Background

Current discussions in health studies concerning the need for high-quality health care are focussed on cross-professionalFootnote ¹ teamwork as a key issue in improving health care quality (cf. Thylefors et al., Reference Thylefors, Persson and Hellstrom2005; Samuelson et al., Reference Samuelson, Tedeschi, Aarendonk, de la Cuesta and Groenewegen2012). The view that cross-professional collaboration is necessary for high-quality care is, however, not new; as early as 1978, the International Conference on Primary Health Care (Alma-Ata) pronounced cross-professional health teams as essential to meeting the multiple (primary) health needs within the community (WHO, 1978). Since then, many countries have followed this vision, implementing primary care teams as well as multi-professional primary health centres and thus providing comprehensive care by integrating health promotion activities, preventive, curative, and rehabilitative care (Saltman et al., Reference Saltman, Rico and Boerma2006; WHO, 2008; Hämel and Schaeffer, Reference Hämel and Schaeffer2014). In the light of today’s fast-ageing population and the increasing number of patients with complex needs, the potential for cross-professional collaboration in the field of primary health care has become even greater than the founders of the Alma-Ata Declaration and initiators of health teams originally imagined. The World Health Report 2008 (46f) indicated that primary care teams are better able to optimise the care process by assuming the coordinator role, thus avoiding task fragmentation and improving the continuity of care even for high-demand patients.

Primary health care can actually be seen as a key impetus for innovation in cross-professional collaboration. Working in cross-professional health teams has challenged care concepts dominated by physicians and led to the implementation of new and more extensive responsibilities for nurses, midwives, physiotherapists, psychologists, social workers and other health professionals working alongside family physicians to promote patient-centred and community-oriented care (Kendall, Reference Kendall2008; Freund et al., Reference Freund, Everett, Griffiths, Hudon, Naccarella and Laurant2015: 738; Kringos et al., Reference Kringos, Boerma, Hutchinson and Saltman2015: 31). Thus, team-based primary health care has led to a greater professionalisation of nurses and other non-medical health professionals, freeing them from their customary subordinate role in health care. Initial research shows that particularly nurses have benefited from this recent development. New chronic care concepts implemented in many countries in the past few years have strengthened nurses’ role as a first contact partner in primary health endeavouring to establish long-standing nurse–patient relationships (cf. Schaeffer et al., Reference Schaeffer, Hämel and Ewers2015; Kendall and Bryar, Reference Kendall and Bryar2017). Consequently, this requires a close collaboration between the personal GP and the personal nurse (cf. Hämel and Schaeffer, Reference Hämel and Schaeffer2014).

Optimally, each health professional in a cross-professional team is responsible for his or her specialised field. Combining the skills, experience and expertise of each profession in a team is seen as the main benefit: the team members have access to diverse knowledge and competencies; this enables the team to provide a broad spectrum of services and generate a more holistic view of the patients’ situation (Thylefors et al., Reference Thylefors, Persson and Hellstrom2005: 102–103). Collaboration between the professionals helps prevent shortcomings of sequential care processes, facilitates learning from other disciplines and increases patient satisfaction as well as job satisfaction (Thylefors et al., Reference Thylefors, Persson and Hellstrom2005; Wen and Schulmann, Reference Wen and Schulman2014; Morgan et al., Reference Morgan, Pullon and McKinlay2015).

Although criticised for certain methodological shortcomings, some studies investigating the effects of team-based care have provided evidence of positive patient outcomes such as higher self-perceived health and life satisfaction as well as higher satisfaction with health care (Martin et al., Reference Martin, Ummenhofer, Manser and Spirig2010; Schepman et al., Reference Schepman, Hansen, de Putter, Batenburg and de Bakker2015). Other studies denote cost-effectiveness of team-based approaches in primary care (Jacobson and HDR Inc., Reference Jacobson2012; Mundt et al., Reference Mundt, Gilchrist, Fleming, Zakletskaia, Tuan and Beasley2015). Even so, research findings regarding effectiveness and outcomes of cross-professional collaboration, in general, remain ambiguous (Barrett et al., Reference Barrett, Curran, Glynn and Godwin2007).

