Exploring the relationship between professional roles and behavioural intentions in chronic kidney disease management: a cross-sectional study among primary and specialist health professionals in Shanghai, China

Abstract

Objectives

General practitioners, nephrologists and renal nurses play key roles in professional integration in chronic kidney disease (CKD) management. Professional roles may influence professionals’ behavioural intentions, namely, the degree to which individuals formulate behavioural plans to attain a behavioural goal. However, little is known about the relationship between professional roles and their behavioural intentions in CKD management. Therefore, in this study, we aimed to explore the relationship between professional roles and their behavioural intentions in CKD management and the mediating role of normative and functional factors.

Design

Cross-sectional.

Setting

A cross-sectional survey study was conducted in Shanghai, China.

Participants

A total of 244 responses were obtained, including 145 from general practitioners, 37 from nephrologists and 62 from renal nurses. We used a self-administered questionnaire to collect data through hospital unit/Community Health Service Centre visits. We performed exploratory factor analysis for behavioural intentions in CKD management. The Karlson-Holm-Breen method was used to decompose the total effect of roles on behavioural intentions in CKD management into direct and indirect (ie, mediational) effects and to calculate the mediated percentage.

Results

The indirect effect of personal norm (should CKD management be included in daily work or not) accounted for 51.91% of the total effect of nephrologists on one-to-multiple CKD management intentions and 43.79% of the total effect of renal nurses on one-to-multiple CKD management intentions.

Conclusion

Our results support the mediating pathways of personal norms on the relationship between roles and behavioural intentions, but the mediating role of functional factors was not supported. These findings suggest that enhancing the personal norms of general practitioners may benefit their behavioural intentions in CKD management.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study benefited from a relatively large sample of practitioners across multiple sites involving primary and specialist health professionals in chronic kidney disease management.

• The mediation analysis was performed under the guidance of the Rainbow Model of Integrated Care.

• A convenience sample may not be representative of the general population.

• Self-reported data might be subject to recall bias.

Introduction

It is estimated that at least 10% of the global population suffers from chronic kidney disease (CKD),¹ which has a major effect on global health in terms of morbidity and mortality and represents an important risk factor for cardiovascular disease.² By 2040, CKD is estimated to become the fifth leading cause of death globally, representing one of the largest projected increases of any major cause of death.³ Effective management is critical to the survival of patients with CKD,⁴ and a comprehensive and effective CKD management strategy can slow or stop CKD progression to end-stage kidney disease.⁵

As a comorbid and progressive disease, CKD management faces many challenges.⁶ Previous research has reported factors related to CKD management at individual patient levels, including limited literacy, cultural/language barriers, low socioeconomic status, frailty and geographicl distance from nephrologists.⁷ More recent research has focused on system-level factors related to CKD management, such as a shortage of skilled healthcare professionals, fragmented referrals, inadequate follow-up care and care coordination.^{8 9} Professional integration is becoming an increasingly vital factor in CKD management at the system level because CKD management requires input from multiple professionals within and across various clinical settings, involving both primary care and specialist nephrology care.⁹ Professional integration refers to interprofessional partnerships based on shared competencies, roles, responsibilities and accountability to deliver a comprehensive continuum of care to a defined population.¹⁰

Behavioural intentions of professionals in CKD management¹¹ are important for professional integration because the willingness of different professionals to participate in various types of CKD management is the basis for enhanced interdisciplinary teamwork. Behavioural intention refers to the degree to which an individual formulates behavioural plans to attain a behavioural goal.¹² In the healthcare system that China is committed to building, there is a hierarchical and collaborative relationship between tertiary care providers, secondary care providers and community health centres. Higher-level providers provide technical support and referral services to lower-level providers, while lower-level providers report to and seek guidance from higher-level providers. At the same time, tertiary and secondary care facilities will work with community health centres to provide training, technical support and referral services to ensure the appropriate allocation of healthcare resources and synergy.¹³ However, clinical integration in CKD management in China is still in development.¹⁴ We believe that understanding behavioural intentions among different professionals in CKD management is the first step in helping to develop strategies for improving clinical integration in the future, such as partnership working and team functioning. According to the current situation of CKD management in China and previous literature, CKD education (including patient education and public education),¹⁵ supporting CKD self-management¹⁶ and providing patient consultation are common CKD management behaviours.¹¹

