Development of a toolkit to improve interprofessional collaboration and integration in primary care using qualitative interviews and co-design workshops

BackgroundDespite numerous attempts to improve interprofessional collaboration and integration (IPCI) in primary care, patients, care providers, researchers, and governments are still looking for tools and guidance to do this more efficiently. To address these issues, we decided to develop a generic toolkit, based on sociocracy and psychological safety principles, to guide care providers in their collaboration within and outside their practice. Finally, we reasoned that, in order to obtain integrated primary care, different strategies should be combined.MethodsDevelopment of the toolkit consisted of a multiyear co-development process. Data originating from 65 care providers, through 13 in-depth interviews and five focus groups were analysed and subsequently evaluated in eight co-design workshop sessions, organised with a total of 40 academics, lecturers, care providers and members of the Flemish patient association. Findings from the qualitative interviews and co-design workshops were gradually, and inductively adapted and transformed into the content for the IPCI toolkit.ResultsTen themes were identified: (i) awareness of the importance of interprofessional collaboration, (ii) the need for a self-assessment tool to measure team performance, (iii) preparing a team to use the toolkit, (iv) enhancing psychological safety, (v) developing and determining consultation techniques, (vi) shared decision making, (vii) developing workgroups to tackle specific (neighbourhood) problems, (viii) how to work patient-centred, (ix) how to integrate a new team member, and (x) getting ready to implement the IPCI toolkit. From these themes, we developed a generic toolkit, consisting of eight modules.ConclusionIn this paper, we describe the multiyear co-development process of a generic toolkit for the improvement of interprofessional collaboration. Inspired by a mix of interventions from in and outside healthcare, a modular open toolkit was produced that includes aspects of Sociocracy, concepts as psychological safety, a self-assessment tool and other modules concerned with meetings, decision-making, integrating new team members and population health. Upon implementation, evaluation and further development and improvement, this compounded intervention should have a beneficial effect on the complex problem of interprofessional collaboration in primary care

Zorgen voor thuiszorg: Een multimethod analyse van de huidige en toekomstige rol van thuisverpleegkundigen

