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Introduction

There are two health networks in New Brunswick: Vitalité Health Network and Horizon Health Network. Vitalité uses French as its administrative and working language, and Horizon uses English. Since 2002, both health networks must actively offer health services in French and English to comply with the Official Languages Act (OLA) (Doucet, 2017; Foucher, 2017)[1]. Active Offer assumes that services in both official languages are offered and that service users can choose the language in which they prefer to receive services without having to request it (Collin et al, 2022; Government of New Brunswick, n.d.). It assumes that services in each of the two languages are of equal quality. It also sets out guidelines for signage, posters, and interactions by telephone, in person, and by electronic means (Government of New Brunswick, 2015).

Data from the New Brunswick Health Council show considerable disparities between the users who prefer to receive health services in English and those who prefer French. In 2016, in the Horizon Network, 42% of users who preferred to receive services in French were served in French, while 80% of users who preferred English services received them in the Francophone Vitalité Network (New Brunswick Health Council, 2017). In a survey on acute care, conducted from December 2018 and March 2019, the Council found that only 36% of patients who preferred French received services in their language in the Horizon Network (New Brunswick Health Council, 2020).

Even though the Act requires active offer (AO), it is clear that the Horizon Network does not always fulfil its obligations in this respect. Research by Forgues and Maillet (2024) uncovered some of the reasons for this gap. They include the failure to understand obligations regarding AO among significant numbers of health professionals, the feeling of being incompetent or insufficiently equipped to do so, and weak promotion of AO in their facility or network. Because of the difficulties certain health organizations face in implementing an AO of service in both official languages, it is important to identify the practices that foster the creation of an organizational culture favourable to AO.

Indeed, after making some progress in AO, the Horizon Health Network administration and those responsible for official languages services[2] realized in 2015 that, despite the measures the Network had put in place, it had not realized the gains expected in AO. The issue of language of service was a source of tension in the Horizon Health Network. Media reports about Horizon Health Network’s failures in the area of AO had caused even greater tensions around the issue of language of service (Raiche-Nogue, 2018). To make matters worse, after discovering that people were pretending to be patients to check to see if AO was made, employees denounced this practice in the workplace and in the media. Concerned that any progress made thus far might be compromised, Horizon’s administration decided to hire a firm of consultants who specialized in situations in which dialogue was difficult. A series of dialogue activities for employees was organized in order to strengthen the culture of AO. The approach selected was designed to be less vertical (hierarchical) and more horizontal (in the form of dialogue), to enable employees to express their ideas about AO freely and in a safe space. In contrast to the awareness activities, information sessions, and training usually offered, this approach gave employees an opportunity to voice their own ideas.

The dialogue activities took place between fall 2018 and spring 2020. Horizon Health Network organized more than 300 sessions with more than 3,400 employees throughout the area it covered (in Moncton, Saint John, Fredericton, and Miramichi).

We adopted a comprehensive approach (Gaudet and Robert, 2018; Paillé and Mucchielli, 2016). We wanted to have a better understanding of how dialogue activities were designed and their effects on participants, to find out if and how this exercise succeeded in a situation in which legal obligations and internal instructions in health facilities had failed. We wanted to find out if these dialogues contributed to the establishment of an “AO culture,” i.e., a generalized, favourable attitude towards AO that would translate into a better offer of services.

Our project is located at the intersection of studies by Forgues and colleagues on the factors influencing the language of service (Forgues et al., 2020 and Forgues et al., 2017) and those of Paulin (2019a, 2019b, 2017) on the use of decision-making tools in a public context, which are part of a broader area of research on the AO of services in French (Drolet, Bouchard, and Savard, 2017). We analyzed the results under the lens of sociology of organizations, assessing the potential that dialogue holds for organizations that function primarily through hierarchical relations and top-down directives (Detchessahar, 2003 and 2019). Our study is also a continuation of Sylvain Vézina’s research on the AO of health services, which reflects “the particular importance of entrenching active offer into the basic values of the health system.” (Vézina, 2017, p. 234).

