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Čáp J, Miertová M, Bóriková I, Žiaková K, Tomagová M, Gurková E. Trust in healthcare professionals of people with chronic cardiovascular disease. Nurs Ethics 2024; 31:1092-1105. [PMID: 37889675 DOI: 10.1177/09697330231209285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
BACKGROUND Trust is an essential phenomenon of relationship between patients and healthcare professionals and can be described as an accepted vulnerability to the power of another person over something that one cares about in virtue of goodwill toward the trustor. This characterization of interpersonal trust appears to be adequate for patients suffering from chronic illness. Trust is especially important in the context of chronic cardiovascular diseases as one of the main global health problems. RESEARCH AIM The purpose of the qualitative study was to gain a deeper understanding of how people with chronic cardiovascular disease experience and make sense of trust in healthcare professionals. RESEARCH DESIGN Eleven semi-structured interviews with participants analysed using interpretative phenomenological analysis to explore in detail their lived experience of trust as a relational phenomenon. PARTICIPANTS AND RESEARCH CONTEXT Participants with chronic cardiovascular disease were purposively recruited from inpatients on the cardiology ward of the university hospital located in central Slovakia. ETHICAL CONSIDERATIONS The study was approved by the faculty ethics committee. Participants gave their written informed consent. FINDINGS FOUR INTERRELATED GROUP EXPERIENTIAL THEMES Sense of co-existence; Belief in competence; Will to help; Ontological security with eight subthemes were identified. The findings describe the participants' experience with trust in healthcare professionals as a phenomenon of close co-existence, which is rooted in the participants' vulnerability and dependence on the goodwill and competence of health professionals to help with the consequence of (re)establishing a sense of ontological security in the situation of chronic illness. CONCLUSION Findings will contribute to an in-depth understanding of trust as an existential dimension of human co-existence and an ethical requirement of healthcare practice, inspire patient empowerment interventions, support adherence to treatment, and person-centred care.
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Affiliation(s)
- Juraj Čáp
- Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovakia
| | - Michaela Miertová
- Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovakia
| | - Ivana Bóriková
- Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovakia
| | - Katarína Žiaková
- Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovakia
| | - Martina Tomagová
- Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovakia
| | - Elena Gurková
- Department of Nursing, Faculty of Health Care, University of Prešov, Slovakia
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Morreel S, Verhoeven V, Bastiaens H, Monten K, van Olmen J. Experiences and observations from a care point for displaced Ukrainians: a community case study in Antwerp, Belgium. Front Public Health 2024; 12:1349364. [PMID: 38989117 PMCID: PMC11233464 DOI: 10.3389/fpubh.2024.1349364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/28/2024] [Indexed: 07/12/2024] Open
Abstract
Background A total of 7,307 Ukrainian refugees moved to Antwerp, Belgium, during the study period (01 April 2022 to 31 December 2022). The city's administration set up three care centers where these people were introduced to the Belgian primary care system, a medical file was created, and acute/preventive/chronic care was delivered. This community case study analyzes the organization and contents of care and reflects upon its meaning for the mainstream healthcare system. Methods This is an observational study using routine electronic medical record data to measure the uptake of care. For a sample of 200 subjects, a retrospective chart review was conducted. Participants All refugees with a medical file at one of the three participating care centers were included. Main outcomes For the observational study, 2,261 patients were reached (30% of the potential users), and 6,450 contacts were studied. The nurses (including midwives) conducted 4,929 out of 6,450 (76%) of all consultations, while the general practitioners (GPs) conducted 1,521 out of 6,450 (24%). Of the nurse consultations, 955 (19%) were followed by another nurse consultation and 866 (18%) by a GP consultation. In the structured case reviews, most contacts were concerned with acute problems (609 out of 1,074, 57%). The most prevalent reasons for encounters and diagnoses were typical primary care issues. The nurses were able to manage half of the cases independently (327, 55%), referred 37% (217) of cases to the GP, and consulted a GP (live, by telephone, or a dedicated app) for 8% (48) of cases. GPs mostly prescribed drugs, referred to a medical specialist, and advised over-the-counter drugs, while nurses more often advised over-the-counter drugs (mostly paracetamol, nose sprays, and anti-inflammatory drugs), provided non-medical advice, or ordered laboratory tests. Discussion The medical care points delivered mostly typical acute primary care in this first phase, with a key role for nurses. The care points did not sufficiently take up chronic diseases and mental health problems. These results will inform policymakers on the use of primary care centers for newly arriving patients in times of a large influx. A nurse-first model seems feasible and efficient, but evaluation of safety and quality of care is needed. Once the acute phase of this crisis fades away, questions about the comprehensiveness, continuity, and integration of care for migrants remain relevant.
