Eileen McKinlay

Effectiveness of a Falls‐and‐Fracture Nurse Coordinator to Reduce Falls: A Randomized, Controlled Trial of At‐Risk Older Adults

OBJECTIVES: To assess the effectiveness of a community‐based falls‐and‐fracture nurse coordinator and multifactorial intervention in reducing falls in older people.

Primary health care in New Zealand: the impact of organisational factors on teamwork

BACKGROUND Although teamwork is known to optimise good health care, organisational arrangements and funding models can foster, discourage, or preclude functional teamworking. Despite a new, enhanced population-based funding system for primary care in New Zealand, bringing new opportunities for more collaborative practice, fully implemented healthcare teamwork remains elusive. AIM To explore perceptions of interprofessional relationships, teamwork, and collaborative patient care in New Zealand primary care practice. DESIGN OF STUDY Qualitative. SETTING Eighteen nurses and doctors working in primary care, Wellington, New Zealand. METHOD Data were collected using in-depth interviews with individual nurses and doctors working in primary care settings. Perceptions of, and attitudes about, interprofessional relationships, teamwork, and collaborative patient care were explored, using an interactive process of content analysis and principles of naturalistic enquiry. RESULTS Nurses and doctors working in New Zealand primary care perceive funding models that include fee-for-service, task-based components as strongly discouraging collaborative patient care. In contrast, teamwork was seen to be promoted when health services, not individual practitioners, were bulk-funded for capitated healthcare provision. In well-organised practices, where priority was placed on uninterrupted time for meetings, open communication, and interprofessional respect, good teamwork was more often observed. Salaried practices, where doctors and nurses alike were employees, were considered by some interviewees to be particularly supportive of good teamwork. Few interviewees had received, or knew of, any training to work in teams. CONCLUSION Health system, funding, and organisational factors still act as significant barriers to the successful implementation of, and training for, effective teamwork in New Zealand primary care settings, despite new opportunities for more collaborative ways of working.

Use of, and attitudes to, clinical priority assessment criteria in elective surgery in New Zealand.

Objectives: To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery. Methods: A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis. Results: Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery. Conclusions: Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.

A model of treatment decision making when patients have advanced cancer: how do cancer treatment doctors and nurses contribute to the process?

This qualitative study describes how doctors and nurses report their contribution to treatment decision-making processes when patients have advanced cancer. Thirteen nurses and eight doctors involved in cancer treatment and palliation in one geographical location in New Zealand participated in the study. Data were collected using qualitative in-depth, face-to-face interviews. Content analysis revealed a complex context of decision making influenced by doctors and nurses as well as the patient and other factors. A model of clinician and patient decision making emerged with a distinct and cyclical process as advanced cancer remits and progresses. When patients have advanced cancer, nurses and doctors describe a predictable model of decision making in which they both contribute and that cycles through short- and long-term remissions; often nowadays to the point of the patient dying. In conclusion, the findings suggest doctors and nurses have different but complementary roles in what, when and how treatment choices are negotiated with patients, nevertheless within a distinct model of decision making.

Equity of access to elective surgery: reflections from NZ clinicians

Objectives To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians’ perceptions of equity and the factors they consider when prioritising patients for elective surgery. Methods A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically. Results General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians’ perceptions of the “value” that patients would receive from the surgery and patients” needs for public sector funding. Conclusions The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

Teaching and learning about chronic conditions management for undergraduate medical students: utilizing the patient-as-teacher approach.

Objectives: This study was undertaken to evaluate the impact on medical student learning of a revised chronic conditions teaching programme based on the chronic care model utilizing patients-as-teachers. Methods: A qualitative questionnaire was completed by students at the start of a primary healthcare rotation to determine existing impressions/understandings about chronic conditions. Following the revised teaching programme, a reflective essay about a home-visit to a person with chronic conditions was completed by students at the end of the rotation. Results: Analysis of the questionnaire at the start of the rotation showed students have some knowledge of the differences between acute and chronic care, have rather negative impressions of what it means to have chronic conditions and know little of overall patient management including the work of an interdisciplinary team. Analysis of the reflective essays completed by students at the end of the rotation showed an increased understanding of chronic conditions, what it means to have a chronic condition and who supports management. Discussion: A structured chronic conditions teaching programme including patient-as-teacher is an effective way of building knowledge and changing students’ impressions of what it means to have a chronic condition.

Clinicians’ reported use of clinical priority assessment criteria and their attitudes to prioritization for elective surgery: a cross‐sectional survey

Objectives:  To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC).

How family carers engage with technical health procedures in the home: a grounded theory study.

Objectives To explore the experiences of family carers who manage technical health procedures at home and describe their learning process. Design A qualitative study using grounded theory. Participants New Zealand family carers (21 women, 5 men) who managed technical health procedures such as enteral feeding, peritoneal dialysis, tracheostomy care, a central venous line or urinary catheter. In addition, 15 health professionals involved in teaching carers were interviewed. Methods Semistructured interviews were coded soon after completion and preliminary analysis influenced subsequent interviews. Additional data were compared with existing material and as analysis proceeded, initial codes were grouped into higher order concepts until a core concept was described. Interviewing continued until no new ideas emerged and concepts were well defined. Results The response of carers to the role of managing technical health procedures in the home is presented in terms of five dispositions: (1) Embracing care, (2) Resisting, (3) Reluctant acceptance, (4) Relinquishing and (5) Being overwhelmed. These dispositions were not static and carers commonly changed between them. Embracing care included cognitive understanding of the purpose and benefits of a procedure; accepting a ‘technical’ solution; practical management; and an emotional response. Accepting embrace is primarily motivated by perceived benefits for the recipient. It may also be driven by a lack of alternatives. Resisting or reluctant acceptance results from a lack of understanding about the procedure or willingness to manage it. Carers need adequate support to avoid becoming overwhelmed, and there are times when it is appropriate to encourage them to relinquish care for the sake of their own needs. Conclusions The concept of embracing care encourages health professionals to extend their attention beyond simply the practical aspects of technical procedures to assessing and addressing carers’ emotional and behavioural responses to health technology during the training process.

New Zealand general practice nurses' roles in mental health care

AIM To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. BACKGROUND Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models. METHODS An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation. FINDINGS Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. CONCLUSIONS Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Observation of interprofessional collaboration in primary care practice: A multiple case study

ABSTRACT Interprofessional collaboration (IPC) is known to improve and enhance care for people with complex healthcare and social care needs and is ideally anchored in primary care. Such care is complex, challenging, and often poorly undertaken. In countries such as Canada, the United Kingdom, the Netherlands, Australia, and New Zealand, primary care is provided predominantly via general practices, where groups of general practitioners and nurses typically work. Using a case study design, direct observations were made of interprofessional activity in three diverse general practices in New Zealand to determine how collaboration is achieved and maintained. Non-participant observation of health professional interaction was undertaken and recorded using field notes and video recordings. Observational data were subject to analysis prior to collection of interview data, subsequently gathered independently at each site. Case-specific themes were developed before determining cross-case themes. Cross-case themes revealed five key elements to IPC: the built environment, practice demographics and location, practice business models, shared goals, and team structure and climate. The combination of elements at each practice site indicated that strengths in one area helped offset challenges in others. The three practices (cases) collectively demonstrated the importance of an “all of practice” commitment to collaborative practice so that shared decision-making can occur.