Primary Health Care Research & Development 2017; 18: 492–506

doi:10.1017/S1463423617000354 RESEARCH
The collaboration of general practitioners and
nurses in primary care: a comparative analysis
of concepts and practices in Slovenia and Spain
Kerstin Hämel1 and Carina Vössing2
1
Professor of Public Health, Health Services Research in Nursing, School of Public Health, Bielefeld University, Germany
2
Research Associate, Working Group Health Services Research & Nursing Science, School of Public Health, Bielefeld
University, Germany

Aim: A comparative analysis of concepts and practices of GP-nurse collaborations in pri-

mary health centres in Slovenia and Spain. Background: Cross-professional collabora-
tion is considered a key element for providing high-quality comprehensive care by
combining the expertise of various professions. In many countries, nurses are also being
given new and more extensive responsibilities. Implemented concepts of collaborative
care need to be analysed within the context of care concepts, organisational structures, and
effective collaboration. Methods: Background review of primary care concepts (literature
analysis, expert interviews), and evaluation of collaboration in ‘best practice’ health centres
in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews,
presentations, observations, and group discussions with professionals and health centre
managers. Findings: In Slovenian health centres, the collaboration between GPs and
nurses has been strongly shaped by their organisation in separate care units and pre-
dominantly case-oriented functions. Conventional power structures between professions
hinder effective collaboration. The introduction of a new cross-professional primary care
concept has integrated advanced practice nurses into general practice. Conventional hier-
archies still exist, but a shared vision of preventive care is gradually strengthening attitudes
towards team-oriented care. Formal regulations or incentives for teamwork have yet to be
implemented. In Spain, health centres were established along with a team-based care
concept that encompasses close physician–nurse collaboration and an autonomous role
for nurses in the care process. Nurses collaborate with GPs on more equal terms with
conflicts centring on professional disagreements. Team development structures and
financial incentives for team achievements have been implemented, encouraging teams to
generate their own strategies to improve teamwork. Conclusion: Clearly defined struc-
tures, shared visions of care and team development are important for implementing and
maintaining a good collaboration. Central prerequisites are advanced nursing education
and greater acceptance of advanced nursing practice.

Key words: cross-professional; nursing roles; primary health care; Slovenia; Spain;
team-based
Received 30 October 2016; revised 23 April 2017; accepted 20 May 2017;
first published online 20 June 2017

Background
Correspondence to: Prof. Dr. Kerstin Hämel, Bielefeld University,
School of Public Health, Universitaetsstrasse 25, 33615 Bielefeld, Current discussions in health studies concerning
Germany. Email: [email protected] the need for high-quality health care are focussed
© Cambridge University Press 2017. This is an Open Access article, distributed under the terms of the Creative Commons
Attribution licence (http://creativecommons.org/licenses/by/4.0/), hich permits unrestricted re-use, distribution, and reproduction
in any medium, provided the original work is properly cited.
 The collaboration of general practitioners and nurses in primary care 493

on cross-professional1 teamwork as a key issue in care concepts implemented in many countries in the
improving health care quality (cf. Thylefors et al., past few years have strengthened nurses’ role as a
2005; Samuelson et al., 2012). The view that cross- first contact partner in primary health endeavouring
professional collaboration is necessary for high- to establish long-standing nurse–patient relation-
quality care is, however, not new; as early as 1978, ships (cf. Schaeffer et al., 2015; Kendall and Bryar,
the International Conference on Primary Health 2017). Consequently, this requires a close colla-
Care (Alma-Ata) pronounced cross-professional boration between the personal GP and the personal
health teams as essential to meeting the multiple nurse (cf. Hämel and Schaeffer, 2014).
(primary) health needs within the community Optimally, each health professional in a cross-
(WHO, 1978). Since then, many countries have professional team is responsible for his or her
followed this vision, implementing primary care specialised field. Combining the skills, experience
teams as well as multi-professional primary health and expertise of each profession in a team is seen
centres and thus providing comprehensive care as the main benefit: the team members have access
by integrating health promotion activities, pre- to diverse knowledge and competencies; this
ventive, curative, and rehabilitative care (Saltman enables the team to provide a broad spectrum of
et al., 2006; WHO, 2008; Hämel and Schaeffer, services and generate a more holistic view of the
2014). In the light of today’s fast-ageing population patients’ situation (Thylefors et al., 2005: 102–103).
and the increasing number of patients with Collaboration between the professionals helps
complex needs, the potential for cross-professional prevent shortcomings of sequential care processes,
collaboration in the field of primary health care facilitates learning from other disciplines and
has become even greater than the founders of the increases patient satisfaction as well as job
Alma-Ata Declaration and initiators of health satisfaction (Thylefors et al., 2005; Wen and
teams originally imagined. The World Health Schulmann, 2014; Morgan et al., 2015).
Report 2008 (46f) indicated that primary care Although criticised for certain methodological
teams are better able to optimise the care process shortcomings, some studies investigating the
by assuming the coordinator role, thus avoiding effects of team-based care have provided evidence
task fragmentation and improving the continuity of positive patient outcomes such as higher self-
of care even for high-demand patients. perceived health and life satisfaction as well as
Primary health care can actually be seen as a key higher satisfaction with health care (Martin et al.,
impetus for innovation in cross-professional colla- 2010; Schepman et al., 2015). Other studies
boration. Working in cross-professional health denote cost-effectiveness of team-based approa-
teams has challenged care concepts dominated by ches in primary care (Jacobson and HDR Inc.,
physicians and led to the implementation of new and 2012; Mundt et al., 2015). Even so, research
more extensive responsibilities for nurses, midwives, findings regarding effectiveness and outcomes of
physiotherapists, psychologists, social workers cross-professional collaboration, in general,
and other health professionals working alongside remain ambiguous (Barrett et al., 2007).
family physicians to promote patient-centred and The most common obstacles to collaborating work
community-oriented care (Kendall, 2008; Freund in cross-professional teams evolve around organisa-
et al., 2015: 738; Kringos et al., 2015: 31). Thus, tional and professional separatism (Jamieson
team-based primary health care has led to a greater and Illsey, 1989; Frenk et al., 2010). Researchers
professionalisation of nurses and other non-medical have established that for effective teamwork
health professionals, freeing them from their between GPs and nurses collaboration needs to be
customary subordinate role in health care. Initial based on an understanding of each other’s profes-
research shows that particularly nurses have bene- sional identity and specific role in the care process as
fited from this recent development. New chronic well as on mutual respect and trust (Pullon, 2008;
Jaruseviciene et al., 2013). Conventional hierarchical
1
structures between health professionals hamper
With reference to Thylefors et al. (2005: 112), we use the term collaboration through differences in status and
‘cross-professional teamwork’ in the broader sense to indicate
‘all situations where professionals from different disciplines are sustained professional rivalry (Nancarrow et al.,
collaborating in a team. It does not say anything about how the 2013; Schadewaldt et al., 2013; Supper et al., 2015;
teamwork is organised’. Schaeffer and Hämel, 2017). The prospect of
Primary Health Care Research & Development 2017; 18: 492–506
494 Kerstin Hämel and Carina Vössing

