Archive for category: Management

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The Public Health Workforce
Matthew L. Boulton, MD, MPH • Edward L. Baker, MD, MPH • Angela J. Beck, PhD, MPH
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be
able to:
1. Identify professions comprising the public health
workforce and describe efforts to determine the public
health workforce size and composition.
2. Describe the places of employment of the public health
workforce, how the workforce is trained, and who is
licensed or certified.
3. Describe the efforts underway to ensure and measure
the impact of public health workforce development,
including leadership development.
4. Describe the essential public health services delivered
by the public health workforce.
5. Define leadership and be able to distinguish leadership
and management.
6. Understand theories of leadership practice a_nd
the related behaviors needed to practice effective
leadership.
7. Understand the needs for leadership development at
various career stages.
KEY TERMS
certification
competencies
enumeration
leadership
licensure
management
multidisciplinary teams
voluntary health organizations
workforce
workforce capacity
307
308
INTRODUCTION
. l forefront of the
Public health is increasmgly at t 1e d re-emergent
national and global response to new anf d adly infechealth
threats ranging from ~utbreak:ho in ~he obesity
tious diseases, to the explosive gro~ . . and vioepidemic,
to disturbing increases m mff1urt~ public
lence makm. g the nee d fo r a l1 1· ghly e ec 1ve f that
health system as vital as ever. Perhaps no part O
public health system is as important as th~ pheo~t1~
who work within it as members of the pubhc ea .
workforce. A well-trained and competent workforce is
essential to the practice of public health and. the successful
delivery of essential public health services. The
professionals and other workers who comprise the
public health workforce share a common awareness
of and commitment to improving health through a
population focus. These workers are uniquely diverse
in terms of the education, skills, and experience they
bring to the field, especially relative to other health
professions. However, unlike other health professions,
the public health workforce has actually become
smaller over the last two decades. At the same time the
variety of occupations comprising that workforce has
diversified and includes new positions such as health
informatics specialists, public health geneticists, and
emergency preparedness professionals which mostly
did not exist just a decade ago. The opportunities for
public health worker training and education have also
grown dramatically as schools and programs of public
health have undergone an unprecedented expansion.
This has been accompanied by a rapid development
of continuing education and other training, often using
distance modalities, offered through national networks
of federally funded workforce centers. These
efforts are creating an increasingly professionalized
workforce that has been reinforced and strengthened
through complementary initiatives aimed at development
of competency-based education and training
worker certification, and accreditation of public health
agencies.
Despite these exciting developments, many contemporary
c?allenges confront attempts to fully characterize
the pubhc health workforce-there is still too little known
about how many workers it contains, the disciplines they
represent, wh~re they d~liver services and how effective
they are at domg so, their demographic composition, the
reasons they enter and leave the workforce, and how th
adapt to unstable funding impacting their job security a~~
future caree~ prospects. And, we continue to wrestle with
the appropnate _benchmarks that define the ideal mix of
educ~tlon, expenence, and diversity needed to produce an
effecnve workfor~e an? how that mix contributes to overall
workforce capacity. F_mally, there is a clear need for more
research on the pubhc health workforce to address these
PART FOUR
ON OF PUBLIC HEALTH SERVICES
pROViSI
l ensure that, ultimately, we hav
. and to a so . h kill . e
many questions f eople with the ng t s s m the right
the right nu~ber ~ Pe to improve and protect the public’s
t the nght um
place a . .
health. ludes with an extensive discussion
The chapter cone ctice of leadership consists of speof
Jeaders~ip. ~~ r~ead to the realization of a shared
cific behaviors :
1
~ plementation of core strategies and
vision through t e imerational reality of specific tactics
I. tion to op . . ·
the app ica t” e of leadership consists of specific
f the prac 1c .
There ore, . h 1 d to the realizat10n of a shared vih
. s whic ea .
be avior h . plementation of core strategies and
sion thr~ug~ t ~~:perational reality of specific tactics.
the apphcatihon . s has developed regarding the skills
A oft eone
range a ct· leadership; one of the most compelneeded
for eue ive · · l d h’
. ublic health practice IS servant ea ers 1p. As
lmg for P 1 leadership development needs to change
leaders evo ve, h” d I
d b ddressed by formal leaders Ip eve opment
an can ea h’ · I
programs. In public health, leaders I•p • IS cendtr ad to a· ddressing
the challenges and opportumties nee e to improve
and protect the public’s health.
PUBLIC HEALTH WORKERS
The effective delivery of public health services is dependent
upon the availability of a skilled, competent
workforce (the population employed in a specified
occupation). A key challenge for governmental and
nongovernmental public health organizations is to
employ the appropriate number of workers who possess
the requisite skills which can be used where and
when they are needed.1 The public health workforce
c~mpri~es a_ highly varied group of professions. The
wide diversity of skills, education, and experiential
~ack~rounds that public health workers bring to the
field ~s a strength given the multitude of factors that
contribute to population health· however it also ere·
ates cha.l l.e n ges · ‘ . ‘ . lil accurately determimno the size,
composition 1• b f . 0 bl’
h I h ‘ 0 unction, and expertise of pu ic
eabtl. whorkers, both individually and collectively. The
pu ic ealth w kf
ways, wi. th a f or orce has been defined in many
the comm i°cus on population health serving as
Accord. on e ement to define a public health worker.
lie heal~~gp:~r:~:i~nstit~t~ of Medicine (IOM) , a pu?health
or a 1 n~l is a person educated in pubhc
re ated dis · 1· ·
prove health th cip me who is employed to 101·
~mportance of t~ough a_ population focus.”2 Given the
mg and protect” e p~bhc health workforce in promot·
to understand ~~~ ; health of populations, it is ke)’
ployed and what k”ll any Workers are currently et11·
gaps in Workfor s 1 s they possess as well as where
d . ce cap · . ‘ .
an retain the . h ac1ty exist and how to recruH
health settings. ng t types of Workers in all public
CHAI”‘ I t:K IO I Ht: PUBLIC HE
ALTH VvOR
KFORCE
WORKPLACE SETTIN
public health workers Gs
f
. b . . can be£
0 10 settmgs m both bl’ 0 unct in .
h
• pu 1c and a Wide
of t ese settmgs may not b private variety
as places where public h
1
e traditionally s~tors. Some
services carried out theree~! s~rvices are ~el:racterized
to the public’s health non th e important co v~red, but
· d · e eless AI h ntnbuti
summa~1ze m this chapter e · t ough the _ons
of public health workers mploy substantial settings
. , not all w k numbe
these settmgs are necessa .1 or ers em I rs
workforce. n Y part of the p u b~li co yheedal tinh
Governmental Public H ealth
The core public health workf
l
. orce is
ernm. enta settmgs ‘ includ’m g 5 9 st et mployed in g ovpubhc
heal~h agencies, nearly 3 0 a e and territorial
partments (mcluding tribal a : OO local health dedes
that contribute to a pubY~n~ies), and federal agenthe
Department of Health icd :;1th
mission such as
vironmental Protection Ao an uman Services, En-
. l oency, and D
Agncu ture, among others W’th’ epartment of
government, public health ~o k
1
m all three levels of
. f r ers are found · ‘d
vari.e ty o programs that focus on areas such m a w1 e
environmental protection c00. . , 1’ d sa1ce ty h ealth a· s energy,
(.m clud.m oo Medicaid) ‘ 1· mmum.z at1. ons’, controlm osfu irnafneccenous
dis.e ases, maternal and child health , mentaI h ealth
occupat10nal health and safety, substance abuse i
health , traffic safety, sexually transmitted infec,tir;:~:
~elfare, and zoning. Many of these programs, orig~
mally developed as part of a department or board of
?ealth, have since been relocated or combined as policy
makers shift preferences for relating programs and
people. For example, pesticide control programs now
housed in agriculture were once part of health departments,
and the function of assuring access to care for
the poor encompassed by Medicaid may have been a
part of the jurisdiction of a board of health. The IOM
described an ideal state health agency that encompasses
all of these programs. :1 However, no such agency exists,
nor is one likely to appear. Consequently, public health
professionals must work collaboratively across program
and agency lines and among public and private and
voluntary partners.
Nongovernmental Public Health
f d in a range of set-
Public health workers can be o~nhealth agencies. For
tings beyond governmental pu~l~~ . dual schools (pub~
xample, school distric~s ao<l
1
~
0
1
v~any public health
he, private, and parochial) em~ s~hool-aged children.
nurses to assure the he_a~th ~nd environmental health
They may also have nutntion_ . t wi’de level to assure
· t a d1str1c –
professionals working a
309
the healthf I Inde, pendeun tn Wesast and safet y o f sc h ool meal programs
tri c• t s also em lo er, sew. er ‘ or waste management dis-·
that standard: fo; ~~1ti’,1c :ealth professionals to assure
In addition I ic ealth protection are met.
(an industry co~ v~ _untary health organizations
fund raising for hns;;hg organizations that engage in
cation, and patiente: :related research, health edufor
public health w ekrv1ces) represent another setting
a speci.a l case of or 1e rs • The Am en·c an Red Cross is
h eal t h and care-g·a v. o untIa ry. a gency, gi.v en the public
ivmg ro e 1t pl d •
response in coord’ . ays urmg emergency
. mat1on with I I officials. It also prov· d ?ca ‘ state, and national
ti~n in many localittesesf~:tens1ve public health educash1p
of HIV/ AIDS ‘ . example, through sponsororganizations
wit/:es~ent10n trai?ing. Other voluntary
elude the A • rong pubhc health presence inCancer
_mencan Lung Association, the American
the S?c1ety, _the American Heart Association, and
th American Diabetes Association. Although each of
ese ~mploys public health personnel, they also use
extensive. networks of volunteers’ some of whom are
also fu~l-t1me public health workers in other agencies
For th~ir. volu~teers who are not public health workers:
~he trammg given for volunteer tasks results in expandmg_
the public health knowledge within communities.
To Illus~ate, few communities would be as strict in control
of mdoor tobacco smoke today were it not for the
thousands of public health volunteers workino through
voluntary associations. Local communities ltlso often
have nonprofit groups with public health and human
services missions who provide important outreach to
the population through health education, health advocacy,
and other public health efforts.
Hospitals and Healthcare Organizations
Many hospitals and health care organizations (including
staff-model and other health maintenance organizations)
employ public health professionals. Many of
the administrators of personal health care services have
earned graduate degrees in administration from programs
housed in schools of public health, and may have
developed a population focus on their work. Among the
most common public health workers in these settings
are health educators, outreach workers, and epidemiologists.
A large institutional system may have its own
sanitarians, environmental engineers, and occupational
health staff as well. Further, many localities expect that
the clinical portion of public health services, such as
immunizations or home-based education and outreach,
will be housed with other care services, and not solely
in the public health agency, and often are inc?rp?1:ate1d
seamlessly into daily practices such as a pediatncrnn s
ongoing care. Conversely, it should be remem~ered,
however, that just providing a health-related service or
PROVISION OF PUBLIC HEALTH SERVl():s
PART FOUR i;;
310
activity outside the walls of a hospital does not mak~ it
a public health activitv. The test for whether something
should be considerei part of public health is the pr~sence
of a focus on a population group or commumt!
and on a preventive strategy or a preventable outcoi~e.
As public health and health care organizations continue
to implement mandates of the Patient Protection and
Affordable Care Act of 2010 (ACA),5 some of the job
tasks of public health workers and hospital workers
may become more integrated and shared across worker
settings.
cal health departments? Enumerations
state n1ul_ lo unt the number of workers ernpl tuct.
( t dies to co · · 0 ies s u d t f agencies or orgamzations) have bY e·d
in a defined se tohe U.S. public health workforce s·een
con ducte o. n te i’ts size. More recent ef f orts esti”‘ ince
Occupational Health
For workforce and other strategic considerations, occupational
health is a subspecialty of public health practice
that may take workers into almost any other field as
a part of the organization’s infrastructure. These public
health professionals include physicians (some board certified
in occupational medicine by the American Board
of Preventive Medicine), nurses, epidemiologists, and industrial
hygienists, and are involved primarily with protection
of workers from hazardous working conditions.
Some also develop workplace-based health promotion
programs or even broader health programs for workers
and their families. Workers concerned about their
health and safety may also employ public health expertise
through unions or professional associations. For
example, occupational health advocates on the staff of
the American Nurses Association were leading activists
in supporting legislation protecting health care workers
from occupational exposure to blood-borne pathogens.
