Addressing quadruple aims through primary care and public health collaboration: ten Canadian case studies.

BACKGROUND: Health systems in Canada and elsewhere are at a crossroads of reform in response to rising economic and societal pressures. The Quadruple Aim advocates for: improving patient experience, reducing cost, advancing population health and improving the provider experience. It is at the forefront of Canadian reform debates aimed to improve a complex and often-fragmented health care system. Concurrently, collaboration between primary care and public health has been the focus of current research, looking for integrated community-based primary health care models that best suit the health needs of communities and address health equity. This study aimed to explore the nature of Canadian primary care - public health collaborations, their aims, motivations, activities, collaboration barriers and enablers, and perceived outcomes. METHODS: Ten case studies were conducted in three provinces (Nova Scotia, Ontario, and British Columbia) to elucidate experiences of primary care and public health collaboration in different settings, contexts, populations and forms. Data sources included a survey using the Partnership Self-Assessment Tool, focus groups, and document analysis. This provided an opportunity to explore how primary care and public health collaboration could serve in transforming community-based primary health care with the potential to address the Quadruple Aims. RESULTS: Aims of collaborations included: provider capacity building, regional vaccine/immunization management, community-based health promotion programming, and, outreach to increase access to care. Common precipitators were having a shared vision and/or community concern. Barriers and enablers differed among cases. Perceived barriers included ineffective communication processes, inadequate time for collaboration, geographic challenges, lack of resources, and varying organizational goals and mandates. Enablers included clear goals, trusting and inclusive relationships, role clarity, strong leadership, strong coordination and communication, and optimal use of resources. Cases achieved outcomes addressing the Q-Aims such as improving access to services, addressing population health through outreach to at-risk populations, reducing costs through efficiencies, and improving provider experience through capacity building. CONCLUSIONS: Primary care and public health collaborations can strengthen community-based primary health care while addressing the Quadruple Aims with an emphasis on reducing health inequities but requires attention to collaboration barriers and enablers.

Organizational factors influencing successful primary care and public health collaboration.

BACKGROUND: Public health and primary care are distinct sectors within western health care systems. Within each sector, work is carried out in the context of organizations, for example, public health units and primary care clinics. Building on a scoping literature review, our study aimed to identify the influencing factors within these organizations that affect the ability of these health care sectors to collaborate with one another in the Canadian context. Relationships between these factors were also explored. METHODS: We conducted an interpretive descriptive qualitative study involving in-depth interviews with 74 key informants from three provinces, one each in western, central and eastern Canada, and others representing national organizations, government, or associations. The sample included policy makers, managers, and direct service providers in public health and primary care. RESULTS: Seven major organizational influencing factors on collaboration were identified: 1) Clear Mandates, Vision, and Goals; 2) Strategic Coordination and Communication Mechanisms between Partners; 3) Formal Organizational Leaders as Collaborative Champions; 4) Collaborative Organizational Culture; 5) Optimal Use of Resources; 6) Optimal Use of Human Resources; and 7) Collaborative Approaches to Programs and Services Delivery. CONCLUSION: While each influencing factor was distinct, the many interactions among these influences are indicative of the complex nature of public health and primary care collaboration. These results can be useful for those working to set up new or maintain existing collaborations with public health and primary care which may or may not include other organizations.

Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors.

AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration. BACKGROUND: Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context. METHODS: This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences successful primary care and public health collaboration at these levels and are important considerations in building and sustaining primary care and public health collaborations.

What systemic factors contribute to collaboration between primary care and public health sectors? An interpretive descriptive study.

BACKGROUND: Purposefully building stronger collaborations between primary care (PC) and public health (PH) is one approach to strengthening primary health care. The purpose of this paper is to report: 1) what systemic factors influence collaborations between PC and PH; and 2) how systemic factors interact and could influence collaboration. METHODS: This interpretive descriptive study used purposive and snowball sampling to recruit and conduct interviews with PC and PH key informants in British Columbia (n = 20), Ontario (n = 19), and Nova Scotia (n = 21), Canada. Other participants (n = 14) were knowledgeable about collaborations and were located in various Canadian provinces or working at a national level. Data were organized into codes and thematic analysis was completed using NVivo. The frequency of "sources" (individual transcripts), "references" (quotes), and matrix queries were used to identify potential relationships between factors. RESULTS: We conducted a total of 70 in-depth interviews with 74 participants working in either PC (n = 33) or PH (n = 32), both PC and PH (n = 7), or neither sector (n = 2). Participant roles included direct service providers (n = 17), senior program managers (n = 14), executive officers (n = 11), and middle managers (n = 10). Seven systemic factors for collaboration were identified: 1) health service structures that promote collaboration; 2) funding models and financial incentives supporting collaboration; 3) governmental and regulatory policies and mandates for collaboration; 4) power relations; 5) harmonized information and communication infrastructure; 6) targeted professional education; and 7) formal systems leaders as collaborative champions. CONCLUSIONS: Most themes were discussed with equal frequency between PC and PH. An assessment of the system level context (i.e., provincial and regional organization and funding of PC and PH, history of government in successful implementation of health care reform, etc) along with these seven system level factors could assist other jurisdictions in moving towards increased PC and PH collaboration. There was some variation in the importance of the themes across provinces. British Columbia participants more frequently discussed system structures that could promote collaboration, power relations, harmonized information and communication structures, formal systems leaders as collaboration champions and targeted professional education. Ontario participants most frequently discussed governmental and regulatory policies and mandates for collaboration.