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Affiliation(s)
- Stefan Morreel
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Veronique Verhoeven
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Hilde Bastiaens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | | | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
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Goh LH, Siah CJR, Szücs A, Tai ES, Valderas JM, Young D. Integrated patient-centred care for type 2 diabetes in Singapore Primary Care Networks: a mixed-methods study. BMJ Open 2024; 14:e083992. [PMID: 38890139 PMCID: PMC11191786 DOI: 10.1136/bmjopen-2024-083992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/31/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE Patients with type 2 diabetes require patient-centred care as guided by the Chronic Care Model (CCM). Many diabetes patients in Singapore are managed by the Primary Care Networks (PCNs) which organised healthcare professionals (HCPs) comprising general practitioners, nurses and care coordinators into teams to provide diabetes care. Little is known about how the PCNs deliver care to people with type 2 diabetes. This study evaluated the consistency of diabetes care delivery in the PCNs with the CCM. DESIGN This was a mixed-method study. The Assessment of Chronic Illness Care (ACIC version 3.5) survey was self-administered by the HCPs in the quantitative study (ACIC scores range 0-11, the latter indicating care delivery most consistent with CCM). Descriptive statistics were obtained, and linear mixed-effects regression model was used to test for association between independent variables and ACIC total scores. The qualitative study comprised semi-structured focus group discussions and used thematic analysis. SETTING The study was conducted on virtual platforms involving the PCNs. PARTICIPANTS 179 HCPs for quantitative study and 65 HCPs for qualitative study. RESULTS Integrated analysis of quantitative and qualitative results found that there was support for diabetes care consistent with the CCM in the PCNs. The mean ACIC total score was 5.62 (SD 1.93). The mean element scores ranged from 6.69 (SD 2.18) (Health System Organisation) to 4.91 (SD 2.37) (Community Linkages). The qualitative themes described how the PCNs provided much needed diabetes services, their characteristics such as continuity of care, patient-centred care; collaborating with community partners, financial aspects of care, enablers for and challenges in performing care, and areas for enhancement. CONCLUSION This mixed-methods study informs that diabetes care delivery in the Singapore PCNs is consistent with the CCM. Future research should consider using independent observers in the quantitative study and collecting objective data such as patient outcomes.
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Affiliation(s)
- Lay Hoon Goh
- Medicine, National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | | | - Anna Szücs
- Medicine, National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - E Shyong Tai
- Medicine, National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - Jose M Valderas
- Medicine, National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - Doris Young
- Medicine, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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ZAVRNIK Č, STOJNIĆ N, MORI LUKANČIČ M, MIHEVC M, VIRTIČ POTOČNIK T, KLEMENC-KETIŠ Z, POPLAS SUSIČ A. Facilitators and Barriers to Scaling-Up Integrated Care for Arterial Hypertension and Type 2 Diabetes in Slovenia: Qualitative Study. Zdr Varst 2024; 63:38-45. [PMID: 38156335 PMCID: PMC10751887 DOI: 10.2478/sjph-2024-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction Arterial hypertension and type 2 diabetes are significant contributors to global non-communicable disease-related mortality. Integrated care, centred on person-centred principles, aims to enhance healthcare quality and access, especially for vulnerable populations. This study investigates integrated care for these diseases in Slovenia, providing a comprehensive analysis of facilitators and barriers influencing scalability. Methods Qualitative methods, including focus group discussions and semi-structured interviews, were employed in line with the grounded theory approach. Participants represented various levels (micro, meso and macro), ensuring diverse perspectives. Data were collected from May 2019 to April 2020, until reaching saturation. Transcripts were analysed thematically using NVivo software. Results Nine categories emerged: Governance, Health financing, Organisation of healthcare, Health workforce, Patients, Community links, Collaboration/Communication, Pharmaceuticals, and Health information systems. Some of identified barriers were political inertia and underutilisation of research findings in practice; outdated health financing system; accessibility challenges, especially for vulnerable populations; healthcare workforce knowledge and burnout; patients' complex role in accepting and managing their conditions; collaboration within healthcare teams; and fragmentation of health information systems. Peer support and telemedicine were the only two potential solutions identified. Conclusions This study offers a comprehensive evaluation of integrated care for hypertension and type 2 diabetes in Slovenia, featuring insights into facilitators and barriers. These findings have implications for policy and practice. Monitoring integrated care progress, refining strategies, and enhancing care quality for patients with these two diseases should be priorities in Slovenia.
