Marcia Hills

Community-based participatory action research: transforming multidisciplinary practice in primary health care

OBJECTIVES Health care systems throughout the world are in the process of restructuring and reforming their health service delivery systems, reorienting themselves to a primary health care (PHC) model that uses multidisciplinary practice (MDP) teams to provide a range of coordinated, integrated services. This study explores the challenges of putting the MDP approach into practice in one community in a city in Canada. METHODS The data we analyzed were derived from a community-based participatory action research (CBPAR) project, conducted in 2004, that was used to enhance collaborative MDP in a PHC center serving a residential and small-business community of 11,000 within a medium-sized city of approximately 300,000 people in Canada. CBPAR is a planned, systematic approach to issues relevant to the community of interest, requires community involvement, has a problem-solving focus, is directed at societal change, and makes a lasting contribution to the community. We drew from one aspect of this complex, multiyear project aimed at transforming the rhetoric advocating PHC reform into actual sustainable practices. The community studied was diverse with respect to age, socioeconomics, and lifestyle. Its interdisciplinary team serves approximately 3,000 patients annually, 30% of whom are 65 years or older. This PHC centers multidisciplinary, integrated approach to care makes it a member of a very distinct minority within the larger primary care system in Canada. RESULTS Analysis of practice in PHC revealed entrenched and unconscious ideas of the limitations and boundaries of practice. In the rhetoric of PHC, MDP was lauded by many. In practice, however, collaborative, multidisciplinary team approaches to care were difficult to achieve. CONCLUSIONS The successful implementation of an MDP approach to PHC requires moving away from physician-driven care. This can only be achieved once there is a change in the underlying structures, values, power relations, and roles defined by the health care system and the community at large, where physicians are traditionally ranked above other care providers. The CBPAR methodology allows community members and the health-related professionals who serve them to take ownership of the research and to critically reflect on iterative cycles of evaluation. This provides an opportunity for practitioners to implement relevant changes based on internally generated analyses.

Nurses' levels of empathy and respect in simulated interactions with patients

The interpersonal skills demonstrated by a nurse affect the quality of care delivered to patients. The patients’ sense of wellbeing and the nurses’ understanding of patient response to medical treatment result from such interpersonal care. The present study was a response to the view that a clear description of the interpersonal skills of practicing nurses is needed to provide a basis for planning the curriculum for training nurses. Available components exist for developing the interpersonal skills of helping professionals but, typically, have not been utilized in nursing education. Most training programs deal with such skills at the conceptual level, providing little or no skill demonstration or assessment. Consideration of such training programs is important because effective interpersonal skills were once thought to be the unique tool of psychiatric nurses, but are currently viewed by such authors as Pluckman (1978) as necessary tools of all professional nurses regardless of area of practice. Initial interactions between nurses and patients on a general medical-surgical unit were selected for study because such interactions establish a basis for effective helping (Combs et al., 1978). Patients’ requests or reactions typically require an instantaneous response from nurses. Interactions which are characterized by empathy, warmth and respect are considered to facilitate the development of the nurse-patient relationship (Pluckman, 1978; Watson, 1979). In a majority (89%) of studies of patient outcomes reviewed by Gerrard (1978), positive patient responses were shown to be related to the interpersonal skills of health professionals. Such responses included relief from pain and distress, improved pulse and respiration rates, and patient reports of reduced worry and anxiety. In an early study of nurses’ interpersonal skills, Mathews (1962) had 122 staff nurses respond to nine simulated nurse-patient situations in a questionnaire format. Only eight nurses in her sample gave responses which encouraged the patient to disclose what he was experiencing. In a later study by Hays (1966), nurses were asked to write verbatim notes

University-college collaboration: rethinking curriculum development in nursing education.

The behavioral approach to curriculum development is inadequate to educate nurses to practice in the future health care system. As a result of a government initiative, a Canadian university and four community colleges had an opportunity to collaborate on development of a nursing program and thereby consider alternative approaches to curriculum development. This paper describes the process used to develop this curriculum and provides an overview of the curriculum development model that emerged. A community development process characterized by a commitment to be futuristic and visionary about nursing while making curriculum decisions was established. The curriculum model that emerged used a phenomenological exploration of our common vision for nursing in the future. The resulting curriculum is based on a human science paradigm that encourages nurses to work from a health promotion perspective with an ethic of caring.

Education and Practice Collaboration: A Strategy for Curriculum Development

Five schools of nursing in British Columbia formed a collaborative partnership in 1989; four represented diploma programs, and one a post-RN program. Their partnership benefited each in the development of a baccalaureate nursing curriculum. Committed to the principle of a curriculum being driven by practice, rather than the reverse, the collaborative partners employed a variety of strategies to include nurses from practice in the development of the curriculum. One strategy used by the partnership was a Delphi survey of nurses in practice. This article describes the results of this survey and their implications for nursing curricula.

