The Changing Workforce, Workplace and Nature of Work: Implications for Health Human Resource Management*
The right number of health care providers with the right qualifications, in the right place, and at the right time, to meet the needs of Ontario hospitals
- A Vision for Health Human Resources in Ontario Hospitals, OHA (November 2005)
We cannot ensure timely access to care without having the right providers and support services in place all along the patient journey - not just the surgeons but the whole team of professionals in our hospitals, in rehab and home care and behind the scenes in planning, sharing information and keeping the workforce healthy and productive.
- Michael Decter, Chair, Health Council of Canada (June 2005)
Every seven seconds, another baby boomer turns 60 (Bartlett 1999). Sixty is the new 40. One of the fastest-growing segments of the population is those over 80 years old (Statistics Canada 2006a). The United Nations predicts that by 2050, there will be 2.2 million centenarians - people who have lived to celebrate their 100th birthday - in the world, or one of every 5,000 people, up from 135,000 centenarians in 1998 (United Nations 1999). We know we are getting older, and the old are getting older, in large part thanks to our effective public health policies, excellent healthcare system and strong and prosperous economy. Our aging population, however, is only one of the factors contributing to the increasing complexity of managing health human resources (HHR) in Canada.
Getting Older, Getting WiserThe aging population puts additional pressure on healthcare resources within a system that is already feeling the effects of an aging workforce. Across the Western world, the average age of the working population - stable at 40, from 1975-1995 - has been steadily rising. From 2010 onwards, older workers (aged 55-64) will, for the first time, outnumber younger workers (aged 20-29), who will themselves represent a smaller and smaller proportion of the working population (Gavigan et al. 1999). Canada leads the industrialized world in the speed at which the labour force over 45 is increasing (Dumas 1995). Whereas in 1991 only 26% of the labour force was older than 45, by 2041 the over-45 cohort is projected to represent 41% of the Canadian labour force (Denton et al. 2000).
The aging population has other repercussions for the Canadian labour force. Coupled with relatively stagnant population growth, the aging population means that Canada's labour force will begin to contract in 2016 (Denton et al. 2000). The most obvious way this trend will be felt is through retirements and the need to replace those leaving the workforce. The exodus of critical workers is perhaps even more acute in the healthcare sector. In Canada, where nearly a third of the nursing workforce is 50 or over, we need to replace approximately 70,000 nurses - more than 25% of the current nursing workforce in Canada - in order to maintain an adequate nursing infrastructure (O'Brien-Pallas et al. 2003). However, the aging workforce also means that elder care supports and compassionate care leaves are in increased demand, all of which lead to severe recruitment challenges.
RetirementIn the last decade, on average, about 225,000 Canadians retired each year. This number is predicted to grow to 370,000 retirements per year by 2010, and to 425,000 retirements per year by 2020 (Baxter and Smerdon 1999). The decision to retire is generally determined by an individual's health, wealth and caregiving responsibilities (Humphrey et al. 2003). However, when considering what, in addition to the aging population, is influencing this expanding number, it is important to note that men's and women's retirement patterns differ.
Men's retirement is somewhat predictable. Men typically make decisions to leave the labour force based on the combined circumstances of their health and their wealth. If their health is good and they feel they have sufficient wealth accumulated that they can afford to leave the workforce, they tend to leave. However, many men say they feel they are being pushed into retirement. They will also leave if they feel they are not wanted, needed or valued.
Women's retirement patterns are somewhat less predictable because we are only now beginning to experience large numbers of women in the paid labour force working until retirement. Women, more often than men, report being pulled into retirement involuntarily or prematurely as a result of spousal retirement, caregiving demands of an elderly family member or personal health reasons (Weaver 1994). A husband's retirement has a significant positive effect on the decision of women to retire. The husband's decision often pulls the wife into retirement with him: one-quarter of women retire in the same year as their husbands (Hurd 1990).
The aging individual's even more elderly family has an additional influence on retirement choices. Many people nearing retirement not only retire prematurely to care for an aging parent or relative, but more employees are experiencing loss of an elder family member. Because wealth - or the perception that one has "enough" wealth - is a key driver for retirement generally (Gustman and Steinmeier 2001/2002), it is important to note that the first large middle class is leaving wealth to their adult children in the paid labour force. For many, this unexpected inheritance offers the financial security or enough wealth to retire early, though fewer people retire as a result of inheritances than is generally thought (Meer et al. 2003). However, for others, elder care and the costs associated with end-of-life care may drain families' resources, leaving not enough wealth to retire when they had planned, so they remain in the labour force involuntarily and often begrudgingly - not a good recipe for creativity and service excellence.
