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1 UvA-DARE (Digital Academic Repository) From cram care to professional care : from handing out methadone to proper nursing care in methadone maintenance treatment : an action research into the development of nursing care in outpatient methadone maintenance clinics in the Netherlands Loth, C.A. Link to publication Citation for published version (APA): Loth, C. A. (2009). From cram care to professional care : from handing out methadone to proper nursing care in methadone maintenance treatment : an action research into the development of nursing care in outpatient methadone maintenance clinics in the Netherlands General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 06 Oct 2018

2 Table of Contents Introduction 11 Chapter 1 Nursing care in outpatient methadone maintenance treatment: from tap gal to a professional nursing practice 1.1 Background of the study Hypothesis, study design and study objectives Research questions Background of the researcher Structure of the thesis 17 Chapter 2 Methadone maintenance in the Netherlands on the threshold of a new era: the collapse of a nursing practice 2.1 Introduction Methadone dispensing in the Netherlands Dual objective Insufficient financing Limited tasks Neglect of buildings and furnishings Conclusions and recommendations 24 Chapter 3 Research methodology: participative action research and quasi experimental design 3.1 Introduction Participating centre and research population Practice-driven research: participative action research Research and change stages Evaluation and conclusion of PAR Role of the researcher in the Co-operative Inquiry Design (CI) Generalization 3.4 Evaluation research 34 Figures Figure 3.1: Heron s action stages 30

3 Chapter 4 Enhancing the quality of nursing care in two outpatient methadone maintenance clinics with help of participative action research: A process evaluation 4.1 Introduction Background Deterioration 4.2 The study Aims Methodology Participants Data collection Rigour Fittingness Ethical considerations Data analysis 4.3 Results Stage Stage Stage Stage Study limitations Conclusions 45 Boxes Table 4.1: Procedure of the study in MMT linked to the four stages of cooperative research of Heron 36 Table 4.2: Models of Johns (reflection stages) and Heron (action stages) 38 Box 4.1: Model of Heron with stages 37 Box 4.2: Model of Johns with stages 37 Box 4.3: Example of the team differences and the necessity for institutional conditions 42 Chapter 5 Enhancing the professional autonomy of nurses in two outpatient methadone maintenance clinics by means of knowledge development 5.1 Introduction Objectives and research questions Theoretical perspectives Gaining knowledge and increasing autonomy Gaining knowledge by means of critical reflection Gaining knowledge and the patient s perspective 5.4 Data collection: patient s perspective Data collection: critical reflection by nurses Data collection: ad hoc care at the dispensing counter Data collection: job satisfaction and perceived autonomy Patient interview results and feedback to nurses 62

4 5.9 Results of the nurses critical reflection Products of critical reflection Results of the ad hoc care inventory Results of job satisfaction and perceived autonomy Conclusions 78 Figures Figure 5.1: Interaction health worker-patient 54 Figure 5.2: Types of ad-hoc care 59 Figure 5.3: Bringing perspectives together 65 Figure 5.4: The HKZ-model 70 Figure 5.5: Diagnostic model/bottleneck analysis 71 Figure 5.6: Bottleneck and innovations 72 Table 5.1: Number of observed days (260) 60 Table 5.2: Number of patients and total number of opening times per day per project 73 Table 5.3: Nursing interventions related to the total number of opening moments per project 74 Table 5.4: Average number of patients, kind of ad hoc care activity per opening hour (60 minutes) 74 Table 5.5: Interventions per opening hour (60 minutes) and per project related to the attendant nurse 75 Table 5.6: Significance calculation of the variance between project 1 and 2 using the t-test 75 Table 5.7: MAS-GZ: job satisfaction 76 Table 5.8: National job satisfaction measurement over several years 77 Table 5.9: Perceived autonomy of both teams; results 77 Appendices Appendix 1: MAS-GZ 81 Appendix 2: MAQ 82 Appendix 3: Raw data MAS-GZ en MAQ 83 Appendix 4: Description of all focus group meetings 85 Appendix 5: Structure for recording the care used in the focus group meetings 88 Chapter 6 Local innovations and their impact: the breakthrough 6.1 Introduction Differences between the participating MMT clinics Research design Research questions and objective Measurement design 92

5 6.6 Innovations Training and education (for the benefit of sub-questions 1 and 2) Mapping out the ad hoc care (for the benefit of sub-question 3) Extension of the opening hours (for the benefit of sub-question 4) Monthly focus Group meetings (for the benefit of sub-question 5) 6.7 Data collection and analysis Contribution of nurses to the multidisciplinary patient reviews Patient file documentation Registration of the ad hoc care activities Incidents of aggression Mapping out job satisfaction and perceived autonomy 6.8 Findings Nursing input in the multidisciplinary patient reviews: analysis of minutes and observations of the meetings Nursing input in the patients treatment plans Ad hoc care Incidents of aggression Job satisfactions and perceived autonomy 6.9 In conclusion 114 Figures Figure 6.1: Bottlenecks, innovations, evaluation parameters, and results 90 Figure 6.2: Observation criteria multidisciplinary patient reviews 97 Figure 6.3: Set-up file research 99 Figure 6.4: Analysis of the file items 99 Figure 6.5: Project 1: number of files containing treatment plans 105 Figure 6.6: Project 2: number of files containing treatment plans 106 Figure 6.7: Differences in results between project 1 and Table 6.1: Design of the measurements 93 Table 6.2: File analysis 98 Table 6.3: Number of structural patient files brought forward in reviews in project 1 and 2 according to kind input 102 Table 6.4: Project 1: total number of contacts in 12 months 108 Table 6.5: Project 2: total number of contacts in 12 months 108 Table 6.6: Calculation decrease/increase number of patients in course of time 109 Table 6.7: Number of patients in project 1 in Table 6.8: Nature and scope of incidents of aggression project Table 6.9: Nature and scope of incidents of aggression project Table 6.10: Increase/decrease incidents of aggression project 1, Table 6.11: Increase/decrease incidents of aggression project 2, Table 6.12: MANOVA results job satisfaction for the total group of nurses 113 Table 6.13: MANOVA results autonomy for the total group of nurses 113 Textboxes Textbox 6.1: Observation example project Textbox 6.2: Observation example project 2 104

6 Appendices Appendix 1: Analysis results of the patient review minutes of project Appendix 2: Analysis results of the patient review minutes of project Chapter 7 The local participative action research and national improvement of the methadone maintenance treatment 7.1 Introduction Local outcome and acknowledgement Recognition elsewhere Acknowledgement of local improvements Local change method implemented elsewhere The RIOB and quality improvement 7.3 Conclusion 128 Table 7.1: Local results in national guideline 122 Table 7.2: The RIOB compared to guidelines abroad 123 Chapter 8 General discussion 8.1 Introduction Answers to the research questions Critical reflection on the research methodology Research findings and changing simultaneously Participation of the research population Cooperative inquiry: four stages Role of the researcher Degree of generalization Social relevance 8.4 Personal review Recommendations for further research 137 Literature 139 Summary 151 Samenvatting 159 Dankwoord 167