General sample characteristics
The response rates in pre-test and post-test were 87% (n = 117)and 81% (n = 127) of all professionals, respectively (Fig. 2). A group of 73 professionals completed both questionnaires.
Although the professional population had changed significantly during the 2-year period, due to a high turnover rate, respondent characteristics were mostly similar for both measurements (Table 1).
Table 1
Characteristics of respondents, in pre-test and post-test, with absolute numbers and percentages.
|
pre-test
N = 117 (%)
|
post-test
N = 127 (%)
|
df
Pearson χ2
|
Two-sided p-value
|
Sex
|
|
|
0.33
|
0.86
|
male
|
9 (7.7)
|
9 (7.1)
|
|
|
female
|
108 (92.3)
|
118 (92.9)
|
|
|
Working experience
|
|
|
2, 2.85
|
0.24
|
0–10 years
|
41 (35·0)
|
57 (44.9)
|
|
|
10–20 years
|
45 (38.5)
|
45 (35.4)
|
|
|
> 20 years
|
31 (26.5)
|
25 (19.7)
|
|
|
Profession
|
|
|
7, 1,52
|
0.98
|
Assistanta
|
12 (10.3)
|
11 (8.7)
|
|
|
Behavioural expert
|
4 (3.4)
|
8 (6.3)
|
|
|
PCH Doctor
|
11 (9.4)
|
10 (7.9)
|
|
|
Youth Care Worker
|
58 (49.6)
|
62 (48.8)
|
|
|
PCH Nurse
|
25 (21.4)
|
28 (22.0)
|
|
|
PCH Speech therapist
|
2 (1.7)
|
2 (1.6)
|
|
|
Screenera
|
3 (2.6)
|
3 (2.4)
|
|
|
Team administratora
|
2 (1.7)
|
3 (2.4)
|
|
|
Discipline
|
|
|
2, 0.127
|
0.94
|
Administrativea
|
17 (14.5)
|
17 (13.4)
|
|
|
Youth care
|
62 (53.0)
|
70 (55.1)
|
|
|
PCH
|
38 (32.5)
|
40 (31.5)
|
|
|
Organisation
|
|
|
2, 0.01
|
0.97
|
PCH 4–18
|
14 (12.0)
|
15 (11.8)
|
|
|
PCH 0–3
|
41 (35.0)
|
44 (34.6)
|
|
|
Youth Care
|
62 (53.0)
|
68 (53.5)
|
|
|
Municipality
|
|
|
5, 1.44
|
0.92
|
Oldebroek
|
17 (14.5)
|
24 (18.9)
|
|
|
Elburg
|
18 (15.4)
|
18 (14.2)
|
|
|
Nunspeet
|
20 (17.1)
|
24 (18.9)
|
|
|
Harderwijk
|
37 (31.6)
|
39 (30.7)
|
|
|
Ermelo
|
21 (17.9)
|
18 (14.2)
|
|
|
Putten
|
4 (3.4)
|
4 (3.1)
|
|
|
a:Non-administrative professionals, invited for questionnaire and excluded afterwards based on missing data pattern analysis.
Self-reported interdisciplinary collaboration
Comparing the overall mean score, non-administrative professionals reported slightly more positive about interdisciplinary collaboration after introduction of EPR-Youth (n = 106, Estimated Marginal Means (EMM) = 3.93, 95%CI = 3.82–4.04) than before (n = 97, EMM = 3.85, 95%CI = 3.74–3.95), although the difference was not statistically significant F (1, 105.9) = 1.70, p = 0.19 (Table 2). Comparable outcomes were found for the separate components of interdisciplinary collaboration. Professionals reported significantly more positive about flexibility after introduction of EPR-Youth (n = 106, EMM = 4.00, 95%CI = 3.86–4.14) than before (n = 97, EMM = 3.79, 95%CI = 3.65–3.92), F (1, 100.7) = 1.97, p = 0.05, whereas rating of the other components improved slightly but not significantly.
