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Table 3 Influencing factors identified pre- and postimplementation

From: Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study

 

Pre

Post

Illustration/citation/score (data source)

Facilitating factor

Participant responsiveness: participants (nurses and patients) are positive about the content and effects of Lively Legs

X

X

- “I think the main value of the program is that it offers a structured method you can use in your clinic hours. All topics that you normally would or would not discuss, they now will be addressed for sure with the program.” (case 5, nurse practitioner)

- Patients valued the program as an 8.4 on a scale from 1 to 10 on average (range 7–10) (data from patient questionnaires)

- Nurses gave an overall program score of 3.8 on a 1 to 5 scale on average (range 3–4) (data from nurse questionnaires); nurses gave an average score of 3.6 on a scale from 1 to 5 on how satisfied they were with the extent to which they were satisfied with the achieved behavior change per patient (range 2–5) (data from evaluation forms)

Possibility to educate oneself on lifestyle counseling was appreciated by nurses

X

X

- “I notice that I use what I learned in the Lively Legs educationand that I use it also in other patients. PersonallyI am more aware of interview techniques, how to start a conversation about it, and showing exercises that people can use.” (case 1, homecare nurse)

- “I was very enthusiastic after the educational meetings. I use what Ive learned, actually in different situations. When I see patients at their homes nowyou always mention lifestyle issuesbut now I do this more completely and I say things in a different way.” (case 2, homecare nurse)

The program gives opportunities to improve professional relationships and collaboration in the region

X

 

I hope we can improve the care for this patient group in this region, to come closer to some kind of collaborative care model or protocol. Then this project would really be regarded as successful” (case 2, homecare manager)

Standardized care process and collaboration between homecare and outpatient clinic

 

X

- “We have set uphow do you call ita safety net. We just have to ask these fixed questions to every patient…. That it is so well organized at our clinic, with this standardized care processI think at our clinic patients dont slip through.” (case 3, dermatology nurse)

- “Actually, I think at our clinic, I know every patient who comes for wound care or compression therapy. I have made myself an overview of which patients I have asked and which ones I have included in the program.” (case 4, dermatology nurse)

Nurses’ own practice hours

 

X

- “… We have the flexibility to scheduleehmYou see, last time we could easily decide that, because one patient did not show up and I thoughtlets just do the lifestyle assessment right away.’ Otherwise, like today, I would schedule the appointment for next week.” (case 5, nurse practitioner)

Hindering factor

No insight in how to recruit patients for the program

X

X

- “I just want to get those referralsautomatically. I will not, every time, because it takes me at least one hour, need to screen the electronic registration system. That just does not work.” (case 2, specialized wound care nurse)

- “I dont have an overview on all referralsNow and then I see a form that has been filled in and then I catch that one.” (case 2, dermatology nurse)

- “…Especially the problem how do you get others to refer to you? And how can you make sure that those agreements are guaranteed? When you work at the outpatient clinic you, are closer and you see these patients yourself.” (case 1, nurse practitioner)

Competition between healthcare organizations

X

X

- “I have bad luckThere are two main primary care practices in this village. Both are now only doing business with the other homecare agency. So, both will not refer patients to us.” (case 1, homecare nurse)

- “I could have referred more patients to her. ButI was told not to. They say, no, you cannot do that because our company delivers homecare to these patients and we dont want company X going to these patients as well. It is just fear that patients will like the nurses from company X better and that we will lose clients to our rival.” (case 2, specialized wound care nurse)

The program is perceived as an extra task with no extra reimbursement

X

 

- “The counseling should be part of the current reimbursement for venous leg ulcers. It would be right if the extra costs are compensated by the healthcare insurer. Are any finances available for this program?” (case 3, manager outpatient clinic)

In rural regions, homecare nurses would have to drive long distances or many homecare nurses would have to be trained to cover the area

X

 

- “If you train just one or two nurses for this whole regionYou see for us it isnt efficient to let them drive from village to village, from patient to patient.” (case 2, homecare manager)

Who should lead the project (due to changing managers)

X

X

- Pre-implementation: in four out of five cases, the outpatient clinic manager changed positions

- Researcher: “So, if I understand you right, you say that part of the implementation problems can be put down to the management?” Nurse: “Yes, they dont exactly accelerate the project if you know what I mean. It takes a long time. They have other kinds of problems, I understand that. But now this project may get stranded. …Honestly, I would love to go to the manager and say, hey there, youve promised this to us.” (case 3, dermatology nurse)

Nurses’ motivation

 

X

- “I should have made more inquiries before I started this project. What is it exactly, what do I have to do and what are others supposed to do? Its just what I said before: Ive been saddled with this project.” (case 2, homecare nurse)

- “Yeahwell real barriersno not reallyThat it didnt succeed was mainly because of me.” (case 4, homecare nurse)

Organizational preconditions (nursing time, consulting room)

X

X

- In three cases, agreements on nursing time were not (totally) met. There were no problems with respect to the availability of consulting rooms. Nurses valued the extent to which organizational preconditions were met with 3.3 on a scale from 1 to 5 on average (data from nurse questionnaires).

- “I can hardly schedule appointments. Because, well I only work on Wednesdays. I want to combine the counseling with wound care consultations andwell if the doctor is not doing clinic hours that Wednesday for exampleIt is difficult to arrange and before you know it is three weeks later.” (case 2, dermatology nurse)

Knowledge and support of colleagues

 

X

- Colleagues scored a 4.5 on a scale from 1 to 5 on average (range 4.2–5.0) with respect to knowledge of the program (data from questionnaire colleagues)

- Nurses scored a 3.3 on a scale from 1 to 5 on average (range 2–5) to the extent to which colleagues were supportive of them in implementing the program (data from questionnaire nurses)