Primary Health Care: A Preferred Health Service Delivery Option for Women

It is well known that gender is a determinant of health, but less understood is whether differences in health status attributable to gender can be mitigated through the implementation of primary health care. Primary health care, notably distinct from primary care, refers to a wide-ranging approach to the delivery of a comprehensive variety of health services. This article traces the similarities between primary health care and women-centred care from their overlapping philosophical foundations to the similar health, social, and economic benefits of both approaches. It is argued that investments in primary health care positively impact womens health, and, as such, should be a preferred option for the delivery of womens community health services. Several models of health service delivery that operate in accordance with principles of primary health care and also address the key tenets of womens-centred care are examined and their merits are compared. The article also identifies the major impediments to the adoption of both primary health care and womens-centred care approaches.

Women-centred care: working collaboratively to develop gender inclusive health policy.

We argue that policies for women-centred care ought to be developed to address the inadequacy of the current health system to recognize that women are affected differently by health policies and programs and that gender is a determinant of health; furthermore, such policies must be created with representatives from relevant health professional organizations so that the policies are translated and operationalized at the organizational and practice level. A collaborative research process, co-operative inquiry, was used to conduct the research. This process engages the participants in rigorous iterations of action and reflection. The result was a clear definition of women-centred care, a set of general guidelines for practice, and specific changes to existing organizational policies. The process and the product of the research built a bridge between existing macro government policies and the guidelines, standards, and ethical codes of the professional health associations.

Vers un modèle d'évaluation de l'efficacité des interventions communautaires en promotion de la santé : compte-rendu de quelques développements Nord-américains récents1

The current systematic reviews to assess the effectiveness of community-based health promotion projects, be they quantitative (numerical meta-analyses) or qualitative (narrative reviews), both have significant drawbacks. Out of the work conducted for two initiatives, the developments for the Global programme on health promotion effectiveness carried at by the North American Region out of the International Union of Health Promotion and Education (IUHPE), as well as the work conducted for the ECIP (effectiveness of community interventions project) of Health Canada, a new way to approach the issue of effectiveness is proposed. Based on a «realist synthesis» epistemological position, this approach has led us to the first formulation of a framework aiming at identifying the mechanisms that explain why local programs are successful.

Being, Becoming and Belonging Getting to Ambassadorship, a New Metaphor for Living and Collaborating in the Community

For non-profit social agencies, new contract funding structures have increased their vulnerability. Collaboration is a strategy for dealing with reductions in the availability of funding and the pressures to ‘do more with less’ but there are few illustrations of how this might be achieved. The main body of literature devoted to creating models for collaboration was developed in the world of the new public administration and market models. Many of the less formal approaches consist of checklists and mock contracts that strive to account for variables that may affect collaborations. While valuable for focussing attention on key aspects, these approaches assume a static set of factors that predict successful collaborations. In this project, an alternative to these types of functional or instrumental methods of partnership development was created through a particular type of action research known as co-operative inquiry. Through the iterative stages of reflection and action, a new conceptualization of collaboration evolved and a subsequent model developed. The model is based on criteria derived from the experiences of the community members and accounts for the dialectical relationship of the individual agency and the collective non-profit sector. Through the process of the research, a transformation in thinking, purpose and practice occurred, resulting in a new metaphor for living and working in the community.

Transatlantic Student Exchange between Canada and Europe: Experiences from the CEIHPAL Project.

International student mobility amongst and between countries has become increasingly common and forms a central feature of the global higher education system. This paper examines the key learning experiences relating to the student mobility component of the Canadian-European Initiative for Health Promotion Advanced Learning (CEIHPAL) project. CEIHPAL was a unique and innovative project that fostered advanced intercontinental education and learning in health promotion from 2005–2008. With co-funding from the European Commission and the Canadian Government, the project facilitated institutional, student and faculty cooperation, by developing a high level of international communication. In particular, this paper focuses on the student mobility component and experiences of the CEIHPAL programme, a central part of the project activities. Feedback from both Canadian and European students themselves is used to document their participation in the programme, including the benefits derived from taking part as well as the problems and difficulties they encountered.

Assets Based Interventions: Evaluating and Synthesizing Evidence of the Effectiveness of the Assets Based Approach to Health Promotion

The chapter is focused mainly on the intervention research and evaluation of actions aimed at strengthening and supporting health assets as a way of producing healthy communities and individuals. There is a need to re-think traditional assumptions related to evaluating the effectiveness of health interventions aimed at strengthening health assets as opposed to eliminating or curing diseases. Working from a concrete example of a 4-year collaborative project in Canada aimed at developing a framework for evaluating the effectiveness of community interventions to promote health and build community capacity. The chapter introduces a series of profound methodological challenges that this type of evaluation research presents, along with a discussion of the attempt to use a ‘realist synthesis’ approach to addressing these challenges.