Moving towards a new vision: implementation of a public health policy intervention.

BACKGROUND: Public health systems in Canada have undergone significant policy renewal over the last decade in response to threats to the public's health, such as severe acute respiratory syndrome. There is limited research on how public health policies have been implemented or what has influenced their implementation. This paper explores policy implementation in two exemplar public health programs -chronic disease prevention and sexually-transmitted infection prevention - in Ontario, Canada. It examines public health service providers', managers' and senior managements' perspectives on the process of implementation of the Ontario Public Health Standards 2008 and factors influencing implementation. METHODS: Public health staff from six health units representing rural, remote, large and small urban settings were included. We conducted 21 focus groups and 18 interviews between 2010 (manager and staff focus groups) and 2011 (senior management interviews) involving 133 participants. Research assistants coded transcripts and researchers reviewed these; the research team discussed and resolved discrepancies. To facilitate a breadth of perspectives, several team members helped interpret the findings. An integrated knowledge translation approach was used, reflected by the inclusion of academics as well as decision-makers on the team and as co-authors. RESULTS: Front line service providers often were unaware of the new policies but managers and senior management incorporated them in operational and program planning. Some participants were involved in policy development or provided feedback prior to their launch. Implementation was influenced by many factors that aligned with Greenhalgh and colleagues' empirically-based Diffusion of Innovations in Service Organizations Framework. Factors and related components that were most clearly linked to the OPHS policy implementation were: attributes of the innovation itself; adoption by individuals; diffusion and dissemination; the outer context - interorganizational networks and collaboration; the inner setting - implementation processes and routinization; and, linkage at the design and implementation stage. CONCLUSIONS: Multiple factors influenced public health policy implementation. Results provide empirical support for components of Greenhalgh et al's framework and suggest two additional components - the role of external organizational collaborations and partnerships as well as planning processes in influencing implementation. These are important to consider by government and public health organizations when promoting new or revised public health policies as they evolve over time. A successful policy implementation process in Ontario has helped to move public health towards the new vision.

Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study.

BACKGROUND: Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses' experiences of patient violence in acute care inpatient psychiatric settings. METHODS: An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation. RESULTS: Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered "part of the job." Nurses often struggled with role conflict between one's duty to care and one's duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace. CONCLUSIONS: Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.

Are parents doing what they want to do? Congruency between parents' actual and desired participation in the care of their hospitalized child.

Family-centered care is integral to pediatric nursing practice, and includes supporting parents to participate in their hospitalized child's care. Research to date suggests that parents' actual participation in care may differ from their desired participation in care, and that such discrepancies may cause parental distress. Supporting parental participation in a way that facilitates congruency between actual and desired participation may contribute to a satisfying experience for families of hospitalized children. This cross-sectional study measured parents' actual and desired level of participation in care of their hospitalized child and examined the congruency between them. Participants (N = 191), the majority of whom were mothers, provided demographic data and completed two instruments measuring desired and actual participation in care. Study results indicate a significant difference between parents' actual and desired participation (t = -9.382, df = 190, p < 0.0001). The majority of parents expressed a desire to increase their participation. The care activities in which these parents participated are described, including providing comfort, assisting with activities of daily living and advocating for their child. Nurses caring for hospitalized children and their families need to remember that parental preferences for participation will vary, and they need to be prepared to support parents' participation at the level parents choose. Understanding congruency between actual and desired levels of participation can promote awareness of parents' preferences for participation.

Using an integrated knowledge translation approach to build a public health research agenda.

BACKGROUND: Public Health Systems Research is an emerging field of research that is gaining importance in Canada. METHODS: On October 22 and 23, 2012, public health researchers, practitioners, and policy-makers came together at the Accelerating Public Health Systems Research in Ontario: Building an Agenda think tank to develop a research agenda for the province. RESULTS: This agenda included the identification of the six top priorities for research in Ontario: public health performance, evidence-based practice, public health organization and structure, public health human resources, public health infrastructure, and partnerships/linkages. CONCLUSIONS: This paper explores the priorities in detail and hopes to bring more attention to this area of research.

