Collaboration between general practitioners and health visitors about children of concern in Denmark: a qualitative study

ABSTRACT

Primary health care services are responsible for preventive measures to optimize child development in the first years of life. In Denmark, these services are shared between general practitioners and municipality health visitors. National guidelines mandate collaboration between these professionals but in reality, they work in parallel. We aimed to explore how professionals experience collaboration and communication regarding children with professional concern about their wellbeing. Seventeen semi-structured interviews were conducted with general practitioners, and health visitors. Both professions considered closer collaboration to be important in meeting children’s needs. Barriers to collaboration and communication included differing legal obligations, Information Technology-systems (IT), lack of financial incentives, lack of mutual professional acknowledgment and respect, and absence of routines for sharing knowledge. The traditional division of responsibilities between physicians and nurses in which all professionals involved in preventive child health care are acculturated seems to impede collaboration based on unequal professional status. IT infrastructure needs to support information sharing and structures to support informal meetings between professionals are warranted to support more collaborative practice.

KEYWORDS:

• Collaboration
• communication
• cross-sector
• general practitioner
• GP
• health visitor

Introduction

Preventive healthcare for new families and small children is a priority for most developed countries (Walraven, 2019). Primary health care services are generally responsible for preventive measures in the early years to optimize child development (Regalado & Halfon, 2001), and delivery of these preventive health programs is often divided among several sectors and professionals (Katz et al., 2002; van Esso et al., 2010). The aim of preventive child health programs is to support good parenting practices and offer health promotion, accident prevention advice, immunizations, and screening for problems in child development (Wilson et al., 2018). These preventive measures have potential to decrease both morbidity and mortality (Altindağ et al., 2022) and are thus an important part of health service provision. Authorities including the World Health Organisation (WHO) have expanded their recommendations on preventive measures from a purely physical focus toward a more family-centered and psychosocial approach (World Health Organization, 2020).

Background

In Denmark, preventive health care is delivered by different types of professionals, specifically general practitioner physicians (GPs) and health visitors (Daníelsdóttir & Ingudóttir, 2020). The GP, who is generally an independent contractor to regional health authorities, often has knowledge about family history but usually sees the child at short appointments in the clinic for acute medical problems and in somewhat longer appointments for developmental assessments. The municipality-employed health visitor has a 3.5-year education as a nurse and 18 months specialization in child health. Professions similar to health visiting exist in several other northern European countries. Municipality-employed health visitors have more time per patient and visit families at home. GPs have a longer-term relationship with families, whereas health visitors have longer consultations than the GP, but for a shorter period of time. In the Danish preventive program, GPs and health visitors complement each other in preventive health work regarding children. The GP is responsible for seven free preventive examinations and conversations with the family about the child’s well-being. The health visitor has five visits to the family´s residence within the first 10 months, thereafter health visitors are responsible for advising parents of young children and functional examinations of the child in school age (Poulsen & Brot, 2019). All Danish families are invited to join these preventive programs voluntarily with the potential for receiving additional visits if needed. The programs are tax funded and free of charge to all citizens.

All children, particularly those in potentially vulnerable situations should benefit from collaborative work between GPs and health visitors with their complementary skills and work settings (Poulsen & Brot, 2019). Collaboration and coordination are, however, often suboptimal (Kuo et al., 2006; Psaila et al., 2014; Schmied et al., 2010; Wilson et al., 2018), and there is potential to increase collaboration and communication between these professionals (Schmied et al., 2015). Cross-sector gaps are generally sensitive to errors and may affect the family’s feelings of safety and coherence. Furthermore, lack of collaboration can lead to concealment of problems and may have negative consequences for children’s health and development, especially among vulnerable families (Brodribb et al., 2016; Brygger Veno et al., 2022; Wendt et al., 2020). Health authorities usually have guidelines for preventive child health care services and the Danish guidelines emphasize interprofessional and cross-sectoral collaboration to support children in vulnerable situations (Poulsen & Brot, 2019). In Denmark and other Scandinavian countries, it nevertheless appears that there is minimal formal communication between municipality child health services and GPs (Ellefsen, 2002; Wilson et al., 2018). Reasons for lack of collaboration and communication are not well established, and the perspectives and experiences of involved health professionals could shed light on this. Thus, the aim of this study was to explore how health visitors and GPs experience collaboration and communication related to children in potentially vulnerable situations due to psychosocial or other issues.

