The analysis identified two contrasting types of factors affecting teamwork — intrinsic and extrinsic factors. Intrinsic components of nurse–doctor interprofessional relationships affected the ability or otherwise of nurses and doctors to work together in teams. Extrinsic factors external to those relationships dictated the success or otherwise of good teamwork. The findings about these extrinsic factors are reported in this paper.
Of the intrinsic factors, interprofessional respect and the subsequent development of trust were found to be key characteristics of successful and enduring nurse–doctor relationships, as previously described.16 However, while interprofessional respect and the development of interprofessional trust are important and essential prerequisites for participative safety in teams,2 and participative safety is a necessary component of effective teamwork, it is not seen as sufficient on its own to result in fully effective teamwork.
Interviewees in this study repeatedly referred to a number of factors external to individual relationships that had the potential to generally affect the ongoing quality of nurse–doctor teamwork and the ability to undertake and maintain fully collaborative practice. Interviewees commented on these extrinsic factors in relation to the following three key areas: current health system policy and funding models for primary care; organisation within practices; and education for health professionals.
Health systems
At the health systems level, current funding models for primary care services were seen as problematic, even though practices of all types were receiving increased population-based funding by the time of the study. Population-based funding was described as potentially supporting teamwork, because, if adequate, it was seen to support all practice activity, not just patient contact time. However, the population-based funding only applied to a proportion of practice income, with the rest either coming directly from patients as a fee-for-service, or from other task-based funding streams such as the Accident Compensation Corporation (ACC — New Zealand's no-fault accident insurance system).
These other funding structures were identified as a barrier to effective teamwork and the most appropriate skill-mix. This contributed to inefficient use of both nurse and doctor time, particularly in a fee-for-service structure based around higher remuneration for doctor–patient contact than nurse–patient contact.
Interviewees described how this directly affected workload:
‘if they [the nurses] were to do that [task] autonomously we wouldn't get funded as much whereas if we do it we get to claim [more] ACC funding for it which is ridiculous … the same job but done by different people but that is the way the system works.’ (Interview C, paragraph 106, doctor self-employed in private practice)
In salaried situations, even though the immediate business responsibilities were reduced, ‘it's a huge relief [to be salaried]’ (Interview K, doctor, paragraph 455). Doctors were still under pressure to consult with as many patients as possible, since the funding to the organisation was still, in some cases, dependent on the number of doctor–patient contacts.
Interviewee K explained that in his practice the funder had eventually agreed to look at team–patient contacts, rather than doctor–patient contacts, as a measure of access to the service, and that this supported much better teamwork:
‘The motivation is that the patient gets looked after; it doesn't matter who [does the work] … as long as they get looked after.’ (Interview K, paragraph 517, doctor employed in salaried practice)
Organisation within practices
At practice level both doctors and nurses identified many of the stresses and challenges inherent in running a healthcare business (whether by individual doctors, nurses, or an organisation). Those working in salaried practices in high-need areas (where the service is often wholly bulk-funded with little or no expectation of a patient part-fee) spoke of the need to maximise access for patients. In contrast, those working in private businesses (where capitated funding is only partial and patients pay part charges on a fee-for-service basis) talked of the difficulties in running a successful business for primary healthcare provision.
