Relationship between nurses' perceptions of the benefits/challenges of nursing and degree of interprofessional and intraprofessional collaboration in all‐inclusive services combining day services, overnight stays and home‐visit nursing for the older people living at home

Abstract Background Many countries are experiencing rapid population aging, and the provision of support for older adults with diseases or disabilities to continue living in their communities is a major global challenge. Japan has established multifunctional long‐term care in small group homes and home‐visit nursing (MLSH) as a service category that integrates medical and care services. These services focus on nursing functions to support continuous, long‐term home, and end‐of‐life care for older adults with high levels of medical care dependency. This study aimed to clarify the relationship between nurses' perceptions of nursing benefits/challenges and the degree of interprofessional collaboration in the context of MLSH. Methods We conducted a mail questionnaire survey of MLSH facilities throughout Japan. All facilities in Japan that had been operating for at least 1 year were included. We analyzed 182 responses (response rate: 36.0%; valid response rate: 98.3%). Results Comparison of scores representing the degree of interprofessional collaboration perceived by nurses showed the highest score was for colleague nurses (3.9 ± 0.5) and the lowest was for external care managers (2.5 ± 0.9). Compared with the weak collaboration group, the strong collaboration group had higher perceptions of the benefits of nursing and lower perceptions of the challenges. Conclusions The results of this study suggest that strong collaboration allows teams to achieve sufficient effects of care while reducing related challenges. It may be necessary to promote collaboration with external professionals to appropriately manage service users' worsened conditions and improve the quality of care.


| INTRODUC TI ON
Many countries are experiencing rapid population aging. 1 Home care for older people has been promoted to improve conventional medical and welfare systems and reduce medical costs in countries with rapidly aging populations.For example, various care programs have been adopted in the United States, including the Program of All-inclusive Care for the Elderly (PACE) 2 and the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. 3The PACE 2 is a comprehensive, community-based model of care that coordinates medical, behavioral, and social services for individuals 55 and above who have high care needs but can safely remain in the community.A previous study showed the PACE was associated with reduced hospitalizations and increased mental and physical health among patients, and caregiver stress was alleviated.Similarly, the CAPABLE program 3 was shown to contribute to facility users' health.However, little is known about how PACE outcomes compare with those of similar caregiving programs internationally.In addition, there are few published comparisons of PACE outcomes versus those of other caregiving programs for older adults in the United States, and available studies reported mixed results. 4 Japan, older people account for 29.0% of the total population. 5The Long-term Care Insurance system plays a central role in the welfare of this population group. 6Japan provides multifunctional long-term care in small group homes and home-visit nursing (MLSH) via a "community-based service category," which integrates medical and welfare services for community-dwelling older people.This community-based service category was established when the Long-term Care Insurance system was revised in April 2012.Multifunctional small group homes (MSGH) comprise another service category, which is mainly centered on day services combined with overnight stays and home visits to support the home lives of older people that require care on a 24-hour basis.Both MSGH and MLSH facilities limit the number of users to 29 people.Professionals employed by these facilities include care managers, nurses, and care workers.MSGH services have only 1.5 nurses on average, 7 which limits the provision of nursing services.MLSH is an extended version of MSGH that includes home-visit nursing.Compared with MSGH, MLSH has enhanced nursing functions, meaning MLSH facilities can provide support and end-of-life care for older people with high levels of medical care dependency.Various nursing benefits that characterize MLSH services have been reported, including enabling users to continue their home lives (even in difficult cases) and expanding the scope of care through interprofessional and intraprofessional cooperation. 8However, some challenges have also been noted, such as inappropriate acceptance of or care for users, and difficulty educating and cooperating with care workers 8 ; these areas require improvement.
In the primary care context, interprofessional collaboration has been reported to improve pain care. 9In addition, patient-centered interdisciplinary interventions appear to be more effective than usual care. 10Nursing and care services in MLSH are flexibly combined and provided according to the condition and needs of individual users.Collaboration among MLSH nurses and external physicians and care managers is also required, with interprofessional and intraprofessional collaboration being likely to become increasingly important.Therefore, we aimed to examine whether the benefits and challenges of nursing in MLSH varied according to the degree of collaboration between MLSH nurses and other professionals.Clarifying the relationships between these nursing benefits/ challenges and interprofessional and intraprofessional collaboration may help in developing measures to improve or promote good relationships and open discussion about effective nursing approaches in MLSH.We anticipate that, if they demonstrate the effectiveness of nursing care in MLSH and identify the factors associated with effective nursing care, the results of this study will help nurses to support patient discharge.This may also contribute to the development of effective support strategies for older people living at home in other aging societies.