Many studies have shown that people plan to work into their 60s and 70s (e.g., EAP Association 2003), but the reality is that very few people choose to work beyond the date that their personal health/wealth equation permits retirement. The few exceptions are academics and self-employed professionals such as accountants, lawyers and engineers (Schellenberg et al. 2005). HHR planners and managers should not expect older workers to keep working into their 60s or 70s, nor can they rely on age data alone to predict employee retirement patterns.
Elder care/compassionate careThough in Canada, 93% of seniors remain living in private households (Health Canada 2002), they often have need for additional support. It has long been known that the vast majority - at least three-quarters - of all elder care is provided by family and friends (General Accounting Office 1981). Canadians are actively involved in elder care; the most recent Census data indicate that 4.3 million Canadians - almost one in five people - provide some form of unpaid care to seniors (Statistics Canada 2003a). Women tend to provide more of this care than men, but men are nevertheless significantly involved in elder care; hours of care provided average 16 hours per week for women and five hours for men (Cranswick et al. 1999). The burden of this care has increased as the average family size in Canada has been shrinking: in 1951 caregivers had three to five siblings to share the responsibility; in 1991 they had one or two. The largest group of caregivers are individuals in their prime working years, between the ages of 45 and 64, and 62% of them remain in the paid labour force while providing care (Wilkins and Park 1998).
Caregiving is time-consuming and can be emotionally draining. Therefore, its influence cannot help but bleed into one's working life. Half of employed caregivers (55% of women and 45% of men) indicated that their caregiving duties affected their ability to work, as well as their health (Cranswick 1997). For those employees who need to deal with grief and loss, their attention will inevitably be focused on non-work priorities. Researchers at the Grief Recovery Institute estimate that over a two-year period following the death of a loved one, every primary mourner will lose 30 days of productivity related to absence from work, on-the-job errors and reduction of engagement (Zaslow 2002).
Fortunately, the Canadian government offers programs to support employees managing through these times. Employees in Ontario are legally entitled to leave from their jobs, with access to Federal Compassionate Care Benefits to partially cover lost income, eligibility for which was expanded in late 2005 (Canada Employment Insurance Commission 2006). However, HHR management policies and practices must include flexibility to support employees upon their return to work after taking advantage of these federal supports. Retaining older workers in the face of their elder care responsibilities and occasional compassionate care requirements means that employers need to develop HHR strategies including succession planning, flexible work arrangements, alternative career paths, flexible retirement options, elder care and compassionate care initiatives and grief, loss and bereavement awareness training. Financial supports, such as elder care/compassionate travel bursaries, cost-sharing of assistive devices and emergency response services, case management services and health and safety audits for employees providing elder care would also help support employees through the financial devastation that often accompanies the care of chronically or gravely ill elder family members (Gross 2006).
Greater Gender, Generational and Cultural DiversityDiversity in the workplace, in terms of gender, age and culture, is transforming the way we work. For example, although women started entering the workforce in droves in the 1970s, it is only recently that occupations that were historically dominated by men, such as medicine and information technology, or by women, such as nursing and administration, have started seeing more gender diversity in their ranks (Hughes 1995, 1996). Generationally, there are up to four distinct generations that currently work side by side in our workforce, with their attendant wide variety of beliefs, expectations and attitudes about work, employment relationships and work-life quality (Lancaster 2003; Zemke et al. 1999). Culturally, there is incredible diversity in all major centres across Canada, diversity that is projected to increase in the coming decades (Statistics Canada 2005). The increased scope, depth and range of diversity affects a variety of HHR strategies, including how employers attract and recruit new employees, design and arrange work and career paths, design benefits and leaves, encourage employee engagement and facilitate training and development.
Gender diversityJust over 50 years ago, when 83% of men were in the labour force, only 23% of women joined them (Browning et al. 1996). In the intervening half-century, men's labour force participation has dropped to 74%, while women's participation has tripled to 62% (Statistics Canada 2007). In the last decade, women aged 45-64 accounted for 80% of the total growth of the Canadian labour force (Roy 2006). Today, the labour force essentially has equal representation of women (46.8%) and men (53.2%) (Statistics Canada 2006c).
