construction, validation, and use of a measurement instrument, measurement models are frequently wrongly or not explicitly specified. As this is likely due to a lack of guidelines, this study uses sustainable employability as an example to demonstrate a) the applicability of an adapted checklist for establishing a construct's measurement model; and b) the use of structural equation modeling to handle formative constructs. STUDY DESIGN AND SETTING: First, the checklist is applied to sustainable employability to establish its measurement model. Second, using observational self-report data from 2,544 employees, structural equation models are estimated to evaluate the structural and criterion validity of sustainable employability as a formative construct. RESULTS: The checklist demonstrates strong applicability, identifying sustainable employability as a formative construct. Model fit indices (Comparative fit indices ≥ 0.932, Tucker-Lewis indices ≥ 0.925, root mean square errors of approximation ≤ 0.034) suggest the formative measurement model for sustainable employability is valid. CONCLUSION: The checklist and structural equation modeling facilitate handling formative constructs. By establishing sustainable employability as a formative construct, individuals' long term ability to function at work can be more adequately studied and intervened upon.

Time takes us all? A two-wave observational study of age and time effects on sustainable employability.

Objectives Various cognitive and physical abilities decline with age. Consequently, sustainable employability research has focused on the labor market participation of older employees. However, it remains unclear whether age actually affects employees' work and labor-market functioning. A major complicating factor is that age effects can be distorted by time effects. That is, changes over time may not be due to aging but to some structural difference between the times of measurement. The present article aims to provide clarity by estimating age effects on sustainable employability while controlling for potential time effects. Methods Based on two-wave survey data from a sample of 2672 employees (ages 35‒65 years) multilevel regressions are estimated to analyze the effects of age and time on sustainable employability. Here, sustainable employability is operationalized as a formative construct consisting of nine dimensions, each capturing a different facet of an individual's ability to function at work and in the labor market. Results The analyses reveal that age has small effects on only two dimensions (employability and perceived health) while time affects three dimensions (fatigue, job performance, and skill gap) of sustainable employability. Moreover, for all dimensions of sustainable employability most variance exists between (61.43-84.96%) rather than within (15.04-38.57%) subjects. Conclusions These findings suggest that the process of aging has a limited effect on working individuals' capacities to function in their job and the labor market. Consequently, the focus on age in the context of sustainable employability policies and research may require reconsideration.

Critical reflections on the currently leading definition of sustainable employability.