The most common obstacles to collaborating work in cross-professional teams evolve around organisational and professional separatism (Jamieson and Illsey, Reference Jamieson and Illsley1989; Frenk et al., Reference Frenk, Chen, Bhutta, Cohen, Crisp, Evans, Fineberg, Garcia, Ke, Kelley, Kistnasamy, Meleis, Naylor, Pablos-Mendez, Reddy, Scrimshaw, Sepulveda, Serwadda and Zurayk2010). Researchers have established that for effective teamwork between GPs and nurses collaboration needs to be based on an understanding of each other’s professional identity and specific role in the care process as well as on mutual respect and trust (Pullon, Reference Pullon2008; Jaruseviciene et al., 2013). Conventional hierarchical structures between health professionals hamper collaboration through differences in status and sustained professional rivalry (Nancarrow et al., Reference Nancarrow, Booth, Ariss, Smith, Enderby and Roots2013; Schadewaldt et al., Reference Schadewaldt, McInnes, Hiller and Gardner2013; Supper et al., Reference Supper, Catala, Lustman, Chemla, Bourgueil and Letrilliart2015; Schaeffer and Hämel, Reference Schaeffer and Hämel2017). The prospect of working (more) independently of the physician is a key impetus for effective collaboration on equal footing. However, this is not a matter of course, not even for the well-educated and highly trained nurse practitioners (Schadewaldt et al., Reference Schadewaldt, McInnes, Hiller and Gardner2013).

In addition, research has confirmed that co-location and a ‘robust organisation’ with formal supportive structures for team-oriented care facilitate effective teamwork (Oandasan et al., Reference Oandasan, Gotlib Conn, Lingard, Karim, Jakubovicz, Whitehead, Miller, Kennie and Reeves2009; Munro et al., Reference Munro, Kornelsen and Grzybowski2013; Schaeffer and Hämel, Reference Schaeffer and Hämel2017). Advantageous are also shared goals, good leadership, clear task division between health professionals, strong communication and regular appraisal of team success (Bodenheimer, Reference Bodenheimer2007: 6; Xyrichis and Lowton, Reference Xyrichis and Lowton2008: 149–150; Kennedy et al., Reference Kennedy, Armstrong, Woodward and Cullen2015: 362). Consequently, health systems with fragmented health care services can be particularly challenging to cross-professional collaboration: a long-established organisational separation of primary care services – health, social, preventive and curative care – promotes incompatible objectives and interests of the involved organisations (Delamaire and Lafortune, Reference Delamaire and Lafortune2010; Schaeffer and Hämel, Reference Schaeffer and Hämel2017).

As primary health care has had to adapt to changing patient needs, professional tasks and roles have changed, for example, professionals now have to support patients in their self-management of chronic conditions. In the last years, many countries have also encouraged a shift in responsibilities for certain tasks from physicians to nurses, in particular (but also to other health professionals) (Maier and Aiken, Reference Maier and Aiken2016). Both the new responsibilities in patient care and the task shifting from physicians to nurses necessitate a redesign in primary health care teams and, consequently, a restructuring of cross-professional collaboration.

Given that many countries are faced with these challenges today, it appears prudent to investigate and compare the different concepts being implemented and the experiences of those involved. This paper, therefore, examines the concepts and experiences of the cross-professional collaboration of GPs and nurses found in Slovenian and Spanish primary health centres. While bearing the specific health care context and traditions in mind, we will focus here on the effectiveness of collaboration.