Previous research showed that the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust) may influence professionals’ intention to participate in care coordination.¹⁷ In some integrated primary care services (eg, community pharmacy in diabetes prevention), financial incentives were identified as a motivating factor for service delivery.¹⁸ General practitioners’ interests and perceived congruence with their role will also influence their priorities when planning services; for example, whether to deliver lifestyle behavioural risk factor screening and management in primary healthcare.¹⁹ However, there is a knowledge gap in understanding what motivates professionals in CKD management and what aspects of CKD management they prioritise as valuable when planning services. Such understanding is the first step in helping to develop strategies for improving clinical integration in the future, such as partnership working and team functioning, to provide implications for improving integrated CKD management.

Previous studies show that professional roles may influence professionals’ behavioural intentions in healthcare, such as decision-making in critical care,²⁰ as well as motivation in persevering as clinical instructors.²¹ General practitioners, nephrologists and renal nurses play key roles in professional integration in CKD management. Nurse-led or multidisciplinary specialist teams are common models of care in CKD,²² and integrated care clinics with allied health professionals or primary care providers are also reported as examples of multidisciplinary care interventions in CKD.^{23 24} Differing views exist on who should be responsible for different tasks of CKD management. For example, nurses occupy a brokering role between patients and physicians (Barley, 1996) and are often more involved in the organisation and provision of care, whereas physicians are involved in diagnosis and treatment decisions, and general practitioners are considered primary care providers and care coordinators for patients.²⁵ Such differences among professional roles may lead to different CKD management behavioural intentions. Coordinated care over time and across professional and organisational boundaries could optimise the experience and outcomes of patients with CKD.^{9 25 26} However, little is known about the relationship between professional roles and their behavioural intentions in CKD management, which may restrict innovative initiatives to maximise professional integration and engagement with the health kidney services.²⁷ Therefore, a deep understanding of the links between professional integration and clinical integration (behavioural intentions) is needed to provide implications for better CKD management.

The Rainbow Model of Integrated Care (RMIC)¹⁰ guided this study. The RMIC describes the complementary roles of integration at the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) levels.¹⁰ The RMIC also assumes functional and normative integration ensures connectivity between the levels.¹⁰ Functional integration refers to coordinated back-office and support functions, while normative integration refers to shared work values.¹⁰ Given the context of this study, with a focus on the professional roles (eg, professional integration and behavioural intentions in CKD management) and clinical integration, we draw on the RMIC and assume that the professional roles could influence their behavioural intention in CKD management, through functional and normative factors (figure 1).

Figure 1. Conceptual framework. CKD, chronic kidney disease.

Therefore, this study explored the relationship between professional roles and their behavioural intentions in CKD management. We hypothesised that the pathways between roles and behavioural intentions are mediated through normative and functional factors. Understanding the potential links between professional roles and their behavioural intentions could facilitate the development of coordinated CKD management and provide implications for improving integrated care for patients with other chronic diseases.

Materials and methods

Design and setting

This cross-sectional survey study was conducted in Shanghai, China, between November 2017 and January 2018, involving 1 tertiary hospital, 1 secondary hospital and 10 community health service centres (CHSCs). The institutes represented different healthcare organisations and showcased a hierarchical diagnosis and treatment system. The secondary hospital and 10 CHSCs were located in the Changning District of Shanghai, which was the first comprehensive reform pilot area for community health service in China,^{28 29} while the selected tertiary hospital was a member of the Regional Medical Association of Changning District. We chose Changning District in Shanghai as representative of a generalist–specialist transfer model of the CKD management system. The analysis of this study was drawn from a larger research project examining CKD management from the perspectives of both primary and specialist health professionals and patients. According to the situation of CKD management in Changning District in Shanghai, the parent study recruited dialysis patients from the tertiary and secondary hospitals and predialysis patients from the community health service centres.