working (more) independently of the physician is a operated cross-professional centres for many years
key impetus for effective collaboration on equal now. It can hence be assumed that physicians and
footing. However, this is not a matter of course, not nurses are well experienced in collaboration
even for the well-educated and highly trained nurse (Albreht et al., 2009; Dedeu et al., 2015). In addi-
practitioners (Schadewaldt et al., 2013). tion, many Slovenian and Spanish primary health
In addition, research has confirmed that centres have increased their efforts as of late to
co-location and a ‘robust organisation’ with formal strengthen teamwork between GPs and nurses in
supportive structures for team-oriented care facil- their primary health centres. The following paper
itate effective teamwork (Oandasan et al., 2009; will begin with a short sketch of each country’s
Munro et al., 2013; Schaeffer and Hämel, 2017). primary care concept. That will be followed by a
Advantageous are also shared goals, good closer examination of their approaches to team-
leadership, clear task division between health work and recent developments. The prospects for
professionals, strong communication and regular cross-professional collaboration between GPs and
appraisal of team success (Bodenheimer, 2007: 6; nurses will then be compared and discussed.
Xyrichis and Lowton, 2008: 149–150; Kennedy
et al., 2015: 362). Consequently, health systems
with fragmented health care services can be parti- Method
cularly challenging to cross-professional colla-
boration: a long-established organisational The findings presented in this paper are focused on
separation of primary care services – health, social, concepts and practices of cross-professional colla-
preventive and curative care – promotes incom- boration of GPs and nurses in Slovenian and
patible objectives and interests of the involved Spanish health centres. They draw on a narrative
organisations (Delamaire and Lafortune, 2010; review of literature available in English on the
Schaeffer and Hämel, 2017). development of cross-professional primary health
As primary health care has had to adapt to care in Slovenia and Spain combined with a
changing patient needs, professional tasks and qualitative analysis of the current situation in
roles have changed, for example, professionals selected health centres based on semi-structured
now have to support patients in their self- expert interviews, presentations, group discussions
management of chronic conditions. In the last and recorded observations.2
years, many countries have also encouraged a shift The literature used for the analysis included
in responsibilities for certain tasks from physicians academic studies published in Slovenia and Spain
to nurses, in particular (but also to other health as well as internationally. These publications
professionals) (Maier and Aiken, 2016). Both the focused on the development of primary care and
new responsibilities in patient care and the task primary care concepts in the two countries as a
shifting from physicians to nurses necessitate a whole, in addition to primary care teamwork,
redesign in primary health care teams and, conse- cross-professional collaboration as well as the role
quently, a restructuring of cross-professional and position of GPs and nurses in the teams in
collaboration. particular. Government documents, official statis-
Given that many countries are faced with these tics and national reports provided information
challenges today, it appears prudent to investigate about the health systems in general, on planned
and compare the different concepts being imple- and initiated reforms and basic data on primary
mented and the experiences of those involved. care. Interviewed experts in both countries also
This paper, therefore, examines the concepts and recommended relevant literature on primary care
experiences of the cross-professional collaboration and on the role of the health professions and pri-
of GPs and nurses found in Slovenian and Spanish mary care providers in each country. Furthermore,
primary health centres. While bearing the specific
health care context and traditions in mind, we will 2
focus here on the effectiveness of collaboration. The data used here was gathered for the research project
‘Primary Health Centres – Concepts and Practices’ (PriKon,
Slovenia and Spain were chosen for this com- 2015–2017; funded by the Robert Bosch Foundation,
parison, because they both have robust primary Germany), which is comparing concepts and practices of pri-
health care systems (Kringos et al., 2015) and have mary health centres in Slovenia, Spain, Sweden and Brazil.
Primary Health Care Research & Development 2017; 18: 492–506
 The collaboration of general practitioners and nurses in primary care 495