Challenging clinical learning environments: experiences of undergraduate nursing students.

Clinical learning is an essential component of becoming a nurse. However at times, students report experiencing challenging clinical learning environments (CCLE), raising questions regarding the nature of a challenging clinical learning environment, its impact on students' learning and how students might respond within a CCLE. Using an Interpretive Descriptive study design, researchers held focus groups with 54 students from two Canadian sites, who self-identified as having experienced a CCLE. Students defined a CCLE as affected by relationships in the clinical area and by the context of their learning experiences. CCLE decreased students' learning opportunities and impacted on them as persons. As students determined which relationships were challenging, they tapped other resources and they used strategies to rebuilt, reframe, redirect and/or retreat relative to the specific challenge. Relationships also acted as buffers to unsupportive practice cultures. Implications for practice and research are addressed.

Viewpoints about collaboration between primary care and public health in Canada.

BACKGROUND: Although there is a global movement toward health system integration and collaboration, little is known about values, beliefs, and attitudes towards collaboration between stakeholders in public health (i.e. promotion, protection, and prevention with vulnerable groups and/or at the population level) and primary care (i.e., family practices, nurse-led clinics). The purpose of this study was to explore viewpoints of key stakeholders regarding primary care (PC) and public health (PH) collaboration in Canada. METHODS: We used Q-methodology to identify common viewpoints held by participants who attended a national meeting in Canada in 2010 to discuss PC and PH collaboration. The study was conducted in two phases. In Phase 1 a Q-sample, a Q-sort table, and a short demographic questionnaire were developed which were used in Phase 2 for data collection. The Q-sorts then were analysed to identify the salient factors and consensus statements. RESULTS: In total, 25 multidisciplinary individuals including researchers, policy-makers, directors, managers, and practitioners (e.g., nurses, family physicians, dietitians) participated. Using a by-person factor analysis, three factors (salient viewpoints) emerged. Factors were named based on their distinguishing statements as follows: a) System Driven Collaborators, b) Cautious Collaborators, and c) Competent Isolationists. System Driven Collaborators strongly believed that a clear mandate from the top is needed to enable PH, PC and the rest of the health system to effectively work together and that people in different branches in the Ministry/ Ministries have to strongly believe in collaboration, actively support it, and develop directed policies to foster organizations work together. Cautious Collaborators strongly supported the idea of having better consciousness-raising about what collaborations might be possible and beneficial, and also reflecting on the collaborations already in place. The Competent Isolationists strongly believed that it is necessary for PC and PH sectors to spend time to ensure that both parties clearly understand the differences between their roles. They believe that physicians, nurses, and social workers will not see the value in collaboration because they lack inter-professional educational programs. CONCLUSIONS: Different viewpoints are held by stakeholders around PC and PH collaboration which have the potential to influence the success of collaborations. Understanding and managing these differences is important to assist change management processes required to build and maintain strong PC and PH collaborations.

A scoping literature review of collaboration between primary care and public health.

AIM: The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success. BACKGROUND: Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone. METHODS: The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English. FINDINGS: The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.

Methods, strategies and technologies used to conduct a scoping literature review of collaboration between primary care and public health.

AIM: This paper describes the methods, strategies and technologies used to conduct a scoping literature review examining primary care (PC) and public health (PH) collaboration. It presents challenges encountered as well as recommendations and 'lessons learned' from conducting the review with a large geographically distributed team comprised of researchers and decision-makers using an integrated knowledge translation approach. BACKGROUND: Scoping studies comprehensively map literature in a specific area guided by general research questions. This methodology is especially useful in researching complex topics. Thus, their popularity is growing. Stakeholder consultations are an important strategy to enhance study results. Therefore, information about how best to involve stakeholders throughout the process is necessary to improve quality and uptake of reviews. METHODS: This review followed Arksey and O'Malley's five stages: identifying research questions; identifying relevant studies; study selection; charting the data; and collating, summarizing and reporting results. Technological tools and strategies included: citation management software (Reference Manager®), qualitative data analysis software (NVivo 8), web conferencing (Elluminate Live!) and a PH portal (eHealthOntario), teleconferences, email and face-to-face meetings. FINDINGS: Of 6125 papers identified, 114 were retained as relevant. Most papers originated in the United Kingdom (38%), the United States (34%) and Canada (19%). Of 80 papers that reported on specific collaborations, most were descriptive reports (51.3%). Research studies represented 34 papers: 31% were program evaluations, 9% were literature reviews and 9% were discussion papers. Key strategies to ensure rigor in conducting a scoping literature review while engaging a large geographically dispersed team are presented for each stage. The use of enabling technologies was essential to managing the process. Leadership in championing the use of technologies and a clear governance structure were necessary for their successful uptake.