Sample

Participants included general practitioners (family doctors), nephrologists and renal nurses who met the following inclusion criteria: (1) male and female subjects, age≥18 years; (2) who have been in the current position for at least 6 months, with general practitioners recruited from the 10 CHSCs, and nephrologists and renal nurses recruited from the two hospitals; and (3) who were able and willing to provide informed consent. The exclusion criteria were as follows: (1) head nurses and nurse managers; and (2) general practitioners (family doctors) or nephrologists who were not involved in patient with CKD management during the past 6 months. Convenience sampling was performed.

We used the G*Power programme (Kiel, Schleswig-Holstein, Germany) to calculate the necessary sample size. With an average effect size (f²) of 0.15, an alpha of 0.05, a power of 0.95 and 12 predictive variables (3 control variables, 4 normative factors, 4 functional factors and roles), the minimum sample size was 182. We approached 300 eligible participants, and finally, 244 participants completed the questionnaires (response rate=81.33%), including 145 general practitioners, 37 nephrologists and 62 renal nurses.

Procedure

We used a self-administered questionnaire to collect data through hospital unit/CHSC visits. The survey development included four phases, and we report the process with Burns et al’s guide.³⁰ In Phase 1 (item generation), survey items were generated through literature reviews. Following item generation, we defined the constructs they wished to explore: behavioural intentions in CKD management, normative factors and functional factors. Then, we grouped the generated items into domains and started formulating questions within the domains. In Phase 2 (item refinement, selection and reduction), we involved six content experts (including a general practitioner, a nephrologist, a renal nurse, a community health centre manager and two experts from health policy and integrated care) to evaluate the first version of the questionnaire regarding the items’ relevance, clarity, meaningfulness and completeness; content validity indices (CVI) at the scale-level (S-CVI) and item-level (I-CVI) were calculated. In Phase 3 (pretesting), we asked colleagues similar to prospective respondents to evaluate each question through interviews to judge the appropriateness of each question to guarantee that respondents understand the items as we intended. In Phase 4 (pilot testing), we measured the internal consistency of items within a domain. The research team visited the hospital units and CHSCs during the clinical meetings. During the visit, the researchers introduced the study’s objective and requested the participation of those who met the above criteria. The questionnaires were distributed to the study participants and were completed and returned to the research team without identification.

Variables and measurements

Outcome variables

Behavioural intention in CKD management was a dependent variable in this study. We developed items based on a comprehensive literature review (we listed reference sources of each item in the online supplemental appendix 1) of similar topics to capture participants’ behavioural intentions in CKD management. Created items were modified based on suggestions from an expert panel, and the final six items were chosen. Each item was answered using a 5-point scale that ranged between 1 (strongly unwilling) and 5 (strongly willing), with a Cronbach’s alpha coefficient of 0.882. I-CVI ranged from 0.833 to 1, and S-CVI for behavioural intention in CKD management was 0.833, which showed good content validity.^{31 32} Exploratory factor analysis was performed to identify the potential factors, and factor scores were generated for further analysis.

Independent variable

Roles were operationalised as a type of professional and were assessed by a categorical variable (general practitioners, nephrologists and renal nurses).

Mediating variables

Normative and functional factors were included as mediators.

Normative factors

We chose four items to assess normative factors related to CKD management³³: (1) Should CKD management be included in the scope of your daily work or not? (yes/no); and (2) What are your most valued factors in regard to your participation in CKD management? Three possible responses were developed and provided based on a literature review of similar topics³⁴: perceived sense of accomplishment, good therapeutic relationship with patients and income. We coded each response as a dichotomous variable.

