Background
Methods
Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Total | |
---|---|---|---|---|---|---|
Identifying influencing factors beforehand
| ||||||
Focus groups | 1 | 1 | - | 1 | - | 3 |
Semistructured interviews with nurses, dermatologists, managers, referrers | 4 | 8 | 5 | 8 | 7 | 32 |
Facilitators and barriers questionnaire in nurses participating in the previous trial | 10 (65%) | |||||
Semistructured interviews with healthcare insurers | 6 | |||||
Evaluation
| ||||||
Monitor of patient recruitment (online tool) filled in by nurses | Yes | Yes | No | Yes | Yes | |
Semistructured interviews and semistructured group interviews with nurses, dermatologists, managers, referrers | 7 | 7 | 2a
| 4 | 2a
| 22 |
Number of patients enrolled in the program | 10 | 18 | 14 | 6 | 5 | 53 |
Number of patients who completed the program within evaluation | 10 | 18 | 7 | 5 | 5 | 45 |
Evaluation forms filled in by nurses | 10 | 18 | 5 | 5 | 5 | 43 |
Patient satisfaction questionnaires | 6 | 9 | 3 | 2 | 0 | 20 |
Facilitators and barriers questionnaire— nurses | 2 | 4 | 1 | 2 | 3 | 12 (86%)b
|
Facilitators and barriers questionnaire— colleagues | 5 | 8 | 3 | 3 | 3 | 22 (61%) |
Observation of counseling sessions | 1 | 1 | 1 | 1 | 2 | 6 |
Description of the Lively Legs intervention
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Session 1
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– Assessment of patients’ lifestyles
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– Give tailored health education related to patients’ health beliefs
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– Demonstrate and practice leg exercises
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– Give education materials to the patient
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– Discuss motivation and self-efficacy towards behavior change
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– Explore barriers and facilitators for behavior change
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– Goal setting on one or more lifestyle topics and home assignments
-
-
- Session 2–5
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– Evaluate behavior change and give feedback
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– Motivational interviewing
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– Discuss motivation and self-efficacy towards behavior change
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– Explore barriers and facilitators for behavior change
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– Goal setting on one or more lifestyle topics and home assignments
-
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- Final (Preferably six months after session 1)
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– Evaluate behavior change and give feedback
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– Summarize the course of the counseling trajectory and the achieved results
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– Discuss maintenance of behavior change
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Selection of the cases
Case | Healthcare settings | Familiar with program?a
| Responsible for program delivery | Individuals involved in implementation |
---|---|---|---|---|
1
| 1. Homecare setting | No | Nurse practitioner | Nurse practitioner, manager, GP |
2. Homecare setting | No | Homecare nurse | Homecare nurse, manager | |
Outpatient clinic (only to refer patients) |
Yes
| - |
Dermatologist, three nurses, team manager
| |
2
| 3. Outpatient clinic | Yes | Dermatology nurse | Dermatologist, two nurses, team manager |
4. Outpatient clinic | No | Dermatology nurse | Dermatologist, two nurses, team manager (the same as in case 4) | |
5. Homecare setting | No | Homecare nurse | Homecare nurse, manager, policy advisor | |
6. Homecare setting | No | Homecare nurse | Homecare nurse | |
7. Specialized primary wound care clinic | No | Specialized nurse | Specialized nurse, clinic manager, specialist elderly care | |
3
| 8. Outpatient clinic | Yes | Dermatology nurse | Dermatologist, dermatology nurse, team manager, hospital manager, homecare manager |
4
| 9. Outpatient clinic | No | Dermatology nurse | Dermatologist, dermatology nurse, team manager |
10. Homecare setting | No | Homecare nurse | Homecare nurse, team manager, manager | |
11. Homecare setting | No | Homecare nurse | Homecare nurse, manager | |
5
| 12. Outpatient clinic | No | Nurse practitioner | Dermatologist, nurse practitioner, medical assistants, team manager |
Two medical assistants |
Identifying potential influencing factors for change
Developing implementation strategies
Evaluation of the implementation of Lively Legs
Data analyses
Results
Data collection
