Background
Older people will increasingly live in nursing homes over the coming decades in Germany [
1] and most Western European Countries. Nursing home residents represent a very dependent, vulnerable and frail subgroup of the elderly should receive the best medical care. It is known that improvement of interprofessional collaboration and communication could contribute to better patient oriented outcomes generally [
2] as well as in the nursing home setting [
3]. On these grounds we explored the situation of medical care in the nursing home setting in Germany with the aim to compile measures for better collaboration and communication between GPs and nurses. These measures were then tested for acceptance and feasibility in an exploratory pilot.
Organisation of medical care in German nursing homes differs from many other countries. Here, mainly self-employed community based GPs provide nursing home visits to the residents who are part of their practice clientele [
4]. On average, 23 physicians (most of them GPs) provided care to a single nursing home in a German study [
4], resulting in a multitude of constellations of GPs and nurses in collaboration. Nurses and nurse aids work in the nursing home mostly in part time, nurse practitioners do not exist in the German Health System [
5]. Not all GPs perform home visits to nursing home residents. Provision of care to nursing home residents is generally seen as a professional obligation which implies high emotional demands and is often considered burdensome [
6]. Nurses in German nursing homes are solely responsible for the basic nursing care of the residents; a physician must explicitly delegate all procedures concerning medical care [
7].
Information on quality of care in nursing homes is rare. Provision of medical care by general practitioners was considered as “sufficient” in a report of the statutory health insurances in 2009. Here on average one visit per quarter was provided by GPs. However an oversupply of psychotropic drugs and antidepressants as well as an undersupply of antidementives was assumed [
8]. The quality of nursing care in nursing homes can only partly be assessed on basis of the three-year reports of the Medical Service of the Health insurers; data is mainly collected from inspection of resident files. Quality of care has been found improved in many fields as compared to the last report three years earlier, whereas management of pain and medication were aspects with room for improvement [
9]. Additionally a recent Health Technology Assessment report indicated that German nursing home residents suffering from dementia or diabetes are over- or under-supplied in some aspects of their medical care because of inadequate documentation, prescribing, and insufficient intra- and interprofessional communication [
10].
In general, issues with communication are thought to be responsible for most mistakes in medical care [
11,
12]. The Advisory Council on the Assessment of Developments in the Health Care System recommends to find new forms of cooperation of health professionals to provide health care more efficiently and effectively [
13]. Recommendations for better interprofessional collaboration in the nursing home setting were published by various German organisations and stakeholders [
14]; and cooperation agreements are now required by law [
15].
In Germany there are a few model or concept projects exploring alternative organisational structures and new forms of collaboration to improve interprofessional collaboration in nursing homes [
16‐
18]. Effects seem to be positive, although scientific evaluation is rare [
10,
19]. To date, only a few German studies have qualitatively explored the perspectives of partners involved in nursing home care, and none have done so to develop specific measures for better cooperation [
20‐
22]. We developed measures to improve interprofessional collaboration and communication between GPs and nurses in nursing homes in a qualitative bottom-up action research process. Finally the measures were implemented in an exploratory pilot study in four nursing homes for a three months period and evaluated qualitatively with regard to acceptance and feasibility.
Discussion
In a thorough bottom-up action research process we developed six measures to improve collaboration and communication between GPs and nurses in nursing homes. Measures were implemented in four nursing homes over a three months period. An exploratory qualitative evaluation showed mainly positive results with regard to feasibility and acceptance.
The project interprof and its results are unique in Germany. Other projects only described the current situation using content analyses [
20] or grounded theory [
22], without developing measures or attempting to act on their findings. Another recently published large German study [
21] provides suggestions for better cooperation in nursing homes through a mixed-methods approach; they used semi-quantitative questionnaires and focus groups as sources; data was analysed using pragmatic techniques focusing on “direct comments”. From our methodological process, especially the interview analyses, we could also capture hidden implicit assumptions in the narratives of the interviewees. In the study by Karsch-Völk, the most frequently stated suggestions for better cooperation were improved communication (9%), higher remuneration for home visits to nursing homes (7%), regular visits (5%) and less bureaucracy (5%) [
21]. These results agree partially with much older data from a postal survey of physicians in Berlin, where 48.7% of respondents suggested a better remuneration for their visits, 23.8% argued in favour of reducing administrative processes, 23.5% supported an increase in nursing home staff numbers and 20.9% recommended improving communication [
31]. None of these projects were designed to be representative. Nevertheless, our six measures encompass some of the aspects mentioned in the above publications such as better communication (established contact partner, recognised processes before and during nursing home visits, meetings to establish common goals) and regular visits (timely notice). Some of the other suggestions were discussed intensively in the focus groups or were recorded from the interviews (remuneration, more personal in nursing homes), but could not be incorporated into the measures, as they require profound changes of the German healthcare and nursing care system. Changing these higher-level organisational and political issues is clearly beyond the scope of our study, though our measures contained some suggestions regarding local bureaucracy (fax form, standardised pro re nata medication, processes before and during nursing home visits).
