Adopting tailored interprofessional protocols in general practice: barriers, strategies, and lessons learned from a CFIR-guided qualitative study

Abstract

Background

As the burden of non-communicable diseases continues to rise, general practices in primary care face increasing challenges in delivering high-quality care while managing workload constraints. Interprofessional care models, supported by practice-tailored protocols, offer a promising approach to optimizing task shifting and enhancing care coordination. However, the transition towards protocol-based interprofessional care remains complex and understudied.

Objective

This study explores the experiences of general practices in developing and implementing practice-tailored protocols to facilitate interprofessional care. Using the Consolidated Framework for Implementation Research (CFIR), we identify key barriers, facilitators and strategies that support this transition.

Method

We conducted a qualitative study in Flanders, Belgium, using semi-structured interviews with 33 healthcare providers from 18 general practices. Participants represented various disciplines, including general practitioners, nurses, dietitians and reception staff. A hybrid qualitative analysis was applied, beginning with an inductive analysis based on Braun and Clarke’s thematic approach, followed by a deductive phase guided by the CFIR-framework.

Results

The findings highlight several key factors influencing the development and implementation of practice-tailored protocols in general practices. Participants emphasized that clear task allocation and communication structures within protocols improved care coordination. External factors, such as financial constraints and high workloads, posed challenges, whereas collaborations with external healthcare providers facilitated interprofessional teamwork. Internal practice dynamics, including a shared vision, mutual trust, and structured team meetings, were identified as crucial enablers. At the individual level, motivation to adopt protocols varies, with some physicians expressing reluctance due to concerns about shifting patient relationships and increasing complexity in their caseloads. The implementation process benefited from a stepwise approach guided by a team leader, clear goal setting, continuous evaluation and peer learning.

Conclusion

The transition towards protocol-based interprofessional care is a complex but mandatory evolution in primary care. While practice-tailored protocols can enhance efficiency and collaboration, their success depends on a structured implementation strategy, effective practice management, and team alignment. Addressing challenges such as gaining trust and provider resistance are critical. Future research should explore scalable support mechanisms and policy adaptations to facilitate widespread adoption of interprofessional care models in primary care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13424-y.

Background

Over the past decades, numerous initiatives have successfully reduced mortality risks associated with non-communicable diseases (NCDs) at the individual level. Despite these efforts, the global burden of NCDs continues to rise [1, 2]. According to a WHO report, NCDs accounted for 74% of global deaths and 63% of disability-adjusted life years (DALYs) in 2019, making them the leading cause of disease burden worldwide [3]. Chronic conditions such as cardiovascular diseases, chronic respiratory diseases and diabetes are among the primary contributors to this burden [4]. This increase is driven by demographic trends associated with a higher prevalence of chronic conditions and multimorbidity, such as population growth and aging [2, 5, 6].

Managing one or more chronic conditions requires continuity of care, with general practices playing a central role in care management. Due to increased prevalence of NCDs, the majority of consultations in general practices are targeted to patients diagnosed with chronic conditions such as cardiovascular diseases or diabetes [6]. Consequently, the rising number of patients with NCDs significantly contributes to the high workload currently experienced in general practices. As a result, general practices are faced with challenges to allocate resources strategically and adopt innovative approaches to organising care in order to meet healthcare demand while maintaining quality.

Interprofessional care is a promising organisational model to address these challenges. This concept is defined by the WHO as a collaboration between multiple health workers from different disciplines and professional backgrounds to deliver the highest quality of care. Interprofessional collaboration means to create a shared understanding that no one had previously possessed or could have come to on their own [7]. Research indicates that an interprofessional team composition enhances continuity of care, ultimately improving overall care quality [8–10]. Additionally, interprofessional primary care may increase efficiency by aligning health-related problems with the appropriate healthcare provider’s competence profile [11, 12]. However, organizing interprofessional care implies bringing together a diverse team of healthcare disciplines with varying experiences, skill sets, and perspectives. Aligning all these actors presents significant challenges to ensure effective collaboration and optimal care delivery [13, 14].

