Partnering for change.

PURPOSE: Despite many calls to strengthen connections between health systems and communities as a way to improve primary healthcare, little is known about how new collaborations can effectively alter service provision. The purpose of this paper is to explore how a health authority, municipal leaders and physicians worked together in the process of transforming primary healthcare. DESIGN/METHODOLOGY/APPROACH: A longitudinal qualitative case study was conducted to explore the processes of change at the regional level and within seven communities across Northern British Columbia (BC), Canada. Over three years, 239 interviews were conducted with physicians, municipal leaders, health authority clinicians and leaders and other health and social service providers. Interviews and contextual documents were analyzed and interpreted to articulate how ongoing transformation has occurred. FINDINGS: Four overall strategies with nine approaches were apparent. The strategies were partnering for innovation, keeping the focus on people in communities, taking advantage of opportunities for change and encouraging experimentation while managing risk. The strategies have bumped the existing system out of the status quo and are achieving transformation. Key components have been a commitment to a clear end-in-view, a focus on patients, families, and communities, and acting together over time. ORIGINALITY/VALUE: This study illuminates how partnering for primary healthcare transformation is messy and complicated but can create a foundation for whole system change.

The early retiree divests the health workforce: a quantitative analysis of early retirement among Canadian Registered Nurses and allied health professionals.

BACKGROUND: Early retirement (before age 65) is the norm among registered nurses (RNs) and allied health professionals (AHPs) employed in Canada's public system. As a country whose population is rapidly aging, it is in Canada's best interest to try and extend the work lives of RNs and AHPs. OBJECTIVES: (1) To test the predictive validity of our conceptual model of early retirement among publicly employed, Canadian RNs and AHPs and (2) to compare, across professions, model fit and factor significance METHODS: We conducted multivariable logistic regression in two data sets, one consisting of 483 retired RNs and the other of 177 retired AHPs. The number of AHP respondents limited our ability to comprehensively test the model. RESULTS: Eighty-five percent of RNs and 77% of AHPs had retired early. (1) Results indicate that 25% of variance in RN early retirement and 19% of variance in AHP early retirement was explained by included variables. (2) Organizational restructuring increased odds of early retirement by more than 100% among RNs and AHPs. Among RNs (but not AHPs), both financial possibility and caregiving responsibilities predicted early retirement at statistically significant levels, while a "desire to stop working" predicted retirement at or after 65 years of age. CONCLUSIONS: Clearly, there is much more to learn about RN and AHP pathways to early retirement. Further research, ideally research exploring the role of workplace characteristics, attitudes, and beliefs towards retirement and work-related factors, could deepen our understanding of the phenomenon of RN/AHP early retirement.

Engaging primary care physicians in system change - an interpretive qualitative study in a remote and rural health region in Northern British Columbia, Canada.

OBJECTIVES: To describe how physicians were engaged in primary healthcare system change in a remote and rural Canadian health authority. DESIGN: A qualitative interpretive study based on a hermeneutic approach. METHODS: 34 transcribed in-depth interviews with physicians and administrators relevant to physician engagement were purposively sampled from a larger data set of 239 interviews gathered over a 3-year period from seven communities engaged in primary healthcare transformation. Interviews were coded and analysed interpretively to develop common themes. SETTING: This research is part of a larger study, Partnering for Change I, which investigated the efforts of Northern Health, a rural regional health authority in British Columbia, to transform its healthcare system to one grounded in primary care with a focus on interdisciplinary teams. It reports how physician engagement was accomplished during the first 3 years of the study. PARTICIPANTS: Interviews with 34 individuals with direct involvement and experience in the processes of physician engagement. These included 10 physicians, three Regional Executives, 18 Primary Healthcare coordinators and three Division of Family Practice leads. RESULTS: Three major interconnected themes that depicted the process of engagement were identified: working through tensions constructively, drawing on structures for engagement and facilitating relationships. CONCLUSIONS: Physician engagement was recognised as a priority by Northern Health in its efforts to create system change. This was facilitated by the creation of Divisions of Family Practice that provided a structure for dialogue and facilitated a common voice for physicians. Divisions helped to build trust between various groups through allowing constructive conversations to surface and deal with tensions. Local context mattered. Flexibility in working from local priorities was a critical part of developing relationships that facilitated the design and implementation of system reform.

