The Challenge of Effective Workplace Change in the Health Sector
There is significant personal injury risk associated with the provision of high-quality healthcare. The magnitude of this risk, combined with the possibility that it can often go underappreciated by caregivers and the organizations they work for, might help explain why the health sector has largely missed out on the benefits of an overall declining trend in injury rates. Despite covering two very different topics in their lead papers, Shamian and El-Jardali and Clements, Dault and Priest present a surprising degree of overlap in relation to what might help enable effective workplace change. Leadership, role clarity, trust, respect, values and workplace culture are all viewed as key enablers of effective teamwork by Clements, Dault and Priest. They could also be considered required ingredients of successful workplace health initiatives, as discussed by Shamian and El-Jardali. A lot of background and positional work regarding teamwork and healthy workplaces exists, but this has not necessarily translated into front-line change. These authors have done an excellent job of pointing out the potential benefits of workplace changes. What is needed now is for someone to take the lead in developing, implementing and evaluating these changes.
The adult human form is an awkward burden to lift or carry. Weighing up to 200 pounds or more, it has no handles, it is not rigid, and it is susceptible to severe damage if mishandled or dropped. When lying in bed, a patient is placed inconveniently for lifting and the weight and placement of such a load would be tolerated by few industrial workers.
- T.C. Tsolakas, J.P. Davies and S. Oram, "The Nurse's Load" (1965)
The rather detached and industrial tone of the above quote from an editorial in The Lancet certainly does not highlight the level of caring and respect for human dignity that forms the foundation for modern healthcare; however, it could be argued that it remains as insightful today as when it was written over 40 years ago. Its message, combined with those in the two companion papers in this journal issue by Shamian and El-Jardali and by Clements, Dault and Priest, demonstrates that we have come a long way over the past few decades in how we view work organization in the healthcare sector, even though we still have a lot to contend with in terms of developing and sustaining "healthy" healthcare workplaces.
Perhaps the greatest relevance of the quote for this journal issue is that it rather creatively highlights an important but often overlooked aspect of health and safety within the health sector - that there are significant personal injury risks associated with the provision of high-quality healthcare. The magnitude of these and other risks, combined with the possibility that they can often go underappreciated by caregivers and the organizations they work for, might help explain why the health sector injury rates have noticeably lagged behind those in other sectors, where steady declines have been observed throughout most jurisdictions over the past decade (Workplace Safety and Insurance Board 2005). The health sector has largely missed out on the benefits of an overall trend in injury reduction, both in the form of a healthier workforce and reduced workers' compensation insurance premiums.
Given the severe staff shortages already being experienced in most segments of the health sector, and in particular with nursing staff, translating work-related absence into "missing" full-time equivalents makes for an even more dramatic story. In Canada, it has been estimated that more than 16 million nursing hours are lost to injury and illness yearly, roughly the equivalent of almost 9,000 full-time nursing positions lost across the country each year (Canadian Labour and Business Centre 2002). It is reasonable to assume that much of this burden of disability is preventable and, indeed, needs to be prevented if the healthcare system is to successfully cope with the already-chronic shortage of nurses and other staff.
Although efforts to improve teamwork and to create healthy workplaces may seem only loosely connected at first glance, the two lead papers present a surprising degree of overlap in relation to what might help enable effective workplace change, the ultimate aim in both papers. Leadership, role clarity, trust, respect, values and workplace [safety] culture are all viewed as key enablers of effective teamwork by Clements, Dault and Priest, but they could also be considered required ingredients of successful workplace health initiatives, as discussed in the paper by Shamian and El-Jardali. Thus, there is clear overlap between teamwork and healthy workplace initiatives - common elements that these two approaches share and, thus, can be used to help support initiatives in each area. The notions of workplace support, empowerment, burnout or stress, job satisfaction, participatory approaches to interventions and workload also come to mind as factors relevant to both, underscoring the pervasiveness that quality work environments can have - not just on health, but on productivity and quality of care as well. The information found in these two papers would support contentions drawn elsewhere that organizations that take an active role in enabling staff in the delivery of high-quality care are also leaders in the provision of a healthy workplace. While both papers make a call for better integration at the clinician [worker or caregiver], management and policymaker levels to facilitate change in workplaces, there is also the suggestion that managers and policy-makers have been so overwhelmed by the current healthcare context - in particular, the hot button issues of staff shortages, wait times and patient safety - that they have been unable to deal with workplace change. The paper by Clements, Dault and Priest sums this situation up nicely: "The current shortage of some health professionals creates a pressure-cooker workplace environment where few people have the time, energy or will to experiment.…"
To be fair, it is not just the day-to-day survival in an incredibly complex and demanding healthcare work environment that people must contend with. The myriad of reports and recommendations that have been released in the past few years, especially in relation to healthy workplace initiatives for nurses, must at some level be overwhelming for administrators and policy-makers. We live in an age of evidence-based practice in the healthcare sector; yet, as pointed out by Shamian and El-Jardali, despite the sheer volume of these reports, there has been very little high-quality research evidence available upon which to base effective interventions. But the scope of the challenges faced when conducting rigorous workplace intervention research should not be underestimated (Cole et al. 2003).