| OBJEC TIVE
The aim of this study was to clarify the relationships between MLSH nurses' perceptions of the benefits/challenges of nursing and degree of interprofessional and intraprofessional collaboration.

| Study design
This study used a cross-sectional design.

| Participants
Although the number of MLSH facilities is increasing, it remains small.Therefore, we decided to include all facilities that had been active for at least 1 year.Participants were managers and nursing directors of 514 MLSH facilities registered with the Care Service Information Publication System in Japan. 11

| Data collection date
October to December 2019.

| Procedure
We conducted this self-administered questionnaire survey via mail.
The survey form, an invitation letter, and a stamped self-addressed envelope were mailed to potential participants.

| Study items
Our survey collected information on facility managers, facilities, and service users (e.g., type of facility, number of employees, service users' age, and care grade) and nurses' attributes (e.g., gender, age, and length of practical experience in MLSH).We measured interprofessional and intraprofessional collaboration using the Relational Coordination Scale (RCS), 12 which was developed to measure teamwork with specific subjects about specific tasks.
A previous study that used the RCS revealed that professionals' satisfaction with the care delivered by community health nurses was positively influenced by relational coordination and enhanced relational coordination between community health nurses and other primary care professionals in the neighborhood, which may improve the delivery of care to community-dwelling frail people.This study used the Japanese version of the RCS (J-RCS 13 ;).Respondents were asked to rate seven profession-specific items on a five-point Likert scale (from "Always/Quite often" to "Never/Seldom").Relational coordination items encompass four communication dimensions (frequent, timely, accurate, and problem-solving communication) and three relationship dimensions (shared goals, shared knowledge, and mutual respect).The sum of the scores for these seven questions divided by 7 gives a total score that represents the ease of collaborating with each profession.Higher scores indicated that nurses perceived good coordination with other team members.The Cronbach's alpha coefficient for the RCS was 0.86-0.90 in a study of nurse managers. 14onbach's alpha for the J-RCS was 0.78-0.86 in a study of home care nurses. 13This scale has previously been shown to have sufficient reliability and validity 13 and has been used by other studies in the community nursing field.One study found that home-visiting nurses' relational coordination with their nursing managers was significantly and negatively related to depersonalization. 15other study that used the RCS showed that enhanced relational coordination between community health nurses and other neighborhood primary care professionals may improve the delivery of care to community-dwelling frail people. 16Furthermore, relational coordination was reported to be positively associated with higher job satisfaction, better work engagement, lower burnout, lower turnover, and reciprocal learning among healthcare professionals. 17Therefore, we considered that the RCS was a suitable scale for measuring interprofessional and intraprofessional collaboration in the community, and used this scale in our study.
We measured respondents' perceptions of 33 items covering the benefits/challenges of MLSH nursing.Responses were on a 5-point Likert scale ranging from "Strongly agree" to "Strongly disagree" ("Strongly agree" corresponded to a rating of "5" on the Likert scale).
These benefits and challenges were identified through the results of our previous survey of MLSH nurses in the Kansai area, 8 and an additional survey in another area.We created a draft benefits/challenges questionnaire after adding items and modifying expressions based on the feedback received from those nurses.We then asked two MLSH nurses to test the draft, and reviewed each question based on their feedback.Finally, we developed a 33-item questionnaire comprising 14 benefits and 19 challenges.
We asked two nursing directors to pretest the draft questionnaire we had developed.On the basis of the pretest results, we modified the expressions of some of the 33 items on the advantages/ problems of MLSH nursing, but made no changes to the J-RCS.