Background Homecare is facing one of its biggest challenges: the growing imbalance between the increasing demand for care at home and the decreasing supply of home nurses. The demographic and economic evolutions and trends increasingly confront home nurses with caring for patients with frailty, functionalities, and multimorbidities, requiring more intensive and technically complex procedures to be done at home. Policymakers responding to these trends aim to shift the healthcare system towards a multidimensional, chronic disease-oriented system. Homecare has to engage in this process to help shaping and managing a model of homecare that focuses on the individual, chronic, healthcare needs of each patient, client, or informal caregiver; on patient empowerment; and on continuity of care. Furthermore, as the demand for homecare is continuously growing, questions arise concerning the supply of home nurses, which increases more slowly than the overall demand. Consequently, the role of home nurses as providers of healthcare has been changing and will continue to change. However, are home nurses ready for this changing role and how does home nursing respond to these trends and evolutions in primary care? The retention of healthcare workers (what are important factors to stay in the job/healthcare); task shifting (what about the possibility of function differentiation); and task purification (what is the contribution of each team discipline to patient care) are important cornerstones to answer these questions. The ultimate aim of this dissertation was to support home nursing in this process by exploring the current and future role of home nurses in the perspective of these three cornerstones. Retention of home nurses In chapter 2 we used the Belimage Homecare instrument to provide insight in the professional self-image of 758 home nurses. This study highlighted both the positive self-image of home nurses and the existence of a delicate balance between the large degree of autonomy that home nurses have and the need to feel supported in their professional role and responsibility. The practice environment, including time pressure, workload and insufficient support, needs to be addressed in order to keep it from having a negative impact on the professional self-image of home nurses in the long-term. Task shifting In chapter 4 the technique of in-depth interviews was used to explore the experiences of twelve home nurses, twelve healthcare assistants and eight home nursing managers with regard to the delegation of nursing activities to healthcare assistants; the supervision of healthcare assistants; and the impact of this integration on the work of home nurses. All the participants reacted positively to the employment of healthcare assistants in the organization: healthcare assistants take care of a less care dependent patient population, allowing the home nurses to spend more time on more complex, technical nursing care. However, the analysis revealed some barriers, such as a knowledge gap and insecurity felt by healthcare assistants leading to unnecessary patient visits by home nurses; unfamiliarity of home nurses with the role of delegating activities and supervising healthcare assistants; and poor face-to-face communication between home nurses and healthcare assistants. These barriers often resulted in a loss of a holistic view on the patient situation. Task purification In chapter 3 the views and experiences of both primary care professionals and hospital healthcare workers were explored with regard to the shift of care from the hospital to the homecare setting. Therefore, in-depth interviews with fifteen home nurses and eight medical specialists, and two focus groups with eight and fifteen general practitioners, respectively, were performed. Three important statements were highlighted. First, it was difficult for the respondents to make a clear distinction between technical and complex interventions. Therefore, more research is needed to provide a clear definition of "technical" and "complex" interventions. Secondly, the earlier discharge of more palliative care patients and more chronically ill patients confronts primary care with more intensive and complex care at home and with a shift from pure technical interventions to more intellectual care. Thirdly, for home nursing to be ready for these changes, some financial and organizational aspects need to be addressed, such as the investment in specialized home nurses; a financing system that covers the daily (24-hour) practice of home nurses; the investment in a more and better integrated and properly financed multi- and interdisciplinary collaboration and communication. In chapter 5 we explored the international literature to evaluate the instruments used to measure the activity profile of home nurses and to determine which activities home nurses perform in their daily practice. We identified nine studies. They all used different measurement instruments of questionable validity. We found that the activity profile of home nurses was mainly characterized by a combination of pure technical and surveillance activities with psychosocial and administrative activities. However, the level of abstraction in the activities performed by home nurses had a major impact on the interpretation of their activity profile. Consequently, in the scope of the absence of a gold standard to measure the daily activities of home nurses in primary care, we developed and psychometrically tested the 24-hour recall instrument for home nursing in chapter 6. The validity and the interrater reliability of this instrument were high: the proportions observed agreement were very high; the strength of kappa agreement was substantial to almost perfect; the prevalence index showed great variety; and the bias index was low. The findings in this study supported the validity evidence based on test content and the interrater reliability of the 24-hour recall instrument. This instrument can be used to investigate the current activity profile of both home nurses, and auxiliary nurses or healthcare assistants in home nursing. This would provide important information for managers and policymakers to profile the activities of home nurses and healthcare assistants and to proactively anticipate to the fast evolving needs of home nursing. In chapter 7 the 24-hour recall instrument for home nursing was used by 2478 home nurses and 277 healthcare assistants. The activity profile of home nurses and healthcare assistants was mainly characterized by self-care facilitation activities. In the combination of data, the activities from the category "self-care facilitation" were mainly performed in combination with other activities related to the categories "Other care", "Administration", and "Psychosocial care" for the home nurses; and "Other care", "Administration", and "Communication" for the healthcare assistants. This study is an important first step in the identification of what it is that home nurses and healthcare assistants do in homecare, using a validated and reliable measurement instrument for home nursing. Conclusion The ultimate aim of this dissertation was to help and to support home nurses to cope with the unfolding evolutions and trends by exploring the current and future role of home nurses in the perspective of the retention of home nurses, task shifting and task purification. We can conclude that home nurses have a positive professional self-image. This is an important foundation to cope with the existing imbalance and to retain the nurses in homecare. Furthermore, healthcare assistants were integrated in home nursing to maintain and improve the efficacy of home nursing. The fact that healthcare assistants take care of a group of patients that does not have a specific nursing indication or nursing need, is an important step in the support of this idea. However, further research is necessary to gain evidence for this statement. Finally, the use of a validated and reliable measurement instrument for home nursing (the 24-hour recall instrument for home nursing) highlighted that the activity profile of home nurses is mainly characterized by self-care facilitation activities in combination with more intellectual activities. However, further research is necessary to explore if the integration of healthcare assistants in home nursing shifted more complex (holistic) care situations to the home nurses and more simple hygiene care situations to the healthcare assistants.nrpages: 166status: publishe

