Exploring organisational readiness to implement a preventive intervention in Australian general practice for overweight and obese patients: key learnings from the HeLP-GP trial

Background

Overweight and obesity are influenced by a range of physical, economic, political and sociocultural factors that interact to produce an obesogenic environment (one that promotes obesity in individuals and populations; Australian Institute of Health and Welfare 2017; Hobbs and Radley 2020). Although interventions based in primary care cannot address all these factors, a positive contribution can be made through individual risk assessment and identification, and the promotion of lifestyle interventions that emphase healthy eating, increased physical activity and support behaviour change (Forgione et al. 2018).

General practice nurses (GPNs) routinely participate in prevention. They are often the first contact for childhood and adult immunisation (Halcomb and Hickman 2016), and they are opportunistic providers of preventive care for smoking cessation, nutrition, alcohol consumption and physical inactivity (McElwaine et al. 2015). Evidence-based weight management programs utilising GPNs have shown some positive results in terms of patient outcomes and cost (Ross et al. 2008), and have been shown to be feasible, acceptable and valuable in the Australian setting (Gray et al. 2017), although not currently funded through Medicare.

Despite progress in developing and testing primary care interventions to support weight management, there is limited knowledge on the practicality of implementing and sustaining potentially effective interventions (Slater et al. 2022). This paper describes the experience of implementing a nurse-led obesity intervention in Australian general practice through the lens of organisational readiness.

Context

HeLP-GP was undertaken in general practices in New South Wales (NSW) and South Australia (SA) 2018–2019. The aim was to help overweight or obese patients to make positive lifestyle changes while assessing the value, sustainability and scalability of the nurse-led intervention. The methodology has been reported (Parker et al. 2018, 2022). In brief, 22 practices (11 intervention and 11 control) consented, and they recruited 315 patients (120 intervention and 95 control). GPNs were pivotal in the intervention (Table 1). They conducted a health assessment based on the 5As model of behaviour change (Glasgow et al. 2006), facilitated patient access to the mysnapp lifestyle app and/or telephone coaching (Get Healthy; Fig. 1), arranged patient appointments, and updated clinical changes in the medical record to enable accurate extraction of trial data.

Fig. 1.

HeLP-GP clinical intervention model.

The trial results have been reported (Parker et al. 2022). At 6 months, based on an intention-to-treat sample, there was a greater increase in the Health Literacy Questionnaire (HLQ) domain 8 score (ability to find good health information; mean DiD 0.22; 95% CI 0.01–0.44) and a small improvement in diet scores (increased fruit and vegetable intake; DiD 0.98 (0.50–1.47); P = 0.026) in the intervention group compared with the control group. This was not maintained at 12 months. No differences in eHealth literacy, physical activity scores, body mass index, weight, waist circumference or blood pressure were found.

Methods

Results

Practice and provider characteristics are provided in Tables 4 and 5. The assessment against organisational readiness domains for each intervention practice are provided in Table 6. One NSW practice did not recruit any patients and is not included in this discussion.

Leadership and communication

Leadership was notably ‘top-down’ in style. The degree of practice leadership observed was variable and often linked to the attributes of individuals rather than a practice-wide norm. Levels of leadership were influenced by staffing arrangements and the consistency or fluctuation of staffing levels. Difficulties establishing good lines of communication were experienced by ROs and facilitators. The primary contact in a given practice could be the GP, the practice manager, the GPN or a combination of these. In some cases, direct contact could be made with reception staff, whereas in others, it was via another discipline. Particularly difficult were those circumstances where access to the primary contact was poor (e.g. a message had to be left for the GP), where the primary contact worked part-time/weekends, and in practices where inter-office communication was disorganised. It was crucial to this research to identify the main contact at each practice, to build individual relationships and develop tailored methods for interactions. This, however, took time, and required considerable patience, interpersonal skills and flexibility. In some practices, the reception staff were consistent, in others, there were multiple receptionists working different shifts, or more than one receptionist working at a time. Lines of responsibility and accountability were frequently vague or hard to discern.

