Trial lecture: The importance of theories in empirical research on interdisciplinary interaction in the health care service.
Ordinary opponents:
- First opponent: Professor Aud Uhlen Obstfelder, Norwegian University of Science and Technology (NTNU)
- Second opponent: Professor Susanne Lindquist, University of East Anglia, England
- Leader of the committee: Associate Professor Dag Karterud, OsloMet
Leader of the public defence is Associate Professor Heidi Holmen, OsloMet.
Supervisors:
- Professor Lisa Garnweidner-Holme, OsloMet
- Professor Kari Almendingen, OsloMet
- Professor Karen Synne Groven, OsloMet
- Associate Professor Bjørn Gjelsvik, University of Oslo
Abstract
Background
The prevalence of people living with multiple long-term conditions (LTCs) is increasing and challenges how healthcare services are organised. Most patients with LTCs in Norway are followed up in general practice. International research literature suggests that extending the workforce in general practice with nonphysician healthcare professionals (HCPs) can improve care quality and facilitate more person-centred care.
In Norway, most general practitioners (GPs) work in solo with their list patients. Little knowledge exists regarding multiprofessional collaboration in Norwegian primary care and the clinical involvement of nonphysician HCPs in general practice. Moreover, research on patient preferences and experiences of multiprofessional care in general practice is scarce.
The overall aim of this PhD project was to explore facilitators and the experiences of multiprofessional care among GPs, nurses, medical secretaries and patients with multiple LTCs in general practice. Results are discussed considering theory on teamwork and Self-Determination Theory and recent governmental initiatives to improve multiprofessional team-based approaches in Norwegian primary care.
Methods
This PhD project is built upon three peer-reviewed published papers. The first paper is a mixed-method scoping review, applying a content analysis to describe facilitators and barriers to collaboration and team-based care among GPs and other HCPs in Norwegian primary care.
Paper 2 explores the experiences of GPs, nurses and medical secretaries related to their role and care approaches in multiprofessional diabetes care, recruited from five purposely selected general practices. Paper three examines the care experiences and preferences of persons with diabetes and multimorbidity recruited from the same multiprofessional practices.
In Papers 2 and 3, qualitative semi-structured interviews were conducted. Six GPs, three nurses, two medical secretaries and 10 patients with type 1 or type 2 diabetes and multimorbidity were interviewed individually during March–September 2017. Data were analysed using thematic analysis and theoretical perspectives from person-centred care.
Results
Paper I
The scoping review revealed that little literature exists on the effects and experiences of multiprofessional collaboration and team-based practice in Norwegian primary care.
Based on 19 included studies, the review summarises organisational, processual, relational and contextual facilitators and barriers to multiprofessional collaboration. In general, a lack of leadership, time and structures for HCPs to share patient information and spend time together to learn about, with and from each other were important elements impacting multiprofessional collaboration.
Paper II
Paper II found that GPs’ personal experience of time pressure and perception of their diabetes care as unsystematic and of inadequate quality motivated the involvement of trained nurses and medical secretaries in diabetes care. GPs felt diabetes controls were easy to standardise and had become more regular, accessible and comprehensive following the delegation of tasks to nurses or medical secretaries.
They related this to how they themselves often forgot to follow up on diabetes when other more pressing symptoms were prominent. Nurses and medical secretaries emphasised that they used various communication techniques to individualise care and provide emotional support. None of the professional groups explained that they used care planning as a tool to uniform diabetes care or to engage patients in setting health goals.
Paper III
Paper III indicated that patients with diabetes and multimorbidity experienced nurses and medical secretaries as attentive to their psychosocial needs and easy to approach with their questions and worries. In this sense, nurses and medical secretaries complemented GP-led diabetes care, which patients often found stressful.
While persons with type 1 diabetes explained that they felt competent and highly involved in decisions related to glucose targets, some persons with type 2 diabetes explained that they lacked the knowledge necessary to successfully self-manage their diabetes and ask relevant questions.
Conclusions and implications
There is a shortfall in published research investigating multiprofessional collaboration between GPs and other HCPs in Norwegian primary care. Introducing new HCP groups in patient follow-up can possibly improve the quality of and add new dimensions to patient care in general practice if HCPs receive relevant training and are enabled to respond to patients’ requests for longer consultation times.
When GPs no longer practice in solo with patients on their list, time must be prioritised for the general practice team to coordinate their actions and manage their relations. This PhD project may provide policy makers with relevant information to improve multiprofessional collaboration in primary care.
Our study suggests considerable work remains related to care organisation, establishment of roles, responsibilities, team activities and removing the financial barriers hindering nurses and other nonphysician HCPs from practicing to the extent of their expertise in Norwegian general practice.
