Participant and practice characteristics
Interviews were conducted with four APNs, two nurses without an APN education, six MPAs, and four GPs. All participants except for the medical doctors were female. All four APNs, one nurse, and four MPAs agreed to be observed in practice. Participants worked in ten different PCPs. Practice and participant characteristics are summarized in Tables 1 and 2.
Table 1: Participant characteristics
|
Professional group
|
|
Age
|
|
Highest education
|
|
Further education
|
|
Clinical work experience
|
|
Research participation activities
|
|
APN
|
Nurse
|
MPA
|
GP
|
|
yrs
|
|
Vocational training
|
Higher vocational training
|
Master in Nursing Sciences (MScN)
|
Doctor of Medicine
|
|
ANP+ or other DAS
|
Diabetes and/or nutrition module for MPA
|
CCM Modules 1&2
|
|
yrs
|
|
Interview
|
Observation
|
GP1
|
|
|
|
x
|
|
57
|
|
|
|
|
x
|
|
|
|
|
|
24
|
|
x
|
|
GP2
|
|
|
|
x
|
|
55
|
|
|
|
|
x
|
|
|
|
|
|
35
|
|
x
|
|
GP3
|
|
|
|
x
|
|
71
|
|
|
|
|
x
|
|
|
|
|
|
44
|
|
x
|
|
GP4
|
|
|
|
x
|
|
32
|
|
|
|
|
x
|
|
|
|
|
|
6
|
|
x
|
|
APN1
|
x
|
|
|
|
|
35
|
|
|
|
x
|
|
|
x
|
|
|
|
18
|
|
x
|
x
|
APN2
|
x
|
|
|
|
|
56
|
|
|
|
x
|
|
|
x
|
|
|
|
32
|
|
x
|
x
|
APN3
|
x
|
|
|
|
|
60
|
|
|
|
x
|
|
|
x
|
|
|
|
33
|
|
x
|
x
|
APN4
|
x
|
|
|
|
|
52
|
|
|
|
x
|
|
|
|
|
|
|
32
|
|
x
|
x
|
MPA1
|
|
|
x
|
|
|
31
|
|
x
|
|
|
|
|
|
x
|
x
|
|
12
|
|
x
|
x
|
MPA2
|
|
|
x
|
|
|
35
|
|
x
|
|
|
|
|
|
x
|
|
|
17
|
|
x
|
|
MPA3
|
|
|
x
|
|
|
58
|
|
x
|
|
|
|
|
|
x
|
|
|
36
|
|
x
|
x
|
MPA4
|
|
|
x
|
|
|
23
|
|
x
|
|
|
|
|
|
x
|
x
|
|
5
|
|
x
|
|
MPA5
|
|
|
x
|
|
|
30
|
|
x
|
|
|
|
|
|
x
|
|
|
12
|
|
x
|
x
|
MPA6
|
|
|
x
|
|
|
32
|
|
x
|
|
|
|
|
|
|
x
|
|
14
|
|
x
|
x
|
N1
|
|
x
|
|
|
|
43
|
|
|
x
|
|
|
|
|
x
|
|
|
25
|
|
x
|
|
N2
|
|
x
|
|
|
|
57
|
|
|
x
|
|
|
|
|
|
|
|
36
|
|
x
|
x
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Notes: Diabetes, nutrition and CCM Modules are offered at different private and public schools for the professional education of MPA in Switzerland Abbreviations: APN: Advanced Practice Nurse MPA: Medical Practice Assistant GP: General Practitioner ANP: Advanced Nursing Practice DAS: Diploma of advanced studies
|
Table 2: Practice characteristics
Practice #
|
Practice type
|
|
Number of health professionals with specific roles in CCM
|
|
Location of practice
|
|
Practice type
|
|
group practice
|
solo practice
|
|
APN
|
MPA
|
Nurse
|
|
Canton
|
Urban
|
Rural
|
|
General practice
|
1
|
x
|
|
|
2
|
|
|
|
ZH
|
x
|
|
|
x
|
2
|
x
|
|
|
|
1
|
|
|
BE
|
|
x
|
|
x§
|
3
|
x
|
|
|
1
|
1
|
|
|
ZH
|
|
x
|
|
x
|
4
|
x
|
|
|
1
|
1
|
|
|
SZ
|
|
x
|
|
x
|
5
|
x
|
|
|
|
1
|
|
|
BE
|
x
|
|
|
x
|
6
|
|
x
|
|
|
|
1
|
|
BE
|
|
x
|
|
x
|
7
|
x
|
|
|
|
|
1
|
|
BE
|
|
x
|
|
x
|
8
|
x
|
|
|
|
1
|
|
|
ZH
|
x
|
|
|
x
|
9
|
|
x
|
|
1
|
|
|
|
GL
|
|
x
|
|
x
|
10
|
x
|
|
|
|
1
|
|
|
ZH
|
x
|
|
|
x
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Notes: §general practice with focus on psychosomatic diseases with a high share of chronically ill patients
|
|
|
|
|
|
|
Key themes
Concepts and themes relating to IPC were all allocated to the NICF domains and are presented in a synthesized form. Figure 2 in the additional files shows the allocation of the themes and concepts to the framework domains. Results regarding the clinical tasks of the different professional groups and organizational issues that arose during the implementation of new roles in PC will be presented in a future article.
