Care-seeking experiences of unattached patients in the Canadian health care system: Qualitative study.

OBJECTIVE: To understand how lack of attachment to a regular primary care provider influences patients' outlooks on primary care, ability to address their health care needs, and confidence in the health care system. DESIGN: Qualitative descriptive study using semistructured interviews. SETTING: Canadian provinces of Nova Scotia, Ontario, and Quebec. PARTICIPANTS: Patients aged 18 years or older who were unattached or had become attached within 1 year of being interviewed and who resided in the province in which they were interviewed. METHODS: Forty-one semistructured interviews were conducted, during which participants were asked to describe how they had become unattached, their searches to find new primary care providers, their perceptions of and experiences with the centralized waiting list in their province, their experiences seeking care while unattached, and the impact of being unattached on their health and on their perceptions of the health care system. Interviews were transcribed and analyzed using a thematic approach. MAIN FINDINGS: Two main themes were identified in interviews with unattached or recently attached patients: unmet needs of unattached patients and the impact of being unattached. Patients' perceived benefits of attachment included access to care, longitudinal relationships with health care providers, health history familiarity, and follow-up monitoring and care coordination. Being unattached was associated with negative effects on mental health, poor health outcomes, decreased confidence in the health care system, and greater pre-existing health inequities. CONCLUSION: Having a regular primary care provider is essential to having access to high-quality care and other health care services. Attachment also promotes health equity and confidence in the public health care system and has broader system-level, social, and policy implications.

"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic.

BACKGROUND: Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities. METHODS: We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed. RESULTS: We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response. CONCLUSIONS: For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond.

INTRODUCTION: Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice. METHODS: We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach. RESULTS: We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward. CONCLUSIONS: The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study.

INTRODUCTION: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care. METHODS AND ANALYSIS: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events. ETHICS AND DISSEMINATION: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Practice- and System-Based Interventions to Reduce COVID-19 Transmission in Primary Care Settings: A Qualitative Study.

Using qualitative interviews with 68 family physicians (FPs) in Canada, we describe practice- and system-based approaches that were used to mitigate COVID-19 exposure in primary care settings across Canada to ensure the continuation of primary care delivery. Participants described how they applied infection prevention and control procedures (risk assessment, hand hygiene, control of environment, administrative control, personal protective equipment) and relied on centralized services that directed patients with COVID-19 to settings outside of primary care, such as testing centres. The multi-layered approach mitigated the risk of COVID-19 exposure while also conserving resources, preserving capacity and supporting supply chains.

"A Band-Aid Solution": Policy Maker and Primary Care Provider Perspectives on the Value of Attachment Incentives.

Approximately 15% of Canadians are without a primary care provider ("unattached"). To address "unattachment," several provinces introduced a financial incentive for family physicians who attach new patients. A descriptive qualitative approach was used to explore perspectives of patient access and attachment to primary care. Semi-structured qualitative interviews were conducted with family physicians, nurse practitioners and policy makers in Nova Scotia. Thematic analysis was performed to identify participant perspectives on the value and efficacy of financial incentives to promote patient attachment. Three themes were identified: (1) positive impacts of the incentive, (2) shortcomings of the incentive and (3) alternative strategies to strengthen primary healthcare. Participants felt that attachment incentives may offer short-term solutions to patient unattachment; however, financial incentives cannot overcome systemic challenges. Participants recommended alternative policy levers to strengthen primary healthcare, including addressing the shortage of primary care providers and developing remuneration and practice models that support sustainable patient attachment.

Emergency department utilization and hospital admissions for ambulatory care sensitive conditions among people seeking a primary care provider during the COVID-19 pandemic.

BACKGROUND: Primary care attachment improves health care access and health outcomes, but many Canadians are unattached, seeking a provider via provincial wait-lists. This Nova Scotia-wide cohort study compares emergency department utilization and hospital admission associated with insufficient primary care management among patients on and off a provincial primary care wait-list, before and during the first waves of the COVID-19 pandemic. METHODS: We linked wait-list and Nova Scotian administrative health data to describe people on and off wait-list, by quarter, between Jan. 1, 2017, and Dec. 24, 2020. We quantified emergency department utilization and ambulatory care sensitive condition (ACSC) hospital admission rates by wait-list status from physician claims and hospital admission data. We compared relative differences during the COVID-19 first and second waves with the previous year. RESULTS: During the study period, 100 867 people in Nova Scotia (10.1% of the provincial population) were on the wait-list. Those on the wait-list had higher emergency department utilization and ACSC hospital admission. Emergency department utilization was higher overall for individuals aged 65 years and older, and females; lowest during the first 2 COVID-19 waves; and differed more by wait-list status for those younger than 65 years. Emergency department contacts and ACSC hospital admissions decreased during the COVID-19 pandemic relative to the previous year, and for emergency department utilization, this difference was more pronounced for those on the wait-list. INTERPRETATION: People in Nova Scotia seeking primary care attachment via the provincial wait-list use hospital-based services more frequently than those not on the wait-list. Although both groups have had lower utilization during COVID-19, existing challenges to primary care access for those actively seeking a provider were further exacerbated during the initial waves of the pandemic. The degree to which forgone services produces downstream health burden remains in question.

