Abstract

Evaluations of major policy initiatives on workplace health and teamwork have found significant progress on some issues and inertia on others. This article explores the applicability of a model describing employees' psychological relationships with work as a framework for considering workplace health initiatives. The Mediation Model contributes a way of focusing on experiences that are integral to staff nurses' day-to-day work life. As such, the model provides direction for developing and evaluating strategies for enhancing the quality of work life, especially pertaining to workplace health. The commentary considers a few key findings from the Nursing Environments: Knowledge to Action (NETKA) study that reviewed the applicability of national policy documents on the healthcare systems of Atlantic Canada. The discussion considers implications of staff nurses' participation in sharing and using new knowledge about workplace health.

The articles by Shamian and El-Jardali and by Clements, Dault and Priest in this issue provide valuable, thorough and insightful overviews of the issues at the forefront of defining the quality of work life in Canadian healthcare systems. They consider the current state of healthy workplace initiatives in Canadian healthcare systems, and a mechanism - teamwork - that can play a defining role in further progress. They present evidence of widespread concern about workplace health from the perspectives of providers, managers, professional organizations and government policy-makers. The authors acknowledge a wealth of information - research based and anecdotal - elucidating the dynamics underlying unhealthy workplaces, the impact on providers' well-being and the ultimate consequences for service recipients. And they identify ways of addressing the challenges, including teamwork, as a method of ensuring the best service delivery while sharing the demands of care among members of diverse professional groups.

The articles note areas of progress, critique shortcomings in approaches and suggest directions for further development. Regarding healthy workplace initiatives, the authors note that there are few indications that healthcare workers, particularly at the front line, are experiencing better working conditions. This perspective is consistent with the findings of the Nursing Environments: Knowledge to Action (NETKA) survey (Leiter 2006), in which nurses gave more positive progress ratings on issues distant from their work (information systems, leadership and scope of practice) than on more immediate issues (workload, hours of work and workplace health). An optimistic perspective is that the impacts of broader policy developments are trickling down to staff nurses and will eventually be evident in their relationships with work. An alternative explanation is that change is stopping at the level of broad policy. The system lacks the capacity (understanding, resources or know-how) to translate policy into the mechanics of job descriptions, staffing plans or accountability frameworks.

This commentary considers the second, gloomier perspective. It proposes that more robust theoretical frameworks guiding initiatives in healthy workplaces and teamwork would support more vigorous progress. Although descriptive research is a necessary and appropriate phase along the way to comprehending a complex challenge, the contribution of that research format diminishes over time. Research guided by theoretical constructs about people, organizations and their interaction makes a more enduring contribution.

Lasting progress on a widespread basis requires a deep rationale for action. Canada and other post-industrialized nations deliver healthcare through large, diverse, geographically dispersed systems. Despite centralization of pivotal issues of policy and funding, local healthcare facilities exercise considerable latitude in managing a workforce with varying degrees of autonomy in their day-to-day practice. They also vary greatly in their capacity to translate policy into action. Settings vary in the priority they assign to specific policy initiatives. They vary in the resources, talent and thoroughness they can devote to an initiative, even when they agree upon its importance.

In this context, initiatives that fit readily with the way people work have a greater potential for success. The system does not have the means to impose awkward practices or procedures. Instead, enduring change requires harnessing positive momentum inherent in positive psychological relationships with work.

A good fit of people with their work environment has been a guiding principle in the Mediation Model (Maslach and Leiter 1997), also known as the Areas of Worklife Model. The model proposes that a congruence of a workplace with employees' aspirations and expectations promotes work engagement; a poor match aggravates burnout. Second, flexibility on the part of individuals and their organizations makes congruence more likely by permitting a wider range of possible ways in which people can connect with their work environments. The third principle is responsiveness. Congruence is more likely when individuals and organizations have access to the information and resources necessary to react to challenges and opportunities that are integral to the complex environments of healthcare institutions. The model identifies six areas of work life, outlined below, that are relevant to the thoughts and feelings that people have about their work. A basic proposal from the model is that initiatives that enhance the potential for congruence in these key areas of work life have a greater potential for enduring success.