Methods

Research design

This was a qualitative study based on 17 semi-structured interviews with health care professionals. In total, 10 GPs and 10 health visitors were interviewed. All interviews were conducted in Danish, and quotations for the manuscript were translated to English. Results were interpreted using interpretative phenomenological analysis focusing on how individuals perceive and make sense of their experiences (Pietkiewicz & Smith, 2014).

Participants and recruitment

To achieve maximum variation, we recruited GPs and health visitors from the Capital and Zealand Regions. We used purposive sampling with inclusion based on variation in professionals’ seniority, gender, practice in rural or urban areas, and patient sociodemographics. Ten interviews were conducted with GPs from 10 different clinics: one clinic’s midwife joined an interview with one of the GPs. Seven interviews were conducted with health visitors; for pragmatic reasons three of these interviews had two health visitors together. Recruitment channels were e-mail and, for some, a follow up e-mail or text message 3 weeks later to ascertain their interest in being interviewed. The first author (RCE) and last author (GO) sent recruitment e-mails. All participants responded by e-mail with written informed consent. GPs were recruited in August-October 2022, and interviews were conducted in September-November 2022. Health visitors were recruited in September-October 2022, and interviews took place during October-November 2022. Six GPs were recruited through the Family Wellbeing trial (Overbeck et al., 2023), three GPs were recruited through the Copenhagen University research and teaching environment, and one GP was recruited through telephone calls. Nine GPs were recruited from Zealand and one from Funen. The health visitors were invited by sending out an invitation e-mail to the municipalities, aiming both to have representation from rural and urban municipalities and to be aligned to the GPs’ locations. There was no previous relationship between the interviewer and the participants.

Procedure

RCE conducted the interviews. The interview guide (see online supplementary file) was developed by RCE, PW, and GO to examine the professionals’ collaborative work with each other. The questions were exploratory to elicit descriptions of and reflections on interprofessional collaboration. Adjustments were made to the interview guide after a pilot interview and when new insights emerged. Sampling continued until the research question had been answered with sufficient data, and no new perspectives emerged.

The interviews were held either face-to-face in the GP’s clinic (n = 4), the health visitor’s office (n = 3), in a conference room at the University (n = 2), or through Zoom® (n = 8), and they lasted from 25 to 77 minutes (mean: 57 minutes). The interviews were audio-recorded and transcribed verbatim by RCE (n = 16) or, in one case, by a student assistant. Nvivo 12 (Lumivero, 2018) was used for coding.

Ethical considerations

The study is part of a larger study, approved by the Research Ethics Committee University of Copenhagen (ref no. 504–0111/19–5000). Participants gave written consent to participate in the interviews.

Data analysis

The exploratory nature of the study made it appropriate to apply an inductive method for coding. Thematic analysis was used for the data using Braun and Clarke’s framework (Braun & Clarke, 2006). In the first step, transcripts were carefully read and thoughts about analysis developed. In the second step initial coding began in which all meaningful sentences were coded in Nvivo (Lumivero, 2018). In the third step RCE and GO grouped similar phenomena into themes. In the fourth step, the themes were reviewed and discussed between RCE and GO and re-coded if necessary. In the fifth step, final themes were set, and a coding tree was made from all the codes. In the final step RCE, SVO, PW, and GO synthesized the findings and selected quotations presented in the results section below. To enhance transparency in reporting, the COREQ checklist was used (Consolidated Criteria for Reporting Qualitative Research; Tong et al., 2007). Table 1 shows participant characteristics.

Table 1. Demographics of interview participants.

Profession	Age (years)	Gender	Professional experience (years)	Community	Regular patient contact
General practitioners	Mean age (GP) = 43.5	n(m, GP) = 5 n(f, GP) = 5	Mean professional experience (GP) = 17.3	n(urban, GP) = 6 n(suburban, GP) = 2 n(rural, GP) = 2	n(yes, GP) = 10
GP1	63	f	23	urban	yes
GP2	42	m	14	suburban	yes
GP3	43	m	16	urban	yes
GP4	42	f	14	urban	yes
GP5	47	m	17	urban	yes
GP6	60	f	31	suburban	yes
GP7	53	f	14	urban	yes
GP8	37	m	13	urban	yes
GP9	53	f	19	rural	yes
GP10	48	m	12	rural	yes
Health visitors	Mean age (HV) = 52.5	n(f, HV) = 10	Mean professional experience (HV) = 19.1	n(urban, HV) = 3 n(suburban, HV) = 2 n(rural, HV) = 5	n(yes, HV) = 7 n(no, HV) = 3
HV1	56	f	20	suburban	yes
HV2	40	f	1	rural	yes
HV3	56	f	21	rural	yes
HV4	59	f	21	urban	yes
HV5	61	f	27	urban	no
HV6	58	f	28	urban	no
HV7	44	f	12	rural	yes
HV8	64	f	32	suburban	no
HV9	40	f	9	rural	yes
HV10	47	f	20	rural	yes
Total number of participants = 20	Total mean age = 50.6	Total n(m) = 5 Total n(f) = 15	Total mean professional experience = 18.2.	Total n(urban) = 9 Total n(suburban) = 4 Total n(rural) = 7	Total n(yes) = 17 Total n(no) = 3