Significant differences in self-reported collaboration were found between organizations, F(2, 134.0) = 7.17, p = 0.001, and between municipalities, F(4,130.8) = 3.80, p = 0.006, before introduction of EPR-Youth. Professionals in preventive child health care among schoolchildren and adolescents reported significantly less positive (EMM = 3.57, 95%CI = 3.31–3.82) about interdisciplinary collaboration than youth care workers (EMM = 4.05, 95%CI = 3.94–4.15). And professionals from the municipality Oldebroek showed a more positive attitude toward interdisciplinary collaboration (EMM = 4.14, 95% CI = 3.93–4.36) than professionals from the municipalities Nunspeet (EMM = 3.69, 95% CI = 3.48–3.90) and Harderwijk (EMM = 3.69, 95% CI = 3.53–3.85). No significant differences in overall mean score and separate components between pre-test and post-test were found for any single organization or municipality.
Table 2
Total and component scores of interdisciplinary collaboration before and after introduction of EBPR-Youth, presented by organisation, municipality and the total research population.
|
Pre-test
|
Post-test
|
Difference pre-test/post-
test
|
|
n
|
EMM* (95% CI)
|
n
|
EMM* (95% CI)
|
F (df numerator, df denominator), p-value
|
Collaboration overall
|
97
|
3.85 (3.74–3.95)
|
106
|
3.93 (3.82–4.04)
|
1.70(1, 105.9), 0.19
|
Interdependence
|
98
|
4.02 (3.92–4.13)
|
107
|
4.08 (3.97–4.18)
|
0.60(1, 110.2), 0.44
|
Newly created
professional activities
|
92
|
3.70 (3.54–3.86)
|
101
|
3.80 (3.65–3.95)
|
0.94(1, 126.7), 0.33
|
Flexibilitya
|
97
|
3.79 (3.65–3.92)
|
106
|
4.00 (3.86–4.14)
|
1.97 (1, 100.7), 0.05
|
Collective
ownership of goals
|
91
|
3.82 (3.65–3.98)
|
102
|
3.93 (3.78–4.09)
|
1.38 (1, 112.7), 0.24
|
Reflection on process
|
96
|
3.72 (3.56–3.87)
|
104
|
3.93 (3.68–3.98)
|
1.49 (1, 119.6), 0.23
|
|
n
|
EMM* (95% CI)
|
n
|
EMM* (95% CI)
|
|
Organization
|
|
|
|
|
|
PCH 4-18b,c
|
10
|
3.57 (3.31–3.82)
|
12
|
3.74 (3.50–3.98)
|
|
PCH 0-3b
|
25
|
3.92 (3.76–4.09)
|
26
|
4.00 (3.84–4.16)
|
|
Youth Carec
|
62
|
4.05 (3.94–4.15)
|
68
|
4.06 (3.96–4.16)
|
|
Municipality
|
|
|
|
|
|
Oldebroekd,e
|
14
|
4.14 (3.93–4.36)
|
22
|
4.06 (3.86–4.25)
|
|
Elburg
|
15
|
3.91 (3.69–4.12)
|
15
|
3.95(3.72–4.17)
|
|
Nunspeetd
|
16
|
3.69 (3.48–3.90)
|
20
|
3.81 (3.62–4.01)
|
|
Harderwijkd
|
30
|
3.69 (3.53–3.85)
|
34
|
3.80 (3.65–3.94)
|
|
Ermelo/Putten
|
22
|
3.80 (3.61–3.99)
|
15
|
4.00 (3.82–4.24)
|
|
a: significant difference between pre-test and post-test measurement, 2-sided p-value = 0.05, as tested with Bonferroni post-hoc |
b−e: significant difference between these subgroups, 2-sided p-value < 0.05, as tested with Bonferroni post-hoc |
*: Estimated marginal means (EMM)were calculated in a mixed model analysis, including organization, municipality, time, interaction between time and municipality, and interaction between time and organization as fixed factors, and ID as random factor.
Focus group interviews and qualitative questionnaire outcomes .
Analysing the qualitative data, we found that using EPR-Youth contributed to three out of five components from Bronstein’s model. ‘Interdependence’, ‘collective ownership of goals’ and ‘newly created activities’ were affected by using EPR-Youth, whereas ‘flexibility’ and ‘reflection on process’ were not affected by using EPR-Youth. Additionally, the contributing factor ‘structural characteristics’ emerged as a relevant theme as well.
Interdependence
Professionals reported that the use of EPR-Youth strengthened their sense of interdependence, mostly in a practical way. Because the system facilitated the sharing of necessary knowledge and information, professionals felt that they became more aware of each other’s expertise and knowledge. As a result, they found themselves better able to complement each other in the care process. Having direct access to relevant information about ‘who is doing what in this case’ contributed to efficiency, and so did the possibility to transfer information between disciplines without contacting each other. Some professionals, however, did not utilize all information in EPR-Youth since they did not feel free to read information that was added by other disciplines.