Description of the cases
Potential influencing factors for change
Pre | Post | Illustration/citation/score (data source) | |
---|---|---|---|
Facilitating factor
| |||
Participant responsiveness: participants (nurses and patients) are positive about the content and effects of Lively Legs | X | X | - “I think the main value of the program is that it offers a structured method you can use in your clinic hours. All topics that you normally would or would not discuss, they now will be addressed for sure with the program.” (case 5, nurse practitioner) |
- Patients valued the program as an 8.4 on a scale from 1 to 10 on average (range 7–10) (data from patient questionnaires) | |||
- Nurses gave an overall program score of 3.8 on a 1 to 5 scale on average (range 3–4) (data from nurse questionnaires); nurses gave an average score of 3.6 on a scale from 1 to 5 on how satisfied they were with the extent to which they were satisfied with the achieved behavior change per patient (range 2–5) (data from evaluation forms) | |||
Possibility to educate oneself on lifestyle counseling was appreciated by nurses | X | X | - “I notice that I use what I learned in the Lively Legs education… and that I use it also in other patients. Personally … I am more aware of interview techniques, how to start a conversation about it, and showing exercises that people can use.” (case 1, homecare nurse) |
- “I was very enthusiastic after the educational meetings. I use what I’ve learned, actually in different situations. When I see patients at their homes now… you always mention lifestyle issues… but now I do this more completely and I say things in a different way.” (case 2, homecare nurse) | |||
The program gives opportunities to improve professional relationships and collaboration in the region | X | “I hope we can improve the care for this patient group in this region, to come closer to some kind of collaborative care model or protocol. Then this project would really be regarded as successful” (case 2, homecare manager) | |
Standardized care process and collaboration between homecare and outpatient clinic | X | - “We have set up… how do you call it… a safety net. We just have to ask these fixed questions to every patient…. That it is so well organized at our clinic, with this standardized care process… I think at our clinic patients don’t slip through.” (case 3, dermatology nurse) | |
- “Actually, I think at our clinic, I know every patient who comes for wound care or compression therapy. I have made myself an overview of which patients I have asked and which ones I have included in the program.” (case 4, dermatology nurse) | |||
Nurses’ own practice hours | X | - “… We have the flexibility to schedule… ehm…You see, last time we could easily decide that, because one patient did not show up and I thought ‘let’s just do the lifestyle assessment right away.’ Otherwise, like today, I would schedule the appointment for next week.” (case 5, nurse practitioner) | |
Hindering factor
| |||
No insight in how to recruit patients for the program | X | X | - “I just want to get those referrals… automatically. I will not, every time, because it takes me at least one hour, need to screen the electronic registration system. That just does not work.” (case 2, specialized wound care nurse) |
- “I don’t have an overview on all referrals… Now and then I see a form that has been filled in and then I catch that one.” (case 2, dermatology nurse) | |||
- “…Especially the problem how do you get others to refer to you? And how can you make sure that those agreements are guaranteed? When you work at the outpatient clinic you, are closer and you see these patients yourself.” (case 1, nurse practitioner) | |||
Competition between healthcare organizations | X | X | - “I have bad luck… There are two main primary care practices in this village. Both are now only doing business with the other homecare agency. So, both will not refer patients to us.” (case 1, homecare nurse) |
- “I could have referred more patients to her. But… I was told not to. They say, no, you cannot do that because our company delivers homecare to these patients and we don’t want company X going to these patients as well. It is just fear that patients will like the nurses from company X better and that we will lose clients to our rival.” (case 2, specialized wound care nurse) | |||
The program is perceived as an extra task with no extra reimbursement | X | - “The counseling should be part of the current reimbursement for venous leg ulcers. It would be right if the extra costs are compensated by the healthcare insurer. Are any finances available for this program?” (case 3, manager outpatient clinic) | |
