This commentary reviews the content of the lead papers through the lens of primary healthcare renewal (PHCR). Although PHCR has been on the national agenda for decades, only since the turn of the century has real progress been made with emerging new practice models based on inter-professional team care. While much is expected, relatively little is known of the function and effectiveness of such teams in Canada. As well, information regarding healthy workplaces has focused on individual professional groups rather than an inter-professional workforce. Much of the knowledge currently available regarding team effectiveness and healthy workplaces comes from the hospital sector and may not be completely transferable. The work of the Interprofessional Education for Collaborative Patient-Centred Practice initiative and the results of the Health Transition Fund and Primary Health Care Transition Fund are additional key sources of research and knowledge transfer to guide the education, function and evaluation of inter-professional teamwork in these new primary healthcare practice models.

Thank you for the opportunity to review and comment on the lead article by Shamian and El-Jardali, which focuses directly on the issues pertaining to healthy workplaces, and the companion article by Clements, Dault and Priest, which views healthy workplaces through the lens of effective teamwork. As nurse practitioner and family physician partners, we have worked together since 1988 as clinicians in a community health centre, as researchers and facilitators for Health Transition Fund (HTF) and Primary Health Care Transition Fund (PHCTF) projects and as co-authors on collaborative practice in primary healthcare (PHC) settings (Bailey et al. 2006; Way and Jones 1994; Way et al. 2000). Therefore, it will come as no surprise that we have viewed both articles through the lens of primary healthcare renewal (PHCR).

The Call for PHCR

The last decade of the 20th century in Canada, as in other industrialized countries, witnessed an overwhelming focus on healthcare reform. Most countries undertook significant changes in both the organization of PHC and the hospital sector. However, although making significant changes in hospital care through consolidation and restructuring, Canada made little progress in PHCR in the 1990s (Decter 2004; Hughes Tuohy 2004; Hutchison 2004).

In comparison, the first six years of this century have seen marked progress. Innovations are under way in all jurisdictions with the introduction of new practice models (Canadian Institute for Health Information 2003; Wilson et al. 2004). Action has resulted from the realizations that (1) the gains of the 1990s with hospital sector restructuring would be lost without a more robust and comprehensive package of PHC services, (2) there are increasing needs of Canadians for assistance with chronic illness and disease prevention requiring PHC services and (3) there is a growing concern regarding inadequate health human resources, especially of physicians and nurses (Decter 2004; Maiona 2004).

The Importance of Inter-professional Teamwork to PHCR

Care delivery through inter-professional teams has been recognized consistently as a key component of PHCR (Canadian Nurses Association 2002; College of Family Physicians of Canada 2000; Standing Senate Committee on Social Affairs, Science and Technology 2002b). Health policy reports from Hastings and LaLonde through to Fyke, Clair, Mazankowski, Kirby and Romanow have called for the implementation of teams (Commission on the Future of Health Care in Canada [Romanow Report] 2002; Saskatchewan Commission on Medicare [Fyke Commission] 2001; Hastings 1970; Health Canada 2003, 2004a; LaLonde 1975; Premier's Advisory Council on Health 2001; Standing Senate Committee on Social Affairs, Science and Technology [Kirby Report] 2002a; Study Commission on Medicare [Clair Commission] 2000). There is now substantial commitment on the part of federal, provincial and territorial governments to move toward inter-professional team care. It is postulated that collaborating teams will accomplish the following:

1. Be better able to deal with the increasing complexity of care
   
2. Increase focus on health promotion and disease prevention
   
3. Coordinate and meet the needs of the population being served
   
4. Keep abreast of new developments (including technological advances and best practices)
   
5. Better integrate care with community and institutional services
   
6. Make the best use of health human resources

While much is expected of this transition to teamwork, current health providers have little experience in working in PHC teams. Community health centres especially in Ontario and Centre Locale Service Communautaire in Quebec have been in existence since the 1970s. However, solo or small-group physician practices are the models that predominate in primary care delivery.

Traditionally, health providers have been prepared for their roles in "educational silos." The need to now prepare providers at both the pre-licensure and post-licensure levels for teamwork is recognized and politically supported. In the 2002 report Building on Values: The Future of Health Care in Canada, Roy Romanow recommended a review of "current education and training programs for health care providers to focus more on integrated provider education approaches for preparing health care teams" (Commission on the Future of Health Care in Canada 2002). The 2003 Health Accord resulted in the formation of Health Canada's Pan-Canadian Health Human Resource Strategy (Health Canada 2003). One of the three key initiatives under this strategy is the Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP) initiative (Health Canada 2006b).

