F2PL: Implementation and evaluation of a support
strategy for the implementation of practical guides for
clinical nurses and social workers working in FMGs:
the educational intervention for the training of trainers
in front-line services.
Yves Couturier, Sylvie Massé, Gilles Gauthier,
Quebec Health Research Fund in partnership with the Ministry of Health and Social Services
6 Quebec family medicine groups located in 3 regions
Training of trainers, nurses, social workers, interprofessional collaboration, practical guides, shared decision-making
In September 2019, the Quebec Ministry of Health and Social Services (MSSS) launched two practical guides for clinical nurses and social workers who practice in FMGs. These guides enhance practice quality and promote interprofessional collaboration between these two professions. The research team offers to support FMG clinicians in adopting practical guides.
What are our goals?
Support implementing and deploying practical guides for social workers (TS) and clinical nurses (IC) in FMGs through an educational intervention to train clinical trainers who will operate throughout Quebec.
Clinical and organizational:
Develop and implement a training and implementation support program (educational intervention) in three phases with the changes in practice promoted by the two MSSS practice guides.
Document the best ways to implement the educational intervention within the targeted CI(U)SSSs and in the various participating FMGs.
Describe the process for implementing the educational intervention.
Evaluate the effects of the intervention on trainers, trainees, managers, decision-makers, physicians in charge and patients of the intervention.
Identify the conditions for scaling up the educational intervention.
To effectively support nurse clinicians and social workers in the appropriation of practical guides, the approach train-the-trainer is used during each of the project's three phases. This consists of training teams of clinical trainers who will, in turn, train teams of clinicians in their region. During the first phase, clinicians from six FMGs in Saguenay-Lac-St-Jean, Montreal and Abitibi-Témiscamingue were trained.
In the second phase, the training will extend to all the clinicians from all the FMGs in Saguenay-Lac-St-Jean, and in the third phase, the training will extend to all of Quebec. The training teams comprise 50% of patient partners because we firmly believe experiential knowledge is as necessary as theoretical knowledge.
Results pre and post-Phase 1
During Phase 1, which began in October 2019, 13 trainers were recruited. 11 were trained as trainers (four nurses, two social workers, and five patient partners). Grouped into teams, the trainers trained 33 clinicians, 25 nurses and eight social workers.
16 items were used to assess participants' reactions to the training
Perceived effects of training:
All trainers had high satisfaction with the training received (4.27/5 ± 0.79 (mean score)). They gave the Development Committee particularly positive marks (from 4.27 to 4.64/5) regarding their skills. In the different items assessed, the level of knowledge of the development committee was the highest-rated item (4.64/5 ± 0.50).
The qualitative validation of the data made it possible to identify the strengths of the training, the dynamism and the ability to communicate.
The following comments testify to the strengths:
"[Diversity in delivery formats and the ways to approach content [of training]. The trainers' dynamism. The trades between participants. There equipment planning (including housing and others)".
- (Social Worker 2)
Points to improve
The least rated element is the trainer's ability to apply the information learned(3.91/5 ± 0.51).
The qualitative validation made it possible to collect data explaining the reasons why the element presented was rated the least:
“[We would have needed] more time for group discussions…»
- (Patient Trainer 1)
"The section on interprofessional collaboration is too heavy for the time available; I think the content could have been more targeted and presented more dynamically and interactively to provide stronger anchors.”
- (Social Worker 1)
The trainers are dynamic and sympathetic. While mastering
their subject very well, they remain
humble and attentive to the group
- (Patient Trainer 2)
Perceived effects of training:
Clinicians also acknowledge being satisfied with the training (3.14/5 ± 0.95 (mean score)) and the competence of trainers(from 3.66 to 3.9/5). They appreciate the trainers' ability to make the training interactive (3.90 ± 0.77) and to communicate information (mean score of 3.90 ± 0.77).
The qualitative validation made it possible to collect the following data:
“[One of the highlights was the diversity of teaching methods, which made the training more dynamic.”
- (nurse 18)
"It was interesting to get together and learn what is done elsewhere in Quebec.”
- (Nurse 5)
Some clinicians reported that the improved train-the-trainer program responded to a need for support from the interprofessional team to solve specific problems already known in family medicine groups, as one of them explains:
Points to improve
Qualitative data shows that the training is not focused enough on the practice guides. Clinicians have mentioned that new ideas had been introduced but not thoroughly explored:
“There was a lot of time [during the training] to present what a family medicine group (FMG) is, a lot of time for the nurses, and there was not enough time in the end to discuss the points I had read in the [practice] guidelines. I would have liked to have had more practice, more time on the action plan than on the things we already do or that are not new concepts to us”.
