La pratique clinique et le bien-être au travail des infirmières selon un processus d’intégration des soins

The aim of this study is to understand processes of transformation of clinical practice among nurses in the context of care and service integration initiatives, and to examine the impact of these processes on nurses’ well-being at work. Specifically, the study’s objectives are to: 1) describe nursing practices that underpin efforts to integrate care and services in Quebec; 2) analyze the relationship between the change processes underpinning integration efforts and nurses’ self-perceived well-being at work; and 3) identify the main levers that organizations can use at management and clinical levels to support nursing practices in an care integration context. The study was set up in three parts, corresponding respectively to the three objectives mentioned above.  The reference framework developed for this study, is the Modèle infirmier du développement de l’intégration des soins (MIDIS – Development model for integrated care in nursing). It is based on the premises of the model of Cazale, Touati et Fleury, (2007) that cover the interrelationships between contextual variables (organizational and institutional), the adoption and institutionalization of integrative practices, and the associated effects on professionals with respect to well-being in the workplace.  To achieve the study’s objectives, a mixed-method design was used, which included: a descriptive quantitative component (Part 1), a correlational quantitative component (Part 2), and a single case qualitative study with nested levels of analysis (Part 3). Data were collected within four care pathways (CPs): autonomy support for the elderly (ASE); palliative oncology services (POS); mental health services (MHS); and chronic obstructive pulmonary disease (CPOD). Data were collected from nurses, health professionals, and managers. For Parts 1 and 2, 107 questionnaires completed and 37 semi-structured interviews conducted for Part 3.  The results of the first part of the study showed not only significant variations across CPs in the development of integration, but also a gap between the evolution of nursing practice and the introduction of changes aimed at greater integration of care. Only two out of nine dimensions of integrative practice (‘quality of care’ and ‘interprofessional teamwork’) were prevalent across all CPs and only one CP (POS) had reached a more advanced stage in the integration process. The results of the second part of the study showed that, as integration became more highly developed, it was associated less with a perception of threat by nurses and more with positive reactions and well-being at work. The third part of the study identified three types of levers that should be used in a complementary way to speed up the progress of integration: organizational processes; clinical-administrative processes; investment in key resources and in renovation of certain organizational structures. These results shed additional light on the challenges posed by the process of integration of care, and show the importance of leading multiple interventions at all organizational levels to facilitate institutionalization of integrative practices and achieve the intended effects.

Keyphrases: Intégration des soins, Leadership clinique, Pratique collaborative, Processus clinico-administratif, Care integration, Nursing practice, Well-being at work, Care  pathways, Organizational change, Clinical leadership, Clientele approach, Collaborative practice, Clinical administrative process, Quality of care