Functional factors

We used four items to measure functional factors related to CKD management based on previous literature³⁵:

1. Self-reported work time per week (hours).

2. How do you feel about the support from your institution’s administration and logistics system?

3. How do you feel about your institution’s organisational structure and daily administration?

4. To what extent does your institution’s current performance appraisal system motivate you to participate in CKD management?

The response categories were scored from 1 (unsatisfied very much/not at all) to 5 (satisfied very much/obviously very much). The four items were used to reflect workload, perceived support functions, perceived back-office functions and perceived performance incentives. Higher scores represent a better functional status for items 2, 3 and 4.

Covariates

Age (years), sex (0=female, 1=male) and education (0=bachelor’s degree and below, 1=master’s degree and above) were used as covariates.

Statistical analyses

We performed exploratory factor analysis for behavioural intentions in CKD management. Descriptive statistics were used to summarise the sample characteristics. One-way analysis of variance and χ² tests were used to assess differences among general practitioners, nephrologists and renal nurses. Post hoc tests were conducted to further explore between-group differences, and Cohen’s d was calculated to show the effect size.

To examine the total, direct and indirect effects of roles on behavioural intentions in CKD management, we conducted regression models in three steps. First, we conducted linear regression models to examine the total effect of roles on behavioural intentions in CKD management. Second, we added normative and functional factors in the linear regression models to examine the direct effects of roles, normative factors and functional factors on behavioural intentions in CKD management. Third, we conducted linear regression models with normative and functional factors as dependent variables to examine whether roles affected normative and functional factors. We controlled factors for age, sex and education in the models.

We further used the Karlson-Holm-Breen (KHB) method³⁶ to decompose the total effect of roles on behavioural intentions in CKD management into direct and indirect (ie, mediational) effects and to calculate the mediated percentage. The KHB method³⁶ applies to linear regression models with discrete measures of independent variables, as well as with multiple mediators, either discrete or continuous, and is easily applied in Stata. The KHB method does not require any assumptions with regard to the distribution of the variable whose effect we wish to decompose.³⁶ Stata SE V.17.0 was used for all statistical analyses.

Results

Exploratory factor analysis for behavioural intention in CKD management

Exploratory factor analysis was performed to identify the potential factors of behavioural intention in CKD management, the results of which are presented in table 1. Two factors were identified and named as one-to-multiple types and one-to-one type. Factor scores for the two types were used to represent the degree of behavioural intention in CKD management in each aspect, where the higher the score, the better the behavioural intention.

Table 1. Exploratory factor analysis for behavioural intentions in CKD management.

Items	Factor loadings
Factor 1: one-to-multiple type	Cronbach’s α=0.876
Provide and popularise CKD knowledge (eg, compose a science popularisation essay) through an online platform (eg, WeChat)	0.796
Give group education class or slide lecture about CKD	0.800
Develop CKD-related applications and use them to manage patients with CKD	0.682
Factor 2: one-to-one type	Cronbach’s α=0.853
Answer questions from patients with CKD through messages or emails	0.728
Telephone follow-up	0.770
Home visits	0.667

CKDchronic kidney disease

Sample characteristics and differences among general practitioners, nephrologists and renal nurses

Table 2 presents the overall characteristics of the participants, normative and functional factors, and behavioural intentions in CKD management by the three professional roles. The total sample comprised 145 general practitioners (59.4%), 37 nephrologists (15.2%) and 62 renal nurses (25.4%). The participants’ average age was 37.4±8.11 years; 23.0% (n=56) were male, and 18.9% (n=46) had a master’s degree or above.

Table 2. Sample characteristics and differences among general practitioners, nephrologists and renal nurses.