Data collection consisted of reviewing documents on the dialogues produced by the Horizon Health Network and conducting semi-structured interviews with organizers and facilitators of the dialogue sessions. Our analysis was applied to evaluations by participants after the dialogue sessions. Participants were invited to complete a survey and to comment on the activity. They were asked if the dialogue sessions enabled them to share their ideas and to obtain information about AO, if the discussions were meaningful and important, if the facilitators encouraged everyone to participate in the discussion, if they were able to talk about what mattered to them, and if they had the opportunity to hear what mattered to others. Participants could share additional comments, as well. In all, 1339 participants submitted comments. These qualitative data were analyzed to capture the perceptions of respondents of both the activity and AO.

We also conducted interviews with the people (N=8) who organized and facilitated the dialogue sessions. These interviews addressed the objectives, organization, format, and outline of the dialogue sessions, as well as the challenges, conditions that fostered dialogue, and the facilitators’ perception of how well the goals had been met. The analysis of the interviews enabled us to understand the design and outline of the sessions, and also the experiences of facilitators.

We analyzed the documents and the transcriptions of interviews with the help of MaxQDA software (Kuckartz and Rädiker, 2020), allowing us to separate the relevant segments and to group them into both predetermined categories and those which emerged in the course of analysis.

1. The design of the dialogue sessions

The idea of organizing dialogue activities in Horizon Health Network took root in a context in which the obligation to make an AO of services in both official languages was becoming a source of tension between those responsible for official language services and employees. The working climate had become tense when employees learned that false or “undercover” patients were checking to see if services were actively offered in both official languages. This method was criticized by the employees and made it difficult to promote AO in the Network. Horizon AO promoters were perceived as “language police.” In response to the organizational dynamic, Horizon administration and staff responsible for official language protection in the Horizon Network decided to change their approach and to promote an organizational culture that encouraged the use of AO. Instead of simply requiring employees to make an AO of services, they explored options to give employees more incentive to implement AO. Making this type of change in an organization’s culture involves changing the perception of employees regarding the obligation to make an AO.

To do so, the administration and promoters of official languages in Horizon decided to organize dialogue sessions for employees, as well as sessions for employees and facilitators, to create an opportunity to share different points of view. Official languages staff wanted to give staff an opportunity to speak, to be heard, and to understand the reasons for making an AO of services. One of the goals was to improve their relations with employees.

As mentioned, the dialogues were organized by consultants specialized in situations where relations among groups are stressful or conflictual. The original intention was to hire consultants to train people (in a train-the-trainer model) to facilitate dialogue groups with employees. Although several Horizon employees facilitated sessions, this method resulted in less fruitful results. The existing workload of these employees and the additional duties of group facilitation made this initiative complicated. Horizon Health Network therefore decided to open a new position entirely dedicated to the facilitation of these sessions.

1.1. Objectives of the dialogues

The dialogue approach was designed to create changes in the workplace culture regarding AO, that is, to produce long-term social and behavioural changes, as well as to obtain better results and to offer better services. A Facilitator’s Guide that outlined six strategies was written for this purpose. The six strategies are

  1. developing a positive attitude towards AO and discussing the strengths of the organization and opportunities of AO, while nonetheless addressing the tensions and conflicts surrounding AO;

  2. making space for emotions, by encouraging participants to discuss their personal experiences;

  3. empowering employees by enabling them to be part of the solution and inviting them to make suggestions;

  4. creating an open, transparent, inclusive space where participants could freely and safely share their experiences;

  5. establishing benchmarks for success in AO;

  6. supporting the leadership that emerged through the dialogue strategy (Horizon Health Network, 2017).

To highlight the fact that this was a new initiative, both separate from and a clear contrast to the earlier approach, the Facilitator’s Guide included the following: “There will be NO audits – because staff told us these were really uncomfortable and made them feel like they were being watched to catch them doing something wrong. Executive Leadership Team has endorsed this approach.” (Horizon Health Network, n.d.) These statements were repeated by the facilitators at the beginning of every dialogue session.

