Shared care requires a shared vision: communities of clinical practice in a primary care setting

Nurses' perception of identity, practice and support needed in primary care: A descriptive qualitative study

AIMS

To explore how primary care registered nurses (PCRNs) describe their professional identity, their perception of their practice, and the support they need to effectively perform the responsibilities of their role.

DESIGN

A qualitative descriptive design using inductive content analysis.

METHODS

Semi-structured interviews were conducted with registered nurses (n = 14) working in primary care settings in the United States between June 2018 and December 2020. Inductive content analysis was used and comprised three phases: preparation, organizing, and reporting. COREQ reporting guidelines were used.

RESULTS

Three categories were discovered related to PCRN identity and practice: Wearing Multiple Hats, Practicing Within Bounds and Change is a Part of Practice. There were also three categories for support needed: Entering In, Ongoing Support and Making it a Better Place. Within each category, subcategories were identified.

CONCLUSION

Primary care registered nurses have a unique professional identity and practice. When entering the setting, nurses must acquire the skills and knowledge to ask the right questions and navigate the system to meet the diverse and complex needs of their patients. PCRNs recognize change is a part of practice and have ideas and visions for what the role of PCRNs could be.

IMPLICATIONS FOR PROFESSION

Recognizing the unique identity and practice of PCRNs is necessary to create an environment that leverages their skills and knowledge.

IMPACT

We identified key elements of PCRN identity and practice and the support necessary to meet their needs. Healthcare organizations must ensure nurses new to the practice setting receive training and support for their unique and essential role. Additionally, leaders must partner with nurses to enhance nursing practice and achieve optimal patient outcomes.

REPORTING METHOD

Adherence to COREQ guidelines were maintained.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Understanding how general practice nurses support adult lifestyle risk reduction: An integrative review

AIM

To review the literature exploring how general practice nurses support lifestyle risk reduction.

DESIGN

Integrative literature review.

SOURCES

CINAHL, Emcare, MEDLINE, Proquest and Scopus were searched for peer-reviewed primary research published in English from 2010 to 2022.

METHODS

Sixteen papers met the inclusion criteria and were assessed for methodological quality using the Mixed Methods Appraisal Tool. Findings were extracted and thematically analysed.

RESULTS

Four themes described general practice nurses: (1) Establishing relational connections; (2) Empowering active participation; (3) Engaging mutual motivation and (4) Enabling confident action. General practice nurses used complex interpersonal, risk communication and health coaching skills to build collaborative partnerships that supported patients' self-determination and self-efficacy. While mutual motivation and confidence were reciprocally enabling, gaps in skills, experience and knowledge plus time, resource and role constraints limited general practice nurses' ability to support lifestyle risk reduction.

CONCLUSION

General practice nurses play a key role in lifestyle risk reduction. Ongoing education, funding, organizational and professional support are needed to enhance their commitment, confidence and capacity.

IMPACT

What problem did the study address? While general practice nurses play a key role in health promotion and risk reduction, their potential is yet to be fully realized. Research examining methods by which nurses working in general practice support lifestyle risk reduction is limited. What were the main findings? Successful interactions depended on personal, professional, organisational and systemic factors which either enhanced or inhibited relational quality, shared decision-making, mutual commitment, and nurses' confidence and capacity to address lifestyle risks. Targeted professional development and peer mentoring are needed to build proficient practice. Where and on whom will the research have impact? Understanding how general practice nurses support risk reduction can inform policy and identify training and support needs to advance their skills and role. Research exploring synergies between themes may illuminate this process.

Scoping review to identify strategies and interventions improving interprofessional collaboration and integration in primary care

OBJECTIVE

To identify strategies and interventions used to improve interprofessional collaboration and integration (IPCI) in primary care.

DESIGN

Scoping review DATA SOURCES: Specific Medical Subject Headings terms were used, and a search strategy was developed for PubMed and afterwards adapted to Medline, Eric and Web of Science.

STUDY SELECTION

In the first stage of the selection, two researchers screened the article abstracts to select eligible papers. When decisions conflicted, three other researchers joined the decision-making process. The same strategy was used with full-text screening. Articles were included if they: (1) were in English, (2) described an intervention to improve IPCI in primary care involving at least two different healthcare disciplines, (3) originated from a high-income country, (4) were peer-reviewed and (5) were published between 2001 and 2020.

DATA EXTRACTION AND SYNTHESIS

From each paper, eligible data were extracted, and the selected papers were analysed inductively. Studying the main focus of the papers, researchers searched for common patterns in answering the research question and exposing research gaps. The identified themes were discussed and adjusted until a consensus was reached among all authors.

RESULTS

The literature search yielded a total of 1816 papers. After removing duplicates, screening titles and abstracts, and performing full-text readings, 34 papers were incorporated in this scoping review. The identified strategies and interventions were inductively categorised under five main themes: (1) Acceptance and team readiness towards collaboration, (2) acting as a team and not as an individual; (3) communication strategies and shared decision making, (4) coordination in primary care and (5) integration of caregivers and their skills and competences.

CONCLUSIONS

We identified a mix of strategies and interventions that can function as 'building blocks', for the development of a generic intervention to improve collaboration in different types of primary care settings and organisations.