GP= General practitioner. HV= Health visitor. m = male. f = female. n = number of.

Results

Five themes and subthemes were identified from the analysis. The themes were: Communication and Collaboration, Initiating Contact or Not, The Interprofessional Interplay, Communication Practices, and Professionals’ Recommendations. Direct quotations are used to illustrate how the interpretations are grounded in the data.

Communication and collaboration

GPs and health visitors reported differing experiences regarding collaboration and communication, highlighting underlying factors they believed to influence the quality of their cooperation. Several subthemes emerged from their discussions, underscoring the complexity of the interactions.

Data sharing

One barrier to contacting the other professional was the perceived need for consent from patients. This was particularly emphasized by health visitors:

(…) we are also concerned about the duty of confidentiality and what, what we are allowed to share. I don’t want my fingers caught there. And there are some skilled and well-functioning parents who can absolutely explain themselves, and therefore I think in any case this is the barrier that makes me not write so often.

(Health visitor 1)

As illustrated here, the respect for patient autonomy weighed heavier than communicating with the GP in cases of professional concern about the child’s wellbeing.

Legal obligation

In cases with children with jaundice, health visitors felt legally obliged by guidelines to contact the GP to secure follow-up: “ … because we actually follow these recommendations and guidelines, that say for example that when that child has had jaundice for such and such a duration then we should recommend seeing the GP or referring to the GP.” (Health visitor 8). Driven by a sense of personal responsibility, some health visitors described reaching out to the GP several times to get a response and have their concerns addressed:

It is in fact my responsibility to make sure that the doctor takes this blood

Sample and that it’s the right one, and it’s my duty to follow up what the result is even though it’s definitely not my field, it’s of course a medical matter. But it is my responsibility to follow that up.

(Health visitor 7)

Because not all GPs liked to be chased up by a nurse, friction could arise between the health visitor and the GP: “For instance, one gets annoyed when they think we should write (…) prescriptions, when we are not supposed to write prescriptions”. (GP 2).

Municipality size

The size of the municipalities was highlighted as a factor, with both health visitors and GPs reporting that it was easier to get in touch with the other group of professionals when municipalities were smaller. In the past, it had been more usual for health visitors/GPs to know the child’s GP/health visitor: “ … it was an easier relationship. I knew the health visitor’s name, and the communication was good.” (GP3). “Back in the day, we had the small municipalities, so there were the two health visitors, and they met with the doctors. Then came the municipal mergers, and everything suddenly became so big, right?” (Health Visitor 8).

Lack of remuneration

GPs highlighted that their practices did not receive remuneration for working time if they met with health visitors. This was a barrier to engagement in collaborative work: “There have not been particularly favorable conditions for the general practitioners to make it worth their while to attend these meetings in relation to their lost earnings, or whatever it’s called.” (Health visitor 6).

Initiating contact or not

Professionals had different needs and preferences for initiating contact with one another. This depended on whether the problem was psychosocial or somatic.

GPs’ first choice: not the health visitor

Generally, GPs thought there were few children of concern, and when they identified a case, they tended to refer the family to other services (e.g., the hospital or social services): “It depends a bit on how they aren’t thriving, but as a starting point I usually put it through the [hospital] pediatricians.” (GP 10).

