Implementation of national guidance for self-harm among general practice nurses: a qualitative exploration using the capabilities, opportunities, and motivations model of behaviour change (COM-B) and the theoretical domains framework

BACKGROUND

Patients who self-harm may consult with primary care nurses, who have a safeguarding responsibility to recognise and respond to self-harm. However, the responses of nursing staff to self-harm are poorly understood, and opportunities to identify self-harm and signpost towards treatment may be missed. It is unclear how to support nursing staff to implement national guidelines.

AIMS

Among primary care nursing staff to: [1] Examine reported barriers and enablers to nurses' use of, and adherence to, national guidance for self-harm; and [2] Recommend potential intervention strategies to improve implementation of the NICE guidelines.

METHODS

Twelve telephone interviews partly structured around the capabilities, opportunities and motivations model of behaviour change (COM-B) were conducted with primary care nurses in the United Kingdom. The Theoretical Domains Framework was used as an analytical framework, while the Behaviour Change Wheel was used to identify exemplar behaviour change techniques and intervention functions.

RESULTS

Nursing staff identified a need to learn more about risk factors (knowledge), and strategies to initiate sensitive conversations about self-harm (cognitive and interpersonal skills) to support their professional competencies (professional role and identity). Prompts may support recall of the guidance and support a patient centred approach to self-harm within practices (memory, attention, and decision making). GPs, and other practice nurses offer guidance and support (social influences), which helps nurses to navigate referrals and restricted appointment lengths (environmental context and influences).

CONCLUSIONS

Two converging sets of themes relating to information delivery and resource availability need to be targeted. Nine groups of behaviour change techniques, and five intervention functions offer candidate solutions for future intervention design. Key targets for change include practical training to redress conversational skill gaps about self-harm, the integration of national guidance with local resources and practice-level protocols to support decision-making, and creating opportunities for team-based mentoring.

Cardiovascular risk reduction with integrated care: results of 8 years follow up

BACKGROUND

Care groups organize integrated cardiovascular risk management programs in primary care for high risk patients. Results of long term cardiovascular risk management are scarce. The aim was to describe changes in low density lipoprotein cholesterol, systolic blood pressure and smoking between 2011 and 2018 in patients participating in an integrated program for cardiovascular risk management organized by a care group in the Netherlands.

AIM

To explore whether long-term participation in an integrated cardiovascular risk management program could lead to the improvement of 3 important risk factors for cardiovascular disease.

METHODS

A protocol was developed for delegated practice nurse activities. A multidisciplinary data registry was used for uniform registration. The care group organized annual education for general practitioners and practice nurses on cardiovascular topics and regular meetings for practice nurses only to discuss complex patient cases and implementation issues. From 2015 onwards, the care group started with practice visitations to discuss performance and support practices with organizing integrated care.

RESULTS

In patients eligible for primary prevention as well as for secondary prevention similar trends were observed: lipid modifying and blood pressure lowering medication increased, mean low density lipoprotein cholesterol and mean systolic blood pressure decreased, patients on target for low density lipoprotein cholesterol and systolic blood pressure increased and the proportion of non-smokers with both low density lipoprotein cholesterol and systolic blood pressure on target increased. Improved registration between 2011 and 2013 was partly responsible for the sharp increase of patients on target for low density lipoprotein cholesterol and systolic blood pressure.

CONCLUSION

In patients participating in an integrated cardiovascular risk management program, we saw annual improvements in 3 important cardiovascular risk factors between 2011 and 2018.

Practice nurses' communication with people living with type 2 diabetes: A scoping review

OBJECTIVE

To identify the key characteristics of practice nurses' communication with people living with Type 2 Diabetes (T2D) where lifestyle activities are discussed.

METHODS

A scoping review of the peer-reviewed literature was conducted. Reflexive thematic analysis was used to identify key themes that emerged. The PRISMA-ScR checklist was followed.

RESULTS

25 studies were retained in the final review. Nurses who were committed to engaging in lifestyle discussions created supportive environments and built rapport to enable change conversations. However, this was present in just 20% of the studies. In most studies, (60%) nurses continued to use traditional health education communication styles, had little understanding of behaviour change theories, lacked skills in behaviour change counselling and were reluctant to engage in behaviour change discussions with people with T2D .

