Qualitative data
Qualitative interviews with 15 staff (3 physicians, 11 nurses, 1 therapist) were conducted, which included 4 individual interviews (physicians, therapist) and 5 group interviews with 2-3 participants (nurses) each. The mean duration of the qualitative surveys was 26 min (range 9 min to 38 min). Regarding factors associated with implementation, the participants addressed the TICD interdependent main themes regarding interprofessional collaboration: (1) Communication and influence, (2) Team processes, and (3) Referral processes.
Theme 1: Communication And Influence
The theme “Communication and influence” describes the extent to which the support of the intervention is influenced by professional opinions and communication (adapted from [12]). Related to the MCA, this theme comprises “Knowledge about the MCA”, “Role of patients”, and “Own role in team”.
Knowledge about the MCA
Each of the staff interviewed had already heard of the MCA. Their knowledge in detail depended on the contact they had with the project and its participants: some staff were more informed by being part of the project, others knew it from a distance without being directly involved. In this context it was also mentioned that it would be helpful to know which people were involved in the project.
„I can’t remember someone saying, we have an MCA conversation today. Never heard that, I don’t know if that happens. See, so little do I know about it.“ (interview 1, therapist)
Role of patients
Patients acted as deliverers of information between the MCA team and other staff. The topic “Role of patients” contains statements about the milestone conversations (MCs) that staff had been informed of by patients.
The majority of interviewees working on the ward mentioned that they could not identify the patients participating in the MCA, although there were no reports of asking patients directly if they were cared for with the MCA, either. While some staff received information from their patients about their participation in the MCA, other patients never mentioned it. Patients who mentioned the MCA to the interviewees reported positive experiences and an enhancement of the treatment process.
"I have heard from patients that the contact to the MCA team is appreciated and maintained [...]. And I always find that in itself [...] an enrichment.” (interview 2, physician)
Own role in team
Even if the interviewees had not received the MCA training, they were able to report how the intervention influenced the roles they had in the team. Physicians for whom MCA was a new experience sometimes felt overruled in their therapeutic decisions when working together with a (trained) nurse navigator.
“I remember a situation with a patient who did not feel well, and then the nurse had already talked to her about discontinuing therapy. That was, for me in that moment it was a bit outside their scope.” (interview 3, physician)
In addition, therapeutic conversations conducted together with a patient were perceived as physician-dominated with the nurse navigator in a secondary role.
“There were conversations which were physician-centred and the nurses had a passive role, but they contacted the patient afterwards. So there was less direct participation during the conversations” (interview 2, physician)
Participant nurses perceived evolution in the doctor-nurse relationship distinct from MCA. From their point of view, the therapeutic conversations generally were conducted in partnership and not physician-dominated.
"There are the somewhat older physicians who are perhaps used to talking and the nurse listening, and today it is already the case with many of them that the conversation is held together. The physician and the nurse" (focus group 1, nurse 2)
Tasks and roles of the different team members were not explicitly defined in the project. Team members could flexibly adapt their roles and responsibilities as part of the implementation process. Over time, clearer definitions of tasks and roles emerged and led to a higher degree of acceptance of shifted responsibilities.
“That was at the beginning when the role of the MCA team wasn’t exactly clear, that was just perhaps a little hyperactivity. Otherwise there is not much to criticise.” (interview 3, physician)
“But that was only at the beginning, I think it was clear that this was also a new concept; both for the doctors and for the nurses - in this form and therefore, that is also quite normal that one has, I say, the one or other point where one is not in agreement and that is why there is this project, I think. We have developed further, I think. Yes." (interview 4, physician)
Theme 2: Team Processes
The theme “Team processes” describes the extent to which teams are involved to support implementation (adapted from [12]). Related to the MCA, this theme comprises Team competencies, Imparting information and Barriers.
Team competencies
Team competencies include aspects and areas of competence that belong to interprofessional collaboration associated with the MCA. Therefore, only staff who were actually in direct contact to the MCA could reflect their experiences first-hand. In our sample, this concerned physicians only. Due to rotation within the hospital, not all of them were trained in MCA but sometimes conducted therapeutic patient conversations in a tandem with a trained nurse navigator.
With the introduction of the MCA, perception of physicians and nurse navigators in the tandem differed about how and when to deliver information to the patients, especially about the prognosis. From the physician’s point of view, nurse navigators wanted the patients to be fully informed from the beginning, while physicians provided information in small pieces for each patient individually. Over time, the tandems found a way to lead satisfactory conversations.
“You have to be very careful and I think that nurses even expect you to explain everything at the beginning. And there were some conflicts, I think with the time they (nurses in the tandem) have also seen that this works differently. Always, so to speak, individually, depending on how much the patient can accept at all, how much information they need and that's what we tend to do at the moment. Yes, I believe that the nurses are also quite content at the moment.” (interview 4, physician)
Members of a tandem perceived each other as supportive in providing information, preparing patients for the conversations, conducting and debriefing the conversations, and documentation. The collaboration within the interprofessional tandem was evaluated positively. Feedback after the MCs was appreciated.