Slovenia and Spain were chosen for this comparison, because they both have robust primary health care systems (Kringos et al., Reference Kringos, Boerma, Hutchinson and Saltman2015) and have operated cross-professional centres for many years now. It can hence be assumed that physicians and nurses are well experienced in collaboration (Albreht et al., Reference Albreht, Turk, Toth, Ceglar, Marn, Pribakovic Brinovec and Schäfer2009; Dedeu et al., Reference Dedeu, Bolibar, Gené, Pareja and Violan2015). In addition, many Slovenian and Spanish primary health centres have increased their efforts as of late to strengthen teamwork between GPs and nurses in their primary health centres. The following paper will begin with a short sketch of each country’s primary care concept. That will be followed by a closer examination of their approaches to teamwork and recent developments. The prospects for cross-professional collaboration between GPs and nurses will then be compared and discussed.

Method

The findings presented in this paper are focused on concepts and practices of cross-professional collaboration of GPs and nurses in Slovenian and Spanish health centres. They draw on a narrative review of literature available in English on the development of cross-professional primary health care in Slovenia and Spain combined with a qualitative analysis of the current situation in selected health centres based on semi-structured expert interviews, presentations, group discussions and recorded observations.Footnote ²

The literature used for the analysis included academic studies published in Slovenia and Spain as well as internationally. These publications focused on the development of primary care and primary care concepts in the two countries as a whole, in addition to primary care teamwork, cross-professional collaboration as well as the role and position of GPs and nurses in the teams in particular. Government documents, official statistics and national reports provided information about the health systems in general, on planned and initiated reforms and basic data on primary care. Interviewed experts in both countries also recommended relevant literature on primary care and on the role of the health professions and primary care providers in each country. Furthermore, they supported us in identifying interesting concepts of cross-professional collaboration.

A major challenge of this study was to gain practical access to health care centres in the chosen countries. In a first step, key experts on primary health care in both countries were identified with help of the literature analysis and through contacts in the European Network for Primary Care. They were then contacted with the request for an interview. Ten expert interviewsFootnote ³ relating to Spain and Slovenia were conducted (see Supplementary material, Table A1). The semi-structured interviews focused on past and recent developments in primary care and cross-professional collaboration in the different countries. Key characteristics and innovative elements of health care centres, roles and tasks assumed by the various health professionals were of particular interest as well as the interaction and co-operation between team members.

The interviewees were also asked to recommend health care centres in the country of their expertise, which they consider particularly good examples of cross-professional teamwork and collaboration in primary health centres. The recommended centres were then contacted with a request to visit. The participants were informed beforehand of the study’s objectives and consented to the audio recording of the entire visit. A weeklong trip was scheduled for each country. In total, seven health centres (Slovenia: three, Spain: four) and their associated health stations were visited. In Slovenia, the primary health centres visited were spread across the country. Due to Spain’s geographical size and time restrictions, visitations there were limited to health centres in Catalonia and the Basque Country – both regions were chosen based on experts’ recommendations.

The visits to each health centre were organised similarly, though they differed in detail. Most began with a presentation by the health centre managers summarising the health centre’s vision, purpose and the organisational structure. This was followed up by a guided tour of the complex. The authors then jointly conducted a series of semi-structured interviews with various health professionals. The interviews focused mainly on key tasks and responsibilities, co-operation in the team and with associated partners of the health centres, for example, secondary care, social services. Additional interviews were conducted with the health centre’s managers focusing on key characteristic and innovative aspects, development, implementation and evaluation of the care concepts, the daily routine, roles in the team and services provided. Finally, in some cases, the centre’s management organised group discussions with health professionals to delve deeper into specific aspects. Since these group discussions were organised spontaneously on site by the hosts, it was not possible to prepare methodical guidelines for them beforehand. They were nevertheless crucial for the understanding of the given health care concepts. The authors were able to ask extensive questions, voice observations and tentative assessments on the care concepts and cross-professional collaboration of the health centre, and discuss these in-depth with the participants. All presentations, interviews, group discussions and observations during the tours through the health centres were digitally recorded.Footnote ⁴ Practically all interviews, presentations and tours were conducted in English as a second language for all participants; only one interview was conducted in German. Where necessary, the interviewees were assisted by a translator.