they supported us in identifying interesting team and with associated partners of the health
concepts of cross-professional collaboration. centres, for example, secondary care, social
A major challenge of this study was to gain prac- services. Additional interviews were conducted
tical access to health care centres in the chosen with the health centre’s managers focusing on key
countries. In a first step, key experts on primary characteristic and innovative aspects, develop-
health care in both countries were identified with ment, implementation and evaluation of the care
help of the literature analysis and through contacts concepts, the daily routine, roles in the team and
in the European Network for Primary Care. They services provided. Finally, in some cases, the cen-
were then contacted with the request for an tre’s management organised group discussions
interview. Ten expert interviews3 relating to Spain with health professionals to delve deeper into
and Slovenia were conducted (see Supplementary specific aspects. Since these group discussions were
material, Table A1). The semi-structured interviews organised spontaneously on site by the hosts, it was
focused on past and recent developments in primary not possible to prepare methodical guidelines for
care and cross-professional collaboration in the them beforehand. They were nevertheless crucial
different countries. Key characteristics and innova- for the understanding of the given health care
tive elements of health care centres, roles and concepts. The authors were able to ask extensive
tasks assumed by the various health professionals questions, voice observations and tentative
were of particular interest as well as the interaction assessments on the care concepts and cross-
and co-operation between team members. professional collaboration of the health centre,
The interviewees were also asked to recommend and discuss these in-depth with the participants.
health care centres in the country of their expertise, All presentations, interviews, group discussions
which they consider particularly good examples of and observations during the tours through the
cross-professional teamwork and collaboration in health centres were digitally recorded.4 Practically
primary health centres. The recommended centres all interviews, presentations and tours were
were then contacted with a request to visit. The conducted in English as a second language for all
participants were informed beforehand of the participants; only one interview was conducted in
study’s objectives and consented to the audio German. Where necessary, the interviewees were
recording of the entire visit. A weeklong trip was assisted by a translator.
scheduled for each country. In total, seven health The recorded material was transcribed as nee-
centres (Slovenia: three, Spain: four) and their ded: the interviews for the most part as full scripts,
associated health stations were visited. In Slovenia, the presentations and centre tours as summaries,
the primary health centres visited were spread the group discussions as a combination of script
across the country. Due to Spain’s geographical size and summary. The data was subsequently analysed
and time restrictions, visitations there were limited by means of computer-assisted qualitative content
to health centres in Catalonia and the Basque analysis using MAXQDA (cf. Meuser and Nagel,
Country – both regions were chosen based on 1991; Gläser and Laudel, 2004). The individual
experts’ recommendations. transcripts were first roughly structured according
The visits to each health centre were organised to the topics discussed in the interviews. The
similarly, though they differed in detail. Most material was then re-read, and inductive categories
began with a presentation by the health centre were defined (eg, status of the nurses). The entire
managers summarising the health centre’s vision, text material was encoded, and individual sections
purpose and the organisational structure. This was of the text were analysed and interpreted in more
followed up by a guided tour of the complex. The
authors then jointly conducted a series of
semi-structured interviews with various health 4
In Slovenia, this encompassed seven expert interviews, three
professionals. The interviews focused mainly on group discussions, three recorded presentations and seven
key tasks and responsibilities, co-operation in the recorded observations of the tours of the health centres. In
Spain, 13 expert interviews and two group discussions were
conducted. In addition, three recorded presentations and seven
3
Eight of the 10 expert interviews conducted were telephone recorded observations during of the tours of the health centres
interviews. Two experts received open-ended questionnaires were collected (see Supplementary material Tables A2
containing our central questions. and A3).
Primary Health Care Research & Development 2017; 18: 492–506
496 Kerstin Hämel and Carina Vössing

detail. The authors worked jointly in all phases of founding of the state Slovenia in 1991, a national
the data collection and content analysis. health insurance system was initiated (Albreht
A case description of each country was then et al., 2016: 21). Under political pressure at the
composed identifying the influencing historical time to ‘free’ the professionals, the government
and cultural factors, current cross-professional allowed health professionals to open private
team model as well as key structures of the practices, also hoping to provide thus a more effi-
model. Experts in the field were given short cient patient-friendly health care (Albreht and
presentations of our initial findings and research Klazinga, 2009: 82).6 Even so, the health centres
hypotheses. The ensuing discussions added owned by the municipalities continued to play a
valuable insights to the analysis. Finally, the case central role in primary health care with 76.5% of
descriptions were used as a basis for the iterative, the primary health care physicians working in
discursive process that followed, in which the municipal health centres. Most recent statistics
authors sought to identify key components of team (2013) count 65 health centres represented in 459
concepts used in each country, their similarities as locations that cover all regions of Slovenia
well as differences. The triangulation of various (Albreht et al., 2016: 118).
data sources, multiple observers and the integra- Today, the Slovenian health centres offer a
tion of the varied perspectives of the researchers as broad spectrum of services: Family medicine,
well as external experts in the course of the health care for women, children and youths, com-
analysis allowed us to cross-check our findings and munity nursing, physiotherapy, occupational
provided us with a deeper understanding of health, laboratory and other diagnostic services,
the concepts and practices of cross-professional dental care and emergency care (Albreht et al.,
primary care in Slovenia and Spain. 2016: 130). Diverse professionals must collaborate
to provide such comprehensive services: family
physicians, paediatricians, gynaecologists, regis-
The case of Slovenia tered nurses,7 nurse assistants, midwives, phy-
siotherapists, speech therapists, occupational
In Slovenia, the first implementation of multi- therapists, dentists, psychologists/psychiatrists and
professional primary health centres took place in other health professionals (Rotar Pavlič et al.,
the 1920s. The aim was to provide general medical 2015: 246; Albreht et al., 2016: 119).8 The GPs and
care, mother, and childcare and preventive medi- the community nurses9 are the patients’ points of
cal care for communicable diseases (such as first contact (Int-Sp25, 606). Both are organised in
tuberculosis) for vulnerable groups in rural areas separate independent units. Since 2011, ‘practice
(Albreht et al., 2006: 238). After the Second World nurses’ also provide first contact (Albreht et al.,
War, Yugoslavia’s national health policy strategy 2016: 111). Before taking a closer look at this new
was to build up the health care system around development, we will outline the given forms of
primary health care centres (Saric and Rodvin, collaboration between physicians and community
1993; Klančar and Svab, 2014: 167). Accordingly, nurses.
the many health centres built in the 1950s and
1960s were responsible for the health needs of the 6
Most private practices in Slovenia have contracts with the
population in specified geographical areas national health insurance, which enable them to get public
(Albreht et al., 2006: 238; Klančar and Svab, 2014: funding for their services (Albreht et al., 2016: 111); 20–23% of
167). To build up an adequately trained workforce the primary health care physicians and 15% of the community
for primary care vocational training for community nurses work in such private practices (Albreht et al., 2016:
118, 137).
nursing was introduced in 1957 (Slajmer-Japelj, 7
Registered nurses have a bachelor’s degree in nursing
1993: 328; Hennessy and Gladin, 2006: 40) and (Albreht et al., 2016: 107).
special training for GPs in 1962 (Bulc et al., 2006).5 8
Roughly 11% of the contacts in specialist (secondary) out-
After their declaration of independence and the patient care occur in these centres since medical specialists such
as radiologists are employed in the larger health centres
5
The academisation of nursing education began in 1993 and (Albreht et al., 2016: 122; Int-Slo9).
9
encompassed general primary health care with an emphasis on Community nurses are registered nurses with a minimum of
health promotion and prevention (Albreht et al., 2016: 107). five years practical work experience (Int-Slo5-613).
Primary Health Care Research & Development 2017; 18: 492–506
 The collaboration of general practitioners and nurses in primary care 497

