6 Primary Health Care

The complexity of delivering effective health and social care means that not one profession can meet the needs of patients in the 21st century — a new and more flexible approach to the delivery of care is required. (Reeves, Macmillan, & van Soeren, 2010, p. 262)

Introduction

Welcome to the world of teams and collaboration! In this chapter, you will begin to understand the importance of effective multidisciplinary relationships with respect to optimal client health outcomes in the community, and in turn, the necessity of interprofessional leadership in negotiating these relationships. No matter the population served, the need for collaborative practice is critical in our health system today.

 

6.1 Background: Why the Need for Interprofessional Collaboration?

Primary Health Care

The urgent need for the implementation of primary health care throughout the world was given international recognition at the World Health Organization (WHO) conference in Alma-Ata, USSR in 1978. Primary health care was described as “a community-based health care service philosophy that is focused on illness prevention, health promotion, treatment, rehabilitation, and identification of people at risk” (Howse & Grant, 2015, p. 132). The Canadian Nurses Association (CNA) issued a position statement strongly supporting the five essential principles of primary health care: “accessibility, active public participation, health promotion and chronic disease prevention and management, the use of appropriate technology and innovation, [and] intersectoral cooperation and collaboration” (CNA, 2015, p. 1). Collaboration and teamwork across the professions and health care sectors are required to meet the five principles inherent within the primary health care service philosophy adopted at Alma-Ata. These principles are the catalyst for interprofessional and inter-sectoral health care collaboration in the provision of comprehensive health care to the public.

 

Providing Primary Health Care: Complex Client Needs and the Shift to Care in the Community Sector

Worldwide, the population of persons over the age of 65 is growing, and in most developed countries the increase is most striking in those aged 80 and older (Kwan, Chi, Lam, Lam, & Chou, 2000). The demographics of Canada are changing rapidly. The population of seniors in Canada is expected to grow from 3.5 million people in 1996 to an estimated 6.9 million by 2021 (Statistics Canada, 2015). By 2021, approximately 18.7 per cent of the population will be over the age of 65 (Health Canada, 2010). In 2014, seniors accounted for approximately 14 per cent of the population and 40 per cent of hospital resources (CNA, 2016). As the population grows older, the incidence of chronic illness will also rise (Government of Canada, 2015). Accordingly, the ability to respond to the health needs of older persons in a clinically (professional) and fiscally responsible manner has become a critical challenge of the current health care system (Canadian Institute for Health Information, 2010; Hirdes, Ljunggren, et al., 2008; Kwan et al., 2000). As stated by Leung, Liu, Chow, and Chi (2004) “even though aging is not synonymous with frailty, elderly people are major consumers of health care” (p. 71).

Moreover, Bernabei, Landi, Onder, Liperoti, and Gambassi (2008) and Hirdes, Ljunggren, et al., (2008) suggest that health care systems are increasingly confronted with older clients who are: affected by complex interactions of physical, social, medical, and environmental factors; receiving multiple and frequently interacting medications and treatments for an array of clinical conditions; and often limited in terms of financial resources and support systems to meet increasing health needs.

Even though current health systems have evolved to provide sophisticated acute care, these systems continue to be challenged by complex geriatric clients with chronic medical, psychological, and social needs. The responsibility for their care, once the domain of the hospital and long-term care facilities, has shifted to the community (Bernabei et al., 2008). A systematic review of the literature documenting outcomes from home-based primary care (HBPC) programs for homebound older adults indicated that “specifically designed HBPC programs . . . can reduce hospitalizations and long-term care admissions while improving individual and caregiver quality of life and satisfaction with care” (Stall, Nowaczynski, & Sinha, 2014, p. 2249). Community health services play an increasingly prominent role in the health care system with the aim of minimizing inappropriate hospitalizations and/or admissions into long-term care (Gray et al., 2009; Hirdes, Poss, & Curtin-Telegdi, 2008).

Special attention must be paid to the Canadian Indigenous senior population. Many have complex health needs, but live in areas where it is more challenging and expensive to provide care. In 2006, almost 5 per cent of Indigenous people were aged 65 or older (Health Council of Canada, 2013). The social conditions on many reserves reflect the historical and political neglect that Canada has shown toward people of Indigenous ancestry (see Native People Social Conditions). Many Indigenous seniors are “isolated and struggling due to multiple factors in their lives and communities; they need more intensive support than non-Aboriginal seniors” (Health Council of Canada, 2013, p. 28). In addition, they may be intimidated by the institutionalized health care system. This intimidation may be attributed to care provider approaches similar to those described in a recent research study in which Indigenous patients “reported stories of bullying, fear, intimidation and lack of cultural understanding” (Cameron, Carmargo Plazas, Salas, Bourque Bearskin, & Hungler, K., 2014, p. E1). Health care providers who incorporate culturally appropriate practices into their care provide a welcoming environment that encourages the use of health care services by Indigenous people.