The recorded material was transcribed as needed: the interviews for the most part as full scripts, the presentations and centre tours as summaries, the group discussions as a combination of script and summary. The data was subsequently analysed by means of computer-assisted qualitative content analysis using MAXQDA (cf. Meuser and Nagel, Reference Meuser and Nagel1991; Gläser and Laudel, Reference Gläser and Laudel2004). The individual transcripts were first roughly structured according to the topics discussed in the interviews. The material was then re-read, and inductive categories were defined (eg, status of the nurses). The entire text material was encoded, and individual sections of the text were analysed and interpreted in more detail. The authors worked jointly in all phases of the data collection and content analysis.

A case description of each country was then composed identifying the influencing historical and cultural factors, current cross-professional team model as well as key structures of the model. Experts in the field were given short presentations of our initial findings and research hypotheses. The ensuing discussions added valuable insights to the analysis. Finally, the case descriptions were used as a basis for the iterative, discursive process that followed, in which the authors sought to identify key components of team concepts used in each country, their similarities as well as differences. The triangulation of various data sources, multiple observers and the integration of the varied perspectives of the researchers as well as external experts in the course of the analysis allowed us to cross-check our findings and provided us with a deeper understanding of the concepts and practices of cross-professional primary care in Slovenia and Spain.

The case of Slovenia

In Slovenia, the first implementation of multi-professional primary health centres took place in the 1920s. The aim was to provide general medical care, mother, and childcare and preventive medical care for communicable diseases (such as tuberculosis) for vulnerable groups in rural areas (Albreht et al., Reference Albreht, Delnoij and Klazinga2006: 238). After the Second World War, Yugoslavia’s national health policy strategy was to build up the health care system around primary health care centres (Saric and Rodvin, Reference Saric and Rodwin1993; Klančar and Svab, Reference Klančar and Svab2014: 167). Accordingly, the many health centres built in the 1950s and 1960s were responsible for the health needs of the population in specified geographical areas (Albreht et al., Reference Albreht, Delnoij and Klazinga2006: 238; Klančar and Svab, Reference Klančar and Svab2014: 167). To build up an adequately trained workforce for primary care vocational training for community nursing was introduced in 1957 (Slajmer-Japelj, Reference Slajmer-Japelj1993: 328; Hennessy and Gladin, Reference Hennessy and Gladin2006: 40) and special training for GPs in 1962 (Bulc et al., Reference Bulc, Fras and Zaletel-Kragelj2006).Footnote ⁵ After their declaration of independence and the founding of the state Slovenia in 1991, a national health insurance system was initiated (Albreht et al., Reference Albreht, Pribakovic Brinovec, Jošar, Poldrugovac, Kostnapfel, Zaletel, Panteli and Maresso2016: 21). Under political pressure at the time to ‘free’ the professionals, the government allowed health professionals to open private practices, also hoping to provide thus a more efficient patient-friendly health care (Albreht and Klazinga, Reference Albreht and Klazinga2009: 82).Footnote ⁶ Even so, the health centres owned by the municipalities continued to play a central role in primary health care with 76.5% of the primary health care physicians working in municipal health centres. Most recent statistics (2013) count 65 health centres represented in 459 locations that cover all regions of Slovenia (Albreht et al., Reference Albreht, Pribakovic Brinovec, Jošar, Poldrugovac, Kostnapfel, Zaletel, Panteli and Maresso2016: 118).