NEKTA Survey

This conceptual framework guided the NEKTA study (Leiter 2006), which examined the impact of major healthcare policy documents on Atlantic Canada healthcare systems. This project differed from parallel projects by its emphasis on knowledge transfer and use among staff nurses as distinct from these activities among decision makers and policy-makers.

One finding was that staff nurses were familiar with the core issues addressed in these reports and recognized the importance of these issues in their work life. But they were not familiar with the reports, their proposed solutions, their recommendations for change or activities arising from these recommendations. As one participant said, "We weren't in a position to receive those; we are staff nurses. I'm not clear on who would be responsible for circulating them to us. I don't know if others in the organization are reading them. I don't know anyone that does. I would assume that some are, depending on their positions."

The problem evident in this pattern is that respondents who were familiar with the reports had a more positive perception of progress. They did not simply know that there were problematic issues; they knew that there were proposed solutions. Knowing that someone at their facility was working on implementing solutions brightened their perception even more.

A second relevant finding was that active participation in sharing and using knowledge on improving workplace health was associated with greater professional efficacy. One potential element of this relationship is that research knowledge on professional issues is high-status information. Being up to date on these issues conveyed a deeper sense of belonging to the profession. It also provided nurses with knowledge that helped them to be more effective in their work. This is a powerful finding as changing perceptions of self-efficacy in any domain of life requires convincing evidence.

A fundamental question arising from these findings is whether successful change in healthcare workplaces requires the active participation of staff nurses. Although there are commendable efforts to bring information to their attention, systems are proceeding as if staff nurses' active participation in the process would be a good thing but not necessarily an essential thing. With good leadership and solid organizational policy, institutions can implement new procedures, structures and policies that are so sufficiently compelling that all will be drawn along in their wake to a healthier, more fulfilling workplace. There are signs that this approach encounters serious limits in practice.

Healthy Workplace Initiatives

A pattern evident in the lead paper by Shamian and El-Jardali is that successful interventions occur at a broad system level. There are more seats in nursing programs and more participation in continuing education. Accreditation and accountability procedures attend more closely to issues of quality of work life. Quality of work life is more thoroughly considered in strategic plans of healthcare organizations. These important developments are within the domain of healthcare systems, a few steps removed from the day-to-day challenges of nurses.

From the National Survey on the Work and Health of Nurses

31% said patients in their care had been injured in a fall.

More than one in four (27%) said the quality of care delivered in their workplace had deteriorated in the previous 12 months, compared to 16% reporting improvements.
http://secure.cihi.ca/cihiweb/dispPage.jsp? cw_page=AR_1588_E&cw_topic=1588

Closer, but still a step or two away, are initiatives to improve the general parameters of healthcare jobs: flexible staffing, phased retirement and an increased proportion of full-time permanent positions. The initiatives that are closest to point-of-care nurses' work life define an 80-20 balance between direct care and professional development in staff nurses' job structures. These initiatives go directly to day-to-day work life, having a direct impact on each of the six areas of work life in the model: workload, control, reward, community, fairness and values.

Workload

The 80-20 balance provides nurses with opportunities to shape the pace, content and variety of their job demands. Responding to patients' needs is demanding from a quantitative perspective (the amount of work to be done), a pacing perspective (when, how promptly and for what duration) and a qualitative perspective (the complexity or difficulty of response). Many aspects of professional development activities are more within the nurses' discretion. An 80-20 initiative allows for more successful resolutions on workload.

Control

Participation in professional development activities provides opportunities for nurses to make decisions about their approach to these activities. By developing new skills, abilities and perspectives through professional development, nurses also enhance the control they can exercise over treatment provision.

Reward

Increased professional development activity produces more opportunities to engage in enjoyable work and receive recognition from others. In the long run, it could enhance nurses' potential for career advancement, providing rewards from position and remuneration.

Community

Changes in the fundamental structure of work affect nurses' relationships with others at work. These activities generally enhance networks among nurses and of nurses with members of other healthcare professions who are concerned with professional issues. Learning, developing and implementing new ideas usually involves teamwork that enriches nurses' social context at work.