At least one million Canadian seniors are currently living with a mental illness (CNA, 2011). Neill, Hayward, and Peterson (2007) argue that there is a dire need to provide access to wellness care that supports healthy aging, noting that “the population of individuals over 60 is expected to increase to almost two billion internationally by 2050” (p. 425). However, clients of all ages suffer with chronic mental health issues. These individuals can be among the most disadvantaged groups in Canada. They are often living with multiple intersecting health and societal issues that potentiate reliance on a range of services (Schofield et al., 2016).

 

 

A report by the Commission on the Future of Health Care in Canada (Romanow, 2002) advocated for a strengthening of the Canadian health care system by inclusion of post-acute care, palliative care, and mental health home care services under a revised Canada Health Act, with these services covered by Medicare. In turn, Shamian (2007) stated:

If policy makers are serious about ensuring the sustainability and quality of our health care system they must turn their attention to the role that home and community care plays. Failing to do so will result in a fragmented, weakened health care system. (p. 296)

A heightened and fundamental role of community services in the provision of health care across Canada is required to meet the growing number of clients in the community with complex and chronic medical, psychological, and social needs. As institutions have downsized and/or closed, the acuity and chronicity of client care has escalated in the community, both in home care and community mental health. Furthermore, the client’s and the family’s desire to remain in the home and to be cared for in the community has become a significant factor as client- and family-centred care evolves.

Yet this brings challenges for the clients, their families, health care providers, and the health care system. How can the complex needs these clients experience be optimally met, keeping quality, safety, and efficiency in mind? How do we as nurses ensure a client- and family-centred approach? How can we as health care providers optimize recovery, wellness in chronicity, and prevention as we provide care in the community?

Complexity, Community Care, and Collaborative Practice: The 3 “C’s”

The increasing prevalence of chronic conditions in Western societies and ensuing need for non-acute quality client care bring the need for collaborative practice to the fore (Xyrichis & Lowton, 2008). Xyrichis and Lowton (2008) suggest that multidisciplinary teamwork will lead to an integrated approach to population health promotion and maintenance, while improving the efficacy and outcomes of client care.

Furthermore, community care encompasses medical, psychological, and social care, as well as health promotion and illness prevention strategies. For such an all-encompassing service to be delivered, an array of professionals and skills are required in a team approach (Xyrichis & Lowton, 2008). Neill et al. (2007) argue that a collaborative interprofessional client care model supports the comprehensive delivery of quality care through the integration of multiple professions.

 

Diversity among the multidisciplinary team encourages cultural relevancy, bringing creativity to comprehensive client care. Nonetheless, Naylor (2012) found there is often inadequate communication among multidisciplinary teams and insufficient engagement with the client and family members. However, Naylor duly noted that in order to interrupt patterns of high health care utilization by the chronically ill and address the negative effects of this usage on quality and costs, innovative solutions to improve professional collaboration and client and family engagement have emerged in many health care settings. An example of such an innovative solution is telenursing, which assists the care providers to overcome difficulties raised by geographical distance and transportation problems (Souza-Junior, Mendes, Mazzo, & Godoy, 2016). Recognition of the client perspective, along with the engagement and participation of the client and family in that client’s care planning and implementation, has led to quality care in many health care settings in Saskatchewan.

 

 

6.2 Leadership

What does it mean to be a leader? Is a leader authoritarian, outspoken, or self-assured? The leadership journey of many beginning nurses is often fraught with mistakes and much learning. Nurse leadership potential is recognized by other health care providers when someone shows an inherent aptitude to be a client advocate while working to meet client needs. When leadership is equated with working with clients and teams rather than “being the boss,” the journey becomes a little less rocky for everyone. The story of one leader’s journey is shared in the following “From the Field.”

Interprofessional Leadership

According to Health Canada (2010), interprofessional collaboration in health care delivery settings is

Working together with one or more members of the health care team who each make a unique contribution to achieving a common goal, enhancing the benefit for patients. Each individual contributes from within the limits of their scope of practice. It is a process for communication and decision making that enables the separate and shared knowledge and skills of different care providers to synergistically influence the care provided through changed attitudes and behaviours, all the while emphasizing patient-centred goals and values.