Collaboration between GPs and community ‘Informally, we work quite well together.
nurses I call the general practitioner and say “this
In a general practice unit in Slovenia, each GP patient needs to be visited at least every sec-
organises his or her own patient list with the ond day, but you wrote [down] only once a
administrative support of an assistant nurse. Com- week; he [the patient] has this, this and this”.
munity nurses are, in contrast, responsible for the If I explain [the situation] using some [good]
population in a specified geographical area (~2500 arguments, it is not a problem’.11 (Int-SloE3,
persons) as a whole. They plan their daily routines 160–162, Community nurse)
in the communal nursing unit. They make house
calls for pregnant women, newborn and school- ‘Mainly, it [collaboration] is over the phone,
children monitoring their health status, detecting and we have these kinds of forms so
health problems and answering questions about that things are written down: Information
pregnancy and childcare (Int-Slo1, 153–158). for the doctor if there are any changes.
Increasingly now, community nurses are also pro- Sometimes, we also go to the general
viding preventive care during home visits for older practice to talk to him personally, but that’s
people10 assessing the health and social situation, not very common’. (Int-Slo10, 343-351,
monitoring health parameters, providing health Community nurse)
counselling and health education (Int-Slo3, 104– Interestingly enough, the structural separation of
111). Both areas of work are defined as ‘preventive the professions in different care units has two sides to
care tasks’ and distinguished from nurses’ ‘curative it concerning collaboration between GPs and com-
tasks’ (Int-Slo5, 117). Community nurses work munity nurses: On the one hand, the separate orga-
independently of the GPs when dealing with pre- nisation of nurses gives them more autonomy to
ventive care tasks; they plan and coordinate their develop their practice further. On the other hand,
activities autonomously (Int-Slo5, 118). Their the restrictive scope of tasks community nurses are
responsibilities are, however, limited once health allowed to perform, forces the nurses to work closely
problems are manifested. In such cases, the patient with the GPs and to a certain extent, be controlled by
is advised to see the physician. Nurses follow phy- them. Furthermore, the lack of a homogeneous
sician’s orders regarding the home treatment when concept of collaboration in the sense of working
executing their curative tasks. The GP determines together towards a common goal as mutually
the care plan for patients, and nurses report to the respected partners hinders efficient collaboration.
GPs concerning changes in health status (Int-Slo1,
302–307). Due to their expertise and knowledge
gained from the patients’ situation, the familial and
social context over the many years of attendance, Model practices: new possibilities for collaboration
the Slovenian community nurses interviewed felt The implementation of the so-called ‘model
capable (to a certain degree) of assessing patients’ practice’ in Slovenia in 2011 represents a step for-
situation and adjusting care plans. ward towards closer collaboration between GPs
and nurses. The model is based on the concept of a
GP-nurse tandem with a well-defined plan for the
Collaboration on demand division of responsibility and the integration of a
The interviewees claim that nurses and physi- practice nurse in a GP practice. Practice nurses in
cians in Slovenia collaborate well. They are able to Slovenia are graduate nurses, specially trained to
discuss questions regarding the care plan or com- provide screening and prevention of eight chronic
plications. However, collaboration appears to be diseases and chronic disease risk factors12 for the
driven by the nurses’ interests and shaped by their
11
limited scope of practice. The perceived quality of The interviewees spoke English as their second language;
collaboration is dependent on personalities, grammar and language usage has been corrected in part for
easier reading.
personal inclinations and expectations. 12
The nurses’ training focuses on eight chronic diseases:
hypertension, diabetes, COPD, asthma, osteoporosis, depres-
10
The health insurance in Slovenia covers two visits per year sion, prostate cancer, cardiovascular diseases (Albreht et al.,
(Int-Slo5, 286). 2016: 121).
Primary Health Care Research & Development 2017; 18: 492–506
498 Kerstin Hämel and Carina Vössing