Retirement Decision-Making among Registered Nurses and Allied Health Professionals: A Descriptive Analysis of Canadian Longitudinal Study on Aging Data.

A population's health is dependent on the availability of skilled health professionals. We know little about retirement decision-making among publicly employed Canadian registered nurses (RNs) and allied health professionals (AHPs). We identified and compared factors reported to influence early versus 65+ retirement decisions among RNs (n = 794) and AHPs (n = 393). RNs, on average, retired at 58.1 years and AHPs at 59.4 years. More than two thirds retired before age 65. Among RNs, caregiving demands predict early retirement - policies supporting employed RN caregivers may reduce early workforce exits among publicly employed RNs.

Creating Partnerships to Achieve Health Care Reform: Moving Beyond a Politics of Scale?

This article critically exams efforts to achieve primary health care reform using a consultative and relationship-building approach. The study is set in a predominantly rural region of British Columbia, Canada, and concerns the efforts of a regional health authority to engage actively with community members to develop more integrated and patient-centered primary health care delivery. We examine points of tension between providers and administrators engaged in the reform process and show how these are often expressed discursively as a binary opposition involving central and local interests. We offer a critical examination of this politics of scale and seek to unpack claims of hierarchy and power as a means to offer insight into health care reform processes more generally.

Conceptual Models of Early and Involuntary Retirement among Canadian Registered Nurses and Allied Health Professionals.

ABSTRACTAvailability of health professionals is fundamental to population health. Multiple trends contribute to provider shortages. PURPOSE: Develop and validate conceptual models of early and involuntary retirement among registered nurses (RNs) and allied health professionals (AHPs). METHOD: A review of retirement literature (n = 23 studies). Any factor reported as predictive of early or involuntary retirement was incorporated into a model. To achieve face validity, we conducted interviews with Canadian RNs/AHPs (n = 14). RESULTS: The conceptual model of early retirement had eight categories (38 variables): workplace characteristics, socio-demographics, attitudes/beliefs, broader context, organizational factors, family, lifestyle/health, and work-related. The model of involuntary retirement had four categories (eight variables): broader context, socio-demographics, lifestyle/health, and family. Caregiving responsibilities (variable) was added based on interview data. DISCUSSION: RNs/AHPs consider many factors when contemplating retirement; some are sensitive to intercession, which generates possibilities for extending the work lives of older RNs and AHPs.

An Institutional Perspective on Accountable Care Organizations.

We employ aspects of institutional theory to explore how Accountable Care Organizations (ACOs) can effectively manage the multiplicity of ideas and pressures within which they are embedded and consequently better serve patients and their communities. More specifically, we draw on the concept of institutional logics to highlight the importance of understanding the conflicting principles upon which ACOs were founded. Based on previous research conducted both inside and outside health care settings, we argue that ACOs can combine attention to these principles (or institutional logics) in different ways; the options fall on a continuum from (a) segregating the effects of multiple logics from each other by compartmentalizing responses to multiple logics to (b) fully hybridizing the different logics. We suggest that the most productive path for ACOs is to situate their approach between the two extremes of "segregating" and "fully hybridizing." This strategic approach allows ACOs to develop effective responses that combine logics without fully integrating them. We identify three ways that ACOs can embrace institutional complexity short of fully hybridizing disparate logics: (1) reinterpreting practices to make them compatible with other logics; (2) engaging in strategies that take advantage of existing synergy between conflicting logics; (3) creating opportunities for people at frontline to develop innovative ways of working that combine multiple logics.

Organizational impact of evidence-informed decision making training initiatives: a case study comparison of two approaches.