1.2. Session plan

The facilitators were designated “mentors” and were asked to create an environment conducive to discussion and to encourage participants to share their concerns and hesitations about AO. Each session consisted of four (4) main activities:

  1. What is OA?

    In the Six-Word Story activity, participants develop a mental image of AO in only six words and explain their importance. Inspired by a story credited to Ernest Hemingway (“For sale: baby shoes, never worn.”), this activity is done in groups of three or four people. Before starting it, the facilitator provides an example of a six-word story she developed herself about AO: “Exceptional care. Every person. Every day.” Participants are then invited to share their six-word stories and the stories are posted on the wall.

  2. Supporting change and different points of view

    Participants in this activity are asked to play roles that require them to adopt different points of view. Each person alternates in the roles of healthcare provider and patient. The goal is to give participants an opportunity to explore different perspectives, including those of patients.

  3. Sharing experiences

    The Socratic dialogue is a method used to stimulate the exchange of personal experiences. Two circles are formed, one surrounding the other (inner circle and outer circle). Inner-circle participants discuss a topic and those in the outer circle remain silent. After a specific length of time, they switch roles.

  4. Finding solutions

    In groups of four or five (people working in the same department are encouraged to do this activity together), a brainstorming session is held. Ideas and solutions expressed in the exercise are used to build an action plan for the department. Suggestions relevant to the entire Network are also considered and later referred to the official languages staff.

Before presenting the results, we will, in the next section, highlight the elements of analysis we obtained through the interviews with organizers and facilitators of the dialogue sessions.

2. Outline of dialogue sessions: organizers’ and facilitators’ perspectives

Facilitators led the discussions, provided information, recorded the participants’ recommendations, and forwarded the recommendations to Horizon staff members responsible for the official languages mandate. Facilitators took part in a three-day orientation session. The training was necessary not only to meet the objectives of the project, but also to learn to lead and manage the discussion, a task that would sometimes be difficult. One facilitator stated that when participants expressed their frustrations or concerns, her role consisted in listening, refraining from judgment and from offering solutions.

The facilitators we interviewed found that some participants showed a closed or negative attitude at the beginning of the dialogue session, and became more open when they realized what this new approach meant for them. The sessions were structured, and the questions were asked in such a way that participants were encouraged to share their individual points of view, their experiences, and the way they felt in specific situations. The discussions led to a deeper understanding of AO and issues related to it, through the diversity of perspectives and experiences of participants.

One of the objectives was to bring participants to a place from which they could see the larger picture, beyond the dimension of language.

This has nothing to do with language and everything to do with people. And when you finally get that perspective and people finally start thinking of it in that way that you’re not dealing with a French person, you’re dealing with a person. [...]. I think a lot of people came away from the sessions seeing that, you know, yes, this is part of patient care. It’s a larger issue than just French versus English.

A5

Furthermore, the conversations that took place during the dialogue sessions could become emotional. In some cases, an empathetic response to the experiences related by other participants seems to have contributed to a better understanding.

So hearing those experiences from others and sharing those experiences, you could see the softened view: “OK, all right, it’s not just the laws out there that’s making my life uncomfortable. This has real people, real emotions, real experiences attached to that”.

A6

Dialogue sessions allowed participants to express their unhappiness and their frustrations with AO. Despite the challenge that specific sessions presented for the facilitators, they had to find a way to ensure that individual participants did not monopolize the discussion and that everyone had an opportunity to freely express their ideas in a respectful and non-judgmental environment.

So we had to work to ensure that we have to respect all. We reiterated it and came back to the values and the safe space, that this was a safe space for all to express their opinions. And “we’ve heard your opinions, now we’re going to hear from others.” So we had to work harder. In relation to ensuring the space was safe, […] we were not there to judge or to say you’re wrong. That wasn’t the whole point, and that’s what I think made the sessions work because there was no judgment.