CONCLUSIONS

Nurses require a deeper understanding of behavioural change theories and skills in behavioural counselling.

PRACTICE IMPLICATIONS

Practice nurses have a unique opportunity to facilitate T2D remission by engaging in evidence-based behaviour change communication. A behaviour change training intervention is needed that recognises the environment of practice nurse consultations. It needs to be pragmatic and fully consider the enablers and barriers to addressing behaviour change in both the nurse and the person with T2D.

[Is it feasible to conduct drug studies in general practice? - Results of a survey among investigating physicians and medical staff]

BACKGROUND

Pragmatic randomized controlled trials are able to make an essential contribution to the further development of evidence-based treatment recommendations for primary care patients. However, drug trials are regulated by specific guidelines and have not yet become a routine task in GP practices. Within the scope of a multi-center, double-blind, randomized controlled trial on treating urinary tract infections in women with and without antibiotics (REGATTA), the feasibility of pharmaceutical studies in GP practices was evaluated by means of a questionnaire sent out to participating physicians and practice nurses.

METHODS

Using a self-designed, non-validated questionnaire, the perspectives, attitudes and experiences of participating physicians and practice nurses were assessed anonymously. In this way, we identified both hindering and beneficial factors affecting the conduct of drug trials in German GP practices.

RESULTS

39 physicians and 48 practice nurses participated in the survey. 95 % of the physicians and 88 % of the practice nurses indicated that the implementation of drug trials with all their regulatory requirements is, in principle, possible in GP practices. In particular, the high amount of time and documentation necessary were identified as barriers. The implementation can be facilitated by formulating a research question that is relevant to practice and patients and by support from the study center.

CONCLUSION

Although participation in a drug trial is an additional burden in everyday practice, it is considered feasible and worthwhile by the GPs and practice nurses involved. Due to an assumed selection bias, the predominantly positive experiences of the respondents may be overestimated and transferable only to a limited extent.

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation.

Evidence-based early stage type 2 diabetes follow-up in Belgian primary care practices: Impact of multi-professional teams and care protocols

AIM

The aim of this research is to explore the current early-stage diabetes mellitus type 2 care in Belgian general practices. This, to find out if the care is provided according to the proposed evidence-based national diabetes care guideline. Additionally, this research aims to detect which person and practice characteristics can be associated with a more evidence-based care provision.

METHODS

People were included in the study if they were recently diagnosed with type 2 diabetes by the participating practice. Practice and person characteristics, and clinical parameter monitoring and lifestyle monitoring data were collected by using a questionnaire and a topic list.

RESULTS

A total of 27 general practices participated and a total of 249 people were included through their patient records. People monitored in a practice according to a self-developed protocol were 5.5 times more likely to have a better clinical parameter follow-up. Larger practices (>2000 patients), follow-up by general practitioners and practice nurses together and according to self-developed protocols were associated with a significantly better lifestyle follow-up.

CONCLUSION

Practices providing multidisciplinary diabetes care, in collaboration with practice nurses, and with diabetes care based on self-developed protocols achieved a more comprehensive follow-up.

How many general practice consultations occur in Ireland annually? Cross-sectional data from a survey of general practices

Background

General practice plays a central role in the Irish health system. This study aimed to determine a baseline estimate of the number of consultations completed in general practice in Ireland annually to facilitate evidence-based healthcare planning.

Methods

A survey was emailed to all 3378 individual members of the Irish College of General Practitioners in February 2020 asking each practice to report on consultations by general practitioners and practice nurses occurring on the previous day of practice.

Results

A total of 507 practices responded to the survey, reporting 34,594 general practitioner consultations and 13,161 nurse consultations on one day. Extrapolating this figure nationally, we estimate 21,353,731 GP consultations and 7,749,615 practice nurse consultations occur in Ireland annually. An Irish person visits their GP an estimated 4.34 times a year and the average consultation time is 13.7 min.

Conclusions

This study shows that over 29.1 million consultations take place in Irish general practice every year. Innovative interventions to increase the capacity of general practice are needed to ensure high-quality care continues to be accessible in Ireland.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01377-0.

What is the role of the practice nurse in the care of people living with dementia, or cognitive impairment, and their support person(s)?: a systematic review

Background

The potential value of expanding the Practice Nurse role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. The purpose of this review was to systematically examine published literature to identify existing and potential roles of Practice Nurse’s in the delivery of care to people affected by dementia and to describe the characteristics and effectiveness of nurse interventions in dementia models of care.