Variables	Whole sample(n=244)	Group 1	Group 2	Group 3	P values	Post hoc test *P valueCohen’s d†
		General practitioners(n=145)	Nephrologists (n=37)	Renal nurses (n=62)
		N (%) or mean±SD	N (%) or mean±SD	N (%) or mean±SD
Age (years)	37.4±8.11	39.7±7.43	33.9±8.22	33.9±7.74	<0.001	1 vs 2: p<0.001; 1 vs 3: p<0.001; 2 vs 3: p=1.000; 0.75†
Sex (male)	56 (23.0)	42 (29.0)	4 (10.8)	10 (16.1)	0.021
Education (master’s degree and above)	46 (18.9)	13 (9.0)	23 (62.3)	10 (16.1)	<0.001
Normative factors
Should not be included in daily work (personal norm)	77 (31.6)	69 (47.6)	4 (10.8)	4 (6.5)	<0.001
Income as a motivator	113 (46.3)	76 (52.4)	21 (56.8)	16 (25.8)	0.001
Good therapeutic relationship with patients as a motivator	77 (31.6)	37 (25.5)	10 (27.0)	30 (48.4)	0.004
Perceived sense of accomplishment as a motivator	45 (18.4)	27 (18.6)	6 (16.2)	12 (19.4)	0.923
Functional factors
Weekly work time	49.8±8.35	48.4±7.75	54.9±8.61	50.1±8.47	<0.001	1 vs 2: p<0.001; 1 vs 3: p=0.504; 2 vs 3: p=0.014; 0.56†
Perceived support functions	3.3±0.78	3.4±0.69	2.7±0.73	3.2±0.87	<0.001	1 vs 2: p<0.001; 1 vs 3: p=0.086; 2 vs 3: p=0.009; 0.68†
Perceived back-office functions	3.4±0.75	3.4±0.68	2.8±0.76	3.5±0.80	<0.001	1 vs 2: p<0.001; 1 vs 3: p=1.000; 2 vs 3: p<0.001; 0.61†
Perceived performance incentives	2.7±0.90	2.6±0.85	2.8±0.99	2.8±0.95	0.231	1 vs 2: p=0.613; 1 vs 3: p=0.460; 2 vs 3: p=1.000; 0.22†
Behavioural intentions in CKD management
Factor score: one-to-multiple	0±0.87	–0.25±0.84	0.27±0.82	0.42±0.75	<0.001	1 vs 2: p=0.002; 1 vs 3: p<0.001; 2 vs 3: p=1.000; 0.76†
Factor score: one-to-one	0±0.85	–0.13±0.87	0.15±0.78	0.23±0.75	0.009	1 vs 2: p=0.196; 1 vs 3: p=0.014; 2 vs 3: p=1.000; 0.40†

^*One-way ANOVAanalysis of variance Bonferroni correction post hoc tests are significant if Pp<0.05 (correction already included).

^†We calculated Cohen’s d using the following formula: [(4η2/1− η2)]1/2.

CKDchronic kidney disease

Significant differences were observed across the three groups in terms of age, sex, education; normative factors (personal norm, income as a motivator, good therapeutic relationship with patients as a motivator); functional factors (weekly work time, perceived support functions, perceived back-office functions); as well as the behavioural intention scores in both one-to-multiple and one-to-one CKD management. Regarding normative factors, general practitioners were more likely to report that CKD management should not be included in daily work (personal norm). At the same time, renal nurses were less likely to report income as a motivator and more likely to report a good therapeutic relationship with patients as a motivator for CKD management. Regarding functional factors, nephrologists had the most weekly work time and reported the least perceived support and back-office functions. In terms of behavioural intentions in CKD management, for one-to-multiple CKD management, general practitioners had the lowest behavioural intention among the three groups, while no significant difference was found between nephrologists and renal nurses. For one-to-one CKD management, general practitioners had lower behavioural intention than renal nurses, and no significant difference was found between nephrologists and renal nurses, as well as between general practitioners and nephrologists.

Mediator analysis

Table 3 presents the mediating effects of normative and functional factors in the association between roles and two types of behavioural intentions. After controlling factors for age, sex and education, personal norms (reporting that CKD management should not be included in daily work) partially mediated the effect of role on one-to-multiple CKD management intentions and fully mediated the effect of role on one-to-one CKD management intention. The indirect effect of personal norm accounted for 51.91% of the total effect of nephrologists on one-to-multiple CKD management intention and for 43.79% of the total effect of renal nurses on one-to-multiple CKD management intention. No significant mediating effects of other normative factors (income as a motivator, good therapeutic relationship with patients as a motivator, and perceived sense of accomplishment as a motivator) on CKD management intentions (either one-to-multiple or one-to-one) were found, nor were there any significant mediating effects of functional factors on CKD management intentions (either one-to-multiple or one-to-one).