“There was another pair of ears and debriefing the conversation I considered helpful. That what was documented, what was fed back or what kind of problem remained to be addressed at the next appointment.” (interview 2, physician)
Other team members were also perceived as providing emotional support.
“Especially in critical situations, you don’t have to carry the load of telling of progression or saying you cannot do any more (tumor centered therapy), you don’t have to carry that alone. That should not be underestimated. So, I think this is also a moral support for the physicians, if there is someone else and supporting the people.” (interview 3, physician)
Collaboration within the team led to more knowledge about the patient: the team regularly exchanged information about the situation and clinical status of the patient. Ambiguities were timely clarified.
“Knowledge gain after the conversation, that MCA team members reflected information back to me, of the conversations and later also in the documentation which supplemented my own picture.” (interview 2, physician)
MCA provided an agenda for topics to be addressed in a conversation. Although structured, the conversations sometimes took unintended turns and therefore lasted longer than planned. Still, it was considered an advantage when nurse navigators addressed patient-relevant issues during the conversation, debriefed with the patients and answered questions arising after the scheduled conversation. From the physicians' point of view, the nurse navigators tended to see the support needs of the patients during the MCs. Nurse navigators were an additional support, which helped to interpret the patient's statements and to address important issues again at a later time.
“During the conversation, there is always one or another issue, that the nurses notice and address. I think that’s great […] there are just questions they then can clarify outside (after the conversation). I consider this very good for patients because we are aware that patients receive a lot of information […] and of course coordinating appointments keeping deadlines, medication, that is very complicated and for them (patients) very supportive. I also had challenges at the beginning but now it works well and both physicians and patients benefit very much.” (interview 4, physician)
Physicians became more aware of the support provided by nurse navigators and used it more often. For patients who were perceived as needing more support, the nurse navigator was informed and able to schedule additional time for debriefing with the patients.
“We constantly call the nurses, ‘do you have time, there is a patient who maybe needs more support’. I think it’s very important because, in the end, we as physicians manage maybe half an hour to three quarter per patient, and you don’t manage, depending on how much information the patient wants, to talk about everything. There are always some minor issues patients don’t dare to ask the physician directly. Such questions are clarified with the nurses” (interview 4, physician)
Although the participating staff perceived advantages in bringing different professional perspectives together and acknowledged the problem-solving opportunities this offered, staff not involved in the tandem highlighted difficulties they experienced figuring out how to include MCA into their daily routine.
“I can imagine that it (the MCA) has advantages, because everybody is sharing their view on the patient, and how problems can be solved, for the patient but also within the team maybe.” (interview 2, physician)
"Well, there are some of our colleagues who cannot yet integrate MCA into our daily activities. [...] Therefore I believe that MCA is a real support for the patient, but it is not yet a benefit for us." (focus group 1, nurse 1)
Some interviewees reported no change in interprofessional teamwork from the introduction of the MCA. But they stressed the point of having had a good collaboration beforehand.
“Here it (interprofessional teamwork) is very good anyway. Otherwise it wouldn’t work. It is trusting and very good. Still. I would be lying if I’d say this has all become much better. It is just good.” (interview 3, physician)
Imparting information
Means by which information was passed to other members of the staff, had room for improvement in the transparency of the MCA. From the interviews, it emerged that staff other than the nurse navigators and physicians who were trained and/or conducted milestone conversations (MCs) were not informed about details of the MCA project. Nevertheless, the project and the exchange with the MCA team provided additional (unstructured) information to the wards.
"It happens from time to time that an MCA-nurse comes and says: ‘(Name of the patient) is not well. I have already called them once, they come (here), they have this and that.’ That's information we usually don't get." (Individual interview 3, physician)
To strengthen information exchange, interviewees articulated the wish to receive a summary of the MCs to improve patient support. As part of the project, the nursing staff on the ward had access to all written information on MCs. Still, they expressed the wish to have a brief oral explanation of what was addressed in the MCs and what the patient's needs were. With this information, they could continue and improve the patient's care.
"A brief feedback session if they are coming to the ward to see some patients anyway." (focus group 2, nurse 3)
“Everything is documented. That’s new, that it is in green now. And on top, it says in big letters ‘MCA patient’, so you know, ’I can call someone if there is something where I cannot answer or don’t have time’.” (focus group 5, nurse)
Barriers
Changes in interprofessional collaboration initiated by the MCA can be best understood by looking at logistic influences on and by the MCA. At the beginning of the implementation, some of the MCs did not proceed as planned. Both organizational and interpersonal factors were identified as reasons for this. In particular, the lack of a fixed place for follow-up calls or debriefing with the patient after an MC was mentioned in the area of organizational aspects.