WORKER ENUMERATION
1908 to est1ma •11ated
ublic health workers per 10?,000 population in
220 p while a national enumeration_ study conducted
1. 98200,0 0 y1. e lded a total of approxim. ately 450 ,O oo 10 t· nally equivalent to a ratio of 158 pub\’ workers na 10 • 1 . 7 1c
k s per 100,000 popu at1on. These stud
health wor er f ” bl’ h ·
. d d’fferent definitions or pu ic ealth Worker”
1es use 1 d 11 t· ak’
d•ff t methods for ata co ec ion, m mg trend
and 1 eren . . 1 Th
. s over time d1fficu t. e most recent enu
comparison . 14 . 1 d .
merat.i on st udy , conducted m 20 , m· e u he s workers in
l l t te and federal health agencies w o are respono’bcla
‘ fs a th’e delivery of essent·i aI pub l1’ c h ea1t h services, s1 e or . . h d .
which is a narrower defimt10n_ t an use m previous
stu d1. es. In this study, approxim.a tely 291,000 pub- 1
.
lie health workers in 14 occupat10na categories were
enu merated using survey data collected by multiple 8 • organizations (see Table 18-1), eqmva1 ~ nt to a rate of
92/100,000 population. Half of the pubhc health workforce
worked in local health departments, which is not
surprising given that the majority of public health services
are provided at the local level; 30 percent worked
in state health departments and 20 percent at federal
health agencies. Additional detail on the recent trends
in governmental workforce data is provided in Chapter
8 (for state health departments) and Chapter 9 (for
local health departments). Enumeration studies provide
valuable information for assessing the size of the workforce,
but usually provide limited information on other
characteristics of the workforce, such as demographics,
Unlike for other health professions such as physicians
and nurses, the U.S. government does not employ a system
for continuously collecting data to count or characterize
the public health workforce. The U.S. Bureau of
Labor Statistics (BLS) produces employment and wage
estimates annually for over 800 professions. 6 Although
public health workers are included in these estimates,
most cannot be counted because they are grouped
within broader health care professions categories that
lack sufficient precision to specifically determine who is
a public health worker. As a result, public health professional
organizations and public health systems researchers
undertake national surveys and studies in an attempt
to collect information on different segments of the
workforce. Most studies are conducted with state and
local health departments because these agencies are easily
identifiable, have a clear public health mission, and
are often willing to participate in such research activities.
Among the most basic of research questions studied
is How many public health workers are employed ‘in
education and training background, and job function
because most data are collected from the organization,
rather than from individual workers.
Public Health Occupations
The occupational categories listed in Table 18-1 represent
the primary professions of public health workers.
The occupational diversity of the workforce is apparen~.
~everal disciplines, each with their own skills and
trammg requirements, work in multidisciplinary teains
t~ contribute to the overall delivery of public health services
· Ad mi·m ·s trat1·v e and clerical personnel, who in~Y
not have a degree in public health but support public
hhealth program activities in local state and federal
ealth. de partments, represent almo’s t 20 p’ ecr cent ofth e
;
0 ~~-fo~e. The largest proportions of workers trained in
(;6 ic ealth service delivery are public health nurses
ers (~ercent), followed by environmental health work-
0th percent), _and public health managers (6 percent).
er occupations w·th f l boratory workers b .1 ewer workers include ~ ‘ pu he health physicians, behav1ora
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
rJ\BLE 18-1 Public Health Workforce Occ .
upat,ons and Enumeration Estimates, 2014
occupation
Administrative/
Clerical
personnel
Public Health
Nurses
Environmental
Health Worker
Public Health
Manager
Laboratory
Worker
Public Health
Physician
Behavioral
Health
Professional
Job Description
Staff who work in bus· f·
d . . mess, inance, auditing, management,
~n accountin~; trained at a professional level in their
f1ehld of expertise before entry into public health · staff
w. o p.e rform support work ·1 n areas of busi.n ess a’ nd
financial operations; and staff who perform nontechnical
supf=’.ort wo_rk in all areas of management and program
adm1n1strat1on.
Wor~ers who plan, develop, implement, and evaluate
nursing and public h_ealth interventions for persons, families,
and_ f?0 Pu!at1o~s. at nsk for illness or disability. This includes
pos1~1ons 1dent1f1ed at the registered nurse (RN) level,
and include~ graduates of diploma and associate degree
programs with the RN license.
Staff who plan, develop, implement, and evaluate standards
and systems to improve the quality of the physical
environment as it affects health; manage environmental
health programs; perform research on environmental health
problems; and promote public awareness of the need to
prevent and eliminate environmental health hazards.
Health service managers, administrators, and public health
directors overseeing the operations of the agency or of
a department or division, including the senior agency
executive, regardless of education or licensing.
Staff who plan, design, and implement laboratory
procedures to identify and quantify agents in the
environment that might be hazardous to human health,
biologic agents believed to be involved in the e~iolo_gy of
diseases among animals or humans (e .g., bacteria, viruses,
or parasites), or other physical, chemical, and biologic
hazards; and laboratory technicians who plan, perform, and
I te laboratory analyses and procedures not elsewhere
eva ua . d ‘ I
classified, including performing routine tests 1n a me 1ca
laboratory for use in disease diagnosis and trea~ment;
prepari·n g v accines, biologics, and serums for disea. se
preven t’1 0n; preparing tissue samples for pathologists or
taking blood samples; and executing laboratory tests (e.g .,
urinalysis and blood counts).
Physicians who identify persons or groups at risk for illness
or d ‘1 sa b1T1 t y an d who develop ‘. implement, and evaluate
programs or · terventions designed to prevent, treat, or r in . . . . h risks· might provide direct medical services
ame ,orate sue , . • d ‘ I
. h’ h text of such programs, 1nclud1ng me 1ca
Wit In t e con r d . I’ d d d tor of osteopathy genera 1sts an spec1a 1sts,
octor an oc . • I h ·
f h have training in public hea t or preventive
some o w om
medicine.
h vide psychological support and assess,
Worke.r s w o pdr om onitor provision of communi·t y servi·c es f or
coo.r dinate, aI’n ts Includes soc1·a I work ers.
patients or c ,en ·
35,000
29,191
13,300
10,100
2,000
2,100
4,000
1: <
311
1 •
II I,
1· ,
I
,, 1
14,559 6,085 55,644
12,286 5,793 47,270
4,618 5,920 23,838
3,296 4,998 18,394
5,699 5,685 13,384
791 6,700 9,591
1,839 895 6,734
PART FOUR PROVISION OF PUBLIC HEALTH St1:1
“Vl~~S
TABLE lS-l (Continued)
Workers who design, organize, implement, communicate,
evaluate, and provide advice regarding the effect of
educational programs and strategies designed to support
and modify health-related behaviors of persons, families,
organizations, and communities.
Nutritionist
Epidemiologist
Emergency
Preparedness
Staff
Public Health
Dental Worker
Public Health
Informatics
Specialist
Public
Information
Specialist
Staff who plan, develop, implement, and evaluate programs
or scientific studies to promote and maintain optimum
health through improved nutrition; collaborate with
p~o~rams that have nutrition components; might involve
clm,cal practice as a dietitian.
Staff who investigate, describe, and analyze the distribution
and determinants of disease, disability, and other health
outcomes and develop the means for disease prevention
and control; investigate, describe, and analyze the efficacy
of programs and interventions.
Workers whose regular duties involve preparing for
(e.g., developing plans, procedures, and training programs)
and managing the public health response to all-hazards events.
Staff who plan, develop, implement, and evaluate dental
health programs to promote and maintain the public’s
optimum oral health, including public health dentists
who can provide comprehensive dental care and dental
hygienists who can provide limited dental services under
professional supervision.
Workers who systematically apply information and
computer science and technology to public health practice,
research, and learning (e.g., public health information
systems specialists or public health informaticists).
Staff who represent public health topics to the media and
public, act as a spokesperson for public health agencies,
engage in promoting or creating goodwill for public health
organizations by writing or selecting favorable publicity
material and releasing it through different communications
media, or prepare and arrange displays, make speeches,
and perform related publicity efforts.
Other or
Uncategorized
Worker
Public health workers in occupations not listed in the
previous categories; workers who cannot be placed in a
category due to missing data
TOTAL
6,715
5,000 1,276 223 6.499
1,800 2,476 4,276
2,900 810 3,710
2,600 356 443 3,399
2,100 729 2,829
2,100 174 2,274
30,200 35,960 20,271 86,431
147,491 86,411 57,056 290,988 ==————– SOURCE: Beck, A.J. and Boulton, M.L.
h 1th professionals, health educators, nutritionists,
e~demiologists emergency preparedness staff, public
ep1 ‘ . . f . . . l
health dental workers, pubhc health _m ormat1cs ~pecia –
1· sts, an d publi· c information specialists. Approxunately
30 percent of the workforce in this study was repre·
sented by an undesignated occupation or was unas·
signed to a category due to underreporting of workforce
information. This further supports the need for n1ore
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
stan dardized metho. dologies for collecting workforce 1· 11-
ation on a national level.
forrn
public health workers who are often excluded from
st public health workforce enumeration studies are
rn’:nrnunity health workers, individuals who conduct
co treach for medical personnel or health organizations
ou . h
irnplement programs m t e community that pro-
:ote, maintain, and improve individual and community
health . 6 Community health workers, sometimes
called lay he~lth workers or ?romotoras, depending on
the community, are a growmg segment of the public
health work_forc_e; they may_ be volunteer or paid, are
found workmg m any pubhc health setting, and generally
do not have a formal educational background
in public heal~h, but are trained to help deliver public
health services to the population. The BLS recently
began collecting data on this segment of the workforce
and estimated that 45 ,800 community health workers
were employed in the United States in 2013, excluding
self-employed and volunteer workers for which
enumeration estimates are unavailable. The number of
employed, paid workers in this discipline is similar to
the number of public health nurses enumerated in oovemmental
public health settings. This diverse grou; of
public health workers could soon represent the largest
group of public health workers in the United States.
Workforce Taxonon-1y
One method for improving the quality of data related
to enumeration and other workforce characteristics is
to develop a common system for classifying workers.
A public health workforce taxonomy was developed
in 2014 by several public health professional groups
and federal agencies providing a framework for worker
classification that could lead to a much clearer picture
regarding workplace settings, type of employment, job
tasks, funding sources for workers, educational background
, licensure and certification , and worker demographics.
9 The taxonomy’s occupational categories,
which include far more than the 14 occupations used
in the most recent enumeration study, provide more
specificity on the types of disciplines represented in the
~ublic health workforce (see Table 18-2). Broadly, pubhe
health occupations can be grouped into four main
categories: management and leadership; professional
and scientific; technical and outreach; and support services.
The workforce taxonomy provides a mechanism
for standardizing the classification of public health occupations
across different workforce surveys, which has
been a persistent challenge for workforce researchers,
~ermitting more valid comparisons while also provid~
ng a framework for ensuring collection of a set of minimum
data elements on all workers in the public health
Workforce.
313
TRENDS IN PROFESSIONALIZATION
The field of public health has been aptly described
as a “loose confederation of professions” because t~e
breadth of skills and experience needed by pubhc
health workers requires highly diverse back~round_s
representing many different disciplines. Histoncally, it
was commonplace for workers in health d~part~ents,
for example, to be primarily trained on the Job w~th no
public health degree and little or no formal educat10n or
even training in public health. However, that began to
change with the IOM’s 1988 report, The Future of Public
Health, which prominently acknowledged th~ need
for significant changes in the training and educat10n of
the national public health workforce, including acces_s
to more educational offerings. That need was dramatically
highlighted and reinforced in the follow-on 2003
IOM report, Who Will Keep the Public Healthy in the
21st Century?, which recommended that the CDC and
Health Resources and Services Administration (HRSA)
“periodically assess the preparedness of the public
health workforce, to document the training necessary to
meet basic competency expectations and to advise on
the funding necessary to provide such training.” These
ongoing efforts to further develop the skills and competence
of the existing public health workforce have increased
substantially since 2000, with greater emphasis
on certification and licensure of public health workers,
and accreditation of governmental public health departments.
Although it may have been true at one time that
public health workers learned most skills on the job and
that any worker in the health department could perform
almost any job task in a pinch, even without any training
or education in that area, that is rapidly becoming
an outmoded perspective and no longer true nor feasible
in the modern public health workforce. As several
enumeration and other workforce studies have revealed
the public health workforce is becomino increasinol~
professionalized as workers are charged
0
with carryhi~
out more complex, specialized, and technical tasks tha~
c~ll for an appropriate level of educational and profess10nal
background training. This has been driven, in
part, b! the enormous changes occurring in health informat10n
technology with the advent of advanced webbased
com?1′:1nicab~e disease surveillance systems, ever
more sophisticated immunization information systems
the ?evelo~ment of large and complex health registries:
the tncreastng use of electronic health records and th
need_ to u~ilize “big data” to improve health, all ,of whic~
r~qmre high levels of technical and professional expertise.
