Challenges and Opportunities of MARSHALL, a community-nursing project in Alessandria's Local Health Authority: a qualitative analysis

This contribution is part of our series of blog posts by students at MCI | The Entrepreneurial School^®. The views expressed are those of the students themselves and are intended to inform and stimulate discourse.

Introduction & Problem Statement

The rise in chronic and degenerative diseases is undermining the effectiveness and sustainability of healthcare systems. In Italy, 5.2% of the population (3.15 million individuals) required daily assistance in 2019, with elderly individuals over 75 years being most affected. The 2020 pandemic highlighted the urgent need for reorganization, particularly in territorial primary care. The 2021 World Health Summit's "Declaration of Rome" emphasized the need to shift from a hospital-centric approach to a more accessible model. Introducing the family and community nurse (FCN, IFOC in Italian) is a proposed solution to provide support, advice, and primary services to patients, caregivers, and families. The World Health Organization (WHO) recognized this role's importance in 1998, but its implementation varies across Europe due to cultural, political, and economic factors. Even within countries, there is often inconsistency in employing and integrating these nurses into healthcare systems.

Given the FCN's significance in primary care and assisting a large portion of the population, this study aimed to overview the legislative history and current implementation of community nursing in Europe, focusing on Italy. The research examined the MARSHALL project, a community nursing initiative within the Alessandria Local Health Authority. The project aims to provide comprehensive care for patients with motor neuron disease through integrated health and social services, forming a multidisciplinary team to develop individualized care plans.

The study identified primary barriers and facilitators for the project's success through stakeholder interviews, offering insights into the challenges and opportunities faced by healthcare professionals and patients. The research questions focuses on the challenges and possibilities of implementing a community nursing project and the current and future status of the IFOC role. The findings aim to guide future implementations and enhance the effectiveness of community nursing within the National Health System (NHS).

Methods

The method chosen were qualitative methods through semi-structured interviews. The qualitative analysis provided complements the quantitative analysis performed by the Biostatistics department of Alessandria’s Hospital.

Data Collection: Semi-structured interviews were conducted to identify barriers and facilitators, covering roles, communication, goals, design, implementation, patient relationships, and community nursing. The interviews were open-ended and allowed for follow-up questions (Adeoye-Olatunde & Olenik, 2021).

Sampling: Initial purposive sampling involved contacting key project directors and social services, followed by snowball sampling to include additional healthcare professionals. The patient and caregiver sample was limited, which represents a study limitation.

The final sample was composed by 16 persons involved in almost all phases of the project: IFOCs, directors, social services workers, physiotherapist, GPs, caregiver, patient associations representative.

Results

The MARSHALL project aimed to enhance primary care by integrating the IFOC into the healthcare system. Local Health Authority (LHA) directors and managers praised the IFOC role for its proactive approach, comprehensive family care, and emphasis on empathy. IFOCs were viewed as primary references for families, transitioning care from reactive to preventive.

IFOCs characterized their role as case managers, providing nursing care, handling bureaucratic tasks, and networking with other operators. However, interviewed GPs had concerns about unclear instructions and guidelines from the LHA, resulting in a lack of consensus regarding the IFOC role. Some GPs saw IFOCs as extensions of their services, while others viewed them as coordinators rather than direct caregivers.

The project, influenced by legislative and patient association input, aimed to establish integrated primary care but faced challenges meeting DM77 standards due to personnel shortages. While team multidisciplinarity and regular meetings were beneficial, meetings became less frequent over time, with communication shifting to phone calls and WhatsApp.

The interdisciplinary nature of the IFOC role initially caused confusion regarding task division with GPs. Effective communication strategies eventually optimized workflow. Collaboration with social services was crucial but still not fully operational and, as IFOCs addressed social issues and coordinated with various professionals.