In recent years, pioneering general practices in Belgium recognizing the need for interprofessional care have overcome this challenge and began developing and implementing practice-tailored protocols. A tool that is recognised by research as an important facilitator in the transition to, and establishment of interprofessional team collaboration [10, 15]. These protocols outline task allocation and shifting within a specific health domain, define subsequent steps in patient pathways, and set up communication guidelines. According to the WHO, task shifting is defined as the rational redistribution of tasks among health workforce teams in order to make more efficient use of existing human resources [16]. An example of task shifting is the (partial) redistribution of the management of diabetes care from a GP to a nurse who may take on responsibilities such as conducting follow-up consultations, providing lifestyle advice monitoring therapy adherence and supporting patient self-management. The organisation of care for patients with type 2 diabetes is a frequently chosen subject for practice-tailored protocols. Although existing examples are available, each practice must tailor these protocols to its unique context, considering the practice’s vision, team dynamics, and patient population characteristics. Beyond improving collaboration among staff members, the development phase of these protocols fosters discussion and reflection on task shifting within a general practice, leading to a more effective utilization of each discipline’s strengths represented in the organization [17]. Matthys et al. (2021) demonstrated that general practices using self-developed protocols are 5.5 times more likely to achieve better continuity of care, suggesting that care tasks among staff members are more effectively organized and aligned with current guidelines [10].

Aside from research highlighting the benefits of interprofessional, protocol-based care, interprofessional practices are gaining momentum and is being promoted by both the WHO and OECD [18–21]. As a result, practice-level care organisation is becoming increasingly important, with more general practices seeking ways to integrate protocols into their daily operations. However, limited knowledge exists on barriers and effective strategies for developing and implementing practice-tailored protocols, making it challenging to provide guidance to undertaking this transition.

General practices that went through the process of developing and implementing these protocols have gained valuable experience and insights into managing the transition towards protocol-based, interprofessional primary care, including potential challenges and opportunities. This qualitative study seeks to explore these experiences, identifying key strategies and barriers in the transition process. The goal is to provide practical guidance for primary health care providers looking to implement practice-tailored protocols within their own organisation.

Methods

Research context

This study employed a hybrid inductive-deductive qualitative approach to address the research questions and was conducted in the Dutch-speaking region of Belgium. Health insurance in Belgium is compulsory, and as such 99% of the population is covered [22]. Freedom of choice is an important principle for both patients (i.e., they can choose their provider), and for providers (i.e., they have therapeutic freedom and freedom to organise their practice as preferred). This is also reflected in two major financial structures existing for general practices between which they can choose: the fee-for-service model, which accounts for 92% of general practices, and the capitation-based model, representing the remaining 8% [18, 19]. In a fee-for-service model, general practices receive reimbursement for each individual service provided to a patient. In contrast, capitation-based practices receive a fixed monthly fee for every patient registered within the practice. The capitation model allows to make more independent decisions regarding the allocation of financial resources to organise care, as the funding is not directly tied to the number of billable services delivered. While a large portion of GPs operates in solo practices, this trend has declined from 67% in 2012 to 45% in 2022, with a corresponding rise in the number of group practices [19]. Reception staff has been present in a minority of general practices for many years, however, the integration of primary care nurses is a more recent development. Despite the fact that many practices are open to this organisational shift [23], they continue to face several barriers [24], including legal restrictions on task delegation and the inability to reimburse nursing services within the fee-for-service model.

Study design

This study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checkslist [25], available in Supplementary File 1. Semi-structured individual interviews were conducted in Dutch using an interview guide (See Supplementary file 2) based on the Consolidated Framework for Implementation Research (CFIR) [26, 27], an established, evidence based determinant framework in implementation science. This CFIR framework (Fig. 1) consists of 48 constructs organized across five domains, providing a systematic approach to assessing implementation projects by identifying potential barriers and facilitators. Table 1 provides a brief definition of each domain, applied to implementing a practice-tailored protocol.

Fig. 1:

Consolidated framework for implementation

Table 1.

1 Definition of the CFIR domains

CFIR-domain	Definition
Innovation domain	The innovation is ‘the thing’ being implemented [26]. In this study, the term innovation is used to refer to the development and implementation of a practice-tailored protocol, facilitating the organization of interprofessional chronic care delivery. Such protocols may include patient pathways, healthcare-related task shifting and/or a communication strategy
Outer setting domain	The outer setting is defined as the setting in which the inner setting exists. This may comprise of multiple levels such as the community level, regional level or federal level [26]
Inner setting domain	The inner setting is the setting in which the respective innovation is implemented [26]. In the context of this study, this translates to implementing interprofessional care protocols (i.e., the innovation) in a general practice (i.e., the inner setting)
Individual domain	This domain includes the roles and characteristics of individuals involved with implementing, delivering, and/or receiving the innovation [26]
Implementation process domain	The implementation process is defined as the activities and strategies used to implement the innovation [26], or in the context of this study, the implementation of protocol-based care in a general practice

Prior to each interview, participants where asked if they could share practice protocols used in their organisation. When available, relevant questions based on these protocols were incorporated into the interview guide. Since the use of practice protocols is not yet standard practice in Belgium, each interview began with exploring and defining this concept together with the participant.

