Professional interests
Professional groups expressed highly positive interest in the reorganised stroke rehabilitation, and professional and collective interprofessional interests strongly coincided. The reorganisation offered services to a patient group that professionals felt had previously received sub-optimal rehabilitation services, as the following quote illustrates:
‘[I]nitially, the interprofessional teams were a cost-cutting exercise to reduce the number of hospital beds. But in fact I feel that this is one of the few examples where cost cutting has helped to open new doors. I feel we have been able to target a patient group that was not included before.’
Occupational therapist, Lakeside.
The reorganisation had a very different initial rationale and this underlines the fact that professionals had a strong sense of meaningfulness. The same was true for patients, as a related study showed [
32]. Meaningfulness centred on the notion of needs-based care, and professionals saw working in the patients’ homes as a way to achieve this. It gave them a more realistic and holistic impression as the following quote by a doctor demonstrates:
‘[T]hey [patients] behave differently in their own homes; you can thus assess many cognitive issues. You can also easily smell if [the patient] is a smoker; you can see if this is the home of an addict. I get thousands of [snippets] of information, which I could not get at the hospital [...]. I feel this [working in the home] gives me a completely different impression.’
Doctor, Valley.
This suggests that working in the home gave professionals a more realistic and holistic impression and made it easier to spot other problems, and to assess the physical infrastructure of patients. Professionals were thus able to tailor treatment and training programmes to the specific needs and resources of individual patients. This also increased the quality of rehabilitation plans, as one physiotherapist stresses:
‘[Professionally] I feel it makes a lot of sense that we come into people’s homes and complete our professional assessment [there]; we are as specific as possible when we draw up rehabilitation plans and pass them on to the professionals in the municipality. I feel our rehabilitation plans have become much better, because we use patients’ home environment to describe their needs [...].’
Physiotherapist, Beachfront.
Providing needs-based care also opened a temporal dimension with greater opportunities to follow patients in the different phases of their rehabilitation trajectory.
From the perspective of professionals, needs-based care had other positive consequences for their practice. This included greater autonomy as one nurse emphasised in the following quote.
Researcher: ‘Does the way stroke rehabilitation is organized now give you greater influence over your work?’
Respondent: ‘Yes, definitely. [...]. I have more responsibility, because there are more issues where I have to find out if they require further [professional] attention.’
Nurse, Mountainridge.
Here greater autonomy was defined in terms of the number of issues that required independent decisions. Other respondents mentioned autonomy in terms of deciding how much time to spend with individual patients and designing individual treatment and training programmes. Professionals identified increased intersectoral coordination as another positive consequence; this was seen to prevent hospital readmissions and to reduce contact to elderly care services.
Working in a home setting was also challenging and required great flexibility as the professionals never knew what/whom they would meet. Other challenges related to the contents of professional practice. For example, the necessary screening on behalf of other professional groups (see below) can be time consuming and not always sufficient. A final set of challenges concerned the structural context of the stroke teams: Some professionals felt that hospital stays were sometimes too short, while existing resources put clear limits on the number of home visits and training available for patients in high need.
Professional strategies: Organising collaboration in the team
The convergence of individual professional and collective professional interests was reflected in the professional strategies centring on needs-based care and (micro-level) health workforce governance. One team member of each team was responsible for assigning patients to other professionals in the team. All teams reported this process to be unproblematic. Professionals mainly drew on strategies of needs-based care: assignment was based on an assessment of patient needs and team resources, and one designated team member was responsible for the patient’s care trajectory.
Seeing patients in their homes reinforced strategies based on needs. It was difficult to maintain a narrow focus on the individual professional speciality in the face of the patient’s individual situation. For example, a nurse might have blood pressure and medication review as main professional responsibility, but in the home other challenges, such as cognitive difficulties or residual, physical impairments, clearly presented themselves and required attention.
The strategy of needs-based care motivated the individual professional to draw on the expertise of other professional groups as the following quote by a nurse illustrates:
‘It is an all-round-picture [I get], because I have to be highly alert [to many issues]. If I am the first to visit [the patient], I check if there is anything cognitive and report [any problems] back to the other professionals. Or I quickly examine if there is anything physical.’
Nurse, Mountainridge.
Being able to include the perspective of other professions rather than to focus exclusively on their own, was exactly what constituted a competent and valued member of the stroke team. This type of engagement in (micro-level) health workforce governance included a number of strategies. The individual professionals worked both independently and on behalf of the team when they were in the homes of stroke patients. It was their responsibility to make a holistic assessment of the patient, initiate rehabilitation and organise timely discharge and transfer to rehabilitation in the municipality. Awareness of own professional strengths and shortcomings, and thus knowing when to include expertise of other team professionals, was integral to this practice. One occupational therapist explained this approach as follows:
‘I have a sense that I do not have to see all patients. I have to see those where it is relevant. I feel we [in the interprofessional team] trust each other, that we draw on our [respective] expertise where this is relevant.’
Occupational therapist, Lakeside.
Thus, there was a degree of skills transfer among team professionals in the sense that they screened patients on behalf of other professions and assessed if such expertise was needed. This is not without pre-requisites, but requires trust as well as experience, as one physiotherapist stresses:
‘This [working in the interprofessional team] requires experience. [...] [Y]ou have to have worked in neurology for a number of years and you have to have a well-established professional background to be able to work with other professionals and retain your own expertise, and to know what you can offer.’
Physiotherapist, Lakeside.
Experience meant not only extensive professional knowledge but also a clear sense of one’s professional strengths; this offered a springboard for defining high specific relationships of collaboration.
Importantly, this two-fold professional strategy to strengthen needs-based care and to promote health workforce governance by organising professional skills in the team in a collaborative way was facilitated by a number of context factors. Needs-based care had a functional and financial imperative; the team simply did not have the resources to send more than one staff member to the patients’ home. Skills transfer was eased by a high level of trust and mutual recognition of expertise in the teams. Professionals expressed confidence in their colleagues’ assessments, decisions and administration of resources and they trusted that their professional perspectives and expertise would be consulted if and when relevant. On the side-line, doctors acted as ad-hoc experts and took charge of formal discharge from team services. They expressed high levels of confidence in the quality of services provided by the team, as the following quote illustrates:
‘I rely on the assessments the occupational therapists and the nurses make in the patients’ homes, because they [occupational therapists and nurses] have a lot of experience in this area [stroke rehabilitation].’
Doctor, Seaside.
Finally, the region had introduced a range of support structures for the teams, including networks across different localities and mono-professional networks.
Professional strategies: Organising collaboration with the municipality
The stroke teams acted as link between hospital and municipalities. Again, the professionals here drew on a two-fold strategy combining needs-based care and health workforce governance. The team member responsible for the individual patient was in charge of handing over the patient to rehabilitation in the municipality. If a municipality was not ready to offer relevant services, the team continued its services, representing a form of skills overlap. The team members highly valued this flexibility as it allowed them to maintain focus on patient needs. This illustrates how closely the two strategies were intertwined. The skills overlap was slightly contested: the teams recognised that patients’ homes were usually considered the municipalities’ turf, and some professionals expressed concern that the level of professional expertise was sometimes lower in the municipalities. The teams also regularly met with their counterparts in the municipalities:
‘We meet every 3 months. Initially, we mainly talked about individual patients. Now we discuss structural issues, what works and what does not work.’
Nurse, Lakeside.
As the meetings evolved, they offered a springboard to normalise the skills overlaps between the teams and the municipalities. This was further helped by the fact that with time the team knew their specific counterparts in the different municipalities they collaborated with; when handing over, they frequently talked on the phone and occasionally arranged to meet at the patient’s home.