Responsibilities and capabilities of health engagement professionals (HEPs): Perspectives from HEPs and health consumers in Australia

Abstract Background In Australia, the National Safety and Quality Health Service Standards (2012) stipulates that partnering with health consumers to improve health‐care experiences is one of the criteria health‐care organizations are assessed and accredited against. This standard has given rise to a role: health engagement professionals (HEPs). While there are no standard requirements for recruitment into this role, this study contributes to much needed research into understanding their responsibilities and capabilities, and their contributions to engagement outcomes. Methods Using a qualitative, interpretive approach, 16 HEPs and 15 health consumer representatives (who have experiences of interacting with HEPs) participated in an in‐depth phone interview in December 2019. We explored (a) the purposes of the role, (b) the responsibilities and work activities and (c) the capabilities required to carry out the responsibilities. Results Health engagement professionals are specialists in designing engagement mechanisms for health‐care organizations to co‐design health services with health consumers. They facilitate partnerships between health‐care organizations and health consumers. They play significant roles in listening to, facilitating understanding amongst different stakeholder groups (eg hospital management, health‐care workers and health consumers) and navigating the bureaucratic structures to influence outcomes. Four major responsibilities (advocacy, education, facilitation and administration) and four categories of capabilities (relational, communication, professional and personal) were identified. Conclusion A list of job responsibilities and desired capabilities of HEPs is provided to help health‐care organizations better understand the requirements for the role. This would help them decide how applicants to these roles would meet the requirements (eg experience of navigating bureaucratic systems).


| INTRODUC TI ON
The primary aims of the National Health Service and Safety Quality Standards 1 in Australia are to protect health consumers from harm and to improve the quality of health service provision through criteria established in consultation with a wide range of stakeholders.
Health-care services can use these standards as a part of internal quality assurance and must use them to meet a minimum level of performance when used as part of an external accreditation process.
The current and immediate past standards request that health-care facilities 'partner with consumers' to improve health-care experiences. To meet this standard, a new type of health-care management professional, referred to as health engagement professionals (HEPs) herein, is emerging alongside existing patient advocates and consumer complaints officers.
Consumer engagement (also known as patient engagement or patient involvement) is essential to improving the quality, safety and delivery of health care. 2 Current research has generally defined consumer engagement as engaging health consumers in 'designing or improving health services through activities such as completing surveys about their care experiences or serving as advisors or members of governance or quality improvement committees'. 3 This practice has evolved in recent years as more research has been conducted to examine consumer partnership in health-care and system planning and decision making. For example, a Canadian study explored motivational factors underlying patient engagement which guides health-care organizations to develop initiatives to better create meaningful engagement opportunities for health consumers. 2 Another Canadian study developed an evaluation tool that identifies the core principles for quality public and patient engagement. 4 In Australia, consumer engagement is a mandatory requirement of hospital accreditation and health consumers are typically referred to as individuals with lived experiences of health-care services. 5 The principle of co-design is applied to invite health consumers to involve in the planning, development and evaluation of health services. 5 Codesign is a principle within consumer engagement that stipulates that individuals with a shared interest in designing and improving health services should be involved in consumer engagement. 2 To ensure that engagement activities contribute to the outcome of improving health services, health service organizations are advised to provide health consumers with training and resources. 6 It is recommended that engagement moves beyond the provision of information, through to active engagement and empowerment of consumers to co-design health-care services. 5,7 Because consumer engagement is mandatory for hospital accreditation, roles specializing in consumer engagement have arisen.
This study refers to them as health engagement professionals (HEPs). In the United Kingdom, they are known as patient and public involvement facilitators (PPIF) whose primary responsibility is to involve patients in service improvement projects. 8 In Australia, HEPs are specialists in developing engagement frameworks and techniques for health service organizations to meet the requirement of the National Health Service and Safety Quality Standards' 1 Partnering with Consumers Standard. According to the Standard, health service organizations should work with health consumers 'as partners in planning, design, delivery, measurement and evaluation of systems and services' and with patients as 'partners in their own care, to the extent that they choose'. 9 Partnerships take place at the individual, service and organization levels to facilitate person-centred care such that care prioritizes the relationship between patients and clinicians for the best health outcomes. But successful consumer partnerships are not without challenges-it requires health services and consumers to redefine their roles and responsibilities, increases costs and conflicts between health consumers and professionals, leads to slower progress in change and could result in tokenism. 6,8,10,11 Existing research has examined the roles of health consumers (also known as patient advisors in the United States and Canada) who are patients who convene on a regular basis to improve service delivery in patient advisory councils (also known as consumer representative groups in Australia). 11,12 The role of HEPs has been researched in the United Kingdom where they are known as patient and public involvement facilitators (PPIF) who play the roles of gatekeepers (ie determining which patients get access to patient and public involvement (PPI) activities), mediator (ie facilitating conversations between staff and patients in committees) and negotiator (ie encouraging health-care professionals to involve patients in projects and implement changes). 8 Although the study 8 has identified some of their responsibilities, the authors recommend that further research be conducted to provide clear definitions of their specific roles and the nature of their responsibilities. Thus, this study is conducted to examine the roles of health engagement professionals (HEPs) who are in paid positions and are embedded within health service organizations in Australia. Their roles are critical for several reasons. First, consumer partnership is founded on the idea that 'healthcare is a human, relationship-based activity'. 13 HEPs are the boundary spanners between health service organizations and health consumers who facilitate that activity. Second, the purpose of the relationship is to create a 'supportive ecosystem' whereby consumer partnerships can lead to the co-production of health services. 13 In addition to designing the activity, HEPs also need to contribute to the creation and maintenance of that supportive ecosystem. Third, although there is ample empirical evidence on consumer engagement and how it should be conducted, the roles of HEPs are not well-understood.
Because of this, they could be constrained by limited training and mentoring opportunities and inadequate financial and physical resources. 8 Research on community engagement professionals (CEPs)