Methods

The PRISMA statement guided the systematic review of the quantitative and qualitative evidence for roles and characteristics of the Practice Nurse in the delivery of dementia care. A comprehensive literature search of seven electronic databases and Google scholar identified relevant original research published in English between January 2000 and January 2019. Thirteen articles met the inclusion criteria and were extracted into the Covidence software for analysis.

Results

The heterogeneity of the included studies purpose, design and outcomes measures and the diversity in health systems and primary care nurses scope of practice made it difficult to synthesise the findings and draw conclusions. The heterogeneity did, however, provide important insights into the characteristics of roles undertaken by nurses working in the general practice setting, which were potentially beneficial to people living with dementia and their support person. These included patient accessibility to the Practice Nurse, early recognition and management of cognitive changes, care management and collaboration with the General Practitioner. Limitations of the provision of dementia care by Practice Nurses included a lack of definition of the role, inadequate dementia specific training, time constraints and poor communication with General Practitioners.

Conclusions

Embedding an evidence-based model that describes the role of the Practice Nurse in dementia care provision has the potential to increase early recognition of cognitive impairment and more appropriate primary care management of dementia.

Systematic review registration

PROSPERO 2018 CRD42018088191.

The role of the general practitioner in managing age-related hearing loss: perspectives of general practitioners, patients and practice staff

Background

For people with hearing loss, the General Practitioner (GP) can play an instrumental role in early detection of hearing loss as well as guiding appropriate and timely choices for addressing hearing concerns. The aim of this study was to generate a conceptual framework for understanding the role of the GP in managing age-related hearing loss.

Methods

Concept mapping techniques were used to gather the perspectives of GPs (n = 8), adults with hearing loss (n = 22), and professionals working with GPs (n = 5), in Australia. Participants generated statements describing the role of the GP in managing age-related hearing loss, and then grouped the statements to identify key themes, via an online portal.

Results

Ninety-eight items describing the role of the GP in managing age-related hearing loss were identified across six concepts: 1) Determine - Diagnose - Discuss, 2) Ask - Assess - Act, 3) Know - Refer - Coordinate, 4) Inform - Advise - Partner, 5) Educate - Strategise - Encourage, 6) Reassure - Support - Empower.

Conclusions

The role of the GP in managing age-related hearing loss is multifaceted and requires partnership that motivates and empowers patients’ to overcome their hearing concerns. Enlisting the help of Practice Nurses, Practice Managers and local audiologists could help GPs improve their hearing loss detection and intervention rates.

Active participation of patients with type 2 diabetes in consultations with their primary care practice nurses - what helps and what hinders: a qualitative study

Background

Patients with type 2 diabetes mellitus (T2DM) receiving primary care regularly visit their practice nurses (PNs). By actively participating during medical consultations, patients can better manage their disease, improving clinical outcomes and their quality of life. However, many patients with T2DM do not actively participate during medical consultations. To understand the factors affecting engagement of patients with T2DM, this study aimed to identify factors that help or hinder them from actively participating in consultations with their primary care PNs.

Methods

Two semi-structured focus groups and 12 semi-structured individual interviews were conducted with patients with T2DM (n = 20) who were undergoing treatment by primary care PNs. All interviews were transcribed verbatim and analyzed using a two-step approach derived from the context-mapping framework.

Results

Four factors were found to help encourage patients to actively participate in their consultation: developing trusting relationships with their PNs, having enough time in the appointment, deliberately preparing for consultations, and allowing for the presence of a spouse. Conversely, four factors were found to hinder patients from participating during consultations: lacking the need or motivation to participate, readjusting to a new PN, forgetting to ask questions, and ineffectively expressing their thoughts.

Conclusion

Patients lacked the skills necessary to adequately prepare for a consultation and achieve an active role. In addition, patients’ keen involvement appeared to benefit from a trusting relationship with their PNs. When active participation is impeded by barriers such as a lack of patient’s skills, facilitators should be introduced at an early stage.

Trial registration

Current Controlled Trials NTR4693 (July 16, 2014).

