HealthcarePapers 7(Sp) January 2007 : 64-66.doi:10.12927/hcpap..18675

Time to Move from Paper to Practice

Marlene Smadu and Colin J. McMillan


The paper by Shamian and El-Jardali provides a timely and important overview of research on healthy work environments and its translation into policy and practice. Although the research is abundant, progress is slow, with most of the efforts focused on nursing. The paper unfortunately does not give justice to key research and policy documents generated by the national nursing and physician sector studies. The elements of healthy work environments common to these two studies speak to the need to approach healthy work environments in a multi-professional manner. They also speak to the need for work environments to address career life cycles in order to foster effective recruitment and retention of health providers. While the authors are subtle in their suggestion of this, this commentary is more explicit in proposing such action. The need to create healthy work environments is urgent, as providers, patients and the system suffer with continued inertia.
The paper by Shamian and El-Jardali illustrates that, despite an abundance of evidence on the impact of healthy work environments, the health system has been slow to uptake and apply such knowledge. The authors begin by acknowledging that it has taken 20 years to bring this large body of knowledge into the health policy arena. In their article, they present a range of federal, provincial, territorial and regional reports that include recommendations for creating healthy working conditions for health workers, albeit limited to nurses. Their review of the literature reveals that progress of these policy directions across various sectors and levels of the health system has been fractional and slow, with little sign of relief for health workers. Acceleration and expansion of current action on healthy work environments are needed to bring about meaningful change.

The research on healthy workplaces illustrates the relationship between workplace environments and three outcomes: provider, patient and system. This is consistent with the Health System and Health Human Resources Conceptual Model by O'Brien-Pallas, Tomblin Murphy, Birch and Baumann (Advisory Committee on Health Delivery and Human Resources 2005) in the Framework for Collaborative Pan-Canadian Health Human Resources Planningreleased by governments in 2005. While Shamian and El-Jardali comment to varying degrees on outcomes, they fail to acknowledge the results of relevant research undertaken through the national Nursing Sector Study and its counterpart in the physician community, Task Force Two: A Physician Human Resource Strategy for Canada. Both of these sector studies provide evidence on the impact of work environments on the health of nurses and physicians. For physicians, "heavy workload is a factor in fatigue, burnout and low morale" (Canadian Labour and Business Centre and Canadian Policy Research Networks 2005: 6). Similarly for nurses, "work environments affected nurses' physical and mental health" (O'Brien-Pallas et al. 2005: 32).

Based on extensive research, the final reports of both of these studies show that creating and sustaining healthy work environments are critical to attracting and retaining health providers, which, in turn, affect the performance and responsiveness of the health system. Elements of healthy work environments common to both studies include the need for continuing education, flexibility in scheduling, manageable workloads, effective teamwork and communication, autonomy and appropriate technology. These two studies were landmark studies that contributed greatly to both research and policy, providing the empirical evidence for what had been suspected for many years.

Shamian and El-Jardali note two important national initiatives in the area of provider outcomes. The Canadian Medical Association (CMA) has created the CMA Centre for Physician Health and Well-Being, which has four priorities: health promotion and disease prevention, awareness and education, research and data collection, and advocacy and leadership. In the spring of 2007, the CMA centre will conduct the first comprehensive national survey of physician health, in partnership with the Canadian Physician Health Network and with support from Health Canada.

The second initiative is the National Survey of the Work and Health of Nurses, which is a partnership of Health Canada, Statistics Canada, the Canadian Institute for Health Information and the nursing community, including the Canadian Nurses Association (CNA). Initial results will be released December 11, 2006, by Statistics Canada and will offer concrete direction with regard to creating healthy work environments that promote positive nursing outcomes. The survey will also measure the effect of various healthy workplace policies and initiatives implemented over the past few years on the health of nurses.

From the National Survey on the Work and Health of Nurses

The proportion of nurses reporting a high level of work stress was higher than for employed people in general. Nearly one in three female nurses were classified as having high job strain, compared to one in four employed women overall. cw_page=AR_1588_E&cw_topic=1588

The CMA, CNA and others have repeatedly advocated for a pan-Canadian inter-professional approach to human resources planning, including recruiting and retaining health providers. At a recent meeting, CMA and CNA executives acknowledged their collaborative work over the years, which provides a basis for the pursuit of a coordinated, inter-professional approach to healthy work environments. This includes the development of frameworks to examine the impacts on other health professions of policies or strategies aimed at one profession. Similarly, the coordinated framework development will need to identify how best to measure the outcomes for patients and the system of policies that direct the establishment of teams of health professionals. Findings from the two national sector studies offer common elements and directions forward.

Perhaps in the future, research such as surveys on the health of health providers should be multidisciplinary in nature, offering comparable findings across professions and offering effective policies for all. Shamian and El-Jardali, in the section on next steps, do not take the opportunity to suggest a multidisciplinary approach to healthy workplace research, policy and practice. Instead, they offer more subtle suggestions of translating innovations related to one profession to another. While this is valuable in terms of sharing lessons learned, a more aggressive, concerted approach is needed to create and sustain healthy work environments. As we move to an inter-professional or teamwork approach to providing healthcare across the country, it is only fitting that we take a similar approach to the environments in which those teams practise. Each day in which health professionals are subjected to unsafe, unhealthy and even intolerable working conditions, providers, patients and the health system are at risk. One promising initiative in this area is the Quality Worklife-Quality Healthcare Collaborative, in which the CNA and CMA and nine other national health partners and some 45 experts have come together in an effort to coordinate, integrate and share learning about improving the quality of work life in healthcare.