A study of core interventions in Home Nursing

AIM: To gain insight into the core interventions in home nursing. METHODS: In this descriptive, quantitative, cross-sectional study two questionnaires, based on the nursing interventions classification, were used to collect data from 501 nurses working in an organization for home nursing in Belgium. Response rate was 88%. RESULTS: The self-care assistance, (im)mobility and (psycho)social interventions are the most frequently performed interventions in home nursing, but they are performed and can only be interpreted in combination with other, more technical interventions. Therefore, these interventions can be considered the core interventions in home nursing.status: publishe

High-risk medication in community care: a scoping review

PURPOSE: To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care. METHODS: Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions. RESULTS: Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care. CONCLUSION: The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.status: publishe

Health Care Assistants in Home Nursing The Holy Grail or the Emperor’s New Clothes? A Qualitative Study

What are the experiences of home health care workers with regard to the delegation of nursing activities, the supervision of health care assistants (HCAs), and the impact of these changes on the work of home nurses (HNs). In-depth interviews were performed with 12 HNs, 12 HCAs, and eight managers in home nursing. HCAs take care of a less care dependent patient population, allowing the HNs to spend more time on more complex, technical nursing care. However, the analysis revealed some barriers, such as a knowledge gap and insecurity felt by HCAs leading to unnecessary patient visits by HNs, unfamiliarity of HNs with the role of delegating activities and supervising HCAs, and poor face-to-face communication between HNs and HCAs.status: publishe

Probleembeleving van type 2 diabetespatiënten voor en na educatie thuis

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Complex qualitative data analysis: lessons learned from the experiences with the Qualitative Analysis Guide of Leuven

In this article, the authors discuss critical factors to be considered when analyzing complex qualitative data. The experiences with the use of the Qualitative Analysis Guide of Leuven (QUAGOL) to analyze qualitative data were used as starting point to develop a deeper understanding of what a good qualitative analysis requires and how to deal with its challenges in less optimal research contexts. A critical analysis and discussion of the strengths and weaknesses of the guide in a broader methodological context supports its potential for use in developing strong qualitative evidence. The analysis highlighted three key strategies of undertaking the analysis of complex narrative data: the case-oriented approach, the method of constant comparison, and the use of data-generated codes. Having a good understanding of the underlying principles and how to implement them are key to conducting methodologically sound analyses.status: accepte

Home care nurses' management of high-risk medications : a cross-sectional study

BACKGROUND: High-risk medications use at home entails an increased risk of significant harm to the patient. While interventions and strategies to improve medications care have been implemented in hospitals, it remains unclear how this type of medications care is provided in the home care setting. The objective was to describe home care nurses’ management of high-risk medications. METHODS: A cross-sectional, descriptive design was set up in home care nurses in Flanders, Belgium. Participants were recruited through convenience sampling and could be included in the study if they provided medications care and worked as a home care nurses. Participants completed an online structured questionnaire. Questions were asked about demographic information, work experience, nurses’ general attitude regarding high-risk medications, contact with high-risk medications and the assessment of risk and severity of harm, specific initiatives undertaken to improve high-risk medications care and the use of additional measures when dealing with high-risk medications. Descriptive statistics were used. RESULTS: A total of 2283 home care nurses participated in this study. In our study, 98% of the nurses reported dealing high-risk medications. Home care nurses dealt the most with anticoagulants (96%), insulin (94%) and hypnotics and sedatives (87%). Most nurses took additional measures with high-risk medications in less than 25% of the cases, with the individual double check being the most performed measure for all high-risk medications except lithium. Nurses employed by an organization received support mostly in the form of a procedure while self-employed nurses mostly look for support through external organizations and information sources. CONCLUSIONS: The study shows several gaps regarding high-risk medications care, which can imply safety risks. Implementation and evaluation of more standardized high-risk medications care, developing and implementing procedures or guidelines and providing continuous training for home care nurses are advised. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s40545-022-00476-2