A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies.

CONTEXT: Significant resources and time are invested in the production of research knowledge. The primary objective of this randomized controlled trial was to evaluate the effectiveness of three knowledge translation and exchange strategies in the incorporation of research evidence into public health policies and programs. METHODS: This trial was conducted with a national sample of public health departments in Canada from 2004 to 2006. The three interventions, implemented over one year in 2005, included access to an online registry of research evidence; tailored messaging; and a knowledge broker. The primary outcome assessed the extent to which research evidence was used in a recent program decision, and the secondary outcome measured the change in the sum of evidence-informed healthy body weight promotion policies or programs being delivered at health departments. Mixed-effects models were used to test the hypotheses. FINDINGS: One hundred and eight of 141 (77%) health departments participated in this study. No significant effect of the intervention was observed for primary outcome (p < 0.45). However, for public health policies and programs (HPPs), a significant effect of the intervention was observed only for tailored, targeted messages (p < 0.01). The treatment effect was moderated by organizational research culture (e.g., value placed on research evidence in decision making). CONCLUSION: The results of this study suggest that under certain conditions tailored, targeted messages are more effective than knowledge brokering and access to an online registry of research evidence. Greater emphasis on the identification of organizational factors is needed in order to implement strategies that best meet the needs of individual organizations. TRIAL REGISTRATION: The trial registration number and title are as follows: ISRCTN35240937 -- Is a knowledge broker more effective than other strategies in promoting evidence-based physical activity and healthy body weight programming?

A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies.

BACKGROUND: A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions. METHODS: A KB intervention comprised one of three KTE interventions evaluated in a randomized controlled trial. RESULTS: KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change. CONCLUSION: As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.

Parenting children with diabetes: exploring parenting styles on children living with type 1 diabetes mellitus.

PURPOSE: The purpose of this study was to examine the extent to which parenting styles is associated with diabetes control in children (aged 5-12 years) with type 1 diabetes, and on child and parent quality of life. METHODS: Data were collected from a total of 216 parent and child dyads, from 4 pediatric diabetes clinics in southern Ontario, using a cross-sectional survey methodology. Each parent and child independently completed the questionnaires. The study instruments included the Parenting Dimensions Inventory, Pediatric Quality of Life (diabetes specific), and chart reviews for glycosylated hemoglobin (A1C) levels. RESULTS: The results of the study demonstrated that parenting styles were not correlated with diabetes control and were weakly correlated with quality of life. Most parents reported behaviors of authoritative or democratic parenting. The mean glycosylated hemoglobin (A1C) for children in the study was slightly above optimal target range, at 8.4%. Parental education had a weak negative correlation with diabetes control. CONCLUSIONS: Parenting styles are not associated with diabetes control and quality of life in children with type 1 diabetes. However, further research should assess the impact of the determinants of parenting on children with type 1 diabetes and quality of life.

Talking with others who "just know": perceptions of adolescents with cancer who participate in a teen group.

Adolescents with cancer have social support needs that are challenging to meet. A qualitative descriptive study was done using in-person interviews with 11 participants between the ages of 14 and 20. The purpose of the study was to explore and describe adolescent's perceptions of a teen support group. Two main themes emerged: Satisfying Elements and Challenges in the teen group. The subthemes under Satisfying Elements include participants being able to talk to others who "just know," sharing experiences while having fun as a normal teenager, and giving or receiving inspiration. Subthemes under Challenges as identified by participants include ensuring that activities during teen events meet the needs of all participants and dealing with the death of a group member. Study findings suggest that adolescent's feel supported when they are among others in similar circumstances while engaging in normal activity. Offering this type of group for adolescents with cancer provides them with the ongoing opportunities for connection with their peers that is often needed throughout the treatment journey.

Public health nurses' perceptions of mobile computing in a school program.

The use of mobile computing (MC) in healthcare practice has grown substantially in recent years, yet little is known about its impact. This descriptive, exploratory, qualitative study explored the perceptions of public health nurses (PHNs) in a school health program about their use of MC. Public health nurses participated in focus group interviews and completed weekly reflections. They perceived that MC (a) increased PHNs' flexibility although they were constrained by work rules, (b) increased peer and employer connectedness yet increased isolation, (c) and increased PHNs' status while creating a wider gap between PHNs and their clients. Public health nurses described their practice as being more efficient and client-focused with MC. Over time, PHNs grew more comfortable with the tool, developed a dependence on it, and learned to deal with technological problems. Although this new technology shows promise, there is a need for further research to examine its impact as a tool to promote public health nursing practice.