The article by Shamian and El-Jardali includes a number of mechanisms by which select governments and organizations have incorporated healthy workplace indicators, including the hospital report on acute care, hospital accountability agreements, accreditation by the Canadian Council on Health Services Accreditation (CCHSA) and others. With the exception of the hospital report on acute care published by the Canadian Institute for Health Information (2005), the performance of healthcare organizations on these indicators is relatively unknown to the public or healthcare workers in general. Many of them are also limited to the hospital sector, with little information on how this is playing out in the community. Empirically and anecdotally, we know that the new generation of health professionals is looking for a better work-life balance than the generations before them. This includes healthy work environments composed of the elements noted above. Health professionals are interested in such information to inform their employment and practice decisions. Employers and recruiters should be prepared to respond to questions from providers regarding the organization's performance on indicators of healthy work environments. This will become increasingly important as critical health professional shortages persist.

Moreover, public reporting of performance of healthcare organizations could serve an important benchmarking function. Benchmarking has been used in other aspects of the health system as a means to promote quality improvement. The hospital report on acute care could serve as a benchmarking tool to allow healthcare organizations to compare themselves with others. Of course, it would need to be expanded to other sectors of the health system such as home care, long-term care and public health to be inclusive of all types of health organizations. It would also be important for health professionals themselves to be involved in the development of the organizations' healthy workplace plan or policy and reporting function. Organizations may indicate that they have a certain policy or program supporting a healthy work environment, but the ability of providers to access that policy or program may limit the effectiveness of the effort.

The article by Shamian and El-Jardali provides evidence of progress on a number of elements of healthy workplace environments, including health and safety programs for health workers, professional development and continuing education and training, mentorship, workload, scheduling and staffing levels. It provides several examples of initiatives focused on retaining older nurses, as well as the creation of full-time employment opportunities for new graduates. These issues lend themselves to a broader discussion of what the CNA and CMA term career life cycle. In June 2005, the CNA and CMA jointly released Toward a Pan-Canadian Planning Framework for Health Human Resources, A Green Paper. This document sets out 10 core principles and associated strategic directions that should underpin a strategic health human resources planning approach in Canada under the themes of patient-centred care, planning and career life cycle. Within the career life cycle theme, the CMA and CNA identify four principles: competitive human resource policies, healthy workplaces, a balance between personal and professional life and lifelong learning. Each of the principles shares a common platform of the need for a diverse set of strategies that are expandable across the career lifespan of the provider. The needs of health providers often vary according to their career stage. For example, young health professionals are looking for full-time employment, while older pre-retirement health professionals may be looking to reduce hours and the physical demands of the job. Strategies employed by government and employers need to respond to the profile and needs of their particular set of health professionals.

Overall, the paper by Shamian and El-Jardali is to be commended as it captures many of the essential elements of this complex issue. The research is explicit and abundant on the benefits of healthy work environments. Canada seems to be struggling with how to translate the evidence into action. Nurses, doctors and other health professionals faced with inaction in this area are fast reaching a frustration level that poses a threat to the sustainability of the health system unless immediate action is taken. Governments, employers and others need to create and sustain healthy work environments for the well-being of health professionals, patients and the health system. Those environments need to be informed by evidence and healthcare providers themselves, be multi-professional in their design and address the career life cycle. Maintaining the status quo is no longer acceptable. The time for action is now.

About the Author(s)

Marlene Smadu, RN, EdD
President, Canadian Nurses Association

Colin J. McMillan, MD, CM, FRCPC, FACP
President, Canadian Medical Association


Advisory Committee on Health Delivery and Human Resources. 2005. Framework for Collaborative Pan-Canadian Health Human Resources Planning. Ottawa: Author.

Canadian Institute for Health Information, Government of Ontario, Ontario Hospital Association and the University of Toronto. 2005. Hospital Report 2005: Acute Care. Ottawa: Canadian Institute for Health Information. < _LND_Webstation.nsf/page/Hospital+Report+2005+Acute+Care >. Accessed December 13, 2006.

Canadian Labour and Business Centre and Canadian Policy Research Networks. 2005. Canada's Physician Workforce: Occupational Human Resources Data Assessment and Trends Analysis Executive Summary. Ottawa: Taskforce Two: A Physician Human Resource Strategy for Canada.

Canadian Nurses Association and Canadian Medical Association. 2005. Toward a Pan-Canadian Planning Framework for Health Human Resources, A Green Paper. Ottawa: Author.

O'Brien-Pallas, L., G. Tomblin Murphy, S. White, L. Hayes, A. Baumann, A. Higgin, D. Pringle, S. Birch, L. McGillis Hall, G. Kephart and S. Wang. 2005. Building the Future: An Integrated Strategy for Nursing Human Resources in Canada - Research Synthesis Report. Ottawa: Nursing Sector Study Corporation.


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