“Because of space, that it is just a problem [...] we already say ‘the admission it is very full, so please make sure that you don't talk to the patient, even if it is only for a short time, because there are already two sitting (patients) there’ and we also talk on the phone, so that nobody just takes a seat, that’s too much.” (focus group 5, nurse 2)
In terms of interpersonal aspects, a barrier was seen at the beginning of the implementation process in that the distribution of roles and the interaction within the tandem was not yet defined. A lack of clarity regarding roles and interaction led to some insecurity on the part of physicians and nurses, which can affect the quality of the counseling. The exchange of information was not only dependent on the individual, but also on surrounding conditions, such as time. Some staff indicated that a good exchange about the patient should take place during the afternoon shift, as many time-consuming nursing and therapeutic measures were carried out on the morning shift.
“in the morning shift it is bad, there is of course little time, but in the afternoon shift I find it suitable” (focus group 3, nurse 1)
Theme 3: Referral Processes
The theme “Referral processes” describes processes of transferring patients within and between outpatient departments and inpatient wards and interprofessional communication (adapted from [12]). Within the MCA, this theme focused on Cross-sectoral communication.
Cross-sectoral communication
Cross-sectoral communication refers to the communication between the outpatient department and the inpatient wards. Overall, staff stated that effective communication between the wards and the outpatient department played an important role for them, as it enabled them to optimize patient care and to provide it in a targeted manner. Nevertheless, communication in the context of the MCA was perceived as controversial. The exchange about patients depended on the relationship between individual members of the staff. Advantages were particularly observed when the nurse navigator was both part of the interprofessional tandem and additionally worked part time on the ward. Nurse navigators in the MCA who had good relationships with staff on the ward communicated more about patients' individual situations.
"I can say that it is sometimes depending on the person, the nurse who has worked in our ward, for example, I am more in contact with her because I interact with her directly [...].” (focus group 1, nurse 2)
One interviewee stated that the tight schedule on the wards allowed only narrow time frames for exchanging information, which often affected communication. The interviewee also described their reluctance to talk to someone if they felt that the other person did not have the time.
"There's bustle, pressure on from care requirements, I'd say, especially on the ward [name of the ward], so that I'm already very reluctant to approach the doctors individually.” (interview 1, therapist)
Quantitative data
Of all 120 members of the staff, 87 (72,5%; 62 female, 22 male, 3 unknown; 44 nurses, 12 psycho-social staff, 1 diagnostic staff, 4 administration, 7 therapists, 13 physicians, 1 other, 5 unknown) completed the survey at least once (t0: n=20, t1: n=48, t2: n=33, t3: n=25).
Attitudes towards communication and teamwork were primarily positive (mean sum score = 17.7, SD=3.0, min-max: 10-23; positive: n=71, 81.6%, neutral: n=15, 17.2%, negative: n=0, 0%). Attitudes did not change over time (Table 1).
The majority of the respondents showed neutral attitudes towards interprofessional interaction (mean sum score = 28.5, SD=5.7, min-max: 13-45; positive: n=14, 16.1%, neutral: n=48, 55.2%, negative: n=22, 25.3%). There were no changes in attitudes across assessments (Table 1).
‘Interprofessional Relationships’ were characterized by primarily positive attitudes overall and across assessments (Table 1; overall mean sum score = 16.0, SD=3.6, min-max: 8-29; positive: n=80, 92.0%, neutral: n=6, 6.9%, negative: n=1, 1.1%).
Table 1
Attitudes of staff towards communication and teamwork, interprofessional interaction, and interprofessional relationships
| | t0 | t1 | t2 | t3 |
Communication and Teamwork | n | 19 | 46 | 32 | 25 |
| M (SD) | 16.7 (2.3) | 17.7 (3.1) | 17.4 (3.4) | 17.4 (3.4) |
| min-max (9-36) | 13-20 | 10-23 | 11-24 | 10-24 |
| positive n (%) | 19 (100) | 36 (78) | 25 (78) | 21 (84) |
| neutral n (%) | 0 | 10 (22) | 7 (22) | 4 (16) |
| negative n (%) | 0 | 0 | 0 | 0 |
Interprofessional Interaction | n | 19 | 47 | 33 | 25 |
| M (SD) | 28.6 (5.6) | 28.4 (5.5) | 30.5 (4.4) | 27.4 (5.5) |
| min-max (9-45) | 21-45 | 15-38 | 22-44 | 13-38 |
| positive n (%) | 3 (16) | 8 (17) | 1 (3) | 6 (24) |
| neutral n (%) | 12 (63) | 25 (53) | 16 (48) | 14 (56) |
| negative n (%) | 4 (21) | 14 (30) | 16 (48) | 5 (20) |
Interprofessional Relationships | n | 20 | 47 | 33 | 25 |
| M (SD) | 15.6 (4.0) | 16.2 (3.7) | 15.8 (3.8) | 14.8 (3.7) |
| min-max (8-40) | 8-29 | 8-26 | 8-29 | 8-23 |
| positive n (%) | 19 (95) | 42 (89) | 31 (94) | 24 (96) |
| neutral n (%) | 0 | 5 (11) | 1 (3) | 1 (4) |
| negative n (%) | 1 (5) | 0 | 1 (3) | 0 |