What is important for interprofessional leadership is the framework within which this collaboration is achieved. Unlike some traditional models of leadership (i.e., those that are hierarchical in nature), interprofessional leadership is realized and practised through a collaborative relationship that is horizontal, relational, and situational. This leadership model is fostered via professional competency and healthy team dynamics (Anonson et al., 2009).

Interprofessional leadership fits with a participatory style of leadership. In turn, interprofessional leadership is supported by understanding and developing emotional intelligence and self-reflection and by understanding the concepts of shared leadership and appreciative inquiry. These three concepts are described in detail in the following sections. The Government of Canada (2015) described its hope for the future of health care as “inter-professional teams of providers [who] collaborate to ‘provide a coordinated continuum of services’ to individual patients supported by information technologies that link providers and settings” (p. 71).

Emotional Intelligence and Reflective Practice

Emotional intelligence (EI) and reflective practice are keys to self-understanding in successful interprofessional leadership, and both are integral to working with clients and teams. While EI has been discussed in Chapter 1, this chapter will emphasize its value in terms of working with clients and teams.

New nurse managers seldom have any formal administrative and leadership orientation, yet they are expected to lead individuals, teams, and service areas that are often vulnerable to emotion and high stress. In terms of influence, leaders who exhibit high EI have an effect on how individuals follow direction, interact with one another, and cope in stressful situations. EI leads to trust in leadership and relationship building, promoting teamwork and conflict resolution (Eason, 2009; Mackay, Pearson, Hogg, Fawcett, & Mercer, 2010; Samad, 2009). Managers with high EI influence by listening, focusing on employee strengths, and spending more time focusing on achievements, all of which results in energized staff and improved mood, especially in vulnerable times of change and uncertainty (Bisaria, 2011).

Daft (2011) tells us that having high EI—being sensitive to oneself and other’s emotions—helps leaders to identify the effect they are having on followers and optimizing their ability to adjust styles in order to create positive outcomes. These leaders become experts at “reading” a situation and adjusting their styles accordingly. Health care environments can change from minute to minute. Leaders who have the ability to read and react according to the environment of the moment will optimize their followers’ abilities to perform to their best.

EI often develops parallel to the growth of the nurse’s experience. However, EI skills cannot be taken for granted, and each one of us needs to be ever mindful to continue utilizing these skills. EI is a critical skill to learn and to harness, whether you are leading, collaborating, or following. Whatever role you are assuming, in a given situation, this skill will potentiate success for the client, the team, and yourself.

 

 

Reflective practice has many parallels to emotional intelligence. Reflective practice is the ability to examine actions and experiences with the outcome of developing practice and enhancing clinical knowledge (Caldwell & Grobbel, 2013). According to the College of Nurses of Ontario (2015), reflective practice benefits not only the nurse, but the clients as well. For the nurse, reflective practice improves critical thinking; optimizes nurse empowerment; provides for greater self-awareness; and potentiates personal and professional growth. For the client, reflective practice improves client quality of care and client outcomes (College of Nurses of Ontario, 2015).

Reflective practice teaches the importance of active listening, which does not come easily to many people. As you reflect on the meetings you have participated in, you may begin to understand that even though you very eagerly provided your perspective and suggestions, you were not as attentive to other’s viewpoints and potential ideas, which may have been diverse, valuable, and creative approaches to problem solving. Conscientiously practicing active listening opens the doors for comprehensive planning, whether that is client care or programming.

In an interview with the Canadian Nurse, David Byres, a registered nurse leader with experience in direct care roles as well as high-profile formal leadership roles, was asked, “What is the best piece of career advice you have received”? His answer: “Listen to learn and learn to listen” (Huron, 2017, p. 38).

Reflective practice and active listening helps the individual engage more deeply with staff, other disciplines, clients, and families. The skill of listening is often undervalued, when in fact it is one of the more critical components of communication within interprofessional leadership and collaboration. As students develop emotional intelligence and reflective practice, a deep awareness of self and others ensues. These key elements for interprofessional leadership support relationships with other professionals and clients.

Shared Leadership

Within a framework of team- and collaborative-based practice, interprofessional leadership is a shared leadership. All practitioners must recognize the necessity of situational leadership, adjusted according to client and family needs, and the professional competencies to meet those needs (Anonson et al., 2009).

Shared leadership can be complicated when the interprofessional team requires a change in leader based on a change in client needs and care (Sanford & Moore, 2015). This happens regularly with complex clients in all settings, and particularly in the community setting. For example, a client’s medical needs may be stable and straightforward, but their emotional or social needs remain. Ideally in this situation, leadership of the interprofessional team moves from medicine to social work or mental health services (Sanford & Moore, 2015).