A6

The facilitators strived to maintain a space that was “safe” for participants, so that each person could feel comfortable to express themselves freely and share their experiences without having to hide their feelings or be afraid of being judged. According to the facilitators, the creation of a safe space was foundational to the success of this activity. Respecting everyone’s opinion was, moreover, one of the principles that guided the facilitator’s work. One of the major objectives of the dialogues was to know how employees felt and perceived AO.

So we wanted to get their feeling, their feedback, what was working well with regards to active offer, what wasn’t working well and what do you think we should or could do to help? So it was an information-seeking project.

A7

To accomplish this, it was essential for all participants to express themselves; hence the insistence on maintain a safe and inclusive space. In addition, by encouraging participants to express their ideas about AO freely and honestly, the facilitators could correct some of their misunderstandings about AO.

We wanted to know their opinions, their thoughts, their ideas. We felt that there was a lot of myths out there and we wanted to debunk those myths. We wanted to set the record straight.

A7

For example, it was important to help people understand that an employee did not necessarily need to be bilingual to implement AO.

Nous avons diffusé un message qui recadrait la pratique de l’OA : accueillir avec Hello/Bonjour démontre simplement une offre de service bilingue, qui n’exige pas de parler en français, mais seulement de rechercher le soutien nécessaire et en aviser le bénéficiaire.

A7

Responding to the question of whether dialogue sessions fostered a positive organizational culture for AO, one of the session organizers stated that this objective would be fully realized only in the distant future. The facilitators did not believe that the dialogues enabled every participant to change their perception, although they did note that some gained a better understanding of AO. They are also aware that some employees remain resistant to AO, even after taking part in a dialogue session. However, this activity may have contributed to changes in the organizational culture, making it more favourable to AO.

Another objective of the dialogue sessions was to create a different foundation for the relationship between the AO promotion team and the employees who were tasked with implementing AO. By creating a space that was intended to be safe, in the sense that employees could express themselves without facing criticism, communication could be reestablished, and their relationship with AO promoters could improve.

une fois que les gens ont la chance de se vider le coeur, après ça, on peut un peu expliquer notre vision, notre perspective, puis notre approche qui n’est pas nécessairement comme les gens la perçoivent comme la police. On n’est pas « the language police ».

A8

The participants’ written comments in the evaluation of this activity enabled us to note their immediate reactions and to observe the impact dialogues had on their perceptions of AO. The next section focuses on these comments.

3. Participants’ perspective

3.1. Positive aspects of the process

The approach used in the dialogue sessions was a pleasant surprise for several participants who were not accustomed to being consulted. The shift in the approach to one of promoting AO, valuing and respecting different perspectives, and facilitating interactions was appreciated by many. The objective of creating a safe forum for discussion where participants would feel comfortable expressing themselves seems to have been met. Indeed, some participants made favourable comments about the less authoritarian approach, very different from the approach used in the past. They found that it encouraged discussion instead of fuelling fear and resentment. The decision to discontinue random checks without prior notice received unanimously favourable ratings, and the fear associated with these quality control measures decreased.

As well as making positive comments about the opportunity to freely express opinions, participants felt that being able to listen to other points of view was also beneficial. Many participants felt that the importance accorded to these interactions was appropriate.

3.2. Negative aspects of the process

As we noted earlier, the freedom to express themselves was also an opportunity for some participants to vent their frustrations. In some sessions, bitter and heated discussions about AO arose and facilitators had to carefully manage the discussion to allow for a more balanced expression of points of view. Other participants also deplored the fact that it was not possible to discuss certain aspects of AO they considered problematic during these sessions.

Some participants commented on the discomfort they felt during the role play, which required them to put themselves in the position of a person making an AO of services. This feeling sometimes stemmed from their disagreement with the principle of AO itself. In addition, we noticed a certain skepticism about the value of the dialogue sessions and their effectiveness in terms of concrete changes.

3.3. Perceptions of AO following the sessions

A number of participants revealed a certain lack of understanding about the objectives of dialogue sessions and, perhaps because they were accustomed to sessions of an informative or instructive nature, they did not feel they obtained any new information about AO.

Some respondents questioned the relevance of these sessions for people who, like them, did not have any difficulty with AO.