The fact that we have a crucial
resource to help us solve problems that we have been trying to work on for years. It gives us a common language of the group of participants.
- (Patient Trainer 2)
Learning was assessed using 26 items to determine intention, trust and commitment from the Kirkpatrick model.
The analyzes show that trainers were less confident in the implementation of the training of trainers, in the training of clinicians and in the communication with the various stakeholders. Only one significant difference was observed before and after the training related to their ability to adapt to coaching (p=0.03).
Qualitative data helps to understand the low level of confidence of clinical trainers during pre-training data:
" The lack of openness and the reluctance to change operations to adhere to best practices.
-(Trainer-Social Worker 1)
“[It all depends on the asked doctors [of their willingness to collaborate to the project].
"I'm afraid I won't have enough time [to fulfill my role as a trainer in the context of my current tasks].”
However, post-training data demonstrate an increase in trainer confidence levels.
Pre- and post-training evaluations generally show an increase in items of clinician confidence levels with the exception of family medicine group management arrangements which decreased (p=0.03).
The most significant trends were observed for the following: integrating into the team (p=0.08), practicing collaborative leadership (p=0.06), and actively participating in problem analysis and resolution concerning the application of directives (p=0.09).
Validation of qualitative data revealed certain elements that have hindered the improvement of their confidence.
Four clinicians justified the drop in their level of confidence by a misunderstanding of their role, while others have raised the fact that sub-optimal collaboration with governance harms their trust:
" We need support [from officials] to make changes in the vision of the medical delegation about nurses' scopes of practice."
Engagement des cliniciens
Chacun des éléments évalués relatifs à l’engagement des cliniciens à utiliser les connaissances a augmenté. Ils ont démontré de l’engagement à se familiariser avec les processus des GMF (P=0.05), à s’intégrer à l’équipe (p=0.01), à assumer leur rôle (p=0.07) et à participer à la résolution de problème lié l’application des nouveaux guides de pratique (p=0.08).
Les données qualitatives ressortent les obstacles à l’engagement des cliniciens dans l’application des connaissances :
Malgré leur engagement élevé, les cliniciens ont signalé une diminution de leur intention d'appliquer les connaissances acquises dans le cadre du programme amélioré de formation de formateurs (p=0,02). Deux participants ont déclaré avoir d'autres priorités que l'amélioration de leur pratique professionnelle, la collaboration et l'engagement des patients, ce qui influencent leur intention.
Forces et limites
[Mon engagement] dépend de ma charge de travail et du soutien [de mon responsable] pour le faire.
Engagement of clinicians
Each evaluated element related to clinicians' commitment to knowledge use increased. They have demonstrated commitment to becoming familiar with the processes FMGs (P=0.05), integrating into the team (p=0.01), assuming their role (p=0.07) and participating in problem-solving related to the application of new practice guidelines (p=0.08).
Qualitative data highlights barriers to clinician engagement in knowledge translation:
Despite their high engagement, clinicians reported a decrease in their intention to apply the knowledge acquired under the enhanced train-the-trainer program (p=0.02). Two participants reported having other priorities such as improving their professional practice, collaboration and patient engagement, which influence their intention.
Strengths (+) and limits (-)
[My commitment] depends on my workload and support
[of my manager] to do so.
One of the first studies to include a team of trainers, including the patient's partner.
Integration of mixed data allows more richness and clarity to explain the results and identify barriers that can be removed.
Geographically relocated environments
No data collection at six months (COVID-19)
No data for other media (Transferability)
Sub-Project: Knowledge Assessment of Integrating Patient-Centred Care, led by Anaelle Morin
The objective of the sub-project is to understand how nurse clinicians in FMGs at SLSJ will appropriate the patient-partner approach and integrate it into their professional practice.
Using a descriptive qualitative approach will make it possible to describe in depth the changes in the practice of clinical nurses in FMGs following the training received. Individual or group interviews will be conducted to explore the practice changes made by nurses and the barriers and elements that facilitate adopting this new practice.
An inductive and deductive thematic analysis will be carried out, and emerging themes will be condensed to make proposals to answer the research question. Analysis and validation circles will be carried out with all the co-researchers of the F2PL team, including the co-responsible patients.
This project will provide a better understanding of how nurse clinicians in FMGs modulate their practices following train-the-trainer type training. This knowledge will facilitate the creation of new training and the strategies favoured by the Ministry of Health and Social Services to appropriate future practical guides.