The Third Mission of Health Faculties, Departments, and Schools: A Role in Society beyond Education and Research

Universities are increasingly playing roles in society beyond education and research, often referred to as a third mission. As such, there are debates within universities about their relationship with society, their desired impact in society, society’s expectations of the institution, and how they can be more accountable to society. This study explored the role that health faculties, de-partments, and schools play in society, beyond the education of health professionals and conducting health-related research. The Faculty of Pharma-ceutical Sciences, School of Nursing, and Department of Physical Therapy at the University of British Columbia (UBC) provided a comparative case study to explore the relationship between a university’s health units and society. A critical discourse analysis of strategic plans and interview data from leaders within each unit revealed an advocacy role that was operationalized similarly and differently across the three units. This advocacy role was grounded in a perceived social contract to meet the health needs of the population they serve, improve the health and well-being of society, and address systemic inequities. This paper explores unique facets of health faculties, departments, and schools within universities that enable them to engage in policy advocacy toward these aims.

. Most generally, the "third mission" of the university is conceptualized as all activities that extend beyond the traditional missions of education and research and involves relationships between the institution and external partners (Compagnucci & Spigarelli, 2020). The features of the university that have endured over time, revealed through an analysis of the Western Medieval (emerged in the 12 th century), Pre-Modern/Renaissance (emerged in the 16 th century) and Humboldtian (emerged in the 19 th century) university, are "the advancement of knowledge, the higher education of students, and service to those beyond the university's walls" (Bourner et al., 2020: p. 42). The third mission, in its current form, was first articulated in 1982 by an OECD CERI think tank (Zomer & Benneworth, 2011). However, many authors who write about the history of the third mission (Bourner et al., 2017;Pinheiro et al., 2015a;Roper & Hirth, 2005;Zomer & Benneworth, 2011) start by identifying two academic revolutions, the first being the nineteenth century Humboldtian reforms, which institutionalized research as a core university mission.
The second, which they agree has been underway since the 1980's, is linked to the emergence of the third mission but can be traced back to the Morrill Act of 1862 in the United States that established land grant universities providing education in agriculture as a way to stimulate economic growth (Bourner et al., 2017;Roper & Hirth, 2005;Zomer & Benneworth, 2011). Today, universities contribute to education; generate new knowledge; further public debate; and engage in partnerships with community and industry (Jones, 2008).
Much of the contemporary third mission literature describes entrepreneurial and commercial efforts, whereby universities aim to contribute to both economic development and the institutions' financial well-being (Compagnucci & Spigarelli, 2020). University efforts in Europe and North America aimed at generating revenue from novel sources have been in response to cuts to government funding and budget shortfalls stemming from a number of economic and societal forces emanating from outside the institution (Fisher et al., 2009). However, the way that the third mission is conceptualized and defined is contextual and subject to multiple internal and external drivers and policy actors (Bourner et al., 2017;Compagnucci & Spigarelli, 2020;Pinheiro et al., 2015b;Roper & Hirth, 2005;Zomer & Benneworth, 2011 programs in the province situated within its largest urban center, with the latter having a distributed program whereby some students are part of a northern rural cohort. The School of Nursing is one of 17 institutions offering bachelor's degrees in nursing in the province, uniquely situated within a research-intensive university. These differences facilitated an exploration of connections and contradictions across the three cases, as well as the impact of both internal and external drivers on their third mission activities.