Health advice and education given to overweight patients by primary care doctors and nurses: A scoping literature review

Health advice for overweight patients in primary care has been a focus of obesity guidelines. Primary care doctors and nurses are well placed to provide evidence based preventive health advice. This literature review addressed two research questions: ‘When do primary care doctors and nurses provide health advice for weight management?’ and ‘What health advice is provided to overweight patients in primary care settings?’

The study was conducted in the first half of 2018 and followed Arksey and O'Malley (2005) five stage framework to conduct a comprehensive scoping review. The following databases were searched: Emcare, Ovid, Embase, The Cochrane library, Proquest family health, Health source (nursing academic), Joanna Briggs Institute EBP database, Medline, PubMed, Rural and remote, Proquest (nursing and allied health) and TRIP using search term parameters. Two hundred and forty-eight (248) articles were located and screened by two reviewers.

Twenty-three research papers met the criteria and data were analysed using a content analysis method. The results show that primary care doctors and nurses are more likely to give advice as BMI increases and often miss opportunities to discuss weight with overweight patients. Body Mass Index (BMI) is often wrongly categorised as overweight, when in fact it is in the range of obese, or not recorded and when health advice is given, it can be of poor quality. Few studies on this topic included people under 40 years, practice nurses as the focus and those with a BMI of 25–29.9 without a risk factor. A ‘toolkit’ approach to improve advice and adherence to evidence based guidelines should be explored in future research.

Implementation of cardiovascular disease prevention in primary health care: enhancing understanding using normalisation process theory

Background

The reorientation of primary health care towards prevention is fundamental to addressing the rising burden of chronic disease. However, in Australia, cardiovascular disease prevention practice in primary health care is not generally consistent with existing guidelines. The Model for Prevention study was a whole-of-system cardiovascular disease prevention intervention, with one component being enhanced lifestyle modification support and addition of a health coaching service in the general practice setting. To determine the feasibility of translating intervention outcomes into real world practice, implementation work done by stakeholders was examined using Normalisation Process Theory as a framework.

Methods

Data was collected through interviews with 40 intervention participants and included general practitioners, practice nurses, practice managers, lifestyle advisors and participants. Data analysis was informed by normalisation process theory constructs.

Results

Stakeholders were in agreement that, while prevention is a key function of general practice, it was not their usual work. There were varying levels of engagement with the intervention by practice staff due to staff interest, capacity and turnover, but most staff reconfigured their work for required activities. The Lifestyle Advisors believed staff had varied levels of interest in and understanding of, their service, but most staff felt their role was useful. Patients expanded their existing relationships with their general practice, and most achieved their lifestyle modification goals.

While the study highlighted the complex nature of the change required, many of the new or enhanced processes implemented as part of the intervention could be scaled up to improve the systems approach to prevention. Overcoming the barriers to change, such as the perception of CVD prevention as a ‘hard sell’, is going to rely on improving the value proposition for all stakeholders.

Conclusions

The study provided a detailed understanding of the work required to implement a complex cardiovascular disease prevention intervention within general practice. The findings highlighted the need for multiple strategies that engage all stakeholders. Normalisation process theory was a useful framework for guiding change implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0580-x) contains supplementary material, which is available to authorized users.

An explorative qualitative study on acceptability of physical activity assessment instruments among primary care professionals in southern Sydney

BACKGROUND

There are a substantial number of instruments for primary-care clinicians to assess physical-activity (PA). However, there are few studies that have explored the views of clinicians regarding comparative acceptability and ease of use. A better understanding of how clinicians perceive instruments could help overcome barriers, and inform future interventions. This study explored the acceptability of five PA-assessment instruments amongst a sample of Australian primary-care clinicians, including family-physicians (FP) and practice-nurses (PN).

METHODS

A purposive sample of FPs (N = 9) and PNs (N = 10) from eight family-practices in southern Sydney consented to participate. Stage-1 involved semi-structured interviews with participants to select preferred instruments. An analysis of the two preferred instruments was conducted as Stage-2, to identify differences in instrument purpose and content. Stage-3 involved participants using the two instruments, selected from Stage-1, for 12-weeks. At the end of this period, semi-structured interviews were repeated to explore clinician experience.

