Wiener-Ogilvie Sharon, Huby Guro, Pinnock Hilary, Gillies John, Sheikh Aziz
General Practice Unit, NHS Education Scotland, Edinburgh, UK.
BMC Fam Pract. 2008 Jun 4;9:32. doi: 10.1186/1471-2296-9-32.
Although the BTS-SIGN asthma guideline is one of the most well known and widely respected guidelines in the world, implementation in UK primary care remains patchy. Building on extensive earlier descriptive work, we sought to explore the way teamwork and inter-professional relationships impact on the implementation of the BTS-SIGN guideline on asthma in general practice.
Qualitative comparative case study using nine in-depth interviews and 2 focus groups with general practitioners and practice nurses, involved in delivering asthma care. Participants were purposively recruited from practices in a Scottish health board with high and low compliance with the BTS-SIGN asthma guideline.
There was a marked difference in the way respondents from practices with high compliance and respondents from practices with low compliance spoke about the value of guidelines and the challenges of implementing them. On both accounts, the former were more positive than the latter and were able to be more specific about the strategies they used to overcome barriers to implementation. We explored the reason for this difference in response and identified practice organisation, centring on delegation of work to nurses, as a factor mediating the practice's level of compliance. Effective delegation was underpinned by organisation of asthma work among practice members who have the appropriate level of skills and knowledge, know and understand each others' work and responsibilities, communicate well among themselves and trust each others' skills. It was the combination of these factors which made for successful delegation and guideline implementation, not any one factor in isolation.
In our sample of practices, teamwork and organisation of care within practices appeared to impact on guideline implementation and further larger studies are needed to explore this issue further. Isolated interventions such as measures to improve staff's knowledge or increased clinical resource and time, which are currently being considered, are unlikely to be effective unless practices are supported in developing their teams in a way which supports the deployment of these resources.
尽管英国胸科学会（BTS）与苏格兰校际指南网络（SIGN）联合发布的哮喘指南是世界上最著名且广受尊重的指南之一，但在英国初级医疗保健中的实施情况仍参差不齐。基于早期大量的描述性研究，我们试图探究团队合作和跨专业关系如何影响BTS-SIGN哮喘指南在全科医疗中的实施。
采用定性比较案例研究方法，对参与哮喘护理的全科医生和执业护士进行了9次深度访谈和2次焦点小组讨论。研究对象是从苏格兰一个健康委员会中，按照对BTS-SIGN哮喘指南的高依从性和低依从性，有目的地选取的医疗机构。
高依从性医疗机构的受访者和低依从性医疗机构的受访者在谈论指南的价值以及实施指南所面临的挑战时，方式存在显著差异。在这两方面，前者比后者更积极，并且能够更具体地说明他们用来克服实施障碍的策略。我们探究了这种反应差异的原因，并确定以将工作委派给护士为核心的实践组织，是影响实践依从水平的一个因素。有效的工作委派以实践成员之间对哮喘工作的组织为基础，这些成员具备适当水平的技能和知识，了解并理解彼此的工作和职责，相互之间沟通良好且信任彼此的技能。正是这些因素的结合促成了成功的工作委派和指南实施，而非任何一个孤立的因素。
在我们的实践样本中，实践中的团队合作和护理组织似乎对指南实施产生了影响，需要进一步开展更大规模的研究来深入探讨这个问题。目前正在考虑的一些孤立干预措施，如提高员工知识水平的措施、增加临床资源和时间等，除非实践机构在以支持这些资源配置的方式发展其团队方面得到支持，否则不太可能有效。