Sample

The study population consisted of healthcare providers working in general practices in the Dutch speaking region of Belgium. A heterogeneous sample was sought by considering factors such as professional roles (e.g., GPs, nurses, dietitians and reception staff), practice financing models (i.e., fee-for-service or capitation-based), and levels of experience with interprofessional care.

In Belgium, the level of interprofessional care in primary care varies widely. While some general practices have successfully transitioned to interprofessional care, others have attempted but failed, often due to misaligned visions or a lack of time and resources. To ensure a comprehensive understanding of the research questions, such practices were also included in this study. To capture the full spectrum from monodisciplinary to interprofessional care, two categories were established based on the integration of nursing roles within the practice and where purposively selected for the sample. General practices where nurses primarily performed technical tasks (e.g., venipunctures, administering injections) were classified as “not interprofessional”, whereas practices where nurses also provided lifestyle advice or managed chronic care follow-up were classified as “interprofessional”.

Prior to this study, initiatives such as individual coaching, study days, and workshops had been organized to facilitate interprofessional collaboration and protocol-based care. To gain a comprehensive understanding of the best strategies for supporting general practices, our study included both healthcare providers who either did or did not previously participate in one of these initiatives.

Recruitment

A non-probability sampling method was used, combining both convenience and purposive sampling techniques. Participants were recruited through multiple channels. First, the authors, who are all academic researchers and trained healthcare professionals (nurses or general practitioners) leveraged their professional networks. Secondly, healthcare providers who participated in one of three aforementioned facilitation projects were invited. Additionally, the study was introduced at several primary care conferences in Flanders, within the Family Medicine research group at University of Antwerp, and at several educational programs for nurses. Finally, a call for participation was published in a journal targeting Flemish general practitioners.

Data collection

All interviews were conducted in person and audio recorded between December 14, 2023 and July 31, 2024, with two interviewers (LD and KD) present in most cases. LD, with a background in primary care nursing, had limited prior experience in conducting interviews at the start of the study. To address this, debriefing meetings with KD followed each interview during which both the interview content and LD’s research competencies were discussed. KD, a general practitioner by training, brought prior experience in conducting in-depth interviews. The triangulation of healthcare disciplines within the research team ensured that data collection and analysis were approached from two professional perspectives. In some instances, both LD and KD had previously provided training to the participant. In these cases, interviews were conducted by one of three independent researchers to foster an open interview environment and minimize the risk of socially desirable responses. These independent researchers, trained either as a nurse or physician, had no further involvement in the study and were no formal part of the research team. After each interview, a debriefing session was held by the interviewers to reflect on the content and discuss any relevant observations.

Analysis

A hybrid qualitative analysis was conducted beginning with an inductive approach followed by a deductive phase guided by the CFIR framework. Initial coding of the data was performed by LD. Subsequently, KD reviewed the transcripts, added additional codes when relevant, and initiated reflective discussions regarding existing codes when deemed necessary. Data analysis was performed by LD and KD together and later discussed with all authors. The inductive phase followed Braun and Clarke’s six-phase model: (1) familiarisation with the data through transcription and repeated reading, (2) generating initial codes, (3) identifying themes, (4) reviewing and refining potential themes, (5) defining themes, and (6) reporting findings. Phase (4), (5) and (6) were further structured using the CFIR framework [26] and followed a more deductive approach. NVivo software was used for coding and analysing. The interviewing, transcribing, and analysis were conducted iteratively, allowing for ongoing refinement of the interview guide as data collection progressed.

After 31 interviews, inductive thematic data-saturation was reached in accordance with the conceptual definition of R.B. Bouncken et al. [28], with no new information emerging during the analysis process. Two additional interviews were conducted beyond this point to confirm saturation. The final codebook of this study is available in supplementary file 3.

Results

Participants

A total of 33 primary healthcare providers from 18 general practices were interviewed in the setting of their own general practices. Of these practices, 11 operated under a fee-for-service model but adhered to regional agreements regarding the maximum consultation fee. The remaining 7 practices received capitation-based financing. The participants comprised two dietitians, two receptionists, 11 nurses and 18 GPs.

Of the 33 interviews, 20 were conducted with healthcare providers who adopted an interprofessional organisation of care (representing 11 practices), opposed to 13 providers working in a practice without an interprofessional organisation (representing 7 practices). One practice was organised monodisciplinary but worked closely with nurses from an external organisation. The average interview length was 41 min, with a minimum of 25 and a maximum of 73 min.

