This response challenges the healthcare system to take full responsibility for the work environments created for health human resources. While the need for healthy work environments and teamwork in healthcare are inarguable, the fact is they are not a reality in today's health system. The authors suggest strategies to address this issue and identify the person or groups that should take responsibility, including governments, organizations, individuals and the public. Strategies include ensuring that policies do not contradict one another and holding each level responsible for the outcomes of a healthy work environment - retention and recruitment of health human resources, better patient/client outcomes and healthcare costs. The need for strong and appropriate leadership for health human resources with "content knowledge" is discussed, along with recommendations for measuring the performance and success of healthy work environments and teamwork. The authors conclude that collaboration at the micro, meso and macro levels is required to facilitate the true change that is needed to improve the work environments of health human resources.

The papers by Shamian and El-Jardali and by Clements, Dault and Priest provide an excellent review of knowledge transfer of the research focusing on healthy working environments and teamwork in Canada. While recognizing that there has been significant progress in the past decade, both papers underline the importance of continued efforts to ensure that this work is firmly embedded in the healthcare system.

An effectively functioning health system is one of the many factors that determine the health of a population. Research has shown that a healthy workforce is a prerequisite for a quality health system. At the heart of any healthcare system are the people who deliver care - health human resources. Promoting healthy working conditions for all healthcare providers is, consequently, an important strategy for improving the health of Canadians. Many governments and organizations have acknowledged the need for healthy workplaces, including teamwork, in order to retain and recruit healthcare workers. However, as both sets of authors discuss, the responsibility for healthy workplaces and teamwork extends beyond the organization and the government. Individual healthcare professionals also need to take responsibility for creating and sustaining healthy workplaces. For example, governments and organizations cannot design policies to mandate respect, a necessary component of a healthy workplace. The decision about how you treat others is not a policy. It is a philosophy that cannot be directed by others. Some of the strategies outlined by Shamian and El-Jardali such as zero-tolerance policies are a step in the right direction, but individuals must take personal responsibility.

In addition to governments, organizations and individuals, the public also needs to take responsibility for, and get engaged in, ensuring a healthy workplace for healthcare professionals. Clements et al. describe the fact that the public expects teamwork as a prerequisite for their healthcare. It is logical to assume that an informed public would assume this as a mode of operating and therefore show limited demand in a public way. This said, recent research has shown that while the public may be interested in and review public report cards, they do not make decisions about their healthcare based on these report cards (Canadian Health Services Research Foundation 2006a). Change will continue to be slow if the public does not react to evidence suggesting, first, that team practice is not necessarily present in the delivery of healthcare and, second, that practice environments are unhealthy and unsafe for both practitioners and the patients they serve. The public must hold organizations and governments accountable for the state of healthcare environments, and must make demands for immediate and ongoing improvement.

Clements et al. speak of the traditional hierarchies as a barrier to both teamwork and healthy work environments. Healthcare organizations are often seen as classic examples of hierarchical, authoritarian structures, with "chain of command" organization, rules and regulations called policies and procedures, departments and disciplines with rigid boundaries, and a "command" mentality complete with "tours of duty" (Gelinas and Manthey 1995). This rigidity can affect outcomes for both staff and patients in these environments. Cumbey and Alexander (1998) showed that organizational structure is a critical variable predicting job satisfaction.

The organizational structure, in turn, influences the organizational climate (Langfield-Smith 1995). Organizational climate is defined as the way it "feels" to work in a particular environment (Snow 2002). Several studies have examined the relationship between organizational climate and job satisfaction. Keuter et al. (2000) identified a significant positive correlation between an aggregate measure of organizational climate and job satisfaction. Kangas et al. (1999) found that a supportive climate led to higher levels of job satisfaction. Tzeng et al. (2002) also demonstrated a positive correlation between nursing job satisfaction and organizational climate. Governments and healthcare organizations have been working to design new organizational structures. In the 1990s, we saw the shift to program management, which was an attempt to design a system that is more patient or client centred. However, this has resulted in varying degrees of success. We still see bureaucratic systems that make it difficult for teams to collaborate effectively.

From the National Survey on the Work and Health of Nurses One in three nurses (35%) report occasional or frequent nosocomial infections (infections that originate in hospitals or other health facilities) in patients under their care. https://secure.cihi.ca/cihiweb/dispPage.jsp? cw_page=AR_1588_E&cw_topic=1588

Contradicting Policies

In addition to hierarchical structures, policies often conflict. As a government or organization focuses on one aspect of its priorities, another often suffers. For example, healthcare-funding models have not kept up with the need to create and sustain healthy work environments. Funding models such as managed competition and hospital funding formulas that are efficiency driven can cause organizations to focus only on the direct costs of providing care, without considering the indirect measures such as support for team training, professional development and so on, which research has shown have an impact on the quality of care. The 1990s saw healthcare workers turned into variable costs and "downsized" in large numbers, along with the elimination of many of the support systems (such as staff development) to meet the immediate cost-reduction needs. However, the long-term costs of these changes (driven by efficiency and cost-reduction policy decisions) are only now being fully understood. Measures that retain staff can be more cost effective in the long term. In an international study of turnover, Shamian et al. (2003) found that the cost of turnover of one nurse is approximately US$22,000 and that the average turnover rate per unit is 9.5%. Governments and organizations are just now beginning to see healthcare workers as a fixed rather than variable cost, thus increasing their tolerance for considering the long term in their decision making. In addition, fee-for-service models may impact teamwork. Current physician funding models that act as barriers to physicians engaging in team practice should be reconsidered. Providing incentives to the team rather than the individual may be a more effective model to break down the hierarchies and support healthy work environments for the whole team.