Today, the Slovenian health centres offer a broad spectrum of services: Family medicine, health care for women, children and youths, community nursing, physiotherapy, occupational health, laboratory and other diagnostic services, dental care and emergency care (Albreht et al., Reference Albreht, Pribakovic Brinovec, Jošar, Poldrugovac, Kostnapfel, Zaletel, Panteli and Maresso2016: 130). Diverse professionals must collaborate to provide such comprehensive services: family physicians, paediatricians, gynaecologists, registered nurses,Footnote ⁷ nurse assistants, midwives, physiotherapists, speech therapists, occupational therapists, dentists, psychologists/psychiatrists and other health professionals (Rotar Pavlič et al., Reference Rotar Pavlič, Švab and Brinovec Pribaković2015: 246; Albreht et al., Reference Albreht, Pribakovic Brinovec, Jošar, Poldrugovac, Kostnapfel, Zaletel, Panteli and Maresso2016: 119).Footnote ⁸ The GPs and the community nursesFootnote ⁹ are the patients’ points of first contact (Int-Sp25, 606). Both are organised in separate independent units. Since 2011, ‘practice nurses’ also provide first contact (Albreht et al., Reference Albreht, Pribakovic Brinovec, Jošar, Poldrugovac, Kostnapfel, Zaletel, Panteli and Maresso2016: 111). Before taking a closer look at this new development, we will outline the given forms of collaboration between physicians and community nurses.

The case of Spain

Multi-professional primary health centres were first established in Spain in the 1980s as a part of the overall democratisation process initiated at the end of the Franco regime. The implementation of health centres was accompanied by a transformation of the health system from a social insurance model to a tax-based national health service (European Observatory – European Observatory on Health Care Systems, 2000). The health centres provide the Spanish population with universal access to health care, integrating preventive, curative and rehabilitative services under one roof (Hart, Reference Hart1990; Borkan et al., Reference Borkan, Eaton, Novillo-Ortiz, Rivero Corte and Jadad2010: 1433; García-Armesto et al., Reference García-Armesto, Begona Abadia-Taira, Duran, Hernandez-Quevedo and Bernal-Delgado2010). Cross-professional primary health care teams were set up to take over a shared responsibility for the primary health care of the population in a specific geographical area (García-Armesto et al., 2010: 57; López, Reference López2011). As of 2003, primary health care teams are operated in all regions of Spain (Gené-Badia et al., Reference Gené-Badia, Ascaso, Escaramis-Babiano, Catalan-Ramos, Pujol-Ribera and Sampietro-Colom2008: 2). A network of 3023 health centres and 10 081 health stations exists today (MoHSE, 2015: 9). Most of them are public organisations administrated by regional health services (ie, the Catalan Institute of Health).Footnote ¹³

The cross-professional teams are composed of GPs, pediatricians, nurses, nurse assistants and administrative staff. Depending on regional concepts, they can also include dentists, social workers, midwives and physiotherapists (Borkan et al., Reference Borkan, Eaton, Novillo-Ortiz, Rivero Corte and Jadad2010: 1434; Dedeu et al., 2015: 257). The teams presently claim a ratio of nearly 1:1 physicians to nurses (MoHSE, 2015: 10). The health centres offer comprehensive services for adults as well as specialised health care services for older people, women, children and youths (García-Armesto et al., Reference García-Armesto, Begona Abadia-Taira, Duran, Hernandez-Quevedo and Bernal-Delgado2010: 138). Their services encompass individual care, clinical care at the health centre, home care and community health activities.

