Workforce development: An important paradigm shift for the alcohol and other drugs sector

Abstract

Over the past two decades, there has been a major paradigm shift in the conceptualisation of workforce development for the alcohol and other drugs (AOD) sector. Foremost, in this regard, is the shift towards a systems approach. Unlike more traditional approaches, which predominantly address the immediate education and training needs of individual workers, a systems approach is broad and comprehensive and targets individual, organisational and structural factors. It also incorporates issues such as innovation dissemination and systems redesign. This paradigm shift and its implications for workers, services and sectors are outlined. Then, an overview of the background, historical and contextual factors impacting current approaches to workforce development is provided. This is followed by a description of changes in the theoretical understandings of effective workforce development which prompted the paradigm shift. A range of factors impacting at the global and individual worker level are then described, such as the impacts of changes to AOD prevention and intervention approaches. Then, a number of aspects of contemporary approaches to workforce development are described, specifically: worker well-being; workforce planning; leadership and management; worker recruitment and retention; effective learning environments; and training. Finally, an example of the application of a systems approach to workforce development is provided in the form of Australia’s National Alcohol and other Drug Workforce Development Strategy 2015–2018.

Keywords:

• Alcohol
• drugs
• workforce development
• innovation dissemination

Introduction

One of the most valuable and pivotal assets of the alcohol and drug (AOD) sector is the workers and the multitude of roles they undertake. However, the needs and requirements of the workforce have often been overlooked, or overshadowed, by more pressing issues. When workforce concerns have been addressed, it has traditionally been from the “bottom up” perspective of individual coal-face workers and largely in the form of training. But that is now changing.

The concept of workforce training has gradually morphed into a more sophisticated understanding of “workforce development”. However, the contemporary conceptualisation of workforce development has been slow to gain traction and remains perplexing for many. While some may be very well acquainted with the more comprehensive approach to workforce development, in some instances, the term is still used synonymously, and erroneously, with training.

Over the past 20 years, there has been a major paradigm shift in the conceptualisation of AOD workforce development that embraces a systems perspective. It has coincided with substantial advances in the theoretical underpinnings of effective workforce development and evidence-based innovation dissemination and implementation.

Interest in AOD workforce development stems from a range of imperatives, including the need for enhanced quality of care and evidence-based, effective and efficient services. More latterly, concern has broadened to encompass considerations such as outcomes-based funding. The well-being of workers has also received greater attention: in part reflecting recognition that good client outcomes are impacted by worker well-being. In all, there is a complex and diverse array of issues captured under the umbrella of workforce development. Some of these issues are elucidated below.

The central tenet of contemporary workforce development is the requirement for a systems focus. Unlike more traditional approaches, a systems approach is broad and comprehensive, targeting individual, organisational and structural factors, rather than just addressing the immediate education and training of individual workers (Roche, 2002). The importance of adopting a systems approach to AOD workforce development is reflected in Australia’s National Alcohol and other Drug Workforce Development Strategy (Intergovernmental Committee on Drugs, 2014) which is outlined below.

AOD workforce development phases

The evolution of a more sophisticated understanding of workforce development has involved three phases. These are described briefly below.

Phase 1: individual worker – bottom–up approach

The initial focus was on individual workers and the provision of resources and education and training programmes to enhance individual workers’ knowledge and skills. Early approaches to workforce development were predicated on assumptions that providing individual workers with the requisite skills and knowledge would result in them transferring the newly acquired training content to their routine practice. Under this “train and hope” approach (Stokes & Baer, 1977) training was the central strategy used to bring about behaviour change and improvements to the provision of evidence-based quality services. Over time, the limitations of this approach became increasingly apparent (Roche, Pidd, & Freeman, 2009).

The effectiveness of training transfer is dependent on organisational culture or climate (Bennett, Lehman, & Forst, 1999; Blume, Ford, Baldwin, & Huang, 2010; Bunch, 2007). Implementing training programmes without also addressing organisational characteristics that may act as barriers to workers implementing new knowledge and skills is unlikely to be successful. Even where training programmes successfully increase workers’ knowledge and skills, quality service delivery remains dependent on a range of organisational, structural and systemic factors beyond the control of individual workers (Roche et al., 2009).

Research that has examined effective approaches to training has also found that single-exposure training models and/or the simple provision of information are generally ineffective in producing practitioner behaviour change. However, in contrast to the evidence, this has been the method most widely used. In terms of pedagogical orientations, such approaches have often relied heavily on didactic presentation of information, sometimes coupled with interactive strategies such as modelling and role-play. Such approaches can be effective for the dissemination of information and can yield increases in knowledge, but are limited in the extent to which they produce consistent or sustained behaviour change (Lyon, Stirman, Kerns, & Bruns, 2011).