population 30 years and older (Poplas Susič et al., (ie, exchange knowledge about the patient’s situa-
2015: 636; Albreht et al., 2016). In their consulta- tion und discussing patient’s conditions).
tions, these nurses provide health information,
education and counselling of patients to promote
healthy lifestyles. The practice nurses follow up Reduction of the GP’s workload as impetus and
patients with chronic diseases or high-risk thereof barrier for team-based care
by monitoring their health status and supporting The misuse of the practice nurses to reduce the
their self-management. The nurses have to follow GP’s immense workload has been identified as a
nationwide implemented protocols that clearly major obstacle of teamwork. Occasionally, GPs
define measures and methods of treatment. These fall back into their traditional role of the task-
protocols also stipulate when nurses are to consult master exploiting the GP-nurse tandem to dele-
or refer the patient to a physician (Poplas Susič gate supportive tasks to the practice nurse:
et al., 2015). ‘She’s helping […]. So when I need her, she’s
The model practice was introduced to here’. (Int-Slo4, 90-92, GP)
strengthen preventive care in the general practice
(Albreht et al., 2016: 116). Supported by the ‘We are trying to implement it, but we are not
Ministry of Health as a pilot project (Poplas Susič always successful in lightening the burden on
et al., 2015: 162), the model practice was quickly the registered nurse’. (Int-Slo3, 187-191, GP)
implemented with the set goal that all general
practice units adapt the new health model by the Although physicians’ considerable workload has
end of 2018 (Albreht et al., 2016: 162). The transfer often been an excellent incentive for accepting the
of responsibilities from physicians to nurses was integration of practice nurses, once the concept has
discussed controversially; however, in the end been accepted it also appears to be a central bar-
considering their own heavy workload, it was rier to any further development of inter-
accepted by most physicians (Poplas Susič et al., professional collaboration.
2015; Rotar Pavlič et al., 2015: 247). ‘We have difficulties forming a team, where
The concept gives Slovenian nurses a new area of they are partners’. (Int-Slo11, 273-281, GP/
practice with a higher level of autonomy. The Medical director)
practice nurses plan their schedules and procedures
independently. Interviewed nurses demonstrated a In summary: The introduction of the model
high level of job satisfaction underscoring the practice into the Slovenian health system based on
opportunity to work with diverse patients a stringent team-based concept has led to
under varied circumstances (healthy and sick, improved preventive health care and health con-
young and old). They point out, in particular, the sultation that is more responsive to patients needs.
advantages of the offered health education and Nevertheless, traditional professional hierarchies
counselling to improve patients’ health and well- have yet to be overcome, and they continue to
being. Moreover, the data collected verify that even hamper effective implementation. Even though
in GP-nurse tandems, the ‘team spirit’ evolves from this door-to-door co-operation has achieved a new
a shared vision of a more patient-centred, responsive and higher degree of collaboration, new challenges
care that can be provided by these new services. are rising. Practicing preventive health care closely
together as a team means nurses must learn to
‘Our medicine has changed; the patient now withstand the traditional dominance of the physi-
[comes] in the centre and we have to cians to develop further and defend their new care
work together for the benefit of the patient’. role, even when they are currently in the midst of
(Int-Slo10, F24, medical director) just learning to fulfil it.

The model practice has also changed the routines

for the GPs, who were used to having sole respon- The case of Spain
sibility for their practice. In keeping with the new
model, they are expected to coordinate patients’ Multi-professional primary health centres were first
care with the practice nurse by team collaboration established in Spain in the 1980s as a part of the
Primary Health Care Research & Development 2017; 18: 492–506
 The collaboration of general practitioners and nurses in primary care 499

overall democratisation process initiated at the end education focus in particular on community care
of the Franco regime. The implementation of health (Zabalegui Yarnoz, 2002: 313; López, 2011:
centres was accompanied by a transformation of the 1722).14 Second, since the health centres were
health system from a social insurance model to a established, inter-professional teamwork has been
tax-based national health service (European seen as crucial for effective primary care (Goñi,
Observatory – European Observatory on Health 1999: 108; Dedeu et al., 2015: 255). The profes-
Care Systems, 2000). The health centres provide the sionals have not simply been gathered under one
Spanish population with universal access to health roof. They have worked hard specifically to
care, integrating preventive, curative and rehabili- develop and strengthen teamwork as well. For
tative services under one roof (Hart, 1990; Borkan example, supplement programmes have been
et al., 2010: 1433; García-Armesto et al., 2010). initiated, such as joint ventures for research
Cross-professional primary health care teams were projects, special programmes for team-based
set up to take over a shared responsibility for the community action and health promotion activities
primary health care of the population in a specific (Martí Arguasca and Argimon, 2008; Dedeu et al.,
geographical area (García-Armesto et al., 2010: 57; 2015). Furthermore, in several autonomous
López, 2011). As of 2003, primary health care teams regions ‘productivity bonuses’ (eg, for the judi-
are operated in all regions of Spain (Gené-Badia cious use of prescriptions or the reduction of
et al., 2008: 2). A network of 3023 health centres waiting time) have been introduced, which in part
and 10 081 health stations exists today (MoHSE, are rewarded as team bonuses (García-Armesto
2015: 9). Most of them are public organisations et al., 2010: 116; MoHSE, 2010: 62).
administrated by regional health services (ie, the
Catalan Institute of Health).13
The cross-professional teams are composed of Doctors for acute cases, nurses for chronic
GPs, pediatricians, nurses, nurse assistants and conditions
administrative staff. Depending on regional In a health centre, each patient has a personal
concepts, they can also include dentists, social GP and a personal nurse, who are his or her first
workers, midwives and physiotherapists (Borkan contact point (Contel and Badia, 1998: 42; Dedeu
et al., 2010: 1434; Dedeu et al., 2015: 257). The et al., 2015: 258). Teamwork of GPs and nurses is
teams presently claim a ratio of nearly 1:1 physi- based on the concept of shared responsibility: GPs
cians to nurses (MoHSE, 2015: 10). The health treat primarily the acutely ill and unstable chronic
centres offer comprehensive services for adults as patients; nurses are responsible for chronic
well as specialised health care services for older patients in stable conditions (López, 2011). Both
people, women, children and youths (García- professionals have their own patient list; however,
Armesto et al., 2010: 138). Their services encom- in most cases, the GP and nurse work together for
pass individual care, clinical care at the health the same patient base (Int-Sp8, 352).15
centre, home care and community health activities. Within their scope of practice, nurses make
Regarding the collaboration between physicians decisions independently (Dedeu et al., 2015).
and nurses in Spain, two aspects are of particular Compared to the more functional differentiation
interest. First, with the implementation of primary of nursing roles in Slovenian primary care, primary
care teams, the nursing profession was given a new care nurses in Spain commonly perform a broader
status in primary care with advanced responsi- range of activities (general nurses). They conduct
bilities. An important prerequisite for this role individual patient consultations at the health
enhancement was the introduction of nursing
education as degree level study programmes in 14
However, Spain’s modern attitude of the nursing profession
1977 (Mariscal Crespo et al., 2010: 341; López, does appear to have limitations: while physicians were offered
2011: 1722). Since 1990, the curricula of nursing the opportunity for a postgraduate specialisation in ‘family and
community medicine’ as early as 1978/1979, the implementation
of a similar postgraduate specialisation for nurses initially
13
Some health centres have been set up as public-private part- drafted in 2005 has been delayed (Dedeu et al., 2015: 257; Int-
nerships, others are privately owned (eg, professional coop- Sp14).
15
eratives) and have health care contracts with the regional health In total, nurses carry out close to half of all consultations done
authorities (Martínez-Garcia, 2004; Ensenyat, 2007). (García-Armesto et al., 2010).
Primary Health Care Research & Development 2017; 18: 492–506
500 Kerstin Hämel and Carina Vössing