Regarding the collaboration between physicians and nurses in Spain, two aspects are of particular interest. First, with the implementation of primary care teams, the nursing profession was given a new status in primary care with advanced responsibilities. An important prerequisite for this role enhancement was the introduction of nursing education as degree level study programmes in 1977 (Mariscal Crespo et al., Reference Mariscal Crespo, Merino Navarro, Mena Navarro, Macia Soler, Zabalegui Yarnoz and Camacho Bejarano2010: 341; López, Reference López2011: 1722). Since 1990, the curricula of nursing education focus in particular on community care (Zabalegui Yarnoz, Reference Zabalegui Yarnoz2002: 313; López, Reference López2011: 1722).Footnote ¹⁴ Second, since the health centres were established, inter-professional teamwork has been seen as crucial for effective primary care (Goñi, Reference Goñi1999: 108; Dedeu et al., Reference Dedeu, Bolibar, Gené, Pareja and Violan2015: 255). The professionals have not simply been gathered under one roof. They have worked hard specifically to develop and strengthen teamwork as well. For example, supplement programmes have been initiated, such as joint ventures for research projects, special programmes for team-based community action and health promotion activities (Martí Arguasca and Argimon, Reference Martí Arguasca and Argimon2008; Dedeu et al., Reference Dedeu, Bolibar, Gené, Pareja and Violan2015). Furthermore, in several autonomous regions ‘productivity bonuses’ (eg, for the judicious use of prescriptions or the reduction of waiting time) have been introduced, which in part are rewarded as team bonuses (García-Armesto et al., Reference García-Armesto, Begona Abadia-Taira, Duran, Hernandez-Quevedo and Bernal-Delgado2010: 116; MoHSE, 2010: 62).

Conclusion and discussion

Like many other countries today, Spain and Slovenia are faced with new challenges in primary care created by a changing spectrum of illness and disorders and the growing necessity to find needs-based solutions for complex, long-term health problems. As our analysis shows, both countries strive to ensure comprehensive, ongoing care and to develop new services for the patients. In order to do this, they also both have chosen to intensify team-based collaboration between GPs and nurses as the key to increasing the effectivity of care services in their health centres. Among other things, our study demonstrates that developments initiated in primary health care, and the outcomes of changes made are influenced by each country’s care history and traditions. Nevertheless, despite cultural differences, the opportunities for and quality of co-operation between GPs and nurses in Spain and Slovenian appear closely linked with the training, task responsibilities of nurses in primary care as well as status within the team. GP-nurse tandems in Spain and Slovenian were most effective, where the position of nurses in primary care had been strengthened and a new, more prominent role of nurses in the care process was accepted.

Thus, a central finding of our analysis is that traditional hierarchies between the professions hinder the possibilities of cross-professional teamwork. Structural hierarchies between the professions continue to exist not only in Slovenia and Spain, as shown here, but also in many other countries (cf. Delamaire and Lafortune, Reference Delamaire and Lafortune2010; Schaeffer and Hämel, Reference Schaeffer and Hämel2017). Although similar issues were discussed extensively in the 1980s (cf. Freidson, Reference Freidson1986; Light, Reference Light1988), they often have been overlooked in the current discussion concerning improvements of cross-professional co-operation (Paradis and Whitehead, Reference Paradis and Whitehead2015). As demonstrated, changing of the hitherto hierarchical structures of co-operation can be difficult without overcoming differences in status and the long-established power gap. The difference in status between the health professions is reflected in the still distinct educational gap between physicians and nurses (as well as other health care professions). Consequently, a key step towards changing given hierarchies entails the further professionalisation of nurses and other health professionals. The academisation of the nursing profession, for example, raises nurses’ status in the society, and thus assists their emancipation from subordinated role placement in health care. As de Geest et al. (Reference De Geest, Moons, Callens, Gut, Lindpaintner and Spirig2008) pointed out, education is a major driver in the development of the advanced practice nursing roles. In Spain and Slovenia, both countries have taken initial steps to integrate nursing and other health professions into higher education. Nevertheless, these professions have few opportunities in postgraduate education, and as of yet, the offered study programmes do not correspond to those in the medical fields.

