Table 3.
QIC factors influencing the achievement of the NPT constructs and depression propositions
| NPT constructs (May and Finch, 2009) |
Corresponding propositions (Gunn et al., 2010) | QIC factors |
|---|---|---|
| Coherence | Depression work requires conceptualization of bounderies (who is depressed, who is not depressed). Depression work requires techniques for dealing with diffuseness. | Facilitators: |
| • The QIC stimulated multidisciplinary team discussions with open exchange of perspectives. The stepped-care model offered clinicians a technique for shared understanding on depression (who is severely and non severely depressed). | ||
| • The BDI offered a framework for dealing with diffuseness of depressive symptoms. | ||
| Barriers: | ||
| • Different professional views on depression causing long discussions. | ||
| • Disagreement of some clinicians with the medical model underlying the stepped-care model. | ||
| Cognitive participation | Depression work requires engagement with a shared set of techniques that deal with depression as a health problem. | Facilitators: |
| • The new low intensity stepped-care treatment options fitted well into the primary care perspective. | ||
| • The QIC meeting helped the exchange of the different views and come to agreements about the local depression care pathway and the task division. | ||
| • Working with the stepped-care model improved the knowledge, skills and self confidence of primary care clinicians. | ||
| • Treatment choices could be easily shared with the patients, leading to better working relationships. | ||
| Barriers: | ||
| • Unfamiliarity within the teams with each others skills and perspectives. | ||
| • The negative attitude of some clinicians towards standardization of depression care. | ||
| • The belief that (pro-active) monitoring is not a normal part of the PCP's work, and rather the patient's own responsibility. | ||
| Collective action | Depression work requires agreement about how care is organized, who is required to deliver care, and their structural and human interactions. | Facilitators: |
| • The possibility to tailor the stepped-care model to the local setting. | ||
| • Training was offered to apply the stepped-care interventions. | ||
| • Regular team meetings to discuss individual treatment plans, helped to agree on how stepped care was delivered. | ||
| • Competition between the different disciplines was not conceived as a problem because of the large amount of work to be divided. | ||
| • Government policies have stimulated 'the stepped-care movement' over the last decade. | ||
| Barriers: | ||
| • Poor organizational infrastructures, such as the absence of links with specialty care. | ||
| • A lack of funding of the new low intensive interventions, such as physical exercise. | ||
| • A lack of patients opting for specific interventions. | ||
| Reflexive monitoring | Depression work requires the ongoing assessment of how depression care is done. | Facilitators: |
| • Improved motivation because outcome measurement can structure and advance care for individual patients. | ||
| • Positive reactions of patients and improved relationships, as a result of sharing the monitoring results. | ||
| • Improved self-confidence of clinicians in making treatment decisions based on objective measurement. | ||
| Barriers: | ||
| • Multiple logistical problems for getting the questionnaires handed out and returned by the patients. | ||
| • The absence of supportive systems (ICT, reminder systems) or staff. | ||
| • The absence within the primary care teams of a culture and skills for process evaluation. | ||