Sustainable employability (SE) is an important topic as it deals with employees' abilities to function adequately at work and in the labor market throughout their working lives. However, until now there has been only one attempt to define SE in the international literature (1). This first definition is a valuable contribution to the field as it rightfully describes SE as a multidimensional concept, recognizes the importance of both employee and work characteristics, and acknowledges the inherently longitudinal nature of SE. Despite these merits, we argue that this definition of SE has some serious omissions that are important in capturing SE comprehensively. Specifically, we argue that the definition could be improved in various ways, namely, it should: (i) clarify which aspects of employment constitute someone's SE; (ii) not counterintuitively treat SE as a characteristic of both the job and the employee simultaneously; (iii) not be based on the insufficiently tested assumption that achieving value in work inherently leads to SE; (iv) be formulated in a way that SE can also apply to unemployed individuals; and (v) adequately specify how the inherently longitudinal dimension of SE should be addressed. We would like to contribute to the discussion by providing guidelines for a new adjusted definition of SE that could facilitate further research on this important concept and its determinants. Introduction SE is a topic of vital importance to individual employees, organizations and society alike. It generally refers to employees' capacities to function in work throughout their working life. As participation in work is important for individuals, organizations, and society as a whole, individuals' ability to function in work is essential. For individuals, work provides meaning, financial security as well as social contacts. Organizations need productive employees to survive. Also from a societal perspective, it is important that as many people as possible participate in the labor market to maintain economic welfare (1). Moreover, as a consequence of population aging (2-6), longevity, rapid changes in technology (7, 8) and changes in the nature of work (1), both the need to promote sustainable employability of individuals in society and the complexity to succeed in doing so increase even further. Only recently, van der Klink et al provided the first definition of the concept in the international scientific literature (1, p74): "Sustainable employability means that throughout their working lives, workers can achieve tangible opportunities in the form of a set of capabilities. They also enjoy the necessary conditions that allow them to make a valuable contribution through their work, now and in the future, while safeguarding their health and welfare. This requires, on the one hand, a work context that facilitates this for them and, on the other, the attitude and motivation to exploit these opportunities." This definition is accompanied by an equally recent operationalization of SE as a set of capabilities (9). Moreover, the definition itself also appeared in an earlier Dutch publication (10), which other international publications about SE most commonly refer to [ie, in comparison with other definitions in the non-international (eg, Dutch) literature] (11-13). As mentioned, the present paper provides a critical reflection on van der Klink et al's aforementioned definition of SE (1). Merits Van der Klink et al's definition of SE (1) has three important merits. First, SE is seen as a multidimensional construct. It is presented as consisting of a broad set of opportunities for employees to create value for themselves and for their employer that cover various aspects of working. Moreover, the individual's health and well-being as well as attitudinal and motivational aspects are included in the definition as well. This acknowledgement of the multidimensionality of SE is favorable, as it illustrates the complexity of the construct and of what constitutes functioning in work. This is in accordance with the International Classification of Functioning, Disability and Health (ICF) (14), in which functioning is seen from three different perspectives (body, activities, and participation). The ICF underlines the multifaceted and complex nature of functioning in which disease, environmental factors, and personal factors play a role. Similarly, the multifaceted nature of functioning is also illustrated by the fact that different disciplines focus on different aspects to understand functioning at work (15, 16). Second, SE is (partially) defined as the degree to which (i) employees are able to work throughout their entire working lives, and (ii) their work context enables them to do so. This suggests that SE is a set of interacting characteristics of the employee and the work context that codetermine the opportunities and conditions affecting employees' capacity to participate in the labor market throughout their working lives. As such, the definition describes an equal responsibility for employee and employer to maintain the employee's ability to work. This could be considered as a great merit, as research shows how strongly an employee's ability to function is influenced by both the individual, work and work-contextual factors (17). Third, van der Klink et al's definition recognizes that SE is an inherently longitudinal construct as clearly embedded in the words "throughout their working lives". This is essential as "sustainable" necessarily implies a time dimension. Need for further development Despite the aforementioned merits, there are important needs for improvement of van der Klink et al's definition of SE. First, it is not immediately clear from the definition what particular element(s) of the work situation constitute(s) SE. The paper provides some clarity by equating SE with the capability set it propagates, as evidenced by these statements: "… in an accompanying paper also published in this issue, we report on the development and validation of a questionnaire that allows for the assessment of sustainable employability based on the concept of capability" (1, p72) and "This [capability] set, in our view, represents the best possible operationalization of sustainable employability" (1, p74). However, in the paper, SE is also referred to as being determined by a worker's capability: "this model holds that an individual's sustainable employability is determined by how he or she succeeds in converting resources into capabilities, and subsequently into work functioning, in such a way that values such as security, recognition and meaning are met"(1, p72). As it is not feasible that SE is predicted by itself in the form of a capability set, perhaps the capability set does not actually refer to SE itself but rather to a favorable employment situation that may cause SE. More clarity on this issue is needed. Second, the definition seems to treat SE as a characteristic of both the job and the individual at the same time. This is counterintuitive and problematic as the job and work context may predict an individual's ability to be sustainably employed, but they can never be aspects that are part of SE. Instead, employability is a characteristic of the individual alone. Of course the individual's ability to be employed does depend on work and work-contextual factors, but these should be predictors and not be embedded in the construct itself. For an adequate definition of SE, it is essential to disentangle these relationships between causes (employment) and effects (employability). Moreover, future approaches should treat SE as an individual characteristic that is an outcome of the complex interaction between other individual, work, and work-contextual characteristics. Third, the definition and operationalization of SE assume that achieving value in work inherently predicts SE and that, therefore, SE can be conceptualized as achieving value in work. This is problematic, as before such claims can be made, such relationships need to be tested with SE as criterion. This is, however, impossible within the approach van der Klink et al provides. (1), as SE is equated with its predictor(s). Therefore, similar to the first conceptual issue, it seems unlikely that the capability set adequately reflects SE. Fourth, the definition by van der Klink et al (1) suggests that SE only applies to individuals who are employed. In the Abma et al publication (9), which accompanies van der Klink's definition paper as a validation paper, this is shown by the way in which capabilities are measured. Moreover, the definition also suggests this because individuals can only be considered to be sustainably employable if their work context enables them to achieve tangible opportunities. However, individuals who are not currently working can still be highly employable and even sustainably so, but just be between jobs. It is therefore not required for individuals to be enabled by their employer to be sustainably employable. Consequently, in line with our aforementioned points on improving the definition, being enabled by an employer to achieve value may be an important predictor of SE, but it is not necessarily part of SE itself. Moreover, future approaches to SE should define the concept in such a way that it is applicable to every individual regardless of employment status. Finally, the definition and operationalization of SE in the form of a capability set do not include any specification on how the longitudinal aspect of SE should be captured. The definition rightfully acknowledges the longitudinal dimension of SE, but its operationalization focuses solely on achieving value. Although achieving value at work may be an important predictor of SE, a complete operationalization and definition should include its longitudinal nature as well. Outlook In conclusion, while van der Klink et al's definition of SE (1) does have strong merits, it requires further improvement. The approach's main drawback is that capabilities seem more apt at describing a potentially important set of predictor(s) of SE than at capturing the construct itself. Either way, future developments in conceptualizing SE should build on the aforementioned merits, but also define SE in a way that (i) clearly labels which aspects of the employment situation constitute SE; (ii) explicitly separates causes and effects; (iii) treats SE as an individual characteristic that may be affected by other employment characteristics at the individual, work, and work-contextual levels; (iv) makes the concept applicable to any individual regardless of their employment status; and (v) clearly addresses the longitudinal nature of SE as embedded in the word "sustainable". These guidelines should not only enable the development of an appropriate definition of SE but also a conceptually sound way of measuring the construct.