For others, discussions and role plays seemed to help them better understand what AO was. For certain participants, the opportunity to adopt different roles (such as that of a Francophone patient) put AO in a positive perception. Others mentioned that the sessions allowed people with different perspectives about AO to come together and find common ground, and that the sharing of personal experiences played a positive role in increasing their understanding of the importance of AO:

Many valued opinions, information provided and that was new to me, able to expand on each other’s views.

They provided stories to make it more meaningful of why we need bilingual services.

Furthermore, when we examine the comments made about AO, we note that many participants expressed resistance towards the principle of AO, even after they had participated in a dialogue session. A significant number of participants voiced criticisms and hesitations about AO. For examples, some did not feel that using the patient’s preferred language was an important part of the quality of care offered or rejected this idea completely.

We should respect and care before we focus on just language.

It is obvious that for many participants, recognizing the professional qualifications comes first, and competence in the French language afterwards. Several times, they emphasized the skills, experience, and the seniority of nurses.

It’s all about medical experience and skills. Language will never save a life.

On the subject of financial resources assigned to the implementation of AO, comments were particularly critical. While healthcare workers face cuts by the administration of the health system, there were sometimes significant concerns with the budget allocated to AO. Many viewed efforts and resources to promote AO as a waste of money.

I don’t disagree with the AO but with the $$$ wasted on this topic.

Participants criticized the uniform application of the OLA to all regions of New Brunswick, which did not take the demographic realities of language use into account.

Apply this as a blanket policy to all areas of Horizon will most likely result in pushback from various areas as each area has varying exposure to the public ranging down to zero exposure, therefore the active offer has no use.

In addition, some participants considered that AO had gained magnitude for political reasons that had little to do with realities in the workplace.

Tell the government to worry more about health care instead of language. You have smart personnel working for you, language is only a government issue.

Feels Active Offer is just to be politically correct blown out of proportion by politics.

The obligation to make an AO had become a source of tension that, according to some respondents, did not allow employees to use their “common sense.”

I think AO has created negativity. Unfortunately, it seems that we are not trusted to have common sense to speak / seek out their preferred language as needed.

Teamwork is stressed when issues are contentious - Eng vs. French.

Regarding AO, some employees wanted people to recognize and call on them for their knowledge and experience. Indeed, the dialogue exercises revealed a desire to become more involved in learning about the issues that AO presented and the development of solutions that could better respond to the situation, according to their evaluation of needs and available resources.

3.4. Bilingualism, confusion, workplace insecurity, and discrimination

The effects of requirements for bilingualism in hiring practices and promotion criteria seem to explain the animosity surrounding the choice of language for healthcare services. Several comments showed the persistence of a perception that bilingualism requirements compromise the career advancement of employees. Posting bilingual positions causes a sense of job insecurity which several unilingual participants experience as a form of injustice. The impression that professional experience and seniority have been replaced by bilingualism in criteria for bilingual positions is accompanied by tensions between language groups.

I don’t mind saying Hello/Bonjour. What I don’t appreciate is that all the jobs are going to bilingual candidates, and this is where the animosity lies.

I strongly feel casual employees that are not being able to apply for jobs that are posted bilingual and going year after year without ever becoming part-time or full-time employees is strongly unfair. These people went to school just like French people! This needs to change!

The lack of job security is a concern for many. In the following comments, one person in particular is expressing the perception that AO requirements is infringing on opportunities for career advancement:

Need to find a way to separate the concept of offering language of choice to patients from bilingual requirements in hiring. Staff are frustrated with job security and they relate it to Active Offer.

Numerous comments denounced what participants perceived to be a form of language discrimination towards unilingual Anglophones working in Horizon Health Network. This perception fuels resentment.

Horizon discriminates against unilingual English staff as you can’t change jobs based on knowledge or experience due to French requirements.

The perception that bilingualism requirements for certain positions represents an obstacle in professional advancement engenders a sense of injustice for unilingual employees, and the dialogue sessions did not seem to have succeeded in alleviating this feeling.

