The family medicine reference clinic : an example of interprofessional collaboration within a healthcare team

https://doi.org/10.14528/snr.2017.51.2.179 Since being introduced in 2011, family medicine reference clinics (FMRCs) have created several advantages in the treatment of patients, but have also drawn attention to areas where improvements could be made (Poplas Susič, et al., 2013). Consistent with competencies and experts, each chronic patient care protocol as well as the prevention protocol strictly follows guidelines or recommendations that define diagnostic and treatment as well as education pathways for patient care in a family medicine practice. They are harmonised and agreed with experts at different levels of healthcare (primary, secondary and tertiary) (Vodopivec Jamšek, 2013). The division of labour among team members in line with the competencies of individual professions and their mutual collaboration (Poplas Susič, et al., 2013; Martínez-González, et al., 2014) are two key elements of patient treatment in FMRCs. Work undertaken by registered nurses in FMRCs requires specific knowledge and skills. Initially, the Nurses and Midwives Association of Slovenia wanted such work to be carried out systematically and under supervision. This represented an innovation upon implementation since registered nurses in primary care did not receive additional training when starting to work in paediatric, school health or gynaecology clinics. Yet this method has proven to be extremely useful: the wealth of new experience, many new skills and professional sovereignty contribute to comprehensive patient treatment (Bender, 2017), which has naturally yielded positive benefits. Following the asthma and chronic obstructive pulmonary disease (COPD) modules (Poplas-Susič, et al., 2015), training was expanded to include the arterial hypertension, coronary disease, diabetes (Petek & Mlakar, 2016), osteoporosis and prevention modules (Petek Šter & Šter, 2015; Petek & Mlakar, 2016). Again something unexpected happened: the modules could no longer be included for implementation in good time for several reasons: the large number of registered nurses entering the system at the point of implementing the new FMRCs, time limitations and the temporal and spatial coordination of lecturers. It was proposed that until training in module form is introduced, registered nurses would be provided with induction by way of mentoring. In other words, an experienced registered nurse from an FMRC should help in the induction process of a new registered nurse in the FMRC until the latter starts an organised education path, which was also the case elsewhere (Lea & Cruickshank, 2017; Spiva, et al., 2017). All work involving patients increasingly reveals a need for full-time education or the regular acquisition of skills (De Los Santos, et al., 2014), which also applies to work undertaken in FMRCs. This is probably best ensured already during a professional master programme so that a family medicine practice obtains a team member who masters a wide range of skills needed in work with patients. This knowledge cannot be fragmented in such a way that one nurse is trained for the needs of diabetic patients, the second for patients suffering from COPD/asthma and the third for arterial hypertension patients. Family medicine is characterised by the comprehensive treatment of patients, meaning that a single patient can be treated for several conditions simultaneously, which in turn requires the entire team's comprehensive knowledge and above all their collaboration (Klemenc-Ketiš, et al., 2014). Registered nurses in FMRCs thus require a broad set of skills to meet the needs of all patients with multimorbidity and to also continue cooperating with a physician. In-depth knowledge is of course needed when a patient is treated at secondary/tertiary level and requires diagnostic and therapeutic procedures as well as health education measures, which cannot be offered by primary care. Leading article/Uvodnik