Phase 2: internal systems approach

In light of the limitations of the “train and hope” approach, broader workforce development efforts subsequently evolved to focus on the internal systems within which workers were employed. This approach targeted organisational systems and structural factors, as well as individual factors (Baker & Roche, 2002).

From a systems perspective, key priorities included: addressing impediments to worker recruitment and retention; adequate workplace support and professional and career development, particularly effective clinical supervision, teamwork, leadership, mentoring and education and training; evidenced-based organisational policies and models of care that enhanced client outcomes; and clear staff roles and functions. Effective information management, knowledge transfer and research dissemination strategies are also pivotal workforce development strategies to enhance evidence-based practice. A further crucial component to a comprehensive systems approach is the importance of measures to enhance workforce well-being (Roche & Pidd, 2010).

An internal systems focus signalled a major paradigm shift where education and training initiatives were viewed as a subset of workforce development activities that were dependent on other strategies to be effective. The essential and complementary roles of infrastructure and organisational issues relative to training are schematically illustrated in Figure 1.

Figure 1. The different levels and components of workforce development (Roche & Pidd, 2010).

Phase 3: an integrated human services systems approach

While a focus on internal systems issues represented a major conceptual leap forward, there remained a growing appreciation of the need to address AOD problems in the context of broader physical, social and environmental issues (Roche, 2013). There was also a growing awareness of the limitations of siloed models of care (Conway, McMillan, & Becker, 2006), coupled with changing expectations of clients, the broader community and funders regarding partnerships and client inclusion.

From this comprehensive perspective, workforce development is viewed as:

…a multi-faceted approach which addresses the range of factors impacting on the ability of the workforce to function with maximum effectiveness in responding to alcohol and other drug-related problems. Workforce development should have a systems focus. Unlike traditional approaches, this is broad and comprehensive, targeting individual, organisational, and structural factors, rather than just addressing education and training of individual mainstream workers (Roche, 2002, p.9).

What does a systems focus for workforce development entail?

A systems approach to workforce development encompasses the individual, organisational and sectoral factors that influence workers’ and organisations’ readiness and capacity to change.

A systems approach entails a top–down focus, involving organisational factors and identification of service standards required to provide the best quality responses to AOD issues. This is not to imply that changes are made without consulting workers. In any organisational redesign efforts, it is essential to tap into the knowledge and needs of the broader workforce regarding how services can be improved. A top–down approach entails a global view of how sectors, agencies and organisations can work more effectively to enhance services and identify the requisite resourcing. Once fundamental decisions are made about required service provision, it is then possible to implement workforce development measures to support their implementation.

System design/redesign

Systems design is a key aspect of a systems approach to workforce development. The starting point is to develop clear service provision objectives. Only then is it possible to understand and develop the appropriate responses required to meet those objectives. Developing clear service objectives involves defining the client group and the aspirational intervention outcomes. Then it is necessary to identify the best available evidence about effective intervention approaches and to establish how sectors and organisations can best work together to achieve the identified outcomes. Following this process enables identification of the skillsets that workers require to achieve the desired client/programme outcomes and the commensurate level of resourcing required.

From this perspective, systems design constitutes the fundamental building block of AOD workforce development. Without clear objectives for, and models of, service provision it is not possible to define the required workforce development outcomes.

Funding

No AOD service system can meet all demand (Ritter et al., 2014). Internationally, AOD service demand exceeds supply. Integral to a systems approach to the provision of substance use services is the accurate estimation of treatment demand and its financial resourcing. Modelling service demand is critically important and forms a core component of workforce planning and development (Ritter et al., 2014).

The level of funding is a pivotal factor influencing the extent and quality of services provided. The efficacy and cost effectiveness of substance use treatment have been well-established. Every $1.00 invested in this treatment provides returns of $7.00 (Ettner et al., 2006). Nevertheless, there are substantial shortfalls in available treatment. In Australia for example, approximately 200,000 people receive AOD treatment in any one year and between 200,000 and 500,000 additional people would seek treatment if it were available (Ritter et al., 2014). The situation is even less favourable in the USA (Hoge et al.,2013).

Innovation dissemination

Ideally, service provision and policy should also be informed by the best available evidence (Davis et al., 2003). However, multiple and complex barriers often exist in regard to the dissemination and implementation of best, or even good, practice (Bywood, Lunnay, & Roche, 2008; Uchtenhagen, Stamm, Huber, & Vuille, 2008), including a lack of information about strategies to promote effective and efficient innovation implementation.

The problem of innovation dissemination in health care is not new. Research from the USA and the Netherlands, for example, estimates that 30–40% of medical treatment does not accord with current evidence, and 20–25% of medical treatment is unnecessary or potentially harmful (Grimshaw & Eccles, 2004).