This major demographic shift has had an important influence on fertility, childbearing and child rearing. Over the same period, the Canadian fertility rate has dropped from an average of four children per woman in the 1950s to a national rate of 1.5 children today (Statistics Canada 2006d). The average age of mothers at the birth of their first child is now 27 years (Statistics Canada 2006b). As a result of workplace policies, employment insurance benefits and employment legislation/ collective agreements, the average duration for maternity/parental leave for new mothers is now 11 months (Ministerial Advisory Committee 2007; Statistics Canada 2006e). Despite the financial implications and the potentially negative impact that taking leave might have on one's career, women choose to stay on maternity leave.
In Canada, women tend to remain in the paid labour force following the birth of their children. Sixty-six per cent of mothers with children under the age of three are now in the paid labour force, along with 70% of mothers with children between the ages of three and five, and 83% of mothers with children between the ages of six and 15 (Statistics Canada 2006b; Luffman 2006). In other words, there are 1.2 million children between birth and five years of age who have a mother in the paid labour force, and an additional 1.8 million children between the ages of six and 12 who have a mother in the paid labour force (Friendly and Beach 2005). As women have become more embedded in the full-time labour market, men have also expanded their role at home and have become more involved with child care and child rearing (Marshall 2006). This trend is demonstrated by an almost 400% increase in fathers taking parental leave during the period 1998-2004 (Canada Employment Insurance Commission 2003, 2006). They are equally likely as mothers to report work-life conflict and high work-life overload. Fathers are also just as likely to request flexibility to care for sick children.
Implications for employers include the need for supportive maternity and parental leave policies, such as top-ups or supplementary benefits (SUB plans) and flexible return to work; accommodations or alternative job or work arrangements that recognize and are respectful of pregnancy or new-parent status; child care supports, such as on-site or near-site care, back-up child care, seasonal care, subsidies, resource and referral services and parenting networks; shift flexibility; and supports for families with unique challenges, such as children with special needs or multiple-generation care demands.
Generational diversityThere are now four generations in the Canadian labour force. Each has its distinct characteristics, expectations and priorities. What makes this type of diversity particularly unique compared to the past is that in today's workforce, generations are more likely to be mixed at all levels of the organization. In other words, in the past, younger workers tended to report to older workers, but this is no longer the case (Families and Work Institute 2005). Generational status is no longer as indication of job status.
Members of different generations face different priorities, imperatives and goals in both their professional and personal lives. The boomers (those currently in their 50s and 60s) are preparing for retirement, may be trying to wind down full-time employment and are preparing for a time when they shift out of their current professional role. The trailing boomers (those in their 40s) are at the height of their careers, but are often feeling pressures of caring for aging parents and supporting children through high school and post-secondary education. The nexus generation (those currently in their 30s) - referred to as "nexus" for the role they play in bridging those born before the Internet and those who grew up with the Internet (known as Generation X in the US) - are ramping up their careers while struggling with the stresses of starting families, buying homes and getting graduate degrees. The net or velos generation(those currently in their 20s) are entering the workplace as tech-savvy, highly educated, confident young workers who are very clear about their expectations about work and the employment relationship.
Although there are many generational differences, one of the most profound for HHR is that four out of every 10 Canadians aged 16 to 25 use computers at home for an average of at least one hour per day, according to a study that examined the link between information and communication technology use and literacy skills (Veenhof et al. 2005). Computer use declined with age, with a particularly sharp drop after age 55. The resistance to the use of technology will decrease with each passing year. In fact, the demand for more technology will increase as the boomers retire and the net generation moves into the workplace.
The Families and Work Institute recently found that one of the most significant differences among generations is that the majority of 20- to 30-year-olds in the workplace are family-centric or dual work/family-centric, while the majority of 40- to 50-year-olds are work-centric. The younger generations place greater value on work-life balance and more focus on family and personal responsibilities (Families and Work Institute 2004). The same study also found that career plans are changing dramatically: in 2002, among college-educated men, only 52% wanted to move into jobs with more responsibility, compared to 68% a decade earlier - a 24% decline. Among college-educated women, only 36% wanted to move into jobs with more responsibility, compared to 57% 10 years earlier - a 63% decline. A study from 2003 found that 34% of women and 21% of men in 10 multinational companies have reduced their career aspirations (Galinsky et al. 2003). The primary reason? "The sacrifices I would have to make in my personal life," cited by 67% of participants.