3.5. Linguistic insecurity

Some of the unilingual participants shared their fear of interacting with Francophone speakers in the workplace.

Many staff note that there are a lot of people not making eye contact with the members of the public wandering around the hospital for fear they will be caught in the situation of not being able to speak the language of that person’s choice. So staff now avoid people. Others say they will not answer a phone for fear they will be put in that position as well.

This fear is related to a form of linguistic insecurity or a lack of confidence in their language abilities when employees feel forced to use a language they do not speak fluently or do not know at all.

I panic when the client requires French and I can’t speak it.

I believe anxiety surrounding not speaking French makes staff not as comfortable with the Active Offer.

A sense of inferiority also seems to characterize the state of mind shared by some of the people surveyed. This discomfort is related to an insufficient level of French.

We are made to feel inadequate if we can’t speak French.

For several unilingual Anglophone participants, the requirement to make an AO produces fear and a feeling that their skills are inadequate to do so effectively. These feelings may be accompanied by a sense of injustice that contributes to a stressful working climate when AO is involved. One of the advantages of the dialogues for staff members responsible for official language is that they gave them a better awareness of the perceptions and the feelings of these employee groups towards AO. Another advantage was that the discussions encouraged them to propose solutions, as we explain in the next section.

3.6. Solutions and suggestions

A portion of each dialogue session was dedicated to formulating ideas for solutions and sharing suggestions to foster the AO of service in both official languages. Participants shared a large number of suggestions. Here are the main ideas they presented.

3.6.1. French-language training

Among the many suggestions made in the sessions was the opportunity to take French courses. Participants called for courses that focus on the specific vocabulary used in health and medicine. Even people who are able to communicate in French may find it difficult to interact in workplace situations because they do not know the correct or precise medical terms in French.

To support language learning, participants suggested offering conversational French practice in the workplace. According to several respondents, practising French regularly is essential to maintain second-language skills.

3.6.2. Translation and multilingualism

The use of new translation technology to overcome language barriers represents another solution frequently mentioned by participants. Access to a telephone line that offers translation service was mentioned specifically by several respondents.[3]

Several participants suggested implementing this type of service, as unilingual Anglophones would then not be prevented from working in positions they cannot currently hold because they do not have a satisfactory level of French. This type of tool and services would reduce the fear many unilingual employees have of not being promoted or obtain higher-level positions in Horizon.

You need more translator within the facility. This will allow experienced people and skills to continue to move on into positions they’re currently restricted from due to language and doesn’t allow them growth.

Rather than trying to make all staff bilingual, have a translation department responsible for translating for all departments. Much more cost-effective.

Another idea was to distribute a list of resource people who could support AO. The list would include employees in each department who speak French—and other language—and would be updated daily. Some participants suggested composing a list of people who could also be contacted “in an emergency” if it was impossible to reach a bilingual or Francophone employee immediately.

In terms of resources, bilingual employees are certainly indispensable. However, participants realized that the workload of bilingual employees increases when their colleagues ask them for help interpreting.

We are really struggling for French-speaking resources. Having someone designated to help unilingual staff so we don’t feel we are bothering our bilingual staff would help me feel more comfortable in providing excellent care.

The heavier workload of bilingual employees remains a concern. As a result, participants suggested finding ways to support bilingual employees.

Several participants stated that they wanted a contingency plan and specific tools to be developed and implemented to deal with situations when no one was available to provide services in French.

Before implementing process should have the necessary tools to incorporate into contingency plan. Why is it up to me to travel around the hospital and inquire with people and don’t know if they have any French personnel that I could list on my plan?

Several participants suggested that services designed to help unilingual healthcare staff with AO be introduced. Although the exact form of these services was not determined and its feasibility has not yet been evaluated, it seems that, from the participants’ perspective, its main advantage would be to simplify AO. Unilingual employees could quickly access this service when a patient chooses to be served in French.

