Health Policy and Development Journal, Vol. 7, No. 1, April, 2009, pp. 51-59
Interaction of Continuing Professional Development, Organisational Culture and Performance in Health Service Organisations: A Concept Paper
John Francis Mugisha
Senior Lecturer, Faculty of Health Sciences, Uganda Martyrs University E-mail: email@example.com
Code Number: hp09007
Whereas Continuing Professional Development (CPD) has been acknowledged as a tool for improving performance through updating and widening of professionals' knowledge and skills, there is no concrete evidence to support this claim. Recent studies on this subject have either shown contradicting evidence or remained utterly inconclusive posing an empirical dilemma. This paper posits that CPD is highly context-dependent and therefore best supports performance where a positive organisational culture plays a moderating role. The paper aims to provide a framework that can be used to analyse the interplay between CPD, organisational culture and performance. It is argued that for CPD to support performance there is need for a culture that is adaptive and receptive to learning, change, innovation and performance improvement.
Continuing Professional Development (CPD) has been recognised as a tool for updating and widening the knowledge and skills of practising professionals (DoH, 1999; Frick and Kapp, 2006). Several authors have associated CPD (or some of its elements like training) with business competitive advantage (Rosow and Zager, 1998; Bennet et al, 1998), growth of intellectual capital (Carnevale, 1990; Quinn et al, 1996), successful company strategy (Guest, 1987) and performance improvement (Strike, 1995; Holly and Rainbird, 2000). As a consequence, many organisations have embarked on employee training and retraining often spending huge sums of money (Noe, 2002; Perks, 2006).
However, despite its wide recognition, there is no concrete evidence to show that CPD contributes to improvements in organisational performance, or even the conditions that would support this to happen. This paper argues that for CPD to support organisational performance there is need to properly understand and control the context in which CPD is conceived, planned and executed - the organisational culture. It therefore explores the moderating role of organisational culture on the relationship between CPD and organisational performance. The paper argues that when the effectiveness of CPD is queried, there is something wrong with the culture of both learning and performance management. Therefore, a positive organisational culture will itself create a symbiotic relationship between CPD and organisational performance.
This concept paper is divided into six sections. After introducing the key conceptual issues and arguments in section one, there is section two which provides the background and hypothesis that underpin the development of the whole concept. Section three explicates the conceptual problem which this paper is trying to address. Section four summarises the literature that informed the design of the concept. Section five proposes a conceptual framework which shows interaction of the key variables. Finally, section six outlines the summary and the conclusion. The object of this paper is to provide a conceptual framework that can be used to analyse or further investigate the interplay between CPD, corporate culture and performance in the context of health care organisations in order to generate empirical evidence.
Conceptual background and hypothesis
The human resource has been recognised as the most important asset of every organisation (Nadler and Nadler 1992; Armstrong 1992; Strike 1995; Lewis et al, 1998). Although this recognition is often not supported with empirical evidence, it cannot be seriously contested that the value added to every establishment derives from the sum of its people's ideas, skills, goodwill and innovative capabilities. However, like any other resources, the human resource - however professional - is prone to depreciation. Its value can, and should, be maintained and increased through a process of systematic and well-planned training and learning (Senker, 2000). In many organisations, this is referred to as continuing professional development (CPD).
The purpose of CPD therefore is to facilitate acquisition of knowledge and skills as a means of transforming professional practice and boosting organisational performance. For the health workers, CPD is underpinned by two factors - one, a belief that there is a discrepancy between pre-service education and field practice; and two, the reality that job requirements are so rapidly changing that there is need for employees to constantly retrain in order to stay up-to-date (AMREF, 1983). For the health managers, CPD should serve as a tool to garner the required skills to improve organisational performance in the face of epidemiological, technological, economic and socio-political challenges, which usually are compounded by shrinking budgets and diminishing resources. Therefore, it should be invested in after a thorough appraisal against other performance improvement tools such as performance-related-pay, workplace redesign, teamwork, employee supervision and others. Of course, some of these could be jointly implemented. Any budgetary allocation for CPD should only be allowed if the CPD event is able to enhance skills and competencies that can raise the expected levels of productivity and effectiveness (Souza and Roschke, 2003).