Intervention specific capacity

GPN skills, knowledge and ability to deliver the HeLP-GP intervention

GPNs were comfortable with the clinical content of the health check, which aligned well with their day-to-day clinical work. Despite this, ROs and facilitators reported significant ambivalence on the part of some GPNs to conduct the health checks, noting a mix of disinterest, reluctance and a lack of confidence to engage patients in the intervention. GPNs demonstrated variable success delivering the health checks. In total 73 of 120 (61%) consenting patients received the intervention (Fig. 2). At the point of health check, 14 patients withdrew, and 16 patients could not be contacted after three attempts by the GPN. The health check was not completed for two patients who received insufficient follow up by the GPN, and one patient who was too busy to attend. Two patients incorrectly received the intervention. GPNs successfully conducted 6-week follow up with 61 of 73 (84%) patients who had received the health check. The mean number of days between the health check and the 6-week follow up was 64.2 days (range 42–199 days), indicating that this was frequently provided outside the trial designated timeframe of 42 days.

Fig. 2.

HeLP-GP intervention summary.

Referral to Get Healthy and set up with mysnapp required attendance at the health check, and were therefore impacted when the health check was not conducted. Referral to Get Healthy could be initiated by phone, fax or email and did not itself present a barrier. Nurses, however, demonstrated variability in skill and confidence related to the introduction and set up of mysnapp. In the cases where GPN confidence was identified as a factor, additional facilitation was provided to encourage maximum uptake.

Within one Sydney practice that prioritised accreditation over the intervention, the GPN model was supplemented by two casual nurses employed by the research to complete the patient health checks. We subsequently also offered this alternative to other practices that were struggling with the completion of health checks, but the offer was declined.

Practice factors affecting the implementation of the HeLP-GP intervention by GPNs

Practices uniformly required a great deal more RO support than anticipated. Many practices required constant reminders and prompting to undertake tasks, and reinforcement about the reasoning behind these. Lack of time and workload were frequently cited as reasons for incompletion. We did not identify a clear program ‘champion’ at any of the practices (i.e. someone who actively supported the intervention and provided continuous leadership), although we did identify some individuals who had a stronger interest in the intervention and responded in a timelier way. We also did not identify specific people (or roles) within the practices prepared to advocate or promote significant changes, either to facilitate the intervention or because of the intervention. In at least half of the practices, the intervention was generally supported by the practice management (usually the GP/s); however, this did not appear to translate to the GPNs feeling supported to undertake the intervention. We identified six of 10 practices where GPNs expressed that they felt insufficiently supported from within the practice to undertake the intervention with patients.

Uptake of resources and the use of trial systems by nurses

An extensive range of resources were developed for the trial, and provided in paper, digital and online modes (Table 7). It was not possible to monitor the uptake and use of all resources, but online training for GPNs was generally well received. Although some GPNs were enthusiastic about the training, the completion of all three modules proved onerous for others, despite being in a format that could be done at any time, and be used to apply for professional and educational recognition. GPNs were not paid to undertake the training. The website designed to support processes and mechanisms for feedback by GPNs and GPs was generally poorly utilised.

Table 7.List of trial resources.

	Resource	Source	Audience
Facilitation	Primary health network flip book guide to facilitation visits	Microsoft teams	Facilitator
	Intervention facilitator diary of practice visits	Microsoft teams	Facilitator
Training	Modules 1, 2, 3	Smart sparrow educational platform via provider website	GPN, GP
Intervention	Overview of the HeLP-GP clinical intervention	Microsoft teams, practice package (hard copy), provider website	Practice
	DCP instructions	Provider website	Practice
	Protocol summary for GPs	Microsoft teams, practice package (hard copy), provider website	Practice
	Flow chart/flip book to support nurses to deliver health checks/follow up	Microsoft teams, practice package (hard copy), provider website	GPN
	Health check template	Practice package (hard copy), clinical software	GPN
	mysnapp information for practices – troubleshooting	Practice package (hard copy), patient website	GPN, Patient
	mysnapp information for practices iOS and Android	Practice package (hard copy), patient website	GPN, Patient
	mysnapp video	Teams, practice package, patient website	GPN, Patient
	Get Healthy referral materials	Teams, practice package	GPN