Table 3. Mediating effects of normative and functional factors in the association between roles and two types of behavioural intentions.

Mediators for two types of behavioural intentions*	Roles	Total effect		Direct effect		Indirect effect		% Mediatedβ (95% CI)
		β (95% CI)	P value	β (95% CI)	P value	β (95% CI)	P value
One-to-multiple
Personal norm	Nephrologists	0.55 (0.21, 0.90)	0.002	0.27 (−0.09, 0.62)	0.145	0.29 (0.07, 0.50)	0.008	51.91
	Renal nurses	0.73 (0.43, 1.02)	<0.001	0.41 (0.09, 0.73)	0.012	0.32 (0.10, 0.54)	0.005	43.79
One-to-one
Personal norm	Nephrologists	0.45 (0.30, 0.91)	<0.001	0.19 (−0.18, 0.56)	0.318	0.27 (0.06, 0.47)	0.011	58.55
	Renal nurses	0.61 (0.25, 0.77)	<0.001	0.31 (−0.02, 0.64)	0.063	0.29 (0.08, 0.50)	0.006	48.58

Note: Models are adjusted for age, sex, and education.

^*Only significant mediators (both total effect and indirect effect were significant) are shown in the table.

^†Percentage mediated was calculated only in the presence of a significant indirect effect

Discussion

This study supported the mediating pathways of personal norms on the relationship between roles and behavioural intentions, but the mediating role of functional factors was not supported. These results extend our knowledge of professional integration in CKD management and indicate that a particular emphasis should be placed on the role of personal norms. The findings also offer evidence for developing targeted interventions to enhance coordinated CKD management among different professional roles.

Consistent with previous research,³⁷ our study supports the importance of personal norms in intentions and behaviours. Interestingly, general practitioners are more likely to report that CKD management should not be included in daily work, whereas nephrologists and renal nurses tend to present the opposite personal norms. This may be because Chinese general practitioners are occupied with comprehensive primary care services,^{38 39} but chronic disease management procedures rarely occur in general practice patient consultations.⁴⁰ As China’s primary-specialist integrated healthcare system is still developing, more targeted measures should be made to involve community healthcare workers in chronic disease management, especially patient education and consultation. Our study suggests that general practitioners should develop further motivation in all primary care areas, and community nephrologists are essential for CKD primary care. In ‘community generalism’, serious conditions are uncommon, and illness of a transient, psychosocial, or unexplained nature is more prevalent.⁴¹ Based on the role of community generalists,⁴¹ we suggest that community nephrologists must be adept at accessing—and discussing with CKD patients—relevant online clinical guidance and negotiating management plans with patients with CKD. We also suggest that relationship-oriented strategies (eg, enhancing extended professional networks and encouraging a patient-centred approach in counselling) are needed to improve general practitioners’ personal norms in CKD management. Dumas et al, posit that segmenting personal and professional domains facilitates the management of role responsibilities, whereas integration is more beneficial for managing workplace identity and relationships.⁴² Experience from integrated palliative care shows that the dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust rather than developing standardised information, exchange and referral pathways.⁴³ Research about lifestyle counselling in general practice also shows that a good, personal doctor–patient relationship creates motivation and obligation to change and allows counselling to be interpreted as care.⁴⁴

