Health human resources have long been a top issue facing Canada's healthcare policy makers and managers. It is also an issue that has seen a dramatic shift in terms of decision-makers' perspectives in recent years. At the beginning of this decade, decision-makers tended to have a rather simplistic understanding of health human resources. In particular, they appeared preoccupied with issues of supply and, as such, were eager to learn about forecasting models to plan for cycles of surplus and shortage (Gagnon et al. 2001). Several short years later, there was a progression in their thinking - they adopted an appreciation for issues of the workforce (i.e., facilitating inter-professional collaboration and regulating scope of practice) versus those of the workplace (i.e., organizational structures and management practices and workplace productivity, stress and absenteeism) (Dault et al. 2004). Today, decision-makers have developed an even more sophisticated understanding of the issues. They have an appreciation for new models for staffing (i.e., new team mixes that include non-traditional health system workers), new models of practice (i.e., collaborative models of care and self-care) and strategies to keep workers, healthy, happy and in the workplace longer (Law et al. 2008).

The Listening for Direction (LfD) national priority-setting process has uniquely captured this evolution in thinking. The primary aim of this consultation process is to identify areas where investments in research are most likely to improve systems-level decision-making. In its first round, in 2001, health human resources emerged as the top research theme (Gagnon et al. 2001). By the second round, in 2004, two themes had evolved: workforce planning, training and regulation and management of the healthcare workplace (Dault et al. 2004). In its latest round, LfD III, the theme, workforce and the work environment, was one of 11 research themes to emerge (Table 1) and be captured in the consultation's February 2008 final report (Law et al. 2008).

Research Funding Based on Priorities

Based on the priority themes coming out of the LfD consultations, CHSRF has funded a number of high-quality research projects, particularly through the Research, Exchange and Impact for System Support (REISS) competition, which is based on a linkage and exchange model and fuels research on the organization, management and policies of the Canadian healthcare system (CHSRF 2008c). We are now starting to see significant results coming out of the 2005 and 2006 REISS competitions under the theme "management of the healthcare workplace." We will share some of the findings from two REISS-funded projects in this area.

Table 1. Research themes from the 2007 Listening for Direction III priority-setting process

Workforce and the work environment* Change management for improved practice and improved health* Data, information and knowledge management Values-based decision-making and public engagement* Patient-centred care Patient flow and system integration Chronic disease prevention and management Health system financing and sustainability Emerging technologies and drugs Quality and patient safety* Linking population and public health to health services

*Priority research themes of the Canadian Health Services Research Foundation, 2008-2011. (CHSRF, 2008a)

Research to Optimize the Healthcare Workforce and Work Environment

If healthcare workers are to offer quality patient care, they must presumably be healthy themselves. This is one of the assumptions behind the research program "Developing Healthy Workplace Environments within B.C. Healthcare." The project was recommended for funding under the 2005 REISS competition and is co-led by Elizabeth Smailes, director of mental health and organizational development for the Occupational Health and Safety Agency for Health Care in British Columbia (OHSAH), and Catherine Kidd, regional director of the Vancouver Coastal Health Authority.

The research program specifically aims to test strategies to improve the mental health and retention of front-line staff in the Fraser, Interior, Northern and Vancouver Coastal Health Authorities by improving their work environments. Results from the project's baseline survey - which, to date, has captured the views of 854 participants - revealed some common workplace stressors for front-line healthcare workers. High workload (including high work demands, employee effort, patient acuity and excessive patient and task volumes) and insufficient staffing were the most frequently cited concerns by participants (Kaseburg et al. 2008). When these concerns were not present, participants were more likely to report higher-quality patient care (Kaseburg et al. 2008). Concerns were also raised about the physical environment (including issues pertaining to a lack of space, limited patient beds and poor cleanliness), organizational communication, input into decision-making and, to a lesser extent, work-life imbalance (Kaseburg et al. 2008).

In early 2008, the project team embarked on the next stage of the research program - facilitating worker-led interventions on the experimental units in the health authorities in the study. Specifically, three to five volunteers from each unit were invited to join an "action team" to lead an intervention throughout the spring and summer of 2008 aimed at improving the overall well-being of front-line workers. Each unit was given funding ($4,000) and a trained facilitator to select, implement and evaluate the intervention. The latest details of the project, including findings of the follow-up survey (fall 2008) and final survey (fall 2009), will be posted on the OHSAH website (OHSAH 2008). This work will provide important insights into making innovative changes for optimizing healthy healthcare workplaces.

Another 2006 REISS-funded research program also offers important insights, particularly into implementing successful organizational change. The project is co-led by Chantal Viens, nurse, professor and researcher with the faculty of nursing at Université Laval, and Sylvie Hains, planning and nursing director of the Ministère de la Santé et des Services sociaux du Québec. Their research program is called "PRO-ACTIVE: Participatory and Evaluative Research Program to Optimize Workplace Management: Application of Knowledge, Transfer of Expertise, Innovative Interventions, Training Transformational Leaders." One of the early outcomes of PRO-ACTIVE is a practical guide and complementary fact sheet, Handbook of Innovative Practice in Care and Work Organization, which present a method for managing, implementing and monitoring change (Bédard et al. 2007a, 2007b). The handbook is based on the analyses of 34 organizational transformation projects carried out in the Quebec healthcare system and conceived in conjunction with the members of the Centre of Expertise in Care and Work Organization (CEOST), care and work managers, project managers, human resources representatives and university investigators. The analyses guided the development of their integration model - by which it is possible to optimize human resources, work processes and the psychosocial environment - and the optimal approach to integration, which highlights the successful phases and key activities to realize and implement changes in an organizational transformation (Bédard et al. 2007b).

Another interesting outcome of this research program is a survey of healthcare managers' use of evidence-based practice, particularly in the context of care and work organization. Specifically, the survey captures the views of 99 Quebec-based healthcare managers on using scientific research in their day-to-day work. Participants reported having no problems understanding and using scientific research evidence, which they said chiefly comes from conferences or training. However, participants also reported that when faced with work issues, they are more likely to approach experienced colleagues for support and advice than to seek "context-free" research evidence. From their point of view, these experienced colleagues are experts who can impart "context-sensitive" evidence as well as important "know-how" (Renaud et al. 2008). To better help healthcare managers, PRO-ACTIVE has since begun providing managers with a team of experts, called coaches, in care and work organization.

Applying Existing Research

CHSRF is promoting the active implementation of research through such programs as the Executive Training for Research Application (EXTRA) program, where fellows lead change management projects, as part of their two-year fellowship (CHSRF 2008b). In order to further enhance the application and implementation of research outcomes, CHSRF has developed a number of tools such as the Promising Practices in Research Use summaries series and Researcher on Call, an interactive series of teleconferences that bring researchers and decision-makers together on a common topic. CHSRF is also launching a series of activities this fall that will focus on helping organizations learn about existing evidence around a particular issue and apply it within their context. As a step in this new direction on organizational learning, CHSRF and its key partners will be hosting a two-day workshop in December 2008 that will highlight effective teamwork innovations in healthcare. In particular, The Teamwork Workshop will focus on proven strategies and practical examples of effective inter-professional teamwork in the Canadian healthcare context. The event will also showcase some of the key research findings in this field and demonstrate how the outcomes of this research can be implemented practically in healthcare organizations. To find out more about the workshop or other CHSRF initiatives, please visit www.chsrf.ca.

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