Rationale for the PHC research in a rural context

Following this intensive period of PHC renewal activity in Nova Scotia, a review of the operations of the Nova Scotia health system was conducted in 2007. The review report specifically highlighted the need for an emphasis on PHC and interprofessional teams in health system transformation (Corpus-Sanchez International Consultancy, 2007). The PHC renewal experiences afforded by the Primary Health Care Transiton Fund required that health care managers and practitioners reconsider the ways in which they have traditionally worked. Health system policies nationally and provincially have generally called for PHC interprofessional team ‘implementation’ (Province of Nova Scotia, 2003; 2008; Ontario Ministry of Health and Long-Term Care, 2009; Government of Alberta, 2010). As a result, many innovative PHC services were developed, some of which utilized interprofessional teams. However, the notion of how to best develop the service delivery team itself could have used more deliberate attention in Nova Scotia. Ideally, an effective and well-functioning team would be developed before services are drastically reformulated. In reality, IPHC team development often occurs concurrently with service development, and sometimes team development and sustainability issues are not focal points at all.

IPHC team development and sustainability is even more complex when the various challenges associated with rural health service delivery are added to the mix, such as human resource recruitment and retention issues, and geographical barriers. Rural IPHC team development has significant implications for program planning and transferability of learnings to other contexts within our province. Many Nova Scotia system-based decision-makers and PHC experts agreed that we needed empirical and conceptual evidence that was particular to our primarily rural contexts so that the policy and practice complexities of rural IPHC team development and sustainability would be guided by best practices in the field. Well developed rural IPHC teams in Nova Scotia was a dominant discourse, but they were a rarity in reality.

To support continued evidence-informed PHC policy and programming in Nova Scotia, a research team was developed consisting of five researchers from Nova Scotia, Ontario, and Alberta, and nine system collaborators/decision-makers from local, regional and provincial contexts in Nova Scotia. The meaningful participation of the system decision-makers was central to developing an appropriate research response to the key rural PHC policy and practice questions. They brought key practice and policy gaps, challenges and successes to the discussions. The researchers came from three different provinces based on past collaborative research partnerships and current PHC research activity so that lessons learned in this type of research could be shared across jurisdictions. Our aim was to develop a rural PHC research project that explored matters consistent with priorities identified through extensive consultation and communication with government, community health boards, organizations, and citizens of Nova Scotia. The proposed research question was: How are rural IPHC teams developed and sustained? Subquestions considered contextual influences on IPHC team development and sustainability, such as issues related to rural contexts.

Establishing our PHC research agenda purposefully aimed to address priorities of the newly launched 3-year Health Transformation action plan for Nova Scotia (Province of Nova Scotia, 2008). The research agenda was intended to support the required philosophical and structural systemic changes inherent in progressive PHC policy and practice reform. A secondary aim of our proposed project was to develop iterative and ongoing knowledge linkage and exchange strategies to further enhance academic-public system partnerships and capacity to support PHC system and policy decision-making. These advances are key in developing a responsive health research community that is a central and integral component of our primary and broader health care system.

Literature-based argument for interprofessional collaboration in PHC

Systemic change is required as we strive towards equitable access to health care services in small rural communities (Ministerial Advisory Council on Rural Health, 2002; Nagarajan, Reference Nagarajan2004; Canadian Institute for Health Information, 2006; McGibbon et al., Reference McGibbon, Etowa and McPherson2008). Collaborative working arrangements have been increasingly recognized as a requirement in systemic change to address complex and contextually laden issues and systems that impact upon the health of Canadians requiring PHC (Begun et al., Reference Begun, Zimmerman and Dooley2003; Westley et al., Reference Westley, Zimmerman and Patton2006; Casebeer, Reference Casebeer2007; Lamothe and Denis, Reference Lamothe and Denis2007; McPherson, Reference McPherson2008). Interprofessional team collaboration, as a specific strategy, is integral to PHC.