Clements, Dault and Priest refer to the great strides made by the IECPCP. To date, this initiative has accomplished the following:

1. Established a National Expert Committee to guide its work
   
2. Commissioned a major literature review and environmental scan (Health Canada 2004b), with a resulting IECPCP model (D'Amour and Oandasan 2005)
   
3. Commissioned a series of nine research papers to fill gaps identified in the literature review
   
4. Funded 20 inter-professional learning projects across Canada
   
5. Supported the development of the Canadian Interprofessional Health Coalition
   
6. Commissioned complementary projects to help address major barriers to the transition to inter-professional care

These complementary projects include addressing accreditation, legislation and regulation and liability issues. Eight of the 20 learning projects involve PHC settings (Health Canada 2006b).

Team Effectiveness in PHC Delivery

While the transition to team care has been embedded into PHCR initiatives, relatively little is known of the function and effectiveness of such teams. In their systematic review for the IECPCP of the existing valid international empirical research, Zwarenstein et al. (2005) determined that the majority of rigorously evaluated studies occurred in the in-patient hospital setting and that "the impact of teams in primary care is essentially untested."

The Canadian Health Services Research Foundation (CHSRF) teamwork synthesis paper, reviewed by Clements, Dault and Priest, refers to important differences between team function across healthcare settings that may not allow for the direct transfer of knowledge from the hospital to the PHC sector. Systemic comparisons of healthcare teams across settings have yet to be done. It is also unclear whether instruments used to measure team structures and processes in one setting will be valid and reliable in another. To illustrate, qualitative interviews conducted for the synthesis paper identified differences in the "boundedness" of teams. A "bounded" team, descriptive of the hospital sector, is often co-located, is supported by resources and management or administrative hierarchies and views itself as a social entity. Providers working in the new PHC practice models as core members may form a bounded team. However, they will also collaborate in "virtual" teams that are fluid in order to respond to patient needs and the availability of health resources. Traditionally, primary care practices have required few structures (policies and procedures) or resources to support team function (Oandasan et al. 2006).

As we discussed in our working paper written for the CHSRF teamwork synthesis paper, the Canadian research literature regarding the effectiveness of PHC teamwork is particularly limited. The synthesis results of pilot projects associated with the HTF and the anticipated results of the PHCTF projects are the principal resources.

The HTF was created to encourage and support evidence-based decision making in healthcare reform as a joint federal, provincial and territorial effort. The HTF synthesis paper on PHC summarizes the key learning from 65 projects. The section on collaborative practice refers specifically to four studies that focused on team building, education and training (Mable and Marriott 2002).

The PHCTF supported transitional costs of implementing large-scale PHCR initiatives to bring about fundamental and sustainable change in PHC organization and delivery. The vast majority of national, multi-jurisdictional and provincial or territorial projects include collaborative practice objectives and activities with the potential for greatly increasing our understanding of the effectiveness of teamwork. The final project reports were received at the end of September 2006. Efforts now focus on synthesis and dissemination. Synthesis products will include summaries and fact sheets for each initiative; a series of analytical reports, one of which will report on collaborative care; and a national conference in February 2007 (Health Canada 2006c). Knowledge transfer from the PHCTF projects to assist the development and evaluation of inter-professional teamwork in the emerging PHC practice models is essential.

Healthy Workplaces and PCHR

Clements, Dault and Priest identify the link between teamwork and a healthier and happier workforce. As Shamian and El-Jardali point out, the healthy workplace agenda has been embedded in the Health Human Resource Strategy as part of recruitment and retention initiatives (Health Canada 2006a). However, it is unclear that healthy workplace strategies have been embedded into PHCR.

Shamian and El-Jardali indicate that robust evidence has been accumulated on the impact of healthy workplaces on workers' health and well-being, quality of care and patient safety, organizational performance and societal outcomes. With their suggestions regarding next steps for research, the authors point out that much of what is known regarding healthy workplaces comes from nursing. Yet, the research for nursing is incomplete, lacking information not only regarding long-term care, public health and home care but also primary care settings. Research has focused on individual professions and not on the inter-professional workforce as an entity. As with teamwork effectiveness, the direct transference of knowledge and impact measures to other health professionals and teams and from the hospital to the PHC sector may not be fully appropriate.

From the National Survey on the Work and Health of Nurses Nurses were much more likely to work overtime than employees overall. Three in ten nurses said they regularly worked paid overtime, while an even greater number of nurses (1 in 2) said they regularly worked unpaid overtime - about twice the national average for female employees. https://secure.cihi.ca/cihiweb/dispPage.jsp? cw_page=AR_1588_E&cw_topic=1588

Summary and Conclusion

Our review and comments are based on viewing team effectiveness and health workplaces through the lens of PHCR. Although much of the findings can be extrapolated to community and primary care settings, there is a clear need for increased understanding of PHC practices regarding teamwork and workplace issues. The emerging practice models across Canada especially need to include processes and measures that ensure team effectiveness is understood, encouraged, measured and rewarded and that PHC practices are "healthy workplaces."

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