For example, a 2002 national study found that
over 40 percent of epidemiologists in state health depa~
tme?ts lacked any education or formal training in
ep1dem~ology;10 similarly a state health department reported
m 2006 that over 60 percent of their workforce
I 1
………
l I ,
I I
I I
314 PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
TABLE 18-2 A Taxonomy for the Public Health Workforce
1.4. Management and Leadership
1.4.1. Public Health Agency Director
1.4.2. Health Officer
1.4.3. Department or Bureau Director
(subagency level)
1.4.4. Deputy Director
1.4.5. Program Director
1.4.6. Public Health Manager or Program Manager
1.4. 7. Other Management and leadership
1.4. 7. 1 . Coordinators
1.4.7.2. Administrators
1.5. Professional and Scientific
1.5.1. Behavioral Health Professional
1.5. 1.1 . Behavioral Counselor
1.5.2. Emergency Preparedness Worker
1.5.3. Environmentalist
1.5.3.1 . Sanitarian or Inspector
1.5.3.2. Engineer
1.5.3.3. Technician
1.5.4. Epidemiologist
1.5.5. Health Educator
1.5.6. Information Systems Manager
1.5.6.1. Public Health Informatics Specialist
1.5.6.2. Other Informatics Specialist
1.5.6.3. Information Technology Specialist
1.5.7. Laboratory Worker
1.5. 7. 1. Aide or Assistant
1.5.7.2. Technician
1.5.7.3. Scientist or Medical Technologist
1.5.8. Nurse
1.5.8.1. Registered Nurse Unspecified
1 .5.8.1.1. Public Health or
Community Health Nurse
1 .5.8.1.2. Other Registered Nurse
(Clinical Services)
1.5.8.2. licensed Practical or Vocational
Nurse
1.5. 9. Nutritionist or dietitian
1.2.
1.3.
1.5
1 _ 1.1. Oral Health Professional
1.1 .1.1. Public Health Dentist
1.1.1 .2. Other Oral Health Professional
1.1.2. Physician
1.1.2.1. Public Health or Preventive
Medicine Physician
1.1.2.2. Other Physician
1.1.3. Medical Examiner
1.1.4. Physician Assistant
1.1.5. Public Information Specialist
1.1.6. Social Worker
1.1 .6.1 . Social Services Counselor
1. 1. 7. Statistician
1.1.8. Veterinarian
1.1.8.1. Public Health Veterinarian
1.1.8.2. Other Veterinarian
1.1. 9. Other Professional and Scientific
1.1.1 O. Student Professional and Scientific
Technical and Outreach
1.2.1 . Animal Control Worker
1.2.2. Community Health Worker
1.2.3. Home Health Worker
1.2.4. Other Technical and Outreach
Support Services
1.3.1 . Clerical Personnel
1.3.1.1 . Administrative Assistant
1.3.1 .2. Secretary
1.3.2. Business Support
1.3.2.1. Accountant or Fiscal
1.3.2.2. Facilities or Operations
1.3.2.2.1. Custodian
1.3.2.2.2. Other Facilities or
Operations Worker
1.3.2.3. Grants or Contracts Specialist
1.3.2.4. Human Resources Personnel
1.3.2.5. Attorney or Legal Counsel
1.3.3. Other business support services
Other
SOURCE: Boulton, M.L. , Beck, A.J., Coronado, F., Merrill, J., Friedman, C. et al.
Jacked a college degree of any type. 11 However, just a
decade later a repeat of the national epidemiology assessment
revealed over 60 percent of epidemiologists
working in health departments possessed a public
health or epidemiology degree and almost 90 percent
had received at least some formal training in epidemiology
(although this may constitute just a single epidemiology
course12). The Jack of formal training within the
workforce resulted in workers who were cross-trained to
fulfill many types of duties: a public health nurse may
have also performed duties of an epidemiologist, such
as outbreak investigation; a health educator may have
also assisted with health facility inspection. Although
the public health professionals continue to work in
multidisciplinary teams (work groups composed of
or combining several usually separate fields of expertise)
and are cross-trained to some extent, public health
disciplines have become much more specialized as t~e
number of accredited schools and programs of public
health have increased in the United States (Figure 18-1).
PUBLIC HEALTH EDUCATION
The first U.S. school of public health was founded in
1916 but the process of formally accrediting these
schools did not begin until the 1940s; two decades
later, the first program of public health (outside of~
school of public health) was accredited. The number 0
schools and programs grew steadily until the 2000S nt
◄
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE 315
70 en
E e en 60
£ 50
“O
C ca en 40
0 ——
0 ~ 30 u —– 50
(/) – 0 20
.! E 10
:::I z
0
—— – – – 31
0 —- 5 — 17
9 13
6 6 5 7
1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s
Decade
\ D Programs D Schools \
FIGURE 18-1 The Growth of Schools and Programs of Public Health in the United States, 1940s-201 Os
which point a dramatic and rapid expansion occurred
(see Figure 18-1). The increased availability of public
health degree programs at the graduate level and, more
recently, at the undergraduate level, in on-campus and
distance learning formats has greatly improved the accessibility
of public h ealth education. Not all public
health graduates choose to work in public health practice;
however, it seems reasonable to expect increases
in the percentage of public health workers with formal
public health education in future years.
The academic core of a public health Master’s (MPH)
degree program, which is the most common type of public
health degree, includes courses in the following five
areas: biostatistics, epidemiology, environmental health
sciences, health services administration/policy, and social
and behavioral sciences, described in Table 18-3. All
schools and programs of public health accredited by the
Council on Education for Public Health (CEPH), the main
national accrediting body, are required to offer courses
in these areas; many also offer courses in areas such as
global public health, health information/informatics, public
health genetics, health disparities, and maternal and
child health, among other specialty areas. Some of these
areas have more recently been developed into formal degree
offerings; in particular global public health, public
health preparedness, and health information technology
are offered as MPH concentrations through a number of
schools and programs of public health.
TABLE 18-3 Knowledge Areas of the Core Academic Components of Accredited Master of Public Health Programs
Biostatistics
Epidemiology
Environmental Health Sciences
Health Services Administration
Social and Behavioral Sciences
………
SOUR.c E: C-oun-cil on Educatt. on for p u blic Health
l
Collection, storage, retrieval, analysis, and interpretation of health data;
design and analysis_ o’. health-related _surveys and experiments; and concepts
and practice of stat1st1cal data analysis
Distributions and determinants of d isease, disabilit ies and death in human
populations; the c~aracteristics and dynamics of human populations; and the
natural history of d isease and the biolog ic basis of health
Environmental factors including biolog ical , physical, and chemical factors that
affect the health of a community
Plann ing, organization, ad1;1 inistration , management, evaluation, and policy
analysis of health and public health programs
Concepts and methods of social and behavioral sciences relevant to the
identification and solution of publ ic health problems
I
316
Continuing Education
Beyond educatin_g students for future work in public
health, substantial resources have been invested by
schools of public health and other public health organizations
to train current public health workers.
The !OM reported that schools of public health have
a responsibility to ensure that appropriate, quality
education and training are available to public health
professionals, other members of the public health
workforce, and health professionals who participate in
public health activities. 2 As a result, federally funded
training centers were developed at schools of public
health across the country to train the existing public
health workforce in foundational public health skills.
A large national network of Public Health Training
Centers (funded by the HRSA) and CDC-funded Preparedness
and Response Learning Centers have offered
trainings using distance learning and a variety
of other modalities to offer instruction which is provided
by public health professionals and faculty covering
a diverse array of public health topics ranging
from short courses related to the five academic core
areas of public health, to emergency preparedness and
response. These trainings tend to be more applied in
nature in order to provide knowledge and skills that
the public health worker can integrate into his or her
daily job tasks immediately and often provide continuing
education credit to meet certification or licensure
requirements.
Licensure and Certification
In keeping with trends of greater professionalization
and training of the public health workforce, there has
been a concurrent increase in the requirement for and
monitoring of worker licensure and certification.
There are several methods for verifying that workers
are adequately trained and capable of performing the
duties required by their positions. Some health professionals
are required to obtain a state license by passing
an examination in order to practice their profession. Examples
common among public health workers include
M.D. licenses for physicians, R.N. licenses for nurses,
R.S. licenses for sanitarians, and R.D. licenses for dietitians.
Maintaining licensure generally requires the
worker to complete training courses to achieve a minimum
number of continuing education credits within
specific time intervals and then report those credits periodically
to a state licensing board. Licensure may be
an effec.tive way to ensure workers continue to hone and
maintain their skills; however, only a minority of the
overall public health workforce is eligible for licensure,
as there is no license for most disciplines within the
public health workforce.
◄
PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
Worker certification is another common method f
encouraging workforce development. Unlike licensu~r
certification is usually voluntary, ~!though_ some Pub:
lie health organizations _and a_ge?c1es m~y mdividual!y
require worker certification. Su~ilar to hcen_sure, Workers
achieve certification by pass!~g a~ ex~mmation and
maintain certification by part1c1patmg m continuin
education opportunities. _Ther~ are many examples 0~
public health worker cert1ficat10n; however, a cenification
open to public health workers of all educational
backgrounds and disciplines does not yet exist. Perhaps
the closest example of a uniform certification for public
health workers is the Cert!fied in Public Heal~h (CPH)
credential. In 2005, a Nat10nal Board of Pubhc Health
Examiners, comprising representatives from academic
and practice organizations,. was _formed to develop and
administer a voluntary cert1ficauon exam for graduates
of public health schools and programs. The CPH is intended
to distinguish public health workers who have
“mastered knowledge and skills relevant to contemporary
public health.”13 Eligibility for certification was
expanded in 2013 to include public health professionals
who have taken core public health courses at an accredited
institution and have relevant job experience or
other education. The CPH is the field’s only certification
for which all public health disciplines are eligible.
Other examples of certification in public health are
discipline specific. Physicians and nurses may achieve
board certification in public health through a combination
of completing clinical or preventive medicine
residency programs, successfully passing board examinations,
and enrolling in other advanced training
or fellowship programs. Workers with a degree and/
or substantial experience in health education are eligible
to sit for a Certified Health Education Specialist
(CHES) exam, which is also offered at a Master’s level
for advanced health educators. Finally, public health
laboratory workers are eligible for a variety of generalist
and specialist certifications within their field.
WORKFORCE COMPETENCIES
Public health education and training, whether provided
by a school of public health or through a training
center’s online offerings, is increasingly being guided
by the development of competencies. Competencies
form the cornerstone of efforts by schools and pro·
grams of public health, governmental public health
agencies, and many public health professional groups
to more systematically ensure that public health work·
ers are equipped with the appropriate level of skills
and knowledge to competently and effectively carry out
their work.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
public health workforce competencies are the
foundational_ knowledge, ski!ls , and abilities necessary
for pubhc_ health profe~s10nals to efficiently and
ffectively deliver the services deemed essential to
;ublic h~alth . Competencies the~selves should be
action-oriented and clearly describable, observable,
and measurable. The CDC, IOM, and the Association
of Schools and Programs of Public Health (ASPPH)
have all strongly endorsed competency development
in order to strengthen the public health workforce.
Competencies improve the workforce by providing a
framework for developing educational and training
programs, delin_ea:ing worker roles and responsibilities
, and perm1ttmg a means for assessing worker
performance and organizational capacity. The first
public health workforce competencies were developed
in the 1980s; more recently many national public
health worker specialty groups including the Council
of State and Territorial Epidemiologists (CSTE) , the
Association of Public Health Laboratorians, the Quad
Council of Public Health Nursing Organizations, the
TABLE 18-4 Public Health Workforce Competency Sets
317
National Commission for Health Education Credentialing,
and the CDC, among others, have develope_d
comprehensive worker competencies specific to their
profession (see Tobie 18-4). 14-18 These practitioner and
profession-specific competencies are complemented by
more general public health competencies such as the
Core Competencies for Public Health Professionals d~veloped
by the Council on Linkages Between Academ~a
and Public Health Practice-developed for all public
health workers19-and the more academically oriented
public health core competencies for MPH students enrolled
in academic degree programs, developed by the
ASPPH Education Committee. For educational accreditation
, CEPH requires academic programs to clearly
identify the competencies expected of their graduates
and to indicate how course-specific learning objectives
will lead to the acquisition of these competencies.
2° Competencies are further addressed in detail in
Appendix B.
A common basis for many of these public health
worker competencies is the 10 Essential Services of Public
Competency,~~:~ Lead Organization -·=• ‘ -· ·~ ·’ · · – –~ ., Date’· Notes ·
Bioterrorism and Emergency Readiness: Columbia University School of Nursing 2002
Competencies for All Public Health Center for Health Policy & Centers for
Workers Disease Control and Prevention
Applied Epidemiology Competencies Council of State and Territorial 2006 Three tiers: Beginner,
Epidemiologists Midlevel, and Senior
Epidemiologist
Master’s Degree in Public Health Core Association of Schools of Publ ic Health 2006
Competency Development Project (v. 2.3)
Competencies for Public Health Centers for Disease Control and Prevention & 2009
lnformaticians University of Washington Center for Public
Health Informatics
Areas of Responsib ility, Competencies, National Commission for Health Education 2010
and Subcompetencies for Health Credentialing, Inc.
Education Speciali sts
Ouad Council Competencies for Public Quad Council of Public Health Nursing 2011
Health Nurses Organizations
Guidel ines for Biosafety Laboratory Centers for Disease Control and Prevention 2011
Competency
Competency Guidelines for Publ ic Health Centers for Disease Control and Prevention & 2014
Laboratory Professionals Association of Publ ic Health Laboratories
Core Competencies for Pub lic Health The Council on Linkages Between Academia 2014 (This is the newest
Professionals and Public Health Practice version)
/’ I I’
I’ I
• I
I
318
Health (ESPH) (Tobie 18-5), described earlier in this text?
ook (see, e.g., Chapters 1, 2, and 11). First formulated
m_ 1994 by the Public Health Functions Steering Com’.~
ttee, these 10 key services summarize the major activities
of ~he workforce in carrying out the responsibilities
of pubhc health and form the core from which necessary
worker knowledge, skills, and abilities are derived. For
example, the CSTE Applied Epidemiology Competencies
and the six national capacity assessments based on those
competencies focus on them largely in the context of carrying
out just four ESPH which are perceived to have a
significant epidemiological focus: ESPH 1 (Monitoring),
2 (Investigate), 9 (Evaluate), and 10 (Research).