PHC is the foundation of Canada’s health care system (Health Council of Canada, 2005a; 2005b). There is robust theoretical and empirical evidence for the association between strong national PHC systems and improved health outcomes (Starfield et al., Reference Starfield, Shi and Macinko2005; Lee et al., Reference Lee, Kiyu, Milman and Jimenez2007; Russell et al., Reference Russell, Geneau, Johnston, Liddy, Hogg and Hogan2007; World Health Organization, 2008; WHO & PHAC Collaboration, 2008). PHC was intended to represent a deliberate effort to counter trends responsible for the gross disparities in the health of populations. Major initiatives have been undertaken globally (International Council of Nurses, 2008; World Health Organization, 2008), and in Canada (Weatherill, Reference Weatherill2007; Health Council of Canada, 2008a; 2008b; 2009) and in other countries (Raymont and Cumming, Reference Raymont and Cumming2003; Rees et al., Reference Rees, Huby, McDade and McKechnie2004; Thylefors et al., Reference Thylefors, Persson and Hellstrom2005; Commonwealth of Australia, 2008; Kalucy et al., Reference Kalucy, Jackson Bowers, McIntyre, Hordacre and Reed2009; National Health Service, 2009) to strengthen PHC since its debut under the Declaration of Alma Ata in 1978 (WHO, 1978). These systemic initiatives take advantage of relatively unexplored interprofessional, interorganizational and cross-sectoral partnerships (McPherson, Reference McPherson2008), and represent a fundamental shift taking place in contemporary PHC, as we move away from simple forms of short-term uniprofessional partnerships towards an ongoing complex network of community- and team-based professionals. According to the World Health Organization (2008), current concerns of PHC reforms include service delivery, leadership, and public policy reforms, with a special emphasis on the unreached populations – ‘those for whom service availability and social protection does little to offset the health consequences of social stratification’ (p. xvi–xvii).

IPHC team sustainability: existing empirical and conceptual evidence

We recognized that many aspects of collaboration are embedded in the success of team sustainability. For example, the above discussion of the literature regarding collaboration emphasizes the need for development of long-term networks of community and team-based professionals, and the ongoing importance of systemic change to address complex issues such as health disparities. Collaboration is thus likely a core foundation of IPHC team sustainability. However, there was a paucity of empirical literature arising from our search strategy that explicitly examined IPHC sustainability. Thus, we examined the community health partnership literature and concluded that there is little evidence that would provide IPHC partnerships with clear guidance on long-term viability. Authors argued that, although community based programs are often evaluated to establish short-term effectiveness, there is little attention paid to whether, how, or why programs and the associated partnerships, systems changes, and direct services sustain themselves in the community over the long-term (O’Laughlin et al., Reference O’Laughlin, Renaud, Richard, Sanchez-Gomez and Paradis1998; Shediac-Rizkallah and Bone, Reference Shediac-Rizkallah and Bone1998; Rootman et al., Reference Rootman, Goodstadt, Hyndman, McQueen and Potvin2001; Alexander et al., Reference Alexander, Weinder, Metzger, Shortell and Bazzoli2003; Pluye et al., Reference Pluye, Potvin and Denis2004).

Pluye et al. (Reference Pluye, Potvin and Denis2004) reviewed empirical studies regarding the health partnership and program sustainability concept. They discussed the structural and temporal dimensions of sustainability in what they termed a concomitancy reconceptualization. They argued that the processes of implementation and sustainability occur concomitantly at the beginning of program development, challenging the popular notion that sustainability occurs only at the final phase of development. They concluded that the stage models of sustainability (O’Laughlin et al., Reference O’Laughlin, Renaud, Richard, Sanchez-Gomez and Paradis1998; Shediac-Rizkallah and Bone, Reference Shediac-Rizkallah and Bone1998; Butterfoss and Kegler, Reference Butterfoss and Kegler2002) do not account for the recursive and reflexive nature of sustainability and the ever-adjusting processes that shape it. Shediac-Rizkallah and Bone (Reference Shediac-Rizkallah and Bone1998), Pluye et al. (Reference Pluye, Potvin and Denis2004), and Scheirer (Reference Scheirer2005) suggested that an empirical knowledge base regarding the factors determining health partnership sustainability is still at an early stage and that the health promotion program sustainability literature has not yet coalesced into a single research paradigm, a shared set of statistical methods, or even a common terminology.