This means that leveraging generational diversity in the workplace requires employers to take work-life balance seriously. According to leading Canadian researchers Linda Duxbury and Chris Higgins (2003), Ontario has the strongest culture of long work hours in the country. For generations looking for more balance, more flexibility and challenging work, without having to make personal sacrifices or hampering their ability to achieve work-life balance, a culture of long hours is not an attractive workplace characteristic.
Therefore, employers need to recognize the importance of creating work environments that understand and respect generational diversity by training leaders how to manage multiple generations; training everyone on inter-generational communication; adapting leadership development and succession planning strategies to accommodate the priorities of multiple generations; and as a priority, implementing comprehensive work-life quality strategies that are sensitive to multigenerational differences (sabbaticals and career breaks, for example, will be requested by all generations, though for different reasons).
Cultural diversityCanada is one of the most multi-ethnic countries in the world. In the last census, Canadians reported their ancestry as belonging to more than 200 ethnic origins (United Nations 2006a). Roughly one out of every five people in Canada was born elsewhere, and currently, 13% of the Canadian population is a member of a visible minority (Statistics Canada 2003b). When Canada celebrates its 150th anniversary in 2017, it is estimated that between 19% and 23% of the nation's population - and more than one-half of Toronto and Vancouver - will be a member of a visible minority (Statistics Canada 2005).
Other than needing to find new language to define the population (how can a majority of the population be a referred to as a "minority"?), we need to find ways to leverage this exceptional diversity to best meet the unique needs and expectations of individuals and families across the province, because the research indicates that we haven't been doing very well to date. Back in 2001, the Conference Board of Canada reported that Canadian employers are not using the labour pool to its full advantage, and that as many as 540,000 people in Canada have education and experience that is unrecognized and under-utilized. Their study estimates that between $4.1 billion and $5.9 billion in wages would be added to the Canadian economy if Canadian businesses used employees to their maximum ability (Bloom and Grant 2001).
As we approach 2016, when the labour force will begin to contract significantly and will be approaching equal representation by visible minorities, employers need to develop strategies that recognize, respect and leverage this cultural diversity. This means finding innovative ways to attract, recruit, hire, train, advance and support an increasingly diverse employee base in ways that maximize operational efficiency and effectiveness, facilitate meeting service and quality targets, and derive maximum benefit from new technologies. Leaders in HHR have begun to acknowledge the importance of managing Canada's cultural diversity (RNAO 2007), but we need to go farther.
GlobalizationThe world population is aging in most developed countries (Anderson and Hussey 2000), while life expectancy in some developing countries (e.g., sub-Saharan Africa) is dropping dramatically (United Nations 2006b), both of which trends lead to increasing demands for HHR worldwide. In the developed world, declining fertility rates are a concern for many countries because of their need to maintain a strong supply of human capital; however, lower birth rates mean greater competition for talent from outside the country (Passaris 1998).
Outsourcing, off-shoring and contracting out services mean that teams may include members in other countries, in different time zones and with different work practices. Competition for talent, work and resources (e.g., research and development investments) requires that organizations develop and maintain a global perspective, global strategies and global solutions. Demands for relocation supports will continue to rise, and challenges with immigration and recognition of foreign credentials will continue to occupy HHR planners and managers. In addition to global competition, HHR planners and managers need to contend with national challenges and competition from other sectors (such as education, academia, public service and private sector industry) as well as other caring fields (such as early learning and child care, and community and social work).
Worker shortagesOne of the largest surveys of individuals' intentions to leave the labour force in Canada was conducted by the Treasury Board about the Canadian federal public service. The public service will experience a wholesale turnover in leadership over the next 10 years. Forty per cent of the civil service plans to retire in under five years; an additional 35% plans to retire in the following five years. Despite the high intent to retire, 49% of respondents indicated that they believed that no succession planning was occurring in their department or agency (APEX 2001). The same is true in other fields as well: four in 10 teachers in Ontario were expected to retire in the next decade (McIntyre 1998).