Since being introduced in 2011, family medicine reference clinics (FMRCs) have created several advantages in the treatment of patients, but have also drawn attention to areas where improvements could be made (Poplas Susič, et al., 2013).Consistent with competencies and experts, each chronic patient care protocol as well as the prevention protocol strictly follows guidelines or recommendations that define diagnostic and treatment as well as education pathways for patient care in a family medicine practice.They are harmonised and agreed with experts at different levels of healthcare (primary, secondary and tertiary) (Vodopivec Jamšek, 2013).
The division of labour among team members in line with the competencies of individual professions and their mutual collaboration (Poplas Susič, et al., 2013;Martínez-González, et al., 2014) are two key elements of patient treatment in FMRCs.
Work undertaken by registered nurses in FMRCs requires specific knowledge and skills.Initially, the Nurses and Midwives Association of Slovenia wanted such work to be carried out systematically and under supervision.This represented an innovation upon implementation since registered nurses in primary care did not receive additional training when starting to work in paediatric, school health or gynaecology clinics.Yet this method has proven to be extremely useful: the wealth of new experience, many new skills and professional sovereignty contribute to comprehensive patient treatment (Bender, 2017), which has naturally yielded positive benefits.
Following the asthma and chronic obstructive pulmonary disease (COPD) modules (Poplas-Susič, et al., 2015), training was expanded to include the arterial hypertension, coronary disease, diabetes (Petek & Mlakar, 2016), osteoporosis and prevention modules (Petek Šter & Šter, 2015;Petek & Mlakar, 2016).Again something unexpected happened: the modules could no longer be included for implementation in good time for several reasons: the large number of registered nurses entering the system at the point of implementing the new FMRCs, time limitations and the temporal and spatial coordination of lecturers.It was proposed that until training in module form is introduced, registered nurses would be provided with induction by way of mentoring.In other words, an experienced registered nurse from an FMRC should help in the induction process of a new registered nurse in the FMRC until the latter starts an organised education path, which was also the case elsewhere (Lea & Cruickshank, 2017;Spiva, et al., 2017).
All work involving patients increasingly reveals a need for full-time education or the regular acquisition of skills (De Los Santos, et al., 2014), which also applies to work undertaken in FMRCs.This is probably best ensured already during a professional master programme so that a family medicine practice obtains a team member who masters a wide range of skills needed in work with patients.This knowledge cannot be fragmented in such a way that one nurse is trained for the needs of diabetic patients, the second for patients suffering from COPD/asthma and the third for arterial hypertension patients.Family medicine is characterised by the comprehensive treatment of patients, meaning that a single patient can be treated for several conditions simultaneously, which in turn requires the entire team's comprehensive knowledge and above all their collaboration (Klemenc-Ketiš, et al., 2014).Registered nurses in FMRCs thus require a broad set of skills to meet the needs of all patients with multimorbidity and to also continue cooperating with a physician.In-depth knowledge is of course needed when a patient is treated at secondary/tertiary level and requires diagnostic and therapeutic procedures as well as health education measures, which cannot be offered by primary care.

Leading article/Uvodnik
The family medicine reference clinic: an example of interprofessional collaboration within a healthcare team Referenčne ambulante družinske medicine: primer medpoklicnega sodelovanja v zdravstvenem timu The large number of chronic patients and prevention, which should already start at an early age, show the need for a registered nurse's assistance over a full, 8-hour working day.In addition, naturally it is necessary that such labour standards be established that standardise the number of services now being reported by registered nurses and which differ by the way of the numbers involved.Moreover, the recording of services should be simplified to include the procedures of prevention, treatment and the monitoring of risk factors.
Research in family medicine is important (Bowman, et al., 2016).Similar to research undertaken by physicians, far less research is conducted by registered nurses working in FMRCs.Although a few research papers have been written by healthcare faculty graduates in health centres, no important publications can be found (Pečelin & Sočan, 2016).The reason for this is not currently clear, yet it is possible that a work method calling for direct contact with patients throughout the entire working time eliminates the desire to pursue research in one's free time.This represents an additional workload for employees and is thus less attractive.
Family medicine is the only clinical speciality among other clinical professions which lacks a defined tertiary level, thus preventing research as part of the work process.With the support of two faculties covering the area of nursing, a step in this direction was taken with the idea of setting up the Clinical Institute of Family Medicine, thereby enabling development based on its own research projects defining, directing and developing work within FMRCs' multi-disciplinary teams so as to add those aspects of work and team members that would direct patients towards a healthy lifestyle and, in the event of a medical condition, offer support where they need it and in the form they want (Fortin, et al., 2013).Only in this way can the FMRC stand shoulder to shoulder with other advanced clinical areas of patient treatment.
In order to ensure the successful further development and upgrading of interprofessional collaboration in FMRCs, it is important that the system is governed and regulated in at least two areas.One is certainly good team management.Physicians as healthcare service operators are responsible for the medical outcomes of the patients they treat and also assume responsibility for the good (or bad) work of the team as leaders, even though in line with competence models each decision made by both registered nurses and junior nurses forms the basis for their own responsibility.It is important that each team member receives optimal training and also has good command of the knowledge and skills required for treating the patients (Greene, et al., 2014) coming to an FMRC, making a structured educational programme within a professional master programme appear like a good solution.
Another area is research and development: experts, in this case a family medicine practitioner, a registered nurse and a junior nurse making up the team in an FMRC (following completion of the project, only the term family medicine clinic is to be used) must be able to pursue their own research, publish and continuously follow the latest findings of the profession.This cannot be achieved solely through projects, which however can be one of the options; the profession needs its own institutional organisation in the form of tertiary activity in order to fulfil its mission regarding patients also by trying to offer new contents, new insights and new methods by way of their own research activity.
Here responsible entities/development experts in the field face a huge challenge, but at the same time decision makers in politics are also confronted with a challenge because sooner or later they will have to take an appropriate decision in this direction (deGruy, et al., 2015).