Although the mediating role of other normative and functional factors was not supported in this study, we found that differences existed among various professional roles. Nephrologists and general practitioners were more likely to report income as a motivator to participate in CKD management, whereas renal nurses were more likely to report a good therapeutic relationship with patients as a motivator for CKD management. This may be related to differences in the division of responsibilities and compensation systems for physicians and nurses. In terms of functional factors, nephrologists had the most weekly work time and reported the least perceived support and back-office functions. This result suggests that the willingness of nephrologists to perform CKD management could be enhanced by increasing resource allocation and support, such as by providing assistants to nephrologists. In addition, the workload of nephrologists may be reduced with the assistance of technology, such as artificial intelligence, which can assist physicians in most steps of patient management.⁴⁵

Regarding behavioural intentions, general practitioners had lower behavioural intentions than nephrologists and renal nurses for one-to-multiple CKD management. One possible explanation for this is related to the actual clinical management of kidney disease in China, where the care of patients with CKD relies heavily on healthcare professionals working in nephrology departments.¹⁶ Moreover, there is increasing evidence that incorporating technology, especially smartphone-based applications (apps), can help support the self-management of CKD and chronic disease.⁴⁶ E-health via cell phones is likely the best option for delivering CKD self-management interventions at scale.¹⁶ Also, it provides support for specialist medical staff to conduct one-to-multiple CKD management. Moreover, information and communication technology has served as a promising channel to shorten distances between healthcare providers and patients and equip users with knowledge, self-monitoring and self-management tools. Telenephrology is a channel of communication that facilitates access to nephrologists for both primary care physicians and patients and has been implemented in several countries.⁴⁷

General practitioners also had lower behavioural intentions than renal nurses for one-to-one CKD management. Personal contact represents one way to better understand this situation. Personal intergroup contact predicts positive intergroup outcomes, and personal contact between teams is thought to enhance the beneficial effects of cooperative interactions between teams.⁴⁸ Personal contact and attendance by physicians and nurses play a significant role in the treatment process of a patient’s disease.⁴⁹ Specialist nurses often have contact with patients during their care,⁵⁰ which may contribute to their intention to be involved in disease management. Our findings suggest that the behavioural intentions in CKD management of general practitioners need to be strengthened in building a professionally integrated CKD management system.

Strengths and limitations

One of the main strengths of this study is the use of survey data to examine the links between professional integration and clinical integration in the context of Mainland China. Drawing on the RMIC, this study assumes that professional roles influence behavioural intentions in CKD management through functional and normative factors. Our findings may benefit innovative initiatives to maximise professional integration and engagement with healthy kidney services and provide implications for better CKD management.

Some limitations should be mentioned. First, this was a cross-sectional study, which precluded inference on causality. Second, the current study was conducted in only one district in one province of China, and we used convenience sampling due to resource restrictions, which may limit the generalisability of the findings. For example, our health professionals were young and more female; although this is similar to previous studies in China,51,53 it should be approached with caution to generalise to other populations. Future national or multicentre studies are needed to improve the generalisability of the findings. Third, although we used the RMIC to guide this study and focused on normative and functional factors, other potential mediating factors may not be included. Fourth, our study focused on the behavioural intentions of professionals due to the fact that clinical integration in CKD management in the current situation of Mainland China is at an early stage; further study is needed to explore clinical integration at the practical level. Nevertheless, this study contributed to the field of professional integration and explored the underlying links between roles and behavioural intentions in CKD management. We used eight single items to measure normative and functional factors. Finally, the single-item normative and functional factors measures have been shown to be valid in prior literature.^{27 29} Still, we encourage future studies to use more sensitive and specific measures to capture other aspects of normative and functional factors.

Conclusion

In this study, we revealed how normative and functional factors influenced the relationship between professional roles and their behavioural intentions in CKD management. Our findings supported the mediating role of personal norms in the relationship between roles and behavioural intentions. The results pointed to the likelihood that enhancing the personal norms of general practitioners may benefit their behavioural intentions in CKD management. Further work is needed to develop targeted interventions to enhance coordinated CKD management among different professional roles.

The study funder had no influence on the study design, collection, management, analysis and interpretation of data, writing of the report or decision to submit the report for publication.

Data availability statement

Data are available upon reasonable request.