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Health Care Practitioners: An Ontario Case Study in Policy Making: Patricia O' Reilly: Books - dilerssowind.tk
Table of contents

Published 29 January Volume Pages 35— Review by Single-blind. Peer reviewers approved by Dr Devang Sanghavi. Editor who approved publication: Dr Scott Fraser. However, the impact of these changes on practitioners has not been well understood. Objective: To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.

Design: Collaborative synthesis of 12 mixed methods studies. Methods: We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context. Results: There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions.

These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups. Conclusion: The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level.

The same characteristic could have both positive and negative influence on different aspects eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice.

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Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level. Keywords: interprofessional care, primary health care, teamwork, research synthesis. Enhancing interprofessional team care has been a key element of primary health care PHC reform in many countries. More comprehensive care can be provided by health professionals from multiple disciplines working together as a team. Interprofessional team-based care has been demonstrated to improve quality of care and outcomes in patients with chronic disease in primary care.

International surveys conducted by the Commonwealth Fund and other bodies have demonstrated considerable intercountry variability in the implementation of interprofessional team care in PHC. Our approach 13 draws upon the principles of participatory action research 14 and narrative, meta-narrative, and realist synthesis 15 — 17 using an open system approach.


  1. X-Ray Microscopy and Spectromicroscopy: Status Report from the Fifth International Conference, Würzburg, August 19–23, 1996.
  2. Institute for Research on Public Policy.
  3. Introduction.
  4. Publications.

In our approach, established investigators were brought together as active observers and participants in a deliberative iterative process of sharing, reflection, and synthesis. Deliberative process allows a group of participants to receive and exchange information, to critically examine an issue, and to come to consensus agreement.

Specifically, an analytic-deliberative approach was used that combines technical and content expertise with the values and experiences and investigators. A distinctive feature of our approach is that a group of researchers from different contexts reflect together over a prolonged time frame to actively reinterpret findings from their own published research as well as raw data. The shared understandings that emerge draw on principles of realist evaluation to focus attention on ways in which contexts and mechanisms could be identified as impacting on study outcomes.

Funding supported virtual and face-to-face engagement between 12 investigators.

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All the investigators were major contributors to primary care practice-based qualitative and quantitative studies from three countries Australia, the USA, and Canada, including three Canadian provinces: Alberta, Ontario, and Quebec. The team comprised five academic family physicians, three sociologists, a medical anthropologist, a public health physician, and an epidemiologist. Three of the team had direct policy-making responsibilities.

A total of 12 studies provided cross-jurisdictional comparisons of interventions on primary practices, practitioners, and patients. These interventions were either generated by changes in primary care policy or through controlled interventions. We drew upon published accounts and secondary reflection and analysis of primary data from each study to generate a cross-context synthesis of peer-reviewed manuscripts and additional unpublished data from 12 mixed methods studies Table 1.

This iterative process of reviewing and synthesizing was accomplished using a combination of monthly teleconferences and four face-to-face retreats conducted between and With this focus, the participants went back to the published studies and reanalyzed the data, some of which was not necessarily published previously, to gain insights into the new research question. We used matrices to thematically arrange data on the implementation of teamwork innovations from each of the different studies. We extracted data to inform the findings matrix through an iterative, emergent process.

First, the lead investigator developed preliminary themes by grouping broad findings from a comprehensive, Ontario-based evaluation of multidisciplinary practices. We considered the variation in these responses according to the intensity of teamwork involved, the existing organizational culture, decision-making processes, and the size and structure of the service. There was variation between studies among the different jurisdictions. Thus, in our findings, we make reference to these jurisdictions eg, Australia, USA, Alberta , although it is not necessarily the case that all the findings observed in the studies can be generalized across the whole jurisdiction as they may not, eg, have covered all types of geographic areas.


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  • There were major interventions and reforms implemented in all jurisdictions over the decade, which directly and indirectly aimed to enhance interprofessional teamwork Table 2. As a result, there was evidence of changes in interprofessional processes of care both within PHC services and with health professionals outside of them. Improvements in interprofessional care processes included the following:.

    The impacts on communication, relationships, roles, and work satisfaction were all variable within jurisdictions Table 3. Improved communication among members of the primary care practice was a universally intended objective of interprofessional team policies or interventions.

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    However, there was considerable variation in the form and quality of communication resulting from specific interventions and policies. Some practices did not hold regular team meetings involving different practitioners and those who did sometimes encountered difficulties due to power dynamics within practices USA, Alberta, Ontario, and Quebec.