PUBLIC HEALTH WORKFORCE
CAPACITY
There have been an increasing number of researchers,
practitioners, and policy makers acknowledging the
need to identify factors that contribute to workforce
capacity, or the ability of the public health workforce
to perform the necessary tasks to effectively deliver the
essential public health services. Deficiencies in organizational
capacity have been theorized to negatively impact
TABLE 18-5 The 10 Essential Public Health Services
1. Monitor health status to identify community health
problems.
2. Diagnose and investigate health problems and
health hazards in the community.
3. Inform, educate, and empower people about health
issues.
4. Mobilize community partnerships to identify and
solve health problems.
5. Develop policies and plans that support individual
and community health efforts.
6. Enforce laws and regulations that protect health and
ensure safety.
7. Link people to needed personal health services, and
assure the provision of health care when otherwise
unavailable.
8. Assure a competent public health and personal
health care workforce.
9. Evaluate effectiveness, accessibility, and quality of
personal- and population-based health services.
1 O. Research for new insights and innovative solutions to
health problems.
SOURCE: Centers for Disease Control and Prevention
PART FOUR PROVISION OF PUBLIC HEALTH SERV1ces
the ability to sustain public health programs and i
ventions 21 -22 an d work fo rce capac1• t y contri.b utesn te.r –
nificantly to the overall capacity of an organizatio sig.
deliver services. ~~ny f actors can contn’b u te to Wno rtko.
force capacity. Ind1v1dual factors such as educational
training background , J.O b experi.e nce, an d J. o b satisfactain d
may play a role, as well as organizational factors such on
whether the organization suppor.t s c.o ntinu. ing educati· oans
for employees. Workforce capacity 1s an ~mportant concept
that needs further research to determme how it m
h t t . . ay
be enhanced and to w at ex en orgamzational performance
may be improved as a result. Consensus amon
public health systems and services researchers and publi~
health practitioners as to how and what to measure in order
to most accurately assess workforce capacity remains
elusive although interest in this area continues to grow.
Public Health Department
Accreditation
Accreditation is the process by which health department
performance is assessed against a set of nationally recognized,
practice-focused and evidence-based standards
that are continually developed and revised. Ultimately,
the goal of the national accreditation program is to improve
and protect the health of the public by advancing
the quality and performance of tribal, state, local,
and territorial health departments while also increasing
value and accountability to public health stakeholders.
The Public Health Accreditation Board (PHAB), a
nonprofit entity charged with developing accreditation
standards and measures as well as evaluating health departments’
abilities to achieve them, strongly supports
development of the nation’s governmental public health
workforce. In addition to the various standards and
measures that detail tasks and responsibilities expected
of public health workers, there are also accreditation criteria
that focus on ensuring that a sufficient number of
workers are staffing health departments, and that those
workers are well-qualified. PHAB encourages the development
of a competent workforce by requiring health
departments to regularly assess staff competencies and
address gaps through training opportunities. 23-24 The
PHAB standards and measures include a domain focused
on maintaining a competent public health workforce.
The two standards within this domain require
health departments to: encourage the development of
a sufficient number of qualified public health workers;
and, ensure a competent workforce through assess·
me_nt_ of staff competencies, the provision of individu~
t~ammg and professional development, and the pr~vi·
s1on of a supportive work environment. 24 Accreditation
measur~s such as these promote the development of _a
well-tramed workforce that can effectively deliver public
health services in health departments.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
WORKFORCE RESEARCH
Research on the public health workforce is typically inJuded
under the broader umbrella of public health sere.
es and systems research (PHSSR) which is defined as
VlCfi eld of study t h at exami.n es t h e organization, finance,
and delivery of public health services in communities
:nd the impact of these service~ on public health.
In the last few years especially, numerous national
workgroups have been convened, meetings held, and papers
written on public health workforce research needs.
Recently, a number of central themes have been developed
to guide the public health workforce research agenda25
and public health workforce has been specifically identified
as one of the four main thematic areas of PHSSR in
a 2012 journal supplement (as shown in Tobie 18-6).2<>
The progress in the conduct of research on these themes
varies and, for example, while the evidence base on public
health worker enumeration and competency development
have both rapidly advanced, in contrast we have
made very little headway in examining issues around (the
Jack of) workforce diversity and disparities, or in addressing
the clear lack of diversity in the current public health
workforce, especially in leadership positions. Nonetheless,
these themes provide a research roadmap that hopefully
will establish a basis for guiding future efforts to develop
a competent, sustainable, and diverse public health workforce
through evidence-based training, career and leadership
development, and strategic workforce planning to
improve population health outcomes.
LEADERSHIP
Leadership is the “process of persuasion or example by
which an individual influences a group to act toward a
common goal.”27 In this definition emphasis is placed
on the processes associated with the practice of leadership
(rather than the personality of the leader)• It
then follows that effective leadership is characterized by
TABLE 18-6 Public Health Workforce Research
Priority Areas
Worker enumeration
Demand, supply, and shortages
Diversity and disparities
Recruitment and retention
Workforce competencies
Educational methods and curricula
SOlJR.CE: Consortium from Altarum Institute, CDC: th~ Robert
Wood Johnson Foundation, and the National C00rdmat1ng Center
for Public Health Services and Systems Research
319
adherence to certain behaviors which can contribute to
improved performance by “followers” and to increased
organizational effectiveness.
In this section, some of the theoretical resea_rch
on leadership practice will be reviewed with a parti_cular
emphasis on applicabilit~ to publ_ic heal~h pract1
::~
Since an emphasis on practice and 1mprovn1:g lea~
ship behaviors flows from that research, a d1scuss10n
of various programs desigi:ied to enh_ance p~blic healt~
leadership development will be provided. Fmall~, som
guiding principles and best practices will be delmeated
as a guide for future leader development.
Leadership versus Management
The processes of leadership and manage~e~t ar~ different.
The process of leadership has been d1stmgm~hed
from the process of management by the aphons~:
“leadership is doing the right thing, management 1s
doing things right.”28 Perhaps the most useful framework
for distinguishing the two processes came from
Kotter. 29 In his formulation, management is designed
to provide order and consistency; leadership is designed
to provide change and movement. To accomplish these
goals, management consists of planning and budgeting,
organizing and staffing, and controlling and problem
solving. Leadership is about providing direction, aligning
people, and motivating and inspiring. 29
Another approach to distinguishing the practices
of management and leadership30 focused on the role
of leaders as providing a compelling vision and core
strategies while management involved translating strategies
into operational reality using specific tactics. In
this formulation, a vision should be “something you can
see”-a visualizable mental picture that is easily communicated
to others. Strategies provide the logic and limited
details for how the vision can be achieved. In public
health, programs are created to operationalize the strategies
and apply concrete tactical solutions to problems.
Theories of Leadership Practice
The commonly used statement that “leaders are born
and not made” derives from a trait perspective toward
leadership.27 As a result of this emphasis, early research
on leadership practice focused on the personal attributes
of effective leaders, leading to the erroneous view
that a basic set of unique traits could be delineated and,
as a result, aspiring leaders should be assessed with respect
to those ideal traits. Selection for leadership positions
then utilized an assessment and matching process.
In the mid-twentieth century, this point of view
was called into question as an era of leadership development
began. Since the trait theory of leadership provides
a very static view of what a leader is and should
I
320
be, ~ystematic development of leadership skills and be~
aviors was devalued. Once this static view was called
mto question, the research field expanded to consider
a range of theoretical foundations that led into formal
approaches to developing leaders.
The Skills Approach
Seminal research31 •32 in the mid- to late-twentieth century
created a useful framework for the elucidation of
the skills needed for effective leadership. Katz’s 1955
paper considered the skills needed at various levels
of an organization. At the supervisory level, technical
and human skills are needed to a greater degree than
con~~ptual skills. As one moves “up” into a managerial
position, ~II ~h~ee skill areas take on equal importance.
Once_ an m~1vidual reaches a top leadership position,
techmcal skill becomes less important while human and
conceptual skills are paramount.
. Mui:nfo_r~ went further by focusing on the relationship
of md1V1dual attributes and competencies as they
relat~ to leadership outcomes, such as effective problem
solvmg and enhanced performance. 32 In his formulation,
there are four key individual attributes:
► General Cognitive Ability
► Crystallized Cognitive Ability
► Motivation
► Personality
These attributes contribute to specific leadership
competencies:
► Problem-solving skills-especially when dealing
with novel and ill-defined problems
► Social Judgment skills-the capacity to understand
people and social systems
► Knowledge-the accumulation of information
needed to apply skills to a particular situation,
along with the ability to mentally structure and
communicate that knowledge
This skills-based framework has fostered the use of a
range of educational approaches designed to enhance
creative problem solving, conflict resolution, listening,
and teamwork. 27
The Situational Approach
Building upon the skills approach, research then evolved
to consider ways in which leadership styles should be
adapted to different situations, particularly as they relate
to the developmental level of the follower. 33 This approach
takes into account the degree to which leaders should focus
energy and attention on tasks versus the development
of relationships. For example, in situations where the “follower”
is less developed, a directive is called for; whereas,
more developed followers can be supported or delegated
to. A central challenge of this approach lies in the ability
PART FOUR PROVISION OF PUBLIC HEALTH SERViqs
of the leader to correctly assess the developmental le
hi /h ve 1o r another person and to adapt s er style according! y.
Transformational Leadership
A more popular, recent theory of leadership practi· .
transformational lea de rs h1. p, wh 1′ c h .ts contrasted wce· ihs
transactional leadership. As described by Burns :J.1, t It . . ‘ ransformational
leadership taps the motives of followers
establishes an interactt.o n be tween Ie a de rs and followaenrds
toward achieveme.n t of .a common goal. In contrast , tr~” nsactional
leadership rehes on the exchange of some ty
of contingent reward from the leader in order to elicitpc
behavior on the part of t_h e 1c 0I I ower:’ lo Tr ~nsformationaal
leadership is seen as evoking a more endunng level of motivation
and a level of performance beyond expectations
Kouzes and Posner36 articulated a set of five fund~mental
practices which p~ovide strategies for practicing
transformational leadership:
► Model the Way
► Inspire a Shared Vision
► Challenge the Process
► Enable Others to Act
► Encourage the Heart
This practice-oriented approach emphasizes that certain
behaviors can lead to better organizational outcomes
and can be learned by the developing leader.
Servant Leadership
Robert Greenleaf in his classic book, Servant Leadership,37
articulated a view of leadership that has resonated for
many:
Servant leadership begins with the natural feeling
that one wants to serve, to serve first … . The
best test is: do those served grow as persons and
will the least privileged in society benefit. 37
Servant leadership behaviors can then be described as
including listening, showing empathy and awareness,
committing to the growth of others, and building com·
munity. 38 Within the context of public health practice,
the servant leadership philosophy has had particular
resonance as a foundation for various approaches to
the development of public health leaders.
Leadership Development
in Public Health
As theories of leadership evolved and an emphasis on developing
leaders increased, organized programs were created
to develop public health leaders beginning in 1990,
The National Public Health Leadership Institute
Following the IOM report on The Future of Public
Health, 3 the CDC, under the leadership of Director
j
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
or. William Roper, c~n~mitted to an extensive effort
to strengthen the pub~ic mfrastructure in 1990. Within
this conte~’t, leadership de~elopment_was identified as
top priority and the National Pubhc Health Leader-
31 •p Institute (PHLI) was formed in 1991. The mission
s1f1 the PHLI was to provi’ d e top pub h. e health leaders 0 ‘th a high-quality development opportunity in which
M .
they were exposed to new perspectives related to the
ractice of leadership within the public health system.
i’he pHLI program was initially designed and managed
by a team of California public health leaders; the proaram
was later managed out of the University of North
0 Carolina.
Over the 20 years of its existence (1991-2011),
the Public Health Leadership Institute included nearly
1,000 scholars in top public health leadership positions,
including a former U.S. Surgeon General, top
CDC and other federal health agency leaders, numerous
state and local health directors, the National Association
of County and City Health Officials (NACCHO)
and Association of State and Territorial Health Officials
(ASTHO) presidents, the current Food and Drug Administration
commissioner, the CEO of CARE, a senior
vice president of a major health foundation, presidents
and executive directors of the American Public Health
Association, Association of Schools of Public Health,
Public Health Foundation, Association of Public Health
Laboratories, deans and professors in schools of public
health, and leaders in many other major health
organizations. 39
An evaluation40,41 of the impact of the PHLI prooram
revealed that 81 percent of PHLI graduates de:
eloped a better understanding of leadership principles
and practices; 73 percent developed ne~ o~ better
leadership skills and behaviors, such as skills m leading
collaborations and managing teams; 82 percent developed
an enhanced awareness of their own personal
leadership behaviors through the use o~ 360 de~re~
assessment, team interaction, and executive coachi?g,
55 percent developed a professional knowle~ge-shar~ng
network focusing on public health leadership practice,
which continued for many years after gradu~t.wn; and
19 percent obtained new or higher level positions as a
result of PHLI participation. PHLI grad_u~tes also led
the creation of new policies and laws gmdmg the practice
of public health such as increasing cigarette taxes,
developing a state trauma registry system, and passage
of a smoke-free workplace act. Finally, gra_duates
increased funding for public health programs mcludi.
n g legislation providing $ 1. 9 mi·1 1·i on for loca.l pu.b –
11.c health departments and an ·m creas e in funding for
school nurses. was the
Another benefit of the PHLI prof~ H alth
creation of an alumni network, the u hic e h
Le adership Society (PHLS), w hi. c h broug t toget er
321
PHLI alumni and alumni of other similar prog~am~ to
enhance lifelong learning. An important contnbutwn
of the PHLS was the creation of a Public Health Code
of Ethics,42 which is discussed in greater detail in
Chapter 5.
