Area of Health Services and Policy Research, Department of Family Medicine, McGill University, Montreal, Québec, Canada.
BMC Fam Pract. 2010 Feb 22;11:15. doi: 10.1186/1471-2296-11-15.
Since 2002 the Health Ministry of Québec (Canada) has been implementing a primary care organizational innovation called 'family medicine groups'. This is occurring in a political context in which the reorganization of primary care is considered necessary to improve health care system performance. More specifically, the purpose of this reform has been to overcome systemic deficiencies in terms of accessibility and continuity of care. This paper examines the first years of implementation of the family medicine group program, with a focus on the emergence of the organizational identity of one of the pilot groups located in the urban area of Montreal.
An in-depth longitudinal case study was conducted over two and a half years. Face to face individual interviews with key informants from the family medicine group under study were conducted over the research period considered. Data was gathered throuhg observations and documentary analysis. The data was analyzed using temporal bracketing and Fairclough's three-dimensional critical discourse analytical techniques.
Three different phases were identified over the period under study. During the first phase, which corresponded to the official start-up of the family medicine group program, new resources and staff were only available at the end of the period, and no changes occurred in medical practices. Power struggles between physicians and nurses characterized the second phase, resulting in a very difficult integration of advanced nurse practitioners into the group. Indeed, the last phase was portrayed by initial collaborative practices associated with a sensegiving process prompted by a new family medicine group director.
The creation of a primary care team is a very challenging process that goes beyond the normative policy definitions of who is on the team or what the team has to do. To fulfil expectations of quality improvement through team-based care, health care professionals who are required to work together need shared time/space contexts to communicate; to overcome interprofessional and interpersonal conflicts; and to make sense of and define who they collectively are and what they do as a clinical team.
自 2002 年以来，加拿大魁北克省卫生部一直在实施一项名为“家庭医学小组”的初级保健组织创新。这是在一个政治背景下进行的，人们认为有必要对初级保健进行重组，以提高医疗保健系统的绩效。更具体地说，这项改革的目的是克服在可及性和护理连续性方面的系统性缺陷。本文考察了家庭医学小组计划实施的头几年，重点是研究所在的蒙特利尔市区的一个试点小组的组织身份的出现。
进行了为期两年半的深入纵向案例研究。在研究期间，对所研究的家庭医学小组的主要信息提供者进行了面对面的个人访谈。通过观察和文献分析收集数据。使用时间框架和 Fairclough 的三维批判性话语分析技术对数据进行分析。
在所研究的期间内确定了三个不同的阶段。在第一阶段，即家庭医学小组计划的正式启动阶段，只有在该期间结束时才提供新的资源和人员，医疗实践没有发生变化。第二阶段的特点是医生和护士之间的权力斗争，导致高级执业护士非常难以融入小组。实际上，最后一个阶段是以与新的家庭医学小组主任推动的意义赋予过程相关的初始协作实践为特征的。
创建初级保健团队是一个极具挑战性的过程，超出了谁在团队中或团队必须做什么的规范性政策定义。为了通过团队为基础的护理提高质量的期望，需要共同工作的医疗保健专业人员共享沟通的时间/空间背景；克服专业间和人际间的冲突；并理解和定义他们作为临床团队的集体身份和所做的工作。