"There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic.

BACKGROUND: Prior to the pandemic, Canada lagged behind other Organisation for Economic Cooperation and Development countries in the uptake of virtual care. The onset of COVID-19, however, resulted in a near-universal shift to virtual primary care to minimise exposure risks. As jurisdictions enter a pandemic recovery phase, the balance between virtual and in-person visits is reverting, though it is unlikely to return to pre-pandemic levels. Our objective was to explore Canadian family physicians' perspectives on the rapid move to virtual care during the COVID-19 pandemic, to inform both future pandemic planning for primary care and the optimal integration of virtual care into the broader primary care context beyond the pandemic. METHODS: We conducted semi-structured interviews with 68 family physicians from four regions in Canada between October 2020 and June 2021. We used a purposeful, maximum variation sampling approach, continuing recruitment in each region until we reached saturation. Interviews with family physicians explored their roles and experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support their patients through the pandemic. Interviews were audio-recorded, transcribed, and thematically analysed for recurrent themes. RESULTS: We identified three prominent themes throughout participants' reflections on implementing virtual care: implementation and evolution of virtual modalities during the pandemic; facilitators and barriers to implementing virtual care; and virtual care in the future. While some family physicians had prior experience conducting remote assessments, most had to implement and adapt to virtual care abruptly as provinces limited in-person visits to essential and urgent care. As the pandemic progressed, initial forays into video-based consultations were frequently replaced by phone-based visits, while physicians also rebalanced the ratio of virtual to in-person visits. Medical record systems with integrated capacity for virtual visits, billing codes, supportive clinic teams, and longitudinal relationships with patients were facilitators in this rapid transition for family physicians, while the absence of these factors often posed barriers. CONCLUSION: Despite varied experiences and preferences related to virtual primary care, physicians felt that virtual visits should continue to be available beyond the pandemic but require clearer regulation and guidelines for its appropriate future use.

Strengthening the integration of primary care in pandemic response plans: a qualitative interview study of Canadian family physicians.

BACKGROUND: As the first point of contact in health care, primary care providers play an integral role in pandemic response. Despite this, primary care has been overlooked in previous pandemic plans, with a lack of emphasis on ways in which the unique characteristics of family practice could be leveraged to create a more effective response. AIM: To explore family physicians' perceptions of the integration of primary care in the COVID-19 pandemic response. DESIGN AND SETTING: Descriptive qualitative approach examining family physician roles during the COVID-19 pandemic across four regions in Canada. METHOD: Semi-structured qualitative interviews were conducted with family physicians and participants were asked about their roles during each pandemic stage, as well as facilitators and barriers they experienced in performing these roles. Interviews were transcribed and a thematic analysis approach was employed to develop a unified coding template across the four regions and identify recurring themes. RESULTS: In total, 68 family physicians completed interviews. Four priorities for integrating primary care in future pandemic planning were identified: 1) improve communication with family physicians; 2) prioritise community-based primary care; 3) leverage the longitudinal relationship between patients and family physicians; and 4) preserve primary care workforce capacity. Across all regions, family physicians felt that primary care was not well incorporated into the COVID-19 pandemic response. CONCLUSION: Future pandemic plans require greater integration of primary care to ensure the delivery of an effective and coordinated pandemic response. Strengthening pandemic preparedness requires a broader reconsideration and better understanding of the central role of primary care in health system functioning.

Family physicians' responses to personal protective equipment shortages in four regions in Canada: a qualitative study.