Anonson et al. (2009) studied participants who were unanimous in their opinions that effective interprofessional team-based practice is the most beneficial framework for successful client outcomes, specifically for clients with complex needs and circumstances. Moreover, these authors found that team leadership was viewed as a shared responsibility of the team as a whole. Given the nature of this collaborative team-based approach that is ideal for our ever-increasing number of clients with complex needs, all practitioners require leadership knowledge, skills, and ability, as well as knowledge of shared leadership practice.

Ultimately, commitment to client outcome rather than one’s own professional discipline is the goal of collaborative health care teams (Anonson et al., 2009). This is where active listening, trust and relationship building, emotional intelligence, and reflective practice become critical, in order to strengthen oneself within that leadership role, while truly understanding distinct client needs and what each discipline has to offer individual clients.

Appreciative Inquiry

The participative leader embraces group involvement in decision making. This involvement fosters an understanding of the issues by those who must carry out the decisions since team members are more committed to actions when they have been involved with the decision making (Darvish & Faezeh, 2011; Daft, 2011). Participative leadership suits the strategy of appreciative inquiry as it engages individuals, teams, and the organization (Daft, 2011). Meaningful change is more likely to occur when those most affected are given the opportunity to decide on the changes themselves (Pan & Howard, 2010).

Appreciative inquiry (AI) reinforces positive actions, focusing on learning from successes and on what is working well in order to bring the desired future into being (Browne, 2008; Daft, 2011). Faure (2006) frames AI as a method for positive change in which the focus is on what works rather than illuminating what does not work, and suggests that the change effort should begin by asking, “What works best and what do we want more of?” According to Browne (2008):

AI is based on the simple idea that human beings move in the direction of what we ask about. When groups query human problems and conflicts, they often inadvertently magnify the very problems they had hoped to resolve. Conversely, when groups study exalted human values and achievements, like peak experiences, best practices, and worthy accomplishments, these phenomena tend to flourish. (p. 1)

AI optimizes continuous improvement and has many applications including team development, multi-agency teamwork, service user engagement, organizational projects, and positive culture change (McAllister & Luckcock, 2009). AI provides opportunities for individual voice through a four-phase process:

1. Discovery or appreciating, where individuals identify and share the best of what exists.
2. Dream or envisioning, where the group imagines what could be and creates a shared vision of the best possible future outside the traditional boundaries of what was done in the past.
3. Design or co-constructing, where plans are made about what the organization needs to do in order to get to where they want. This phase sets the stage for new and innovative practice.
4. Destiny or sustaining, where the group translates plans into action steps and commits to implementation and evaluation of the new design or changes (Daft, 2011; McAllister & Luckcock, 2009; Pan & Howard, 2010; Richer, Ritchie, & Marchionni, 2010). The group values the positive focus of AI and is keen to work together using an AI strategy. Once the process begins, it is carried out over several sessions.

Appreciative Inquiry Applied

The following section provides as an example of how the four phases of appreciative inquiry can be successfully applied.

Discovery. A multidisciplinary group was assembled and included a client representative and a facilitator. The group began to discover by thinking about the organization’s strengths and best practices or about positive client experiences. The following discussion ideas and questions, adapted from Lewis et al. (2006) and Jones (2010) were presented to the group.

When are you most engaged at work and what do you value most about yourself and the organization? Describe a positive hospital stay from the client perspective. Describe a positive experience with a discharge plan and execution (from a staff perspective and a client perspective). Share a process you have heard or read about that you think may enhance discharge planning.

Each discussion idea or question was presented on a large poster, and the participants were invited to share their answers on sticky notes, which were then applied to the posters. The following themes emerged:

1. Staff are most engaged at work when the team and all care providers involved in a client’s care communicate and work well together, when timelines for diagnostics and treatments are met, and when there is time to discuss concerns with the client and family.
2. Staff values the ability to provide quality client care. Staff values autonomy, good communication, and service areas that trust and respect one another. It is such a good feeling when staff from another service area calls to say “thanks” for the excellent transfer information.
3. From the client perspective, it was revealed that it is important to be informed, to feel listened to by care providers including their physician, and to be very involved in their care planning decisions, including plans for home or for long-term care.
4. Staff and clients described an effective discharge experience as one that is contributed to by the client and all care providers involved, one that is written and understood by the client, and one that is started shortly after the client is admitted to the hospital. The group described two situations in which this has occurred.
5. Two individuals shared that they have read about a new process called “D minus three,” which is related to identifying anticipated client readiness for discharge within three days.

During the discovery stage, the group was getting to know one another and positive relationships were developing.

