Collaborative practice in health systems change: the Nova Scotia experience with the Strengthening Primary Care Initiative.
Recently attention has been focussed on the significance of primary care to the Canadian healthcare system. Nova Scotia. Like other provinces, is seeking ways to improve the healthcare that it provides within a financially constrained publicly funded system. The Strengthening Primary Care Initiative in Nova Scotia (SPCI) was a primary care demonstration project to evaluate specific goals related to primary care. Although the provincial government conceived the SPCI, the approach to its planning and implementation was participatory and consultative. Funded through the federal Health Transition Fund (HTF) (Health Canada 2002) and the government of Nova Scotia, the SPCI involved changes in four communities over a three-year period (2000-2002). These changes included the introduction of a primary healthcare nurse practitioner in collaborative practice with one or more family physicians; remuneration of the family physician(s) with methods other than a solely fee-for-service (FFS) arrangement; and the introduction and utilization of a computerized patient medical record. The SPCI was committed to a consultative process with stakeholders, and this gave rise to several challenges. Initially there was disagreement on the requirement for nurse practitioners at each of the demonstration sites. The Minister of Health confirmed that a nurse practitioner was a required component at each demonstration site. Differences in perspectives on the role of allied health professionals in the SPCI were encountered, and the significance of the role pharmacists have in primary care was not fully appreciated until after the SPCI had started. At the time the SPCI began there was no legislation for nurse practitioners in Nova Scotia; therefore, an approval mechanism for nurse practitioner practice was authorized through the provincial regulatory bodies for nursing and medicine. Malpractice and liability issues, particularly on the part of providers who had never worked with nurse practitioners before, were an initial concern. Recruitment of nurse practitioners into the three rural sites mirrored the difficulties with recruitment of healthcare providers encountered in other parts of rural Canada. The authors discuss their perspectives on the challenges related to interdisciplinary collaboration in health systems change that were encountered during the planning and implementation of the SPCI. Although nurse practitioner Legislation has existed in Ontario and Newfoundland and Labrador for several years, many provinces are grappling with the challenges associated with the introduction of nurse practitioners and collaborative practice. This paper conveys the experience of one province and will be of interest to administrators, educators and practitioners elsewhere in Canada who are engaged in primary healthcare renewal.