Characteristics of participants and case contexts
A total of 29 professionals were interviewed, the majority of which were women (n = 23). Work experience ranged from 1 to 47 years. NPs worked in two general practices, one each. Additionally, registered nurses (RNs) and nurse assistants from home healthcare in the area of the general practices with the NPs were interviewed. The two NPs worked part-time in the home healthcare organisations (Table 3).
Table 3: Characteristics of the interviewed professionals
|
General practice A
|
General practice B
|
General practice C
|
General practice D
|
General practice E
|
Number of interview participants (n)
|
8
|
9
|
4
|
4
|
4*
|
Gender
Female
Male
|
7
1
|
8
1
|
3
1
|
2
2
|
3
1
|
Age in years
(mean)
|
19-56
(35.6)
|
23-66
(47.2)
|
29-57
(43.8)
|
22-53
(32.3)
|
23-52
(41.7)
|
Professions
GP
NP
RN
MPC
MPA
Nurse assistance
|
1
1
2
0
2
2
|
2
1
2
1
1
2
|
2
0
0
2
0
0
|
2
0
0
1
1
0
|
2
0
0
1
1
0
|
Work experience in years
(mean)
|
1-20
(11.0)
|
1.5-47
(20.6)
|
9-30
(20.0)
|
3-25
(11.8)
|
4-33
(20.0)
|
Workload in percent
(mean)
|
20-100%
(81.3)
|
40-100%
(84.6)
|
55-100%
(89.0)
|
40-80%
(70.0)
|
60-100%
(83.0)
|
Workplace
General practice
Home healthcare
General practice and home healthcare
|
3
4
1
|
4
4
1
|
4
0
0
|
4
0
0
|
4
0
0
|
*No information from one person on age, work experience, and workload
In total, 34 patients were interviewed, the majority of which were women (n = 19). About one third (n = 11) of the participants lived alone at home and needed support. Another nine participants received support from healthcare services. Endocrine disorders (n = 21) and cardiovascular diseases (n = 20) were predominant (Table 4).
Table 4: Characteristics of the interviewed patients
|
General practice A
|
General practice B
|
General practice C
|
General practice D
|
General practice E
|
Number of interview participants (n)
|
7
|
8*
|
7
|
8
|
4
|
Gender
Female
Male
|
3
4
|
4
2
|
3
4
|
5
3
|
4
0
|
Age in years
(mean)
|
65-84
(71.1)
|
70-91
(79.50)
|
67-78
(73.9)
|
67-89
(75.1)
|
78-79
(78.5)
|
Living situation
Lives with partner or family
Lives alone
Other
|
5
2
0
|
1
4
1
|
7
1
0
|
6
2
0
|
2
2
0
|
Needs support at home
Yes
No
|
3
4
|
5
1
|
1
7
|
3
5
|
2
2
|
Gets support at home from
Relatives
Health service
|
3
2
|
4
5
|
0
1
|
3
1
|
2
0
|
Frequency of support
1 to 2 per week
3 to 4 per week
≥ 5 per week
|
0
1
2
|
2
0
3
|
1
0
0
|
2
0
1
|
1
0
1
|
Common medical diagnoses
Endocrine disease
Cardiovascular disease
Musculoskeletal disease
Oncological disease
Mental disease
No information
|
6
4
2
0
0
0
|
0
1
4
0
0
2
|
6
6
1
1
0
1
|
6
7
5
0
1
0
|
3
2
3
0
2
0
|
Medications per day
0
1 – 2
3 – 4
≥ 5
|
1
1
2
3
|
2
0
0
4
|
2
0
0
4
|
1
2
1
4
|
1
1
1
1
|
*No receipt of sociodemographic information from two interview participants
According to the questionnaire (ESAS), the most common symptoms of patients were tiredness (2.8 mean), pain (2.6 mean), and lack of appetite (2.3 mean). Patients often had limitations due to pain/discomfort (n = 18) and impaired mobility (n = 16). Patients in general practices without NPs rated their health as very good (mean: 84.3; 79.4; 83.8) compared to patients in general practices with NPs (mean: 60.0; 69.0) (EQ-D5-L5). Interprofessional collaboration (AITCS, SIPEI) was considered positive by most healthcare professionals; however, areas of optimization included coordination of interprofessional activities or having access to education on interprofessional collaboration. Patients also rated the interprofessional collaboration among the health professionals as positive. The questionnaire results are presented in Additional file 2.
