Health Canada
www.hc-sc.gc.ca
Common menu bar links
Institutional links
The Supply, Distribution and Working Context of Health Professionals: Why do Things (almost) Never Change
Investigator Name: Dr. John N. Lavis
Project Completion Date: June 2006
Research Category: Research
Institution: McMaster University
Project Number: 6795-15-2003/5990006
Summary
Statement of the issue
Debates about the supply, distribution, and working context of health professionals have a cyclical nature. But why do things (almost) never change? We sought to: 1) describe the knowledge-translation (KT) activities of health human resource (HHR) researchers who contributed to the research knowledge on the supply, distribution, and working context of physicians, nurses, nurse practitioners, and midwives; 2) describe federal and provincial public policymakers awareness of, knowledge of, attitudes towards, and self-reported use of the research knowledge; 3) describe researchers and federal and provincial public policymakers assessments of the factors that influence public policy decisions about the supply, distribution, and working context of physicians, nurses, nurse practitioners, and midwives; 4) determine whether, how, and under what conditions public policymakers in relevant federal and provincial government departments have used the research knowledge; and 5) derive concrete implications for Health Canada and others about how they can improve the transfer and uptake of the research knowledge.
Background / literature review
Researchers and public policymakers (among others) could undertake a variety of KT activities to support the use of research knowledge on the supply, distribution and working context of health professionals: improve the general climate for research use, produce (or support the production of) more relevant research, and undertake a variety of activities to ensure that optimally packaged, high quality research is brought to the attention of public policymakers, made available for them to access easily, and used as an input to briefing materials and interactions among researchers, public policymakers, and relevant stakeholders. But research and related KT activities are just one set of influences on public policy. The policymaking process can be divided analytically into three stages: an issue makes it onto the governmental agenda, an issue makes it onto the decision agenda, and policy choice related to the issue. An issue can come onto the governmental agenda either because of events within the "problem stream" or events within the "politics stream". An issue comes onto the decision agenda because the problem, policy and politics streams become coupled, thus creating a window of opportunity for policy choice. Research can inform both the problem and policy streams. Four categories of factors institutions, interests, ideas and external events can explain policy choice. Research can be understood as one category of ideas.
Methods
For our survey of researchers we identified the study sample -- researchers who were the first author on one or more books, articles or reports about the supply, distribution or working context of one of the four provider groups under study by searching for all research literature about the supply, distribution and working context of physicians, nurses, nurse practitioners and midwives in Canada that was published between 1990 and August 2004. For our survey of policymakers we identified our study sample Ministers, Deputy Ministers, Assistant Deputy Ministers and their top policy advisors in federal, provincial, and territorial departments of health, human resources / labour, and education and training by searching government websites, contacting government departments and archives, and contacting those identified through websites or contacts. We developed the questionnaires by drawing on and/or refining questions previously asked as part of other research studies and we followed rigorous procedures for survey administration and follow-up and for data management and analysis. For our case studies we employed interviews and documentary analysis to examine the (lack of a coordinated) intergovernmental response to the Barer-Stoddart report on physician human resources, the (initial lack of) attention to nurses working context during a period of hospital restructuring and downsizing in Ontario, the introduction of nurse practitioners in rural and remote parts of Newfoundland and Labrador to address (at least in part) physician maldistribution, and deciding not to publicly fund midwifery services in Alberta in response to perceived crises in maternity care. We employed a constant comparative method of analysis.
Results
We identified six of the most salient findings from our review of the researcher and policymaker surveys: 1) a low proportion of both researchers and policymakers reported that systematic reviews of HHR research were frequently or always provided or received without an explicit request; 2) a low proportion of policymakers reported frequently or always interacting with HHR researchers to obtain research unrelated to research projects with which they were involved; 3) low proportions of policymakers reported frequently or always obtaining HHR research through websites and obtaining HHR research by commissioning it directly; 4) a high proportion of both researchers and policymakers agreed or strongly agreed that physician associations exerted a strong influence on HHR policymaking; 5) a low proportion of both researchers and policymakers agreed or strongly agreed that research did not help policymakers to document HHR problems and that research did not help policymakers to identify potential strategies to address HHR problems; and 6) researchers and policymakers views diverged most dramatically in their agreement or strong agreement that broad challenges in intergovernmental relations hindered HHR policymaking. We also identified three of the most salient findings from our case studies: 1) a perceived problem or set of related problems (rather than political factors) were consistently what brought a particular issue to the governmental agenda; 2) issue framing and the supportiveness of the political landscape (which can itself be "tilled" to make it more supportive of particular issues) emerged as central to our understanding of why and how an issue moved to the decision agenda; and 3) policy legacies, particularly those related to the "private delivery / public payment" bargain with physicians and hospitals, emerged as central to our understanding of what influenced policy choice.
Discussion
Public policies related to the supply, distribution and working contexts of health professionals can change. Our study constitutes the first effort to examine both "sides" of the research / policy divide in health human resources. Its strengths include: 1) employing a rigorous approach to survey design, administration and follow-up; 2) preparing for (and then augmenting) the interviews with extensive documentary analyses; and 3) conducting interviews that probed the full array of factors that may influence policymaking and that explicitly sought to confirm or refute emerging themes. The study's weaknesses include the potential for social desirability bias and the low response rates to our surveys. The study suggests that HHR research and related KT efforts can be a positive force for change.
The views expressed herein do not necessarily represent the views of Health Canada
