The challenge of adopting a collaborative information system for independent healthcare workers in France: a comprehensive study

Sample characteristics

Our initial sample included 30 participants but 3 obstetricians were ineligible because they did not use the collaborative information system. We therefore analysed the interviews of 27 participants: 22 midwives (including 2 males), 3 obstetricians (2 females and 1 male), and 2 general practitioners (1 male and 1 female). Saturation was reached at this point according to FM. The duration of the interviews ranged from 35 to 75 min, with a majority lasting around 50 min. The mean age of the study population was 41.5 years.

We identified three major themes and eight subthemes related to the use/adoption of the collaborative information system through thematic analysis of the interviews (Table 3).

Theme 1: implementation challenges

Necessity of collaborative information system

The introduction of a collaborative information system is perceived as a significant advancement by healthcare workers. A general practitioner reflects on the potential benefits: “If I had software that would be straightforward and where, at the end, it’s as if my patient had been seen by another midwife or another physician at the hospital, that would be amazing” (General practitioner, in his 40 s, independent).

Work habit changes

Adapting to the new system requires healthcare workers to modify their established work routines, a process which is not without challenges. One midwife candidly shares: “But when there are particular problems, it’s true you don’t have to note it; if the baby’s in intensive or special care, and why, that’s written on the health booklet, but then, you’d have to read it, you’d have to ask questions, and that’s work” (Midwife, in his 40 s, independent). This highlights the effort required to fully engage with the new system and utilise its potential effectively. Despite the challenges, healthcare workers recognize the potential of the collaborative information system to enhance communication and coordination in patient care. Another midwife notes: “Most of the time, it’s more efficient to use the phone. Afterwards, there is everyone’s email addresses. The way it’s structured, it’s quite easy when you know their names and their first names, to find their email addresses.” (Midwife, in her 50 s, independent), suggesting that while the system delivers upon its promise, existing methods of communication still play a crucial role.

Theme 2: system utilisation barriers

Time constraints

Healthcare workers expressed concerns about the time-consuming nature of integrating the new system into their workflow. One midwife highlighted the duplicative nature of tasks, stating, “The hospital midwife who sees my patient is already taking her history, and all that history, if she sent it to me, I wouldn’t have to do it again. It would save me an incredible amount of time” (Midwife, in her 50 s, independent). Another midwife elaborated on the process, “We midwives do half-hour consultations. … If everything goes well and it’s quick, in 20 min, it can be done. And afterwards, I will take the time … I have to transform [my consultation report] into PDF, and send it to My Documents, then go to … my [professional software] account, then the patient’s account, [back to] My Documents, to transmit the PDF. It takes me an incredible amount of time” (Midwife, in her 50 s, independent).

Training and technical issues

The lack of training and technical support was another significant barrier to the system’s effective use. One midwife suggested, “Maybe there should be training for professionals as well… and show us that it works, that it functions, that it’s easy, that it doesn’t take time” (Midwife, in her 50 s, mixed hospital-independent practice). Technical limitations also posed challenges, as another midwife pointed out, “We’re limited in the size of the attachments. So, depending on how we scanned them or not, not all attachments fit” (Midwife, in her 50 s, independent).

Theme 3: interprofessional dynamics

Hospital vs. Independent practice

Healthcare workers from independent practices often perceive a divide in professional respect and acknowledgment compared to their hospital-employed counterparts. One independent midwife expressed, “There are a lot of [hospital healthcare workers] who think that the real midwives are in the hospital, and that as an independent, it’s… it’s sub… [we’re] sub-midwives.” (Midwife, in her 50 s, independent). This sentiment was echoed by an obstetrician who felt marginalized by hospital processes, stating, “The hospital doesn’t need us, that’s the way we feel. But we need to know what’s going on in the hospital.” (Obstetrician, in her 60 s, mixed hospital-independent practice). The lack of communication and collaboration between these two sectors was a recurring concern, with one midwife regretting the absence of information sharing by the hospital, “Given modern means of communication [and that] she was first seen at the hospital, they could send me a letter saying, ‘you’re going to have this patient to follow up, here’s the history, here’s what we did.’ No, they don’t do that.” (Midwife, in her 50 s, independent).

Cure vs. care

A tension between the technical, medical aspects of healthcare (cure) and the supportive, preventative side (care) was also highlighted. An obstetrician commented on the collaborative information system’s limitation in transmitting medical instructions, reflecting a broader issue in the interprofessional dynamics, “Finally, it is important to note that the software was built to allow the exchange of information about women’s care and situation, but not to transmit medical instructions. Their profession [speaking about midwifery] is one of support, it’s not a profession of medical decision-making.” (Obstetrician, female, in her 60 s, mixed practice).

Professional recognition

The quest for professional recognition was a significant concern among independent healthcare workers. The feeling of being undervalued or not fully recognized by hospital counterparts was a common theme. This segment also highlights the dissatisfaction of independent healthcare workers with tasks they deem menial, such as floor cleaning or filling out collaborative information system, further contributing to their sense of underappreciation. A midwife shared how her frustration of her work at the hospital was what led her to become independent, “I didn’t study midwifery to type on a computer or mop floors. I didn’t like it any more. So, I decided to go into independent practice, where I’m devoted solely to my patients.” (Midwife, in her 50 s, independent). The desire for a more collaborative and respectful relationship between hospital and independent healthcare workers was evident, with one midwife emphasising the importance of direct communication with women, “We midwives usually have half-hour consultations. I am there for the woman, to talk with her, to respond to her.” (Midwife, in her 50 s, independent).

Theme 4: hidden influences

Hierarchical influences

The hierarchical structure within healthcare settings can greatly affect the flow of information and collaboration. For example, “I have always found it difficult, the relationship with midwife-managers, with the whole pyramidal and hierarchical system of the hospital. I wasn’t comfortable with that. And I found that as an independent practitioner, you’re really in control, you work as you want, you do what you want…” (Midwife, in her 30 s, independent). This quote highlights how hierarchical pressures can drive healthcare workers towards independent practice, seeking autonomy over their work. A tool, even collaborative, imposed by the hospital could give them the feeling of returning to hierarchical dependency.

Funding and resources

The availability of funding and resources is a critical yet often overlooked aspect that can determine the success or failure of implementing new systems. The need for adequate support is encapsulated in the frustration of a midwife: “If I had a secretary, I could ask her to do it, but I don’t have a secretary, I’m on my own. So once, twice, three times and after a while I stopped because it was too complicated.” (Midwife, in her 30 s, independent). This statement underlines the challenges healthcare workers face when expected to manage additional administrative tasks without the necessary support infrastructure or financial resources.

Confidentiality concerns

Confidentiality remains a paramount concern in the healthcare sector, especially when transitioning to a collaborative information system. The delicate balance between sharing necessary information and protecting patient privacy is articulated by a midwife: “I don’t enjoy writing on her file that the patient was raped when she was 15 years old: ‘difficulties, visits her shrink+++’. I can’t do it. I’m not gonna write that on her chart. If she sees it, she’s going to think the midwife said that something was wrong.” (Midwife, in her 20 s, independent). This quote illustrates the ethical dilemmas healthcare workers face when documenting sensitive information in a collaborative information system.