Healthcare employment statistics linked to the Baby Boomer generation have been tracked for decades. This data shows that the majority of the current healthcare workforce is over the age of 45. This group is not demographically balanced by workers under the age of 30, and without question, this dynamic will significantly shape the future healthcare landscape from both a quality and financial perspective.

Central to many discussions is a core concern for brain drain, or a loss of information, as older workers retire. While a significant out-migration of knowledge is grounds for concern, there is an even more critical issue involving a loss of psychomotor skill mastery - the combination of cognitive learning and motor skill development.

The importance of skill development

Firmly rooted in experience gained from a lengthy human resource career, my opinion as to what can be done by the healthcare industry to effectively address this out-migration has been significantly influenced by the works of John R. Anderson and P.M. Fitts - Acquisition of Cognitive Skill and Perceptual-Motor Skill Learning, respectively - in which the authors attest to the strong impact that repetition and practice has upon skill development.

The applicability of these works in the medical arena is striking. Anyone with healthcare experience can attest to the fact that the only pathway to developing proficiency in the multitude of psychomotor skills involved with the delivery of care is through repetition. Mastery of a skill can only be attained through extensive practice, and once attained, can only be maintained through ongoing repetition of that skill.

Unquestionably, as we consider the array of psychomotor skill mastery that exists within healthcare, a significant percentage of that mastery resides with more senior healthcare professionals - those who have had the greatest opportunity to engage in the prerequisite skill practice, which has moved their competency to mastery.

Competency loss as senior professionals retire

For decades, the measurement and improvement of motor skill mastery has been focused upon the individual practitioner. Focus upon a group competency has been largely neglected, even though reality dictates that no patient encounter is ever a one-on-one experience and is actually myriad interactions between the patient and multiple healthcare providers. Playing a unique role in this array of interactions is something I call "group compensational dynamics."

Within the day-to-day functioning of a healthcare workforce pool, compensational dynamics are constantly in play. Take for example, the RNs who have the responsibility of delivering professional nursing care on a particular unit and shift. Within this workforce pool, there exists a broad range of competencies related to specific psychomotor skills involved in providing care. For the more routine tasks, skill proficiency is an expectation, and it is rare that any group compensational dynamics would come into play. However, for the more complicated, infrequently done tasks, the expectation that proficiency (never mind mastery) exists within all members of the pool wanes considerably and a significant level of group compensational dynamics will occur within the members of the pool to accomplish the required tasks.

The success of any healthcare organization is directly linked to how adept that organization is at managing the group compensational dynamics that take place. The quality and cost containment of the organization is directly proportional to the efficiency of that organization in balancing the overall makeup of the mastery that is present. Group competency, and subsequently the overall success of an organization, will be negatively affected when an imbalance in mastery occurs. The degree of this impact depends upon which skill mastery is in a state of imbalance, and to what extent.

In light of group compensational dynamics, healthcare organizations, particularly hospitals, should be particularly cognizant of what effect attrition will have on the balance of skill mastery within their organization. The organization should critically analyze which specific psychomotor skill mastery is leaving the institution, how important that mastery is to the competency of the workgroup, how difficult it will be to replace that mastery, and what would be the most effective means of replacement. The replacement process is simply not a matter of "one-size-fits-all." Unless the mastery that exists is replaced with equal or greater mastery, the group compensational dynamics will be damaged, ultimately affecting quality and cost.

Unfortunately, the healthcare industry has a poor track record in regards to succession planning, never mind considering a model based upon the concepts of skill mastery balance and group compensational dynamics. Most healthcare organizations are so enmeshed with surviving the here-and-now that they have very little time, or resources, to devote to developing a well-integrated succession planning program, and efforts are generally limited to management-level positions.

What must happen now

In hindsight, the healthcare industry should have begun addressing the inevitable imbalance of skill mastery at least 15 to 20 years ago. Tragically, the failure to act before now has significantly affected options on how to address the impending exodus. We no longer can address the issue by allowing mastery to develop through its traditional course of growth - that of psychomotor skill practice through live patient encounters over an extended period of time.

The predicament can be simply stated, but the solution is far from easy. We must find a viable means through which less experienced members of the healthcare workforce can attain the requisite psychomotor skill practice opportunities to develop mastery of those skills. The task is complicated by the fact that practice opportunities must be condensed into a significantly shorter timeframe.

One viable mechanism through which this dilemma can be addressed is by augmenting existing training programs with increased use of simulation-based technologies, thus allowing increased opportunities to engage in focused, repetitive practice; capture of a wide variety of patient problems and conditions; make and correct errors without adverse consequences; and stop and start training as needed.

This may truly be the best and worst of times for healthcare. But in such times exists tremendous opportunity to utilize innovative technologies such as simulation-based training to build upon what is best in healthcare training and to mitigate away from what is worst, for the sake of patient care and a more efficient and affordable healthcare system.

Patrick J. Dudley is president of the National Center for Healthcare Informatics. He began his healthcare career as a medical technologist then move to the human resource field at St. James Healthcare in Butte, Montana. In 2004, he helped found NCHI, which is dedicated to advancing healthcare information technology research and development as well as developing resources to support the continuing education needs of healthcare professionals; pdudley@mtech.edu.

2010 ASTD, Alexandria, VA. All rights reserved.