| Analysis
The degree of collaboration with each profession was determined by the median J-RCS score.Using this score, we divided respondents from each occupation into two groups: a strong coordination group and a weak coordination group.In a previous study, nurses were divided into two groups according to the mean score, 7 but in this study, we considered it appropriate to divide participants into two groups using the median because the normality of the distribution could not be assumed.We compared the two groups using Mann-Whitney Utests.The level of statistical significance was set at p < 0.05.

| Ethical considerations
This survey included an invitation letter that specified the study objective, measures to ensure participants' anonymity, voluntary participation, and the consent process.Respondents were advised that returning a completed survey would be considered provision of consent to participate in this study.The completed anonymous questionnaires were filed and stored in a locked vault.Electronic data were analyzed and stored only on password-controlled PCs managed by the research institution, and both paper and electronic data were managed only by the first author (the principal investigator).This study was approved by the Ethics Committee of Chiba Prefectural University of Health Sciences (No.2019-21).
In total, 3.1 ± 3.8 users had received end-of-life care in the facility over the past 1 year (Table 1).Furthermore, among all facility users, 8.7 ± 7.3 lived alone (including those living alone only during the daytime), and 8.0 ± 6.9 regularly received home-visit medical services.
After confirming that there were no ceiling effects in the scores for each profession, we compared the level of perceived nursing benefits/challenges between the strong and weak collaboration groups.When limited to items with significant differences, the strong collaboration group showed higher perceptions of nursing benefits and lower perceptions of challenges compared with the weak collaboration group.This tendency was observed for 23 of the 33 items when comparing strong (J-RCS score ≥ 4, n = 97) and weak (J-RCS score < 4, n = 84) collaboration with colleague nurses.Similar trends with significant differences were observed in 22 items for colleague care workers, 19 items for colleague care managers, and 13 items for external care managers and physicians.
For external care managers, there were significant differences according to the degree of collaboration in three benefits, and the weak collaboration group had significantly higher perceptions of 10 of the 19 challenges than the strong collaboration group.For physicians, there were significant differences between the two collaboration groups in 10 of the 14 benefits and three of the 19 challenges (Tables 3 and 4).
In terms of the relationships between nursing challenges and professions, the level of perceived "difficulty in providing nursing care in the absence of a physician" was significantly lower among those who collaborated strongly with external care managers than in the weak collaboration group (2.4 ± 0.9 vs. 3.0 ± 1.1, p = 0.005).The level of perceived "tendency of care workers to excessively rely on nurses in care" was also significantly lower among those who collaborated strongly with colleague care workers than in the weak collaboration group (2.2 ± 1.2 vs. 3.0 ± 1.2, p < 0.001).