Fortunately, it’s not often that we have small children that fail to thrive … If it’s mental wellbeing or problems with child wellbeing in relation to an institution, then we look a lot toward PPR [pedagogical psychological counseling, based alongside social services] and what the municipality psychologist can do. (GP8)

GPs were sometimes in doubt whether they should have referred to social services instead of contacting the health visitor:

How is it actually, if I write to the health visitor? Is it “half a report” [to the social services]? I know it’s not a complete one, but when activating the system of the municipality, then it is kind of. (GP3)

Psychosocial concerns could make gps initiate contact with health visitors

Sometimes GPs contacted the health visitor when their concern was related to the child’s psychosocial wellbeing and when they wanted the health visitor to follow up the child or family: “The mother was having a hard time with something psychological, and the father didn’t have much energy either, so we made contact with the health visitor and asked them to follow up on the family side, right?” (GP9).

In this case, the GP initiated and delegated a task to the health visitor. However, such initiation did not happen the other way around: “We don’t refer to the GP if we think there are challenges with the relationship between mum and child, we don’t.” (Health visitor 9).

Ruling out somatic disease

Ruling out somatic disease was important for the health visitors and the most frequent reason for referrals to the GP. Most contact from the GPs to the health visitors was also to rule out somatic disease (e.g. in cases of weight problems, and jaundice): “I think that the only times I have been in contact with health visitors has actually been if the children did not gain weight.” (GP5). “But the correspondence with the GPs was not around poor well-being in relation to, what’s it called, attachment, it was more on the physical level that we had a talk.” (Health visitor 2).

The interprofessional interplay

Lacking knowledge about the other profession

Clinicians demonstrated a fundamental lack of knowledge of the tasks, expertise and competences of the other profession: “For instance, I don’t know what the GPs do in their 5-week exam.” (Health visitor 2). “They could also prepare an information letter for us, in which they wrote how they [health visitors] actually work.” (GP6).

In one case, a GP was concerned about a family where both mother and father had psychiatric conditions and had difficulty taking care of their baby. The GP referred the family to a psychiatrist instead of starting by contacting the health visitor, because of lack of confidence in the health visitor team’s professional competence regarding mental health:

And I don’t know who is at the other end - is it a health visitor? Or is it a locum or someone who has the competence to take care of it or not? (…) that’s why I just refer to psychiatry.

(GP7)

Frustrations

Power relationships took various forms. The interplay between GPs and health visitors sometimes led to new discoveries and positive experiences but occasionally also to frustration and conflict. Health visitors missed in-depth discussion with the other party and GPs thought that the other profession lacked academic rigor. Some health visitors had experienced disagreements with GPs about child assessments. For instance, a health visitor experienced a GP strongly disagreeing with her in the assessment of a mother’s parenting skills. The health visitor had been trained in the use of a screening tool (The Alarm Distress Baby Scale – ADBB; Guedeney & Fermanian, 2001) for evaluating the mother-infant relationship. The GP did not approve of the health visitor’s recommendation based on the ADBB and thus disagreed with her arguments for making a report to social services. The GP argued against the health visitor in a meeting set up to settle the conflict:

They are difficult to spot, but as you know we use ADBB screening, we see very early on that the relationship is not what it is supposed to be, and then we start to dig into what is going on here?… It is a screening method, where you assess the child’s social competences (…). And (…) the GP, he says, “Well, I have a strong gut feeling from many years of experience”. (Health visitor 5)

This conflict illustrates the health visitors perspective that evidence-based screening tools may be superior to clinical gut-feeling in pediatric assessments.

Health visitors were sometimes frustrated when GPs put a lot of responsibilities on them either because the GPs were only temporary locums in the area, or they simply did not know enough about pediatrics: “It is often we’re told, well ask your health visitor about it (…). And that can also sometimes be a bit of a challenge because we don’t have the medical skills.” (Health visitor 10).

Several GPs were frustrated when health visitors referred parents to them with “trendy ailments,” which they experienced as coming in waves:

(…) we see trends such as talk about tongue tie, or periods when they all talk stiff necks and that they are going to the osteopath, and times when then they all talk about acid reflux, reflux and they need treatment for that. And that’s how the waves go and “my health visitor says, my health visitor says.”

(GP4)

Health visitors frequently felt professionally rejected by a GP when trying to get in touch with them about a problem. As a work-around, health visitors sometimes contacted the emergency department at the hospital instead and insisted on talking to the resident doctor:

(…) then you feel unrecognised as a professional. So if we can see a child is looking pale, has bad breathing, then we’re not just someone who is worried, we have some expertise and some experience to contribute - that a child shouldn’t look like that, right?. So it wasn’t something that could wait until tomorrow.