In addition, our findings imply that effective change in dominance patterns and responsibility must be actively supported at the grassroots level, that is locally, in individual teams. Changes in co-operation and communication patterns, which are necessary for successful teamwork, do not occur automatically in the process of introducing teamwork. Supportive processes for change must be implemented systematically and deliberately adopted by all team members. A closer look at the local team performances in both countries gives a clearer picture on options to promote (or hinder) cross-professional teamwork:

1. (1) Our findings confirm the importance of clearly defined structures for teamwork by means of agreed definition of tasks and/or areas of responsibility. Moreover, the mutual acknowledgement and understanding of each profession’s scope of practice are a key factor in promoting cross-professional teamwork (cf. Clarin, Reference Clarin2007; Jaruseviciene et al., Reference Jaruseviciene, Liseckiene, Valius, Kontrimiene, Jarusevicius and Lapao2013): In both Spain and Slovenian, well-structured procedures and clear task assignment assisted the implementation of new methods. Misunderstandings and/or backslides into long-established roles, and behavioural patterns were prevented or counteracted through active and continuous communication between the participating professionals. This allowed nurses the needed space to test their new capabilities and grow into their (new) responsibilities. In Slovenia, responsibilities and tasks were defined by means of protocols established in the initial introduction of practice nurses into GPs practice. In Spain, the need for further clarification of procedures and tasks often became prevalent in the course of daily practice as nurses delved into new areas of responsibility. It would be interesting to focus further research on the appropriateness of the different procedural approaches (protocols and detailed description of tasks versus definition of areas of responsibilities). Our study indicates that particularly in health centres with little experience in cross-professional teamwork and a hitherto hierarchically oriented understanding between doctors and nurses; it could be beneficial initially to define tasks assigned to the nurses clearly, and in the process give them the needed space to develop new roles.

2. (2) Our results also indicate that clear definitions of tasks and responsibilities alone do not provide a sufficient basis for collaborative action in a cross-professional team. Rather, the professionals must learn how to work jointly. Particularly, in situations where unilateral profession-oriented interests dominate relationships, collaborative teamwork can become difficult. This also holds true when concerns arise in the team caused by disparate interpretations of function and task descriptions. Our study gives evidence that shared visions of the professionals such as patient-oriented care (cf. WHO, 2015) can provide additional guidance and motivation for collaboration. However, in the process of developing shared visions, misunderstandings can influence the discussion on the development of teamwork and the expansion of care negatively. As demonstrated above, there are risks, for example, in arguing for more task responsibility for nurses to counter a shortage of physicians or to save costs as opposed to emphasising the advantages for patients. Instead of encouraging collaborative behaviour, such arguments tend to buttress unilateral interests and short-term objectives.

3. (3) Finally, opportunities for cross-professional teamwork lie in the increased accessibility of expertise and skills in patient care to all team members (inter-professional expertise). Effective cross-professional teams provide time and space for team development processes and systematically promote them. Our study shows that, when initiating change, particularly by means of task shifting, collaborative negotiations on work procedures in the team are particularly important. The time thus made available can also be used to address 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 team’s development, the results of which look quite promising for the further development of the team’s tasks.Footnote ¹⁹ Regular team meetings and the exchange of experiences provide opportunities not only to strengthen teamwork top-down but also to develop it bottom-up further by utilising the expertise of the participants. Interestingly enough, providing time and space for team development appears to be of greater relevance for team performance in Spain than financial incentives. In Slovenia, the full potential of team development processes has yet to be utilised. Introducing strategies to develop team development processes further will be an important task toward improving the effectivity of their cross-professional teams in the future.

Our stated aim of this paper was to take a closer look at possibilities of co-operation between GPs and nurses in primary care in Slovenia and Spain in the context of their country-specific primary care concepts and further refinement. The comparative analysis enabled us to identify differences in conceptual and procedural methods employed in the two countries; this provided us with valuable insights into various aspects of change in specific social-cultural frames. We confirmed that clearly defined structures, shared visions of the professionals and opportunities for team development are of great relevance for the effective implementation and sustainability of collaboration between general practitioners and nurses in primary care. However, in the course of the analysis, we also uncovered common challenges and typical difficulties, for example when attempting to increase responsibility, autonomy and status of nurses in the team. When developing and implementing care concepts that aim to strengthen the collaboration between physicians and nurses in the future, these problems and issues should be anticipated and confronted proactively. Further means of dealing with conflicts within the teams need to be developed and tested.