Article Text
Abstract
Introduction Clinical pathways (CPs) are detailed longitudinal care plans delineating measures to be conducted during a patient's treatment. Although positive effects on resource consumption and quality of care have been shown, CPs are still underutilised in many clinical settings because their development and implementation are difficult. Evidence underpinning successful development and implementation is sparse.
Methods The authors conducted semistructured face-to-face interviews with key staff members involved in the design and implementation of CPs in a large surgery department. Interviewees were asked to provide opinions on various issues, which were previously identified as potentially important in CP development and implementation. The transcribed text was read and coded independently by two researchers.
Results Respondents highlighted the importance of a multidisciplinary participatory approach for CP design and implementation. There was a strong initial fear of losing individual freedom of treatment, which subsided after people worked with CPs in clinical everyday life. It was appreciated that the project originated from people at different levels of the department's hierarchy. Likewise, it was felt that CP implementation granted more autonomy to lower-level staff.
Conclusion The structured qualitative approach of this study provides information on what issues are considered important by staff members for CP design and implementation. Whereas some concepts such as the importance of a multidisciplinary approach or continuous feedback of results are known from theories, others such as strengthening the authority especially of lower-level health professionals through CPs have not been described so far. Many of the findings point towards strong interactions between factors important for CP implementation and a department's organisational structure.
- Clinical practice guidelines
- culture
- qualitative research
- surgery
- teamwork
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Introduction
Clinical pathways (CPs) are multidisciplinary longitudinal treatment plans. CPs describe all desired diagnostic and treatment steps to ensure continuity and coordination of care.1–5 CPs have been advocated as a tool to transfer available evidence and clinical guidelines to the patient's bedside.1 6–9 Numerous studies have shown that they reduce resource consumption and improve quality of care.10–13 However, CPs are still implemented well below their potential and frequently not adopted or respected by providers.14–17 One of the reasons is that CP development and implementation are difficult, resource-consuming and often hampered by resistance or insufficient staff involvement.8 16
Most studies on CPs focus on morbidity, mortality, cost and patient satisfaction.13 18–20 Few studies have assessed key factors related to development and implementation,13 21–32 with most21–25 28 30–33 based on theoretical concepts or the implementers' viewpoint rather than a structured scientific approach. We attempt to fill this gap with a qualitative study including key staff members involved in CP development and implementation in a surgery department.
Methods
Setting
The study was carried out in the surgery department of a German university hospital, which has 142 beds, treats approximately 5000 patients annually and employs 45 physicians and 99 nurses.
Organisation and structure of the department
The head of the department is the final decision-maker for all clinical and managerial matters. Consultants perform surgeries independently and give directives for the treatment of patients in specific units. They are directly subordinate to the head of the department and expected to consult him on difficult decisions. Residents perform surgeries or take relevant clinical decisions only under a consultant's supervision. This structure leads to a hierarchical organisation, where it is uncommon for junior staff members to introduce initiatives themselves. Nursing staff has its own hierarchy, with a head nurse as the overall manager and specifically trained nurses in charge of each ward. Physicians make all medical decisions; thus, the autonomy of nurses is very limited regarding issues other than those closely related to nursing. Other disciplines, such as anaesthesiology, are part of the treatment for only certain, defined periods.
CP development and implementation
CPs were first introduced in July 2006 for kidney transplantation. In April 2007, four CPs were implemented for thoracic surgery, followed by two for colorectal surgery in January 2008. CPs were introduced upon the initiative of one consultant, who obtained formal approval from the head of the department and was closely assisted by a junior resident. An interdisciplinary team of surgeons, anaesthesiologists and nurses, at all levels of hierarchy and with varying professional seniority (table 1), was involved in CP development and implementation. The consultant and resident acted as team leaders.
Data collection and analysis
Semistructured face-to-face interviews were conducted with key staff members involved in CP development and implementation in July/August 2008 (table 1). All interviews were conducted in German by AL, who was external to the department and not involved in the CP design or implementation. Respondents were asked to: (a) describe their experiences regarding CP development and implementation; (b) reflect on support and/or resistance from colleagues; and (c) characterise positive and negative changes induced by CPs.