The results are presented according to the five domains of the CFIR framework. A visual synthesis of the key strategies or conditions that should be met, are presented in Fig. 2. Selected quotations to present the results were translated into Englisch by the first author and reviewed by a bilingual member of the research team to ensure accuracy and preservation of the meaning.

Fig. 2:

Strategies to ensure effective implementation of interprofessional protocol-based care structured in the CFIR-framework

Innovation domain

Participants stated that the design and content of a protocol is fundamental for successful and sustainable implementation. It must include clear goals, identifying the targeted population, outline the patient flow, define the tasks and responsibilities of each team member and offer templates for topics such as referring, lab requests or goal-oriented care. The protocol should be a practical guide for managing patient trajectories and supporting collaboration among internal and external healthcare providers.

“Sometimes, we see patients for drawing blood without a lab-request […] with the protocol we want to make it clear what we can order ourselves, and what not.” (P16 – Nurse)

While it is accepted by participants that medical guidelines should be followed, they noted that applying all elements of guidelines can be challenging. They emphasized the need to balance evidence-based care with high workload demands, team competencies and existing regulations, which often hinder task shifting and limit the autonomy of nurses and other healthcare professionals. Furthermore, a practice protocol should be flexible to adhere to the principles of patient-centred care. Some providers expressed concerns that practice protocols could restrict their professional autonomy, reducing their motivation to apply them.

“Not everything should be incorporated in a protocol. For me personally, I don’t really like cookbook-medicine. But I do believe that in a lot of cases it is better to have guidelines and agreements.” (P5 – GP).

Another concern raised by GPs was that task shifting to non-medical staff might leave them with more complex cases, further increasing their already heavy workload. Additionally, GPs would retain responsibility for patients they see less frequently, requiring supervision and coaching skills for what they are not always trained in. Lastly, it was mentioned that implementing interprofessional care requires significant time investments, both initially, for the development of a protocol and its implementation, but also for the organisation of team meetings, regular protocol evaluations and adaptations.

“That is also a concern, that I will only consult patients with uncontrolled diabetes, only the complex cases. That it will increase the workload of my consultations. That I will be empty at the end of a day, whilst now, variation between complex and less-complex consultations feels nice.” (P27 – GP).

Outer setting domain

Participants described that providing high quality, chronic care often requires more frequent or longer consultations. However, currently, healthcare providers face a significant workload and often struggle with an overload of consultations, making it challenging to allocate time for transitioning to an interprofessional care model. Additionally, most general practices in Belgium operate under the fee-for-service model, which does not cover the cost of time invested in practice organisation or hiring non-medical staff, such as nurses.

“… We are being overwhelmed with the regular patient care and administrative tasks as it is, without developing or managing practice protocols.” (P4 – GP).

A key facilitator of interprofessional care in the outer setting, reported by participants, was the development of partnerships with local healthcare providers such as dietitians, social services, medical specialists, physiotherapists and home nurses. During the interviews, it was stated that protocols should include contact information of local care organisations and provide clear instructions on how to manage communication with those partners.

“After every home visit, I give an update to the home nurse […] I do find it important, also for us, that we have agreements about what they [home nurses] may expect from us.” (P23—GP)

Participants emphasized the value and need of collaborative learning by exchanging experiences, successes and challenges with other colleagues. Furthermore, sharing protocols across general practices was cited as a crucial enabler for transitioning towards protocol-based interprofessional care. They noted, however, that these shared protocols should serve as a source of inspiration and should always be adapted to the specific context of each individual practice rather than being copied-pasted directly.

“We were all wondering: why does every practice who wants to develop a protocol has to reinvent the wheel? But of course, you have to adapt it to the specific patient population of the practice and the needs of your own team.” (P10 – GP).

“That also was something very good, meeting with colleagues from other practices so you can compare how they do it and how we do it?” (P33 – Nurse)

Inner setting domain

In the interviews, having a shared vision and mission regarding interprofessional protocol-based care was considered fundamental. Additionally, participants emphasized that these discussions should specifically address role definition and task shifting to ensure clarity and effective collaboration. Moreover, the discussions and resulting agreements should be documented so they can be reread and reviewed when necessary.

“It always starts with vision. Everyone must go in the same direction to achieve something.” (P19 – Nurse)

The work culture within a practice and the relationships among staff members were found to play an important role in fostering effective interprofessional care. Trust, mutual appreciation and a supportive climate, where it is safe to give and receive feedback, were deemed essential components.