K E Y W O R D S
Australia, co-design, consumer engagement, health consumers, health engagement professionals, patient involvement has identified the need to understand their knowledge, skills and abilities in order to ensure that they can facilitate partnerships that contribute to the outcome of engagement. 14 To date, there is limited research on HEPs and this omission in the literature is striking given they set up and implement the interactions for consumer engagement 'on the ground'. 15 Thus, this study examines an overarching research question: What are the responsibilities and capabilities of health engagement professionals (HEPs)?

| ME THODS
To address the research question, we (a) conducted a review of re-

| Phase I literature review
We began formulating this study by browsing the job advertisements looking to recruit HEPs in Australia from which we found a diversity of job titles and no defined responsibilities and capabilities. Since we could only identify one study on HEPs, 8 we conducted a literature review of community engagement professionals (CEPs) on their job responsibilities instead. Our literature review identified several categories of responsibilities including the need to ensure diversity and equity in their work, 16 to advance engagement practice and to influence administrators, 16 to act as intermediary and project manager and to ensure project development in terms of complying with laws and regulations, 15 to advocate for system and process change 17 and to participate in and lead the strategic planning process as 'institutional change leaders'. 18 The 'relational work' that CEPs are engaged in requires them to be self-aware, conscious of power relations and knowledgeable of resources and opportunities in order to build trusting relationships and partnerships. 19 Although research on CEPs has helped to identify some of the responsibilities that are also applicable to HEPs in the health context, such research has not addressed the question of the capabilities which are needed to carry out the work. As such, we also completed literature review on essential capabilities in the context of health.
Although there is no research dedicated to the capabilities of HEPs, we identified four categories of capabilities that applied to other health professionals. First, as the relationship between patients and health professionals is characterized by asymmetry in power and authority, relational capabilities are amongst the most critical key attributes that contribute to improving interactions to positively affect health perceptions and outcomes. Specifically, these relational capabilities include not sounding authoritative and dominant 20 and the demonstration of empathy, 21,22 cultural sensitivity and respect. 23 Second, communication capabilities, including active listening, 24 assertiveness, 25 non-verbal communication, 26 showing a genuine interest in patients by encouraging questions 27 and providing timely, accurate and frequent communication, 28 are identified as some of the key attributes. Third, personal capabilities or qualities, including emotional intelligence, 29 being open and honest 30 and self-awareness, 31 are amongst the key attributes identified. Last and above all, professional capabilities (ie skills which are essential to fulfilling the job responsibilities) include leadership, 32 educator, 33 advocacy 34 and being able to navigate conflicts and barriers. 35