Effective innovation dissemination requires the synthesis and dissemination of research findings and an understanding and application of implementation science. It entails widespread acceptance that the innovation will optimise patient/client outcomes, while reducing the risk of unnecessary or harmful treatment (Buchan, Sewell, & Sweet, 2004).

Implementation science is in its infancy and its application to AOD practice is embryonic (Tansella & Thornicroft, 2009). Nevertheless, there is an emerging literature to inform AOD innovation implementation (Bywood et al., 2008; Roche et al., 2009; Roche & Pidd, 2010).

Historically, implementation strategies have largely focused on the distribution of paper-based best practice guidelines (Grimshaw, Eccles, Walker, & Thomas, 2002), and rarely included complementary implementation resources and activities. Other strategies included: continual professional development (Davis et al., 2003); systematic reviews of research findings (Grimshaw et al., 2002); and implementing behaviour change interventions that targeted a particular practice (Michie et al., 2005).

Such approaches seldom facilitate the real-world application of innovative, research-based practice (Metz, Blase, & Bowie, 2007). In addition, many AOD workers have not been trained to critically appraise the expanding research literature and are unlikely to be adequately resourced to undertake such intensive endeavours.

Grimshaw, Eccles, Lavis, Hill, and Squires (2012) summarised the findings of two Cochrane reviews that examined approaches to closing the gap between research and practice. Innovations were found to be more successful if informed by assessment of likely barriers and facilitators.

Multiple barriers may impede access to best practice knowledge and skills, including workers’ low expectations of positive outcomes; lack of motivation to change, confidence, skills or reinforcement for implementation (Gotham, 2006; Grol & Wensing, 2004). Attitudinal and motivational barriers may also exist. Some workers may lack a sense of role adequacy or role legitimacy to provide AOD services and do not feel capable of providing services to this client group, or not see it is as a legitimate part of their work role (Anderson et al., 2004; Silins, Conigrave, Rakvin, Dobbins, & Curry, 2007; Skinner, Roche, Freeman, & Addy, 2005). For others, there may be a question of “deservingness”, that is, whether individuals with AOD problems are perceived to be deserving of assistance (Skinner et al., 2007).

What works in innovation dissemination in health care?

Overcoming these barriers to innovation dissemination requires a nuanced approach.

Numerous theories and models pertaining to effective innovation dissemination have been developed. A systematic review by Bywood et al. (2008) identified four effective strategies, from a potential array of sixteen, to change individual health care professionals’ behaviour, namely:

• Educational meetings

• Educational outreach

• Prompts and reminders

• Audit and feedback.

However, Bywood et al. (2008) noted that even if staff were aware of the need to change and accepted that an innovation would fulfil their needs, the organisational culture may moderate the effectiveness of strategies used to facilitate uptake. Hence, the successful uptake of innovations may be influenced by characteristics of dissemination strategies or contextual factors that may facilitate or inhibit the implementation process. Bywood et al. (2008) cautiously concluded that most successful implementation strategies include features outlined in Table 1. Even then, achieving practice and organisational change is not a rapid process. The successful implementation of evidence-based practices has been found to typically take 2–4 years (Metz et al., 2007).

Table 1. Approaches to enhance the uptake of innovation among health professionals (Bywood et al., 2008).

Issue	Recommended approach
Characteristics of messages	• Give clear and succinct messages, providing accurate, evidence-based information • Use focussed learning objectives that require small practical changes • Use an interactive format that is appealing, persuasive and encourages participation • Use tailored information that is personalised, modified to the local setting and relevant to practitioner and client needs • Use reinforced messages, with additional materials and support • Sustain the messages over a long period • Have a reliable and credible information source.
Structural factors	• Have clear identification of roles and activities • Involve systems or procedures that are accessible and easy to use, with little effort required to comply • Include an assessment of, and focus on, barriers to change • Address change at multiple levels, including the individual practitioner behaviour, organisational structure and culture, and health system policy • Involve organisational changes that require practitioners to respond or take action (e.g. automatic prompts and obligatory responses)

One approach to innovation dissemination is the US Addiction Technology Transfer Center (ATTC) Network. Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the ATTC Network facilitates alliances among counsellors, treatment and recovery services agency administrators, faith-based organisations, policy makers, the health and mental health communities, consumers and other stakeholders (ATTC, 2011). See http://www.attcnetwork.org/home/.

While there is still much to learn about implementation science, the available evidence highlights the importance of adopting a systems approach to innovation dissemination, rather than simple, particularly one-off, training approaches.

Alcohol and other drug workforce development challenges

Around the world, AOD workforce development faces a number of challenges. These are discussed below in terms of global and individual worker issues.

Global issues

Contemporary AOD workforce development is also posited in the context of macro-level driving forces, including what the World Health Organization (WHO) has described as a severe global health workforce crisis (WHO, 2011) with major shortfalls globally. For instance, an additional 2.4 million doctors, nurses and midwives are needed worldwide (WHO, 2011). It is estimated that by 2022, Organisation for Economic Co-operation and Development (OECD) countries will be facing a health workforce shortfall of approximately 22–29% (KPMG, 2012).