3.6.3. Coaching

Participants also noted that moral support for employees was important. People should not assume automatically that staff is at fault if there is a problem. This type of comment was made quite frequently, and shows that employees feel they are blamed for certain failures or gaps in AO. Several would prefer an approach based on positive reinforcement, both when they are learning French and when they make efforts to integrate AO into their professional work.

Several staff members said they would like to see the best practices already adopted by employees to be recognized. A number of comments showed that employees wished to be better supported and recognized in their work, in contrast to the punitive approach through which employees that do not make an AO are reprimanded.

3.7. Follow-up to dialogues

Numerous participants emphasized the fact that the dialogue sessions provided an opportunity to present many promising solutions and asked that the ideas expressed during the sessions be applied to concrete actions and changes. The sessions also gave rise to expectations about the ideas which arose in the sessions: the concerns to be addressed and the suggestions to be put into action.

I hope that in having all Horizon employees take this session that management + government listens to front line workers concerns and puts some suggestions into action!

Some people would like to know what action will be taken, based on these suggestions. Several times, participants asked for tangible results from these dialogue sessions, at which suggestions were presented, and they wanted to follow the progress of actions and changes implemented as a result.

Participants recommended pursuing this initiative to enrich communication and provide a forum to express ideas. The verbs “continue to,” “keep engaging,” and “keep listening” were frequently used. The desire to take part in solutions concerning AO was also expressed often. Healthcare staff members were of the opinion that they were in the best position to determine how to respond to AO issues.

3.8. Dialogue sessions: a summary

These last comments express the appreciation shown by participants for the fact they were able to speak and be listened to. The dialogue approach, which many hoped would continue, makes room for the competence of employees who implement AO. Staff members want management to rely on their judgment when it comes to complying with the legal requirement for making an AO. This demonstrates that the dialogues generated expectations among the employees.

Many participants expressed their need to be better supported and better recognized for their implementation of AO. They appreciated the new approach that was more collaborative, informed by a dialogic strategy, in which employees are part of the solution. Following this approach, employees would no longer be singled out for their failure to make an AO; AO would become the responsibility of the entire facility, which must equip employees to put AO into practice.

Even though dialogues were successful in creating a better understanding of AO among a number of participants, a certain proportion of unilingual employees remain uncomfortable when they are asked to use it. They feel inadequate when they interact with patients who choose to communicate in French. This may reflect a persistent misunderstanding about AO. Nonetheless, facilitators reminded participants at dialogue sessions that AO can be made by unilingual Anglophone employees as well. AO can be made by saying one or two phrases in French. For instance, if, after being greeted with “Hello/Bonjour,” the patient continues in French, an employee may simply ask them to wait—“un moment s’il vous plait”) while they go to look for a bilingual co-worker. The discomfort of staff members with AO may, however, reflect practical difficulties; bilingual employees may be overworked or unavailable. Their coworkers may feel uncomfortable bothering them when they are working.

We noted that several employees continue to resist the AO of service and question the ways in which it is implemented. Comments revealed attitudes of resentment and frustration because AO is still associated, with bilingualism requirements for some positions. Language criteria, in the opinion of these employees, limit their opportunities for career advancement.

Conclusion

The dialogue sessions finished in spring 2020. Many participants believe they benefited from taking part in them, especially because they were able to share their points of view and experiences. Several would have liked the sessions to continue. Approximately one-third of the staff of Horizon Health Network had the opportunity to express their ideas about AO and share their experiences with it. This was, moreover, one of the main objectives of the sessions: to gather information on the perceptions of employees regarding AO. Thus, staff responsible for carrying out the official languages mandates in facilities were able to discover, for example, the degree to which employees had false ideas about AO and what it entailed, and the hesitation or fervent opposition they felt towards it. During the dialogue activities, it was possible to refute these ideas and to build a better understanding of AO, its implementation, and its importance. The analysis of the methods used to conduct the dialogue sessions and the evaluations enabled official language staff and the administration of Horizon Health Network to introduce new measures to enhance AO. For example, AO promoters came to understand the importance of engaging employees and building relationships with them before problems arise. Indeed, since the dialogue activities began, AO promoters have been asked to create a friendly relationship with employees rather than authoritarian relationships in which they are viewed as the “language police.”