Role clarification
The three concepts ‘promotion of the acceptance of new roles’, ‘role profile of APN in the GPs view’ and ‘skepticism towards APN in PC’ coming from our data were connected to this competency domain. These concepts included data on how health professionals and GPs see the importance of promoting new roles of health professionals as well as why it is important that roles are clarified within teams and communicated to patients.
All participants stated that establishing their role in the general practice when they started working in the PCP was a difficult process, as these new roles are yet to be fully established in every practice. For health professionals, it is crucial that their new roles are accepted and recognized by patients and by the GPs they work with. How the GPs communicate the new health professional roles to patients is vital to increasing patients’ acceptance of these new roles, as well as to promoting these roles more broadly.
It mainly depends on how I phrase it. (GP2)
It’s most important how the GP communicates with patients, or, umm, only just to say that I exist and that they (patients) will see me; that is, they don’t say “you’re poorly controlled with your blood sugar and you have to see Miss X now” but “you are now allowed to see Miss X because she knows more about it.” (MPA6)
Within health professional practice teams, it is essential that the team members’ roles and competencies are clear to GPs so that they recognize the benefit APNs, nurses, or MPAs can provide to patients and that they refer their patients to them. The competencies and roles of health professionals are clarified through the concepts put into place when the health professionals started working in the practice, as explained by an MPA:
Before I started, we have determined with the GPs which tasks I am allowed to fulfill independently and which not. (MPA1)
Others had to explain their competencies to GPs:
In the beginning, I once presented my work so that they know a bit what the aim of my work is and what are my competencies and what do they (doctors) do, and I have the impression that it helped. (MPA5)
In practices where the roles and competencies of APNs, MPAs, or nurses are less clear to GPs, there is often more skepticism and fewer referrals from GPs to these health professionals.
The role profile of an APN from a GP’s point of view was discussed in two interviews with one GP who works with an APN who described her role as:
At the moment, many things are still discussed with me (by the APN), but I think maybe, most of all, chronically ill patients or follow-up checks with diabetic patients and adjustments can be handled autonomously (by the APN). (GP4)
Another GP, who works with an MPA in his practice, describes his vision of the APN’s role as not focusing on general practice but on community care:
These colleagues that I know who have employed a nurse as APN, I find it the wrong way; for me, an APN should be in the “Spitex” (community care). Nursing belongs to nursing. (GP1)
I would like to rely on a competent “Spitex” where I know they provide the services I would expect from my APN and especially also in further education, coaching, where she should have a certain leading function in Chronic Care so that I can delegate it. (GP1)
These statements show that there are different opinions about which roles health professionals should take on in general practice, and role clarification is crucial for health professionals and GPs to practice effective interprofessional collaboration.
Team functioning
This competency domain includes the concepts ‘Motivation of GPs to delegate or not to delegate tasks to the health professionals’, ‘motivation of health professionals to assume new roles’, ‘role of trust in collaborative working’ and ‘support of health professionals among each other”. These concepts contain data on the process of delegation of tasks from the GP to health professionals, the role of trust in this process and how health professionals worked together with each other.