Globally, workforce shortfalls have wide-reaching implications for addressing AOD issues. Employing agencies need to attract and retain staff in increasingly competitive job markets. A challenge made more difficult given the stigma associated with AOD clients, services and workers (Hoge et al., 2013; Skinner, Feather, Freeman, & Roche, 2007).

Around the world, agencies are unable to meet the demand for treatment services. In Australia, fewer than half of those seeking AOD treatment are currently able to access it (Ritter et al., 2014). In the USA, only 10.8% of those needing treatment received it in 2011 (Office of National Drug Control Policy, 2013). Likewise, a multinational study of treatment demand for alcohol-related services found that across a range of countries 78.1% of treatment demand was unmet (Kohn, Saxena, Levav, & Saraceno, 2004).

Globalisation has also resulted in unprecedented connections between markets and increased competition for skilled labour. Recruitment and retention are now a core component of any workforce development strategy. The neo-liberal economy has further increased global competition and cost pressures, resulting in greater demands for efficiency and quality. This has led to a broadening of the skill base required of workers, including the need to work more effectively with diminishing resources and work across agencies and sectors to improve client outcomes.

Mass migration has also facilitated the movement of people across national and regional borders in a manner that was previously inconceivable, resulting in unpredictable drains on human resources in developing countries and large turnover in developed countries.

Technology has also become more central to a range of occupations. Many AOD workers now need to be proficient in the use of technology, and aware of technologically based interventions and diverse online applications. This has necessitated the development of skills that extend well beyond those related to direct client care or traditional service provision.

Important societal changes are also occurring, including initiation into AOD use at both earlier and later life stages coupled with the ever-evolving array of new substances (e.g. synthetics/pharmaceuticals/smart drugs) and patterns of use. Such changes are occurring against a backdrop of increasing community demands and expectations as well as service restructuring which often results in diminished resources to meet greater demands (Nicholas, Adams, Roche, White, & Battams, 2013).

Another key factor influencing AOD problems in different countries is the extent of income difference between its citizens. That is, the more unequal a country is, the greater the prevalence of a range of social problems, including AOD problems (Wilkinson & Pickett, 2010) (see Figure 2). For example, social determinants strongly influence inequities in alcohol consumption and related harms. In general, lower socio-economic groups experience more harm than wealthier groups with the same level of alcohol consumption (Roche et al., 2015).

Figure 2. Drug use is more common among countries with greater income inequality. Source: (Wilkinson & Pickett, 2010).

Factors impacting individual workers

Various personnel are involved in addressing substance use problems¹, including those with university-level qualifications [e.g. nurses, medical practitioners (psychiatrists, addiction specialists and general practitioners), occupational therapists, social workers and psychologists] and others who may not have formal qualifications, such as AOD workers, consumers and carers, peer workers, needle and syringe programme workers and prevention workers. Others may draw on their lived experience to inform their work roles. In some countries, particularly the USA, there are increasing numbers of peer workers in volunteer and paid roles within community organisations and treatment programmes. This represents an important change in the provision of AOD services in some countries (White, 2009).

The AOD workforce is also facing growing pressures. Large cohorts of older workers are due for retirement, resulting in loss of experienced workers and difficulty in replacing long-term corporate knowledge. Retirement of the baby boomer generation and a general ageing of the population in developed countries will require a substantial workforce development effort to replace it (Hoge et al., 2013; Jacobs & Hawley, 2009).

There have been calls to adopt a more systematic approach to address worker shortages, high turnover, lack of diversity and enhance the effectiveness of the substance use workforce in the USA. This includes the need to broaden the workforce to include other health care providers and consumers; enhance recruitment and retention and education and training; and create financial and technical structures to better support the workforce (Hoge et al., 2013).

As the intensity of AOD work increases, so too does risk of burnout and loss of experienced staff (Duraisingam, Pidd, & Roche, 2009; Evans et al., 2006, Skinner & Roche, 2005). Staff turnover and replacement are costly and disruptive to therapeutic relationships (Substance Abuse and Mental Health Services Administration, 2013). Staff in organisations with high turnover experience higher work demands and feel less supported by their organisations (Knight, Becan, & Flynn, 2012). Increased work intensity can also reduce the time and incentives available for workforce development activities (Skinner & Roche, 2005).

AOD workers are also experiencing increased occupational exposure to violence. Workplace violence perpetrated against workers leads to increased absenteeism, burnout, job dissatisfaction, decreased productivity and decreased sense of safety among workers (Phillips, 2016).