(Health visitor 5)

Some clinicians, however, did not experience barriers to getting in touch with the other professional when they needed it.

Duplicated work

In relation to duplicated work the different electronic patient records systems in themselves were experienced to complicate sharing of information: “(…) it’s hard when working in different palettes, right?” (Health visitor 10).

Both health visitors and GPs were aware that a lot of duplicated work arose because of their lack of collaboration and communication: “And maybe it’s a bit of duplicated work, right? I visit and then straight away they go to the GP. So in one way or another it’s a waste of resources, the fact that we don’t communicate better.” (Health visitor 9).

(…) families experience an element of an incongruent healthcare. Since we do not work closer together some of them say, ’I have just been to the health Visitor 4 days ago.’ It is crazy. I mean it is bad planning somehow, right?

(GP3)

Communication practices

Limited direct communication

Overall, there was limited communication between the professions but when they did communicate; it was most often from health visitors to GPs through electronic messaging, sometimes by telephone and rarely by meeting. Generally, health visitors experienced a one-way communication from them to the GP, leading to a feeling of being unnoticed despite working together in the same preventive program:

My impression is that it is mostly us who write. I have tried, I mean I have been here for 12 years now, right? I may have come across at most a handful of times that the GP has written to me.

(Health visitor 7)

Some GPs lacked basic contact information about health visitors such as telephone numbers, where to send correspondence etc. Telephone communication was reported by both professional groups to be time-consuming, hard to figure out or simply impossible: “(…) but we don’t have a direct number for the general practice, we do have the one the patients call on, but we can’t sit and wait half an hour for discussion about a topic” (Health visitor 9). “Yes it would be lovely if we knew where to call” (GP4).

Telephone communication was not often used for communicating, but a few GPs had tried to contact health visitors in urgent matters and some GPs trusted that health visitors would call them if they were concerned: “I was incredibly happy that the GP called me, because it rarely happens, then you (…) think yes, it’s just great and good for the family that a little more attention is paid to them.” (Health visitor 7). “I mean the health visitor, erm (…) if they are worried, then they will call me, I am sure they would, but I have never experienced it.” (GP3).

In-person communication was the least used form of communication: GPs and health visitors rarely met. A few clinicians reported that they had previously met up with each other and found it beneficial for their collaboration: “We were at a meeting; it was several years ago, where the health visitor was also present (…) and we spoke to several health visitors. They were very interested in developing some collaboration.” (GP9)

Feedback

GPs wanted more information from the health visitors especially when the health visitors had recommended a consultation with the GP:

In fact, it would have been nice if they wrote to us directly as health professionals instead of the parents having to be the communicator there because also, what if the child had jaundice and the parents were foolish and didn’t come for the 5-week check-up?

(GP2)

Parents often worked as messengers who carried information from profession to another: “Overall, we don’t have much communication. It is extremely little communication. And by far most of the communication I have with the health visitors takes place via parental handover.” (GP2).

Both professional groups reported a lack of feedback after having initiated a treatment, a checkup or an observation on a common patient: “it would just be very logical for me that when I make a referral, well then I also get an answer back.” (Health visitor 10). “(…) because if I don’t get feedback, then I don’t know if it went well.” (GP4).

Professionals’ recommendations

Participants shared thoughts about how collaboration and communication could be improved in the future by meeting up, having more interprofessional discussion, and by sending e-mail to each other.

More collaboration

Overall, both GPs and health visitors wanted to have more collaboration. Meeting up occasionally was generally perceived as a good idea. Some GPs and health visitors had met up in the past but this had stopped. Some GPs thought that inviting health visitors for their multi-practice quality development meetings could be valuable as well as inviting them for meetings with social service involvement around children of psychosocial concern: “I’m thinking of quarterly meetings or half-yearly meetings, it could be hugely cool, (…) just to come for a quarter of an hour just to say what’s going on with us at the moment, right?” (Health visitor 5).

Within both professions, some thought that the other group of clinicians might benefit from interprofessional discussion: “I think that health visitors feel very isolated (…) because they have no one to support them – beside each other – but they don’t have anyone else. I think there is poor medical support, for example.” (GP3). “I also think that, when you are a general practitioner, you also sometimes have to deal with things where they [GPs] would like another professional opinion on that as well.” (Health visitor 5).