Clements, Dault and Priest also point to the "hierarchical culture of healthcare" as being one of the key barriers to implementing teamwork interventions. Work in other sectors suggests that this problem should not always be dismissed as "creeping credentialism" or some other "turf" issue. When groups or key individuals do not feel that they have been a legitimate part of the change process in a workplace, the effectiveness of the process can be jeopardized. Evidence accumulating from research in other sectors regarding the effectiveness of different approaches to workplace change suggests that the participatory action model could be potentially useful for interventions related to either teamwork or a healthy workplace. The success of the participatory action model is built upon on the direct involvement, at all levels in the change process, of those potentially affected by the changes under consideration (Cole et al. 2005a).
|From the National Survey on the Work and Health of Nurses
Job dissatisfaction was more prevalent (12%) among nurses than among employees in general (8%) - but only 4% intended to leave the profession.
It is important to note that both papers also make a call for integrating researchers, clinicians [workers and caregivers], managers and policy-makers to further the agenda in workplace change. Researchers perhaps need to focus their efforts on addressing some of the key deficiencies present in prior research. For example, developing a set of valid indicators for measuring workplace health would permit the monitoring of workplaces in a prospective manner and thereby provide a stronger basis for evaluating change (Cole et al. 2005b). There are other gaps to be addressed as well, including how healthcare workers from outside the regulated health professions can participate in and benefit from healthy workplace and teamwork activities, and how certain segments of the healthcare sector, such as long-term care and home care, have been relatively neglected in comparison with the rest of the sector. We might also need to start considering the impact of generational differences when devising workplace interventions: Are younger workers, from Generations X and Y, going to be interested in the same things as older workers? Are we going to have to start thinking about the flexibility of workplaces as never before to ward off the impending shortages that could overwhelm the potential benefits of even the best intervention efforts?
It is worth noting that, for several reasons, nursing could be best situated to take a lead in these activities: nurses typically make up the majority of the healthcare workforce; their demographic profile portends continued high turnover in the near future; they work in a wide variety of settings; and they routinely interface with patients and all other members of the healthcare workforce. These factors, combined with the extent of recent teamwork and healthy workplace activity directed solely or primarily at nursing (such as the new National Survey of the Work and Health of Nurses mentioned in Table 1 of the paper by Shamian and El-Jardali), give them both a head start and a potentially stronger imperative to initiate action. As a potential champion for the health sector, they could lead the way to effective change, as the new slate of Healthy Work Environments Best Practice Guidelines, developed by the Registered Nurses' Association of Ontario (2006), might suggest.
Clearly, a lot of background and positional work regarding teamwork and healthy workplaces exists, but for whatever reason, this has not necessarily translated into front-line changes in workplaces. The authors of these two papers have done an excellent job of pointing out the potential benefits of workplace changes. What needs to be done now is for someone to take the lead in developing, implementing and evaluating these changes.
About the Author
Michael S. Kerr, PhD
School of Nursing, Faculty of Health Sciences
University of Western Ontario
Scientist, Institute for Work and Health
Cam Mustard, ScD
Professor, Department of Public Health Sciences
University of Toronto Faculty of Medicine
President and Senior Scientist
Institute for Work and Health
Canadian Labour and Business Centre. 2002. Full-Time Equivalents and Financial Costs Associated with Absenteeism, Overtime, and Involuntary Part-Time Employment in the Nursing Profession. Ottawa: Canadian Nursing Advisory Committee.
Cole, D.C., I. Rivilis, D. Van Erd, C. Cullen, E. Irvin and D. Kramer. 2005a. Effectiveness of Participatory Ergonomic Interventions: A Systematic Review. Toronto: Institute for Work and Health.
Cole, D.C., L.S. Robson, L. Lemieux-Charles, W. McGuire, C. Sicotte and F. Champagne. 2005b. "Quality of Working Life Indicators in Canadian Health Care Organizations: A Tool for Healthy, Health Care Workplaces?" Occupational Medicine 55(1): 54-59.
Cole, D.C., R.P. Wells, M.B. Frazer, M.S. Kerr, W.P. Neumann, A.C. Laing and the Ergonomic Intervention Evaluation Research Group. 2003. "Methodological Issues in Evaluating Workplace Interventions to Reduce Work-Related Musculoskeletal Disorders through Mechanical Exposure Reduction." Scandinavian Journal of Work, Environment and Health 29(5): 396-405.
Registered Nurses' Association of Ontario. 2006. Healthy Work Environments Best Practice Guidelines. Toronto: Author. http://www.rnao.org/Storage/16/1067_BPG_Sustain_Leadership.pdf. Accessed November 15, 2006.
Tsolakas, T.C., J.P. Davies and S. Oram. 1965. "The Nurse's Load [Editorial]." Lancet 40: 422-23.
Workplace Safety and Insurance Board. 2005. EIW Firm Experience by SWA Snapshot Period: March 2005. Toronto: Author.
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