Step 1. Develop a proposal for change with stakeholders
Before proposing a change to stakeholders, a literature review on the
innovation to be implemented was needed to understand its
characteristics.23 The CCM (and the role of the care
manager) was our evidence-based practice to improve the role of primary
care nurses and collaborative care in FMGs. We identified the main
characteristics of the CCM, i.e. components, professional activities or
tasks involved in the CCM, factors that might influence its
implementation and related outcomes.8,16,17 A scoping
review was conducted to explore a specific aspect of the CCM: challenges
of adopting the role of the care manager by primary care
nurses.14 We also identified key interventions and
materials on the CCM to prepare the implementation of change.
Among seminal publications in the field, we included the first large
randomized controlled trial of treatment for depression that took place
in the USA: Improving Mood-Promoting Access to Collaborative Treatment
(IMPACT).24,25 Since then, IMPACT has been widely
studied and adopted in many other countries, and a team of researchers
at the University of Washington Advancing Integrated Mental Health
Solutions (AIMS) Center developed tools to help researchers and managers
implement the CCM. For instance, they created a checklist to evaluate
the principles and main tasks (professional activities) of the CCM and
published a full description of the care manager
job.26,27
The review of the literature also helped to plan the methodology, such
as identifying which type of participants should be recruited and it
facilitated the development of data collection tools. Interview guides
for each type of participant (patients, family doctors, primary care
nurses, and other primary care providers) were developed to analyze
actual practices and challenges to collaborative practice for people
with CMDs and LTCs in FMGs. The three interview guides were respectively
tested and reviewed by the research team with a patient partner, a
primary care nurse and a psychiatrist not otherwise involved to the
study.
To ensure feasibility of the project, we needed the collaboration and
support of the Nursing Directorate at the regional hospital centre where
the project was conducted. From January 2017 to September 2018, the
principal investigator met with nurse managers of the Nursing
Directorate twice to propose an improvement in nursing and collaborative
practices for people with CMDs and LTCs in FMGs. The first meeting was
to present a proposal for change based on previous
studies.28,29 The second meeting was to confirm their
interest in changing practices and to identify potential FMGs that might
be of interest in the study. Three FMGs were targeted.
FMGs are organizations that are distinct from the hospital centre and
are led by family doctors. Thus, we contacted the family doctors
responsible for targeted FMGs by e-mail, including a one-page summary of
the project describing the goal, staff involvement and timeline. When
family doctors manifested their interest in the study, a face-to-face
meeting was organized to present the project. A total of three urban
FMGs were recruited (see Table 1).
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Insert Table 1
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In each FMG, health care professionals involved in the care of people
with CMDs and LTCs were invited to participate in the study (e.g. nurse,
family doctor, psychologist, social worker). With regard to patients, we
asked recruited primary care nurses to identify one patient (adult) with
at least one LTC and depression or anxiety. Identified patients were
then individually contacted by a member of the research team to explain
the project and obtain informed consent.
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Insert Table 2
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Within each FMG (n=3), a local working group was created, including at
least one primary care nurse and one family doctor. They were involved
to discuss the gap in their practices as well as to select and adapt
strategies. The participant recruitment process for the working group
differed between FMGs as we adapted our method to local preferences and
procedures. In general, leaders of the group or those who were
identified as champions in mental health care by their colleagues were
involved in the working group. Moreover, a nurse manager at the regional
hospital centre was also invited to attend the first meeting in each
FMG. The number of participants involved in the first meeting of each
working group ranged from 3 to 8 participants.
Finally, an advisory committee was created to counsel the research team
on potential strategies to implement a change of practice based on the
provincial and local context and to contribute to knowledge mobilization
among FMGs. Members of the committee were invited based on their
collaborative care expertise in primary care of people with CMDs and
LTCs. This committee included 2 patient partners with a history anxiety
or depression, and at least one LTC, who received primary care services
for their mental and physical health problems. Other committee members
included 3 researchers in the field of collaborative mental health care
and nursing, 1 nurse manager, 1 family doctor, 1 primary care nurse, 1
psychiatrist, and 1 psychologist. Most of the participants were from
different regions across the province of Quebec (n=4) except for one who
was in another Canadian province (Ontario). However, the majority of
experts (n=6) were from the region where the project took place.
In January 2019, an initial meeting with the Advisory Committee was held
to share current CCM evidence and to discuss the feasibility of
implementing main components of the CCM in FMGs. Throughout the process,
the first author also met individually with certain members of the
Advisory Committee to further address specific issues mentioned during
the meeting such as primary care nurse training, the role of the
psychiatrist, population-based care and mental health outcome measures.
Discussion on lessons learned. This step was beneficial
to the development of a collaboration with nurse managers at regional
hospital centres and with the leaders of each FMG, to initiate a
reflection on the challenges to implementing the CCM in FMGs and to
further our understanding of the CCM. The primary activity, which took
almost a year to carry out, was to engage a variety of stakeholders in
the project. In order to optimize stakeholder engagement, it is
important to have a flexible agenda, to adapt communication methods to
individual preferences, to simplify and synthesize scientific
information as much as possible, being clear on the type of involvement
and human resources needed.