Acceptance and feasibility of our measures were preliminarily confirmed in our explorative pilot study. In another German project, nursing home nurses received an educational intervention focusing on nurse-physician communication; multipliers were educated to pass on their knowledge and skills to their colleagues. Following this, nurses experienced a more structured communication with GPs including the definition of goals and nursing assistants also felt more self-confident when communicating with physicians [
32]. In a recent US study trainees of several healthcare professions and medical specialties in their first year, conducted individual interviews with nursing home residents prior to a weekly interprofessional meeting, in which they discussed individual residents´ health status and developed interprofessional care plans [
33]. Similar to the findings of our pilot study, these students considered team meetings (pilot study: meetings to fix common goals) to improve the quality of care, though direct effects on resident outcomes were not evaluated. In the ELDER project, health care workers but not GPs took part in a three year curriculum to improve interprofessional communication and collaboration in the care of older adults [
34]. Teamwork and communication knowledge did not significantly rise between pre- and post-testing, and participants working in long-term care felt time constraints prevented them from collaborating with other professions, although they wished to do so [
34]. Time constraints were also mentioned in the interviews of our pilot study. The GPs generally considered interventions as time consuming, although they realised the advantages and benefits of the implementation. A recent review found that interventions in nursing homes are more effective for resident health if resident’s GP and/or a pharmacist are involved. Moreover, improved team communication and coordination had a positive impact [
3]. Following this work, we will now (April 2017) start to implement the measures in a randomised controlled trial to assess effects on residents´ health.
The strength of this study is the stepwise bottom –up approach to develop measures to improve collaboration. Measures were shaped by the real experience, needs and wishes of all stakeholders. Moreover, the composition of the interprofessional team which conducted the interviews and focus groups in the three centres and the analyses and discussion of the data in mixed professional teams contributed to the diversity of findings. Our approach, as described in our study protocol [
7], is of high rigour according to Guba and Lincoln [
35].
Limitations
In this study interprofessional collaboration between two professional groups was evaluated: GPs and nurses. We did not involve other allied health professions, e.g. physiotherapists, behavioural therapists, psychologists or social workers. While being aware of the important role of these medical professionals in residential care, we felt it important to focus on the GPs and nurse interaction in this environment. Interprofessional collaboration between all medical staff is important and therefore should also be explored with further research and interventions.
We moreover should disclose some methodological weaknesses: it was not possible to perform theoretical sampling due to organisational reasons (transcription time needs, teamwork of different study centres, difficulties of recruitment in nearly all groups). Given this, we mainly performed purposive sampling for the recruitment of interview partners. However, we reached saturation in the data of all interviewed stakeholder groups later on.
Similarly, participatory observations of nursing home visits were also challenging to organise. Several attempts failed due to the limited and often spontaneous visits by GPs. In the end, only five observations were conducted over a much longer period than initially planned. However, aspects of the observed interactions influenced the analyses of the interviews.
Residents or relatives were not integrated into the focus groups for the development of the measures; this was not part of the proposal. With hindsight we should have endeavored at least to include relatives and invite them to additional focus groups. We did though manage to invite a relative representative to the expert workshop, who gave valuable input.
It can be also criticised that the measures are neither really new nor extensive and could have been compiled using common sense. We agree that the measures appear quite straightforward. However, they have been identified and prioritised by key professional staff groups and experts. In addition, nursing homes chose varying combinations of measures, as some had not been implemented before.
Moreover, the pilot study only provides an impression of the acceptance and feasibility of the implementation of the measures in the nursing homes and cannot provide robust data. The findings give an orientation of the usefulness of the measures and possible barriers during the implementation process. Moreover, the numbers (implemented measures, nursing homes, participating nurses and GPs and residents/relatives) were small. Another weakness is the low number of residents and relatives that participated in the evaluation of the pilot study. Unfortunately, most residents were not able or willing to be interviewed and despite significant effort on our part we could find only one relative of the 20 residents who was willing to participate. The resulting information from the resident and relative interview was therefore insufficient.
Acknowledgements
We thank all the participants in this study. We are also grateful to Juliane Langen and Franziska Blank for data collection and in parts of the analyzing process. We would also like to thank the researchers who were involved in designing the interprof study: Gudrun Theile and Hendrik van den Bussche. Special thanks go to Susan Smith for copy-editing. We acknowledge explicitly Christina Geister for methodological support and supervision.