Informed consent was obtained prior to the interview. All interviews were audio-recorded, transcribed and translated into English. Transcribed texts were read and coded independently by AL and MDA, who later compared and converged the findings. As a final stage of analysis, the experiences of the two project leaders were solicited in an open discussion to ensure the inclusion of both the initiators' and staff's perspectives.
Results
Findings are illustrated using verbatim translated quotations. Demographic information is omitted to preserve confidentiality.
Initial response to implementation
Seven of the eight respondents reported that CP development and implementation were initially met with reluctance. Some respondents themselves reported being initially sceptical. Others stated that they had experienced resistance among physicians and nurses not directly involved in CP development. Respondents at higher hierarchy levels expressed concerns about losing the opportunity of treating patients according to their individual judgement. Respondents at lower levels feared additional work.The initial scepticism was that pathways would restrict individualisation of therapy.
People need to be motivated (…) this motivation is lost due to the enormous workload.
In addition, in spite of their own personal involvement, many respondents felt that CP development and implementation had not been sufficiently participatory. Respondents indicated that many colleagues viewed CPs as an imposition. Respondents reported that the briefing sessions preceding implementation had been insufficient, leading to an initial information gap regarding the initiative's benefits.People must be motivated in a better way, rather than just presented with a ready-to-use pathway. People should meet as a team and listen to opinions of the nursing staff and tell them what advantages pathways offer.
Respondents greatly appreciated that CP implementation had been initiated and led not by the head of the department, but by two subordinates at lower hierarchy levels.Usually, the boss commissions the development of a new initiative. But in this case (…) his staff members initiated the pathways and asked for his green light.
Delayed response to implementation
All respondents indicated that resistance decreased as implementation proceeded. At the time when the interviews were conducted, most physicians and nurses viewed CPs as beneficial. This progressive attitude shift was motivated by the fact that physicians and nurses alike could directly observe CP benefits for patients and staff. Respondents also noted that internal dissemination of early results on improved quality increased acceptance.Not all staff members adhered to the pathways during the initial implementation stage. This general appreciation developed with some delay.
Results on the development process were fed back. This created trust and acceptance.
Respondents felt that CPs facilitated the work of junior physicians and nurses by providing clear instructions for everyday practice, making them more autonomous from senior staff. Physicians at higher hierarchy levels indicated that CPs provided clear guidance without limiting their ability to make individual decisions. All respondents acknowledged that CPs improved efficiency in terms of communication and collaboration between the many parties involved in care.Now nurses do not need to ask physicians at every step, because things are predefined.
Now everybody who takes an individualised decision (…) must think of why this is done and why deviation from the pathway is necessary. The anticipated disadvantage of ‘cookbook medicine’ has not turned out to be true in practice.
Respondents felt that they could not judge what benefits CPs brought in terms of increased quality and reduced costs, but greatly appreciated how they enhanced transparency of treatment. In particular, nurses found this beneficial for interactions with patients.Patients are in a state of pronounced uncertainty. Every measure that ultimately reduces this feeling is positive.
Discussion
This study assessed key issues in CP development and implementation. Compared with previous work based exclusively on project initiators' subjective views,21–25 28 30–33 our study gives a more comprehensive account of the issues at stake by employing structured methods to explore the experiences of interdisciplinary staff members at all hierarchy and seniority levels. To our knowledge, there is only one previous study using structured qualitative methods to assess CP implementation.34 In addition, the use of an external interviewer and external analysts minimised bias. A drawback of our study is its small sample size, which was due to the single-centre design and limited number of people actually involved in the project. Since the focus was on CP development and implementation, staff that later participated in CPs were purposely not interviewed. Their views are undoubtedly valuable but constitute material for a separate study. Given the described limitations, our findings primarily apply to the specific setting in which the study was conducted. Therefore, generalisations to other settings might be limited.