Attention to the importance of replacing these lost workers is not restricted to public and broader public sectors such as education and healthcare; it touches every sector (McMullan et al. 2004). Shortages are also expected in other fields besides human services. For example, because the construction industry currently has a shortage of between 35,000-60,000 workers, one in 20 jobs in the sector goes unfilled (Skills Canada 2003). The Athabasca oil sands project in Alberta is 50% over budget -more than $2 billion - in large part due to labour shortages (Lavelle 2003). Even in high tech, recent estimates reveal that the industry is operating at only 75% to 80% capacity because of worker shortages (Downie et al. 2004). In healthcare, these worker shortages are a result of challenges in both labour supply (low fertility, restricted immigration) and demand (the increasing need for healthcare services in Canada). Provincial public policies also influence Canadian labour supply, at least in terms of its migration. A move to Quebec for a net or nexus generation employee means better maternity and parental benefits, paternity benefits for new fathers, longer leaves from work, longer compassionate care leaves and seven-dollar-a-day child care, compared to national averages between $35 and $50 a day elsewhere in Canada - all of which make moving to Quebec more attractive than staying in Ontario.
In the study of public service workers who want to exit the labour force, the most cited reasons for wanting to leave are to escape work frustrations, to find reprieve from excessive workload and to find better work-life balance (APEX 2001). The more ways employers in HHR can find to increase individuals' job satisfaction with interesting work, appropriate compensation and recognition and appreciation of employees' contributions - as well as offering the opportunity for part-time work, sabbaticals, flexible benefits, compressed work weeks and telework - the greater the likelihood they will remain on the job.
Strategies and SolutionsThe data are clear and compelling: HHR challenges are many and becoming more urgent by the day. External factors such as demographics, globalization and technology, along with internal factors such as competition, expectations and accountability, are affecting how HHR planners, recruiters and managers fulfill their responsibilities. With a clear understanding of the data and the implications for HHR, the mandate HHR faces is to deploy the most meaningful strategies, implement the most effective action plans, monitor the most valuable metrics and develop the most efficient processes for revising and adapting within these rapidly changing circumstances. To succeed, HHR planners, recruiters and managers need to consider each challenge as the flip side of an opportunity, and to consider each step from both the employer's and the employee's perspective. Effectively addressing the top seven challenges (or rather, seizing the top seven opportunities) requires careful consideration, creative thinking and a fresh approach.
1. Attraction to the sector: Choosing a healthcare professionCompetition for talent begins in high schools around the world. For the health sector to best compete, key partners need to be engaged in attracting students to healthcare. Competing with high-pressure recruitment efforts from other professions, and in particular other human service professions, begins early. Traditionally, family involvement or family influence has led people into medicine or healthcare. Today, career decisions are more likely to be influenced by friends, media (popular culture, social marketing campaigns, the Internet) or experience (personal contacts, social interaction). Successfully attracting people to the sector depends on engaging those with the greatest influence. In addition to parents, teachers, guidance counsellors, employment counsellors, co-op placements and work experiences, adolescents and young adults, as well as the media, will need to be included in any attraction strategy.
2. Recruiting to your workplace: Build early commitmentRecruitment for a position requires a pool of individuals from which to draw. The sector must target recruitment strategies customized to appeal to the unique interests and needs of both sexes, as well as multiple generations and cultures. For example, to attract the net generation, prepare to counter concerns related to long hours, work-life balance and work demands, and be ready to offer opportunities for challenging work, the ability to make a difference, the chance to work in a team and the prospect of working in high-tech environments. Have young professionals tell their stories of success within your field or organization; give examples of how their views are consulted in management and work environment enhancements, continuous quality improvement and raising performance standards; describe opportunities for career breaks and alternative career paths; talk about how the organization fulfills its environmental responsibilities (beyond just recycling!); and talk about customized work arrangements and good labour relations.
3. Retention: Charting a career pathOnce you successfully attract people to the sector and recruit the right ones to your organization, the next challenge/opportunity is to keep them engaged and committed to your workforce. Like attracting people to the sector, retention requires strategies that recognize the unique needs of different sexes, generations and cultures. For example, phasing into retirement will keep people working longer only if the recognition, roles and responsibilities, challenges and opportunities, flexibility, compensation and benefits remain comparable to those working full-time in mid-career. For employees with young families, retention will depend on the ease with which they can step out of the "fast lane" with occasional career breaks such as maternity/parental leaves, compassionate care leaves and sabbaticals, and then access career "on-ramps" (and perhaps later "off-ramps") again - maintaining a stimulating and challenging career path with reasonable work demands in terms of hours, workload, responsibilities/authority, autonomy and access to equipment and supplies, while balancing multiple responsibilities at home, at work and in the community.