The safe space in which employees could freely express themselves without the fear of being judged was certainly appreciated by participants. First, by asking them about the stumbling blocks in AO, it was possible for them to talk about obstacles they faced, both those that had arisen in the working environment and those that were rooted in their perceptions. In addition, by inviting employees to propose solutions, official language staff not only benefited from concrete solutions, but also fostered the adoption of a positive attitude about AO. This was one of the objectives of the role play activity in which participants had to imagine themselves in the position of a healthcare professional interacting with a Francophone client and vice versa. Because of the dialogue sessions, participants were able to better understand the reasons for making an AO and to develop a positive attitude towards it.

The decision to end the dialogue sessions, however, contradicted the organization’s stated intention to adopt a more horizontal management structure that engages employees in the development of solutions. Employees were not informed of the outcomes of the dialogue sessions. This was a disappointment to the participants who appreciated the recognition of their knowledge and experience in the field during the sessions. Researchers have emphasized the importance of follow-up measures in tracking progress in decision-making processes as well as in informing and thereby engaging participants in the outputs resulting from this exercise of democracy (Rowe et Frewer, 2004).

The results show that there is still a proportion of unilingual employees who feel resentful towards AO and worry that language requirements for positions will limit their career advancement. They deem the work associated with AO too cumbersome in current conditions and propose solutions such as using support services (a mobile team or a translation service, for instance) to help with AO. They also want to redefine the rules of AO to their advantage, so that their unilingualism will not be an obstacle in their career path. A portion of participants make a distinction between technical skills and language skills, and want the former to take precedence over the latter. In their opinion, their inadequate level of French should not restrict their opportunities in their profession.

These findings are similar to those of Vézina (2017), who noted the confusion between AO and bilingualism. Although unilingual staff members should also feel they are contributing to the collective effort to make an AO of services, Vézina observed that they did not feel comfortable making an AO because they feel that the Hello/Bonjour formula delivers a false message to Francophone patients. Thus, “the emphasis placed on bilingualism is often perceived by unilingual people as a threat to the balance of powers within the system, often leading to resistance towards any measure favourable to active offer” (Vézina, 2017: 233). A few years later, our analyses show that the dialogue exercise was not sufficient in altering the discomfort felt by unilingual staff members.

According to Killian (2008), studies of organizational change generally focus on changes in structures and procedures, and ignore the importance of administrative culture as a catalyst of long-term change, including shifts in management practices and the development of new public policies. While culture has to be taken into consideration when organizational changes are being carried out, this organizational dimension is a complex challenge. As Killan states, culture has an emotional component and a symbolic dimension related to the belief systems and perceptions shared by members of an organization. Culture incorporates organizational memory, which gives a sense of continuity to those involved, and at the same time is subject to transformations. Most importantly, organizational culture may foster or inhibit change.

The dialogue exercise can be seen as an 18-month parenthesis in the history of Horizon Health Authority. We may well ask ourselves what real impact this activity made. For a member of Horizon staff, was a single dialogue session sufficient to produce a more favourable attitude towards AO? We believe that continuing this exercise for all employees, including new ones, would have a better chance of producing long-term results and developing a positive AO culture in the organization.

However, we need to remember that this initiative took place in an organization which also offers many other activities to raise awareness about AO among its employees and to improve their French-language competency (language training, social events, etc.), provides tools to communicate in French (guides, documents with key phrases, tips and recommendations, etc.), and, as part of its departmental human resource planning, strives to make bilingual staff available to help unilingual employees in their work.

It would also be useful to analyze the longer-term effects of the dialogue exercise, as well as the effects of discontinuing the activity, especially in terms of the expectations of employees. Horizon Health Network has recently developed a training session on AO for managers, based on information gathered during dialogue sessions and other activities. It would also be interesting to study this initiative in order to identify its effects in the future. We believe that active offer will become an essential part of organizational culture when a series of measures or, even better, a global strategy to integrate it, is put into place throughout the entire organization.