centre, home care for immobile patients as well as Nevertheless, collaboration conflicts are inevi-
health promotion activities at the health centre table. In some teams, the working environment is
and in community settings16 (Martí-Arguasca less congenial:
and Argimon, 2008: 11; Int-Sp7, 66–72; Int-Sp1,
114–127). During the patient consultations, nurses ‘In some teams, there is a good collaborative
make a comprehensive assessment of the social atmosphere; in others, there are lots of
and health situation of the patient, including life- battles between doctors and nurses’.
style and health-related behaviour. They also (Int-SpE5, 140-142, Centre manager)
follow-up the health status of patients and give ‘But it’s not the same for everybody. Some
self-management support. The information that
doctors are stiffer. Some are [more relaxed],
nurses collect is of great relevance for the GPs as
and then they are easier to work with’.
well; and vice versa, GPs’ diagnosis and treatment
(Int-Sp12, 357–358, Nurse)
plan are essential for nursing care. In Spain, the
exchange of information is facilitated using an In other words, conflicts can hinder effective
electronic health records system, which has been collaboration. Obviously, teamwork is shaped by
established in nearly all Spanish health centres the personalities of individuals. It is also influenced
(Borkan et al., 2010). This tool allows each by the degree of willingness to work together.
professional access to the diagnosis, further Specifically to cope with such problems, certain
developments regarding the patient’s health, processes and structures have been implemented
current health status and treatment plan. to facilitate collaboration in Spain.

Teamwork on equal footing Team co-operation and team development

GPs and nurses set up the care plan as a team A measure used to promote team collaboration
(Dedeu et al., 2015). In cases of increasing com- in the Spanish health centres is to include time
plexity, co-operation is intensified. For example, in their weekly schedule for team activities
when dealing with immobile patients with complex (Goñi, 1999: 108; Dedeu et al., 2015). The fre-
health needs, joint visits at patient’s home may be quency of these time slots varies from once a week
arranged (Int-Sp1, 124).17 In the comprehensive to daily (Int-Sp21, 80; Int-Sp22, 109). This sched-
field of chronic care (including health promotion uled time is used for team meetings, training or
and self-management support), nurses are accre- other joint activities for the entire health centre
dited with a distinguished status due to their staff. During the meetings, the team members
separate field of expertise. GPs and nurses appear convene to discuss organisational issues or com-
to collaborate closely when coordinating patients’ plex cases, exchange views on new programmes as
care. To attain a holistic view of patients’ situation, well as deliberate current qualification require-
they have to combine their expertise and care ments (Int-Sp3, 33–35). The joint participation of
skills. Our analysis shows that this arrangement (inter-)professional training may be planned as
often works efficiently. In many teams, the physi- well. The health centres also offer team members
cians and nurses value one another as equals and opportunities for further training and thus support
work together as partners. professional advancement in the team. Such
opportunities help broaden the spectrum of ser-
‘Nurses and doctors are talking at the vices provided, but even more important, it moti-
same level and integrate their competencies’. vates the professionals to develop their individual
(Int-Sp2, 29, Nursing Director) expertise further according to their interests and
capabilities (eg, nutrition, emergency care). The
16
For example, courses for patient groups with diabetes, cour- idea is that the team as a whole can benefit from
ses for dealing with depression or health promotion in schools. the knowledge gained. The trained health profes-
17
When necessary, cooperation can be extended including sionals become first contacts for questions that
additional members of the (expanded) cross-professional pri-
mary health care team, for example in the process of care arise in the team concerning their field of
planning, a social worker (European Observatory on Health expertise. Team projects are also encouraged as
Care Systems 2000: 66; Int-Slo12–560). another way of promoting specialisation; for
Primary Health Care Research & Development 2017; 18: 492–506
 The collaboration of general practitioners and nurses in primary care 501