Leadership

Governments and organizations with human resource-specific leadership in place have shown great strides in healthy workplace initiatives. Only some provinces have provincial chief nursing officers at the senior level of government, and not all organizations have chief nursing officers or chiefs of professional practice at their most senior levels. Ontario has a regulatory requirement for all hospitals to have a chief nurse executive reporting to the chief executive officer. In addition, Ontario has added an assistant deputy minister for health human resources to bring the health human resource agenda to the forefront of decision making. The addition of this content expertise to the most senior levels of government and organizations ensures that policy decisions take into account the health human resource perspective. Individuals in these roles can translate the research and information into a language that others can understand, identifying the impact that all decisions can have on healthcare providers, organizations and the system.

Accountability

It is also important to ensure that when new policies are being implemented, corresponding performance measures are also developed and implemented. A government or an organization that invests in healthy work environment strategies will want to demonstrate a return on its investment. These performance measures need to be clear and measurable, and then governments, organizations and individuals need to set a reasonable time frame to track this effect - change does not happen quickly.

Who should be accountable, and how do we hold them accountable for facilitating team-based and healthy work environments? This accountability needs to be shared between governments, organizations and health professionals. Governments should be accountable through their policies and funding formulas for the health system. Organizations should be accountable through performance contracts, accountability agreements and retention rates - held accountable by the government, communities and their current and prospective employees. Finally, individuals should be held accountable by their peers and colleagues and formally noted through performance appraisals.

Further Research

Success will be measured through continuing support for research and evaluation of the existing initiatives. That said, there are significant gaps in the research. Little research has been focused on the needs of a multi-generational, multicultural workforce that has mixed values, beliefs, needs and preferences. Further research is needed to determine how to create a work environment that meets this diverse workforce. Research on teams needs to focus on those with multi-generational and multicultural variables to determine the mix of strategies to support a broad range of individuals.

Collaboration

Clements, Dault, Priest, Shamian and El-Jardali have reminded us that the factors that create healthy workplaces are well known. However, making change a reality will take the involvement of multiple stakeholders, including provincial, territorial and federal governments, healthcare organizations, professional associations and individual healthcare providers. Fortunately, this collaboration is beginning to take place.

At the heart of any healthcare system are the people who deliver care - healthcare professionals. This workforce is the healthcare system's greatest asset. Canada's ability to provide access to quality, effective, patient-centred, team-based and safe health services depends on the right mix of healthcare providers with the right skills in the right place at the right time. As Clements et al. suggest, historically, decision makers have focused more on the supply or quantity of health human resources than on qualitative retention strategies such as healthy workplaces or effective teamwork. Increasingly, decision makers are recognizing that supply issues will be resolved, in part, through these retention strategies, which keep healthcare professionals through supportive, positive work environments.

Clements et al. note the role that collaborative, team-based work environments play for improvements in quality of care and overall job satisfaction and performance of the organization. Increasingly evidence suggests that collaborative, team-based practice results in improved job satisfaction - a critical element of a healthy work environment. The research also suggests that these two concepts are fundamentally linked. Collaborative team practice is a vehicle for healthy working environments (Canadian Health Services Research Foundation 2006b; D'Amour and Oandason 2005), while team practice most effectively occurs in an environment that is positive and progressive. The federal government's investment in the Interprofessional Education for Collaborative Patient-Centred Practice is contributing to a growing evidence base promoting positive working relationships and working environments in which tomorrow's healthcare providers will practise (Health Canada 2006).

A Framework for Collaboration

Finally, one of the most exciting policy levers on the horizon appears to be the recently developed Framework for Collaborative Pan-Canadian Health Human Resources Planning. The framework was developed through the Advisory Committee on Health Delivery and Human Resources (a federal, provincial and territorial committee reporting to the Conference of Deputy Ministers of Health) (Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources 2006). The vision for the framework includes more supportive satisfying work environments for healthcare providers through collaborative strategic health human resource planning. It underlines the importance between collaborative team practice and healthy working environments, which is consistent with the reflections of Clements et al. The framework will provide a powerful tool in further facilitating change in the working environments of healthcare providers.

Clements, Dault, Priest, Shamian and El-Jardali are right in saying that change is occurring. However, we need to stay the course. Indeed, the work has just begun. Collaborative team practice is good for patients and contributes to a healthy working environment. Further changes and continuing investments need to occur for this progress to be sustained. Collaboration, at multiple levels, will facilitate the required system level change. The Framework for Collaborative Pan-Canadian Health Human Resources Planning offers a positive policy lever for such change.

Canada's healthcare providers are a part of a constantly evolving healthcare landscape in which factors such as an aging population and workforce, new technologies and healthcare reforms, including policy movements such as patient wait-time reductions, are constantly being challenged. However they, our healthcare providers, remain our healthcare system's greatest assets. Their health and well-being predict the quality of care that will be delivered within our health system. Healthy working environments translate into healthy healthcare providers. They, in turn, will assist all levels of government, healthcare organizations, health professional associations and other healthcare providers to attain our common goal of health for all. The power is in collaboration.

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