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Affiliation(s)
- Črt ZAVRNIK
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000Ljubljana, Slovenia
| | - Nataša STOJNIĆ
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
| | - Majda MORI LUKANČIČ
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
| | - Matic MIHEVC
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000Ljubljana, Slovenia
- Primary Healthcare Centre Trebnje, Goliev trg 3, 8210Trebnje, Slovenia
| | - Tina VIRTIČ POTOČNIK
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
- Primary Healthcare Centre Slovenj Gradec, Partizanska pot 16, 2380Slovenj Gradec, Slovenia
- University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska ulica 8, 2000Maribor, Slovenia
| | - Zalika KLEMENC-KETIŠ
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000Ljubljana, Slovenia
- University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska ulica 8, 2000Maribor, Slovenia
| | - Antonija POPLAS SUSIČ
- Community Health Centre Ljubljana, Primary Healthcare Research and Development Institute, Metelkova ulica 9, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000Ljubljana, Slovenia
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Stray K, Wibe T, Debesay J, Bye A. Older adults' perceptions and experiences of interprofessional communication as part of the delivery of integrated care in the primary healthcare sector: a meta-ethnography of qualitative studies. BMC Geriatr 2024; 24:146. [PMID: 38347442 PMCID: PMC10863142 DOI: 10.1186/s12877-024-04745-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/24/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Communication between patients and healthcare providers, and effective interprofessional communication, are essential to the provision of high-quality care. Implementing a patient-centred approach may lead to patients experiencing a sense of comfort, validation, and active participation in own healthcare. However, home-dwelling older adults' perspectives on interprofessional communication (IPC) are lacking. The aim is therefore to explore how home-dwelling older adults experience communication in connection with the delivery of integrated care. METHODS The meta-synthesis was conducted in line with Noblit and Hare's seven phases of meta-ethnography. A systematic literature search was conducted by two university librarians in seven databases using the search terms 'older adults', 'communication', 'integrated care' and 'primary care'. All articles were reviewed by two authors independently. 11 studies were included for analysis. RESULTS Older adults are aware of IPC and have preferences regarding how it is conducted. Three main themes were identified in the reciprocal analysis: (1) Inconsistent care perceived as lack of IPC, (2) individual preferences regarding involvement and awareness of IPC and (3) lack of IPC may trigger negative feelings. CONCLUSIONS This meta-ethnography shows the perspective of older adults on IPC as part of integrated care. Our study shows that older adults are concerned about whether healthcare personnel talk to each other or not and recognise IPC as fundamental in providing consistent care. The perspectives of older adults are relevant for clinicians and politicians, as well as researchers, when developing and implementing future integrated care services for home-dwelling older adults.
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Affiliation(s)
- Karoline Stray
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway.
| | - Torunn Wibe
- Centre for Development of Institutional and Home Care Services, City of Oslo, Oslo, Norway
| | - Jonas Debesay
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Asta Bye
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37466272 PMCID: PMC10355136 DOI: 10.1002/14651858.cd013603.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37434293 PMCID: PMC10335778 DOI: 10.1002/14651858.cd013603.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Stojnić N, Klemenc-Ketiš Z, Mori Lukančič M, Zavrnik Č, Poplas Susič A. Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study. BMC Health Serv Res 2023; 23:362. [PMID: 37046293 PMCID: PMC10091568 DOI: 10.1186/s12913-023-09353-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Integrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation. METHODS Eight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program. RESULTS We identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful. CONCLUSION Primary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.
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Affiliation(s)
| | - Zalika Klemenc-Ketiš
- Community Health Centre Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | | | - Črt Zavrnik
- Community Health Centre Ljubljana, Ljubljana, Slovenia
| | - Antonija Poplas Susič
- Community Health Centre Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Michielsen L, Bischoff EWMA, Schermer T, Laurant M. Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review. BMC PRIMARY CARE 2023; 24:98. [PMID: 37046190 PMCID: PMC10091550 DOI: 10.1186/s12875-023-02050-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired. METHODS Six literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC. RESULTS Four guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired. CONCLUSION This review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.
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Affiliation(s)
- Leslie Michielsen
- School of Health Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands.