The National Public Health Leadership
Development Network
In 1994 the National Public Health Leadership Network
(le’d by the Saint Louis University College for
Public Health and Social Justice) was formed to share
information and to develop collaboration across the
growing number of state, regional, and national public
health leadership institutes. The network of leade_rship
institutes ultimately expanded through academ~c
and practice collaboration among schools of pubhc
health and state public health departmen~s, ~esulting
in the establishment of 1~ state~ba~ed mst1tutes,
10 regional institutes, 6 national mst1tutes, and 3
international institutes. As a result, 4 7 states plus the
District of Columbia and Puerto Rico had access to
a state, regional, or national public health leadershi_P
program. These programs graduated over 6,000 pubbc
health practitioners from across the world. A full report
on these public health leadership programs can be accessed
through http://www.heartlandcenters.slu.edu.
Furthermore, the network created a competency
set which guided the design and development of public
health leadership institutes for over a decade. -i-3
The National Leadership Academy
for the Public’s Health
The National Leadership Academy for the Public’s
Health (NLAPH) began in 2011 to provide training to
four-person multisector teams from across the country
to advance their leadership skills and to achieve health
equity in their communities. The program, managed by
the Public Health Institute in Oakland, California, uses
an experiential learning process that includes webinars,
a multiday retreat, coaching, peer networking, and an
applied population health project.
In its first year, NLAPH was successful in advancing
participants’ leadership skills, strengthening team functioning,
increasing intersectoral collaboration, and helping
teams make progress on their community health
improvement project. Through 2014, 69 teams from 33
states along with two national teams have participated
in the NLAPH pmgram.
Schools of Public Health and Academic
Public Health Programs
Some schools of public health and academic public
health programs have included courses in the curriculum
related to leadership theory and practice. Often ,
I
322
graduate public health students may have access to
leadership development experiences through business
schools within their own university. Some schools (e.g.,
University of North Carolina at Chapel Hill, University
of Illinois at Chicago, and Harvard) have developed
doctoral programs in public health leading to DrPH
degrees that focus on leadership practice and provide
opportunities to develop leadership skills as part of a
fom1al degree program.
In 2009, the Association of Schools of Public
Health developed a set of competencies for DrPH
programs which included specific leadership competencies
to develop the ability to create and communicate
a shared vision for a positive future; inspire trust
and motivate others; and use evidence-based strategies
to enhance essential public health services. (More information
can be found at http://www.aspph.org by
searching “DrPH Model.”) Graduates of such DrPH
programs are expected to acquire the following leadership
skills:
► Communicate an organization’s mission, shared
vision, and values to stakeholders.
► Develop teams for implementing health initiatives.
► Collaborate with diverse groups.
► Influence others to achieve high standards of
performance and accountability.
► Guide organizational decision making and planning
based on internal and external environmental
research.
► Prepare professional plans incorporating lifelong
learning, mentoring, and continued career progression
strategies.
► Create a shared vision.
► Develop capacity-building strategies at the individual,
organizational, and community level.
> Demonstrate a commitment to personal and
professional values.
These competencies now provide a basis for curriculum
development and course creation in schools of public
health and academic public health programs.
Lea~ership Development Programs Sponsored by
National Public Health Organizations
PRovisioN OF PUBLIC HEALTH SERVicl:’. .. l· PART FOUR Q
. h lth directors in a mentoring relationshi’
with new ea d J h d p.
d
. f m the Robert Woo o nson an de Beau
Fun mg ro · l ·
mont Fo un d a ti·ons has been essentla to support the se
programs.
Leadership Development Needs at Stages
of Career Development
As leaders develop, they may evolve through a series
of stages in which devel?pmental needs differ.44 The
emerging leader (sometimes refe~red ~o as a “rising
star”) needs to be identifie? an~ assisted m developing a
personal awareness of their umque talents and abilities.
Further these emerging leaders benefit from exposure
to lead~rship concepts and theories ~as noted above)
and involvement in a formal mentormg relationship.
Emerging leaders should seek out a mentor, rather than
hoping one will come along.
At a later stage, often when a young leader enters a
full-time job situation, needs evolve as she/he enters the
stage of the “early leader.” In this stage, technical skills
are often central in public health occupations (e.g., epidemiology);
however, leadership development must
also advance skills in adaptive change. At this stage, formal
360 degree assessments are useful along with participation
in formal leadership development programs
of the type noted above. Peer networks are also of great
value as ways to share lessons learned and promote lifelong
learning.
As leaders progress to becoming established leaders,
they will continue to benefit from activities noted
at earlier developmental stages and should take note
of the need for ongoing peer-to-peer interaction with a
struc~red approach to formal executive coaching. Often,
established leaders fail to commit to leadership develop·
~~°:t as the? _bec~me saddled with increasing responsi·
bihties. Pa~c1pat10n in some type of formal development
program swted to their needs can offset the tendency to
procr~stinate with regard to ongoing leadership learning.
Fmally, as leaders enter the emeritus stage of their ca·
reers, they may be uniquely qualified to serve as coaches
and m_ent?r~ to those at early career stages. In this way,
these mdividuals may pass on the wisdom of experi·
ence tha.t goes b eyon d fo rmal courses or programs ·in
leadership.
Both ASTHO (http://www.astho.org) and NACCHO
(~ttp://www.naccho.org) have sponsored programs designed
to enhance leadership skills in directors of state
or local health departments. ASTHO has also created
a leadership development experience designed for senior
deputies. Each of these programs relies on a competency-
based format and a cohort model in which
peer learning and network development is enhanced.
The NACCHO program-the “Survive and Thrive
Program”-pairs experienced local health directors
PROFILES IN PUBLIC HEALTH
LEADERSHIP
Many of the princi 1 exemplified d .
1
. P es and practices noted above arc
Two example:
1
(f;:~he work of public health lea~ersd
here) are useful . many hundreds not describe
practice of publicm h p roviding 1 f the 1 h concrete examp es o .
Exhibit 18-1. eat leadership, as shown beloW 111
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
tXlllBIT 18-1 Leadership Profiles
f c•j=• § liii) # ;l =!M: ~
As Director of the Massachusetts Commission of Public
Health, John Auerbach led efforts to capture and codify
the role of public health in the Massachusetts Health Reform
effort that has served as a national model for health
system change. In an article titled: “Lessons From the
Front Line: The Massachusetts Experience of the Role
of Public Health in Health Care Reform,” 45 he stated five
key principles that enabled public health contributions to
landmark health policy change:
1. Get a Seat at the Table
2. Take an Open Minded and Critical Look at What Public
Health Does Now
As Director of the Kane County (Illinois) Health
Department, Paul Kuehnert was faced with a daunting
challenge during the Great Recession of 2008. Budget
cuts prompted an in-depth reassessment of the role
of the public health agency that ultimately led to the
transfer of personal health services out of the health
agency into three federally qualified health centers and
SUMMARY
The public health workforce comprises a diverse group
of health professionals who are uniquely varied in terms
of the education, skills, and experience they bring to the
job, although all share a common awareness of and commitment
to improving health through a population fo~s.
Over the last decade the public health workforce, unhke
?ther health professions, has grown smaller while also
increasing in occupational diversity to encompass n_ew
fields such as health informatics, public health genetics,
~nd emergency preparedness. The opportunities for public
health training and education have never been greater
as the number of programs and schools of publ~c health
have rapidly expanded along with more o~tions for
continuing education. The result is an increasmgly p~ofessionalized
public health workforce that has been further
~trengthened by enhancements to co~pe~ency-basecl
t~ainings, worker certification, and accred1tatJOn °_f pu~hc
health agencies. Despite these advanc~s, too httle 18
known about the number and type of pubhc healt~ workers
and the reasons they enter and leave ~he workfo~ce. ,
. A key concept related to workfare~ is that of lea~ership,
defined as the “process of persuaswn or example by
Wh1· ch an m. d1. v1. dual i. nfluences a gr oup to act tow. ard. a
cornrnon goal.” Leadership is essential to the reahzat10n
323
3. Defend the Traditional Public Health Approach When
Called For
4. Keep on the Lookout for Opportunities
5. Envision a Better Model and Take Steps to Make It
Real
These principles, which were instrumental in leading
the Massachusetts Health Reform effort, reflect the
leadership attributes described in this section and are
broadly applicable to other public health challenges and
opportunities.
a reduction in the agency workforce by 50 percent.46
This case study exemplifies the practice of front line
leadership within a public health agency (in addressing
major organizational changes) as well as leadership outside
the agency (to navigate major political challenges
related to accomplishing unprecedented organizational
change).
of a shared vision, and a number of theories have been
developed regarding the skills required for effective leadership,
although “servant leadership” is an especially
compelling model. Outstanding leadership for the public
health workforce will be needed to successfully address
the challenges and opportunities to improve and
protect the public’s health in the twenty-first century.
REVIEW QUESTIONS
1. What are some of the professions that comprise
the public health workforce and what do they share
in common’?
2. What are some of the key trends in public health
worker professionalization ‘?
3. What are competencies and why are they valuable’?
What are some of the public health professions
which have developed profession-specific
competencies’?
4 . How does the practice of leadership differ from the
practice of management’?
5. What are the key feahires of servant leadership’?
6. What do “early leaders” need to enhance their own
leadership skill development’?

UNDERSTANDING WORKER
PARTICIPATION AND
ORGANIZATIONAL
PERFORMANCE AT THE FIRM
LEVEL: IN SEARCH FOR AN
INTEGRATED MODEL
Jan Kees Looise, Nicole Torka and Jan
Ekke Wigboldus
ABSTRACT
Last decades scholars in the field of human resource management
(HRM) have intensely examined the contribution of HRM to organizational
performance. Despite their efforts, at least one major research
shortcoming can be identified. In general, they have devoted far too little
attention to an aspect of HRM potentially beneficial for organizational
performance: worker participation, and especially its indirect or
representative forms. In contrast, for academics embedded in the
industrial relations tradition, worker participation is a prominent theme,
even though less emphasized in its relationship with company objectives.
One might defend traditional scholars’ reservations by arguing that
participation’s main goal concerns workplace democratization and not
Advances in Industrial and Labor Relations, Volume 18, 87–113
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organizational prosperity. However, several writers state that industrial
democracy involving worker participation can channel conflicts of interest
between employees and employers and stimulate desired employee
attitudes and behavior, consequently enhancing organizational performance
(e.g., Gollan, 2006; Ramsay, 1991; Taras & Kaufman, 1999).
And, indeed, several studies have shown positive effects of both direct
participation (e.g., European Foundation for the Improvement of Living
and Working Conditions, 1997) and indirect participation (e.g., Addison
et al., 2000, 2003; Frick & Mo¨ller, 2003) on organizational performance.
Nevertheless, to date, the absence of an integrated model explaining the
connection between worker participation and organizational performance
leads to the following question that still is in need of an answer: how do
direct and indirect forms of participation – separate as well as in
combination – affect organizational performance? This chapter aims to
contribute to the filling of the aforementioned knowledge gaps. In so
doing, we focus on direct and indirect, nonunion participation on the firm
level, using a Western European and especially Dutch frame of reference.
Keywords: Direct participation; indirect participation; firm-level;
performance; the Netherlands
INTRODUCTION
Industrial democracy is still a central theme in industrial relations (IR)
debate and research. Industrial democracy refers to worker participation in
both its direct and indirect or representative forms. Direct participation
refers to employees’ immediate communication, interaction, and co-decision
making with management; indirect participation to one or more employees
who act in a representative function for other employees in dealings
with management. This happens in a vast variety of organizational forms
including committees, councils, and unions (Kaufman & Levine, 2000; Taras &
Kaufman, 2006).
The global economic downturn in the mid-1980s pushed adherents to the
emerging human resource management (HRM) rhetoric to advocate onesided
employer demands, undermining IR’s position in teaching and research
(themes) (Clarke et al., 2009). One of the most influential HRM models (e.g.,
Beer, Spector, Lawrence, Quinn Mills, & Walton, 1984) advocated worker
88 JAN KEES LOOISE ET AL.
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participation as one of the so-called ‘‘high performance management
practices’’ that contribute to organizational effectiveness, and later research
supported this assumption (e.g., Addison et al., 2000, 2003; Frick & Mo¨ ller,
2003). However, compared to other practices such as job design, pay, and
development opportunities, participation – particularly indirect forms – and
its effects have received relatively little interest in HRM studies. Many IR
scholars also remained silent on the relationship between worker participation
and organizational performance. This is not surprising given IR’s
traditional view that worker participation epitomizes industrial democracy.