Generally, health visitors seemed more excited about shaping a collaboration than the GPs, and they would go some distance to make this happen: “(…) eye infection is probably not, what preoccupies us most in relation to collaboration. But if that’s what ignites our collaboration then that’s what we’re going with, right?” (Health visitor 5)

Some health visitors wanted medical dialogue, thereby shaping the health visitor’s professional profile as more a health professional than a social worker. This could help increase their identity as health specialists among municipality colleagues:

In general, we just want a little more [collaboration], yes precisely in terms of there being a little more medical discussion on the challenges. In other words one can quite quickly become preoccupied with a social work discourse in the municipalities so the more medical one … we think that would be great.

(Health visitor 6)

Some health visitors had positive experiences in collaborating with GPs and wanted more professional discussions about their mutual patients: “We think it’s a good collaboration, I just want even more, you could say, I’d like it to develop into having more medical professional discussion” (Health visitor 3).

Collaboration about all patients – or only when concerned?

Some GPs wanted a record summary of every health visitor’s visit, including an update on how the child was and what plans were made: “(…) it’s just nice to have written communication that runs directly into the system and over the health network, so that it is always archived in the right place in medical records, that could be helpful.” (GP2).

Other GPs preferred only to be informed if the health visitors were concerned about something affecting their common patient: “I don’t think it is necessarily an advantage that we just send everything to each other … but need-based access to each other could be nice” (GP8).

Prioritising between collaboration partners

A few GPs did not feel a need for more collaboration with health visitors and would rather have more collaborative work with other professionals: “It’s rarely necessary for me to get involved, so when they involve me, it is usually quite obvious that it is time to refer further.” (GP10).

Discussion

We explored how GPs and health visitors experienced collaboration and communication with each other around children of concern. All professionals generally desired a closer collaboration and communication. Overall, there was limited communication between the professions, and when communication took place, it was mostly electronic, going from health visitors to GPs, or it took place via parents. Health visitors’ perceived need for consent and constraints by rules and regulations raised the bar to communication with GPs in cases of concern. From the GPs’ perspective, large municipalities and lack of remuneration complicated any communication. Overall, GPs rarely felt an urgent need to communicate with health visitors around children of concern and they would mostly refer to other services. Health visitors often experienced a need to contact GPs, most often to rule out somatic conditions. The interplay between GPs and health visitors was often characterized by professional unfamiliarity with each other’s work, conflicts, frustrations, and lack of record sharing. Some GPs wanted a needs-driven approach, and many health visitors noted a lack of feedback. Most professionals saw meeting up occasionally as a good idea for future collaboration.

Given the extent of everyday interprofessional interfaces in primary care across health care systems, it is noteworthy that there is so little research in this area (Brodribb et al., 2016; Ellefsen, 2002; Schmied et al., 2010; Turley et al., 2018). This study adds knowledge about how the power balance and (lack of) mutual professional recognition is a crucial factor in a preventive health care model where professionals are expected to collaborate about their mutual patients. A significant barrier to effective collaboration related to longstanding asymmetry in the doctor-nurse power relationship, including lack of interprofessional respect, and this is in line with the literature emphasizing a need for health professionals to respect each other’s competences in order to promote collaboration (Clavering & McLaughlin, 2007; Ellefsen, 2002; McMahan et al., 1994). Silo-thinking can contribute to asymmetry in the GP-health visitor’s relationship and this was demonstrated through unfamiliarity with one another’s roles and competences (Ellefsen, 2002) and could lead to conflicts (McMahan et al., 1994).

In health services with a shortage of physicians, where there are policy pressures toward multi-disciplinarity and delegation of tasks, there is a corresponding need to address asymmetry in the relations between health visitors and GPs. A Scottish/Norwegian study (Ellefsen, 2002) showed that health visitors experienced collaborative strain and tension through not feeling recognized by GPs who lacked knowledge about their competences. This is in line with our finding that the unfamiliarity with each other’s roles was mutual.

The study of collaboration between physicians and nurses is, in general, also a study of gender inequality – at least historically. It is notable that all the health visitors in our study were female. Health visitors are educated as nurses and educated to respond collaboratively to the physician’s professional initiative. In the professional role of health visiting, they are mandated by national and local guidelines and regulations to initiate actions on an equal basis with the physicians in cases of concern and potentially compel GPs to undertake tasks on their initiative (Olley et al., 2017).