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Erik W M A Bischoff
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tjard Schermer
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Science Support Office, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Miranda Laurant
- School of Health Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, the Netherlands
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Understanding factors affecting implementation success and sustainability of a comprehensive prevention program for cardiovascular disease in primary health care: a qualitative process evaluation study combining RE-AIM and CFIR. Prim Health Care Res Dev 2023; 24:e17. [PMID: 36883652 PMCID: PMC10050826 DOI: 10.1017/s1463423623000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
AIM Our aim was to evaluate the implementation process of a comprehensive cardiovascular disease prevention program in general practice, to enhance understanding of influencing factors to implementation success and sustainability, and to learn how to overcome barriers. BACKGROUND Cardiovascular disease and its risk factors are the world's leading cause of mortality, yet can be prevented by addressing unhealthy lifestyle behavior. Nevertheless, the transition toward a prevention-oriented primary health care remains limited. A better understanding of factors facilitating or hindering implementation success and sustainability of prevention programs, and how barriers may be addressed, is needed. This work is part of Horizon 2020 project 'SPICES', which aims to implement validated preventive interventions in vulnerable populations. METHODS We conducted a qualitative process evaluation with participatory action research approach of implementation in five general practices. Data were collected through 38 semi-structured individual and small group interviews with seven physicians, 11 nurses, one manager and one nursing assistant, conducted before, during, and after the implementation period. We applied adaptive framework analysis guided by RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) and Consolidated Framework for Implementation Research (CFIR). FINDINGS Multiple facilitators and barriers affected reach of vulnerable target populations: adoption by primary health care providers, implementation and fidelity and intention to maintain the program into routine practice. In addition, our study revealed concrete actions, linked to implementation strategies, that can be undertaken to address identified barriers. Prioritization of prevention in general practice vision, ownership, and shared responsibility of all team members, compatibility with existing work processes and systems, expanding nurse's roles and upskilling competence profiles, supportive financial and regulatory frameworks, and a strong community - health care link are crucial to increase implementation success and long-term maintenance of prevention programs. COVID-19 was a major barrier to the implementation. RE-AIM QuEST, CFIR, and participatory strategies are useful to guide implementation of prevention programs in primary health care.
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Danhieux K, Buffel V, Remmen R, Wouters E, van Olmen J. Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study. BMC Health Serv Res 2023; 23:141. [PMID: 36759890 PMCID: PMC9911183 DOI: 10.1186/s12913-023-09115-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types. METHODS Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices. RESULTS The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks. CONCLUSIONS Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.
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Affiliation(s)
- Katrien Danhieux
- Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium.
| | - Veerle Buffel
- Center for Population, Family and Health, University of Antwerp, Antwerp, Belgium
| | - Roy Remmen
- Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Center for Population, Family and Health, University of Antwerp, Antwerp, Belgium
| | - Josefien van Olmen
- Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
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Fradelos EC, Barisone M, Lora E, Valiakos E, Papathanasiou IV. COMPETENCIES AND SKILLS NEEDED IN THE MANAGEMENT OF CHRONIC PATIENTS' NEEDS THROUGH TELECARE. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:403-416. [PMID: 37756462 DOI: 10.36740/merkur202304116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Aim: To identify the necessary competencies that future professionals must obtain in order to effectively manage patients with chronic conditions. We employed a multilayer review in PubMed, Scopus and Cochrane. PATIENTS AND METHODS Materials and Methods: We applied three searches in PubMed, Scopus, and Cochrane using various terms in order to identify the necessary skills and competences needed for healthcare professionals to provide distance care in patients with chronic conditions. From the initial search, a total of 1008 studies were identified while 54 met the inclusion criteria and were retained for data extraction. After the review of the 54 studies, we grouped the proposed skills and competencies in eight major categories. Those groups were Clinical Knowledge, Critical Thinking Skills, Technological Skills, Clinical skills, Communication skills, Implementation skills, Professionalism and professional ethics, Evidence based Practice. CONCLUSION Conclusions: Although telehealth is gaining ground in healthcare practice and healthcare professionals possess the necessary knowledge and skills to provide safe, effective, and personalized care, additional specialized training is nevertheless required to provide telecare. Therefore, the integration of telehealth into various healthcare professions curricula - both at undergraduate and postgraduate levels - is required for the development of education and the dynamic development of healthcare.
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Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148467. [PMID: 35886317 PMCID: PMC9323996 DOI: 10.3390/ijerph19148467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 02/04/2023]
Abstract
Cardiovascular diseases are the world’s leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders’ views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.