Yet, an increasing number of IR scholars focused attention on the fact that
worker participation, and mainly nonunion representation on the firm level,
also has a fundamental economic value. These researchers emphasize that from
a managerial point of view employee involvement can be seen as a business
tool: worker participation as a means to reduce transaction costs associated
with the employee-organization relations and, consequently, improving
productivity (e.g., Colling, 2003; Frenkel, Korczynski, Donaghue, & Shire,
1995; Freeman & Lazaer, 1995; Gollan, 2006, 2010; Kaufman & Taras, 2000;
Kaufman & Levine, 2000; Ramsay, 1991; Rogers & Streeck, 1995; Taras &
Kaufman, 1999). Moreover, it can be argued sustainable successful worker
participation on the firm level has to meet employers and employees interests:
in this view enhanced organizational productivity and performance are
aligned with an improvement of the ‘‘social good’’ for workers in terms of
higher wages, improved working conditions, and increased job security. After
all, only companies with sustained productivity and profitability are able to
ensure further enhancement of workers’ conditions.
Against this background, investigating the effects of worker participation for
organizational performance is legitimate. This chapter addresses this issue by
focusing on direct and indirect nonunion forms of worker participation on the
firm level using aWestern European and especially Dutch frame of reference that
we know best. More specifically, the goal here is to explore possible solutions to
the following puzzle: how do direct and indirect forms of participation – separate
as well as in combination – affect organizational performance?
We decided to leave union involvement out of our consideration because in
most Western European countries (like the Netherlands, Germany, Austria,
Belgium, France, and Spain) union interference is restricted to collective,
sector-level bargaining with a strong focus on remuneration packages and
decision making in regard to individual organizations lies outside the unions
mandate. Furthermore, Gollan (2010, p. 212) states that in Anglo countries
the interest in nonunion firm-level participation is increasing because union
density is in decline, and legislative changes more and more ban closed shop or
In Search for an Integrated Model 89
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compulsory union arrangements. For example, in the UK nonunion joint
consultation between management and worker representatives seems to be
growing (Hall, 2009) partly under influence of the recent European Directive
on information and consultation of employees. In contrast, in the Netherlands
(and other European countries) indirect nonunion worker participation
is a rather old phenomenon.We can thus by concentrating on countries with a
long tradition offer arguments for those who want to promote these forms of
participation in countries and firms with a different history.
At the end of this chapter we present an integrative model that can guide
future research on the participation–performance link and policymaking in
this field. We will explore two streams of research which have shaped this
model. The first concerns the connection between direct participation and
employee outcomes like commitment, and consequently organizational
performance. After presenting a brief overview, we proceed to concentrate
on the indirect participation–organizational performance connection, with a
strong focus on the role of Dutch works councils. By combining insights
from the direct and indirect participation–performance links we are able to
present our integrated model in the last paragraph.
DIRECT PARTICIPATION AND ORGANIZATIONAL
PERFORMANCE
Direct participation can potentially touch all workers directly in relation to
their work tasks, work organization, and working conditions. Such
participation is strongly contingent on a voluntary management decision
and can be seen as an HRM-practice (see Introduction). Despite the vast
amount of research on the performance effects of HRM-practices, very little
work has been done to illuminate the contribution of direct participation to
organizational performance. The EPOC Group’s research (European
Foundation for the Improvement of Living and Working Conditions,
1997) showed it was valuable to investigate this relationship.
The EPOC Research Group studied direct participation in 10 Western
European countries.1 Close to 6,000 general managers participated in this
survey about the coverage, scope, and intensity of different forms of direct
participation (total response rate: 17.8%). They found evidence of direct
participation in 82% of the workplaces in Western European countries, with
group consultation in permanent groups as the leading form (43% of the
workplaces: 29% permanent and 14% temporary), followed by individual
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consultation (33%), group delegation (13%), and individual delegation
(11%). The Netherlands and Sweden had the highest scores in workplaces
with direct forms of participation: 90% and 89% of the workplaces (see also
Gill & Krieger, 1999). This means that in almost all workplaces in these
countries forms of direct participation exist. Positive effects of direct
participation were found for three categories of performance outcomes,
namely:
1. economic performance (cost reduction, reduction of throughput time,
improvement of quality of product or service, increase in output);
2. indirect labor costs (decreases in sickness, absenteeism); and
3. direct labor costs (reduction in number of employees, managers).
Table 1 gives an overview of the performance effects of different forms of
direct participation as perceived by the respondents as reported in the EPOC
survey. In the table only three of the six investigated forms of direct
participation are shown, namely, individual consultation (‘‘face-to-face’’),
group consultation (permanent groups), and group delegation. Not included
are individual consultation (‘‘arms length’’), group consultation (temporary
groups), and individual delegation.
Table 1. The Effects of Different Forms of Direct Participation
(EPOC, 1997).
Effects Individual
Consultation (%)
Group
Consultation (%)
Group
Delegation (%)
Economic performance
Reduction of costs 61 61 56
Reduction of throughput time 64 62 66
Improvement in quality 92 94 94
Increase in total output 52 53 58
Indirect labor costs
Decrease in sickness 39 37 32
Decrease in absenteeism 42 39 37
Direct labor costs
Reduction of number of employees 27 26 30
Reduction in number of managers 26 22 31
In Search for an Integrated Model 91
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The results show direct participation has the strongest effect on economic
indicators, especially quality improvement, but also on reduction of
throughput time and cost and increase of the total output. The effects on
indirect (i.e., decrease in sickness, decrease in absenteeism) and direct labor
costs (i.e., reduction in number of employees, reduction in number of
managers) seem to be weaker, but are still important.
When we take into account different forms of direct participation, the
EPOC research shows that effect differences between the diverse forms of
direct participation are rather small. This is also the case with reference to
the forms that are missing in the table. Only group delegation seems a little
more effective when it comes to direct labor costs. Another interesting
finding is that temporary group delegation can be as effective as more
permanent forms. It thus seems reasonable to conclude that it is more the
opportunity of direct participation as such less the form of that opportunity
that is decisive for organizational performance.
Although the EPOC study seems to suggest an immediate relationship
between direct participation and organizational performance, based on
HRM rhetoric and research, it is wise to acknowledge that intervening
factors cause this connection. Numerous HRM scholars present models
aiming to illustrate the HRM and performance relationship (e.g., Beer et al.,
1984; Fombrun, Tichy, & Devanna, 1984; Guest, 1997; Paauwe, 2004;
Paauwe & Richardson, 1997) and they all agree there is a relationship
between the organizations’ strategy, the choice for a certain HRM approach
(or system), and specific outcomes or effects. For example, when choosing
for quality as a strategy to foster competitive advantage, this target has to be
aligned within the various HR-practices (e.g., Baird & Meshoulam, 1988).
Concerning the effects, a distinction has been made between employee and
organizational outcomes. Employee outcomes refer to the effects of HRM
on employee attitudes (e.g., satisfaction, commitment) and consequent
behavior (e.g., absenteeism, turnover, organizational citizenship behavior
[OCB]), and these are expected to influence organization outcomes. Thus,
employee attitudes and behavior are the missing link in the direct
participation and organizational performance relationship (see also Cox,
Zagelmeyer, & Marchington, 2006; Purcell & Georgiadis, 2006)
Organizational performance refers to both objective (e.g., profit, return
on investment; productivity, growth) and subjective performance outcomes
(e.g., quality of products and services, client satisfaction, innovativeness).
Several researchers (e.g., Paauwe, 2004; Addison & Teixeira, 2006; Forth &
McNabb, 2008) emphasize the current common research approach to
organizational performance in its sole focus on financial performance is
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too narrow. They urge an alternative use of a multidimensional performance
perspective that includes further objective (e.g., employment growth) and
subjective performance measures (e.g., employee well-being, societal wellbeing).
We fully agree about expanding the parameters in studying
organizational performance, but here limit our discussion to the more
economic effects of (direct) participation.
Building on the general notions we have raised about the connection
between HRM and performance, we can assume the following relationships
between direct participation and organizational performance (see Fig. 1).
As Fig. 1 shows, direct participation appears to have an impact on
organizational performance in three rather basic ways.
First, employees with direct participation opportunities can influence
organizations’ performance directly: they can offer suggestions leading to
more efficient processes or better product quality. In doing so, employees
can contribute to higher labor productivity and process innovation (e.g., De
Leede, 1997).
Second, like other HR policies and practices, direct participation
influences employee attitudes which in turn support employee behavior
that is beneficial for organizational performance (e.g., reduced turnover
and absenteeism, improved productivity and product quality; see also
Doucouliagos, 1995; Dundon, Wilkinson, Marchington, & Ackers, 2004).
Recent findings support the assumed relationships: Torka, Schyns, and
Looise (2010) found direct participation is significantly connected to
affective organizational commitment, and Meyer et al.’s (2002) metaanalysis
shows that this form of commitment strongly influences employee
Organizational
strategy
cost (cost efficiency)
focus (quality)
differentiation
(innovation)
HR policies and
practices
function/job design
hr flow
appraisal and reward
Employee
outcomes
Attitudes:
commitment
motivation
Behaviour:
absenteeism
turnover
collaboration
flexilbility
Organisation
outcomes
growth
labour
productivity
product
quality
product
/process
innovation
direct participation
Fig. 1. The Relationship between Direct Participation and Organizational
Performance.
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health and well-being, turnover, absenteeism as well as task- and extra-role
performance (i.e., OCB). Thus, direct participation can impact organizational
performance indirectly through the just mentioned employee
outcomes.
Third, the model shows that direct participation has a rather prominent
position as part of the HR policies and practices. In other words, managers
should offer employees opportunities to (co-)decide on those HR issues
that clearly affect them. Older research by Beer et al. (1984) supports this
idea with two arguments: (1) ‘‘If ’’, they claim, ‘‘employees are major
stakeholders in the enterprise, then it is critical that managers design and
administer various mechanisms for employee influence’’ and further
(2) ‘‘employee influence in its broadest sense is a central perspective in
the formulation of all human resource management policies.’’ This last
proposition about the critical role of both direct and indirect participation
has been ignored by many scholars and practitioners. Just a sparse handful
of investigators have recognized the point and gone so far as to claim
direct participation should even have a special status within research on
performance: direct participation presumes listening to employee needs and
only when meeting their needs will desired outcomes be gained (e.g.,
Bryson, 2004; Bryson, Charlwood, & Forth, 2006; Gollan, 2003; Torka,
Van Riemsdijk, & Looise, 2007). Given our review of unmistakable
patterns of blind sight in the accumulated evidence, when compared to
other HRM-practices, there can be little doubt that participation deserves
at least equal attention in organizational performance research and
practice.
Finally, Cox et al. (2006) state that more emphasis needs to be placed on
the perception of direct participation. Therefore, it can be argued that
getting insight into the absence or presence of participation opportunities
(see, for example, Forde, Slater, & Spencer, 2006) is less important than the
quality of the given opportunities as perceived by employees. Employees’
satisfaction and justice perceptions can be seen as indicators of the
employee–organization relationship (EOR) quality (e.g., Coyle-Shapiro,
Shore, Taylor, & Tetrick, 2004; Kuvaas, 2008). We know from prior
research that satisfaction with HR-practices is a good predictor of affective
organizational commitment (e.g., Kinnie, Hutchinson, Purcell, Rayton, &
Swart, 2005; Meyer, Stanley, Herscovitch, & Topolnytsky, 2002). Several
studies show that justice perceptions are quite directly correlated with job
satisfaction and organizational commitment (e.g., Colquitt, Conlon,
Wesson, Porter, & Ng, 2001; see also Colquitt, 2001 for different dimensions
of justice and measurements). Moreover, managerial strategies lacking a
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perception of fairness seem to undermine productivity (Kick, Fraser, &
Davis, 2006). Therefore, we can legitimately assume employees’ satisfaction
with and perceived fairness concerning participation can shed significant
light on the quality of participation. Finally, concerning quality, research
found that participation is often seriously in need of improvement. The role
of managers, the quality of participation policies and practices, and job and
workforce characteristics are still insufficiently taken into account or ever
even considered (e.g., Bryson et al., 2006; Cunningham & Hyman, 1999;
Torka, Van Woerkom, & Looise, 2008).
INDIRECT PARTICIPATION AND
ORGANIZATIONAL PERFORMANCE
There are, as stated earlier, good reasons to focus on indirect nonunion
participation, also known as an integrative form of bargaining, like works
councils and joint consultation committees, and not on union involvement (i.e.,
distributive forms of bargaining). In many Western European countries (the
Netherlands, Germany, Austria, Belgium, France, Spain) both types of
bargaining take place in different institutions, while in others (the Scandinavian
countries and the United Kingdom) both forms of bargaining are executed, but
in a separate mode by union representatives at the company level. According
to the EPOCResearch Group, forms of joint consultation exist in about half of
the organizations in the tenWesternEuropean countries that participated in the
research, with higher levels for Germany and the Netherlands and lower levels
for the United Kingdom and Portugal (see also Gill & Krieger, 1999).
