Abstract
Clinical Practice Guidelines (CPGs) provide evidence-based recommendations for Healthcare Providers (HCPs) to utilize when making patient care decisions. Rural providers face challenges in the provision of evidence-based care, including the use of guidelines. The aim of this article is to explore the complexities of providing healthcare in rural areas. This article will focus on a specific aspect of rural maternity care with well-established CPGs, the prevention of Rhesus D factor alloimmunization. An applied health research approach, interpretive description, utilized semistructured interviews with HCPs across the vast geographic region of northern British Columbia. The study found that HCPs are aware of guidelines but face various barriers during implementation. In order to implement guidelines within practice, rural HCPs adapt processes to overcome local barriers. These process adaptations need to be identified and shared across a large health authority with a complex geography and healthcare system to ensure quality of care.
Introduction
Canada has seen an increase in the regionalization of healthcare systems across provinces and territories since the late 80s. 1 These centralized health authorities are complex, delivering care to large populations and covering vast geographies, with leaders having to ensure that healthcare is delivered equitably across all catchment area communities.
Despite the regionalization of healthcare existing in Canada for over 2 decades, there is a lack of research exploring the impact of regionalization at the provincial/territorial level. 2 Further to this, there is minimal research addressing the impact of regionalization on the day-to-day operationalization of healthcare delivery within rural communities. Rural communities are faced with many barriers in providing equitable access to healthcare within regionalized systems and are further problematized by healthcare provider (HCP) recruitment and retention issues and limited access to services and resources. 3,4 These particular challenges lead to diminishing services to rural populations 5 resulting in inequitable access to healthcare services and resources within a regionalized healthcare system designed to provide evidenced-based and patient-centred care.
Healthcare providers who work in rural areas have to make patient care decisions with limited access to resources available through regionalized care. This complicates the delivery of care using the best available evidence, including Clinical Practice Guidelines (CPGs). 6 –8 The use of CPGs, if readily available, provides the HCP with evidence-based recommendations intended to aid in consistent patient care decision-making. 9 –13 Barriers to the uptake of guidelines in rural areas are limited access to continuing education, professional isolation, limited resources including human resources, recruitment, and retention of HCPs, and the complexity of CPGs. 6 –8 The limited literature that exists identifies that in order for HCPs to use guidelines, the following needs to be in place: improvement in the dissemination of CPSs to all regions, increase in continuing education for those working in a rural community, and that guidelines should have a rural section. 7
In order to gain a deeper understanding of decision-making in rural areas within regionalized healthcare systems, this article will explore the use of CPGs by HCPs in rural and northern British Columbia (BC). A specific example of maternal care will be used to illustrate the point of the complexity and issues in regard to healthcare delivery in the north. The prevention of Rhesus D Factor (RhD) alloimmunization is an established clinical program based on national Society of Obstetricians and Gynecologists of Canada (SOGC) guidelines and an effective prophylaxis, Rh Immune Globulin (RhIG). 14,15 Despite best practice guidelines, RhD-negative women continue to be at risk. 16 In Canada, seven cases of RhD alloimmunization resulting in severe neonatal hyperbilirubinemia occurred over a 7-month period in 2016. 17 This study, as do prior Canadian studies, suggest that RhD-negative pregnant women are still at risk of developing Rh alloimmunization in a country with an established prevention program. 18 –20
This aim of this article is to explore the experience of HCPs in delivering care to a specific population within a rural context. The purpose of focusing the study on RhD-negative pregnancies was to understand the nuances that exist in providing care with established guidelines in resource-limited areas within a large regionalized healthcare system. From their use, the research garnered from this example to extrapolate and build approaches and strategies that ultimately will lead to better health access and outcomes for those in rural and regional areas of Canada.
Methods
Study design
The study presented in this article was part of a larger doctoral research project undertaken by the first author, T.M.F. 21 A qualitative applied health research approach, interpretive description, was used to guide the research project 22 and involved semistructured interviews with HCPs. An Integrated Knowledge Translation (IKT) approach was put in place and included a stakeholder committee with a membership of knowledge users, including a patient representative, decision-makers, and HCPs. Following the IKT principles, 23 the stakeholder committee was involved in the creation of the research question, the interview questions, reviewing data, and guiding knowledge dissemination. Ethics approval was obtained from the Research Ethics Board at the University of Northern British Columbia and Northern Health (NH).
Participants and setting
This study took place in the vast geographic region of northern BC. This health region includes 17 local health areas within the larger health authority, NH, covering approximately 617,279 square kilometers of land, 24 and faces challenges in recruiting and retaining HCPs in rural and remote areas. 3,4
Healthcare providers working in northern BC were invited to participate in this study. Snowball sampling was utilized as the recruitment strategy. This involved the stakeholder committee members sending the study’s information letter to their colleagues across the north for consideration. Recruitment and data collection occurred between June and December 2016.