Methodology
Through a comparative case study, this research examined how specific health units articulated and operationalized a third mission; drivers that influenced the way in which they did so; and how their third mission influenced and was influenced by their education and research missions. This comparative case study adopted an iterative approach (see Figure 1) that involved an exploration of process, discovery, and description (Merriam, 1998).  Heads from each unit illuminated the findings from the document analysis of their strategic plans (Brenner, 2006). Data collected from the interviews determined the focus group format and questions. An interdisciplinary focus group with different leaders from each unit, explored some of the themes that emerged during the interviews (Brinkmann, 2013). This iterative approach, whereby the collection of data informed the collection and analysis of subsequent data, facilitated a deeper understanding of what the third mission meant to those involved, exploration of that meaning, and description of how the third mission of three health units was operationalized. This study received ethics approval from the UBC Behavioural Research Ethics Board (BREB) to conduct semi-structured interviews (n = 7: 2 pharmacy; 3 physical therapy; 2 nursing) and a focus group with different participants (n = 4: 2 pharmacy; 1 physical therapy; 1 nursing).
Critical discourse analysis (CDA) offered a useful approach for unpacking the ways in which the third mission of the health units was articulated and operationalized, as it is often applied to institutional discourse, draws on critical social theory, and has the ability to examine the ways in which macro-structures play out (Rogers et al., 2016). This study drew on both Fairclough's (2004) and Gee's (2010) approaches to CDA, the latter providing a number of tools to support the analysis. Thematic analysis acted as a means to unpack interview and focus group data, identifying connections and contradictions across the three cases.
Thematic analysis overlaps with discourse analysis, focuses on latent themes, and allows the researcher to "theorize the sociocultural contexts, and structural conditions, that enable the individual accounts that are provided" (Braun & Clarke, 2006: p. 85).

Findings
The third mission explicitly described in each strategic plan was reflective of a provincial context within which there are inequities that the leaders from each unit felt that it was their mission to address. Each strategic plan described a third mission, which they also defined as "core areas," "pillars," "activities," and "commitments"-Partnerships (Department of Physical Therapy); Community Engagement (School of Nursing); Practice (Faculty of Pharmaceutical Sciences).
These missions were conceptualized broadly and were connected to a goal of extensive societal impact. The Department of Physical Therapy's strategic plan stated that "through teaching, research and partnerships, the Department of Physical Therapy strives to meet its social contract of reducing health inequities, addressing population health needs and contributing expertise to specialized areas of practice" (UBC Department of Physical Therapy Strategic Plan, 2018: p. 10).
The Dean of Pharmaceutical Sciences described an environment of rapid change within which they were setting out their strategic priorities for the coming years (Catalyst for Change, 2017). In the opening of the School of Nursing strategic The health care system is facing crisis-climbing costs, decreasing access to care, lack of equitable resourcing-simultaneously our knowledge continues to explode: the microbiome and cellular level, genetic effects on health as well as the social determinants of health and impact of trauma and stress. Our need for an understanding of chronic disease management in addition to communicable disease control and the impact of diet, exercise, and mindfulness on health and well-being challenges the models of health care we have come to depend upon. ((En)Vision 2020, 2016: p. 1) Interview and focus group data moved beyond findings related to the way that the Department of Physical Therapy, School of Nursing, and Faculty of Pharmaceutical Sciences at UBC articulated a third mission within their strategic plans, revealing the key themes of a "social contract" and "advocacy role".

A Social Contract
Interview participants from each unit said the relationship of their respective unit with society was being driven by a "social contract," originating from the university as a publicly funded institution and the responsibilities of the health professions they have a mandate to train. Several participants from the School of Nursing talked about how their relationship with society stemmed from the nursing profession and its commitment to access, justice, and equity. One participant discussed the role of nursing in meeting society's needs throughout history: That's sort of a universal, internationally, that nursing's history and tradition has been about sort of seeing what the need is and flexing and adapting toward meeting that need.
This participant also provided some insight into how being in service to society was achieved through consultation and advice by offering their disciplinary expertise; in doing so, they were committed to improving health equity and social justice, which were clearly the paramount objectives of the School of Nursing and its role in society: It's really about that service to society that involves creating things open access or actually attending to and providing consultation, advice, and practice to improve health equity and social justice…I would say for our school, probably one of the key fundamental values is health for all and with a very specific and explicit attention to health equity and social justice.
Participants from the Department of Physical Therapy equated their social contract with their education mission, stressing the importance of access and distribution of services across the province and meeting the needs of rural and remote communities. For example, one participant from the Department talked about their distributed program where students are trained in rural communi-ties, with the goal that they are more likely to work in those communities when they graduate: We are also the only physio program in BC, and are expanding and distributing too, with the primary goal to physiotherapists, you know, there's huge vacancies, as I'm sure there are many health professionals. So, one of our goals is to educate future physios in communities that they will actually serve. So that I think is a huge kind of societal piece.
Participants from the Department of Physical Therapy also raised issues of access, equity and justice and their contract with society, specifying a commitment to serve marginalized populations. For example, one participant spoke about the importance of Indigenous health in relation to their contract with society: So, you know a big priority right now is around Indigenous health, racism, and healthcare, identifying and serving marginalized populations.
Participants from the Faculty of Pharmaceutical Sciences referred to their relationship with society stemming from the fact that they are part of a publicly-funded institution. However, they identified a mandate to specifically impact healthcare and patient outcomes, which they linked to the relationship between the pharmacy profession and society: I see healthcare as a serving, healthcare is a service industry, if you will. And we are in service to patients and society. Again, society in particular in Canada, socialized healthcare system.
As the only educator of pharmacists in the province, they recognized a provincial mandate that echoed that of the Department of Physical Therapy. Through their education mission, they committed to meeting the needs of underserved communities. Pharmacy reflected a service discourse and one of transformation, specific to the context of the healthcare sector. They too embodied a discourse that suggested pharmacists and the Faculty had the power to transform the health system and improve health outcomes.