“We have a verry safe climate in our practice. Because of this everyone dares to give an opinion, and those opinions are respected.” (P15 – Nurse).

To achieve such a culture, team members must be familiar with each other’s competencies, talents, and areas for improvement, as well as maintain a culture of open communication without hierarchy. This is a process that might require time. Additionally, it was deemed important for practice leaders to strategically assess talents within their team and leverage these strengths to drive practice improvement.

“As a practice, you really should reflect on what you need, to deliver good care, and who is most suited to deliver this, who can contribute on what area […] so everyone can reach their full potential.” (P24—GP).

Participants stated that building trust as a non-medical healthcare provider can be challenging, but might be facilitated through regular, open and reflective communication with physicians. Some participants mentioned that not all physicians are equally open to change and may prefer to maintain existing workflows. In such cases, it is essential to develop a strategy that addresses the concerns and needs of all team members, including those who are less inclined to adopt a new interprofessional protocol.

“For such a project, it is fundamental that there is an open environment, that there is trust. That you are really part of the team, that I am not JUST the nurse.” (P12 – Nurse)

“Open and honest communication, and also showing your own capabilities, and dare to be vulnerable […] those have been aspects which were crucial to gain trust from the GPs.” (P18 – Nurse)

A well-structured communication strategy was considered vital to support the shared vision and relational dynamics within the practice. This included regular practice-level meetings to discuss management and care related issues, discipline-specific meetings (e.g., nurses, GPs and receptionists), and meetings focused on patient care. Larger meetings require effective leadership by someone who determines the topics in advance and who chairs the meeting to ensure focus and facilitate decision-making. When planning such team meetings, it was deemed important to consider absences and to avoid discussing key topics when a significant portion of the team is not present. Beyond formal meetings, participants emphasized the importance of colleagues being approachable in-between consultations. Nurses in this study highlighted that when task shifting occurs, they need to feel safe asking questions to GPs, both for their own professional development and to ensure the delivery of safe and high-quality healthcare.

“It is important that there are structured meetings […] We also need someone who would be responsible for the project, otherwise nothing really happens.” (P2 – GP)

Lastly, practices indicated the need for adequate structural resources, including sufficient consultation rooms and effective software tools for electronic health records (EHRs). Participants noted that incorporating interprofessional care into EHR systems presents challenges because these systems are not inherently designed to support interprofessional collaboration. Additionally, legal restrictions prohibiting the use of data hubs in Belgium, limit the efficient sharing of patient information across different disciplines and healthcare facilities. Given these constraints, respondents emphasized the importance of critically evaluating the functionalities of existing EHR software and identify ways to leverage its capabilities to better facilitate team-based care.

“I don’t have access to certain functionalities of the EHR. For example, I am not authorized to send a report to a specialist since I am not a GP. […] I have to ask a GP to do this for me.” (P25 – Dietitian).

Individuals domain

At the individual level, it was considered important that healthcare providers are motivated to strive towards the provision of high-quality care and are committed to adopting new interprofessional care models and their associated protocols. It was stated that the process of individual adoption may vary, with some team members adapting more quickly than others. Factors such as long-standing GP-patient relationships, combined with concerns about losing personal connections with patients when tasks are shifted between disciplines, may negatively impact motivation to change. This can lead to non-compliance with new protocols and potentially jeopardize the success of the transition towards protocol-based interprofessional care.

“Some colleagues want to keep things in their own hands.” (P22 – GP)

“It depends on the attitude of the GP and how they are trained. Young physicians are learning how to work with nurses and see it as normal.” (P19 – Nurse)

Capability was the second major factor which appeared from the interviews and relates to the individual domain. Both medical and non-medical staff need to possess sufficient knowledge to provide high-quality care. This is especially important in case task shifting is implemented from medical to non-medical staff, as it helps them build self-confidence in their skills and gain trust from physicians. Similarly, reception staff need adequate knowledge to efficiently triage patients, ensuring a smooth daily practice management. Additionally, having someone with leadership and management skills, someone who is willing to guide the project, was considered an important determinant, but often lacking in general practices. During the interviews, it was cited multiple times that while they were trained as healthcare providers, they were not trained as managers. The issue, however, was not that primary healthcare providers are incapable or unwilling to manage a project, but they indicated a lack of training to establish such managerial competencies.

“Changing is difficult, it is really super difficult (…) Just the fact that you are not really trained to do so, we are a team comprised of GPs, reception staff, a dietitian and now a nurse, we simply did not learn the skills required to lead change during our training.” (P6 – GP).

