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.
————————————–
Insert Schema 1
————————————–
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.