Despite the associated challenges and stigma, most workers find AOD work a very rewarding experience. Many derive great satisfaction and reward from the opportunity afforded to help people. Many also have a strong belief in the worth of their work in terms of contributing to society, together with the opportunity it affords for personal and professional growth (Gallon, Gabriel, & Knudsen, 2003). Nevertheless, in the context of the range of factors impacting workers, maintaining and enhancing worker well-being are critically important aspects of workforce development.

Worker well-being

Worker well-being is an issue of particular relevance to AOD workforce development as their roles involve emotional work, which may elevate risk of stress and burnout (Ewer et al., 2015; Roche et al., 2013; Volker et al., 2010). Worker well-being is important for workers themselves, organisational functioning and client outcomes (Skinner & Roche, 2005). There is evidence of a strong link between worker well-being and client/patient outcomes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Hanrahan, Aiken, McClaine, & Hanlon, 2010; Poghosyan, Clarke, Finlayson, & Aiken, 2010; Shanafelt et al., 2010; Shirom, Nirel, & Vinokur, 2006; Stimpfel, Sloane, & Aiken, 2012; Teng, Shyu, Chiou, Fan, & Lam, 2010). Organisations can enhance client outcomes by ensuring the wellbeing of their workers.

There are reasons to be vigilant about the well-being of the AOD workforce. Research indicates that excessive workplace stress, burnout and secondary traumatic stress or vicarious trauma affect a substantial proportion of the AOD workforce (Baldwin-White, 2016; Bride & Kintzle, 2011; Duraisingam et al., 2009; Duraisingam, Roche, Pidd, Zoontjens, & Pollard, 2007; Ewer, Teesson, Sannibale, Roche, & Mills, 2015; Oyefeso, Clancy, & Farmer, 2008; Roche et al., 2013; Volker et al., 2010). A number of workforce development approaches to enhancing worker well-being are discussed below.

Worker support

There are two key workforce development aspects of worker support. Social/emotional support directly focusses on enhancing workers’ well-being, while instrumental support ensures that workers are capable of effective performance which indirectly enhances their well-being (Skinner, 2005). Support can be provided by organisations, managers/supervisors or co-workers as summarised in Table 2.

Table 2. Potential strategies to provide support for alcohol and other drug workers (Skinner, 2005).

	Social/emotional support	Instrumental support
Organisation	• Ensuring fairness of treatment • Providing valued rewards • Ensuring supportive supervision	• Ensuring good job conditions (physical safety, job security, promotion paths, autonomy) • Addressing work overload • Addressing role ambiguity or conflict • Providing access to high-quality resources and equipment
Managers/supervisors	• Channelling/facilitating organisational support • Providing positive social interaction (praise, encouragement, caring, respect) • Recognising and rewarding good work • Involving workers in decision-making
Co-workers	Providing positive social interaction (praise, encouragement, caring, respect)	• Providing help and advice • Filling in when others are absent • Assisting with heavy workloads • Providing constructive feedback • Appreciation and recognition • Sharing duties and responsibilities

Table 3. Seven steps to effective workforce planning (Cotten, 2007) adapted for the AOD field.

Step	Task
Define future strategic directions for services	Document future strategic directions and identify the core or strategic skills needed
Scan internal and external environments	Assess likely service provision requirements, demographic changes among staff and clients, labour market forecasts, technology and treatment trends and workers in the educational pipeline
Model the current workforce	Model workforce demographics, characteristics, capabilities and distribution
Assess future workforce needs and project future workforce supply	Match anticipated characteristics and levels of treatment demand and compare this to projected workforce supply trends across all occupations (new workers and exiting workers)
Identify gaps and develop gap-closing strategies	Identify gaps (more workers, different skill sets or positions and work process redesign), retain workers with needed skills, recruit or develop workers, retain essential knowledge and build worker skills
Implement gap-closing strategies	Implement chosen gap-closing strategies
Evaluate the effectiveness of gap-closing strategies  and revise as needed	Check that workforce planning assumptions were valid; strategies are being implemented as planned; and strategies are having the desired impact

Mentoring and clinical supervision

Mentoring and clinical supervision are particularly important workforce development strategies to enhance worker well-being and service outcomes.

Mentoring

Mentoring is an informal and flexible approach to leadership, supervision and professional development. The mentor and protégé set professional and personal development goals. Mentoring relationships can occur between a mentor and a protégé, or a small group of protégés, or it may involve peers who act as mentors for each other. It can occur through formal or informal processes and involves encouraging protégé/s to develop solutions themselves while drawing on the mentor’s experience (Roche, Todd, & O'Connor, 2007).

Mentoring offers a range of benefits for individual AOD workers and for workforce development more broadly. It can build and sustain skills, knowledge and self-esteem and support work practice change and act as an incentive to attract skilled and qualified workers and retain existing employees. Finally, mentoring can create networks and links between different professions and agencies which can be especially important for rural and remote areas (Eby, Allen, Evans, Ng, & DuBois, 2008; McIntyre, Mills, & Brown, 2014; Roche et al., 2007).

