What is the nurses role in coordinating integrated care?

Participants referred to two categories of factors that influenced the organization’s capacity to implement and sustain a nursing practice that met the requirements of integration. The first had to do with availability of organizational resources, and the second involved deployment of a set of organizational and clinical-administrative processes (Fig. 4).

Fig. 4

Strengths of and impediments to an organization’s capacity for response

With regard to resources, three key factors were seen as having a determining influence on nursing practices to support integrated care, either serving as catalysts or generating a variety of constraints.

Human resources

Participants pointed out that certain investments in human resources played a key role in the organization’s capacity to put in place various structures to foster integration of care. Examples of new structures that required appropriate human resources staffing included the single-window access point (a single gateway for patients in the healthcare system, where they are assessed and guided according to their needs) for mental health services, the breast health clinic (POS), and the smoking cessation clinic (COPD). These new investments also resulted in the deployment of specific professional roles (e.g. nurse navigators in palliative care, care for the elderly, and oncology; mental health liaison nurse, etc.), the opening of new nurse positions in targeted areas (need for better integration of patient care), and support for new continuing education activities for personnel.

Despite these investments, participants emphasized two factors that, under current conditions, impeded a nursing practice oriented toward care integration. The first was that, in their view, there were not enough nurses to meet the demand. According to participants, having enough nurses is essential to respond effectively to patients’ complex needs and ensure the stability required for continuity of care. When personnel is insufficient, as was reported in several programs, nurses are over-extended, both in terms of quantity and complexity of care, and do not have enough time to provide the full range of services to each patient. In the medical unit, nurses reported they sometimes had to limit themselves to looking after patients’ basic care needs due to lack of time, and that they would neglect relational activities, for instance, to concentrate on complex or prescribed care. Several participants noted that staff shortages also compromised access to care at various points along the care continuum.

“A workload reduction would help promote a practice of more continuous care for patients. We could be on top of everything, it would be easier” (MPOC) (free translation)

“Sometimes I’m all over the place, I have to refocus on my objectives, and my boss helps a lot with that… The staff is starting to get tired and worn out. Two years ago, 25 patients a day in chemo was a big day, now it’s around 47-48 patients…” (POS) (free translation).

In the MHS pathway, this shortage of personnel was associated with long wait lists for primary care services. Staff shortages were also associated with nurses’ lack of availability to attend intra- or interdisciplinary team meetings, continuing education activities, or discussions with colleagues—all elements that foster integrative and collaborative practice.

A second obstacle had to do with team instability, manifested most notably by frequent changes in personnel, numerous replacements, and intensive use of external labour. These instability factors were associated with nurses’ difficulties in becoming fully integrated into the team, taking part in unit activities, establishing relationships of trust with other members of the intra- or interprofessional teams, and mastering the operational aspects of care—all elements that can compromise care continuity. Replacement staff do not necessarily know the different resources that are available. Thus, an agency nurse might not be as quick to refer a hospitalized patient who wants to quit smoking to the smoking cessation clinic, or to call upon the palliative care nurse navigator to coordinate a patient’s transfer to the palliative care centre. Replacement personnel would also have more difficulty in using the nursing treatment plan, a key tool for monitoring and coordinating care from one shift to another, one care location to another, or even one professional to another.

The physical setting for care provision

The creation of local health networks specific to the Quebec context has significantly modified the spatial configuration of services, with impacts for both patients and professionals. According to nurse participants, the modernization and expansion of the hospital and renovations to various care settings had made it possible to create the spaces needed for various new strategic services in which nurses are fully involved and which should foster greater integration. Setting up the infrastructure needed to implement a centralized wait list, for example, helped create a single point of entry for health services for certain target patients (e.g. MHS, POS, ASE). Developing this infrastructure (offices, telephone lines, information systems, documentation) placed nurses at the centre of the care integration process by giving them a set of resources with which to manage requests for services and patients’ records, and to conduct assessments, set priorities, initiate treatments, and direct patients toward other appropriate services. The implementation of a system to manage COPD patients was another example of how providing certain material conditions, such as organizing physical spaces to accommodate all care team members (nurse, respirologist, respiratory therapist) and supplying all the necessary material and equipment, had facilitated various nursing interventions. These included systematically applying pulmonological assessment protocols, using digital tools to monitor patients, and developing educational capsules for patients. For participants, the various arrangements involving new construction or renovation and investments in certain equipment (e.g. meeting rooms, computer equipment, consultation rooms, and rooms for examinations or specific interventions) were interpreted as an appropriate response to the different needs associated with functioning as a network: physical spaces for meetings and conversations, communication and monitoring from a distance, and intra- and inter-establishment interactions.

