Abstract

A major theme in the public policy literature of the new millennium has been that changes in society, including decentralized government and a growing private sector, require new approaches to old problems. One of the more eloquent critics has been Lester Salamon, who, in The Tools of Government, argued for a "new governance" where public problem-solving is a "team sport" with a range of actors engaged, including professionals, advocacy groups and the public. For Salamon, these "collaborative systems" require the engagement of both those who are willing and those who need to be urged to action (Salamon 2002). We confess that on beginning the process of writing our paper, we intended to focus on teamwork as one component of a healthy workplace, not as a policy approach to solving the problem of unhealthy workplaces. However, these thoughtful commentaries suggest to us that it is indeed a useful way to think about engaging various actors in making healthcare workplaces healthier. This is the message we take from the commentary by Kerr and Mustard, as they remind us that the very same qualities that allow teams to flourish, including trust and respect, are the conditions that make some job sites healthy places workers want to go to every day. They also reinforce for us that leaders have an essential role in helping stay the course, beyond solving the most immediate workplace issues, such as injuries and other risks of staffing shortages and illness.

Indeed, these commentaries provide lessons for the relative roles of many key players as we seek to build collaborative systems for change. To begin with, Oandasan, the lead author of the teamwork synthesis commissioned by the Canadian Health Services Research Foundation (CHSRF), shows us a role for educators and those involved in professional development. While many see that collaboration is as natural as breathing, it is in fact a competency that must be nurtured among even the most skilled health professionals and, by extension, those in the policy and management spheres. It is not simply a matter of goodwill: plenty exists among the players. In addition, as we continue the task of amassing the evidence for "healthy teams," we cannot lose sight of the need to ensure the processes by which we seek to transform healthcare workplaces are equally well informed by evidence - both rigorous and more colloquial forms.

In their piece on the work of the Quality Worklife-Quality Healthcare Collaborative (QWQHC), Strelioff et al. provide a useful resource for administrators and other managers willing to make a commitment to work toward healthcare workplaces that are better for patients and providers. Beyond the will to change, these leaders must find the resources and capacity to make this work a priority in their organizations. "E-cubed" - evidence of effective engagement - is indeed the new math for quality workplaces and quality healthcare. The QWQHC's self-assessment tool helps organizations to understand where they are now and to chart a course for their future. The CHSRF is proud to be on board as a partner organization and to co-chair a knowledge exchange working group.

In addition, Nicklin and Barton outline how accreditation may empower administrators to further strengthen the work-life standards. A doubling of the number of criteria that measure work life will help health services delivery organizations to see how they measure against these enhanced standards and to identify areas for improvement. The leadership of the Canadian Council on Health Services Accreditation (CCHSA) in "contributing to improving the quality of work life and to improving the health of work environment for all members of the healthcare team" positions it as a strong partner in bringing about significant change across the Canadian health services delivery landscape.

We are encouraged by the commentary by Silas, which serves as a strong voice from front-line nurses in supporting accountability, participation and leadership for policy change at all levels and sectors for "real" sustainable change. The willingness of these nurses and their associations to partner for positive change is often recognized too late in the game, and the lack of effective engagement with front-line nurses is unfortunately often the norm. Leiter's commentary reminds us of the consequences on this absence of engagement. Involving point-of-care nurses in finding and implementing solutions to improve their workplace realities is indeed a key to successful change management. The Mediation Model (Maslach and Leiter 1997), describing employees' psychological relationships with work, is a framework that provides significant opportunity for considering the contribution of workplace health initiatives. By focusing on experiences integral to staff nurses' day-to-day work life, it provides direction for developing and evaluating strategies that are aimed at enhancing the quality of work life and workplace health.