BACKGROUND: The impact of efforts by healthcare organizations to enhance the use of evidence to improve organizational processes through training programs has seldom been assessed. We therefore endeavored to assess whether and how the training of mid- and senior-level healthcare managers could lead to organizational change. METHODS: We conducted a theory-driven evaluation of the organizational impact of healthcare leaders' participation in two training programs using a logic model based on Nonaka's theory of knowledge conversion. We analyzed six case studies nested within the two programs using three embedded units of analysis (individual, group and organization). Interviews were conducted during intensive one-week data collection site visits. A total of 84 people were interviewed. RESULTS: We found that the impact of training could primarily be felt in trainees' immediate work environments. The conversion of attitudes was found to be easier to achieve than the conversion of skills. Our results show that, although socialization and externalization were common in all cases, a lack of combination impeded the conversion of skills. We also identified several individual, organizational and program design factors that facilitated and/or impeded the dissemination of the attitudes and skills gained by trainees to other organizational members. CONCLUSIONS: Our theory-driven evaluation showed that factors before, during and after training can influence the extent of skills and knowledge transfer. Our evaluation went further than previous research by revealing the influence--both positive and negative--of specific organizational factors on extending the impact of training programs.

Legitimizing new practices in primary health care.

BACKGROUND: Finding ways to reinvent primary health care is imperative. One way is to change practices from a physician-focused model to an interdisciplinary team approach where other health professionals (nurses, nurse practitioners, dieticians, rehabilitation therapists, and other qualified primary care providers) collectively take on much stronger roles-often providing services instead of the physician. Health care policy makers and professionals agree that these new practices are a good idea, and yet they have not been widely adopted. PURPOSE: Our goal was to understand how new interdisciplinary practices became legitimized as the new accepted working standards. METHODOLOGY: We conducted a qualitative, longitudinal comparative case study of 8 primary health care innovation sites established to provide services through interdisciplinary teams. We followed changes in practices over a 3-year period by conducting 150 interviews with professionals and managers across the 8 sites. FINDINGS: At the end of 3 years, new practices were adopted in 5 of the sites, but in 3 sites, they were not. We explain the differences by identifying a series of strategies used by managers in the successful sites and compare them with those used in the other 3 sites. Strategies used in the successful sites were (a) gaining full engagement, (b) enticing people to try new practices, (c) encouraging structured disagreement, and (d) staying focused on overall goals. PRACTICE IMPLICATIONS: Managers of health care change initiatives must gain buy-in from professionals, but that is not enough. They must also facilitate trying the new practices as soon as possible. Open disagreement should be carefully encouraged, but any concerns must also be successfully addressed. Finally, managers must keep professionals focused on the overall goals of change rather than allowing paralysis in response to external events.

Attitudes and beliefs about hand hygiene among paediatric residents: a qualitative study.

BACKGROUND: Despite the knowledge that contaminated hands play an important role in the transmission of healthcare-associated pathogens, and that hand hygiene (HH) reduces the transmission of these organisms, healthcare worker's adherence with HH is poor. OBJECTIVE: To understand the common beliefs and attitudes held by paediatric residents about HH. DESIGN: Qualitative study design. SETTING: Tertiary care paediatric hospital in Edmonton, Canada. METHODS: Semistructured interviews were conducted and themes were identified from interviews. PARTICIPANTS: 22 paediatric residents. RESULTS: Paediatric residents self-reported their HH adherence at 70-99% and perceived hospital-wide adherence at 45-80%. Four major themes were identified during interviews including the importance of role modelling, balancing time spent on HH with other competing factors, self-protection as a driving factor for HH and cues as an important part of habit that stimulate HH. CONCLUSIONS: Staff physicians were viewed as integral to initiating group HH events, but at times, the first person in the room acted as a role model for the rest of the group. In certain instances, such as a cardiac arrest, decreased adherence with HH was viewed as acceptable. Residents engaged in HH to protect their own health. Residents relied on personal cues, which they integrated into their own HH habit. Future HH adherence strategies should ensure that the physician training environments permit the formation of good attitudes and habits towards HH. There are no additional data available.