CPs were initially met with reluctance. In line with the literature, respondents recognised the cohesiveness of the multidisciplinary team as a key success factor for effective implementation.6 8 9 21 22 25 27 28 31 33 34 It was almost unanimously reported, however, that such cohesiveness was not sufficiently achieved, at least during the early stages. The implicit criticism was that a ‘top-down’ approach was taken towards CP development and implementation without sufficient participation, especially of the nurses. Interestingly, this criticism emerged in spite of the fact that the project initiators felt they had done everything to create a participatory atmosphere and involve nurses from the very beginning to foster the sense of a ‘bottom-up’ project. It is likely that the initiators' efforts to create a collaborative atmosphere were not sufficient to counteract underlying hierarchical norms, which govern relationships between people at different levels within a surgery department.35 36 In spite of being part of the development team, nurses might have not felt sufficiently empowered to contribute actively to CPs and thus felt marginalised within the team. This suggests that underlying hierarchical structures cannot be easily overcome by single initiatives. Conversely, although standard in many international settings,6 8 37 38 the integral involvement of nurses in a quality improvement project from its inception constituted a ‘revolutionary’ approach for the department. For many staff members, this might have appeared unconventional, since it broke existing boundaries between disciplines. However, it later proved to be crucial for the initiative, as it progressively fostered a new sense of collective ownership and collaboration. Together with the finding discussed above, this highlights how the specificities of a given setting ought to be considered to secure successful CP development and implementation.5 16 39
Respondents emphasised that efforts made to continuously feed back ad interim results increased CP acceptance. Such internal feedback was previously identified as a key success factor in increasing direct participation by providing a venue to collect suggestions for improvement.23–27 29 39 40 Incorporating such suggestions into existing CPs can initiate a sustainable positive cycle, rewarding staff for their contribution and increasing motivation to collaborate.21 23 41
In contrast with the notion that ‘champions’ are important for CP implementation,21 22 26 41 respondents did not value the need for such prominent leaders. The two project initiators were appreciated for their initiative in a setting where most new projects are carried out by direct or indirect order of the head of the department. They were viewed, however, as team facilitators rather than ‘champions.’ This experience differs from opinions advocating the need for an external project leader.22 An external leadership approach has the advantage that many project goals can be pursued without inducing conflict. Nonetheless, acceptance by the team may be hampered if the external facilitator is not perceived as a genuine member. Again, this indicates that there is not just one strategy for successful CP implementation but rather a need to work within existing structures and expectations.16 42
An issue of utmost importance in CP implementation is the preservation of the autonomy of single physicians and nurses.39 The argument most frequently raised against CPs is that they produce ‘cookbook medicine’ and preclude individually tailored treatments.1 5 26 43 44 Most higher-level physicians expressed this as their initial scepticism. CPs in fact represent a transition from ‘eminence-based’ to ‘evidence-based’ medicine.9 Furthermore, such fears did not materialise, as CPs did not limit therapeutic freedom, but simply introduced structured guidance. In line with previous studies, this allowed young physicians and nurses greater autonomy in making treatment decisions and communicating with patients.35 42 45 46 This resulted in an empowerment process that increased confidence in junior staff, as reported in another recent study.34 As it challenges traditional hierarchical structures, this element of junior staff empowerment may enhance or hamper CP development, depending on the specificities of the setting.
In summary, this study provides insights into the issues important for CP development and implementation. It shows how these processes should be embedded within the structure and culture of a department. Some results, such as the importance of a participatory approach and continuous feedback, have already been identified in previous publications. Other findings, such as the strengthening of authority and gain of staff motivation at all levels, have not yet been discussed. Given the limited scope of this study, efforts should be channelled towards replicating similar studies elsewhere and developing quantitative instruments to assess these issues. This would allow studies to be conducted with larger samples to quantify the association between certain variables and successful CP development and implementation.
Acknowledgments
We thank S Yamamoto and U Goldberger from the Mannheim Institute for Public Health, Social and Preventive Medicine for their language-editing efforts.
References
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.