Despite these investments, various factors related to the physical environment were perceived as important constraints to the integration of services provided by nurses. The limitations of physical spaces, which in many cases were considered too small and poorly adapted, made it difficult not only to accommodate patients, but also to deploy personnel optimally and to gather all members of the interdisciplinary team around patients. Lack of space in the oncology centre, for example, limited the number of patients that could be seen daily, the quantity and type of services that could be provided, and even the number of nurse navigators and other professionals who could practice on the unit at the same time. Nurses had to go from one place to another in the organization to ensure continuity of care to patients, or to attend team meetings or training activities. Furthermore, the merger of several organizations that were geographically dispersed inevitably resulted in physical distance between professionals in the different missions (e.g. primary care, hospital care, residential care for the elderly) who were expected to work together. According to the participants, this geographical dispersion of facilities, with the associated dispersion of equipment, patients, and personnel, posed a significant challenge for communication, complicated interdisciplinary activities, forced both patients and staff to navigate among the different facilities, and ultimately made continuity of care more difficult to achieve.

“We don’t have enough space in the oncology unit, because the amount of traffic has increased significantly, the clinic is overloaded. Even if we wanted another nurse navigator, there wouldn’t be any room for her. The care is less personalized, there is more assembly-line work, and the wait times are too long (6-7 hrs for 30 min. of treatment). Luckily, there is an expansion project underway. All the services will be located together and there will be less patient movement. Which is much appreciated by the patients and professionals” (POS) (free translation).

Technological resources

In terms of technological resources, participants pointed out several assets available to the organization for fostering nursing practice to support integrated care, reinforce communication and exchange with other professionals, and mitigate the negative impacts of geographic dispersion. The intranet, widely deployed and accessible across the organization, was associated with an integrative function because of the opportunities it offered, both clinically and administratively, as well as for training. It was presented as a lever for ensuring liaison among different members of the care team, communicating information in a timely manner, and promoting a high quality of practice. For example, for the nurses working in ASE, whose patients have numerous and complex health problems, the intranet was a useful consultation tool for exchanges on clinical practices and for promoting best practices. A second asset mentioned was the progressive implementation of computerized medical records. Because it created conditions that facilitated data organization, access, and circulation, the computerized medical record was widely considered to be a lever for encouraging care coordination among nurses and facilitating interactions with other members of the interdisciplinary team. For example, a designated nurse used computerized medical records to identify patients who were high users of emergency services, then made the necessary arrangements to coordinate and mobilize the interdisciplinary team to respond optimally to these patients’ needs for care and services. A third asset consisted of computer-based resources, such as specialized software, that provided nurses with monitoring and assessment tools to ensure better care coordination. A software program developed especially for COPD patients and used by nurses in FMGs and ambulatory care centres helped systematize patient assessment and monitoring and provided a shared tool for intervention and coordination used by nurses, respiratory therapists, and physicians.

The possibilities associated with these technological resources were, however, limited by certain obstacles. Nurses complained about slow deployment of computerized medical records, about obsolescence of the technological tools, which were not updated quickly enough to keep up with technological advances, and about inadequate support for professionals who need to use these technologies (training, availability of support technicians, time required to use them, etc.).

“Computerized records have not enabled technological support for a daily watchlist available to practitioners in the network. We are dependent on maintaining the ‘pop-up’ of information, there is no mechanism to alert the team when someone arrives in emergency” (MPOC) (free translation).

In all, participants strongly associated the organization’s level of investment in the three types of resources (physical, technological, and human) with the creation of conditions fostering greater integration of the care provided by nurses. Such investments depended very much on the budget allocated to the organization. The MSSS or the Health and Social Services Agency (ASSS) provided funding for specific projects (e.g. development and implementation of a clinical project). However, participants’ general perception was that the organization had very little room to manoeuver when it came to investing in resources required for the integration project. They saw this underfunding as a major cause of the various structural obstacles to integration mentioned above: physical space constraints, insufficient personnel for key care-provision functions, obsolete technologies.

Clinical-administrative processes

Six main process-related factors were seen as having a determining influence on nursing practices to support integrated care, involving both administrative (governance mechanisms, service organization, quality and performance management) and clinical aspects (introduction of care integration roles, support for interdisciplinary team work, capacity strengthening).