Different IT systems, legal constraints, and lack of remuneration constituted common barriers to collaboration, as these factors prevented smooth everyday collaboration, in line with findings from previous studies (Brygger Veno et al., 2022; Schmied et al., 2015; Wilson et al., 2018). Participants expressed a profound wish to respect patient autonomy (Haahr et al., 2020).

The perceived need for consent before sharing information about children of concern is a general problem across Nordic countries (Wilson et al., 2018). In Denmark there is no legal barrier to asking all families at their child’s birth for consent to pass on information if needed; therefore the hesitancy to share data may be a mechanism to maintain a “silo mentality” (Bento et al., 2020). In line with existing literature, GPs in this study overall experienced better collaboration with health visitors than vice versa (Ellefsen, 2002; Gittell et al., 2013). Our study adds to the body of literature on barriers to interprofessional collaboration including poor communication (House & Havens, 2017).

Our findings also correspond well with other studies demonstrating that closer collaboration can lead to fear of losing professional identity (Rawlinson et al., 2021). We demonstrated ambivalence related to enhanced interprofessional communication, where both parties agree on the value of cross-sectoral collaboration (Mbwili-Muleya et al., 2000; Myors et al., 2013; Schmied et al., 2015) and at the same time fail to meet regularly. Similar to findings from other studies (Homer et al., 2009; Kruske et al., 2006; Schmied et al., 2010), GPs in our sample wished to get feedback on their common patients or a record summary of the health visitors’ visit but this does not seem to happen (Jeyendra et al., 2013).

Implications

This study adds to the knowledge that GPs and health visitors generally want to collaborate and communicate but they experience different barriers to achieving these goals. Improvement of IT systems, remuneration arrangements, legal frameworks, and better knowledge about each other’s roles and competences could lead to better collaboration.

Policy makers, and service managers should examine the type and quality of information that could be shared and establish clearer channels of communication and collaboration between the professions. Policy makers should additionally create spaces for professionals to negotiate boundaries and overlaps in work and possibly introduce team or network settings for collaboration (Schot et al., 2020). Future researchers could investigate the role of power asymmetry in the GP-health visitor relationship.

Today, many more women are physicians than was the case a few decades ago and there is a need for a theoretical framework that reflects modern society. There is a need to develop a contemporary, less gender specific theoretical framework for physician-nurse collaboration that takes into account that physicians today are not necessarily male. Very few health visitors currently are male. Most literature concerning nurse-physician collaboration is related to hospital settings (Ellefsen, 2002; Rawlinson et al., 2021), thus, there is a need for knowledge about cross-professional collaboration in a cross-sectoral setting (Overbeck et al., 2018; Wilson et al., 2018).

Strengths and limitations

Our study explored a diverse group of Danish GPs and health visitors, most having regular pediatric contact. The first author’s dual expertise as a physician and nurse, along with the last author’s language psychology background informed extensive discussions on interviewer reflexivity (Dodgson, 2019). In-person interviews yielded detailed, dynamic insights. However, the participants’ strong interest in child health might have influenced their views on collaboration. The lack of data from extremely deprived areas could limit the study’s broader applicability. Although most interviews were face-to-face, some online and dual-professional sessions offered additional perspective. Our findings, while informative about nurse-physician collaboration, may have some elements that are specific to Denmark’s child preventive health programs. Generalizability to other healthcare systems may therefore be limited.

Conclusion

This study contributes to the under-researched topic of the collaboration between GPs and health visitors when concerns arise about children. GPs and health visitors generally want to collaborate and communicate more effectively, but there are barriers in terms of legal obligations, different IT systems, lack of remuneration and asymmetry in the power balance between GPs and health visitors. Policymakers and service managers should consider promoting better collaboration and communication between GPs and health visitors in order to improve support for children of concern.

Acknowledgments

The authors thank Clara Lundmark Appel for her transcription of an interview.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13561820.2024.2357118

Additional information

Funding

This work was supported by the Lundbeck Foundation (6 months research scholarship) and TRYG Foundation (part time salary for senior researchers).

Notes on contributors

Rebekka Consuelo Eið

Rebekka Consuelo Eið is a medical doctor with a registered nursing background.

Sarah Strøyer de Voss

Sarah Strøyer de Voss is a medical doctor and PhD-student with a special interest in mental health and pediatrics.

Philip Wilson

Philip Wilson is an academic general practitioner with a special interest in child health.

Gritt Overbeck

Gritt Overbeck is a language psychologist specialized in cross-sector collaboration.