RESULTS

Clinicians indicated preferences for the GP-Physical-Activity-Questionnaire and 3-Questionnaire Physical-Activity-Questionnaire. These instruments demonstrated distinct variations in content, theoretical orientation, and outcome measures. Reasons for preference included; variations in individual clinician PA levels, knowledge in PA-assessment and instrument features.

CONCLUSION

Findings demonstrated two instruments as preferred. Reasons for preference related to internal characteristics of clinicians such as variations in the level of individual PA and external circumstances, such as instrument features.

Communication channels to promote evidence-based practice: a survey of primary care clinicians to determine perceived effects

BACKGROUND

Research suggests that the channels through which evidence-based practices are communicated to healthcare professionals can shape the ways they engage with, and use, this information. For instance, there is evidence to suggest that information should be communicated via sources that are deemed to be credible, like government departments, professional bodies and peers. This article examines the contention that information should be communicated via credible sources. More specifically, the article examines the different communication channels through which primary care clinicians learnt of resources on evidence-based sexual healthcare - namely, clinical aides and online training programs. Furthermore, the article determines whether these communication channels influenced the perceived impact of the resources.

METHODS

Primary care clinicians in Australia (n = 413), notably General Practitioners (n = 214) and Practice Nurses (n = 217), were surveyed on the GP Project - a suite of resources to promote evidence-based sexual healthcare within primary care. Survey items pertained to the source of information about the resources (or communication channel), perceived usefulness of the resources, frequency of use, subsequent contact with the Sexual Health Infoline and a sexual health clinic, as well as the perceived impact of the resources. To determine the relationships between the different communication channels and the perceived impact of the resources, a one-way ANOVA using Tukey's post-hoc test, an independent sample t-test, a χ(2) test, and a Kruskal-Wallis H test were performed where appropriate.

RESULTS

Of the respondents who were aware of the clinical aides (49.9%), the largest proportion became aware of these through an educational event or a colleague. Of those who were aware of the online training programs (36.9%), the largest proportion became aware of these through a professional body or government organisation, either directly or via their website. Although both resource types were reported to improve clinical practice, the reported use and the perceived impact of the resources were not influenced by the way the clinicians learnt of the resources.

CONCLUSIONS

These findings cast doubt on the suggestion that the channels through which evidence-based practices are communicated to healthcare professionals shape the ways they engage with, and use, this information, as well as the perceived impact of this information. Given the importance of evidence-based practices, these curious findings suggest that the source of this information might be of little consequence.

Practice related factors that may impact on postpartum care for mothers and infants in Australian general practice: a cross-sectional survey

Background

While there is a significant focus on the health and well-being of women during pregnancy, labour and birth, much less emphasis is placed on the care of postpartum women and their infants in primary care following the birth. Some studies have investigated the role of GPs in postpartum care, and others examined facilitators and barriers to mothers accessing care. However there is little information available to investigate the effect of practice related factors on access to care of mothers and infants at this time.

Methods

A 20-item questionnaire for completion by the practice managers was mailed to 497 general practices in Southern Queensland, Australia between February and July 2013. Questionnaire items included practice demographics, practice procedures and personnel including appointment scheduling, billing, practice nurse function and qualifications and a free-text option for comments. Descriptive statistics are presented as numbers and percentages. Chi Squared test compared practice location with methods of identification of postpartum women, practice size with other Queensland data and ANOVA compared practice size with the number of postpartum appointments. Logistic regression was used to predict variables that were related to booked appointment times. Free text responses were grouped in common themes.

Results

The response rate was 27.4 %. At 67.2 % of the practices, mothers had to self-identify as needing a postpartum consultation and most consultations were allocated 15 minutes or less. Only 20 % of practices accepted the government insurance payment (bulk-billing) for all maternal and infant services, with more practices bulk-billing children only. Out-of-pocket expenses ranged from $10-$60. Nearly 80 % of practice nurses saw postpartum mothers or infants ‘nearly always’ or ‘sometimes’. Approximately 30 % had midwifery or child health training. There were higher odds of longer booked appointment times for solo practitioner practices (unadj OR 3.30 95%CI 1.03-10.57), but no other variables predicted booked appointment times

Conclusions

This study identified a number of practice related factors that, if addressed, could positively impact on postpartum care. These include ensuring ongoing practice relationships to assist with booking appropriate consultation times and guaranteeing that there are no financial impediments to women accessing care. Some factors can easily be adapted within practices. Others would require changes of policy at a local or national level.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1508-1) contains supplementary material, which is available to authorized users.