But can CPD in itself change professional practice and boost organisational performance? As will be shown through literature review in section four, there is conflicting evidence which itself poses an empirical dilemma. Yet, the reality of many practical changes and challenges which health professionals have to deal with seems to strengthen the appeal of CPD as a performance tool. And as observed by Dr. Carl Sagan (see http://www.carlsagan.com), "absence of evidence is not evidence of absence". It may be necessary to shift from studies that simply correlate performance outcomes with specific CPD interventions to those which analyse the organisational context in which CPD is conceived, planned, implemented. And, as will be shown later, nothing summarises organisational context than organisational culture. It is this paradigm of context that this paper seeks to construct, while deconstructing the CPD model that is based on belief and unproven logic. Henceforth, the hypothesis underpinning this concept is that organisations which have a positive corporate culture are more likely to maximize the benefits of CPD to support organisational performance.
It appears that most health professionals, managers and planners have adopted the assumption that employee development automatically leads to improvements in the performance both of the health workers concerned and the organisations in which they work. It is not clear whether this assumption has been created by some authors (Guest, 1987; Armstrong, 1995) or has simply been reinforced by them. It is quite probable that this sort of thinking did influence some authors. Whatever the case, it is now known that many health service (and other) organisations do spend colossal sums of money on employee development (Noe, 2002; Perks, 2006). The assumption that CPD leads to better performance has, in effect, passed as straightforward commonsense. However, as hinted on before, there is lack of evidence to support the claim, causing the need to query (or rethink) the CPD strategy.
In the fairly recent past, there has been a management revolution that has placed emphasis on results-oriented management (ROM) and return on investment (ROI). This has come along with demands for accountability. In the foreseeable future, this accountability will shift emphasis from the signed payment vouchers, invoices and receipts of funds spent on learning and training materials to accountability for outputs that result from the CPD events. Decentralisation has brought increased autonomy and responsibility to many Health Unit Boards. Given the considerable allocation of resources to CPD, these Boards will begin to put Health Unit managers to the task of explaining the connection between the CPD efforts they spend on and the benefits to the organisations that accrue from these efforts; lest, they will not approve the budgetary allocations. They will first ascertain the possibility of a return on (CPD) investment. There will be efforts to consider that CPD events are worth the money spent on them; and to ask if CPD really makes a difference.
There is real danger that uncertainty about whether CPD expenses can be recovered might lead to underinvestment in CPD activities, which could lead to diminishing quality of health services with its associated effects such as increased morbidity and mortality, reduced quality of life and low productivity. For the developing countries, this would constitute a real roadblock to poverty eradication given the connection between health and development. This paper advocates for a research approach that goes beyond statistical correlations (between CPD and performance outputs) to include analysis of institutional dynamics and context surrounding and affecting CPD; an approach that discerns the attitudes, values, beliefs and processes which trigger the desired changes in professional practice and organisational performance. It is here that the need to examine the moderating role of organisational culture in the relationship between CPD and organisational performance has its niche.
Review of literature
In order to examine the relationship between CPD, organisational culture and performance, it is important to examine the existing research on these variables, establish the gaps and synthesise the knowledge into a sensible framework. The literature examined in this section provides the theoretical and knowledge base upon which the conceptual framework suggested in the next section is built. Literature is replete with materials on the key variables - CPD, organisational culture and performance - although the materials are scattered. This analysis adds value to this stock of information by synchronising the scattered data and examining connections between the different variables involved. A further contribution is to create propositions on the basis of theoretical analysis and to point out unanswered questions and knowledge gaps which can be pursued in an empirical investigation.
Conceptualising CPD: A confusing terminology?
CPD is multidisciplinary and connotes different things to different professions. Friedman and Phillips who have extensively investigated CPD across various professions have concluded that in its current form, CPD is "both confused and contested and many professionals find the concept bewildering and its practice difficult" (Friedman and Phillips, 2001:1). They add, however, that what is ambiguous about CPD is not because it reflects confusion on the part of professionals but its involvement of learning beyond traditional school years which, they argue is "fraught as a brief account of the concept of lifelong learning". The Construction Industry Council in 1986 adopted a definition that has come to be one of the most accepted ones for CPD: A systematic maintenance, improvement and broadening of knowledge and skill and the development of personal qualities necessary for execution of professional and technical duties through out the practitioner's working life. (Construction Industry Council, 1986. p.3).