Designing strategies to implement research-based policies and procedures: a set of recommendations for nurse leaders based on the PARiHS framework.

Organizational policies and procedures are one vehicle for translating research into nursing practice and improving quality and patient and organizational outcomes. However, their existence alone is not sufficient to ensure use. In this article, we describe the Promoting Action on Research Implementation in Health Services framework and how nurse leaders can use the framework to support the implementation of research-based policies and procedures.

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.

Experiences of regionalization: assessing multiple stakeholder perspectives across time.

This paper constructs a beginning frame for analyzing experiences of regionalizing in healthcare systems. Using Alberta as a case example, it traces the perspectives of multiple stakeholders (government, RHAs, frontline staff and public) on key organizational dimensions to describe the various experiences of organizing healthcare through regionalization. As a team of organizational and health researchers, we have been studying this case together and separately for 10 years. We present the framing and our case example to encourage future discussions, debates and consideration of this structural arrangement for healthcare that has swept across most of Canada. We believe that it is critical to learn more about both the pitfalls and potentials that regionalization produces across time and through change for the delivery of care and the protection and improvement of health. And we believe that perspective matters when assessing the full impacts of regionalizing and re-regionalizing and the multiple change processes embedded within these large structural reconfigurations.

Challenges and leadership strategies for managers of nurse practitioners.

AIM: The aim of this paper is to report on the findings from our research into the recent introduction of nurse practitioners in Alberta, Canada. Through an organizational research perspective, we identify the critical role of health care managers in developing a sustainable nurse practitioner role. BACKGROUND: Previous literature has focused on nurse practitioners themselves as the key factor in their integration into the health care system. Although they are qualified and organizationally well placed, managers of nurse practitioners have been overlooked as a critical part of implementation strategies. KEY ISSUES: We interviewed 25 nurse practitioners and seven of their managers. Through our data analysis we identified three major challenges for managers: (1) clarifying the reallocation of tasks; (2) managing altered working relationships within the team; (3) continuing to manage the team in an evolving situation. Associated with these challenges, we propose leadership strategies that managers may find useful as they work through the consequences of introducing the nurse practitioner role. These strategies are: * encourage all team members to sort out 'who does what'; * ensure that task reallocation preserves job motivating properties; * give consideration to how tasks have been allocated when issues identified as 'personal conflict' arise; * pay attention to all perspectives of the working relationships within the team; * facilitate positive relationships between team members; * lead from a 'balcony' perspective; * work with the team to develop goals that are not over focused on the nurse practitioner; * regularly share with other managers the experiences and lessons learned in introducing nurse practitioners. CONCLUSION: For managers to be most effective, they need to address three challenges that are of a managerial, not clinical, nature. By implementing specific leadership strategies, managers of nurse practitioners can facilitate the introduction of the new role and improve its sustainability in health organizations.

Toward a communicative perspective of collaborating in research: the case of the researcher-decision-maker partnership.

In the shift to a post-industrial order, the production and use of knowledge is gaining greater importance in a world beyond science. Particularly in the health sciences, research foundations are emphasising the importance of translating research results into practice and are experimenting with various strategies to achieve this outcome, including requiring practitioners to become part of funded research teams. In this paper, we present a case of a partnership between researchers and decision-makers in Canada who collaborated on an investigation of implementing change in health care organisations. Grounded in this case and recent empirical work, we propose that such research collaborations can be best understood from a communicative perspective and as involving four key elements: relational stance that researchers and decision-makers assume toward each other; purpose at hand that situates occasions for developing and using knowledge; knowledge-sharing practices for translating knowledge; and forums in which researchers and practitioners access knowledge. Our analyses suggest that partnerships are most effective when researchers see the value of contextualising their work and decision-makers see how this work can help them accomplish their purpose at hand.