Introduction
Faced with growing healthcare needs and expenditures due to ageing populations and increasing numbers of patients with chronic conditions, many high-income countries are reorganising their healthcare systems to reduce the fragmentation in overall care delivery and reinforce primary care provision (Kringos et al. Reference Kringos, Boerma, Hutchinson and Saltman2015; Polin et al. Reference Polin, Hjortland, Maresso, van Ginneken, Busse and Quentin2021). One of the main strategies used to ensure the continuity of care and reduce that fragmentation of care for patients with complex healthcare needs is improving the coordination of care (Penm et al. Reference Penm, MacKinnon, Strakowski, Ying and Doty2017; Stille et al. Reference Stille, Jerant, Bell, Meltzer and Elmore2005). Improving care coordination is a complex process requiring major changes in how the provision of care is organised. Organisational interventions described in the literature concern several areas, such as setting up multidisciplinary PC teams (Powell Davies et al. Reference Powell Davies, Harris, Perkins, Roland, Williams, Larsen and McDonald2006). The latter usually integrate other healthcare professionals, such as nurses, pharmacists, or social assistants (Cohidon and Senn Reference Cohidon and Senn2023; Saint-Pierre, Herskovic, and Sepulveda Reference Saint-Pierre, Herskovic and Sepulveda2018; Ramond-Roquin, Allory, and Fiquet Reference Ramond-Roquin, Allory and Fiquet2020) and new organisational elements that assist integration, such as case management or care planning (Edwards, Dorr, and Landon Reference Edwards, Dorr and Landon2017; Cardinaux et al. Reference Cardinaux, Ochs, Michalski, Cornuz, Senn and Cohidon2020).
Nurses’ roles and activities in these new organisations vary between countries depending on their healthcare system’s general organisation and policy commitments. They help to respond to this sector’s needs via two mechanisms: the diversification of care delivery and the transfer of tasks from GPs to nurses, especially when involving advanced practice nurses. Diversified care delivery has come through new nursing activities developed in the fields of health promotion and the follow-up of patients with chronic conditions (Pelletier et al. Reference Pelletier, Vermette, Lauzier, Bujold, Bujold, Martin and Guillaumie2019; Stephen, McInnes, and Halcomb Reference Stephen, McInnes and Halcomb2018). In contexts where tasks are transferred away from GPs, nurses can perform certain diagnostic acts and even prescribe treatments within well-defined frameworks (Bourgueil, Marek, and Mousques Reference Bourgueil, Marek and Mousques2008).
Working rarely in interprofessional organisation, GPs’ practices in Switzerland require also some organisational changes to face the challenges of our healthcare system (Senn, Ebert, and Cohidon Reference Senn, Ebert and Cohidon2016). To this end, various pilot projects aimed at including other professionals, especially nurses in GPs’ practices have recently emerged in Switzerland. They show promising results. However, implementing them on a large scale and in the long term remains challenging due to legal frameworks and financing mechanisms. (Altermatt-von Arb et al. Reference Altermatt-von Arb, Stoll, Kindlimann, Nicca, Lauber, Staudacher, Sailer Schramm, Vokt and Zuniga2023; Gysin et al. Reference Gysin, Sottas, Odermatt and Essig2019; Walger et al. Reference Walger, Bramaud Du Boucheron, Haberey-Knuessi, Pedrotti and Giovannini2024)
To strengthen primary care and enhance care coordination in GPs’ practices, a two-year pilot project was carried out in eight practices across the canton of Vaud, in Switzerland (Schutz Leuthold et al. Reference Schutz Leuthold, Schwarz, Marti, Perraudin, Hudon, Peytremann-Bridevaux, Senn and Cohidon2020). This project consisted in integrating registered nurses into GPs’ practices, developing new activities, including case management with an individual care plan. This project is the result of a collaboration of the canton of Vaud’s public health authorities, who fully funded the nurses, and the Department of Family Medicine (DFM) at Unisanté.
Aim of the study
This work aims to describe the implementation of nursing activities during the pilot project’s first 12 months (2019–2021), especially relating to what was initially planned in the nurses’ job description. Thus, our rationale was to assess the progress and influencing factors of transitions and change at the critical point of one year.
Methods
Study design
To describe the rollout of these nursing activities, we conducted a mixed-methods approach, collecting and analysing both quantitative and qualitative data through a convergent design. Mixed methods were particularly appropriate as they provided a deep understanding of the intervention’s complexity in primary care research (Guetterman, Fetters, and Creswell Reference Guetterman, Fetters and Creswell2015; Vedel et al. Reference Vedel, Kaur, Hong, El Sherif, Khanassov, Godard-Sebillotte, Sourial, Yang and Pluye2019). The methods, results, and discussion set out below were prepared according to the STROBE guidelines for reporting observational studies (von Elm et al. Reference von Elm, Altman, Egger, Pocock, Gotzsche and Vandenbroucke2014) and the SRQR guidelines for reporting qualitative research (O’Brien et al. Reference O’Brien, Harris, Beckman, Reed and Cook2014; Tong, Sainsbury, and Craig Reference Tong, Sainsbury and Craig2007).
Study setting
The study occurred in eight GPs’ practices (Table 1) employing a total of 20 full-time equivalent (FTE) GPs in the canton of Vaud. GPs’ practices entered the scheme progressively between July 2019 and March 2020, and the study focused on the one-year period from their entry date. This period was marked by the first wave of COVID-19, during which non-emergency care activities partially stopped. The selection criteria for practices were their interest in the project, their location (to ensure diversity across urban and rural areas), and their workforces (to ensure solo and group practices).
Practices’ characteristics before entry into the pilot project
MAs*: medical assistants.
Quantitative study
Population
Anonymised quantitative data on nurses’ activities were collected for all patients in the eight GPs’ practices.
Data
Nurses’ activities were collected through a web application developed specifically for the project. This consisted of a pre-established list of practice activities in four categories, prepared with the GPs and nurses involved in the pilot project (Table 2).
Nursing activities per categories
Nurses recorded in the web application their daily activities and specified the types and categories of those activities and how long they took throughout the pilot project’s first year. SLM and EHF monitored data completion throughout the pilot project and supported nurses in the data collection.
Analyses
To analyse the distribution and evolution of nursing activities over time, we calculated average time and range per month for each category of nursing activities. Additionally, the numbers of patients managed by nurses each month over this period was assessed to link them with the time dedicated to the activities. We used StataSE V.16. software to calculate standard descriptive statistics.
Qualitative study
Population
For convenient reason, qualitative data were collected in five GPs’ practices illustrating the specificities and characteristics of all eight GPs’ practices in term of human resources, location, and activities. In each practice, the data collection involved GPs, nurses, and patients (Table 3) and was performed by two researchers not involved in implementing the pilot project (SLM and SJ). SLM recruited volunteer nurses and GPs by email to take part in interviews. Nurses recruited face-to-face volunteer patients who gave a written informed consent to participate to interviews.
Characteristics of qualitative study participants
Data
Data collection occurred from December 2020 to April 2021. JS conducted 90-minute face-to-face in-depth semi-structured interviews with five nurses. SLM conducted 30–50-minute face-to-face in-depth semi-structured interviews with five patients benefiting from nursing follow-up. Interviews were conducted in a GP’s consultation room. SLM and SJ jointly conducted the focus group discussion (FGD) with six GPs via a videoconference lasting approximately 90 minutes. Interviews with nurses and the FGD with GPs collected information regarding practice organisation, functioning, the delegation of tasks, and staff satisfaction. Information collected through patient interviews included the satisfaction of nursing follow-up and the impact on their self-empowerment and health, their experience regarding care coordination, and their global satisfaction. Interview guides were specially developed for the study by SLM, reviewed and internal tested by SJ, CC, and EHF (Kallio et al. Reference Kallio, Pietila, Johnson and Kangasniemi2016). All interviews were audio recorded.
Analyses
Audio recordings of the FGD and interviews were transcribed in full. To ensure confidentiality, identifying data were removed. Transcripts were imported in MAXQDA software (V.20). We performed a thematic analysis, using an inductive approach, to extract categories, assemble these into themes (Thomas Reference Thomas2006; Gale et al. Reference Gale, Heath, Cameron, Rashid and Redwood2013). SLM analyses all qualitative data. EHF coded 20 percent of the data. Emerging categories and themes coded by both researchers were discussed and adapted within the research team (SLM, EHL, SJ, and CC), including an expert in qualitative research (SJ). SLM established a coding book and adapted it through the analysis process.
Results
The findings of our quantitative and qualitative analyses are presented jointly under the two main themes of the rollout of nursing activities and the factors influencing that rollout.
Nursing activities
During the first year of the pilot project’s implementation, nine nurses (5.75 FTE positions) recorded 12,862 activities performed with 2,359 patients managed. The median activity duration was 30 minutes (range: 2 to 510).
As Figure 1 illustrates, we observed a general 12-month increase, across all the practices but one (practice 5), in the monthly duration of the activities performed by nurses within a care plan. At six months, the median monthly time dedicated to activities within a care plan was 21 h 58 (range: 9 h 25 to 64 h 50 across nurses). At 12 months, the median time was 48 h 43 (range: 11 h 01 to 59 h 51). The rollout of activities occurred more comprehensively in some GPs’ practices (e.g., practices 1, 2, 3, and 8) than in others (e.g., practices 5 and 7).
Duration (hours:minutes) of nursing activities performed within patient care plans during the pilot project’s first year (the first wave of COVID-19 struck in April 2020, which was project implementation month 10 for practices 1 and 2, month 5 for practices 3 and 4, month 4 for practice 5, month 3 for practice 7, and month 2 for practices 7 and 8).
Figure 1 also shows a decrease in activities during the first wave of COVID-19. Between March and May 2020, nurses performed activities linked to COVID-19 (El Hakmaoui and Cohidon Reference El Hakmaoui and Cohidon2021).
As Figure 2 shows, the monthly duration of one-off activities performed for patients without care plans increased faster but stopped increasing after six months. The median time dedicated to these activities was 40 h01 (range: 13 h 44 to 74 h 53 across nurses) at six months and 40 h 30 (range: 9 h 38 to 76 h 51) at 12 months. The general evolution of one-off activities was more irregular and quite up and down.
Duration (hours:minutes) of one-off nursing activities perfomed for patients without care plans during the pilot project’s first year (the first wave of COVID struck in April 2020, which was project implementation month 10 for practices 1 and 2, month 5 for practices 3 and 4, month 4 for practice 5, month 3 for practice 7, and month 2 for practices 7 and 8).
Qualitative interviews analysis
Qualitative data from nurses’ interviews confirmed the monitoring data and highlighted a general increase in the implementation of nursing activities within patients’ care plans, particularly follow-up activities such as secondary prevention and therapeutic education. ‘In fact, you move gradually, because first, you need to figure out how you can best support the patients’. Most nurses also described how, even after a year, the distribution of activities was still evolving: ‘[My job description] will continue to evolve’.
Several issues explaining this rollout emerged from interviews including nursing background, GPs’ willingness to refer patients and patient acceptance.
Nurses’ professional experience, skills, and knowledge
Nurses perceived their diverse prior professional experiences to be an advantage regarding their work in GPs’ practices: ‘For me, having diverse professional experience is a great asset, […] which leads me to see lots of possibilities, in fact’. Nurses’ prior professional experience also influenced the scope of the activities they implemented. For example, nurses with professional experience in emergency care dealt with some of their practice’s emergencies: ‘I took care of some of the emergencies—right from the start—because I have a lot of experience in emergencies’.
On the contrary, a lack of skills and experience in certain domains were considered barriers, such as secondary prevention and therapeutic education: ‘I don’t consider myself as qualified as an addictologist for giving this kind of [tobacco cessation] support’. ‘In fact, you move gradually, because first, you need to figure out how you can best support the patients’.
GPs’ willingness to refer patients to nurses
We also found that GPs’ willingness to refer patients to nurses for follow-up within a care plan was a major influencing factor in the rollout of activities. Indeed, all the patients interviewed were referred to a nurse by a GP. But several factors influenced GPs’ willingness to refer patients for nursing follow-up.
Firstly, the lack of existing interprofessional collaboration within GPs’ practices and the fact that GPs had previously been taking care of patients on their own were barriers to their willingness to delegate tasks to nurses. As one doctor said, ‘I think [the difficulty delegating] is also a question of practice, of medical culture’.
Interviewed nurses described GPs’ trust in their skills as another factor influencing task delegation. Nurses mentioned having to practically demonstrate their skills and gain GPs’ trust. This was confirmed by one GP who expressed how, ‘as time passes, we see [her] range of nursing skills more and more clearly, and then the range of collaboration that takes place’.
Nurses and GPs both identified two other factors: GPs’ knowledge of their patients and GPs’ work schedules. It was easier for GPs to identify and refer patients for follow-up within a care plan when they had a comprehensive overview of their case. Furthermore, they were keener to refer patients to nurses when they had a busy schedule, as one nurse explained: ‘If it is a more experienced doctor, you tend to cooperate more with one another because he has greater knowledge about his patients and a busier schedule’. GPs affirmed this: ‘My two colleagues, who use [nurses’ support] the least, are those who have recently started medical practice, and they are not fully booked yet’.
Patient acceptance
Adding another healthcare professional, i.e. a nurse, to the organisation of care was generally well perceived by patients. However, nurses assessed that the potential initial reticence to being managed by a nurse was related to the novelty of this idea: ‘We had a few [patients] who found it difficult to accept [nursing follow-up]. However, it’s often enough that they meet me [a first time in order to initiate a therapeutic relationship]’.
Nevertheless, patients considered the quality of care provided by nurses to be equivalent to that provided by GPs, as illustrated by the following two patient quotes: ‘For me, the care provided by a nurse is as good as that of a doctor’.
Moreover, the patients appreciated the relationship developed with their nurses and those nurses’ human qualities, which they found validating, supportive and motivating. ‘With the nurse, it’s simpler, more human, like a family member who explains everything to you’. Some patients also reported feeling more comfortable talking with nurses about certain health issues: ‘With a nurse, I think […] that the patient will say more than with the doctor. […] for me, yes’. They also appreciated nurses’ availability and accessibility: ‘I think that it’s good with the nurse because she takes the time to explain things clearly’.
Discussion
The present findings showed that the rollout of nursing activities, especially activities performed within the framework of a care plan, generally progressed throughout the pilot project’s first year. This process was influenced by several factors, such as nurses’ skills and experience, GPs’ willingness to refer patients and patient acceptance.
The nursing role is still relatively unknown in Switzerland (Gysin et al. Reference Gysin, Sottas, Odermatt and Essig2019) and registered nurses often have similar roles to medical assistants (Josi and Bianchi Reference Josi and Bianchi2019). Nurses in the MOCCA project therefore did not have a model to rely on to develop their role and activities, which explains the slower uptake for more specific activities such as case management. This gradual increase can also be attributed to the time nurses took to acquire skills and experience in family medicine care. This acquisition was faster when nurses had previous experience in a primary care (PC) setting. Training is also crucial for nurses to gain confidence in their role and activities (Busca et al. Reference Busca, Savatteri, Calafato, Mazzoleni, Barisone and Dal Molin2021; Drennan et al. Reference Drennan, Goodman, Manthorpe, Davies, Scott, Gage and Iliffe2011; McCullough et al. Reference McCullough, Whitehead, Bayes, Williams and Cope2020). In the absence of pre-graduate training, it is necessary to implement early training to support nurses.
Several studies also corroborate that teams working (e.g. nurses) in GPs’ practices depend on the task delegation by GPs (Condon, Willis, and Litt Reference Condon, Willis and Litt2000; Willis, Judith, and Litt Reference Willis, Judith and Litt2000; Finlayson and Raymont Reference Finlayson and Raymont2012; Jaruseviciene et al. Reference Jaruseviciene, Liseckiene, Valius, Kontrimiene, Jarusevicius and Lapão2013). Finlayson et al. describe how 68% of nursing work in GPs’ practices was delegated by a GP (Finlayson and Raymont Reference Finlayson and Raymont2012). Other studies have also identified that nurses rely on the workflow of GPs (McInnes et al. Reference McInnes, Peters, Bonney and Halcomb2015; Condon, Willis, and Litt Reference Condon, Willis and Litt2000). Due to the fee-for-time payment system of the Swiss PC system, nurses have also encountered this issue. This highlights the limitations of this payment system in transforming private healthcare structures into multiprofessional organisations, especially in the initial stages. Alternative payment systems, such as bundled payment system or blended payment system are more appropriate for such organisation (Nolte and Woldmann Reference Nolte, Woldmann, Amelung, Stein, Suter, Goodwin, Nolte and Balicer2021; Feldhaus and Mathauer Reference Feldhaus and Mathauer2018; Edwards et al. Reference Edwards, Bitton, Hong and Landon2014).
Another key element facilitating the integration of nursing activities, which was also identified in our study, is trust among professionals. Several authors have also identified trust as a key element of collaboration (Pullon Reference Pullon2008); it builds over time and depends (among other things) on the development of mutual understanding (Bradley, Ashcroft, and Noyce Reference Bradley, Ashcroft and Noyce2012). Other studies have also shown that even if GPs trust nurses and recognise their skills and added value, some have difficulty sharing care responsibilities with them (Willis, Judith, and Litt Reference Willis, Judith and Litt2000; Pullon Reference Pullon2008). Interprofessional education (IPE) can help address this issue (Karam et al. Reference Karam, Macq, Duchesnes, Crismer and Belche2021). In the context of the MOCCA project, IPE was limited to a single day and did not involve all teams. Strengthening IPE at the beginning of the project is clearly necessary.
Finally, at patients’ level, the apprehension of the unknown is quickly overshadowed by the satisfaction of the quality of nursing care. Patients are generally just as satisfied with the care provided by a nurse as they were with that provided by a GP (Laurant et al. Reference Laurant, van der Biezen, Wijers, Watananirun, Kontopantelis and van Vught2018). However, it is necessary to work on the understanding of the nursing role with patients. Doctors are best positioned to do it.
Strengths and limitations
The present study had several strengths, including its real-world conditions and the mixed-methods approach used to contextualise the implementation of activities. Furthermore, qualitative data from multiple perspectives (nurses, GPs, and patients) allowed for a comprehensive exploration of experiences and perceptions within GPs’ practices. However, limitations were also present. Nurses self-reported their activities, potentially introducing memory bias, and patients interviewed may have been subject to selection bias as only patients who agreed to nurse follow-up were included. Social desirability bias may also have influenced qualitative data. Further evaluation of this two-year pilot project is needed to confirm these initial findings and provide a deeper understanding of the implementation of nursing activities and influencing factors.
Conclusion
The rollout of new nursing activities into GPs’ practices was a progressive increase in the number of nursing activities, principally for the delivery of nurses’ patient follow-up activities. These results highlight the importance of early nursing training to assume their new role, as well as training staffs in interprofessionality.
Data availability statement
The data are stored at the institution. Datasets generated and analyzed during the current study are not publicly available. At this point, researchers are still working on the material. However, it is available from the corresponding author on a reasonable request.
Acknowledgments
We are very grateful to all the GPs, nurses and patients who participated in the interviews and focus groups for this project.
Author contributions
S.L.M. wrote the main manuscript text, collected qualitative, and analysed the qualitative and quantitative data, as well as prepared the tables and figures. S.J. and E.-H.F. contributed to the qualitative data collection and analyses. R.S. carried out the quantitative data collection and management. All authors reviewed the manuscript. S.N. and C.C. are joint senior authors.
Funding statement
The pilot project was supported financially by the Canton of Vaud’s public health authorities.
Competing interests
The authors declare no competing interests with regard to this project.
Ethical standards
This study was carried out in compliance with Swiss law and conducted in accordance with the Declaration of Helsinki. The project was approved by the Human Research Ethics Committee of the Canton of Vaud (Req-2019-00544).
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