This definition, as observed by Friedman and Phillips (2001. p.3) "encompasses personal as well as professional qualities". They argue that since the scope of CPD is not just to maintain knowledge and skill but also to broaden them, it is very inclusive and therefore ambiguous. However, multi-conceptualisation of CPD could be due to differences in its aims and benefits as applied in various professions. For instance, Perry and Ball (1996, p.1) describe professional development from the perspective of Education as "that which teachers engage in to extend their competencies and skills with the intended aim of being a more effective teacher." This goes without telling who is an effective teacher and who is not. Further to this are differences in the nature of CPD policies and programmes not only between different countries but also professions. All these contribute to various interpretations of CPD as a concept.
In the health sector, CPD encompasses all professional learning by health care providers after basic (or pre-service) training (O'Sullivan et al, 1999; Pakenham-Walsh 2003) and targets to improve the capacity of the health professionals to become more effective both in technical work and in their other multifaceted tasks (Jaafar, 2006). This wide definition encompasses all those activities, both formal and informal, which improve professionals' capacity to become more effective members of their institutions. However, the informal aspect of CPD does not mean that it can take place haphazardly. Rather, it means that CPD involves learning which can occur at any time and in ways that are not formally arranged. Certainly all learning, be it formal or informal, involves a systematic and deliberate cognitive process with a clear purpose to think and reflect on experiences and activities taking place. Hence, activities such as conferences and workshops, writing for journals, short courses and seminars, case studies, bedside coaching and ward rounds, reading in libraries and self directed learning all constitute CPD events.
In many countries, CPD is mandatory for health professions who are required to submit evidence of CPD as a precondition for annual licensure (Kanyesigye, 2002; Shahabudin, 2003). Whereas this measure is critical to ensuring that all health professionals undertake to learn in order to ably face the challenges posed by the dynamic health systems, there is no evidence that measures are being taken to guarantee that CPD is relevant. Many health professional bodies have not sorted out issues of quality assurance, monitoring and control of CPD. Nor are there proper accreditation policies in many countries. Unless organisations put in place effective strategies for its planning, implementation and evaluation, CPD is unlikely to serve its purpose. There is need to have appropriate structures, mechanisms and tools to support CPD and to create an organisational environment that values and fosters work-based learning, relevant programmes of study and portfolio keeping (Jones and Jenkins, 2006). There is also a need to shift from compiling (and demanding) evidence of training to evidence of learning.
Perspectives of organisational performance
Different organisations are pursuing excellence and their managers are eager to know if their efforts are working. They can only tell this from the data that are got through measurement. Cannell (in CIPD, 2006) contends that those who cannot measure cannot manage. Hornby and Forte (2002) also argue that managers need the tools to enable them to measure how well they are meeting the targets that have been set for them and to be accountable for the resources they manage. Obviously, the need for measurement does not apply only to managers but also to professional teams and individuals.
Organisational performance can be defined as the ability of the organisation to fulfil its purpose. Of course, organisations have a multi-pronged purpose which could combine elements such as satisfying customers, making profit, reducing costs of operations, improving service utilisation etc. Therefore taken from a narrow perspective of any one of the elements above, organisational performance could mean different things to different people. What appears to be less contentious, regardless of one's perspective, is that organisational performance can only be achieved through people (ICF International, 2006) hence the need to link it with CPD. Effective performance measurement should connect individuals and teams to organisational business strategies, goals and values. This link is summarised by ICF International thus:
For an organisation to achieve its goals, it is essential for each employee to understand individual roles and responsibilities for goal achievement, and there must be continuous dialogue between leaders and employees to set performance expectations, monitor progress and evaluate results (ICFI, 2006).