Given that there was little empirical literature that specifically addressed IPHC team development and sustainability, we then broadened our literature review to possible related concepts. We considered issues such as factors impacting PHC collaborative care practices, teamwork, and primary care and PHC team effectiveness. Table 1 provides an overview of our literature review findings. We use Martin-Misener and Valaitis’ (Reference Martin-Misener and Valaitis2008) categories of interpersonal, organizational, and systemic factors (barriers and facilitators) to primary care-public health collaboration heuristicallly to present the factors arising from our literature review. We acknowledge that many factors, such as interprofessional power and control issues, do not by their very nature fit neatly into discrete categories. However, they are clustered in this manner for presentation purposes. Significantly, possible team development and sustainability issues were recurring throughout this literature, such as respect for team members and communication (individual factors), role and responsibility clarification (organizational factors), and interprofessional education and power hierarchies (systemic factors).

Table 1 Factors related to interprofessional PHC team collaborations arising from literature review

PHC = primary health care.

¹Martin-Misener et al. (Reference Martin-Misener, Downe-Wambolt, Cain and Girouard2009); ²West et al. (Reference West, Farer and Whyte2004); ³O’Neill and Cowman (Reference O’Neill and Cowman2008); ⁴Geneau et al. (Reference Geneau, Lehoux, Pineault and Lamarche2008); ⁵Rygh and Hjorttdahl (Reference Rygh and Hjorttdahl2007); ⁶Martin-Misener and Valaitis (Reference Martin-Misener and Valaitis2008); ⁷Fear and de Renzie-Brett (Reference Fear and de Renzie-Brett2007); ⁸Curran and Sharpe (Reference Curran and Sharpe2007); ⁹Bunniss and Kelly (Reference Bunniss and Kelly2008); ¹⁰Boudioni et al. (Reference Boudioni, McLaren, Woods and Lemma2007); ¹¹McNair et al. (Reference McNair, Brown, Stone and Sims2001); ¹²Jenkins-Clarke and Carr-Hill (Reference Jenkins-Clarke and Carr-Hill2001); ¹³Sicotte et al. (Reference Sicotte, D’Amour and Moreault2002); ¹⁴Rees et al. (Reference Rees, Edmunds and Huby2005); ¹⁵Murray et al. (Reference Murray, Silver, Patel, Dupuis, Hayes and Davis2008); ¹⁶Sargeant et al. (Reference Sargeant, Loney and Murphy2008); ¹⁷Bateman et al. (Reference Bateman, Emery, Bastable and Bailey2003); ¹⁸Hann et al. (Reference Hann, Bower, Campbell, Marshall and Reeves2007); ¹⁹Orchard et al. (Reference Orchard, Curran and Kabene2005); ²⁰Gabhainn et al. (Reference Gabhainn, Murphy and Kelleher2001); ²¹Minns Lowe and Bithell (Reference Minns Lowe and Bithell2000); ²²Kharicha et al. (Reference Kharicha, Iliffe, Davey and Fleming2005); ²³Jesson and Wilson (Reference Jesson and Wilson2003); ²⁴Samuels et al. (Reference Samuels, Xirasaar, Elder and Probst2008); ²⁵Galvin et al. (Reference Galvin, Andrewes, Jackson, Cheesman, Fudge, Ferris and Graham1999); ²⁶West et al. (Reference West, Borrill, Dawson, Brodbeck, Shapiro and Haward2003); ²⁷Nolan and Hewison (Reference Nolan and Hewison2008); ²⁸Lincoln (Reference Lincoln2006); ²⁹Stewart (Reference Stewart2002); ³⁰Jansen (Reference Jansen2008); ³¹Grant et al. (Reference Grant, Huby, Watkins, Checkland, McDonald, Davies and Guthrie2009); ³²Stevenson et al. (Reference Stevenson, Baker, Farooqi, Sorrie and Khunti2001).