| DISCUSS ION
Our examination of the relationships between nursing benefits/ challenges and interprofessional and intraprofessional collaboration showed that the level of perceived benefits tended to be higher and that of challenges tended to be lower in the strong collaboration group compared with the weak collaboration group.This suggested that teams in which members (regardless of their profession) favorably communicated with each other and shared goals could achieve sufficient effects of care while reducing related challenges.These results supported those of previous studies that showed that interprofessional collaboration improved the quality of care for users. 9,10previous study showed that psychological safety strengthened the relationships among hospital nurses. 19In this study, some nurses perceived there to be lower "Difficulty of cooperation among nurses because of differences in attitudes" when cooperation among nurses was stronger, which suggested that psychological safety among nurses strengthened cooperation and decreased the perceived difficulty in cooperation.For issues that tended to be regarded as challenges in nurse-nurse relationships (represented by "difficulty in educating nurses with different experiences"), the level of perceived challenges was relatively low among those that collaborated strongly with colleague care workers and care managers.Another noteworthy aspect of the findings was that the level of perceived nursing challenges in MLSH tended to be low among external care managers in the strong collaboration group.In the current system, MLSH nurses rarely exchange user information directly with external care managers, as shown by the small number of external care managers with strong collaboration in this study.Furthermore, the perceived level of "empowering nurses" (as a benefit) was higher in the strong collaboration group for all professions.These findings suggested that interprofessional and intraprofessional collaboration may be essential to address nursing issues and improve the quality of nursing.
The results of this study indicated that collaboration with external professionals was difficult; therefore, the degree of collaboration perceived by nurses remained low.A previous study identified hierarchy and authoritarian leadership as barriers to psychological safety in multidisciplinary teams in the primary care context. 20Hierarchy and authoritarian leadership may also be factors associated with nursing challenges, such as "difficulty in collaborating with physicians in terms of communication." However, although the hierarchical culture in the healthcare context negatively affects communication, industry-academia collaboration promotes communication. 21Therefore, cooperation with research institutions may also be an effective strategy to improve communication.
The results of the present study suggest that strong interprofessional and intraprofessional collaboration promoted the benefits of nursing and helped to resolve challenges.Both education 22 and use of communication tools 23  nities to improve their quality of care.It is likely that the medical fee system will be revised to apply this category to nursing, meaning more training seminars on municipal subsidies and use of communication tools could be held going forward.To improve cooperation between professions, it would also be useful to raise awareness and increase managerial support in using daily duties as opportunities to strengthen cooperation.For example, an MLSH nurse could be present at regular medical visits to ask family physicians about the health of particular clients that the staff were concerned about, and to obtain instructions from the physician.In this context, nurses can act as mediators between the staff and the attending physician.Therefore, managers should try to coordinate nurses' work schedules to facilitate such mediation and thereby encourage interprofessional collaboration.
Various countries appear to be developing systems in various forms to comprehensively support the daily lives of older people.
For example, in the United States, the "Comprehensive Primary Care Initiative," which was a primary care practice transformation model, was found to reduce hospitalizations and emergency department visits. 24In addition, a Canadian initiative, "Seniors" Campus Continuums', offers a model of care that seeks to broaden access to an array of services and housing options to meet the growing health and social needs of aging populations. 25MLSH is an example of this type of comprehensive support system.One outcome of the present study was that we identified interprofessional and intraprofessional collaboration as an important factor in improving the quality of care in MLSH.In addition, we highlighted the importance of promoting collaboration, both within a facility and with external professionals.
These findings may be useful to inform the development and review of systems for home care based on cooperation among multiple professionals.

| LI M ITATI O N S
This study has a number of limitations.For example, it may be difficult to generalize our results because of the low response rate (36.0%).In addition, we could not determine causal relationships between nursing activities and study factors because this study used a TA B L E 2 J-RCS score for each profession; mean ± SD (N = 182).

Colleague care managers
External care managers Physicians 3.9 ± 0.5 3.6 ± 0.6 3.8 ± 0.5 2.5 ± 0.9 3.1 ± 0.7 Reference: Evaluation of the home-visit nursing care station a  Note: Only values for items with significant differences are shown.Active collaboration group: median J-RCS scores: colleague nurses/colleague care workers/colleague care managers ≥4; external care managers/physicians ≥3.
Abbreviations: J-RCS, the Japanese version of the Relational Coordination Scale; MLSH, multifunctional long-term care in small group homes and home-visit nursing.
are considered effective in promoting collaboration.Therefore, we propose that multiple professions receive training together, including training with outside professionals, on the theme of strengthening interprofessional cooperation and the use of communication tools.Furthermore, in Japan's Long-term Care Insurance system, additional fees for the improvement of care worker management may serve as an incentive for training care workers or creating training opportu-

13 TA B L E 3 7 . 9 .
Abbreviations: J-RCS: Japanese version of the Relational Coordination Scale; SD, standard deviation.a Naruse et al.13 Outline of facilities, users, and nurses.
Only values for items with significant differences are shown.Active collaboration group: median J-RCS scores: colleague nurses/colleague care workers/colleague care managers ≥4; external care managers/physicians ≥3.Relationships between nurses' perceptions of nursing challenges and degree of interprofessional collaboration (N = 182).
Note:TA B L E 4