An Advocacy Role
Each interviewee also explicitly referred to an "advocacy" role for their unit, which was then expanded on by focus group participants. For example, one participant from the School of Nursing said: Nursing also has that sense that it has a special role as something that looks out for where the system's not doing what it means to be doing, speaks up as the advocate, and kind of recognizes problems and gaps.
Another participant from nursing echoed this comment, saying: Nursing's role in, not just providing care and practice, but also advocacy and policy as part of our scope. But also, in our conversations around set- Participants from the Department of Physical Therapy referred to an advocacy role related to the profession, with one interviewee articulating this explicitly: So, one of our strongest advocacy works really is advocating with government for an increase in the number of seats. 1 I mean, basically we could double the number of seats and still have everybody walk out into a job.
Another interviewee said: And so, I really do think there's this whole kind of discussion and kind of wrestling with-we need to be advocates for our profession. And we need to be, as a university, we need to be pushing that forward. We need to be a strong voice and advocates for the scope and value of our profession, and our knowledge and what we have to offer, and really carving out those opportunities.
Participants from the Faculty of Pharmaceutical Sciences talked about an advocacy role related to both the profession itself and models of care, with one interviewee saying: You know, I think there are some things you know, advocating for the profession, I think is really important. It's another thing is part of our, you know, strategic plan and how do we influence, how do we influence the decision-makers to move the needle on the scope of practice for example.
Another did not use the term "advocacy" explicitly, but expressed a similar idea: So, the whole catalyst for me was to push an agenda to try and change that for pharmacists. This was pre-patient medical home, pre-primary care network, pre-everything. We presented the concept to the Ministry. The Ministry loved the concept and asked us to develop business case, we did.
As they talked about the advocacy role their units played, interview and focus group participants identified features of the university generally, and the health units specifically, that they thought enabled them enact this role. They enumerated enablers such as leadership, professional expertise, and institutional support. Participants from all three units attributed their ability to play an advocacy role to their belief that there was a perception on the part of external partners that their respective School, Department, and Faculty were leaders in society.
Specifically, they connected their ability to play an advocacy role to the combi- members. They reflected a passion and commitment from nurses, physical therapists, and pharmacists who saw issues in their practice and society that needed to be addressed and who came to work at the university as a way to do that. They alluded to different skill sets that the health professions brought to research that extended beyond traditional notions of academic research, seeking to contribute to society in meaningful ways. They also described the university as the only place they could generate knowledge and contribute in this way. Participants across all three units talked about the importance of institutional support for faculty members involved in advocacy work and other externally focused activities as being key to their unit having an impact in society.