Context and IPHC team development and sustainability: existing empirical and conceptual evidence

Again, since there was relatively little literature arising from our search that specifically addressed IPHC team development and sustainability, we maintained a broader search perspective for IPHC team contexts as well. We considered evidence related to concepts such as well-functioning IPHC teams and related contextual factors.

Over the past decade, scholars have identified multiple historical, political, economic, and social contextual challenges within a complex health and broader public service system that are associated with well-functioning collaborative interprofessional community-based teams (Scott et al., Reference Scott, Ruef, Mendel and Caronna2000; Alexander et al., Reference Alexander, Weinder, Metzger, Shortell and Bazzoli2003; Greenhalgh et al., Reference Greenhalgh, Robert, Macfarlane, Bate and Kyriakidou2004; Arevian, Reference Arevian2005; Watson and Wong, Reference Watson and Wong2005; Hogg and Ogilvie, Reference Hogg and Ogilvie2006; Borgatti and Foster, 2003; Casebeer, Reference Casebeer2007; Lamothe and Denis, Reference Lamothe and Denis2007; Pluye et al., 2004; Hogg et al., Reference Hogg, Rowan, Russell, Geneau and Muldoon2008; McPherson, Reference McPherson2008; Sargeant et al., Reference Sargeant, Loney and Murphy2008). IPHC team functioning is dependent on the base of a well-functioning PHC system at federal and provincial levels (Province of Nova Scotia, 2003; Health Council of Canada, 2005a; 2005b; Canadian Institute for Health Information, 2006; Barrett et al., Reference Barrett, Glynn, Curran and Godwin2007; Rygh and Hjorttdahl, Reference Rygh and Hjorttdahl2007). Freeman and Pech (Reference Freeman and Pech2006: 408) reinforced the highly contextual nature of integrated partnerships: ‘complex social interventions requiring enactment by individuals within specific contexts, typically involving many service changes against a turbulent policy background’. In a review of the literature, Xyrichis and Lowton (Reference Xyrichis and Lowton2008) cited the contextual nature of IPHC team working, focusing on system complexities surrounding teams. Rummery (Reference Rummery1998) identified the benefits and challenges in PHC policy in the UK, highlighting the impact of the policy contextual environments in which PHC change has been taking place. Meads (Reference Meads2006a; Reference Meads2006b) argued that each changing model of PHC belongs to its own particular cultural context. Thus, the basic conundrum for policy-makers – whether national, provincial, or regional – is to develop PHC programs capable of working in diverse settings with reasonable degrees of equity, efficiency and predictability (Watson et al., Reference Watson, Broemeling, Reid and Black2004). This outcome is difficult enough to achieve in large urban settings, let alone when applied in rural and remote settings.

RuralFootnote 2 health care providers face a unique set of contextual challenges. The development of collaborative forms of interaction is particularly relevant in providing integrated services in rural areas (Rygh and Hjorttdahl, Reference Rygh and Hjorttdahl2007). The influence of geography is increasingly being acknowledged as central to a comprehensive understanding of health (Burge et al., Reference Burge, Lawson. and Johnston2005; Leipert and George, Reference Leipert and George2008; Canadian Institutes of Health Research, 2009; McGibbon, Reference McGibbon2009). Rural communities have associated population health indicators, specific workforce characteristics, and health and other public service challenges of importance to IPHC team providers, such as access to secondary care facilities, to centers of decision-making, and to professional education and support (Pong, Reference Pong2000; Rygh and Hjorttdahl, Reference Rygh and Hjorttdahl2007). Rural PHC is underpinned by a number of organizational and philosophical features that require understanding when considering the implementation of initiatives developed in an urban working environment (West et al., Reference West, Farer and Whyte2004). Competition and organizational differences are frequently cited barriers to rural PHC innovation (Samuels et al., Reference Samuels, Xirasaar, Elder and Probst2008). Kamien (Reference Kamien2009) called for a re-examination of evidence-based policy for the realities of rural health care, arguing that there is a gap between central urban developed policies and contextually dependent rural implementation sites. There needs to be a recognition of how rural health contexts impact upon PHC service provision and the constraints limiting health service responses (Humphreys, Reference Humphreys2009).