Governance mechanisms

With respect to governance, participants first highlighted efforts made by the organization to promote a shared vision of care integration and to set some broad orientations. In particular, these efforts took the form of activities to involve different groups, including nurses, in developing an organizational project and a strategic plan for the institution. Such activities included, for example, days of reflection, consultation meetings, training sessions, collective problem-analysis approaches, and problem-solving discussion groups or workshops. Another strategy seen as facilitating was the implementation of governance structures to ensure collective responsibility for the integration project and allow shared leadership to be developed at all levels of the organization. This resulted in participative management approaches that included, among other things, interdisciplinary workshops, working committees at different organizational levels involving employees from different shifts and points of service, the use of various spokespersons representing different groups in the organization, and a relative increase in clinical-administrative meetings through which the contributions of the different organizational groups could be solicited. Nurses in the different pathways were engaged to varying degrees in the process of carrying out the clinical project. The Nursing Directorate itself (which includes the Director of Nursing at the HSSC and plays a key role in all strategic decisions related to the organization and delivery of care and services) invested in promoting a cross-disciplinary view of patient care, using clinical nursing consultants. At a more operational level, nurses were directly involved in developing the care pathways. The mental health liaison nurse developed a process for emergency room triage assessment of patients with mental health problems that enabled them to be referred more rapidly to the appropriate service. A clinical nurse consultant with a master’s degree developed and implemented a project to evaluate high users of emergency room services, with mechanisms for interdisciplinary follow-up of these patients (COPD). Participants interpreted these various activities as developing an integration-oriented culture that was based on providing more opportunities for interactions among the actors (health professionals and managers), creating a variety of spaces for collaboration and learning, and involving the actors in various collective learning processes.

Nevertheless, despite the efforts that had been made, participants noted various gaps in governance that explained the delays seen in service integration. In contrast to the ideal of shared leadership originally espoused, leadership was fragmented among different departments whose interventions were not sufficiently coordinated, which impeded care continuity in the care pathways. One respondent in mental health explained, for example, that for a mental health patient with multiple pathologies, the departments of physical and mental health needed to work together, which was not always the case. Moreover, while the subcultures of certain units or institutions (e.g. CLSCs, primary care mental health services) are very much accustomed to interdisciplinary work and referral mechanisms, other settings, such as hospitals, have maintained a culture of working in silos. Another problem mentioned by several participants was the different actors’ varying levels of involvement in the change process, depending on their settings. Some nurses in the COPD pathway working in the medical unit expressed frustration at feeling marginalized in these change processes.

“It’s a big machine, things are complicated. Before, it was smaller. Was it better? I don’t know. Sometimes the trouble arose from questions of values between groups. Adjustments have to be made on all sides; departments, managers, coordinators, practitioners. There are many small cultures that have to be plugged in (ASE) …Things change, there are links that form, we weren’t as closely tied to the CLSC before. In some ways, it’s also gotten more weighed down. People don’t quite know who to refer to anymore when there’s a need” (MHS) (free translation)

They reported that they had not been involved in any way in the change process, not due to lack of interest, but rather because they had not been given the opportunity. Other participants noted that some professionals were reluctant to engage in the change processes for various reasons: misgivings, negative perceptions of change, lack of information. Rumours circulating to the effect that a number of nursing positions in secondary care (e.g. intermediary resources) in the MHS pathway would be cut in order to open nursing positions in primary care (e.g. home care) naturally raised concerns among the nurses involved.

Service organization models

In this area, participants referred to various service reorganization processes and clinical-administrative instruments that were associated with better patient management and with the capacity to provide a better-coordinated range of services. They spoke about three types of processes. The first were processes to strengthen links between primary and secondary care teams. One example was a program of shared services between the two levels. There was a significant service to support general practitioners in the territory, wherein a contact psychiatrist helped clarify diagnoses and made recommendations regarding medical treatments. The second type involved processes and tools to facilitate patient navigation of the system and refer them to the most appropriate services. This involved developing, for example: detailed maps of MHS pathways; protocols to guide follow-ups and transfers to appropriate services; service provision guidelines for the oncology nurse navigator or for nurses managing the wait list; mechanisms to clarify the roles of professionals providing ASE services; and intervention instruments, such as decision-support tools and intervention plans tailored to the patient’s condition for ASE nurses. The third type of process consisted of grouping together in one location a set of complementary services provided by an interdisciplinary team to respond more effectively to the needs of certain types of clienteles (e.g. intake clinic in respirology, palliative care centre, general practitioner/psychiatrist shared services program). However, certain obstacles were mentioned as factors that impeded the above-mentioned processes.

