Formalisation and subordination: a contingency theory approach to optimising primary care teams

Equity, power and resources in primary health care reform: insights from Aotearoa New Zealand

BACKGROUND

New Zealand's District Health Board reform (2000-2022) was underpinned by the goal of reducing inequities in health outcomes between population groups and improving health overall. A key policy vehicle for achieving the goal was a system-wide shift to population health with increased strategic focus on and investment in primary health care.

METHODS

This research explored shifts in power and resource to understand how equity as a policy goal for primary health care fared over the District Health Board era, and examined how the distribution of power and resources in the health sector changed for PHC over the period 2000-2020. The study used an exploratory case study methodology based on insights from key informant interviews.

RESULTS

The study found that despite policy intent, actors holding political power shaped health outcomes under the reforms, curtailing the mechanisms that could have made a significant impact on equitable health outcomes between population groups.

CONCLUSION

It concludes that exploring power and resource shifts sheds light on power dynamics within a reform. Since power shapes how resources are deployed, attention to power and resource complements technical elements of health system reform, by helping to understand where and how to intervene so that reforms achieve their desired goals.

Scaling up integrated care: Can community hospitals be an answer? A multiple-case study from the Emilia-Romagna region in Italy

Integrated care is considered to be essential in improving care for people with chronic conditions who need continuous care. In 2022, the Italian Government asked all regions to build or renovate a massive number of community care facilities, employing European Next Generation funds, to be spent by 2026. Under the theoretical lens of the Structural Contingency Theory, the paper aims at aims at describing the contextual and organizational factors underlying the interconnection between integrated care and community hospitals. The study employs a multiple-case study design, relying both on quantitative and qualitative data, conducted in a 6 months-period. It investigated seven community hospitals belonging to a single Local Health Authority in Emilia-Romagna region in Italy. The choice of the empirical context was driven by Emilia-Romagna's long- and well-established tradition of community-based care. Overall, our analysis shows that community hospitals offers opportunities of integrated care, including better integration between care sectors, between primary care and specialist staff, between healthcare structures and their local community. The study confirms the value of the Structural Contingency Theory and its key message: implementation is not a mechanical step of the policy cycle and requires important adjustments to the planning phase according to environment and organizational factors.

Exploring Norwegian homecare healthcare professionals' perceptions of risk and the link to high-quality care: a qualitative multiple case study

OBJECTIVES

Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience.

DESIGN

The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted.

SETTING

The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case.

PARTICIPANTS

Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups.

RESULTS

Four themes were identified: 'professionalism is constantly prioritising and aligning care based on here-and-now observations' 'teamwork feels safe and enhances quality' 'taking responsibility for system risk' and 'reluctantly accepting the extended expectations from society'.

CONCLUSIONS

To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients' condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Primary care micro-teams: an international systematic review of patient and healthcare professional perspectives

BACKGROUND

International trends have shifted to creating large general practices. There is an assumption that interdisciplinary teams will increase patient accessibility and provide more cost-effective, efficient services. Micro-teams have been proposed to mitigate for some potential challenges of practice expansion, including continuity of care.

AIM

To review available literature and examine how micro-teams are described, and identify opportunities and limitations for patients and practice staff.

DESIGN AND SETTING

This was an international systematic review of studies published in English.

METHOD

Databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus) and grey literature were searched. Studies were included if they provided evidence about implementation of primary care micro-teams. Framework analysis was used to synthesise identified literature. The research team included a public contributor co-applicant. The authors conducted stakeholder discussions with those with and without experience of micro-team implementation.

RESULTS

Of the 462 studies identified, 24 documents met the inclusion criteria. Most included empirical data from healthcare professionals, describing micro-team implementation. Results included characteristics of the literature; micro-team description; range of ways micro-teams have been implemented; reported outcomes; and experiences of patients and staff.

CONCLUSION

The organisation of primary care has potential impact on the nature and quality of patient care, safety, and outcomes. This review contributes to current debate about care delivery and how this can impact on the experiences and outcomes of patients and staff. This analysis identifies several key opportunities and challenges for future research, policy, and practice.

How to measure the collective intelligence of primary healthcare teams?

INTRODUCTION

The capacity for teams and organizations to evolve and to thrive in ever-shifting environments is attributed to their collective intelligence. Collectively, intelligent team could prevent repetition of past mistakes and can help organizations and people work more efficiently. Researchers aimed to find a framework or a tool that could help explain collective intelligence in primary healthcare organizations.

METHODS

The framework was developed iteratively following a three-step process based on the Pragmatic utility concept analysis, each step fetching data from both literature and the team's expertise: (i) finding an existing framework, (ii) developing an initial framework, (iii) testing and refining the framework.

RESULTS

A broad literature search led researchers to focus more specifically on two interrelated frameworks, both concepts were created within the educational field. We first adapted these concepts to healthcare teams, then to the increasing interdisciplinarity of primary healthcare teams. We also subdivided the framework into clinical or organizational domain. Finally, we performed a secondary analysis from existing data of a larger project that aimed to evaluate seven primary care teams in Quebec.

CONCLUSIONS

This first attempt to conceptualize collective intelligence in a way that is specific to primary healthcare teams helps identify strengths and areas in which teams could potentially improve. From a theoretical perspective, the framework facilitates understanding of the concept of collective intelligence in primary healthcare teams. Our current results show a strong potential for this tool, but other tests and systematic validations are to be expected in order to better link collective intelligence and team performance.

New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning

BACKGROUND

Optimising health professionals' contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada).

METHODS

We used Giddens' structuration theory to guide our study given its' facilitation of the understanding of the dynamic between structural constraints and actors' actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016-2017.

RESULTS

Forty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others' inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs' sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity).

CONCLUSION

Several new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.