Clinical supervision

Clinical supervision involves collaboration between an experienced practitioner and a less experienced practitioner or two practitioners of equal seniority and breadth of experience (Roche et al., 2007). It aims to develop less experienced workers’ clinical practice skills via support and guidance from a more experienced supervisor through regular, systematic and detailed exploration of a supervisee’s work with clients.

There are many benefits to effective clinical supervision. It can enhance support for workers and provide a forum to discuss clinical issues. This can build clinical skills and promote standardised use of the skills across the organisation. Clinical supervision can increase workers’ job satisfaction and self-confidence and improve communication amongst workers (Roche et al., 2007).

Clinical supervision can also impact emotional exhaustion/turnover intention among AOD workers. The perceived quality of workers’ clinical supervision is strongly associated with perceptions of job autonomy, procedural justice and distributive justice, which are associated with lower levels of emotional exhaustion and turnover intention (Eby & Rothrauff-Laschober, 2012; Knudsen, Ducharme, & Roman, 2008; Knudsen, Roman, & Abraham, 2013). In this way, quality clinical supervision has potential to yield important benefits for workers and their employing organisation.

Other Strategies

Other potential workforce development strategies to enhance worker well-being, recruitment and retention include:

• Competitive salaries and financial and non-financial incentives to enhance staff motivation and morale

• Opportunities for promotion and career advancement and development

• Ensuring that staff have realistic job expectations and adequate employee orientation programmes

• Training staff on self-care strategies

• Equitable distribution of workload and rewards and fairness in decision-making procedures

• Clear job descriptions/expectations and clinical supervision and mentoring

• Providing social/emotional and instrumental support for workers and routinely assessing burnout

• Providing effective organisational leadership (e.g. open-door policies with management) flexible work schedules and social events and informal support

• Ensuring good job conditions (physical safety, job security, promotion paths, autonomy, staffing levels) (Broome, Knight, Edwards, & Flynn, 2009; Paris & Hoge, 2010; Skinner & Roche, 2005).

Workforce planning

Workforce planning is a continuous process of shaping and structuring the workforce to ensure there is sufficient and sustainable capability and capacity to deliver services, now and in the future. To be effective, workforce planning needs to be integrated into other planning frameworks. It also needs to clearly identify the human resource strategies required to continuously deliver the right people. It involves having people with the skills and capabilities necessary for the required work, in the right numbers, in the right place and at the right time (Australian Government: Australian Public Service Commission, 2013). Critically, workforce planning includes predictions of how delivery of services will change in the future and mechanisms for adjustment according to changing circumstances (WHO, 2010).

The starting point of health workforce planning is a situational analysis, which incorporates the major factors that may influence its size and shape in the future. This provides a base from which decision-makers and managers can explore the implications of internal and external changes on the need for, and supply of, human resources in the health system (WHO, 2007).

Several modelling approaches have been used to assess the demand for AOD services (Clemens & Ritter, 2008; Dewit & Rush, 1996; Harris et al., 2014). The use of models is an essential feature of making projections and provides a mechanism for defining the nature of the issues to be addressed and can test and communicate possible solutions (WHO, 2010).

Seven steps to effective workforce planning have been identified (Cotten, 2007) at organisational, sector or systems levels (see Table 3).

Changing prevention and intervention approaches

The nature of the work undertaken by the AOD workforce is also changing as prevention and intervention approaches are shaped by emerging evidence. There is a range of ways in which AOD prevention and intervention approaches are changing. For example, the need to reduce AOD harms at the population health level is gaining increased prominence. New prevention paradigms, such as tackling the social determinants of AOD problems, have led to innovative approaches (Roche et al., 2015). Similarly, increased awareness of the high prevalence of multiple morbidities among AOD clients has necessitated more holistic interventions. There has also been pressure for enhanced consumer input and increased emphasis on family sensitive practice stemming from a better understanding of AOD use on harm to others (Gell, Ally, Buykx, Meier, & Hope, 2015). The shift in service provision in some countries towards a recovery orientation is a further driver of change. This involves an enhanced emphasis on strengths-based approaches, with interventions increasingly occurring in community rather than specialist settings (Best & Lubman, 2012). All of these changes require AOD workers to continually update their skills (Nicholas et al., 2013) and services to adapt their models of delivery.