Finally, it was noted that addressing individual team members’ needs was important. This may relate to personal competencies or development, relational needs or the desire to work towards a meaningful objective.

Implementation process domain

A clear goal was frequently mentioned as both a facilitator when present and a barrier when absent. Reflecting about, and eventually defining the goal, provides a foundation for further development and implementation of the protocol while also serving as a guide for evaluating whether the intended outcomes have been achieved.

“Start with reflecting on what you want to achieve, do you want to enhance the quality, increase the capacity. that's something I think about a lot more now when starting something new.” (P24 – GP)

A team-based approach was also highlighted as a critical factor, acting as either a facilitator or a barrier depending on its presence. A core project team should be appointed, representing the relevant practice disciplines, and given the responsibility and autonomy for the development of the protocol. In addition to frequent meetings within the project team, regular meetings with the entire practice team were deemed essential, allowing everyone to provide feedback and elaborate on certain topics.

“I think it is very good that every team-member is responsible for a certain task, then you really can have a shared responsibility […] It also creates a team feeling, I think it makes a team stronger.” (P15 – Nurse).

The project team must establish clear, achievable and measurable (sub)goals, develop a project plan, and set deadlines to ensure the project stays on track. Within this team, a project leader plays a key role in managing the process, motivating active participation and overseeing the overall timeline. Furthermore, participants emphasized the importance of accessible feedback channels during the implementation phase, lowering the barrier to give and receive questions and feedback to each other.

“Timing is really important. Please don’t do it in January, during the flu season.” (P23 – GP)

“They focus too much on what they want to achieve, not on their current situation and what might be appropriate intermediate goals. They wanted to achieve the perfect outcome too fast which resulted in something bad. It’s like trying to climb Mount Everest from the first time.” (P26 – GP).

During the planning phase, the target patient population should be analysed to identify potential patient-related risks. One concrete example given was examining the average age of the population and considering this when deciding on the use of emails or other electronic applications to invite them. It is deemed important to engage patients by informing them about novelties in the organization of chronic care. Special attention should be given to vulnerable patients, as they often face numerous barriers. Additionally, participants emphasized the importance of designing an evaluation strategy before implementing an innovation. This strategy might include pre- and post-measurements but should also incorporate an iterative element to ensure that the innovation will be kept up-to-date and aligned with the changing context in which general practices operate. One respondent suggested that benchmarking outcomes against other practices could provide valuable insights.

“Actually, we only figured this out two weeks ago. We realized that we did this project, but how are we going to follow it up?” (P12 – Nurse)

“We evaluate projects yearly. What goes well, what doesn’t. Or we conduct intermediate evaluations when we face certain issues […] That is how we learn.” (P19 – Nurse)

For the actual implementation, participants indicated that it is recommendable to proceed gradually, starting with a small group of patients or involving only a few healthcare providers. This approach allows for the identification and resolution of certain issues and provides an opportunity to demonstrate the added value to team members who may not yet be fully convinced of the need for this innovation.

“I found it easy that me and my colleague tested it ourselves with the nurse. That way, we could evaluate if it worked and how it went.” (P27 – GP)

Facilitating the implementation of protocols can be approached in various ways. As stated in the methods section, this study purposefully included some general practices that had received some form of facilitation. One such method was individual coaching at the practice level, with a frequently mentioned strength being the external pressure from a coach who assigned tasks and deadlines. The individualized nature of coaching allowed teams to leverage their strengths and address practice-specific needs effectively. However, a noted drawback was the lack of intervision with other general practices, limiting opportunities to learn from experiences of peers. Another method consisted out of a three-part workshop series in which the possibility to leverage on the experience and ideas of other practices were mentioned as an important strength. Some participants mentioned that coaching trajectories can be time-consuming and sometimes progress slowly. Therefore, it is deemed essential to tailor the coaching program to the unique needs of each practice, ensuring that it remains practical and feasible within their specific context.

“The external pressure really worked. Someone who visits, who gives assignments and comes back within 2 months to check the progress you made.” (P07 – GP)

“It was good that we sat together with other practices, to hear what they are doing, to compare with what we are doing and how we can adjust. It was verry valuable to reflect with colleagues.” (P33 – Nurse).

Discussion

A growing demand for chronic, primary care presents general practices with challenges in delivering high-quality care within the constraints of currently available human resources. Interprofessional care is an organizational model which offers a solution by incorporating various healthcare professions [29], enabling workload distribution and task shifting while maintaining or even improving care quality [10]. However, transitioning towards interprofessional care often leads to more diverse and larger teams, making collaboration, task shifting and effective communication strategies essential components of the care model.