| Phase II development of interview guide
Upon completion of literature review, an interview guide was con-

| Phase III data collection
After obtaining approval from the University's ethics committee to proceed with data collection, our research study was advertised on Health

| Phase IV data analysis
The audio-recorded interviews were transcribed first automatically using an automated transcription service, Trint, and were then manually checked and revised by the first two authors of this study. The authors then followed the process of thematic analysis to analyse the interview transcripts. 37 Thematic analysis is useful for identifying, analysing and reporting themes (or patterns) within data during the process of which researchers play an active role in discovering themes, selecting which themes are of interest and choosing certain themes to be reported. 37 The process of thematic analysis allows the researchers to code and analyse the data based on what they want to know. The first two authors first read through all the data after which they discussed their preliminary findings. They then proceeded with open coding and discussed their definitions and categorizations of the codes identified. Upon reaching an agreement, they proceeded with axial coding to group the codes into categories. Each HEP participant was de-identified with an anonymous code ranging from 1A to 15A with 'A' denoting 'advisor', and each health consumer representative participant was de-identified with an anonymous code ranging from 1C to 16C with 'C' denoting 'consumer/carer'.

| RE SULTS
The findings identified the specialized role of HEPs as specialists in designing engagement mechanisms to facilitate consumer partnerships, defined as the bridge between hospital management/staff and health consumers/carers. Health consumers and carers are invited to convey their voices in the research, planning, design, delivery and evaluation of health services, and HEPs advocate for them as a group when they are not able to advocate for themselves. HEPs develop systems to enable health consumers/carers to co-design health services which reflect a better understanding of their needs and result in better care.

| Responsibilities and activities of HEPs
The responsibilities of HEPs are coded into four categories: advocacy, education, facilitation and administration. These responsibilities are outlined in Table 1.

| Advocacy
The responsibility of advocacy comprises activities including (a) the promotion of consumer inputs in the health system, (b) creating a receptive environment to influence change and influence culture to make sure it is person-centred, (c) reviewing and providing policy and

| Administration
The responsibility of administration comprises activities at the or-

| Capabilities
The four categories of capabilities are outlined in Table 2.

| Relational capabilities
To fulfil the responsibilities (and activities), the capability to build and maintain relationships with health staff/management and health is amongst the most critical capability. The words 'relational' and 'relationship' were the most frequently mentioned in the interviews.  HEPs need to follow through by providing materials to read before the meetings and providing timely feedback after the meetings.

| Professional capabilities
Professional capabilities, defined as those essential to fulfilling the job responsibilities, include themes such as (a) advocating for improvement They also need to make sure that 'no one dominates, that everyone has an opportunity to speak in equal measure' [3C] As for innovation, a HEP [8A] shared that her organization implemented a consumer community online and a web platform so that consumers could connect with them on a regular basis and receive regular updates on opportunities to be engaged. This capability is particularly important when some consumer groups can be 'staid' and 'siloed' such that they are no longer challenging the system [4A]. Thus, innovative methods of engagement often need to be brought in to spark creativity.