In an attempt to improve responses to AOD problems arising from inequity-related issues, service changes are occurring to incorporate primary care, hospitals, housing, employment and social support for families and children (Roche, 2013). Some countries, such as Canada, have adopted such a systems approach. The Canadian approach recognises that most people affected by substance use do not use specialised addiction services, but instead access primary health care, housing and education services. Providing appropriate services and supports across a range of systems will not only reduce substance use problems, but also improve a wide range of outcomes related to health, social functioning and criminal justice. This necessitates collaboration between primary care, hospital-based care, specialised AOD services, housing, employment, family support and carers. The goal is to develop a tiered continuum of services and supports to address a range of risks and harms. Canada moved in this direction by creating the following tiered and integrated system:

• Tier 1 comprises community-based, outreach services and support groups including prevention and health promotion initiatives targeted at the general population and/or at-risk populations

• Tier 2 involves early identification and intervention, primary care, social services, housing, emergency care and employment programmes for people not previously detected or treated

• Tier 3 involves engaging people experiencing substance use problems who are at risk of secondary harms (e.g. blood-borne diseases or victimisation). It includes active outreach, risk management and basic assessment and referral services, outpatient counselling, home-based withdrawal management, supervised injection rooms and methadone and buprenorphine maintenance treatment

• Tier 4 consists of more intensive services such as comprehensive assessment and treatment planning, case management and counselling

• Tier 5 services address complex substance use and other problems, where lower-tier services and supports are inadequate (e.g. residential programmes for the treatment of concurrent disorders, hospital-based medical withdrawal management services) (Rush, 2010).

In summary, efforts to enhance AOD workforce development are occurring in a complex contextual environment. The pressure from diverse sources requires strong leadership and management.

Leadership and management in workforce development

Leadership support and enhancement are core components of workforce development. Contemporary leaders in health and community services face a range of challenges. They must take account of the complex and inter-related nature of services as making changes in one part of the system may lead to unintended consequences in other parts. Leaders must address divisions between professional groups while building capacity for flexible workforce deployment and multidisciplinary team care. They must also deal with scepticism about the motivations of leaders that result from multiple reforms and restructures and perceived failure to impact on clinical, preventive and organisational outcomes (Health Workforce Australia, 2012).

Leaders also need to promote innovation that leads to improved community and client outcomes and increase the speed at which improvements and innovations are generated and spread through the organisation and build organisational cultures that optimise capacity and tolerance for innovation (Health Workforce Australia, 2012).

There is extensive evidence that the quality of organisational management substantially impacts AOD worker well-being via workloads, extent of workers’ job control, degree of centralised decision-making and fairness of workload distribution and decision-making. In addition, workers’ perceptions of the quality of their leaders substantially impact worker well-being (Broome et al., 2009; Eby & Rothrauff-Laschober, 2012; Knudsen, Ducharme, & Roman, 2006; Vilardaga et al., 2011).

Good health care system leadership and management involve providing direction to, and gaining commitment from, partners and staff, facilitating change and achieving better health services through efficient, creative and responsible deployment of people and other resources (WHO, 2007).

Recruitment and retention

Recruitment problems

With increased global demand for health workers, recruitment of AOD workers is a growing challenge. In both developed and developing countries, recruitment challenges include:

• Stigma attached to working in the AOD field

• Perceptions of lower status of AOD workers compared to other helping professionals

• Lack of qualified applicants

• Lack of resources to fund service provision

• Inadequate salary packages

• Limited scope for advancement and promotion and lack of job security

• High turnover, leading to a lack of role models to attract new staff

• Remoteness of services

• Inconsistent training and credentialing (Duraisingam, 2005; Hoge et al., 2013).

Retention problems

Staff turnover among AOD workers is a common problem. A 2008/9 US study of 27 substance use treatment organisations found an annual turnover rate of 33% and 23% for counsellors and clinical supervisors, respectively. For both groups, turnover was mostly voluntary (employee-initiated) (Eby, Burk, & Maher, 2010).

Minimising turnover and retaining workers are important workforce development strategies in delivering high-quality services and underscore the importance of addressing worker well-being and supporting managers. High staff turnover, combined with recruitment difficulties, can compromise continuity and quality of care and be a major impediment to the implementation of evidence-based practices (Woltmann et al., 2008). It limits service provision by more experienced and competent workers who require less direct supervision. In addition, it reduces the available pool of mentors and supervisors and organisations receive less return-on-investment for worker training; it disrupts development of cohesive work groups and teams (Mental Health Workforce Advisory Committee, 2011).

Enhancing Recruitment and Retention

Workforce development measures to enhance recruitment include:

1. Reducing stigma associated with working with AOD clients

2. Promoting the AOD sector as a career of choice

3. Increasing opportunities for training placements

4. Better career pathways

5. Developing appropriate qualifications

6. Enhancing early career exposure to AOD use problems

7. Increasing relevant teaching in undergraduate clinical and public health/policy tertiary courses (Skinner, Roche, O’Connor, Pollard, & Todd, 2005).