example, improving established processes the team development – are vital factors for high-
or developing new modes of teamwork (Int-Sp3, quality teamwork.
113–123; Int-Sp6, 263–267).
Team development also comprises the
advancement of professional roles. In Spain, the Conclusion and discussion
teams have implemented their own processes
locally. Nurses, in particular, have been allowed to Like many other countries today, Spain and
take on responsibilities beyond set standards. For Slovenia are faced with new challenges in primary
example, the authorisation for nurses to prescribe care created by a changing spectrum of illness and
medications is pending legislative approval for disorders and the growing necessity to find needs-
many years. As a reaction, several local teams based solutions for complex, long-term health
developed their own procedure to enable nurses to problems. As our analysis shows, both countries
prescribe medications when necessary by devising strive to ensure comprehensive, ongoing care and
special protocols (Int-Sp1, 291).18 to develop new services for the patients. In order
Finally, an attempt has been made to increase to do this, they also both have chosen to intensify
the motivation of Spanish primary care teams by team-based collaboration between GPs and nurses
benchmarking, rating individual as well as team as the key to increasing the effectivity of care
success. The team sets specific goals they wish to services in their health centres. Among other
achieve jointly. Thus, the team creates shared things, our study demonstrates that developments
objectives (Int-Sp8, 81). Special team funding has initiated in primary health care, and the outcomes
also been introduced as a financial incentive for of changes made are influenced by each country’s
high team performance; teams rewarded these care history and traditions. Nevertheless, despite
funds may use them for joint activities such as cultural differences, the opportunities for and
advanced training. However, various interviewees quality of co-operation between GPs and nurses in
maintained that this particular strategy has had Spain and Slovenian appear closely linked with the
little effect on the quality of co-operation in their training, task responsibilities of nurses in primary
teams (Int-Sp6, 265). care as well as status within the team. GP-nurse
In summary: When introducing health centres in tandems in Spain and Slovenian were most effec-
the mid-1980s, Spain’s government simultaneously tive, where the position of nurses in primary care
focused on setting up team-based care. Since then, had been strengthened and a new, more prominent
many health centres have worked hard on refining role of nurses in the care process was accepted.
their concept of a primary care team. Regarding Thus, a central finding of our analysis is that
the GP-nurse collaboration, it should be noted that traditional hierarchies between the professions
Spanish nurses have their own domain of respon- hinder the possibilities of cross-professional
sibility (not simply regarding certain well-defined teamwork. Structural hierarchies between the
tasks). The nurses now collaborate with the GPs professions continue to exist not only in Slovenia
on terms that are more equal; nevertheless, and Spain, as shown here, but also in many other
personal conflicts can lead to professional dis- countries (cf. Delamaire and Lafortune, 2010;
agreements. As a result, supporting structures Schaeffer and Hämel, 2017). Although similar
for team development have been implemented. issues were discussed extensively in the 1980s
Particularly interesting is the fact that Spanish (cf. Freidson, 1986; Light, 1988), they often have
cross-professional teams have developed their been overlooked in the current discussion
own strategies to improve teamwork; for example, concerning improvements of cross-professional
by shifting task responsibilities from physicians to co-operation (Paradis and Whitehead, 2015). As
the nurses in bottom-up processes. As indicated by demonstrated, changing of the hitherto hier-
our analysis, both these aspects – the increased archical structures of co-operation can be difficult
professionalisation and autonomy of nurses and without overcoming differences in status and
the long-established power gap. The difference in
status between the health professions is reflected
18
A legal framework for prescribing medications was intro- in the still distinct educational gap between
duced in 2013 (Romero-Collado et al., 2014). physicians and nurses (as well as other health
Primary Health Care Research & Development 2017; 18: 492–506
502 Kerstin Hämel and Carina Vössing

care professions). Consequently, a key step practice nurses into GPs practice. In Spain,
towards changing given hierarchies entails the the need for further clarification of procedures
further professionalisation of nurses and other and tasks often became prevalent in the course
health professionals. The academisation of the of daily practice as nurses delved into new
nursing profession, for example, raises nurses’ areas of responsibility. It would be interesting
status in the society, and thus assists their emanci- to focus further research on the appropriate-
pation from subordinated role placement in health ness of the different procedural approaches
care. As de Geest et al. (2008) pointed out, edu- (protocols and detailed description of tasks
cation is a major driver in the development of the versus definition of areas of responsibilities).
advanced practice nursing roles. In Spain and Our study indicates that particularly in health
Slovenia, both countries have taken initial steps to centres with little experience in cross-
integrate nursing and other health professions into professional teamwork and a hitherto hier-
higher education. Nevertheless, these professions archically oriented understanding between
have few opportunities in postgraduate education, doctors and nurses; it could be beneficial
and as of yet, the offered study programmes do not initially to define tasks assigned to the nurses
correspond to those in the medical fields. clearly, and in the process give them the
In addition, our findings imply that effective needed space to develop new roles.
change in dominance patterns and responsibility (2) Our results also indicate that clear definitions
must be actively supported at the grassroots level, of tasks and responsibilities alone do not
that is locally, in individual teams. Changes in provide a sufficient basis for collaborative
co-operation and communication patterns, which action in a cross-professional team. Rather,
are necessary for successful teamwork, do not the professionals must learn how to work
occur automatically in the process of introducing jointly. Particularly, in situations where uni-
teamwork. Supportive processes for change must lateral profession-oriented interests dominate
be implemented systematically and deliberately relationships, collaborative teamwork can
adopted by all team members. A closer look at the become difficult. This also holds true when
local team performances in both countries gives a concerns arise in the team caused by disparate
clearer picture on options to promote (or hinder) interpretations of function and task
cross-professional teamwork: descriptions. Our study gives evidence that
shared visions of the professionals such as
(1) Our findings confirm the importance of clearly patient-oriented care (cf. WHO, 2015) can
defined structures for teamwork by means of provide additional guidance and motivation
agreed definition of tasks and/or areas of for collaboration. However, in the process of
responsibility. Moreover, the mutual acknowl- developing shared visions, misunderstandings
edgement and understanding of each profes- can influence the discussion on the
sion’s scope of practice are a key factor in development of teamwork and the expansion
promoting cross-professional teamwork of care negatively. As demonstrated above,
(cf. Clarin, 2007; Jaruseviciene et al., 2013): there are risks, for example, in arguing
In both Spain and Slovenian, well-structured for more task responsibility for nurses to
procedures and clear task assignment assisted counter a shortage of physicians or to save
the implementation of new methods. costs as opposed to emphasising the advan-
Misunderstandings and/or backslides into tages for patients. Instead of encouraging
long-established roles, and behavioural pat- collaborative behaviour, such arguments tend
terns were prevented or counteracted through to buttress unilateral interests and short-term
active and continuous communication objectives.
between the participating professionals. This (3) Finally, opportunities for cross-professional
allowed nurses the needed space to test their teamwork lie in the increased accessibility of
new capabilities and grow into their (new) expertise and skills in patient care to all
responsibilities. In Slovenia, responsibilities team members (inter-professional expertise).
and tasks were defined by means of protocols Effective cross-professional teams provide
established in the initial introduction of time and space for team development processes
Primary Health Care Research & Development 2017; 18: 492–506
 The collaboration of general practitioners and nurses in primary care 503

