Ann McKillop

Patients' engagement in primary care: powerlessness and compounding jeopardy. A qualitative study

Primary health care does not adequately respond to populations known to have high needs such as those with compounding jeopardy from chronic conditions, poverty, minority status and age; as such populations report powerlessness.

Reaching their potential: Perceived impact of a collaborative academic-clinical partnership programme for early career nurses in New Zealand☆

BACKGROUND The dynamic nature of healthcare ensures that early career nurses enter an uncertain and complex world of practice and consequently require support to develop their practice, build confidence and reach their potential. The New Zealand Nurse Entry to Practice programme for registered nurses in their first year of practice has been operating since 2005 to enable safe and confident practice, improve the quality of care, and positively impact on recruitment and retention. This academic and clinical programme was offered as a partnership between a university and a clinical provider with postgraduate academic credits gained. AIM The aim of this study was to explore the perceived impact of postgraduate university education for early career nurses in one regional health area of New Zealand. METHODS Participants were registered nurses who had completed the early career nurse programme and their clinical preceptors. The research was conducted via an online survey of 248 nurses and three focus groups to explore how the programme was experienced and its impact on knowledge and practice. RESULTS Early career nurses and their preceptors found that the programme enables improved knowledge and skills of patient assessment, application of critical thinking to clinical practice, perceived improvement in patient care delivery and outcomes, enhanced interprofessional communication and knowledge sharing, and had a positive impact on professional awareness and career planning. CONCLUSIONS This clinical-academic partnership positively impacted on the clinical practice and transition experience of early career nurses and was closely aligned to an organizations strategic plan for nursing workforce development.

The Power of Synergy: An Academic/Clinical Partnership for Transformational Change

Background. A programme of postgraduate study was developed in partnership between a health board and a university in New Zealand, having identified critical thinking and practice change as key determinants of good care delivery. Aim. To explore the impact after 12 months of a postgraduate programme for registered nurses on patient assessment and clinical reasoning, and the status of implementation plans for improved patient care. Design. Outcome evaluation using a survey and focus groups. Setting. On location at a hospital in a small city in New Zealand that provides healthcare services for 102,000 people across rural and urban areas. Participants. Registered nurses who had completed the programme () and seven clinical mentors. Methods. A survey, focus groups, and follow-up data about quality improvement projects were used to explore how the programme was experienced and its impact. Results. The survey revealed perceptions of improved knowledge and skills but a lack of confidence in communicating with medical staff. Of 28 quality improvement projects planned, all but three had been implemented and were still in use. Two themes were generated from focus group data: “new ways of thinking” and “doing things differently.” Conclusions. This academic/clinical partnership positively influenced nurses’ knowledge and skills, encouraged critical thinking and self-efficacy, and resulted in the sustained implementation of nurse-initiated projects intended to improve patient care.

New light through old windows: nurses, colonists and indigenous survival.

The aim of this study was to explore the influences, processes and environments that shaped the practice of European nurses for indigenous New Zealand (NZ) Māori communities who were being overwhelmed by introduced infectious diseases. Historical data were accessed from multiple archival sources and analysed through the lens of colonial theory. Through their work early last century, NZ nurses actively gained professional status and territory through their work with Māori. By living and working alongside Māori, they learned to practise in new ways that influenced Māori health. By developing a new role in new professional territory, nurses extended their practice to include health promotion as well as disease prevention. Māori survival from epidemics improved, and the population grew over that period. For Māori, however, Eurocentric care alleviated their immediate health problems, but the detrimental impact of the mechanisms of colonisation overall has continued to the present day.

Mapping for Conceptual Clarity: Exploring Implementation of Integrated Community-Based Primary Health Care from a Whole Systems Perspective

Introduction: Studying implementation of integrated models of community-based primary health care requires a “whole systems” multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a “whole systems” approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models. Theory and methods: This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham’s Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study. Results: A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps. Discussion and conclusion: This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.

Are Patient and Carer Experiences Mirrored in the Practice Reviews of Self-management Support (PRISMS) Provider Taxonomy?

Introduction: Patient self-management support is central to care for long term conditions and for integrated care. Patients and their carers are the final arbiter of whether support for self-management has been effective. A new taxonomy lists 14 categories of provider activities that support patient self-management (Practical Reviews in Self-Management Support, PRISMS). We asked whether we could recognise these provider activities in narratives from patients and carers. We sought to extend the theoretical framework of the taxonomy to include the view from patient and carers. Methods: We interviewed 28 patients and family carers in a case study of primary health care in New Zealand in 2015 to determine which components of the taxonomy were visible. We drew on interviews with clinicians and organisation persons to explain case study context. Results: We found, within patient and carer data, evidence of all 14 components of provider self-management support. The overarching dimensions of the taxonomy helped reveal an intensity and consistency of provider behaviour that was not apparent considering the individual components. Conclusions: Patient and carer data mapped to provider activities. The taxonomy was not explicit on provider relationships and engagement with, or separate support needs of, patients and carers.

Understanding the Attributes of Implementation Frameworks to Guide the Implementation of a Model of Community-based Integrated Health Care for Older Adults with Complex Chronic Conditions: A Metanarrative Review

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated community-based and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them.

When equity is central to research: implications for researchers and consumers in the research team

This paper is a response to our recognition that approaches to equity and consumer involvement in research differed in emphasis between our researchers and jurisdictions. Whilst we shared common aspirations we varied in our priorities between equity groups and methods to represent consumer interests. New Zealand has a historical focus on equity for indigenous Maori and shares with Canada concern about enduring inequalities that affect people’s lives.

Educating new graduate nurses in their first year of practice: The perspective and experiences of the new graduate nurses and the director of nursing

New graduate nurses are the future of nursing and the education they receive as they transition into the workforce as a newly registered nurse is critical for building a suitably qualified nursing workforce that will adequately serve the future population. Variation exists in education programmes for new graduate nurses in their first year of practice which is known to impact on transition experience. A qualitative study using focus groups and semi-structured interviews was undertaken to explore the experiences and perceptions of New Graduate Nurses undertaking a new graduate programme and Directors of Nursing supporting them to complete the programme which may or may not have been inclusive of a postgraduate course (Masters Level). The findings of this study are in line with previous research and support the value of new graduate programmes but did reveal a lack of consensus in regards to the structure and content of such programmes. This study revealed some commonalities and challenges between the differing programmes but has identified the need for further research to establish the impact of postgraduate education in the first year of practice and how this impacts on nursing practice and patient care. There are numerous terms in the literature with reference to new graduate programmes; transition to practice programme, nurse entry to practice programme, first year of clinical practice programme, new graduate programme and early career nursing programme. For the purpose of this article the term Nurse Entry to Practice (NETP) will be used in reference to any form of new graduate programme.

A Research Program on Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH): An International Collaboration

Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is “What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?” and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Québec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.