Evidence-based strategies to increase retention in AOD services include:

1. Maintaining good supervisor–worker relationships

2. Providing professional development opportunities

3. Providing challenging and varied work

4. Ensuring adequate clinical supervision

5. Offering rewards and recognition for good work

6. Supporting workers’ capacity to balance work and family life

7. Providing new or potential workers with realistic work expectations

8. Creating appropriate promotional and professional development opportunities and career mobility

9. Conducting exit interviews to identify organisational issues or problems (Duraisingam, 2005).

Effective training

Training remains an important component of workforce development. Rather than it being the primary focus of workforce development it is posited here as one of the later stage, downstream considerations. That is, training only has potential to be effective when applied in the context of the broader issues addressed above.

Various effective training approaches have been identified, including:

• Academic detailing

• Inter-professional education

• Problem-based learning

• Coaching

• Reminders

• Self-regulated learning (Lyon et al., 2011).

Evidence-based training also incorporates adult learning theory (Knowles, 1984) as one of the fundamental theoretical bases for innovation dissemination in health care.

The learning environment

Adult learning must meet workers’ physical and psychological needs and create effective partnerships between learners and instructors. Creating a learning environment that fosters partnerships with adult learners includes strategies such as group work, deviating from conventional classroom routines, using humour and supporting opportunities for individual problem-solving (Imel, 1994). Adult learners should feel both safe and challenged. They should not feel anxious about appearing foolish or exposing themselves to failure, but they should not feel so safe that they do not question their current assumptions or be challenged in other ways (Imel, 1994; Knowles, Holton & Swanson, 2015). Educators need to balance being supportive with challenging learners (Rogers 1989). An ideal adult learning climate is non-threatening and non-judgemental where adults share in the responsibility for their learning (Imel, 1994).

A systems approach to workforce development: Australia’s national alcohol and other drugs workforce development strategy

Internationally, there are few national AOD workforce development strategies. Hence, there are few guides to strategically direct workforce development initiatives. Australia has recently produced a national strategy commissioned by the Australian Government – the national Alcohol and other Drug Workforce Development Strategy, 2015–2018 (Intergovernmental Committee on Drugs, 2014), http://nceta.flinders.edu.au/general/news/australias-national-alcohol-and-drug-workforce-development-s/ written by the authors. It documents a national approach and mechanism by which to undertake a systems approach to AOD workforce development implementation and outcomes. The Strategy includes the health and welfare, education, criminal justice and aged care sectors and aims to enhance the capacity of the AOD workforce to prevent and minimise alcohol and other drug-related harm across the domains of supply, demand and harm reduction activities. It also aims to create a sustainable AOD workforce capable of meeting future challenges, innovation and reform.

The Workforce Development Strategy supports Australia’s National Drug Strategy and its overarching approach of harm minimisation. It also addresses the National Drug Strategy’s three pillars of supply reduction, demand reduction and harm reduction (Intergovernmental Committee on Drugs, 2014).

In recognition of the need for a systems approach to workforce development, the Strategy seeks to:

• Better understand the specialist and non-specialist AOD workforce and identify gaps in current and future workforce demands

• Address workforce recruitment and retention issues

• Enhance the capacity of generalist health workers and those from the welfare, education and criminal justice sectors to prevent and reduce AOD harm

• Ensure that interagency and intersectoral “joined up” service provision arrangements are available for AOD clients with complex needs.

Other countries are encouraged to explore the possibility of developing locally tailored workforce development strategies to ensure a co-ordinated and comprehensive approach.

Conclusions

The adoption of a systems approach to AOD workforce development is essential if workers, agencies and sectors are to cope with existing and future challenges. The “train and hope” approach to up-skilling workers (Stokes & Baer, 1977) can no longer be sustained as a viable and effective approach to optimising responses to the ever growing and increasingly complex issues associated with AOD use. Not only does this approach lack effectiveness, but also it defines workforce development challenges in overly narrow, limited and out-dated terms. Continuing to perceive workforce development challenges as problems of worker skill deficits means that little effort will be directed to addressing pivotal structural and contextual issues. These issues include worker well-being, recruitment and retention, workforce planning and innovation dissemination, the need for joined up service provision, service system redesign and adequate funding.

There is still much to learn and understand about workforce development as it applies to the AOD sector. Nevertheless, a growing evidence base of effective approaches is now available and is sufficient to form the foundation of a range of enhancements and to inform the development of comprehensive workforce strategies needed in all countries. What is required is the courage and imagination to think outside the square and beyond traditional and narrowly conceived boundaries.

Declaration of interest

None. The author's centre receives funding from the Australian Government Department of Health.

Note

Notes

1. While many health care, welfare, law enforcement, education and related workers have increasing roles to play in responding to people with mental health and/or addiction problems, this paper focuses on those workers whose primary role involves responding to individuals with addiction problems including paid and unpaid workers and peer support workers.