| Personal capabilities
Although personal capabilities could be considered complementary, we propose that personal capabilities are critical to achieving success in these other three categories and should also be included as essential foundation, not complementary. Personal capabilities reflected some personal beliefs which supported the other three categories.
The themes identified include (a) self-awareness to be able to accept others' views (being non-judgemental), (b) persistence and determi-

| D ISCUSS I ON
This study has identified a list of responsibilities (and activities under reach responsibility) and four categories of capabilities for the roles of HEPs. Table 3 shows a summary of noteworthy findings.

| Loyalty to whom?
HEPs are not advocates for individual consumers (even though health consumers have emphasized this responsibility), but they are advocates for changes in the systems that support health consumers

TA B L E 3 Summary table of noteworthy findings
Loyalty to whom?
• HEPs stressed that they were not advocates for individual consumers; they are advocates for improvement in the systems. On the other hand, health consumers emphasized that HEPs' primary responsibility was to advocate for individual consumers.
• Tension could arise as HEPs are responsible for choosing a selected group of individuals to serve as health consumer representatives to represent the collective voices of all health consumers in the process of consumer engagement. It is important to ensure that the 'selected' voices can represent the collective in improving the systems.
• HEPs ought to believe that system-level change is possible and be committed to follow through on how the voices of health consumers are incorporated into the systems.
• The roles of HEPs could be embedded into health service organizations differently. Some of them could have other responsibilities such as handling patient complaints. This could affect the roles of HEPs in fulfilling their responsibility as advocates for improving the system.
• Some health consumers conveyed that HEPs should have 'lived experiences' like the patients themselves so that they could empathize with them. But HEPs highlighted that they needed compassion and boundaries because they were not trained in counselling.
• There is a need to re-examine the attribute of empathy in healthcare professionals and distinguish it from compassion.
Can HEPs be trained?
• The job descriptions for HEP roles do not often have predefined required and desired qualifications and capabilities.
• Some of the capabilities identified in this study including the relational, communication and personal capabilities may come with the person and cannot be acquired by training; an example is one's commitment and persistence to navigate through the bureaucratic systems.
• Some professional qualities such as health literacy, process literacy and policy literacy can be acquired through training.
as a group. Although HEPs felt that they were advocates for improvement

| Empathy vs compassion?
HEPs and health consumers differ in their views on the importance of empathy as a relational capability. Some health consumers have conveyed that HEPs should have 'lived experiences' as patients themselves so that they could empathize with them. One health con-

| CON CLUS ION
This study has contributed to the understanding of HEPs as intermediaries between health service organizations and health consumers. In their roles, the most important yet the most difficult activity in partnering with consumers is often the shift of control from the health-care professionals to the health consumers to create a 'balanced' partnership. 10 To date, consumer engagement is well-understood in the health setting but the roles of HEPs in this practice require further research. This study has identified their job responsibilities and associated activities and the capabilities required or desirable for the roles. Nevertheless, many still consider consumer engagement to be a 'tick-the-box' obligation carried out to meet accreditation requirements, consistent with the findings from a study in the United Kingdom. 8 Furthermore, more education regarding the practice of consumer engagement and HEPs within the healthcare organization and in the communities is still needed. Without such understanding, the ability of HEPs to influence and bring about changes in the system could be limited.

| S TUDY LIMITATI ON S AND FUTURE RE S E ARCH
This study has several limitations. First, this study was conducted

ACK N OWLED G EM ENTS
The research team would like to thank the health engagement professionals and health consumer representatives who generously shared their time and experiences as interview participants in this project. The research team also thank Health Consumers Queensland (HCQ) that helped to promote participant recruitment for this study through its newsletters.

CO N FLI C T S O F I NTE R E S T
The authors whose names are listed in this study certify that they have no affiliations or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

PATI E NT O R PU B LI C CO NTR I B UTI O N
Sixteen health consumer representatives and fifteen health engagement professionals (HEPs) participated in this study as interview participants.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared.