‘Sink or Swim’: A Qualitative Study to Understand How and Why Nurses Adapt to Support the Implementation of Integrated Diabetes Care

Abstract

Background: Integrated care, organising care delivery within and between services, is an approach to improve the quality of care. Existing specialist roles have evolved to work across settings and services to integrate care. However, there is limited insight into how these expanded roles are implemented, including how they may be shaped by context. This paper examines how new diabetes nurse specialists working across care boundaries, together with hospital-based diabetes nurse specialists, adapt to support the implementation of integrated care. Methods: We conducted semi-structured focus groups and interviews with diabetes nurse specialists purposively sampled by work setting and health service region (n = 30). Analysis was data-driven, coding actions or processes to stay closer to the data and using In Vivo codes to preserve meaning. Findings: Community nurse specialists described facing a choice of “sink or swim” when appointed with limited guidance on their role. To ‘swim’ and implement their role, required them to use their initiative and adapt to the local context. When first appointed, both community and hospital nurse specialists actively managed misconceptions of their role by other staff. To establish clinics in general practices, community nurse specialists capitalised on professional contacts to access GPs who might utilise their role. They built GP trust by adopting practice norms and responding to individual needs. They adapted to the lack of a multidisciplinary team “safety net” in the community, by “practicing at a higher level”, working more autonomously. Developing professional links and pursuing on-going education was a way to create an alternative ‘safety net’ so as to feel confident in their clinical decision-making when working in the community. Workarounds facilitated information flow (i.e. patient blood results, treatment, and appointments) between settings in the absence of an electronic record shared between general practices and hospital settings. Conclusions: Flexibility and innovation facilitates a new way of working across boundaries. Successful implementation of nurse specialist-led integrated care requires strategies to address elements in the inner (differences in practice organisation, role acceptance) and outer (information systems) context.

Adoption and Initial Implementation of a National Integrated Care Programme for Diabetes: A Realist Evaluation

“…However, their capacity to do so depended on others’ familiarity with the role and their relationships with existing staff, together with external validation and the legitimacy afforded by guidelines. It was challenging for individual HCPs to achieve this without complementary systematic service level communication, the lack of which was highlighted in a recent evaluation of the national clinical programmes as a whole [ 52 ], or changes to existing team structures in primary or secondary care [ 53 ]. International work suggests that when clinicians are working across boundaries – physical boundaries between care settings, or professional boundaries between disciplines within a multidisciplinary teams – there will be issues in terms of the understanding and implementation of new roles [ 54 55 56 ].…”

The Mechanisms of Implementation Support - Findings from a Systematic Integrative Review

“…Equal attention will be required from organizational leaders when defining the scope of ISP roles, which, in promoting implementation practice change, depend on a clearly defined description of their core function and responsibilities. In the absence of such clarity, ISPs would be at risk of facing misconceptions of their role among the stakeholders they work to support (Riordan, McGrath, Dinneen, Kearney, & McHugh, 2019), potentially reducing their ability to build the trusting and constructive work relationships that enable them to facilitate learning. Furthermore, embedding ISPs-and with them a focus on implementation practice-into the established structures, routines, and domains that connect different professions, for example, social workers, psychologists, or educators, as well as different organizational roles, for example, supervisors, middle managers, or administrative personnel, has the potential for causing friction.…”

The UK haemophilia specialist nurse: Competencies fit for practice in the 21st century

“…Specialist nurses, in the UK are registered nurses who practice at an advanced level to manage and improve patient care, satisfaction and outcomes, have a similar and broad spectrum of roles regardless of the specialty in which they work [20][21][22][23][24][25] due to the commonality of traditional nursing functions and their more recently developed roles as patient advocates and service co-ordinators/navigators. The HNA was in the vanguard of professional development when it published the role description for haemophilia nurse specialists in 1994, 2 providing the model from which the UK haemophilia nursing profession has since developed.…”

“…Benner, a nursing theorist, is recognized for developing a model of clinical competence which describes five levels of learning and skill acquisition (novice to expert) through which nurses progress as their career develops and their professionalism grows 22 . Nurses in the UK now enter the profession at degree level and may have passed the novice stage due to the inclusion of clinical competencies in their degree pathway which were not included when Benner designed her theoretical model.…”