“There again, everything goes to secondary. There’s an issue there. So, do I try to make secondary care more competent to provide services to patients with serious conditions, to make it functional and efficient? If so, that’s excellent, but what do I do with primary care that then isn’t keeping up? This takes some thought. It’s the major challenge” (MPOC) (free translation)

The obstacles included, among others: resources being concentrated in secondary care, slowing the deployment of primary care services; a lack of knowledge about the range of existing services, both among patients and among the professionals themselves; professionals’ scope of practice often being defined more by their position or assignment to a given unit than by patients’ needs; and a narrow conception of care pathways that only partially covers patients’ real needs. The inclusion criteria determining patients’ access to certain care pathways were seen as limiting the management of a variety of situations, especially for patients with multiple pathologies. For instance, professionals working in the COPD pathway could not manage on their own the substance use problems presented by some of their patients.

Quality and performance management

In this area, participants listed three facilitating factors as levers used to foster nursing practice aligned with organizational orientations regarding care integration. The first had to do with the professionals’ efforts to align care with best practices. For example, in ASE the nurses and physiotherapists adopted the same practices for mobilizing residents, based on evidence drawn from the literature. In another case, a pressure sore protocol for patients receiving terminal care at home was adopted by the key professionals involved: nurses and occupational therapists. The second factor had to do with the organization’s vigilance in compiling statistics on several nursing-sensitive quality indicators. These indicators included, among others: smoking cessation rates (nicotine addiction clinic); numbers of hospitalizations and lengths of stay; effectiveness of patient education activities in relation to symptom management (COPD clinic); levels of service use (high users of emergency services); numbers of consultations (oncology nurse navigator, primary care mental health nurse, ASE wait list managers); and occupancy rates for stretchers in psychiatric emergency or in palliative care. The third factor involved reports that were required to be submitted to various internal and external bodies (regional agency; accreditation bodies; professional associations; local complaints commissioner; users’ committee; quality assurance committee; council of physicians, dentists, and pharmacists; council of nurses; etc.) regarding services, including those provided by nurses. Participants associated several of these reporting instruments with a desire to assess nurses’ performance, whether directly or indirectly: staff and patient surveys as part of the accreditation process; patient satisfaction questionnaires; stretcher occupancy rates in MHS; and incident/accident reports.

According to participants, however, implementation of these performance management tools masked several significant limitations. The instruments (measurement tools, information systems) used to measure the quality of nursing services were still considered inadequate. Several new roles had been introduced (e.g. palliative care nurse navigator, COPD liaison nurse) and had not yet been formally evaluated.

“Unfortunately, we know that performance associated with stretcher occupancy rates is more important than the level of performance in quality of care. A drop in performance could mean we risk losing stretcher to [physical] medicine for example. In all that, is the quality of patient care really being evaluated?” (MHS) (free translation)

The gap between needs and resources, as well as the pressure associated with certain performance requirements (mainly in terms of service volumes), generated significant stress for the personnel. In the MHS ambulatory clinic, a key performance indicator was the number of patient assessments performed daily. The oncology unit’s recognition as a regional cancer centre depended, among other requirements, on the number of patients managed by the nurse navigator.

Introduction of care integration roles

In this area, participants referred repeatedly to several new nursing roles that were considered integrative roles: liaison nurse, nurse navigator, nurse clinician consultant, case manager, network professional. These roles were seen as levers for improving the coordination of services for certain target patient groups, for supporting them in transitioning among different levels of care, for ensuring more rapid access to certain professional resources, and for optimizing the use of those services through more accurate referrals of patients needing them. The oncology nurse navigator contributed to care integration by orchestrating the oncology patients’ medical records. At work, she was available to respond to her patients’ needs, made connections between the various health professionals (e.g. multidisciplinary team) involved in patients’ care, and ensured that patients were appropriately followed both outside and inside the department of oncology, as needed. The liaison nurse in the medical unit contributed to the COPD care integration process by mobilizing necessary resources and linking with professionals to ensure patients continued to be followed, mainly after discharge or upon returning home. The ASE nurse clinician consultant looked after the quality of care provided to elderly patients by all institutions in the network. Based on her comprehensive overview, she ensured that nursing services to these patients were optimized; she did clinical coaching and developed tools, protocols, and collective prescriptions; and she trained teams in collaboration with physicians and pharmacists.