Discussion
The way that the health units are funded in BC, based on their responsibility for training health professionals to meet the needs of the province, has resulted in a situation where they have responded to fiscal pressures differently from other facets of the university. The three health units in BC receive government funding to train a specified number of students in accordance with what the government deems to be the provincial demand for that particular profession. While Faculties like Business and Science develop innovative programing that responds to market demands, and attract and enroll international students who pay higher tuition rates in order to generate revenue (Bourner et al., 2020), the relationship between the health units and society is impacted primarily by the fact that they are responsible for training regulated health professionals.
The internal and external factors that influence the relationship between health disciplines and society (i.e. their third mission) include workforce demand, in addition to institutional environment, organizational culture, and resource allocation (Preston et al., 2016). The three units in this case study exist within a provincial context plagued by gross health disparities. Like many other provinces in Canada, BC has been increasingly working to address the high cost of healthcare that impacts the sustainability of the publicly funded healthcare system, which has been rising due to changing demographics and needs of the population (BC Ministry of Health, 2015). Further, the health needs of the population have become increasingly complex, particularly around the prevalence of chronic disease, cancer, mental health, and substance use issues (Aggarwal & Hutchison, 2012). Collectively, these three units articulated a commitment to meet the health needs of the population of British Columbia, improve the health and well-being of society, and address systemic inequities. Leaders from each unit spoke about a third mission advocacy role that contributed to these aims.
Participants from the Department of Physical Therapy presented an advocacy role in working with government to increase the number of seats in their program in order to meet provincial demand for the physical therapy profession.
The way they discussed this advocacy role reflected the concept of a social accountability mandate, which often focuses on the distribution of services to mar-  Participants from the School of Nursing did not identify an advocacy role in the same ways as those within the Department of Physical Therapy and Faculty of Pharmaceutical Sciences around access and improving models of care. They did not focus on meeting provincial demand for nurses or expanding scopes of practice. Participants acknowledged that they were able to play a unique advocacy role based on the fact that they are one of 17 schools in the province, all working toward a common goal-to meet the demand for nursing-which allowed them to play a leadership role that they attributed to being uniquely situated within a research-intensive university. They highlighted contributions to policy across the health sector and beyond and influencing legislation. The focus of nursing's advocacy role was centred on ensuring that nursing perspectives and expertise contributed to policy decisions. Leaders celebrated the successes of their faculty members in providing consultation and advice, offering their disciplinary expertise to improve health equity and social justice. This was achieved through knowledge generated from the professional experiences of nurses, putting them in "a unique position to recognize and identify how social and political institutions, as well as government policy, intersect with the lives and health of the individuals and communities they serve" (Paquin, 2011: p. 65 (Paquin, 2011). While this research revealed features of the university that enable them to play these types of third mission activities, competition for resources across disciplines and perceived hierarchies that motivate particular disciplines to advocate for their contributions over others can present obstacles to advancement of the third mission across the university.

Conclusion
This research reveals an important advocacy role for health faculties, departments and schools that will help meet the health needs of the population, improve the health and well-being of society, and address systemic inequities. At the most basic level, health faculties, departments and schools have a social contract to ensure access and meet provincial needs for the profession they have a mandate to educate, and may advocate for an increase in the number of seats in their program as a means to ensure they do so. If a unit is not able to fulfill this social contract, then they do not have the ability to engage in other types of third mission advocacy activities, despite their desire to do so, as was the case with the Department of Physical Therapy. Once the demand for the profession is met at a minimum, they can engage in third mission activities that focus on innovations that aim to contribute to improved quality and health outcomes, as reflected in the Faculty of Pharmaceutical Sciences' third mission advocacy activities to integrate pharmacists into primary care. The ability of a unit to work towards broader systems impact, demonstrated by the School of Nursing, comes from being in a situation where they are not constrained by other aspects of their social contract.
These types of third mission advocacy roles and the university's social contract need to be integrated into the strategic plans and frameworks of the institutions (Maassen et al., 2019). While the advocacy-related activities enumerated in this paper have been valued within their respective unit, these activities are not explicitly reflected in their strategic plans. As communication tools and guides for setting priorities and allocating resources, strategic plans are important documents for influencing the activities that take shape and are implemented across the university. The health units need to make their third mission explicit to give it strategic weight, ensure supports and resources are allocated, and make sure that it is institutionalized within university structures (Maassen et al., 2019). In order to support their third mission activities, specifically their advocacy role, the health units should continue to recruit and support faculty members with professional experience who have burning questions and a desire to address the complex challenges facing both the health system and society (Paquin, 2011).
Individuals within the institution need to develop both advocacy and leadership skills, which can start at the pre-licensure professional program level through the education mission of each unit (McGowan & Stokes, 2015). These activities also need to be given equal weight, alongside education and research, within tenure and promotion. These strategic missions of the health units need to be commu-

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.