Similarities and differences in general practices
A total of three themes of similarities and differences of the general practices with and without NPs are presented below. These themes are based on the CCM’s main themes, namely community, health systems, and productive interactions.
Community
In this theme, issues around the community were compiled as the CCM suggests that resources and strategies are important [15]. These included the fact that the participating general practices were well established in the community and the importance of networking among various health services in communities, as well as having a sufficient number of healthcare professionals.
Similarities:
All general practices had been embedded for years in the rural areas. The shortage of healthcare professionals had increased over the years. Staff shortages and unfilled positions kept the teams busy, as the observations demonstrated. One GP stated:
We must take care of the next generation. Not only in the field of medicine, in the field of rural primary healthcare, but we also must make sure that we continue to function as a team. (GP 5)
Patients noticed the shortage of healthcare professionals; however, they much appreciated the local care provided in the rural areas. One patient maintained:
Doctors do not like to go to work in the countryside. But we are lucky to have a group practice in the village. That's nice, that you do not have to go to city. (Patient 18)
Differences:
Observations showed that some general practices worked with several health services in the same building. This was perceived as a great added value by the health professionals, as one medical practice coordinator (MPC) said:
Being under one roof makes things much easier because you can quickly go over to the home healthcare and clarify questions. (MPC 2)
However, when health services were located in other parts of the area, NPs provided a bridge. As a result, interface management was improved, and more information on the patient’s home situation was transferred to the general practice. One GP explained:
I think, ever since the NP has been present, there has been more feedback. Communication may have changed a little bit. But we have also learned more about how patients function at home. (GP 2)
The NPs were observed to use their network to provide optimal care for patients. Until the arrival of the NP, one patient with particularly complex dressings and bandages was cared for at home by the home healthcare team. The NP visited this patient at home afterwards and discussed the situation. Together, the patient and the NP decided that the patient needed to see the NP in the general practice later on. The NP was better equipped with materials at the general practice. It was also easier for the NP to arrange for referral to wound experts in the general practice.
Health Systems
In this theme, issues around the health systems were compiled as the CCM suggests that self-management support, delivery system design, decision support, and clinical information systems are important [15]. These included defining roles and distributing tasks, conducting effective self-management support strategies, embedding evidence-based guidelines, sharing information, and coordinating care.
Similarities:
Chronic care was perceived to be challenging by all general practices. For example, health professionals cited the lack of guidelines for multimorbidity, the increased need of coordination, and the growing administrative workload. Similarly, reimbursement for the new roles (e.g., NPs) was not regulated for the general practices. In addition, coordinative tasks for chronically ill people could not be billed, neither by the GPs or the NPs.
All GPs in the participating general practices saw themselves as guides for the patients, and they conducted the medical management from A to Z. One GP described:
You are the person who keeps the overview and has things under control. Something important is coordination when special disciplines are involved. (GP 6)
However, the GPs had the final responsibility. Due to the NPs, the GPs experienced a relief in their daily work. Medical practice assistants (MPAs) and MPCs were perceived to be the pillars of general practice. These professionals were mainly responsible for organisation within the general practice. According to the observations, the tasks of MPAs and MPCs were clearly delineated. These included, for example, telephone triage, lab work, and minding the reception desk. MPCs additionally provided specific education on blood sugar testing for stable, chronically ill diabetic patients. Most chronically ill patients had routine check-ups every three months. During these check-ups, MPCs used checklists to monitor the patients’ health status. Both observations and interviews revealed that MPCs provided delimited care and counselling to chronically ill people. Specifically, MPCs were able to advise predominantly chronically ill people with diabetes mellitus type 2 in stable condition. More complex patient situations or people with instable chronic diseases presented many challenges for MPA and MPC counselling. Similarly, MPCs were not well equipped to advise people with other chronic conditions, such as chronic obstructive pulmonary disease (COPD) or heart failure, as is illustrated by one of the MPCs:
For me, the hardest thing is to advise people when they come up with things that are not my specialty. I can offer advice when it comes to diabetes. But most of the time it is like: can you look here, I have yet another problem. (MPC 4)
In these situations, MPAs and MPCs handed the patients over to the GPs. Each general practice had an internal electronic information system. Analysis of patient records showed that this system facilitated communication as well as collaboration.