To be eligible to participate, HCPs had to practice in northern BC and be a family physician, midwife, nurse practitioner, or an emergency physician. Both family physicians and nurse practitioners had to have involvement in the care of pregnant women.
Data collection and analysis
Participants were interviewed over the phone or in-person and the interview was 30 to 60 minutes in duration. Interviews were recorded and transcribed verbatim by a third-party transcriptionist. To ensure anonymity, participants were assigned unique identifiers (HCP). With the use of coding software, NVIVO 12, 25 data were analyzed utilizing a two-cycle approach that identified themes within the data. 26
Results
Thirteen providers were interviewed about their provisions of care for RhD-negative pregnant women. Seven of the 13 participants had practiced for over 10 years and 3 of the 13 for less than 5 years. In order to preserve anonymity, the type of providers that participated were not individually indicated by provider type but were represented in the sample by all eligible criteria and given a code (HCP): emergency physicians, family physicians, midwives, and nurse practitioners.
The analysis of the interview data found two main themes: the use of guidelines and health system processes. Both themes were complicated within the context of rural care within a large centralized healthcare system. The theme of process includes two sub-themes, barriers and adaptation of process. The themes will be described in the next section and include quotations from the interview data.
Guidelines
At the time the study was conducted, the SOGC guidelines for the prevention of RhD alloimmunization were from 2003, making them 12 years old. 27 Since 2016, when data collection took place, the SOGC has published an update guidelines. 14 Healthcare providers were asked about the use of guidelines and how that impacted the way they cared for RhD-negative pregnant women.
The most current practice guidelines are not always readily available to HCPs and in rural areas where colleagues are not always available to consult can be problematic. One rural provider described the questions they had when they first started as the sole provider in a rural area about the local processes for obtaining and administering RhIG; I know the way things have to go with an injection before and an injection after especially with a Rh-positive father, but do I give that injection, do you give that injection? Does she get the injection from the nurse? How does it work in this general area? (HCP 01) There’s no easy way to know if there’s a guideline for the particular question you’re asking. (HCP 13).
Process
The prevention of RhD alloimmunization is handled differently in rural communities across northern BC. The barriers that exist in delivering care to RhD-negative pregnant women have, in some clinical situations, required HCPs to adapt processes.
Barriers
The participants and stakeholder committee described the challenges that HCPs face when providing timely preventative care. Access to RhIG, human resources, and the inability to provide RhIG impeded the process.
Administering RhIG to a pregnant RhD-negative woman is challenging in a rural community with limited HCPs and lack of a clinic and/or outpatient laboratory. In some communities, HCPs stated that RhD-negative women would need to receive RhIG at the local hospital’s ED. The patient would be triaged and the RhIG ordered and administered when the physician is available. In larger centres, the woman is required to pick up the prophylaxis from the hospital laboratory and bring it to the physician’s office where it would be administered.
When an RhD-negative woman is experiencing a sensitizing event, providing timely and critical RhIG was not always easy. Healthcare providers faced barriers to providing RhIG in these situations due to unstaffed hospital laboratories after hours, communities that do not have access to RhIG because of its shelf-life, and/or patients facing discrimination when attempting to obtain RhIG for a medical abortion.
Early medical abortions in rural areas were brought up by two HCPs (HCP 03, 05). These providers struggled with implementing processes that provide anonymity, safe, and timely interventions for RhD-negative women seeking medical terminations. In one instance, HCP 05 told a story of women being refused RhIG at the laboratory stating that the lab personnel refused to give it because it was indicated for the abortion of pregnancy; I think we looked it up with the lab because there was some delay in some women who had the medicated abortion and RhoGAM was not given because the lab personnel refused it. (HCP 05)
Providers in EDs in rural communities face another obstacle, availability of resources and services after hours. The interviewer was told that when an RhD-negative woman presents to the ED with a sensitizing event after laboratory hours, the provider has to make the decision about the provision of RhIG. The choice is between calling the laboratory staff to come in after hours to prepare the RhIG or to ask the woman to come back the next day during opening hours. Both choices are complex in nature. If the laboratory staff are called in after-hours, then there is a cost associated with that person coming back into work. If the patient is asked to return the following day, there is a risk that they might not be able to return and/or choose not to return. In a larger community, the laboratory is staffed 24 hours a day, making this less of a challenge. These barriers impact the delivery of care potentially resulting in near miss and/or patient safety incidents.
Adapting processes
Healthcare providers experience barriers in the prevention of RhD alloimmunization, particularly during sensitizing events in pregnancy. The participants in this study described their methods and strategies for adapting processes to fit within the confines of rural healthcare practice and in the delivery of evidence-based care.