BACKGROUND: Despite well-documented increased demands and shortages of personal protective equipment (PPE) during previous disease outbreaks, health systems in Canada were poorly prepared to meet the need for PPE during the COVID-19 pandemic. In the primary care sector, PPE shortages impacted the delivery of health services and contributed to increased workload, fear, and anxiety among primary care providers. This study examines family physicians' (FPs) response to PPE shortages during the first year of the COVID-19 pandemic to inform future pandemic planning. METHODS: As part of a multiple case study, we conducted semi-structured qualitative interviews with FPs across four regions in Canada. During the interviews, FPs were asked to describe the pandemic-related roles they performed over different stages of the pandemic, facilitators and barriers they experienced in performing these roles, and potential roles they could have filled. Interviews were transcribed and a thematic analysis approach was employed to identify recurring themes. For the current study, we examined themes related to PPE. RESULTS: A total of 68 FPs were interviewed across the four regions. Four overarching themes were identified: 1) factors associated with good PPE access, 2) managing PPE shortages, 3) impact of PPE shortages on practice and providers, and 4) symbolism of PPE in primary care. There was a wide discrepancy in access to PPE both within and across regions, and integration with hospital or regional health authorities often resulted in better access than community-based practices. When PPE was limited, FPs described rationing and reusing these resources in an effort to conserve, which often resulted in anxiety and personal safety concerns. Many FPs expressed that PPE shortages had come to symbolize neglect and a lack of concern for the primary care sector in the pandemic response. CONCLUSIONS: During the COVID-19 pandemic response, hospital-centric plans and a lack of prioritization for primary care led to shortages of PPE for family physicians. This study highlights the need to consider primary care in PPE conservation and allocation strategies and to examine the influence of the underlying organization of primary care on PPE distribution during the pandemic.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

Community pharmacists' expanding roles in supporting patients before and during COVID-19: An exploratory qualitative study.

BACKGROUND: Timely access and attachment to a primary healthcare provider is associated with better population health outcomes. In Canada, community pharmacists are highly accessible and patients struggling to access a family physician or nurse practitioner (i.e., "unattached") may seek care from a community pharmacist. Community pharmacists took on additional roles during the COVID-19 pandemic; however, little is known about how community pharmacists managed the needs of attached and unattached patients before and during the COVID-19 pandemic. AIM: To describe Nova Scotian community pharmacists' roles in caring for unattached patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access. METHOD: Semi-structured interviews with community pharmacists (n = 11) across the province of Nova Scotia (Canada) were conducted. RESULTS: Five key themes were noted: (1) rising pressure on pharmacists to meet unique health needs of attached and unattached patients; (2) what pharmacists have to offer (e.g., accessibility, trustworthiness); (3) positioning pharmacists in the system (e.g., how pharmacists can address gaps in primary healthcare); (4) pharmacist wellbeing; and, (5) recommendations for practice post-pandemic (e.g., maintain some policy changes made during the COVID-19 pandemic). CONCLUSION: Before and during the pandemic, community pharmacists played a significant and increasing role providing care to patients, especially unattached patients. With growing numbers of unattached patients, it is vital that community pharmacists are supported to provide services to care for the health needs of patients.

Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry.

BACKGROUND: Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care. METHODS: In this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (n = 18 family practice residents; n = 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province. RESULTS: Participants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as "everything but obstetrics"). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants' decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences. CONCLUSIONS: Individual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs' choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels.

"It was horrible for that community, but not for the way we had imagined": A qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19.

The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs serving communities experiencing marginalisation during COVID-19, and the impact the pandemic and pandemic response have had on physicians' ability to provide care. We conducted semi-structured qualitative interviews with FPs from four Canadian regions, October 2020 through June 2021. We employed maximum variation sampling and continued recruitment until we reached saturation. Interviews explored participants' roles/experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support communities experiencing marginalisation throughout. We used a thematic approach to analyse the data. FPs working with communities experiencing marginalisation expressed the need to continue providing in-person care throughout the pandemic, often requiring them to devise innovative adaptations to their clinical settings and practice. Physicians noted the health implications for their patients, particularly where services were limited or deferred, and that pandemic response policies frequently ignored the unique needs of their patient populations. Pandemic-related precautionary measures that sought to minimise viral transmission and prevent overwhelming acute care settings may have undermined pre-existing services and superseded the ongoing harms that are disproportionately experienced by communities experiencing marginalisation. FPs are well placed to support the development of pandemic response plans that appreciate competing risks amongst their communities and must be included in pandemic planning in the future.

Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study.

INTRODUCTION: Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary care, FPs face added barriers to prioritizing and sustaining preventative care when health systems are strained, which was evident during the COVID-19 pandemic. This study aims to describe FPs' experiences providing preventative care during the COVID-19 pandemic and their perceptions of the impacts of disrupted preventative care in primary care settings. METHODS: Using a qualitative descriptive approach, we conducted semistructured interviews with FPs across 4 provinces in Canada (i.e. Newfoundland and Labrador, Nova Scotia, Ontario, British Columbia) between October 2020 and June 2021 as part of a larger multiple case study. These interviews broadly explored the roles and responsibilities of FPs during the COVID-19 pandemic. Interviews were coded thematically and codes from the larger study were analysed further using an iterative, phased process of thematic analysis. RESULTS: Interviews averaged 58 min in length (range 17-97 min) and FPs had a mean of 16.9 years of experience. We identified 4 major themes from interviews with FPs (n = 68): (i) lack of capacity and coordination across health systems, (ii) patient fear, (iii) impacts on patient care, and (iv) negative impacts on FPs. Physicians voiced concerns with managing patients' prevention needs when testing availability and coordination of services was limited. Early in the pandemic, patients were also missing or postponing their own primary care appointments. Change in the provision and coordination of routine preventative care had negative impacts on both patients and physicians, affecting disease incidence/progression, physician workload, and psychological wellbeing. CONCLUSION: During the COVID-19 pandemic, upstream care efforts were impacted, and FPs were forced to reduce their provision of preventative care. FPs contribute direct insight to primary care delivery that can support pandemic planning to ensure preventative care is sustained during future emergencies.