Over the trial period, most practices experienced some technical difficulties, particularly with internet connection and speed, which proved particularly problematic for GPNs when trying to set up mysnapp for patients. We had anticipated difficulties with the app set up and had provided detailed troubleshooting documents and a reference video, but we do not know the extent to which these were utilised. Nurses appreciated the guidance and support provided through the facilitation visits. We envisaged a total of three 1-h facilitation visits to each practice; however, an average of 4.7 visits were required (4.5 visits NSW; 5.3 visits SA). Facilitation 2 (the visit where the GPNs were briefed around the intervention), took an average of 98 min. This extra time was due to a combination of higher GPN need (unfamiliarity with apps, uploading health check templates and training to use trial software) and repeat visits due to GPN turnover. The distance of some practices from the research centre resulted in just over 5 h per practice of travel time (Table 8).

Table 8.Facilitation summary.

Average number of visits	NSW (8 practices)	4.5	Range 1–7
	SA (3 practices)	5.3	Range 1–8
	All practices	4.7
Average time spent (min) per visit:	Scheduling	9
	Travel	67
	Waiting	14
	Facilitation	48
	Follow-up visit 1 only	40
	Follow-up visit 2 only	98
	Follow-up visit 3 only	34

Discussion

Using an organisational readiness lens provides a valuable opportunity to reflect on factors influencing this GPN-led obesity intervention, and to provide context around the trial results. Despite the natural variation in the size, workforce, context and capacity of Australian general practices (NSW Agency for Clinical Innovation 2015), the identification of common organisational elements presents some broad observations and suggestions regarding the level of organisational readiness required for this type of nurse-led activity. Although we noted variation across all domains of the organisational readiness framework, the domain of intervention-specific capacity displayed the largest variation among practices.

Practice interest in this trial was largely driven by the ability to provide an in-house weight management program in response to growing numbers of overweight and obese patients. The HeLP-GP intervention was, however, not highly prioritised by practices, and the need to follow protocols, collect data and work within timeframes was frequently overlooked. We acknowledge that difficulties experienced with trial software and internet issues contributed to frustration and negative attitudes among some GPNs and receptionists, and the length of the trial (12–14 months) may have resulted in some research fatigue.

The turnover of GPNs was much higher and widespread than anticipated, and this severely impacted the trial. This affected both groups within the trial, with half of all GPNs who initially consented leaving at some point. Nurse turnover was experienced in half of the intervention practices, possibly contributing to reduced numbers of health checks, increased delays in follow up, and facilitation with the app and Get Healthy. This turnover may have led to delays with patients getting appointments, and some disengagement and dissatisfaction among patients with the intervention. We are unclear what this level of turnover represents, although nurse retention is a widespread problem in Australia (Dawson et al. 2014), and low satisfaction has been associated with poor retention among Australian GPNs (Halcomb et al. 2021).

The positioning of GPNs within general practice appears to have influenced, at least in part, the enthusiasm and willingness of some to participate fully in the HeLP-GP intervention. Although GPNs were frequently autonomous in their clinical work, we observed a general lack of practice-based support for them related to intervention delivery. Disorganised, dynamic environments and lack of strong leadership or ‘top down’ decision-making were observed, and this potentially contributed to a reduced sense of teamwork or lack of acknowledgement for the GPN (McInnes et al. 2015). Similarly, the lack of ‘champions’ for prevention and the project within the practice was an important deficiency, and has been noted in other research (Shaw et al. 2012). Despite efforts at recruitment to speak to and engage as many GPNs as possible, they were often not included in the decision to participate in the trial. GPNs’ time was reimbursed to the practice, but there were few direct incentives for the GPNs to participate (apart from a certificate for continuing education and a fitness tracker). This has been shown in other nurse-led weight management programs to cause poor ownership and commitment (Ross et al. 2008). Additionally, high turnover meant that many GPNs inherited a role they were not prepared for and possibly did not want. GPNs were responsible for the bulk of the trial responsibilities, including in many cases, coordination of the receptionists and the GPs. In part, intervention success was therefore reliant on the individual’s level of interest, expertise and availability (and in one practice this was enhanced by employing casual nurses). Many GPs and GPNs expressed concern at the outset about the possible impost on GPNs. Approximately 65% of GPNs were employed in the practice part-time, and it appeared that many GPNs were under-resourced to take on the extra work. Although some remuneration was provided through the trial, GPNs could not bill their time to Medicare.

