Step 3. Problem analysis of the target group and setting
This step means identifying determinants of change, i.e. factors that
might hinder or enable improvements, through data collection with
stakeholders such as interviews or focus groups.37 The
analysis of actual practices helped begin the analysis of the problem,
so we combined the main data sources (schema on the process of care,
thematic analysis, analysis tables) with evidence on factors influencing
the implementation of the CCM in primary care
settings.8,14,16,17
For each FMG, we highlighted the main factors influencing each activity
of the CCM and primary care nurses. We also used analysis tables from
the previous step (analysis of actual practices) and combined the
results from each FMG into one table. This provided a broader picture of
the problem and enabled easier visualization of targets for change. In
addition, we used colour and symbols to visualize the level of
achievement for each activity (see Additional File 4 for an example).
Schemas on the process of care in each FMG also helped to visualize
which professionals are involved in the collaborative care process and
to support the analysis of the problem.
Some barriers to change were not under the control of FMGs (e.g.
external factors such as mental health policies or lack of resources in
mental health). For this reason, the research team needed to rigorously
assess the problem with the Advisory Committee and to identify
determinants that FMGs are able to impact.
Therefore, a 90-minute meeting was organized in April 2019 with the
Advisory Committee to present the preliminary results from our previous
analysis. The objective was to clarify the problem and to explore the
types of strategies that might be appropriate to improve the role of
primary care nurses and collaborative care for people with CMDs and LTCs
in FMGs. Two problems were prioritized: The lack of involvement of
nurses in the follow-up of CMDs and suboptimal collaboration between
nurses and family doctors. This problem may be related to a
misunderstanding of the role of primary care nurses in providing care to
people with mental health problems or to the nurses’ level of training
to care for people with CMDs. Consequently, two strategies were proposed
to resolve these issues: 1) Clarify the role of nurses and other members
of the team in the follow-up of people with CMDs and LTCs; 2) Improve
the nurses’ knowledge of care for people with CMDs.
Discussion on lessons learned. Analyzing the problem was
a challenging task because the CCM is a complex model involving multiple
actors at different levels through a variety of activities and requires
many resources (e.g. technologies, humans, treatments, services). The
tools that we used facilitated understanding of the problem, especially
the schemas describing the current process of care and the results from
analysis tables. For example, schematization helped illustrate the
complexity of delivering non-pharmacological treatments, and that nurses
were not involved in the same way, at the same time in the collaborative
care process in each FMG.
However, analysis tables presented to the Advisory Committee covered too
many activities and did not provide a quick overview of the
relationships between the professional activities included in the CCM,
i.e. logical order of main professional activities involved when
delivering collaborative care. Consequently, we built a schema
illustrating the process of delivering collaborative care according to
CCM evidence (see Schema 1). This schema can be an effective tool to
rapidly illustrate the location of a problem and to share this with
stakeholders. Therefore, we strongly recommend that researchers or
decision makers schematize the process of care involved in the
innovation to be implemented as this will represent the “gold
standard” for the analysis of actual practice. This schematization can
be done following a literature review at the beginning of the planning
process.
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Insert Schema 1
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There is little evidence regarding methods that can be used to identify
determinants of change and to prioritize the problem; researchers often
need to use their creativity to do so.21 This was the
case in our study as we developed our own methods, but we later
discovered that schematization of the process of care can be compared to
a quality improvement method called “process mapping”. A process map
can be defined as “a diagram showing components, relationships and the
sequence in which a system functions”.39 p.61 Indeed,
quality improvement (QI) methods can help to analyze actual practice and
prioritize the problem before implementing change. For instance, the
Quality Enhancement Research Initiative (QUERI), developed by the U.S.
Department of Veterans Affairs,40 uses scientifically
supported QI methods to implement evidence-based practices.
Nevertheless, QI methods may need to be adapted and tested in various
types of health care organizations and for different types of research
issues.