    In Ontario, one family health team FHT never held meetings between administrative and clinical staff working in the organization, and all decisions were made by a group of FHT owners. By contrast, in other FHTs, staff met regularly, actively organized mentoring, and actively reflected on processes of collaboration.

    Ottawa Hospital Research Institute

    The successful implementation of intrapractice teamwork implies bridging of the traditional communication gap between reception front office and clinicians back office to office workflow and patient flow. Much communication was informal — associated with the transfer charting, details of next appointment, etc or seeking of information the best specialist to refer to, getting sign-offs on prescription renewals, new scripts, etc. In all jurisdictions, there were some improvements in interorganizational relationships and partnerships.

    The traditional loose federation of autonomous physicians was simply not consistent with the sharing and ongoing learning required for continually improving patient-centered care USA. However, the links between primary care organizations and other community-based organizations remained weak Ontario except in Quebec where PHC reform was embedded in a broader reform of locally organized hospital- and community-based care networks.

    At an interprofessional level within practices, there were generally improved relationships.

    Physically isolated providers found it hard to integrate with their colleagues and were less able to give others an idea of their skills and potential contributions Ontario. At the beginning [the] GP did not entirely trust allied health professionals [dieticians] to treat the patient as he wanted them treated, so he was doing all the work himself. Now he is [referring to] dieticians and can see the value of their participation … [Nurse facilitator, Australia] There was adaptation to extended roles for nonphysician staff within practices across jurisdictions.

    In some practices, clear roles emerged and strong support for different professionals was evident. Teamwork makes general practice sustainable.

    Introduction

    It also means everyone in the team is valued for what they do and this engenders happiness amongst the staff. However, a clear division of roles was not always achieved with some confusion about roles, which created tension in some practices Ontario, Alberta, and Quebec. Conflict emerged as some providers felt their power was challenged USA. This led to dissatisfaction with communication, and the processes for sharing care and changes were met with resistance, disengagement, or conflict Australia, USA, Ontario, and Quebec.

    This is great, but what do we do with you? Sometimes the lead physicians, managers, or CEOs did not necessarily know the skills, knowledge, or experience possessed by other members of their team Australia and Ontario. Nurses seeking an expanded role were particularly frustrated with these hurdles:. Change created uncertainty about what their responsibilities were and how best to respond to a new set of circumstances Australia, Alberta, and Ontario. This situation was applied not only to clinical staff but also to administrative staff who were sometimes uncertain about what procedures they should follow especially in engaging other staff in management.

    Some identified roles that they had not previously perceived that they had. For example, reception and nursing staff played roles in triage, support, advocacy, and listening. In all jurisdictions, redefinition of roles challenged the way health care providers especially doctors thought about their professional identity and autonomy.

    Adopting team care challenged some physicians who had deeply held beliefs that the role of the family physician was grounded in a strong, trusting relationship between the patient and physician. Permitting other practice staff to have meaningful patient interactions for team care meant expanding that special relationship and required an identity shift.

    Publications

    Physicians who had deeply held beliefs about the centrality of the doctor—patient relationship found permitting other practice staff into that relationship particularly difficult as it required a shift in their identity USA. There was evidence that although many clinicians were ready to change prompted at least in part by a degree of work dissatisfaction , this needed to be adapted to the individual practice context and culture Australia, USA, Alberta, and Ontario. In some practices, the changes were viewed as increasing the burden on the organization eg, with increased paper work and stretching capacity eg, by increasing the workload of some health professionals or, conversely, not drawing sufficiently upon staff to work to the full scope of their practice Australia, USA, Alberta, Ontario, and Quebec.

    Practice leadership was often seen as important in facilitating readiness to change Ontario and USA. Our findings on leadership are described later. In all jurisdictions, there were improvements to work satisfaction where teamwork was purposefully implemented.

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    Doing stuff in the context of a team is so much better than trying to do it all myself. All I can say is, everything is more doable and more enjoyable with a team. These improvements made attracting new staff easier and could be part of a virtuous cycle where the climate of teamwork was in turn attractive to staff who were committed to working in an interprofessional environment Quebec.

    There was a complex association between changed teamwork and work satisfaction. Those staff members who were somewhat more dissatisfied with their current work situation were more ready to change their team roles, and they were more likely to actively participate in the change Australia and Ontario.