Co-determination via worker representatives in supervisory boards and worker
directors can be found in Germany and the Netherlands.
In the Netherlands, only a few large companies bargain directly with
unions. In large measure the unions’ mandate is restricted to negotiations on
the sector-level, the foremost concern being pay and benefits specified in
collective agreements. The works council is the most important institution
for representative participation on the firm level, and mandatory for all
firms with 50 and more employees. The Dutch Law on works councils (Wet
op de ondernemingsraden, WOR) states that works councils have to be
installed ‘‘in the interest of the good functioning of the company in all its
goals’’ (article 2). According to the WOR, Dutch works councils have
different rights.
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First, the right to give advice about a number of economic and organizational
issues, including the transfer of control over the company, lasting cooperation
with other companies, the closing down of the company or parts of it, major
organizational changes, major investments and loans, and – more recently –
the introduction of new technology.
Second, the right to veto employer proposals regarding changes in social
and personnel policies, including working hours, holidays, remuneration,
job evaluation schemes, working conditions, recruitment, promotion, and
training. These rights are only in effect when such arrangements are not
determined by a collective labor agreement.
Third, the right to appeal – in various courts – when the aforementioned
rights of veto or advice are not respected by the managing director.
Fourth, the right to initiate proposals with respect to all matters related to
the company, to which the employer is obliged to respond.
Finally, the right to assemble at least six times a year during work time
(excluding the presence of the managing director), to follow courses outside
the company (five days a year), and to consult external experts.
The rights of Dutch works councils are comparable to those in other
European countries such as Germany, Austria, and Belgium.
The growing interest in involving representative firm-level participation (e.g.,
unions, partnerships, work councils, and other forms of joint consultation) in
performance research has led to research focused on its consequences for
companies. These investigations seem to be inspired by an economical–political
or managerial point of view: in Western Europe, the popular discussion about
the relative competitive position of European economies.
In Germany, the system of firm-level representative, nonunion participation
has been long debated, questioning if the two institutions within
the firm (the ‘‘betriebliche Mitbestimmung’’ in works councils on company
issues and the ‘‘Aufsichtsrat’’ or supervisory board on concern issues)
hamper or stimulate German competitiveness (‘‘Standort Deutschland’’).
In 2006 the so-called Commission Biedenkopf concluded revision of
the system was unwarranted inasmuch as research failed to detect or
establish any relationship with poor company performance. In point of
fact, the opposite seemed to be the case: extensive research indicated the
German mandatory works councils may well improve firm performance
and certain kinds of productivity (Addison et al., 2000, 2003; Frick &
Mo¨ ller, 2003).
Furthermore, research in other countries shows a positive relationship between
(the presence of) representative participation in firms and performance.
Concerning unions on the firm level, research by Addison (2005), Rose and
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Woolley (1992), and Sengupta (2008) highlights the importance of unions for
high-performance work systems and firm performance. Concerning works
councils, Kleiner and Lee’s (1997) research among large South Korean firms
shows effective works councils can be associated with higher levels of employee
satisfaction and productivity.
The debate on the performance effects of works councils has not achieved
as high a level in the Netherlands as in Germany, due in part to the
unavailability of empirical data on this issue. However, recent initiatives
have been undertaken to address this topic in new research (Karel, Heijink,
Van den Tillaart, Boekhorst, & Van Rijsingen, 2010) and a reassessment of
earlier research (Van den Berg, Grift, & Van Witteloostuin, 2009). This
research when combined with the now growing interest in economic effects
of other legal and institutional arrangements (like the legal arrangements
regarding dismissals and extension of collective agreements, the position and
role of the unions) should fuel the debate on the economic effects of works
councils in the Netherlands.
Up to now scholars have not been generally very explicit in defining the
way(s) representative forms of participation like work councils can
influence performance. However, Dutch research on works councils can
be helpful in developing an understanding about if and how representative
participation can contribute to organizational performance. Based on Van
het Kaar and Looise’s (1999) study on the position and functioning of
Dutch works councils, three ‘‘channels’’ – one direct and two indirect – can
be distinguished regarding the influence of works councils on company
performance.
The researchers sent questionnaires to both the managing directors and
works councils of a representative sample (N¼3,500) of all Dutch
organizations with a works council (about 15,000). Four hundred and
seventy five managing directors (response rate: 14%) and 450 works
council representatives (response rate: 12%) participated in the study.
Although the response rate of this study was rather low, it is in line with
that of other large-scale empirical studies (for example, the EPOC
research). Moreover, more recent Dutch research (Karel, et al., 2010)
seems to corroborate the results. Table 1 shows the answers of both
managing directors and works council members to questions about the
perceived effects of works councils on organizational performance. These
questions were not deliberately developed to understand the contribution
of the works council to organizational performance (i.e., developed to
measure some effects of works councils), but offer a welcome opportunity
to understand the channels by which representative forms of participation
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can influence organizational performance (for more information, see also
Wigboldus, Looise, & Nijhof, 2008).
Table 2 shows both managing directors and works council members
acknowledge performance effects of works councils. However, indirect effects
seem to receive stronger recognition than direct effects, particularly in the case
of managing directors. The fact both parties perceive more indirect than direct
effects of works councils on organization performance is in itself not
surprising inasmuch as influencing organizational performance is a major
responsibility of top management and not Dutch works councils. Against this
background, it is likewise unexceptional that management finds it harder to
‘‘admit’’ the contribution of the works council in this respect. However, the
table also shows that despite managers (average) perception, even they still
perceive a direct contribution of the works council to performance aspects like
efficiency, profitability, and innovation.
Table 2 also shows that both indirect channels receive substantial support
from managing directors and works council members. Regarding the first
indirect channel, managing directors acknowledge especially the effects of
works councils on employee attitudes in terms of acceptance of necessary
decisions with employees, while works council members stress the improved
Table 2. Works Council Effects Based on Perceptions of Managing
Directors and Works Council Members (Based on Van het Kaar &
Looise, 1999).
Effects Management
(%)
Works Council Members
(%)
Direct channel
Enhancing efficiency 9 26
Enhancing profitability 4 10
Enhancing innovation 12 24
Indirect channel 1
Improved acceptance among employees 64 43
Improved representation of employees’ interests 55 78
Reduction of power differences 28 27
Indirect channel 2
Improvement of decision making quality 38 52
More careful decision making 65 67
Faster decision making 3 11
Note: The values are the percentages of managing directors and works council members that
have answered the questions.
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representation of employee interest in decision making. Since we can assume
that both effects are interrelated – a good representation of employee
interests in decision making will enhance the acceptance of the decision by
the employees – the underpinning of this channel seems to be quite
convincing. Also, the reduction of power differences – while less strongly
supported – appears to follow from these circumstances. Finally, the second
indirect channel receives ample support: It was beyond doubt that the effect
of works councils on careful decision making is recognized by a large
majority of both groups of respondents.
Before presenting a deeper exploration of the direct and indirect effects of
representative participation on organizational performance (see also
Wigboldus et al., 2008), we first present a simple explanatory model that
aims to illustrate this interaction and these relationships.
The direct channel contributes to organizational performance through
new information and/or new solutions. Due to their legal rights and/or their
contacts with top-management, representative bodies can directly influence
organizational performance, either by communicating their ideas in their
meetings with top management, or advising and/or negotiating on plans and
policies. By passing on new information, representative participation adds
to the decision making process. This information can potentially improve
management decisions and thereby adds to better performance. The specific
position of works councils or committees as elected representation of all
workers enables the council to acquire information that otherwise would not
come to the attention of senior management without delay and distortion.
This so-called asymmetry approach is supported by Freeman and Lazaer
(1995) who argue works councils’ (and other committees) economic effects
can depend on conveying unknown information from the work floor to
management (see also Lahovary, 2000). Because of the information
asymmetry between management and worker representatives, their interactions
can produce new points of view and new solutions for advantageous
management problem-solving. Addison (2005) found this approach sound
in his study of channeling employee’s preferences to be an important works
council function. Although this does not produce new information to
management, it helps management to deal with the different employee
preferences such as work hours or benefits. Dilger (2002) has shown with his
voice approach that the asymmetry effect goes beyond organization and work
procedure improvement ideas. Representative bodies also may express
complaints and problems that are frustrating circumspect employees, helping
reduce unnecessary employee turnover and so-called mental resignation.
As concluded above, the direct effect of representative participation on
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organizational performance seems to be rather limited when compared to that
of indirect effects. To be sure, this does not mean it should be neglected:
representative participation is able to contribute directly to organizational
outcomes.
The first indirect channel contributes to organizational performance
through an enhanced positive organizational climate. Organizational
climate is the overall meaning derived from the aggregation of individual
perceptions of a work environment (James et al., 2008, p. 15), and research
shows that a positive climate affects employee and organizational outcomes
in a favorable way. Climate is a critical mediating construct for exploring
the relationship between HRM and performance. In a strong positive
climate organizational members display significant congruence concerning
organizational values, and routinely act according to these values by
contributing to organizational performance through, for example, accomplishing
cost effectiveness, quality, and innovativeness. (Bowen & Ostroff,
2004; Ostroff, Shin, & Kinicki, 2005).
Heretofore the possible positive impact of representative participation
on the firm’s climate has been largely neglected. However, research generally
shows that participative organizational climates are perceived as more
effective in terms of trust than authoritarian climates (Farris, Senner, &
Butterfield, 1973), and trust influences labor–management relations (Taylor,
1989), enhanced readiness to change (Lawler, 1992), and negotiation
(Bazerman, 1994). Regarding the latter, the assumption of a reversed effect
of trust seems quite appropriate: trust – an important condition and
consequence of a strong climate – may influence the quality of both direct
and indirect participation.
The activities of representative bodies can contribute to an organizational
climate with fewer power differences, less inequality, and more trust in the
organization. After all, at least in the Netherlands, works councils represent
all employees and their rights; they are restricted to general employee goods,
and do not extend to individual employee interests. Therefore, representative
participation occurs by definition on an aggregated level: next to
organizational interests, representatives embody the shared interests of
(groups of) employees. As such, representative bodies operate on a climate
level, and climate stimulates employee commitment and consequently
performance (see also paragraph on direct participation and organizational
performance and DeCotiis & Summers, 1987; Van den Hooff & De Ridder,
2004). Besides that, a positive organizational climate (co-)created by
representative participation might have a direct positive influence on
organizational performance through improved communication. Lahovary
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(2000, p. 6) supports this idea and concludes works councils intensify the
communication flow between management and employees and communication,
itself is critical for organizational performance (Snyder & Morris, 1984).
Given the evidence of this cascading role of a strong organizational climate,
representative participation can and should be viewed and understood as an
explicit attempt to integrate mutual benefits of managers’ and employees–
organizational and employee well-being. What results is enhanced organizational
performance.
The second indirect channel contributes to organizational performance
through the organization system, and management’s attitudes and behavior.
In many of the (larger) Dutch organizations, the works council has
developed into a player in the corporate governance structure that cannot be
ignored (Van het Kaar & Looise, 1999). Its relatively clear view of what
management does and fails to do, and its communication line with the
supervisory board, are crucial. They have made it possible to get
dysfunctioning CEOs dismissed. Representative bodies’ interventions may
correct and prevent opportunistic management behavior and through this
contribute to better organizational performance.
This assumption is amply supported by empirical evidence. Falkum (2003)
points to the fact that performance is not only positively affected by
management supporting employee participation, but also by employees
resistance: for example, when employees or their representatives are opposed
to bad management strategies and decisions. Van den Berg (2004) is even
more specific, arguing indirect participation can restrict or even prevent
management from placing their own pecuniary interests above company
interests. This is possible by using information and consultation rights, as well
as through interaction with the supervisory board. Van den Berg considers
this mechanism an extension – albeit an unorthodox one – of the principalagent
approach; although it is not meant to foster shareholder interests, it
aims to put the general interest of the company above management’s tendency
to act opportunistically. A similar line of thinking is found in Addison (2005)
who quotes Jirjahn’s (2003) study. He found that works councils can
contribute to company performance by curtailing rent seeking management
behavior, especially when they discuss profit sharing schemes for executives.
A manager working at the large German company Bayer very briefly
expressed the opportunism preventing functioning of the works council: ‘‘The
works council requires of us that we manage well.’’ (in Wever, 1994, p. 475).
Finally, with regards to indirect participation, it is useful to stress that the
quality of participation is decisive. The quality essentially determines the
real power these institutes can have on performance, and this power may
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potentially exceed even minimum rights given by (country-specific) regulations.