Practice protocols are a promising tool to address the complexity of interprofessional collaboration, outlining task allocation and establishing communication guidelines among team members [10, 15]. The potential of these protocols has created a growing demand for sharing these protocols, however, transitioning towards interprofessional protocol-based care is not as simple as adopting existing protocols. Each practice has unique characteristics such as vision, culture, team composition, and patient population, necessitating the need of protocols tailored to the general practice. Developing and achieving a sustainable implementation of these protocols requires competencies in project management, an area in which most healthcare professionals (e.g., GPs, nurses, dietitians) have limited to no formal training, a statement frequently emphasized by the respondents of this study as a major barrier to overcome. This study adopted the CFIR-framework to identify strategies, barriers and facilitators for developing and implementing practice-tailored protocols.

The findings indicate that developing and implementing a practice-tailored protocol is a complex task and does not only include aspects related to organizing practice-level care such as task allocation and establishing efficient and qualitative patient flows. It is emphasized that a successful implementation requires fostering support among all team members, which involves reaching consensus on the vision, goals and targeted population for the protocol. Furthermore, the balance between the volume of the targeted population and the available resources has to be carefully considered. Once these preconditions are met, a practice-tailored protocol can be developed, ideally by a core project team that regularly provides feedback to the larger practice team, ensuring that everyone has the opportunity to contribute or provide feedback. After development, it is important to assess whether all team members agree with the final protocol and possess the required competencies to effectively carry out the protocol. Finally, the evaluation phase was frequently highlighted as essential. Based on the initial goals, the project team must assess the implementation of the protocol to identify opportunities for further improvement. These findings align with the phased approach to implementing integrated care described bij Minkman et al. [30]. Respondents of the study presented in this paper frequently emphasized concepts associated with the first two phases – design and execution—such as establishing a shared vision, defining clear goals and outlining roles and responsibilities. While some attention was given to the third phase (monitoring), the fourth phase (consolidation) received very limited focus. This lack of attention to consolidation suggests that interdisciplinary, practice-tailored protocols are still a relatively new concept, with few general practices having experience in embedding such projects as sustainable components of their organizational structures.

In some practices included in this study, resistance to change occurred, particularly with experienced physicians accustomed to established workflows and who may by unfamiliar with team-based approaches, a barrier also found in other studies focusing on interprofessional collaboration in primary care [23]. It was noted that this resistance often stems from a great sense of responsibility and the fear of losing control and losing part of their connections with patients. Addressing these concerns requires more than merely introducing a protocol. A report that investigated the future of care pathways in Flanders (Belgium) emphasized that the process of developing a care pathway is equally or even more important as the final product itself [17]. Research of Vanhaecht et al. (2009) stated that the development phase fosters teamwork, encourages discussions about current practices, and generates new ideas for improvement. Such interactions are enriching, even for practices in which team members have been working well together in the past [17, 31].

Some respondents expressed concerns that practice protocols limit their therapeutic freedom, raising fears of “cookbook medicine.” This concern aligns with the tension between population health management (PHM) and person-centered care (PCC). While protocols may risk promoting a more generalized approach to patient care at the expense of individually tailored care, it is important to understand that PHM and PCC are two distinct concepts that are inherently not conflicting. When managed effectively, they can complement and strengthen each other. According to Vissers et al. (2004), there are five levels in the theory of Health Operation Management: (1) Strategic planning, (2) Volume planning, (3) Resource planning, (4) Group planning, and (5) Patient planning [32, 33]. Practice-tailored protocols belong to the fourth level (group planning), where care for patients with similar characteristics is planned to improve efficiency and quality of patient care [10]. This group planning is followed by the fifth level, patient planning, in which care is tailored to the needs of an individual patient, addressing the concepts of PCC. As indicated by the theory of Health Operation Management, ‘group planning’ and ‘patient planning’ are consecutive phases. This means that a general practice can plan and organize care for a specific patient group while allowing for individualized adjustments (based on a patient’s specific needs) during consultations. Moreover, while research indicates the importance of group planning through the use of protocols [34, 35], it also emphasizes the significance of person-centred care [36, 37], suggesting that both concepts are important to address within a general practice.

During the interviews it was stated that healthcare providers are trained as healthcare providers, not as managers, which presents challenges when transitioning towards interdisciplinary, protocol-based care. As a result, this research uncovered many aspects related to project management. However, one aspect that was discussed less frequently was the role of leadership in this transition. An interpersonal quality attributed to an individual that enables them to influence a team towards a common goal, without relying on hierarchical authority [38, 39]. The limited attention to leadership at the practice-level may be a contributing factor hindering the effective implementation of an interprofessional organisation of care.