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Casey M, O'Connor L, Rohde D, Twomey L, Cullen W, Carroll Á. Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland. Health Sci Rep 2022; 5:e555. [PMID: 35284651 PMCID: PMC8905424 DOI: 10.1002/hsr2.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 11/11/2022] Open
Abstract
Background Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP. Aim To explore the role of general practice nurses and their interest in becoming an ANP. Design A survey design. Method A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM). Results General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources. Conclusion General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.
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Affiliation(s)
- Mary Casey
- UCD School of Nursing, Midwifery and Health SystemsDublinIreland
| | | | - Daniela Rohde
- UCD School of Nursing, Midwifery and Health SystemsDublinIreland
| | - Liam Twomey
- UCD School of Medicine and Medical ScienceCollege of Health and Agricultural SciencesDublinIreland
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Scaling-up an Integrated Care for Patients with Non-communicable Diseases: An Analysis of Healthcare Barriers and Facilitators in Slovenia and Belgium. Zdr Varst 2021; 60:158-166. [PMID: 34249162 PMCID: PMC8256765 DOI: 10.2478/sjph-2021-0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/28/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Although the concept of integrated care for non-communicable diseases was introduced at the primary level to move from disease-centered to patient-centered care, it has only been partially implemented in European countries. The aim of this study was to identify and compare identified facilitators and barriers to scale-up this concept between Slovenia and Belgium. Methods This was a qualitative study. Fifteen focus groups and fifty-one semi-structured interviews were conducted with stakeholders at the micro, meso and macro levels. In addition, data from two previously published studies were used for the analysis. Data collection and analysis was initially conducted at country level. Finally, the data was evaluated by a cross-country team to assess similarities and differences between countries. Results Four topics were identified in the study: patient-centered care, teamwork, coordination of care and task delegation. Despite the different contexts, true teamwork and patient-centered care are limited in both countries by hierarchies and a very heavily skewed medical approach. The organization of primary healthcare in Slovenia probably facilitates the coordination of care, which is not the case in Belgium. The financing and organization of primary practices in Belgium was identified as a barrier to the implementation of task delegation between health professionals. Conclusions This study allowed formulating some important concepts for future healthcare for non-communicable diseases at the level of primary healthcare. The results could provide useful insights for other countries with similar health systems.
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Schlunegger MC, Aeschlimann S, Palm R, Zumstein-Shaha M. Competencies and scope of practice of nurse practitioners in primary health care: a scoping review protocol. JBI Evid Synth 2021; 19:899-905. [DOI: 10.11124/jbies-20-00554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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van der Gulden R, Haan NDSD, Greijn CM, Looman N, Tromp F, Dielissen PW. Interprofessional education and collaboration between general practitioner trainees and practice nurses in providing chronic care; a qualitative study. BMC MEDICAL EDUCATION 2020; 20:290. [PMID: 32883272 PMCID: PMC7469346 DOI: 10.1186/s12909-020-02206-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 08/22/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Effective interprofessional collaboration (IPC) is essential for the delivery of chronic care. Interprofessional education (IPE) can help support IPC skills. This makes IPE interesting for GP practices where chronic care is delivered by GPs together with practice nurses, especially for GP trainees who have to learn to collaborate with practice nurses during their training. The aim of this study is to gain insights in how IPE and IPC occur between GP trainees and practice nurses during the delivery of chronic care in GP training practices. METHODS We conducted a qualitative research using semi structured focus groups and interviews with GP trainees, practice nurses and GP supervisors. All respondents were primed to the subject of IPE as they had followed an interprofessional training on patient-centred communication. The verbatim transcripts of the focus groups and interviews were analysed using thematic analysis. RESULTS Despite the overall positive attitude displayed by respondents towards IPE and IPC, the occurrence of IPE and IPC in GP training practices was limited. Possible explanations for this are impeding factors such as limited knowledge, prejudice, lack of role models and a hierarchical organisational structure. Contributing to IPE and IPC use was the integration of IPE in daily practice, e.g. via recurring scheduled meetings. CONCLUSION We found a limited occurrence of IPE and IPC in GP training practices. Our results show a discrepancy between respondents enthusiasm for IPE and IPC and their actual behaviour. IPE activities have to be initiated in GP training practices, otherwise, despite good intentions, IPE and IPC will be ineffective.
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Affiliation(s)
- R van der Gulden
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - N D Scherpbier-de Haan
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - C M Greijn
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - N Looman
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - F Tromp
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - P W Dielissen
- Department of Primary and Community care, Radboud university medical centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands.
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