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High-Quality Workplaces in the Health Services

March 20 2002 - CPRN has recently published a discussion paper which focuses on a number of human resource issues in Canada's health services. It begins by noting that health care is still the number one public policy issue in Canada. Employees are at the heart of health care and their wages and professional fees make up a high proportion of service costs. But they have been asked to do more with less for a decade as budgets have been squeezed. Yet they work in high demand/low control environments:

'The people who deliver the care do not control these complex systems, which are regulated by governments and professional bodies, technology intensive, and exposed to media scrutiny. The rules of the game change often, as governments change and new ministers are appointed - 73 in the last nine years in Canada and the provinces.'

People have coped but at a considerable price for themselves and the system through burnout, declining morale and staff shortages. There is concern about the recruitment and retention of trained staff in these circumstances.

The paper reflects a need to treat employees as 'assets to be nurtured rather than costs to be controlled.' There is a need to create a virtuous circle of high-quality workplaces, a good quality of working life for individuals, and high-quality organizational performance. The recommendations in the paper envisage health services built around recruitment, retention, staff development and quality of working life.

Current problems

* The crisis is multi-dimensional in terms of symptoms, underlying causes and consequences.

* Employee relations have been deteriorating for years, including strikes and other actions by health workers.

* Employee (lack of) commitment to employers has reached new depths.

* Nurses have the highest national rates of sickness absence due to ill-health or injury.

* Burnout and other forms of psychological distress are prominent. The paper cites the comment by the Clair Commission about 'moroseness' among Quebec health workers.

* A predicted shortage of 60,000 nurses by 2011 (one quarter of requirement).

The situation has been worsened by political decisions to cut health care budgets, demographic changes (an ageing population) leading to fewer available trained staff but more patients. In turn, these pressures cause more pressures as staff are exposed to greater physical demands, refused leave and given compulsory overtime. High demand, low personal control leads to stress ... leadng to more absences ... causing more stress for remaining staff.

Often, attempts to improve matters by creating teams or allowing local decision making have been thwarted by the cost-cutting imperative. Short-term bottom-line priorities inevitably produce damaging long term consequences. The authors say that the solution demands a recognition that organizational performance depends on 'motivated, knowledgeable, and well-resourced employees.' Moreover, the qualities that would produce such employees are exactly those required for effective organizations. Hence the need for a virtuous circle.

Achieving a high-quality workplace?

Studies show that autonomy, improved communication and respect are associated with job satisfaction, recruitment and positive assessments of people's working environments. Job redesign and integrated HR initiatives such as the 'bundling' of elements (for example, teamwork, decision-making and work allocation) found in high-performance approaches would be beneficial but, in the case of high-performance HR, have been rarely tried in the health sector. Specifically, the following are highlighted as being significant improvers of nurses' job satisfaction:

1. Autonomous clinical practice where nurses are involved in decisions and believe they have some control.

2. Status, significance and value given to the nursing profession by administrators and physicians.

3. Supportive relationships between nurses, physicians and managers with mutual respect and care for the quality of health care.

Work-life conflict has been largely ignored. In fact, the paper cites a study which shows that work-life conflict cost Canadian industry $2.7 billion in work absences in 1997 and cost the health industry $425.8 million in physician's visits, and makes a memorable and scathing point:

'Yet employers may not see a need to address either of these problems because their accounting systems are unable to measure the economic impact of employee health.'

The authors argue that a crucial point learned from studies of high-performance work systems and lean performance is that the former have positive results on workers' perception of their working environment while the latter has entirely negative consequences. Yet the health industry has focused on a 'lean production' mentality. Never mind the consequences on employees' health and general wellbeing.

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