In rural regions, homecare nurses would have to drive long distances or many homecare nurses would have to be trained to cover the area | X | - “If you train just one or two nurses for this whole region… You see for us it isn’t efficient to let them drive from village to village, from patient to patient.” (case 2, homecare manager) | |
Who should lead the project (due to changing managers) | X | X | - Pre-implementation: in four out of five cases, the outpatient clinic manager changed positions |
- Researcher: “So, if I understand you right, you say that part of the implementation problems can be put down to the management?” Nurse: “Yes, they don’t exactly accelerate the project if you know what I mean. It takes a long time. They have other kinds of problems, I understand that. But now this project may get stranded. …Honestly, I would love to go to the manager and say, hey there, you’ve promised this to us.” (case 3, dermatology nurse) | |||
Nurses’ motivation | X | - “I should have made more inquiries before I started this project. What is it exactly, what do I have to do and what are others supposed to do? It’s just what I said before: I’ve been saddled with this project.” (case 2, homecare nurse) | |
- “Yeah… well real barriers… no not really… That it didn’t succeed was mainly because of me.” (case 4, homecare nurse) | |||
Organizational preconditions (nursing time, consulting room) | X | X | - In three cases, agreements on nursing time were not (totally) met. There were no problems with respect to the availability of consulting rooms. Nurses valued the extent to which organizational preconditions were met with 3.3 on a scale from 1 to 5 on average (data from nurse questionnaires). |
- “I can hardly schedule appointments. Because, well I only work on Wednesdays. I want to combine the counseling with wound care consultations and… well if the doctor is not doing clinic hours that Wednesday for example… It is difficult to arrange and before you know it is three weeks later.” (case 2, dermatology nurse) | |||
Knowledge and support of colleagues | X | - Colleagues scored a 4.5 on a scale from 1 to 5 on average (range 4.2–5.0) with respect to knowledge of the program (data from questionnaire colleagues) | |
- Nurses scored a 3.3 on a scale from 1 to 5 on average (range 2–5) to the extent to which colleagues were supportive of them in implementing the program (data from questionnaire nurses) |
Implementation strategies
Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Cases (n = 5) | Settings (n = 12) | |
---|---|---|---|---|---|---|---|
Agreements on (extra) nursing timea
| Yes | Partly | Yes | Partly | No | 4/5 | 8/12 |
Training Lively Legs (two days)a
| Yes | Yes | Yes | Yes | Yes | 5/5 | 12/12 |
Training Lively Legs after implementation (½ day)a
| Yes | Yes | Yes | Partly | No | 4/5 | 10/12 |
Monitor patient recruitmenta
| Yes | Yes | No | Yes | Yes | 4/5 | 10/12 |
Monthly feedback on patient recruitmentb
| Yes | Yes | No | Yes | Yes | 4/5 | 10/12 |
One practice visit by researchersb
| Yes | Yes | Yes | Yes | Yes | 5/5 | 11/12 |
Website with information and program materialsb
| Yes | Yes | Yes | Yes | Yes | 5/5 | 12/12 |
Communicate the referral procedure in teamc
| Yes | Yes | Yes | Yes | Yes | 5/5 | 12/12 |
Determine referral procedure with external referrersc
| Yes | Partly | No | Partly | No | 3/5 | 4/12 |
Sending a letter to external referrersc
| No | No | No | Yes | No | 1/5 | 1/12 |
Forum on website for questions and feedbackc
| No | No | No | Yes | Yes | 2/5 | 2/12 |
Ask researchers for supportc
| Yes | Yes | Yes | Partly | Yes | 5/5 | 6/12 |
Hand out information leaflet to referrersc
| Yes | Partly | No | Yes | No | 3/5 | 5/12 |
Publish information on company website/paperc
| No | Yes | No | Yes | Yes | 3/5 | 7/12 |
Inform others about lifestyle in leg ulcer patientsc
| Yes | No | No | No | No | 1/5 | 1/12 |
Hand out cards with lifestyle advices and referral procedure (only in cases 4 and 5)c
| - | - | - | Yes | No | 1/2 | 2/5 |
Number of strategies carried out of planned (range)d
| 12/15 | 12/15 | 7/15 | 15/16 | 9/16 | ||
(11–12) | (8–12) | (7) | (4–14) | (9) |
Evaluation
Criteria | Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Data source | |
---|---|---|---|---|---|---|---|
Perceived implementation success | Implementation score (1–10) | 5.0 | 4.9 | 6.0 | 5.3a
| 7.0 | Interviews with nurses |
Half-year implementation expectation (1–10) | 5.0 | 5.4a
| 8.5 | 7.5 | 8.0 | Interviews with nurses | |
Patient recruitment | Patients enrolled in program (n = 53) | 10 | 18 | 14 | 6 | 5 | Monitor |
Patients completed program within evaluation (n = 45) | 10 | 18 | 7 | 5 | 5 | Monitor and nurses’ registration | |
One new patient per month | No | No | Yes | Partlya
| Yes | Monitor | |
All eligible patients are recruited according to nurse | No | No | Yes | Partly* | Yes | Interviews with nurses |