Family physician leadership during the COVID-19 pandemic: roles, functions and key supports.

PURPOSE: Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify supports and barriers to formalizing these roles in future pandemic plans. DESIGN/METHODOLOGY/APPROACH: This study conducted semi-structured qualitative interviews with family physicians across four regions in Canada as part of a multiple case study. During the interviews, participants were asked about their roles during each pandemic stage and the facilitators and barriers they experienced. Interviews were transcribed and a thematic analysis approach was used to identify recurring themes. FINDINGS: Sixty-eight family physicians completed interviews. Three key functions of family physician leadership during the pandemic were identified: conveying knowledge, developing and adapting protocols for primary care practices and advocacy. Each function involved curating and synthesizing information, tailoring communications based on individual needs and building upon established relationships. PRACTICAL IMPLICATIONS: Findings demonstrate the need for future pandemic plans to incorporate formal family physician leadership appointments, as well as supports such as training, communication aides and compensation to allow family physicians to enact these key roles. ORIGINALITY/VALUE: The COVID-19 pandemic presents a unique opportunity to examine the leadership roles of family physicians, which have been largely overlooked in past pandemic plans. This study's findings highlight the importance of these roles toward delivering an effective and coordinated pandemic response with uninterrupted and safe access to primary care.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Family Practice Nursing in Newfoundland and Labrador: Are Reported Roles Reflective of Professional Competencies for Registered Nurses in Primary Care?

BACKGROUND: Family practice nurses are Registered Nurses who work collaboratively in primary care and deliver a range of services. Professional competency statements have been developed to describe the skills and knowledge of family practice nurses as a distinct field. PURPOSE: We conducted a secondary analysis of qualitative interview data to examine how family practice nurse roles/activities relate to recently developed professional competencies. METHODS: Family physicians and family practice nurses in Newfoundland and Labrador (NL) participated in semi-structured interviews, during which they discussed roles/activities and scope of practice surrounding family practice nursing. For this secondary analysis, we used competency statements to inform thematic coding of the transcribed interviews. RESULTS: For the initial study, a total of 8 participants (5 family practice nurses; 3 family physicians) were interviewed from diverse practices. All transcripts from the original study (n = 8) were included in the secondary analysis and analysed across 47 competencies encompassing 6 domains (Professionalism; Clinical Practice; Communication; Collaboration and Partnership; Quality Assurance, Evaluation and Research; Leadership). Roles/activities reported by participants were reflective of the competencies, but with substantial variation in expression. CONCLUSIONS: Family practice nursing competency statements reflect the actual activities of family practice nurses in NL. The professional competencies can serve as a framework to examine contributions of family practice nurses and identify areas warranting further training. The use of competencies to explore family practice nurses' roles and activities can assist with optimizing scope of practice.

Development of a primary care pandemic plan informed by in-depth policy analysis and interviews with family physicians across Canada during COVID-19: a qualitative case study protocol.

INTRODUCTION: Given the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians' roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. METHODS AND ANALYSIS: We will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians' proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses. ETHICS AND DISSEMINATION: Approval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.

A qualitative study exploring the influence of clinic funding on the integration of family practice nurses in Newfoundland and Labrador.

AIM: This study explores the contributions of family practice nurses in primary care across Newfoundland and Labrador funded by fee-for-service and alternate payment plans to examine the influence of funding arrangements on nursing roles/activities. DESIGN: A qualitative descriptive design was employed. METHODS: Semi-structured telephone interviews were conducted between March-July 2018 with physicians and Registered Nurses working in primary care settings in Newfoundland and Labrador. Interviews were transcribed verbatim, and a content analysis approach was used to identify recurring themes. RESULTS: Clinic funding was instrumental in the integration of family practice nurses into primary care settings and influenced roles/activities. In fee-for-service practices, nurses work with physicians and focus on one-on-one patient care in office-based settings, whereas nurses in alternate payment plans practices work more independently, in a wider range of settings and with emphasis on both individual and group-based encounters. Compared with alternate payment plans practices, fee-for-service practices tend to be more restrictive due to physician billing requirements.