Representative participation quality depends on both the managers’
attitudes toward such institutions, as well as the expertise and skills of
representative participation agents. Moreover, it can be argued that the
quality of indirect participation increases when management and worker
representatives share interests. This interest alignment approach is supported
by Vroom (1964), who assumes rational workers’ behavior and claims a
workers’ effort is determined by his dual expectancy of the opportunities that
this effort will lead to a certain performance and by the degree to which this
performance will help to reach a certain desired outcome. Applying this idea
to our subject means that representative bodies will only put effort in
contributing to better profits if (a) it is likely to really have an effect on these
profits, and (b) this contribution will lead to a desired outcome. Grimsrud,
Kvinge, and Gunnes (2003, p. 8) support this overall line of reasoning: ‘‘(y)
to be successful, increased involvement by employees in decision making must
be linked to a gain-sharing mechanism, which offers the opportunity for
workers to gain financially from taking on the extra responsibility.’’
Freeman and Lazaer (1995) suggest works councils will only have positive
economic effects in those situations where there is power equilibrium
between management and works council. When works councils have too
much power they will claim more of the total firm profits for the employees
than they have contributed, but when they have insufficient power they will
not be motivated to contribute to better firm results. Pe´rotin and Robinson
(2002) in their study of performance effects of financial participation by
employees underline that organizational performance depends not only on
the working efforts of employees, but also on management decisions and
external factors. They conclude that employee influence on management
decisions is necessary to prevent that these decisions from harming share
value and profit levels, factors that could undermine employees’ efforts to
earn a fair living.
THE INTERRELATEDNESS OF DIRECT
AND INDIRECT PARTICIPATION
AND ORGANIZATIONAL PERFORMANCE
Both direct and indirect participation can be offered by management on a
voluntary basis, but it can also be mandatory for the organization – forced
by laws, collective agreement(s), or union power position. Overall, direct
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forms of participation seem to be more based on voluntary management
decisions, and indirect forms of participation on (legal) regulations. In the
Netherlands, laws on direct participation have not emerged while there is
extensive legislation law on works councils. However, it is interesting to note
that there are other Dutch laws, like the one on working conditions (Arbo
Law) that refer to direct participation of all employees of an organization
concerning this type of issues. Moreover, the Law on works councils is
patently proscriptive, instructing these organizations to stimulate direct
participation in their work. Overall, works councils in the Netherlands are
not very active on this topic: only half of the works councils pay attention to
direct participation (Van het Kaar & Looise, 1999). This is probably due to
the fact that direct participation is already commonplace in the Netherlands
and works councils give priority to other, even more demanding tasks. It may
also be a result of the fact that works councils see direct forms of
participation as a competitor and as a by-pass for management. There is
some empirical evidence of the use of direct participation as a ‘‘unionavoidance
strategy’’ by management (e.g., Kochan, Katz, & McKersie,
1986). However, based on the EPOC research of Fro¨ hlich and Pekruhl
(1996), it is permissible to conclude that ‘‘our data suggest that in countries
with a system of works councils or elected representatives at the establishment
level, employee representatives are generally not by-passed by
management’’ (p. 138).
Surprisingly, the relationships between direct and indirect participation
and their ‘‘combined effect’’ on organizational performance have been
rarely studied. After all, several authors explicitly assume interrelatedness
between both forms of participation. Strauss (1998) stated that institutionalized
indirect participation is inevitable for successful direct participation.
Kleiner and Lee’s (1997) and Poutsma, Ligthart, and Veersma’s (2006)
empirical studies support this generalization. Kleiner and Lee found that
both work councils and unions enhance direct participation in several key
personnel practices, while Poutsma and colleagues’ research reveals
substantial effects of country-specific institutions on direct participation in
European firms.
In the EPOC study some attention has been given to the ‘‘regulation’’ of
direct participation via indirect participation, as well as to the incidence and
effects of both forms of participation. A first conclusion from this study is
that ‘‘the extent of employee information and consultation about the
introduction of direct participation is high.’’ In on average 44% of the
workplaces in the participating ten EU countries, extensive consulting with
employee representative bodies like works councils or joint consultation
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committees has been about the introduction of direct participation in the
work place, and 22% report that they were extensively informed or limited
consulted. Only 34% report no involvement of indirect participation in the
introduction of direct participation. These findings suggest that (according to
a majority) direct participation should not be seen as a purely ‘‘management
instrument’’ aimed at weakening the role of indirect participation, but rather
as an instrument or HR-practice approved by the works council or similar
bodies (see also Gill & Krieger, 1999).
Furthermore, the results also show the (potential) role of indirect
participation in the introduction of HR-practices as discussed above. In the
case of the Netherlands the Law on works councils governs the effect of
the veto-right of works councils on social and personnel matters.However, the
EPOC results do show that in other European countries representative bodies
are also entitled to be informed about or to be consulted over HR-practices
like the introduction of direct participation.
A third fundamental conclusion is that according to managers the extent
of representative bodies involvement affects the actual (assumed) performance
outcomes of direct participation. Table 3 gives an overview of the
effects of direct participation in combination with no involvement (No),
limited consultation (Limited), and extensive consultation (Extensive) with
indirect participation. The table shows that in every case the effects of direct
participation are stronger when representative bodies were consulted on the
Table 3. The Extent of Indirect Participation in the Introduction of
Direct Participation and the Effects of Direct Participation (EPOC,
1997).
Effects No (%) Limited (%) Extensive (%)
Economic effects
Reduction of costs 47 65 61
Reduction of throughput time 61 66 64
Improvement in quality 90 91 96
Increase in total output 13 47 63
Effects on indirect labor costs
Decrease in sickness 15 33 44
Decrease in absenteeism 16 37 48
Effects on direct labor costs
Reduction of number of employees 28 31 34
Reduction in number of managers 23 21 35
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introduction of direct participation. This seems to be true for economic
effects like cost reduction and increase of total output, and with indirect
labor cost effects like decreasing sickness and absenteeism. With the
exception of cost reduction and reduction of throughput time, the effect is
even stronger when the consultation with employee representatives is more
extensive.
With this background of specific results and our earlier presented models
(anchored in an exploration of prior research and theory) about the way(s)
direct and indirect participation can independently influence organizational
performance, we are now able to offer an integrated model on their
combined effects on organizational performance.
Fig. 3 shows the combination of Figs. 1 and 2, highlighting their mutual
connections. This model illustrates that both direct and indirect participation
have their own roles and functions within organizations, and that there
is no foundation for the fear by either of the other taking over (part of) these
roles or functions. In other words, the role and function of representative
participation cannot be taken over by direct participation, or vice versa.
A second critical point is the role of indirect participation with respect to
HRM and direct participation. Indirect participation is not (only) an HRMpractice:
indirect participation can potentially ‘‘co-design’’ HRM policies
and practices. Representative committees anchored in legal regulations (like
Dutch works councils) have a prescribed agenda to discuss and co-decide on
a list of HRM topics such as benefits, job design, and employee health. In
that sense, indirect participation channels influences on HRM policies and
practices such as those related to direct forms of participation. However,
when indirect participation lacks such protection from legal regulations and
Organization
system
goals/strategy
governance
structure
culture
management
behaviour
Representative
participation
(legal) rights
composition
relationship with
constituency
militancy
Organizational
climate
less power
inequality
more trust
enhanced
readiness to
change
Organization
outcomes
productivity
profit
growth
employment
product quality
innovation
Fig. 2. The Relationship between Indirect Participation and Organizational
Performance.
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thereby legal rights, ‘‘real’’ influence and power concerning issues that affect
employees depend even more on representatives’ quality (e.g., skills,
knowledge).
Members of these indirect bodies should be progressively more aware of
these options, and use them to strengthen direct and indirect participation in
their organizations. A third important point is the combination of social
climate and employee outcomes, especially commitment. While social climate
refers to collective experiences, employee consequences such as commitment
and satisfaction refer to the impact of participation on individuals’
perception. However, research shows that collective and individual experiences
are interrelated (Carr, Schmidt, Ford, & DeShon, 2003) and have a
clear-cut positive impact upon performance (Katz, Kochan, &Weber, 1985).
Representative
participation
(legal) rights
composition
relationship with
constituency
militancy
Organizational
climate
less power inequality
more trust
enhanced readiness
to change
Organization
system
goals/strategy
governance
structure
culture
management
behaviour
Employee
outcomes
Attitudes:
commitment
motivation
Behaviour:
absenteeism
turnover
collaboration
flexilbility
Organization
outcomes
productivity
profit
growth
employment
product quality
innovation
HR policies and
practices
function/job
design
HR flow
appraisal and
reward
direct
participation
Fig. 3. An Integrated Model for HRM, Participation, and Organization
Performance.
106 JAN KEES LOOISE ET AL.
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CONCLUSION AND DISCUSSION
Our aim was to contribute to the understanding of the way(s) direct and
indirect worker participation – separate and in combination – can
contribute to organizational performance. After all, knowledge about this
blending and especially indirect participations’ potential contribution is still
limited. Our integrated model adds to the development of this stream of
scholarly (and perhaps also practitioner) attention and should be extended
in further empirical research.
The first step of our approach concerned the relationship between direct
participation and organizational performance. Grounded in prior literature
and research, it can be assumed direct participation is an HR-practice, like
other HRM-practices. As a consequence, direct participation similarly
contributes to employee outcomes and organizational performance like
those other HR-practices. However, we argued there are two basic reasons
that direct participation in comparison with other HR-practices holds a
special position: (1) direct participation can directly contribute to company
performance (in terms of suggestions for improvement of products,
processes, organizational features) and (2) direct participation can influence
the development and implementation of other HR-practices. In our opinion
these possible contributions of direct participation deserve more theoretical
and empirical recognition. Given its extensive diffusion in (European)
organizations – and in fact practitioners seem aware of the possible impact
of this form of participation (EPOC, 1997) – there is an urgent need for
further exploration of this part of the model.
In our second step, we portrayed the relationship between indirect forms
of worker participation and organizational performance. Our focus in the
main was on institutionalized forms of representative participation in
Western European countries – those who practice integrative forms of
bargaining like works councils and joint consultation committees. Relying
on Dutch research we argued representative bodies can influence organizational
performance via three channels, one direct and two indirect. The
direct channel relates to representative participations direct contributions to
organizational performance (e.g., suggestion for improving efficiency,
profitability, and innovativeness).
The first indirect channel operates through indirect participations’
potential strength to enhance an organizational climate that influences
employees and organizational outcomes. The activities of representative
bodies can lead to an organizational climate with less power differences and
inequality, and more trust in the organization. Such an organizational
In Search for an Integrated Model 107
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climate will in its turn lead to better employee outcomes and consequently
organizational effectiveness. Moreover, a positive organizational climate
can directly influence organizational outcomes. The second indirect channel
works through the organization system and management attitudes and
behavior. Representative bodies’ interventions may correct and prevent
opportunistic management behavior and thus this contributes to better
organizational performance. More comparative international research on
this aspect of the model is badly needed.
In our third step, we blended together the ‘‘separate’’ knowledge from
steps 1 and 2 into an integrated model. Additional empirical evidence leads
us to claim that direct and indirect participation are closely interrelated.
After all, research shows that in a majority of cases consultation of
representative bodies precedes the introduction of direct participation.
Thus, these forms of participation should not be seen as ‘‘competitors,’’ but
rather as ‘‘partners.’’ Moreover, the involvement of indirect participation in
the introduction of direct participation seems to add to the effects of direct
participation (especially economic effects like cost reduction and increase of
total output; and indirect labor cost effects like decrease of sickness and
absenteeism). In our integrated model this has been explained by the
positive effect of indirect participation on the introduction and implementation
of direct participation, organizational climate, and employee outcomes;
these stimulate the effects of direct participation on organizational
outcomes. In follow-up studies we will test this model in an international
context.
We recognize but have not discussed here the special role manager’s
expertise and skills play for successful worker participation (e.g., Bryson,
2004; Bryson et al., 2006). The significance of direct supervisors’ attitudes
and behaviors, as well as top managers’ competence to direct these, cannot
be underestimated. Concerning the ideal of fairness, compared to relevant
others, there is no doubt that both participation as an ‘‘outcome’’
(distributive justice) and the process of participation (procedural justice)
itself are vitally important. The inclusion of both of these relevant variables –
the role of the managers’ and direct supervisor a well as justice – is still
relatively rare in research focused on participation in general or the
‘‘isolated’’ participation–performance link. Regarding the latter, a comparable
conclusion is appropriate for the role of the social climate, employee
outcomes (attitudes and behavior), possible routes in the participation–
performance chain, and broader operationalization of performance.
Theoretical and empirical insights support our idea that research on
indirect participation deserves more sustained interest. Future research
108 JAN KEES LOOISE ET AL.
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should aim for answers on how to improve not only organizational, but also
employee and societal well-being. Our insights, largely based on the work of
colleagues, can enhance the position or increase the implementation
probability of representative, nonunion participation in contexts of choice
where such arrangements are rather new or upcoming. On the organizational
level, this knowledge can be beneficial for managers in their general
design of HRM, as well as in upgrading their capability of coming to terms
with representative participation. HR managers and consultants may profit
from this knowledge when advising top management, and the agents of
representative participation may ‘‘exploit’’ these ideas to improve their use
of intervention strategies.
NOTE
1. These countries were (in alphabetical order) Denmark, France, Germany,
Ireland, Italy, Netherlands, Portugal, Spain, Sweden, and United Kingdom.
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