Exploring the value of social network 'care maps' in the provision of long-term conditions care

OBJECTIVES

There is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of 'care maps' - a patient-identified social network map of their care community - for health professionals in providing person-centred care.

METHODS

We piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes.

RESULTS

Health professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients' support networks, synthesising what is known and unknown. Health professionals understood patients' perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice.

DISCUSSION

Care maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had 'social function' for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients' lifeworlds.

Are patients ready for integrated person-centered care? A qualitative study of people with epilepsy in Ireland

The National Clinical Programme for Epilepsy (NCPE) in Ireland aims to deliver a holistic model of integrated person-centered care (PCC) that addresses the full spectrum of biomedical and psychosocial needs of people with epilepsy (PwE). However, like all strategic plans, the model encompasses an inherent set of assumptions about the readiness of the environment to implement and sustain the actions required to realize its goals. In this study, through the lens of PwE, the Irish epilepsy care setting was explored to understand its capacity to adopt a new paradigm of integrated PCC. Focus groups and semi-structured one-to-one interviews were employed to capture the qualitative experiences of a sample of Irish PwE (n = 27) in the context of the care that they receive. Participants were from different regions of the country and were aged between 18 and 55 years with 1 to 42 years since diagnosis (YSD). Highlighting a gap between policy intent and action on the ground, findings suggest that patient readiness to adopt a new model of care cannot be assumed. Expectations, preferences, behaviors, and values of PwE may sustain the more traditional constructions of healthcare delivery rather than the integrated PCC goals of reform. These culturally constituted perceptions illustrate that PwE do not instinctively appreciate the goals of healthcare reform nor the different behavior expected from them within a reformed healthcare system. Recalibrating deep-rooted patient views is necessary to accomplish the aspirations of integrated PCC. Patient engagement emphasizing the meaningful role that they can play in shaping their healthcare services is vital.

Igniting intersectoral collaboration in chronic disease management: a participatory action research study on epilepsy care in Ireland

Models of care developed to improve the lives of people with chronic diseases highlight integrated care as essential to meeting their needs and achieving person (patient)-centered care (PCC). Nevertheless, barriers to collaborative practice and siloed work environments persist. To set in motion some groundwork for intersectoral collaboration this study brought two expert groups of epilepsy care practitioners together to engage in participatory action research (PAR). The expert practitioner groups were hospital-based epilepsy specialist nurses (ESNs) and community-based resource officers (CROs). The PAR highlighted, that while the participants share a mutual interest in caring for people with epilepsy, underdeveloped CRO-ESN relationships, arising from unconscious bias and ambiguity can result in missed opportunities for optimal care coordination with consequent potential for unnecessary replication and waste of finite resources. However, through dialogue and critical self-reflection, a growing emotional connection between the disciplines evolved over the course of the PAR. This allowed for buds of collaboration to develop with CROs and ESNs working together to tackle some of the key barriers to their collaboration.

Cocreation as a Caring Phenomenon: Nurses' Experiences in Palliative Home Care

A new concept in palliative care, cocreation, appears to be a part of caring in nursing but has not yet been explored as a caring phenomenon. The aim was to, from a caring science perspective, explore how cocreation can be experienced as a phenomenon by nurses working in palliative home care. A hermeneutical approach and thematic analysis were used. The material consisted of texts from in-depth interviews with 12 nurses in a home care context. Informed consent regarding study participation and the storage and handling of data for research purposes were sought from participants. One main theme and 4 subthemes emerged. Cocreation can be viewed as an essential part of caring and being involved in patients' health and holistic care is a profound endeavor. Further research should focus on illuminating cocreation from patients' perspectives.

The rhetoric and reality of integrated patient-centered care for healthcare providers: An ethnographic exploration of epilepsy care in Ireland

In line with healthcare reform across the world, the National Clinical Programme for Epilepsy (NCPE) in Ireland describes a model that aims to achieve holistic integrated person (patient)-centered care (PCC). While generally welcomed by stakeholders, the steps required to realize the NCPE ambition and the preparedness of those involved to make the journey are not clear. This study explored the perceptions of healthcare providers in the Irish epilepsy care ecosystem to understand their level of readiness to realize the benefits of an integrated PCC model. Ethnographic fieldwork including observations of different clinical settings across three regions in Ireland and one-to-one interviews with consultant epileptologists (n = 3), epilepsy specialist nurses (n = 5), general practitioners (n = 4), and senior healthcare managers (n = 3) were conducted. While there is a person-centered ambiance and a disposition toward advancing integrated PCC, there are limits to the readiness of the epilepsy care environment to fully meet the aspirations of healthcare reform. These are the following: underdeveloped healthcare partnerships;, poor care coordination;, unintended consequences of innovation;, and tension between pace and productivity. In the journey from policy to practice, the following multiple tensions collide: policy aims to improve services for all patients while simultaneously individualizing care; demands for productivity limit the time and space required to engage in incremental and iterative improvement initiatives. Understanding these tensions is an essential first step on the pathway to integrated PCC implementation.

Healthcare teams as complex adaptive systems: understanding team behaviour through team members' perception of interpersonal interaction

BACKGROUND

Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members' interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members' interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour.

METHODS

An interview study was done with 21 palliative home-care nurses, 20 community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle.

RESULTS

All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members' interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified.

CONCLUSIONS

This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research.

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.