Differences:
The tasks and processes of NPs were less clearly delineated as determined from the interviews, the patient record analysis, and the observations. One NP described:
In the beginning, there were sometimes misunderstandings, who takes over which tasks, what does the doctor do, what do the MPAs do, and what do I do. (NP 1)
As time went by, NPs took more and more care of people in stable, unstable, and complex situations. NPs introduced a comprehensive patient-centred, nursing perspective into the general practice, which was new for everyone. They also responded to the nursing needs that emerged in the general practice. Similarly, they provided support regarding nursing care in the home healthcare agencies associated with the respective general practice and the associated nursing homes. As part of the nursing care, NPs coached healthcare professionals in home healthcare and nursing homes. NPs discussed (more frequently than GPs) chronic disease management and self-management at home. NPs also made frequent home visits. In addition, they provided education to chronically ill patients regarding new skills such as completing a dressing of a wound at home. These issues were rarely or insufficiently addressed up until the moment NPs became part of the general practice. One of the NPs stated:
A patient, chronically ill, multimorbid, with diabetes and cardiac failure, and neglected, had decompensated due to his various diseases. He now comes to see me regularly in the general practice or I go on home visits. He has stabilized sufficiently, is now taking care of himself, and is again socially active. (NP 2)
Home visits were handled differently in every general practice. For example, homes were only visited in cases where the patients were immobile. Structured and regular exchanges with home healthcare and nursing homes was missing in some general practices. The lack of a common electronic information system and electronic patient records across various healthcare providers, including home healthcare, was one contributing factor. In addition, the right to access these electronic resources varied widely among the participating general practices. Not every health professional had the same access rights.
Strikingly, some patients did not want to be integrated into decision-making processes, according to the interviews. They preferred deferring to the GPs themselves. Other patients were supported by both the GPs and the NPs in the decision-making process. In contrast, the MPAs and MPCs had little involvement in decision-making processes. One patient said:
It is simply like this. I say in each case: You are a doctor, you are studied. I do what you say, that's best. (Patient 23)
Productive interactions
In relation to the idea of the informed, activated patient and prepared, proactive practice team of the CCM, another main theme was developed, namely productive interactions [15]. These included trust and collaboration.
Similarities:
All patients of all participating general practices maintained that they wanted to be perceived as a whole person. The atmosphere was considered friendly and familiar. Trust and continuity were important. One patient stated:
I feel well taken care of, they (team) are so uncomplicated, I can then sometimes just take the medication for the husband. So, you are not just a number. (Patient 16)
Across all general practices, the GPs trusted in the teams. Interactions within the teams occurred in an appreciative manner, and the health professionals were passionate about their work. One GP explained:
We love what we do. Yes, we don't think of it as work so much as it is our job. The profession has something to do with vocation. We also feel here, in practice, a high degree of team spirit and a high degree of idealism. (GP 6)
Differences:
In general practices with NPs, the team was constantly in the process of change. There were higher demands placed on the NP as a person because they were new to the team. In contrast to NPs, MPCs struggled with challenging communications with the team and with patients. This is evident in the observations but also in the interviews. One MPC stated:
There are people with whom it is quite simple and straight forward to have a nice conversation, who do what you tell them. And then others question everything. I think it is very important to make people their own coaches of their illness so that they have enough information. (MPC 3)
The GPs were seen as the main reference person for health issues; however, patients perceived frequent changes of GPs in some general practices to be worrisome. In the general practices with NPs, patients were more likely to perceive the NPs as the reference person and to identify differences with other healthcare professionals, e.g., concerning expert knowledge. Most of these cases involved patients with home visits. One patient explained:
It seems to me that what she (NP) is saying makes sense. I have noticed that several times. And she just has a way with people. She knows quite a bit; she really knows more than the other health professionals. (Patient 11)