4. Employment relationship: Framing expectationsThe employer-employee relationship will continue to evolve as the labour shortage becomes more acute. Employees will have more negotiating power and employers will need to be more creative in order to maintain a strong labour force. Labour unions will need to be more innovative. Employees will have more choices, more flexibility and more control over how, where and when they work. Benefits plans will need to be more flexible, customizable and portable. Time will be the primary currency and will be bought and sold at the demand of the employee. Hours of work (daily, monthly, yearly and over a career) will be the cornerstone of positive employee-employer relationships. Predictability of time will be more important and more valuable than ever before. Flexibility will become essential: management will need to be more responsive, and work environments more engaging and more dynamic. Leadership and management will need to be more collaborative, consultative and adaptable. Managers will need to be skilled at not only balancing multiple responsibilities, perspectives and priorities but also at modelling creative problem-solving and work-life balance themselves. Managers will need to be excellent communicators, facilitators and mentors. Decisions will need to be made quickly and competently, actions taken decisively and issues resolved quickly and efficiently.
5. Terms of employment: Negotiating customized work arrangementsFollowing from the customization required as part of setting up a harmonious employment relationship, treating employees equitably but individually will be the main constraint under which of the terms of employment will be negotiated in this new HHR landscape. Employment terms will need to be individually negotiated, and consistently and fairly managed. Collective agreements will likely need to be restructured to ensure adequate flexibility while still ensuring protection, equity and seniority. Managers will need to have access to tools, templates and training to ensure they have the communication, negotiation, problem-solving and conflict resolution skills they will require to lead a diverse workforce. They will also need support and guidance from human resource professionals.
6. Measuring performance: Fulfilling responsibilities at home, at work and in the communityPerformance expectations in HHR are rising to meet the increasing expectations of both the public and the healthcare sector's major funders (both governments and private donors). Therefore, performance measures and metrics need to change to promote best and promising practices. People working in healthcare will need fast feedback, clear directions, high degrees of autonomy, high levels of control and the support of their team and managers to fulfill their responsibilities effectively, reach their full potential and maximize their contributions in the workplace, as well as at home and in the community. Recognition and rewards systems (including opportunities for advancement and project assignments) will need to align with the performance management strategy in order to be effective.
7. Creating a healthy workplace: Managing stress, maintaining health and well-beingThese first six imperatives make sense, and will work, only if the new world of work is also designed to support employees' health and well-being. The added expectations and responsibilities of today's workers can be met only if individuals feel healthy and strong, both emotionally and physically. Every workplace in the healthcare sector will need to model healthy workplace practices, both in terms of physical health (illness and disease prevention, infection control, etc.) and mental health (strain reduction/stress management, workload management, early identification, stigma elimination, appropriate and adequate interventions, etc.). Healthcare sector employers will need to create supportive work environments in which all employees can achieve work-life quality as they define it personally and professionally. And healthcare sector employers will need to advocate for illness prevention and health promotion in other workplaces.
ConclusionsEffective HHR management is the cornerstone of a high-quality, efficient, publicly funded healthcare system. If the ultimate HHR goal is to ensure the right number of healthcare providers with the right qualifications, in the right place and at the right time, to meet the needs of Ontario hospitals, we need to think holistically and creatively.
Hospitals need to recognize global competition for both professional and non-professional personnel; leverage gender, generational and cultural diversity; reframe HHR from a set of challenges to a set of extraordinary and unprecedented opportunities; reposition the key HHR priorities to see them from the employee's perspective; and increase creativity and innovation in the workplace to embrace technology, engage employees and model wellness. To be successful, this initiative will take courage, visionary leadership and true partnerships among boards, labour, schools, professional regulatory colleges and the community. The sector is full of possibilities and potential, but the time to act is now.
About the Author(s)
President, Work-Life Harmony Enterprises
Assistant Professor of Organizational Behaviour
London Business School
Former Associate, Work-Life Harmony Enterprises
Correspondence may be directed to: Nora Spinks, President, Work-Life Harmony Enterprises, 3555 Don Mills Rd., Suite 18-222, Toronto, ON M2H 3N3; tel.: 800-965-2414; e-mail: firstname.lastname@example.org.
Acknowledgment* This paper is based on a presentation given by the authors at Vision 2020, a Think Tank in January 2006, sponsored by the Ontario Hospital Association and the Change Foundation.
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