The COVID-19 pandemic has tested the resilience of health systems broadly and primary care (PC) specifically. This paper begins by distinguishing the technical and political aspects of resilience and then draws on a documentary analysis and qualitative interviews with health system and PC stakeholders to examine competing resilience-focused responses to the pandemic in Alberta, Canada. We describe the pre-existing linkages between the province' s central service delivery agency and its independent PC clinics. Together, these central and independent elements make up Alberta' s broader health system, with the focus of this paper being on PC' s particular vision of how resilience ought to be achieved. We describe two specific, pandemic-affected areas of activity by showing how competing visions of resilience emerged in the central service delivery agency and independent PC responses as they met at the system' s points of linkage. At the first point of linkage, we describe the centralized activation of an incident management system and the replies made by independent PC stakeholders. At the second point of linkage, we describe central efforts to disseminate infection prevention and control guidance to PC clinics and the improvisational efforts of staff at those independent clinics to operationalize the guidance and ensure continuity of operations. We identify gaps between the resilience visions of the central agency and independent PC, drawing broadly applicable policy lessons for improving responses in present and future public health emergencies. Finding ways to include PC in centralized resilience policy planning is a priority.

This paper outlines the rapid integration of social scientists into a Canadian province’s COVID-19 response. We describe the motivating theory, deployment and initial outcomes of our team of Organisational Sociologist ethnographers, Human Factors experts and Infection Prevention and Control clinicians focused on understanding and improving Alberta’s responsiveness to the pandemic. Specifically, that interdisciplinary team is working alongside acute and primary care personnel, as well as public health leaders to deliver ‘situated interventions’ that flow from studying communications, interpretations and implementations across responding organisations. Acting in real time, the team is providing critical insights on policy communication and implementation to targeted members of the health system. Using our rapid and ongoing deployment as a case study of social science techniques applied to a pandemic, we describe how other health systems might leverage social science to improve their preparations and communications.

Background The integration of nurse practitioners (NPs) into primary care health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing access, and lowering cost. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing primary care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed by key stakeholders and to draw out policy lessons. Methods Fifteen semi-structured interviews with NPs and other stakeholders in Alberta’s primary care system were conducted, recorded, transcribed and analyzed using the interpretive description method. Results Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: 1) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP’s reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are not afforded sufficient authority over their role or how the key concept of ‘care team’ is defined and operationalized. Conclusions In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province’s primary care system. Policy adjustments that enable NPs to access funding not only from within but also outside PCNs, and modifications to allow greater NP input into how their role is utilized would likely improve the NPSP’s ability to reach its goals.

IntroductionThe COVID-19 pandemic prompted widescale use of clinical simulations to improve procedures and practices. We outline our deployment of a virtual tabletop simulation (TTS) method in primary care (PC) clinics across Alberta, Canada. We summarise the quality and safety improvements from this method and report end users’ perspectives on key elements.MethodsOur virtual TTS used teleconferencing software alongside digital whiteboards to walk clinic stakeholders through patient scenarios. Participants reviewed and rehearsed their workflows and care practices. The goal was for staff to take ownership over gaps and codesigned solutions. After simulation sessions, follow-up interviews were conducted to collect feedback.ResultsThese sessions helped PC staff identify and codesign solutions for clinical hazards and threats. These included the flow of patients through clinics, communications, redesignation of physical spaces, and adaptation of guidance for cleaning and personal protective equipment use. End users reported sessions provided neutral spaces to discuss practice changes and built confidence in delivering safe care during the pandemic.DiscussionTTS has not been extensively deployed to improve clinical practice in outpatient environments. We show how virtual TTS can bridge gaps between knowledge and practice by offering a guided space to rehearse clinical changes. We show that virtual TTS can be used in multiple contexts to help identify hazards, improve safety and build confidence in professional teams adapting to rapid changes in both policies and practices. While our sessions were conducted in Alberta, our results suggest this method may be deployed in other contexts, including low-resource settings.

The COVID-19 pandemic exposed primary care (PC), and policies aimed at integrating it into provincial health systems, to a "shock test." This paper draws on documentary analysis and qualitative interviews with PC and health system stakeholders to examine shifts in Alberta' s pre-pandemic PC integration model during the first nine months of the pandemic. We begin with an account of three elements of the province' s pre-pandemic model: finance, health authority activity and community activity. We describe these elements as they shifted, focusing on two indicators of change: novel virtual care billing codes and personal protective equipment (PPE) distribution channels. We draw out policy planning lessons for improving PC integration under normal and future pandemic conditions, namely, by facilitating rapid updates of virtual care billing codes, analyses of the impact of care delivery and backstopping of PPE markets and supply chains for PC. RésuméLa pandémie de COVID-19 a soumis les soins de santé primaires (SSP), de même que les politiques visant à les intégrer dans les systèmes de santé provinciaux, à un « test de choc ». Cet article s' appuie sur une analyse documentaire et des entretiens qualitatifs avec des intervenants des SSP et du système de santé pour examiner les changements dans le modèle d'intégration pré-pandémique des SSP en Alberta au cours des neuf premiers mois de la pandémie. Nous commençons par rendre compte de trois éléments du modèle pré-pandémique de la province : les finances, l' activité des autorités sanitaires et l' activité communautaire. Nous décrivons ces éléments au fur et à mesure de leur évolution, en nous concentrant sur deux indicateurs de changement : les nouveaux codes de facturation des soins virtuels et les canaux de distribution des équipements de protection individuelle (EPI). Nous tirons des leçons de planification politique pour améliorer l'intégration des SSP dans des conditions normales ou de pandémie éventuelles, notamment en facilitant la mise à jour rapide des codes de facturation des soins virtuels, en analysant l'impact de la prestation des soins et en soutenant les marchés et les chaînes d' approvisionnement des EPI pour les SSP.