The general profile of GPNs in Australia is one of varying levels of experience and training, compounded by the geographic location in which they work, the type of population they see and the parameters placed on their role by their employers (Australian College of Nursing 2019; Halcomb et al. 2021). GPNs are constrained by the lack of postgraduate opportunities for training relevant to general practice (Heywood and Laurence 2018) and a preference for roles geared towards procedural support tasks that can be reimbursed through Medicare (Henderson et al. 2014). In this trial, we observed substantially different individual levels of proficiency with intervention tasks, possibly due to variations in skill levels, confidence to provide education and motivational interviewing, interest, and/or priority. This has similarly been reported in other studies in which nurses support lifestyle risk reduction for obesity (Zhu et al. 2013; Phillips et al. 2014; Campbell-Scherer et al. 2019; Hinks 2022). Specific intervention training was provided, and monitoring and reinforcement provided through the facilitation sessions. Basic clinical tasks inherent in the health check (bloop pressure, body mass index, waist circumference etc.) and follow up of patients did not produce notable difficulties; however, we observed some difficulty/reluctance to get patients to attend the health check or to provide sufficient follow up to get patients through the intervention. Referral to the telephone coaching also did not prove problematic, but we noted low confidence among some GPNs with instructing their patients on mysnapp. It may have been this lack of confidence that resulted in low willingness to help patients to install the app or to teach them to use it. Although some GPNs were very comfortable with the technology, it may be a role that could be delegated to non-clinical community health workers with more time to support patients in its use (Li et al. 2022).

The HeLP-GP intervention aimed to assess the value, sustainability and scalability of a nurse-led model to provide prevention and management to overweight and obese patients. The challenges identified have implications for this in future. The option used in one NSW practice, where additional nurses were paid to conduct the health checks for enrolled patients, proved more efficient and generally more successful than using the usual GPN. Although this may be a suitable solution for short-term research, it is not a low-cost, easy to implement, scalable or sustainable model for general practice. Our experience suggests that undertaking a health check and undertaking lifestyle management for this population is a relatively complex organisational activity that requires more than training to integrate into daily workflow.

Strengths and limitations

The use of a recognised organisational readiness framework provides an additional avenue by which to build context around the HeLP-GP trial findings, particularly the structures, organisation and funding, which are important implementation considerations in this setting. The decision to assess organisational readiness was, however, done post-hoc. Quantitative data were obtained from a range of trial instruments, and qualitative documentation was collected by the ROs and facilitators through their interactions with the practices. The use of these data and the group workshop to populate the framework, was done post-intervention. Although this provided a broader and richer understanding of the factors affecting organisational readiness within the trial, as well as substantiating the views of individuals, it is possible that some bias may have been introduced. Researchers may have already developed ideas and beliefs (positive or negative) about individual practices that were reflected in their responses at this juncture. Also, the assessment of organisational readiness reflects the period of the trial only, and therefore only whatever cultural or workforce situation was present within each practice at this time. As general practices are fluid entities, this may be an indication only of their state of organisational readiness.

Conclusions

This evaluation of organisational readiness among the intervention practices in the HeLP-GP trial has provided valuable contextual information to supplement the trial results. It would be a valuable resource to employ pre-trial to identify practices and practitioners that might be best able to deliver the programme, or to identify barriers to capacity prior to commencing research. Within general practice this should assess both the capacity of the individual responsible for the implementation and the practice generally. This study showed a lack of general ‘readiness’ inherent in the GPN role. If GPNs are to participate in research, and fulfil their potential in supporting patients to reduce risk and adopt healthier life choices, our study indicates that more could be done to improve their workforce positioning and remuneration, which may improve continuity of care, retention and individual motivation.

Supplementary material

Supplementary material is available online.