However, participants noted many obstacles to full deployment of these new roles. Several participants reported that a significant proportion of clinicians and managers had a poor understanding of these roles and their potential, resulting in under-utilization of the persons in these roles. Another major difficulty had to do with financial constraints, which often made it difficult to ensure the sustainability of positions associated with these roles.

“I could see myself intervening more in complex care situations. I am not being used at full capacity. Since I can move between facilities, I could easily act as a bridge between situations, which is not often enough the case” (POS) (free translation).

Finally, because these roles were not very standardized in terms of how they were defined and enacted, they varied considerably depending on the specifics of different settings and professionals. The resulting ambiguity added to the complexity of collaborating with other members of the interdisciplinary team, thus impeding integration of care.

Support for collaboration

On this theme, participants referred to four types of activities they perceived as being levers for promoting collaboration among team members and for coordinating their interventions more effectively.

The first type of activity involved strengthening methods of communication and transmission of clinical information. The progressive deployment of computerized medical records in all the CSSS settings was perceived as an important resource for transmitting clinical information. In addition to the computerization of medical records, various activities were used to develop new tools for exchanging information, making referrals, and following patients. The second type of activity consisted of putting in place shared working tools to improve patient management: progressive implementation of the nursing treatment plan, in which all nursing team interventions were recorded; development of standardized protocols and care tools based on best practices, involving collaboration between physicians and nurses. The third type consisted of increasing opportunities for intra- and interprofessional interaction by making more dedicated spaces available; holding monthly meetings and admission/discharge meetings in the ASE pathway; attendance at regional interdisciplinary round tables by nurses in the MHS pathway; and initiatives that were currently being introduced to hold more systematic interdisciplinary and team meetings in the MHS pathway. The fourth type of activity consisted in creating or strengthening roles dedicated to clinical coordination. Nurse clinician consultants, nurse navigators, and liaison nurses were working to support teams in adopting new practices and working tools and in coordinating their interventions more effectively. The RISPA nurse (Réseau intégré de soins pour la personne âgée—Integrated network of care for the elderly) was mandated to coordinate the activities of all professionals involved in providing care to elderly patients. An oncology nurse was assigned to manage all transfers to palliative care and to ensure coordination among the various professionals and managers involved in these transfers.

According to participants, the possibilities associated with these various activities were constrained by several factors: a lack of human resources; difficulties encountered by the people in these positions making themselves available for team activities, such as interdisciplinary meetings; a lack of preparation for interdisciplinary work; difficulties encountered by some professionals in interacting or sharing information with others; variability in the opportunities available to different professionals depending on their work context (e.g. fewer opportunities for interaction among persons working evening and night shifts, or working in relative isolation—such as the smoking cessation nurse—or even those in care units where the culture of holding interdisciplinary meetings was less developed).

“One mentality and philosophy that should be changed would be to remove the words ‘my patient’ from our vocabulary. It’s ‘our patient’ or ‘the patient you referred to me’… Also, to see other professionals as complementary, rather than as threatening. There are people who want to do everything with their patient, rather than using the strengths of everyone, which would enable the person to move forward … and bring other ideas and intervention possibilities to our team discussions” (MHS) (free translation).

Capacity strengthening

In this area, participants referred to the organization’s investments in two main types of activities that supported nursing practices to support integrated care. First, the implementation of care pathways gave nurses access to several new learning opportunities. Interdisciplinary meetings, involvement in the development of new tools and service models, and participation in working committees were perceived as opportunities to acquire knowledge and develop competencies needed to implement more integrated care. Along the same lines, participants highlighted the support received in communities of practice and in intra- and interdisciplinary co-development groups. In POS, for example, the tumour board, made up of members of the medical, professional, and nursing team, provided regular opportunities to discuss complex cases and reach consensus on the best treatments. Second, the organization had engaged nurse clinicians, nurse consultants, nurse navigators, and liaison nurses in a series of activities aimed at offering formal training activities, promoting self-study activities, and providing clinical support to nurses, such as through coaching or mentoring. Nurses with a particular expertise were invited to present training capsules or lunch conferences on topics of interest related to best practice development.

“Certainly, having moments to think, to review your situation, and to create the opportunity to share with other practitioners, it’s amazing how enriching it is, but it’s not easy within the organization or for a nurse in the SAD [home support] who has to answer for her day’s caseload” (MHS) (free translation).

The main obstacle to implementing these activities was nurses’ lack of availability, in contexts often characterized by inadequate staffing or excessive workloads. In addition, because of the physical distances involved, training tended to be designed for each setting rather than around care pathways, making standardization more complex.