After the inclusion of an APN, a nurse, or an MPA into care teams in the observed PCPs, health professionals and GPs had to adapt to the new composition of the team and to a new distribution of responsibilities. GPs stated that, in the beginning, it was difficult to delegate tasks previously performed by themselves to an MPA or an APN:
The first step was really to let go and to say I’m not the only one who knows everything but that really this is something that could maybe even work better interdisciplinarily. (GP2)
Another GP confirmed:
In the beginning, one controls probably more often but, umm, in the beginning, it was not easy, for sure not. (GP4)
One nurse argued that the reason not to delegate tasks to her could be the doctor’s fear that she would “steal them some work” (N2). Health professionals assumed that it is difficult for doctors to give away full control of their care for the patient:
There are still doctors who want to do everything by themselves and want to bear the full responsibility and know everything about their patient; I do that all by myself. (APN1)
Building trust was crucial for team functioning. For APNs and MPAs, it is crucial that the GPs have trust in their competencies, as described by an APN and an MPA:
They trust that I will refer back to them if I’m not sure and that is, also, there I must ethically take the responsibility for what I’m doing. (APN1)
They give us all a lot of freedom in our practice, and they know very well that when something is not good, that I would give feedback. (MPA1)
On the other side, one GP confirmed:
It is correct that I have to have trust that she is doing it well. (GP2)
After trust was built, many participants gave diverse reasons for GPs to delegate tasks to health professionals. The most important reason was that GPs are relieved from workload pressures through the work of an MPA or an APN. One GP also saw an advantage for the patient:
In my opinion, this is really also a good and useful supplement where I also think that patients are better cared for if one does it like that…I think it can make everything even more interesting if this model develops and we care for patients as a team. (GP2)
For APNs and MPAs, taking on new roles and responsibilities was a challenge but, at the same time, increased their motivation for their work, which, in turn, positively influenced teamwork. Notably, the MPAs regarded their new roles as an opportunity to advance their career:
It is a challenge and an additional motivation to manage something or keep on working (as an MPA) for a longer time. (MPA1)
Some health professionals felt that often tasks that the GPs do not like to perform themselves are delegated. One example is the control of feet in diabetic patients. One nurse described it the following way:
All the tasks that I don’t like, and I don’t have time for, I’m very happy that you are there to do it. And everything else is still under competition. (N2)
In those practices where APNs and MPAs work together, they did not see each other as competitors but supported each other in their work and their new roles.
We never have a discussion on what I should do and what you should do but more ‘could you help me with this?’ (APN1)
In difficult patient situations, the nurse or APN was described as a source of help and advice for the MPA.
In general, teams in the observed practices functioned well because mutual trust was built over time, and the responsibilities of the health professionals were mostly clear to all team members. This enabled task division between GPs and MPAs or APNs who were willing and motivated to take on new tasks and roles.
Collaborative leadership
To this framework domain the concepts ‘dealing with self-responsibility and consultation with the doctor’ and ‘requirements for the implementation of interprofessional teams’ were allocated. They give valuable information on how self-responsibility influenced the work of APN and MPA and what was needed for effective collaboration in practice.
In the observed PCPs, the collaboration between GPs and health professionals was very tight. MPAs and nurses performed most services on the instruction of GPs. Oversight remained with the GP, who defined the specific need of the patient and the goal of the consultation, which was then performed by the MPA or the nurse.
It is clear that I can make a suggestion, or I can say “I would maybe do it like this or that,” but the decision and the prescription how it should happen remains clearly with the doctor. (MPA6)
APNs worked with a high level of responsibility but in close cooperation with GPs. Decisions were often made together, or the APN provided feedback to the GP after consultation with the patient, as described by an APN:
If I can bear the responsibility, I decide by myself but afterward, I inform the responsible doctor. (APN2)
In order to collaborate effectively when decisions were made, for health professionals, it was important that trust was built, competencies were clarified, and GPs could hand over some of the responsibility. One nurse explained it in the following way:
What is important is that everyone knows what he or she is allowed to do, where his or her competencies are and at the end, if this is clarified and it works at the interpersonal level this is all no problem. (N1)
A GP explained further that:
One has to get to know each other well and has to know what she can (the health professional) do on her own responsibility and where am I really needed in addition. (GP4)
Interprofessional conflict resolution
This competency domain included the concept named ‘Difficult situations in practice’. Under this concept participants described conflicts that occurred in practice and how they have resolved them.