Expanding access to pain care for frail, older people in primary care: a cross-sectional study

Background

Although untreated pain has a negative impact on quality of life and health outcomes, research has shown that older people do not always have access to adequate pain care. Practice nurse-led, comprehensive geriatric assessments (CGAs) may increase access to tailored pain care for frail, older people who live at home. To explore this, we investigated whether new pain cases were identified by practice nurses during CGAs administered as part of an intervention with the Geriatric Care Model, a comprehensive care model based on the Chronic Care Model, and whether the intervention led to tailored pain action plans in care plans of frail, older people.

Methods

We used cross-sectional data from the older Adults: Care in Transition (ACT) study, a 2-year clinical trial carried out in two regions of the Netherlands. Practice nurses proactively visited older people at home and administered an in-home CGA that included an assessment of pain. Pain care-related agreements and actions (pain action plans) based on CGA results were described in a tailored care plan. We analyzed care plans of 781 older people who received a first-time CGA by a practice nurse for the presence of pain, pain location and cause, new pain cases, and pain action plans. We used descriptive statistics to analyze our data.

Results

We found that 315 (40.3 %) older people experienced any type of pain. Practice nurses identified 20 (10.6 %) new pain cases, and 188 (59.7 %) older people with pain formulated at least one therapeutic or non-therapeutic pain action plan together with a practice nurse. More than half of the older people whose pain had already been identified by a primary care physician wanted a pain action plan. Most pain action plans consisted of actions or agreements related to continuity of care.

Discussion and conclusion

Practice nurses in primary care can contribute to expanding older people's access to tailored pain care. Future researchers should continue to direct their focus at ways to overcome the barriers that restrict older people’s access to pain care.

Combining intensive practice nurse counselling or brief general practitioner advice with varenicline for smoking cessation in primary care: study protocol of a pragmatic randomized controlled trial

INTRODUCTION

Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown.

MATERIALS AND METHODS

A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner; both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation.

DISCUSSION

This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects.

TRIAL REGISTRATION

Dutch Trial Register NTR3067.

A nurse-led interdisciplinary primary care approach to prevent disability among community-dwelling frail older people: a large-scale process evaluation

BACKGROUND

The complex healthcare needs of frail older people and their increased risk of disability require an integrated and proactive approach. In the Netherlands, an interdisciplinary primary care approach has recently been developed, involving individualized assessment and interventions (tailor-made care), case management and long-term follow-up. The practice nurse as part of a general practice is case manager and plans, organizes and monitors the care process and facilitates cooperation between professionals. The approach has shown positive indications regarding its feasibility in a small pilot, but its implementation on a large scale had not hitherto been investigated.

OBJECTIVES

To examine the extent to which the interdisciplinary care approach is implemented as planned and to gain insight into healthcare professionals' and frail older people's experiences regarding the benefits, burden, stimulating factors and barriers.

DESIGN

A process evaluation was conducted using a mixed methods design.

SETTINGS

Six GP practices in the south of the Netherlands.

PARTICIPANTS

Practice nurses (n=7), GPs (n=12), occupational therapists (n=6) and physical therapists (n=20) participated in the process evaluation. Furthermore, 194 community-dwelling frail older people (≥ 70 years) were included using the Groningen Frailty Indicator. People who were terminally ill, were confined to bed, had severe cognitive or psychological impairments or were unable to communicate in Dutch were excluded.

METHODS

Quantitative data (logbooks and evaluation forms) were collected from all the participating frail older people and 13 semi-structured interviews with a selection of them were conducted. In addition, data from healthcare professionals were collected through 12 semi-structured interviews and four focus group discussions.

RESULTS

Although some parts of the protocol were insufficiently executed, healthcare professionals and frail older people were satisfied with the care approach, as it provided a useful structure for the delivery of geriatric primary care and increased the attention to preventive treatment. Frail older people felt acknowledged by healthcare professionals and experienced support in handling their problems and fulfilling their wishes.

CONCLUSIONS

The findings of the study revealed several positive aspects of the interdisciplinary primary care approach. Given its complexity, the implementation of the nurse-led interdisciplinary care approach is challenging and some parts of the protocol need special attention.