Surprisingly, while the concepts of performance measurement and evaluation have existed for many years, there is increasing demand that organisations begin to institutionalise these practices. It is therefore necessary to establish the performance metrics used by different health care organisations and how they tie up with CPD and organisational culture. One essential requirement in assessing organisational performance is to identify the main performance issues - issues that the organisation needs to resolve so as to improve its performance. Typically, organisational performance issues centre on effectiveness (relating to achievement of mission and goals), efficiency (relating to the use of resources in operations), relevance (relating to mission) and financial viability (relating to adequacy of funding to ensure that the organisation can continue to perform in the short and long terms) (Lusthaus et al, 1999:18). It is not the intention of this paper to analyse the metrics of organisational performance, but to illustrate the connection between performance measurement and CPD and the possible moderating role of organisational culture.
CPD and organisational performance: An emerging concern
CPD is a vital component of human resource development (HRD). The fundamental belief underpinning HRD is that sustainable competitive advantage is achieved through people (Armstrong, 1992). The main concern of HRD therefore is to develop people and enable them to make the best use of their abilities and perform their duties to their fullest potential for both their own good and the good of the organisation. The potential of CPD as an HRD strategy to increase the competitive advantage of organisations has been widely acknowledged (Jones and Robinson, 1997; Pfeffer, 1994; Stewart, 1996). The appeal of CPD as a strategy for improving professional and organisational performance appears uncontentious. But on closer inspection there are serious gaps in evidence that leave several questions unanswered: what forms of CPD deliver results and which ones do not? What specific performance objectives require CPD intervention? And what type of organisational context would maximise the benefits of CPD?
In a way, the CPD strategy is in the dock. There is a growing concern over CPD outcomes particularly its ability to impact positively on organisational performance. Given the considerable allocation of resources to CPD, managers are being challenged to ascertain if CPD is giving them the results they want (MSH, 2006). Lack of sufficient evidence could have negative implications on resource allocation for CPD further injuring the health care industry whose performance in the developing countries is already limping. Yet, it is only logical that at management level, the huge expenditure on CPD should only be justified if it is able to enhance professional skills and competencies and if this can be demonstrated through increased organisational performance outputs. It is against this backdrop that the need of research to document evidence of effectiveness of CPD becomes very critical. Findings from previous studies also need to be reviewed.
Contradicting evidence from studies: An empirical dilemma
There is conflicting evidence from different studies that have been conducted to assess the impact of CPD on performance. For some studies, the findings have been contradictory while others have been clearly inconclusive. A critical analysis of these studies, however, indicates that they do not only reflect lack of evidence of the effectiveness of CPD but also flaws in their own design and methodology. Following is an outline of some of these studies and a commentary on their methodological weaknesses.
Dunn, et al (1988) studied family doctors with an aim of establishing a correlation between quality of care with participation in continuing education. Using two cohorts of family doctors - those they exposed to the CPD event and the control group which they did not - they came to a conclusion that there was no correlation between the CPD event and quality of care.
Sibley et al (1982) had earlier done a similar study and come to a conclusion that formal continuing education makes no difference. They compared over 4,500 episodes of care provided before and after the involved physicians had received continuing education. These episodes were classified according to quality and a control group was selected for comparison. While tests confirmed that the study physicians learned from the packages, there was little effect on the overall quality of care and the control group showed as much improvement as the study group. Paradoxically, when the taught topics were not preferred, the study group provided better quality care compared to the control group!
Several other studies were inconclusive on the effect of continuing education on performance of health professionals or the health care organisations. Researchers like Stein (1981), Haynes et al (1984), Davis et al (1992) and Beaudry (1990) all concluded that sometimes the effect of continuing education is there, sometimes it is not there. However, they did not state when the impact of continuing education is not likely to be realised and when it is likely to be realised; and the conditions that would maximise this process.
Interestingly, most of the aforesaid studies did not establish the reasons why continuing education could not influence better physician practice. Marshall (1998) who ventured into this area reported that there was a general mismatch between what general practitioners wanted from specialists and what the specialist were offering in continuing education. Such a mismatch could still be in existence even today especially in developing countries where there has not been sufficient research to evaluate continuing education for health professionals. As already mentioned, the studies conducted all tended to document the effect of isolated education interventions or events in changing physician behaviour. But the real impact of continuing education can only be fully understood within a context of other vital intervening variables.