We are heartened that Laschinger, whose research has shown that alarming numbers of hospital nurses are experiencing severe emotional exhaustion, sees effective collaboration in teams as an important component of making workplaces healthier. And we take to heart her suggestion that team members need to "retain their professional identity and [be] clear about what they bring to the healthcare process." Three major studies have shown that the primary predictor of emotional exhaustion and burnout was excessive workload, followed by a perceived lack of fairness of organizational procedures, poor interpersonal relationships in the work setting, a perceived lack of recognition for their contribution to organizational goals, a lack of congruence between their own and organizational values, and a disempowering work environment and lack of respect. With substantive evidence that nurses' work environments are less than optimal, Laschinger suggests that nursing still has a long journey ahead to create healthy work environments where basic human factors foster individual health and well-being.

An effective role for professional associations, including those representing nurses, is exemplified in Grinspun's commentary. The executive director of the Registered Nurses' Association of Ontario highlights the evidence-informed leadership and advocacy her association has brought forward in the form of Clinical Best Practice Guidelines and Healthy Work Environments. These "suites" of evidence help decision makers, whether they are at the point of care or at the program planning and budgeting level.

Jones and Way, authors on the CHSRF teamwork synthesis, point to the need for better representation from community healthcare. Indeed, much of what we know about healthy workplaces is still from the acute care sector and is most often focused on individual professional groups. Their research tells us there is a need to implement and study effective collaboration in team-based, patient-centred care in primary healthcare. With each major health policy report since Marc Lalonde's (1975) white paper comes another call for strengthening teamwork. However, few providers have had the opportunity to experience teamwork and its contribution to patient-centred care. By finally moving toward inter-professional teams, Jones and Way suggest we will be better able to deal with the increasing complexity of care in the community.

Like the authors of the lead papers, Matthews and MacDonald-Rencz stress the need for continued efforts at the policy level in driving a healthy workforce capable of creating a quality healthcare system. The federal government's support in moving the teamwork and healthy workplace agendas forward in its strategic program funding and research through Interprofessional Education for Collaborative Patient-Centred Care healthy workplace initiatives, the QWQHC and the Canadian Interprofessional Health Collaborative (CIHC) is a major contribution. In addition, the Framework for Collaborative Pan-Canadian Health Human Resource Planning enforces the tenets of collaborative team practice and healthy work environments - potentially a very powerful tool.

A number of the commentators outline that the team-based approach to building healthier workplaces needs researchers as players, not as spectators. For example, the Canadian Nurses Association's Smadu and the Canadian Medical Association's McMillan say the role of researchers is not just to translate findings but, rather, to take a lead role in building understanding between different professional cultures. In addition, O'Brien-Pallas emphasizes the need for ongoing Canada-wide evaluation of evidence-informed policy interventions, noting the scarcity of comprehensive, system-wide studies to date. In particular, nursing workload remains an area where we need to develop and test definitions, approaches and measures in productivity and utilization. The "next generation of workload measurement" systems need to be validated across sectors and settings and have the capacity to quantify cost, quality and outcomes if we are to influence their (workload measurement systems) uptake by decisions makers.

Finally, we end this piece where we began: the public. We note in our lead paper that effective teamwork in healthcare is something that patients assume to be in place. Ward points out that the changing face of healthcare in Canada prompts the need for new roles for patients, or at least new recognition of these roles. It will be vital that researchers, policy makers, managers and clinicians ensure they engage the public effectively in shared decision making, as true team members.

Getting many players to work together is no easy task, in healthcare or any sector. As the "Old Perfessor" Casey Stengel once put it, "Gettin' good players is easy. Gettin' 'em to play together is the hard part." Nonetheless, the willingness of the major players to participate, as exemplified by their participation in this special issue, gives us hope for success.

About the Author

* Janet Helmer is acting senior program officer for the Management of the Healthcare Workplace, Canadian Health Services Research Foundation. She kindly contributed to this response as Myl├Ęne Dault is currently on maternity leave.

References

Lalonde, M. 1975. A New Perspective on the Health of Canadians. Ottawa: Department of National Health and Welfare.

Maslach, C. and M.P. Leiter. 1997. The Truth about Burnout. San Francisco: Jossey Bass.

Salamon, L.M. 2002. "The Tools Approach and the New Governance: Conclusion and Implications." In L.M. Salamon, ed., The Tools of Government: A Guide to the New Governance. New York: Oxford University Press.