In the observed PCPs, conflicts were rarely mentioned or observed. The APN stated that tensions in the team sometimes occurred when new GPs or assistants started working in the practice:
If a doctor starts working in our practice, they don’t really know what I can and cannot do and what not and then it happens that they keep controlling me more often. (APN2)
Such conflicts were then resolved through discussion and by showing the doctors or assistants what competencies the APNs have and that they are able to work autonomously.
One nurse said that she initially did not feel welcomed by the team:
…where I recognized that a nurse is not so welcome among the MPA because I can imagine that there are still places (practices) where one clearly still says ‘I do have more competencies than you have’. (N2)
This same nurse resolved the situation by showing the other team members that she wished to collaborate with them and did not want to be seen as someone at a higher hierarchical level.
There appeared to be some potential for conflict when health professionals referred patients to the GP for a further check or examination. In some cases, these patients were not referred back to the health professional to continue consultations after the initial consultation.
And then I realised that I have to see that patients are coming back to me, otherwise then they (doctors) keep them, and I think these are in fact, my patients. (APN2)
Interprofessional communication
Interprofessional communication comprised the concepts ‘communication between APN and nurses or MPA’ and ‘communication between GPs and APN, nurses or MPA’. These concepts describe how communication worked in practice and which communication strategies were applied in order to facilitate effective collaboration.
Communication between GPs and health professionals was based on personal dialogue or the electronic health record, which enabled them to indicate if an in-person consultation was not possible during the working day. One MPA said:
Everything we discuss during the consultation the GP is informed about. That means I make good entries in the electronic health record where the GP can trace what we have discussed or what has been done. (MPA2)
If there were urgent questions, it was in most cases possible to immediately ask the GP in the practice, as explained by an APN:
If I have a question, I can go and get the doctor immediately. (APN2)
One GP explained that good interaction between team members was essential:
If we have good contact and we are engaged in conversation and try to find a common language, that is very relieving. (GP1)
In teams where APNs worked together with MPAs, it was important that the APN knew who in the MPA team was in charge of MPAs’ issues in order to communicate and organize task-sharing.
For me, it’s important if I have to know something from an MPA, I know that she (Name) is my contact person because she is the team leader. (APN1)
Patient-centered care
To this competency domain the concepts ‘patients’ views on care they receive from health professionals’ and ‘trust from patients towards health professionals’ were allocated. They comprise important information on how patient-centred care is carried out and on how the patients’ view influenced professional practice of health professionals and their collaboration. It furthermore shows, how health professionals think the care provided to patients is seen by patients.
From the participant’s perspective, their care was patient-centered and resulted in positive outcomes for patients. Health professionals believed that their care increased the quality of PC. They also remarked that they felt that patients are not concerned with who is caring for them as long as the quality of care is high, and they feel they are being treated well. An APN said:
I always tell them that I am a nurse and not a doctor and then they always say ‘I don’t care that much’ well, they don’t care that much, they want that someone listens to them and they want to be taken seriously. (APN2)
Another APN added:
I think it has a lot to offer to them, in my opinion, they enjoy optimal care for diabetes and wounds delivered by MPA. (APN1)
Participants also affirmed that they had more time at their disposal for patients, which, in turn, appeared to be much appreciated by patients.
It’s mostly the time I think, that one has more time for them, that one listens to them, that they can talk about their issues, I think this is what doctors cannot offer anymore. (MPA4)
Health professionals also observed that their care led to an increase in patients’ self-management.
And if you discuss with patients what they can do themselves, how important it is to take medication if they have to, if you discuss everything in detail, they can do so much, and that serves a lot because they have to come to the practice less often. (MPA4)
MPAs, APNs, and nurses felt that patients trusted them and that the barriers to trust-building were lower for them than for GPs.
One MPA stated:
It’s more that barriers are lower, they can recount more confident things, and they know if I know this, all will be good. (MPA3)
Another MPA added:
Patients dare to ask more, “I’m having this diabetes for ten years but actually, I don’t know what it is or what exactly I have,” or they maybe dare to write an email to me. (MPA6)
Findings from observations
During the observations of APNs and MPAs, only a few occasions of IPC between those two professional groups could be observed. There is, therefore, the potential to increase the collaboration between APNs or MPAs and GPs. On both occasions, the observations confirmed what the qualitative data analysis had already shown: The clarification of profession-specific roles and team functioning is crucial for effective IPC. Team functioning was found to be highly dependent on interprofessional communication, but the observed health professionals were already highly skilled in these areas and therefore functioned well as a team.