Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach.

Background: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective: To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. Methods: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. Results: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.

Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions.

Background: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. Results: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries.

CONTEXT: A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. 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. SETTING: Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec). 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). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

Introducing a nurse practitioner: experiences in a rural Alberta family practice clinic.

OBJECTIVE: To report on the experiences of introducing a nurse practitioner (NP) into a rural physicians' clinic in Taber, Alberta. DESIGN: Case study, grounded theory qualitative approach. SETTING: A rural community-based family practice in Taber, Alberta. PARTICIPANTS: Twenty relevant stakeholders, including physicians, office staff, Regional Health Authority health professionals and community members. METHOD: Open-ended interviews supplemented with a patient survey, billing and work time records. MAIN FINDINGS: Successful introduction of the NP in the Taber clinic relied on: 1) flexibility in the first stages of developing the role; 2) strong connections to key individuals outside the clinic to maintain integration with the community; 3) support and guidance provided by a mentor group who assisted in developing positive working relationships; and 4) cost sharing (matched with benefits) by the clinic and provincial health system for sustainability of the position. CONCLUSIONS: The NP role in Taber was viewed positively by clinic physicians and other stakeholders because of high patient satisfaction with the NP, billing potential that surpassed salary costs, and increased integration of physician services with RHA initiatives.

Case study on priority setting in rural Southern Alberta: keeping the house from blowing in.

OBJECTIVE: This case study describes the priority-setting process undertaken by health care providers in the Municipal District of Taber, Alta., to improve and integrate chronic disease services within a fixed budget. METHODS: Providers first reviewed the current chronic disease management system, then considered alternatives based on program priorities and costs and benefits of potential changes. RESULTS: Despite reaching consensus that a chronic disease clinic was the top priority for funding, providers were unable to redesign services accordingly. Redesign efforts were hampered by the groups' difficulty in identifying services that should receive fewer resources in order to fund priority areas, inexperience with priority-setting frameworks, group composition, the belief that many programs were already at "bare bone" funding levels, and perceptions of limited budget control. In the end, recommendations were made to use attrition to release resources, establish multi-disciplinary teams and group visits, where appropriate, and relocate providers to a centralized location. Upon review of study outcomes, Taber providers were granted more decision-making authority. CONCLUSION: Overall, the use of a systematic priority-setting process, culminating in recommendations for action, has moved Taber providers closer to an integrated model of service delivery. It is recommended that formal priority-setting frameworks continue to be used in Taber for primary care renewal or at any level where consideration of existing evidence and projected costs is required.