The concerns of these two interviewees working in private practice, one in a nurse-led and owned practice and the other in a doctor-led and owned practice, reflected the need to run a healthcare business efficiently:
‘It's generally very hard for practices to make money these days, isn't it, so in fact one way of turning that around is maybe utilising the nurses more effectively, but then at the same time I think … the overall job satisfaction then for a doctor might not be quite so good, because [when they are there] they would perhaps be seeing way more patients.’ (Interview I, paragraph 406, nurse employed in nurse-owned and led private practice)
‘Financial viability in [New Zealand] general practice is something that underpins everything you do … if you're not in front of the patient, you're not earning money … you need to maximise contact time, maximise charging, leave off other things that we are not going to be reimbursed for.’ (Interview J, paragraphs 112, 583, 602, doctor, independent contractor)
At practice level the following were mentioned repeatedly: good systems for patient flow-through; adequate space in which to work (especially for nurses); uninterrupted and dedicated time for meetings; open communication; and valuing of all points of view regardless of professional discipline or employment status. These were seen not only as essential for good teamwork and interprofessional practice but also for running a good business:
‘We have the doctors' and nurses' meetings every second month; we have all-staff-right-across-the-board meetings every other month. We have strategic planning once a year, everyone is very approachable. [In our practice] I think everyone feels they can say … about things that are worrying them. We have a stress monitor that we fill in at our staff meetings … red is the danger area so the practice manager monitors that … and she can start putting things in place.’ (Interview N, paragraphs 85–88, 92, nurse employed in private practice)
In comparison, effective teamwork was precluded in practices with inefficient work spaces, no commitment to regular meetings, and no opportunity for sharing of ideas and common goals:
‘In some practices I think that you just don't have that team scene at all … some practices don't have staff meetings full stop … so how can you have collaboration if people are not communicating?’ (Interview A, paragraph 55, nurse employed in private practice)
A doctor interviewee identified lack of attention to practice systems as a constant source of stress at a past workplace:
‘So you have this patient who is half sorted and you have got nowhere to put them, and … they've got their bandages down … and I think a lot of the stress came from the fact that … not enough attention had been paid to … basic systems … you get your systems right, everything works, everything works without you thinking about it.’ (Interview J, paragraph 528, doctor, independent contractor)
In New Zealand doctors often own general practices with nurses being employees. Salaried practices, whether in high-needs areas or not, where both nurses and doctors are employed alongside each other, removed this direct employer/employee relationship. This factor was sometimes perceived to be a barrier to effective teamwork.21 Whether the barrier is perceived or actual, the effect can be significant, as this nurse who worked with several practices described:
‘When nurses are employed [by the doctor], that dynamic within a relationship is quite hierarchical, whether implied, perceived, or actual … [when we are all salaried] it puts people on a level playing field so “it's not I'm working for the doctor but we are working for the patient”.’ (Interview P, paragraphs 316, 332, nurse employed by a primary health organisation)
Several interviewees in the study worked in practices where everyone was salaried, and some described this employment arrangement as promoting teamwork. This in turn supported and enhanced the development of better working relationships.
Here, a nurse previously employed in salaried practice, now employed in a doctor-owned practice, describes the difference:
‘I think that the personnel there … were conducive to working as a team, but also the fact that we were all salaried made a huge difference. I mean everybody was on the same sort of level.’ (Interview A, paragraph 55, nurse employed in private practice)
Good teamwork was readily identified by some who worked in private practices, but this nurse considered it far from universal:
‘I think it is very variable actually. I think I work in a really good practice … in terms of how people get on, how people's skills are valued … and where I know I can make a good contribution and where people are appreciative … doctors and patients and receptionists, everyone, and nursing colleagues too. [But] I'm on the practice section, which is the local practice nurse committee … I certainly hear a lot of gripes … I mean some practices don't probably even have team meetings or anything like that, and so I think … I do work for a good practice and I think it is probably exceptional rather than the norm.’ (Interview N, paragraphs 188–192, nurse employed in private practice)
Nevertheless, findings in this study pointed towards good overall business practice as the key to successful teamwork, not the contractual arrangement alone, similar to findings in the UK when new Personal Medical Services projects were reviewed.22
However, in privately owned practices, the responsibility for good organisation or otherwise is heavily dependent on the individual owner-doctors (or, very occasionally, owner-nurses). When doctors have both clinical and business roles within a practice, the necessary expertise and time for the work of running a business may be compromised. Until recently, there has been little routine accountability for good business practice in general practice, although since 2005 the Cornerstone practice accreditation programme has provided a now widely accepted voluntary benchmark.23