Fairness

Increased opportunities for professional development convey a strong vote of confidence from the employer. It is an investment in nurses' long-term potential, conveying recognition that they have the talent and dedication to support a more substantial contribution to the mission of their hospital or clinic. The respect experienced by nurses in this position is in sharp contrast to the sense of injustice communicated by many Canadian nurses in surveys.

Values

The 80-20 balance provides a means for nurses to deepen their dedication to professional values. With the active support of their employer through job redesign, the initiative emphasizes congruence between organizational and personal values. This meeting of the minds on core values is fundamental to nurses developing work engagement rather than gravitating toward burnout. Anecdotal reports of 80-20 initiatives suggest that they are associated with reduced sick leave for the participants, permitting at least a partial recovery of the costs of providing coverage for the 20% reduction in direct patient care activities. This experience is in sharp contrast to the situation reported by nurses experiencing burnout. This example is not meant to indicate that an 80-20 job design is a panacea. It may be feasible, desirable or appropriate only in certain circumstances, which research is still in the process of identifying. The point of the example is that it demonstrates the relevance of a specific model of work life. This sort of analysis suggests that the initiative's benefits make sense within a perspective on employees' psychological relationships with their work. The 80-20 structure appeals to the thoughts and feelings that nurses have about themselves, their service recipients, their employers and healthcare in general. It demonstrates ways in which the initiative can enhance their perspectives on aspects of work life that are closely tied to their basic energy level, potential for meaningful involvement and sense of professional efficacy. These are the core dimensions on which job burnout differs from work engagement.

Conclusions

The central point of this commentary is a reiteration of the idea that there is "nothing more practical than a good theory" (Lewin 1951: 169). The discussion applies a framework developed to explain the organizational context of psychological relationships with work that range from burnout to work engagement. It proposes that theoretical frameworks are useful. They have the potential to bring policy changes closer to the work of point-of-care healthcare providers and to sustain the hard-won gains of those leading improvements in teamwork and workplace health. The model is not the only relevant theory, and it may not provide an exhaustive framework for every situation. But its conceptual framework and translation into a short questionnaire, the Areas of Worklife Survey (Leiter and Maslach 2004, 2006), argue for its use to evaluate workplace initiatives. It is a framework on which to build additional constructs, such as personal knowledge transfer involvement (Leiter 2006; Leiter et al. in press) and empowerment (Laschinger and Wong 2006).

Regardless of the framework, policy initiatives benefit from good theory. They deepen one's appreciation of organizations as environments that shape behaviour and respond to actions and feelings of their members. The understanding derived from these concepts will help researchers, decision makers and policy-makers develop initia- tives with lasting, positive impact on the work lives of healthcare providers.

About the Author

Michael P. Leiter, PhD
Canada Research Chair in Occupational Health and Well-Being
Professor of Psychology, Acadia University
Director, Centre of Organizational Research and Development

References

Laschinger, H.K.S. and C.A. Wong. 2006. "The Impact of Staff Nurse Empowerment on Person- Job Fit and Work Engagement/Burnout." Nursing Administration Quarterly 30: 358-67.

Leiter, M.P. 2006. Nursing Environments: Knowledge to Action. Ottawa: Health Policy Research Program, Health Canada.

Leiter, M.P., A. Day, P. Harvie and K. Shaughnessy. In press. "Personal and Organizational Knowledge Transfer: Implications for Work Life Engagement." Human Relations

Leiter, M.P. and C. Maslach. 2004. "Areas of Worklife: A Structured Approach to Organizational Predictors of Job Burnout." In P. Perrewé and D.C. Ganster, eds., Research in Occupational Stress and Well Being (Vol. 3: 91-134). Oxford: Elsevier.

Leiter, M.P. and C. Maslach. 2006. The AWS Manual (4th ed.). Wolfville, NS: Centre for Organizational Research and Development.

Lewin, K. 1951. Field Theory in Social Science: Selected Theoretical Papers. New York: Harper & Row.

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