Establishing the research agenda

PHC, in its broadest sense, has made considerable advances in its research capacity and productivity over the past 40 years, and the academic research community is experiencing great change and opportunity (Lester and Howe, Reference Lester and Howe2008). However, according to the Health Council of Canada (2009), ‘we still have a long way to go towards developing good systems of PHC, and even in understanding what all of the right ingredients are’ (p. 34). Wakerman (Reference Wakerman2009) examined the literature pertaining to innovative PHC models in rural and remote areas to identify areas where knowledge is lacking and to describe future research priorities. He reported that there is generally a dearth of rigourously collected information regarding rural health service delivery, and a need for more rigorous health services evaluation focusing on a number of issues including supports for team practice and the optimal range and mix of providers. This is also within a context of concerns regarding the sustainability of healthcare workforces in rural settings (Hunsberger et al., Reference Hunsberger, Baumann, Blythe and Crea2009). In a study commissioned by the Canadian Health Services Research Foundation evaluating Canada’s PHC research capacity (Russell et al., Reference Russell, Geneau, Johnston, Liddy, Hogg and Hogan2007), widespread deficiencies in the sustainability and coordination of Canadian PHC research were reported. The author argued that many provinces are beginning to make major changes in the delivery of PHC, and that ‘these changes necessitate PHC research and evaluation that can inform decision-making by policy makers, health system managers, practitioners, and members of the community’ (p. 3). Further, PHC researchers are often isolated in their own organizations and regions, few have close links with policy makers, and many are challenged by the requirements of knowledge translation and exchange. In its 2007–2008 corporate annual report, the Health Council of Canada (2008c) highlighted several issues among the gaps in knowledge needed to inform us about the progress of health care renewal in Canada, including the issue of sustainability of PHC models and systems, and a focus on best practices and dissemination of this knowledge.

Leaders in PHC renewal in Canada suggest that we still have a long way to go towards achieving the renewal goals (Barnes and MacLeod, Reference Barnes and MacLeod2008; Hutchison, Reference Hutchison2008a; Reference Hutchison2008b; Katz, Reference Katz2008; Nicklin, Reference Nicklin2008; Starfield, Reference Starfield2008; Swerissen, Reference Swerissen2008; van Soren et al., Reference van Soren, Hurlock-Chorostecki, Pogue and Sanders2008), a conclusion recently reaffirmed by the Health Council of Canada (2009). Several authors contend that we have yet to create a culture and a system that supports IPHC team development (Orchard et al., Reference Orchard, Curran and Kabene2005; Fear and de Renzie-Brett, Reference Fear and de Renzie-Brett2007). IPHC team implementation methodologies remain elusive (Leese et al., Reference Leese, Baxter, Goodwin, Scott and Mahon2001; Jansen, Reference Jansen2008), and as PHC evolves through reformed delivery models, it is important to examine its structural and organizational features, because these are likely to have a significant impact on performance (Hogg et al., Reference Hogg, Rowan, Russell, Geneau and Muldoon2008). Within our Nova Scotia context and well beyond, increasing our understanding of how to best develop and sustain IPHC teams is fundamental to solid service and policy development, and ultimately to equitable health access and outcome improvement.