The role of organisational culture
Deshpande and Webster (1989) defined organisational culture as a "pattern of shared values and beliefs that help individuals understand organisational functioning and thus provide them with the norms for behaviour in the organisation" (p.4). Other authors like Chatman and Jehn (1994) summarise organisational culture as widely shared and strongly held values. Rousseau (1990) outlines the elements of organisational culture as ranging from fundamental assumptions through values and behavioural norms to actual patterns of behaviour. Others argue that the defining elements of organisational culture are the values and that the norms, symbols, rituals and other cultural activities revolve around them (Enz, 1988).
There is a well articulated view that all organisations have cultures which become more effective when they are used to create consensus and unity that motivate staff (Mabey and Salaman, 1995). This view argues that such cultures have an effect on corporate performance. According to this school of thought, organisational cultures can be assessed, constructed, and managed in a way that enhances organisational effectiveness. Employees' norms, beliefs and values can be managed to support development of appropriate behaviour, organisational commitment and support for organisational strategy. To this end, culture can be used to integrate the organisation, and if well managed, be an effective key managerial success in areas of CPD and performance management.
A number of empirical studies have established that culture can lead to successful implementation of performance measurement systems (Rashid et al, 2003). Such studies have underlined, as a prerequisite to performance, a corporate culture that does not punish employees' errors and which encourages innovation and open discussion of performance measures. In the same way, several researchers on organisational culture have founded out that culture itself shapes and influences behaviours and attitudes of employees (Handy, 1985; Schein, 1985; O'Reilly and Chatman, 1996).
Elsewhere, researchers have established that organisational culture is related to organisational strategy (Schwartz and Davis, 1981; Choe, 1993), market orientation (Deshpande and Farley, 1999), organisational commitment (Rashid et al, 2003) and financial performance (Kotter and Hestkett, 1992). It can therefore be said that culture affects organisational success. Unfortunately not much has been done to establish the influence of organisational culture on CPD although the need for such studies has been clearly articulated by some scholars (Teichler, 1999; Alemna, 2001; Frick and Kapp, 2006). It is necessary, therefore, that this need be satisfied.
The Interplay between CPD, organisational performance and culture: Towards a conceptual framework
This paper focuses on the role of organisational culture in maximizing the benefits of CPD to support organisational performance. CPD is highly context-dependent. So is organisational performance. Professional skills and competencies will be more successfully maintained, developed and expanded if CPD initiatives effectively address (and are supported by) the practitioners' context which is provided by a positive organisational culture. CPD is likely to be a more effective tool for supporting organisational performance in organisations where there is a culture that is receptive and adaptive to learning, and supportive of change, performance measurement, flexibility and innovation. The Figure 1 below demonstrates the conceptual relationship between CPD, organisational performance and corporate culture.
The framework shows the different elements that constitute CPD, organisational culture and organisational performance and how they are interlinked and should interact with each other. At the heart of the framework is a culture that is characterized by positive attitude to change and innovation, people orientation, team spirit, good leadership and highly cherished values. These are supportive of learning and will necessarily boost CPD. Orientation to quality will ensure that learning is relevant (i.e. based on the needs both of the organisation and the wider health sector). Monitoring and evaluation of learning will reinforce the culture of performance measurement to establish the effect of CPD on professional practice. And when the professionals acquire knowledge and skills, they easily transfer them to the job and utilize them to improve performance because there is peer support, technological support and management support. But the types (forms) of CPD also matter because they have to be appropriate to the needs and will also influence the method of monitoring and evaluation.
This concept paper has underlined the need to further investigate the effectiveness of CPD and especially how it enhances performance. It has been argued that lack of evidence on the effectiveness of CPD might cause underinvestment in professional development of health workers, which might reduce the quality of care leading to poor quality of life and low productivity. The paper has demonstrated that prior studies in this area came up with conflicting evidence posing an empirical dilemma. The paper has quoted studies which left several questions unanswered hence leaving knowledge gaps. The paper has questioned the methodology used in those studies and presented a case for shifting the research strategy from correlating specific CPD events with targeted performance outputs to understanding the context in which CPD is conceived, planned and executed - the organisational culture. The paper has presented a conceptual framework which depicts the moderating role of organisational culture between CPD and organisational performance. Basing on the above, a hypothesis can be advanced that organisations which have a positive culture are more likely to utilise the benefits of CPD to support organisational performance. However, there is still need to conduct empirical research to verify it.
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