IFOCs valued the additional time spent with patients compared to their previous roles as ADIs (home care nurse). However, the educational program for IFOCs was deemed essential but lacked practical preparation, suggesting the need for more practical training with GPs and primary care specialists. Low enrolment in the IFOC Master's program was attributed to unclear role definitions and future prospects.

In conclusion, while MARSHALL showed potential for integrating IFOCs to improve patient care, challenges such as personnel shortages, unclear guidelines, and communication gaps hindered its full potential. Recommendations included enhanced training, better collaboration with GPs, and increased personnel for future implementations.

Conclusion

The study highlights the necessity for innovations in primary care due to the increasing prevalence of chronic diseases, the ageing population, and the high demand on emergency departments (EDs). The introduction of the Family and Community Nurse is intended to redirect patient needs away from EDs and implement a comprehensive, patient-centred care routine. However, the integration of IFOCs into the Italian National Health Service (NHS) has been inconsistent.

The MARSHALL project in Alessandria and Valenza evaluated the effectiveness of IFOCs. Stakeholder interviews reveal positive outcomes, with the new care path being well-received by directors, healthcare personnel, and patients. The project promotes a proactive approach to medicine and has high patient enrollment. However, barriers include fragmented communication with General Practitioners (GPs), limited personnel availability, lack of structural integration with social services, and unclear roles for IFOCs initially.

The recommendations for improvement include expanding disease coverage, developing a shared clinical record system, improving collaboration with GPs, and creating a separate department for IFOCs. A comparison of similar European models highlights key elements for success at the macro, meso, and micro levels, including laws, healthcare system structure, organisational culture, collaboration, training, and patient involvement. The study calls for further research to understand decentralised integrated primary care and suggests broadening the implementation of IFOCs to various contexts. This study emphasises the importance of a shift from reactive to proactive care, and thus serves as a valuable resource for policymakers and healthcare providers alike, offering insights into the key factors for successful primary care innovations.

Bibliography & Other Relevant Literature

Adeoye-Olatunde, OA., Olenik NL. (2021). Research and scholarly methods: Semi-structured interviews. Journal of the American College of Clinical Pharmacy, 4(10), 1358-1367. https://doi.org/10.1002/jac5.1441

Bagnasco A., Alvaro R., Lancia L., et al. (2023). Protocol for evaluating quality and safety for the public through home care nursing in Italy: a multicentre cross- sectional descriptive observational study. BMJOpen;13:e071155.doi:10.1136/bmjopen-2022-071155

Caristia S. (2020). L’infermiere di famiglia e comunità in Piemonte: una professione in crescita. IRES Piemonte, Relazione Annuale 2020, Background Paper

Conti A., Albanesi B., Busca E., Martini L., Costa C., Campagna S. (2021). L’infermiere di famiglia e comunità: panoramica sull’esercizio della professione in Europa. ASSIST INFERM RIC 2021; 40: 131-136

Italian Government. (2012). Decree Law 158/2012, “Disposizioni urgenti per promuovere lo sviluppo del Paese mediante un piu' alto livello di tutela della salute” 13/09/2012, n.158

Italian Government. (2020). Decree Law 34 of the 19 May 2020, “Misure urgenti in materia di salute, sostegno al lavoro e all'economia, nonche' di politiche sociali connesse all'emergenza epidemiologica da COVID-19”, converted into law n.77 of the 17 July 2020

Italian Government. (2022). Decree Law 77/2022, “Regolamento recante la definizione di modelli e standard per lo sviluppo dell'assistenza territoriale nel Servizio sanitario nazionale”, 23/05/2022

WHO (1998). Health21, An Introduction to the Health for All Policy Framework for the WHO. European Region Series, ISBN 92 890 1348 6 ISSN 1012-7356

WHO - Regional Office for Europe.(2000). The family health nurse: context, conceptual framework and curriculum. World Health Organization. Regional Office for Europe. https://iris.who.int/handle/10665/107930

Zainal Z. (2007). Case study as a research method. Jurnal kemanusiaan, Vol. 5 N. 1