As described in the previous section, access to RhIG when a medical abortion is indicated is challenging in rural contexts due to privacy concerns, stigma, and discrimination. Healthcare provider 03 described the frustration with obtaining RhIG for RhD-negative women obtaining outpatient medical abortion; “…so now I look after my own. I go to the lab, I get it myself, I sign for it and I give it,…” (HCP 03)
These process adaptations in the provision of RhIG in medical abortion scenarios was new information for the stakeholder committee members. This new information in process adaptation demonstrates that nuances in the larger healthcare system are not widely shared across a vast regional approach to healthcare delivery.
Discussion
This study focused on preventing a rare clinical event, RhD alloimmunization. Although a specific case was used, the prevention of RhD alloimmunization provided a look at the implementation and adaptation of guideline recommendation processes to deliver care in a vast rural geography within a regionalized healthcare system.
The SOGC provides best practice guidelines for the prevention of RhD alloimmunization and are referred to at the provincial level in BC. 14,28 The findings of this study suggest that the uptake of these guidelines in rural environments can be problematic because they offer a one size fits all model. The uptake is problematized by barriers, such as lack of resources and services to ensure quality and timely care. These barriers are not unique to maternal care 29 and are addressed by implementation sciences research through the development of frameworks and tools to assist organizations in adapting and implementing CPGs. 30,31 More research is needed to explore the adaptation of CPGs within localized settings situated in regionalized healthcare organizations.
The resolution to barriers of implementing best practice in rural settings is adaptation. When confronted with barriers, rural HCPs find strategies that address these challenges. In a large regionalized health authority, such as the one in this study, adaptations to processes in the delivery of care are often localized and informal. This creates silos and isolates change behaviour across larger complex systems. This can be referred to as decoupling, meaning the separation of practice from policy. 32 Developing localized processes addresses immediate problems but does not resolve the larger issue(s) that may be at the organization and/or at the systems level. When this happens, there is an opportunity for failure to occur. 33
The expertise of HCPs is considered to be the use of, and the ability to, identify gaps of knowledge. 34 –36 In instances where a knowledge gap is acknowledged, it has been found that HCPs will engage in problem-solving processes. 35 During this process, an HCP will seek information to satisfy the knowledge gap. This behaviour is dependent on the HCP’s expertise within their own practice and their ability to adapt to the situation. In this study, rural HCPs adapted processes to ensure that RhD-negative pregnant women received the best care possible based on recommendations from national prevention guidelines. These providers demonstrated expertise in their practice by developing solutions within their localized healthcare system to ensure RhD-negative women receive adequate care. It should be noted that rural HCPs are experts in identifying gaps in knowledge and within the system and problem-solve to overcome and/or adapt processes to meet local needs.
Recommendations
If the processes to meet the recommendations made by best practice guidelines are being adapted at the local level in informal and ad hoc ways, this should be addressed at the systems level to ensure quality of care. For instance, if an RhD-negative woman becomes sensitized during the first pregnancy after having had a medical abortion with the previous pregnancy, this clinical scenario should be investigated. Perhaps there is a need to adapt processes at both the local and regional systems level. Without investigation, a local adaption that is made in isolation could lead to a patient safety incident and/or identify a larger systems issue that could lead to patient harm. Such investigations would ensure that the ongoing processes within a large complex system are still working and intact, learn from other sites, and gain a broader perspective. Studies of guideline uptake identify that successful implementation of a process relies on continuous evaluation of implementation. 37 Following Greenhalgh and Papoutsi’s recommendations, an approach to spreading and scaling up innovation and/or improvement should include an approach that incorporates mechanistic, ecological, and social aspects of implementation. 38 The rapid review identified that a combination of implementation, complexity, and social sciences are critical in the successful spreading of improvement across large complex healthcare systems. This would involve including rural HCPs and patients in the investigation and health improvement process to ensure that healthcare deemed well-established is in fact equitable across all service delivery areas within a regionalized system.
Conclusion
Rural HCPs are aware of CPGs but face many barriers to implementing recommendations within practice. These barriers can impede the processes involved in the delivery of care. To overcome these barriers, rural HCPs have remained flexible and have adapted processes in their local healthcare systems to address these barriers. This work has demonstrated that HCPs are experts in rural medicine because of their ability to remain flexible and adaptable to health system issues. Moving forward, leaders of regionalized health systems should ensure that these adaptations are shared across the large and complex health authorities and are considered for long-term implications.
Footnotes
Authors’ note
This study received ethical approval from the University of Northern British Columbia Research Ethics Board (Approval Reference number E2016.0413.032.00) and received operational approval from the Northern Health Authority Research Review Committee in May 2016.
Acknowledgments
Authors would like to acknowledge the time and generosity of the participants for sharing their experiences with the researchers for this study.
Funding
This project was partially funded by the Canadian Foundation for Women’s Health.