The findings of this study highlight key elements and insights for the development and implementation of practice-tailored protocols. However, persistent barriers remain, including a lack of financial incentives, and limited training in formal educational programs. At the macro level, there is a need for policy measures that incentivize the initiation and sustainability of practice-level projects aimed at improving both the quality and efficiency of care, this should apply not only to general practices operating under a capitation-based system but also to those employing a fee-for-service model. At the meso level, educational institutions should acknowledge the growing importance of interprofessional care models by embedding relevant competencies into their curricula, particularly those related to project management and interprofessional collaboration and communication.

In this study, we aimed to identify key strategies for advancing interprofessional care through the development and implementation of practice-tailored protocols. This was achieved by including a diverse group of healthcare professionals, selected not only based on their professional roles, but also considering the financial structure of the general practice and the level of integration of nursing roles. Additionally, the research team comprised of experts from both nursing and family medicine, with strong connections to the working field, enhancing contextual understanding of the data but also allowing to comprehend the implications of the findings and how to report them.

The interview guide and analysis were informed by the well-established Consolidated Framework for Implementation Research (CFIR) [26], ensuring a comprehensive exploration of key determinants of implementation of an innovative strategy or care intervention. While CFIR has proven valuable in this study, its distinction of determinants into five separate domains poses a risk of compartmentalization without fully capturing the complexity of real-world implementation projects, where numerous relationships and interactions exists between implementation determinants. Additionally, using a determinant framework, like CFIR carries the risk of losing information during the analysing process as certain codes may not fit neatly within a predefined (sub)construct.

The study sample included only two dietitians and two receptionists. Consequently, the specific needs and expectations of these disciplines may not have been fully captured. Additionally, other types of healthcare providers, such as physiotherapists, psychologists or social workers, were also absent in the study sample, despite being integrated in some general practices. Although thematic data-saturation was achieved, the authors recognize the uniqueness of each general practice and acknowledge that additional interviews with these specific types of providers might have given further insights. However, they believe that the data was sufficient to address the research question and feel confident to make this claim given the heterogeneous sample based on multiple criteria, the combined expertise of the researchers as both healthcare providers and academics, and the triangulation of professional perspectives (GP and nurse) within the research team.

Conclusions

Transitioning towards a model of interprofessional care provision in general practices is essential, not only to alleviate the workload but also to safeguard the provision of high-quality and continuous care. Practice-tailored protocols serve as a crucial tool for fostering and implementing such interprofessional care models. However, challenges related to practice and project management, as well as limited training and experience of many healthcare providers in these domains, must be addressed. Fortunately, some general practices initiated projects to transition towards interprofessional care organisations. As demonstrated in this study, these practices offer valuable insights into potential threats, opportunities and effective strategies for developing and implementing interprofessional protocol-based care. Key strategies include appointing a core project team with a designated team leader, establishing feedback channels throughout the implementation phase, and creating collaborative learning networks with other local healthcare organisations. Future research should explore how general practices can be effectively and efficiently supported in their transition towards interprofessional care.

Disclaimer

This manuscript was edited using ChatGPT-4, an AI language model, to improve grammar, sentence structure, and overall clarity where necessary. While the AI-application was used solely as a linguistic refinement tool, the content, ideas, and conclusions were developed by the team of authors.

Authors’ contributions

LD, EG, PVB and KD: development of the research question and research strategy. LD and KD: data collection and analysis. EG: review of data-analysis. LD: writing of the manuscript. EG, PVB and KD: reviewing the manuscript. All authors contributed to the article and approved the submitted version.

Funding

This study is part of the JACARDI-project which aims to develop, implement and evaluate an intervention to guide general practices in the transition towards protocol-based interprofessional care. The JACARDI-project has received funding from the EU4Health Programme 2021–2027 under Grant Agreement 101126953. Views and opinions expressed are, however, those of the author(s) only and do not necessarily reflect those of the European Union or the European Health and Digital Executive Agency (HaDEA). Neither the European Union, nor the granting authority, can be held responsible for them.

Data availability

The dataset generated and analyzed during the current study is stored in a secure, closed online cloud environment accessible only to the authors. To protect participant privacy, the data is not publicly available. Data sharing requests will be evaluated by the authors.

Declarations

Ethics approval and consent to participate

This research was performed in accordance with the Declaration of Helsinki. Participants in this study provided a written informed consent and received financial compensation for their time invested. Ethical approval for this study was obtained from the ethics committee of the University of Antwerp.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.