Dream. The group took the next step and started thinking about “what could be” if those themes in discovery became the norm (Daft, 2011). The group was quick to identify with and agree that the desired future state is safe, high-quality client care that includes timely diagnostics and treatment throughout the client’s hospital stay and beyond the client’s discharge or transfer to another facility. This desired vision included a well-informed team, a well-informed client who understands his or her medical progress and anticipated length of hospital stay, and a discharge plan that is created with the client. Underlying this vision is dignity and respect for all. Relationships and trust within the group continued to grow.

Design. Planning began here in terms of transforming the vision into reality. The group reached consensus that staff in all departments within the hospital and home care must work closely and be highly communicative on a regular basis, and that the client must have a high level of engagement regarding his or her care activities and discharge care planning. The group agreed the physician is an integral component of the team with the same communication and relationship responsibilities as the rest of the team. Ideas for improved processes materialized.

Destiny. Process leads were determined and the group committed to initiate and evaluate the following action steps:

• Implement daily multidisciplinary rounds on the medical unit with a focus on client progress and discharge planning. Discharge lead for each client will be established and close communication with client and team will ensue. Discharge care plans will be in writing and available to all team members in the hospital, in home care, and to the client.
• Create an information pamphlet specific to the client containing relevant information and questions for the client to consider in preparation for discharge.
• The need for long-term care assessment will be established by the client and the multidisciplinary team once the client is stable and care needs are evident. If the client’s needs can be met at home, that assessment will be completed in the home, as will the wait for a placement. If the client needs to remain in 24-hour care, a transfer to an outlying facility will be discussed with the client and family well in advance of the transfer.
• The medical unit will re-establish the use of expected length of stay guidelines. The physician representative in the group will provide educational support to all admitting physicians.
• “D minus three” will be investigated by representatives from the hospital and home care.

The discovery phase should take place again, following implementation of actions to ensure continued reflection and sustainability (Richer et al., 2010).

This was a start for the hospital and so began the positive change for discharge planning as it related to the client, the family, and the work of the multidisciplinary team. The key for success was framing the issues in positive ways, in the building of relationships and trust, and in the human potential to co-create a better future (Daft, 2011; Richer et al., 2010).

6.3 Collaboration and Teamwork

Collaborative Practice

“Many leadership theorists and practitioners have recognized the value of teams in decision making and in accomplishing the work of the organization” (Sanford & Moore, 2015). Collaboration refers to a collective action focused on achieving a common goal “in a spirit of harmony and trust” (Franklin, Bernhardt, Lopez, Long-Middleton, & Davis, 2015, p. 2). The question is what makes this process successful, and what potentiates the synergistic influence?

 

Dynamics of Teamwork

One must acquire an understanding and develop a sense of when it is important to be the leader, the collaborator, and indeed, at times, the follower. Likewise, a keen understanding of being a mentee, and when to transition from a mentee to a mentor, is critical. Ultimately one moves back and forth between these roles over the course of a relationship, including the relationship with the client and relationships within interprofessional collaborative teams. The videos in the following activity illustrate the relational dynamics of successful teams.

 

Summary

Given the increasing complexity of client needs and the shift to community care, leadership and interprofessional collaboration are paramount in our current health system. Sound interprofessional leadership and collaborative practice should be the cornerstone of any nursing leadership practice, whether one is working with or mentoring a group of employees, or engaged with a multidisciplinary team in a complex client’s care.

Client and family engagement has never been more important in our health care system than it is today. As health care providers and nurse leaders, our ultimate role is to meet our client needs with a client- and family-centred philosophy, which aims to understand “where the client is at.” As a registered nurse, make this engagement happen—promote it and nurture it. It is the client’s right, and indeed the client can be one of your greatest resources in determining a plan of care for successful client outcomes.

Leadership and interprofessional collaboration are strengthened with the knowledge and skill set of emotional intelligence, reflective practice, shared leadership, appreciative inquiry, and with the ten lessons in collaboration so eloquently outlined by Gardner (2005). Healthy and positive team dynamics are essential for optimal interprofessional collaborative relationships. It is critical to identify and understand any challenges related to these dynamics and to have transparent team discussions about such challenges early on in your team relationships.

Always seek to understand others, place your focus on strengths, and continuously reflect and learn when things do not go as expected. With these, your nursing world will open to endless possibilities, for the client, for your team, and for you personally.

Additional resources on interprofessional collaboration can be found on the Canadian Nurses Association website.

 

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Bisaria, A. (2011). Intelligence and leadership: Climbing the corporate ladder. CMA Magazine, March/April.

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