It is important that we as colleagues in the Centre for Youth and Family know each other and know each other’s work and professional roles, to make use of each other’s expertise, involve each other when needed, and contribute to each other’s strength.
[Youth Care Worker, Pre-test questionnaire; 6:41]
I don’t need to transfer the record to PCH 4–18 when a child is 4 years old. And when I need information about an older child, I don’t need to mail to my PCH 4–18 to ask her, because I can find it myself with permission from parents.
[PCH Nurse, Focus group interview 1; 2:4]
Newly created professional activities
Developing and implementing EPR-Youth together with all different disciplines in the CJG-teams was considered a very impactful newly created professional activity. Focus group participants reported that developing and using EPR-Youth helped them realize how working processes and procedures were differing between the three organization. Consequently, they felt an urgency to develop more newly created professional activities, such as synchronizing working processes and registration habits, and clarifying and describing each other’s role and tasks in those processes.
…sometimes they (nurses) report client questions in EPR-Youth and sometimes they don’t. We have no clear agreement about this. I would very much like to have a guide in which we have made some statements: this is how we agreed to work together.
[PCH doctor, Focus group interview 2; 4:195]
Collective ownership of goals
Because EPR-Youth provided the opportunity to create a shared care plan for a child or a family, in which different disciplines could be involved, professionals felt that EPR-Youth contributed to a collective ownership of these care plans. Every professional could register his own actions and add them to the same plan. This was in line with the regional aim to create ‘one plan for each family’ instead of separate plans from each professional’s own perspective. Moreover, professionals considered the transparency of a fully client-accessible health record supportive for the working relation between client and professional, creating more equality and rendering more responsibility to clients then before. Consequently, ownership of care plans and goals was shared not only between different professionals, but between client and professional as well.
I think it (EPR-Youth) can be a very powerful instrument to collaborate with parents and to leave the responsibility where it belongs.
[Youth Care worker, Focus group interview 1, 2:67]
Flexibility
Changes in flexibility, as described by focus group participants were rather related to organizational facilities than to using EPR-Youth. Youth care professionals reported a lack of flexibility among PCH colleagues when planning interdisciplinary meetings. Attending these meetings was not mandatory and was not facilitated equally for each involved organisation.
‘PCH 4–18 colleagues have fixed working days and schedules that are not flexible. That means that we as youth care workers must be even more flexible, coming to the office on our day off.’ [Youth care worker, Post-test questionnaire, 8:31]
Reflection on process
Using EPR-Youth had not initiated any reflection on using EPR-Youth itself or on integrating the use of EPR-Youth in collaborative working processes. However, the need for reflection became clear during the focus group interview, when participants concluded that they lacked knowledge about the match between system, vision on care for youth and actual working processes. They unanimously felt that this lack of knowledge limited EPR-Youth’s potential to strengthen interdisciplinary collaboration.
‘That confirms the need for training, not only about how the system works, what buttons you need to press, but also how we use it. How do we synchronize our working processes, how do we report correctly…’ [Behavioural Scientist, Focus group interview 2, 4:131]
Structural characteristics
Barriers reported by professionals were mainly associated with the factor ‘structural characteristics’ in Bronstein’s model. Overall, professionals mentioned lack of time as an important barrier for interdisciplinary collaboration. Especially in the questionnaires, professionals reported (n = 14) that their collaboration with PCH 4–18 professionals was limited, because these colleagues were facilitated less by their organization to collaborate with other disciplines than PCH 0–3 professionals and youth care workers. Professionals felt that the PCH 4–18 organization did not provide their professionals with enough time, nor with flexibility in their working schedules, to join meetings with their colleagues from other disciplines. Moreover, PCH 4–18 professionals were mainly working at schools and not at the office, which was reported as another barrier for interdisciplinary collaboration due to lack of meeting opportunities.
Finally, ‘being part of multiple teams’ was reported to be a barrier for collaboration since professionals had to divide their attention between different teams and between different interacting systems.
‘Working in the same building helps to find each other faster and to know each other’s qualities. I find it difficult that there are parent companies behind the three organisations that shape their working processes in a different way than the Centre for Youth and Family does.’
[Unknown, Post-test questionnaire 8:23,24]