and systematically promote them. Our study implementing care concepts that aim to strengthen
shows that, when initiating change, particu- the collaboration between physicians and nurses in
larly by means of task shifting, collaborative the future, these problems and issues should be
negotiations on work procedures in the team anticipated and confronted proactively. Further
are particularly important. The time thus means of dealing with conflicts within the teams
made available can also be used to address need to be developed and tested.
possible personal conflicts between the team
members, which otherwise might be ignored
due to demanding daily routines. In Spain, a
bottom-up design has been implemented for Limitations
team’s development, the results of which look
quite promising for the further development When appraising these research findings, it is
of the team’s tasks.19 Regular team meetings important to take into account that the selected
and the exchange of experiences provide health centres were recommended as best-practice
opportunities not only to strengthen facilities in the two countries. Using a different
teamwork top-down but also to develop it sampling strategy, greater challenges and further
bottom-up further by utilising the expertise of obstacles to co-operation between physicians and
the participants. Interestingly enough, provid- nurses might have become visible. For example, in
ing time and space for team development the health centres investigated here, the adminis-
appears to be of greater relevance for team tration clearly supported attempts to strengthen
performance in Spain than financial co-operation between nurses and physicians. The
incentives. In Slovenia, the full potential of management’s support and advocacy of teamwork
team development processes has yet to be are vital for its evolvement (CHSRF, 2006;
utilised. Introducing strategies to develop Morgan et al., 2015).
team development processes further will be It must also be noted that health centres visited in
an important task toward improving the Spain were limited to only two regions, Catalonia
effectivity of their cross-professional teams in and Basque Country. Given practical limitations of
the future. research, we chose to focus on gathering diverse
perspectives from a broad spectrum of actors active
Our stated aim of this paper was to take a closer
in a few health centres and thus assuring a robust
look at possibilities of co-operation between GPs
analysis rather than investigating a multitude of
and nurses in primary care in Slovenia and Spain in
health centres. Nevertheless, our findings indicate
the context of their country-specific primary care
that the assessments and concepts of ‘successful’
concepts and further refinement. The comparative
teamwork put forward by the GPs and nurses
analysis enabled us to identify differences in interviewed diverge according to their differing role
conceptual and procedural methods employed in
definitions and expectations for their own and
the two countries; this provided us with valuable
other professions. An in-depth analysis of these
insights into various aspects of change in specific diverging perceptions could help us better under-
social-cultural frames. We confirmed that clearly
stand the opportunities and obstacles of co-
defined structures, shared visions of the profes-
operation between physicians and nurses and
sionals and opportunities for team development
develop viable strategies and concepts for
are of great relevance for the effective imple-
strengthening co-operation.
mentation and sustainability of collaboration
Finally, it should be pointed out that the focus of
between general practitioners and nurses in pri-
this paper was on the collaboration between nurses
mary care. However, in the course of the analysis,
and physicians. Many primary care concepts today,
we also uncovered common challenges and typical
however, encompass cross-professional collabora-
difficulties, for example when attempting to
tion with a much broader spectrum of profes-
increase responsibility, autonomy and status of sionals. Due to the increased complexity of the
nurses in the team. When developing and
patient’s needs today, the need to work closely
with one another continues to increase. More
19
We have similar results for Brazil (see Hämel et al., 2017). research is also needed in this area.
Primary Health Care Research & Development 2017; 18: 492–506
504 Kerstin Hämel and Carina Vössing

Acknowledgements Barrett, J., Curran, V., Glynn, L. and Godwin, M. 2007. CHSRF
synthesis: interprofessional collaboration and quality
The authors express their deepest gratitude to the primary healthcare. Ottawa: Candian Health Service
experts and managers who supported us in the Research Foundation.
organisation of the field visits, to the health pro- Bodenheimer, T. 2007: Building teams in primary care: lessons
learned. Oakland: California Health Care Foundation.
fessionals that devoted their time to give us a bet- Borkan, J., Eaton, C.B., Novillo-Ortiz, D., Rivero Corte, P. and
ter understanding of their daily work. Special Jadad, A.R. 2010: Renewing primary care: lessons learned
thanks also go to Virginia Penrose, research con- from the Spanish health care system. Health Affaires
sultant and language editor, for her valuable input (Millwood) 29, 1432–441.
and support. Bulc, M., Fras, Z. and Zaletel-Kragelj, L. 2006: Twelve-year
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Financial Support Slovenia: contribution of WHO Countrywide Integrated
Noncommunicable Diseases Intervention Program.
The project was financed by the Robert Bosch Croatian Medical Journal 47, 469–77.
Stiftung. Canadian Helath Services Research Foundation (CHSRF)
2006: Teamwork in healthcare: promoting effective
Conflicts of Interest teamwork in healthcare in Canada. Ottawa: CHSRF.
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