Sandra Grace

Integrative medicine: enhancing quality in primary health care

OBJECTIVES Integrative medicine (IM) is an emerging model of health care in Australia. However, little is known about the contribution that IM makes to the quality of health care. The aim of the research was to understand the contribution IM can make to the quality of primary care practices from the perspectives of consumers and providers of IM. DESIGN This interpretive research used hermeneutic phenomenology to understand meanings and significance that patients and practitioners attach to their experiences of IM. Various qualitative research techniques were used: case studies; focus groups; and key informant interviews. Data sets were generated from interview transcripts and field notes. Data analysis consisted of repeatedly reading and examining the data sets for what they revealed about experiences of health care and health outcomes, and constantly comparing these to allow themes and patterns to emerge. SETTING The setting for this research was Australian IM clinics where general medical practitioners and CAM practitioners were co-located. RESULTS From the perspective of patients and practitioners, IM: (1) provided authentically patient-centered care; (2) filled gaps in treatment effectiveness, particularly for certain patient populations (those with complex, chronic health conditions, those seeking an alternative to pharmaceutical health care, and those seeking health promotion and illness prevention); and (3) enhanced the safety of primary health care (because IM retained a general medical practitioner as the primary contact practitioner and because IM used strategies to increase disclosure of treatments between practitioners). CONCLUSIONS According to patients and practitioners, IM enhanced the quality of primary health care through its provision of health care that was patient-centered, effective (particularly for chronic health conditions, nonpharmaceutical treatments, and health promotion) and safe.

Implementing large-scale workforce change: learning from 55 pilot sites of allied health workforce redesign in Queensland, Australia

BackgroundIncreasingly, health workforces are undergoing high-level ‘re-engineering’ to help them better meet the needs of the population, workforce and service delivery. Queensland Health implemented a large scale 5-year workforce redesign program across more than 13 health-care disciplines. This study synthesized the findings from this program to identify and codify mechanisms associated with successful workforce redesign to help inform other large workforce projects.MethodsThis study used Inductive Logic Reasoning (ILR), a process that uses logic models as the primary functional tool to develop theories of change, which are subsequently validated through proposition testing. Initial theories of change were developed from a systematic review of the literature and synthesized using a logic model. These theories of change were then developed into propositions and subsequently tested empirically against documentary, interview, and survey data from 55 projects in the workforce redesign program.ResultsThree overarching principles were identified that optimized successful workforce redesign: (1) drivers for change need to be close to practice; (2) contexts need to be supportive both at the local levels and legislatively; and (3) mechanisms should include appropriate engagement, resources to facilitate change management, governance, and support structures. Attendance to these factors was uniformly associated with success of individual projects.ConclusionsILR is a transparent and reproducible method for developing and testing theories of workforce change. Despite the heterogeneity of projects, professions, and approaches used, a consistent set of overarching principles underpinned success of workforce change interventions. These concepts have been operationalized into a workforce change checklist.

CAM practitioners in integrative practice in New South Wales, Australia: a descriptive study

OBJECTIVES The aim of this study was to examine the role of complementary and alternative medical (CAM) practitioners in integrative practices where general practitioners (GPs) and CAM practitioners were co-located. DESIGN This study used grounded theory, a qualitative methodology from the interpretive paradigm. SETTING A total of 23 integrative practitioners (10 general practitioners and 13 naturopaths) were interviewed. The informants were drawn from 16 integrative practices and one non-integrative general medical practice. RESULTS In 11 out of 16 integrative practices the CAM practitioners yielded their primary contact role to the GPs. CAM practitioners were restricted to expanding the range of treatment options available to patients. However, the role of the CAM practitioners was influenced by the level of CAM training the GP(s) in the practice had undertaken. The more CAM training the GPs had undertaken, the more CAM practitioners were enlisted as diagnosticians as well as treatment providers. CONCLUSION CAM practitioners in integrative practices had an accessory role to the GPs in the practice, deferring diagnosis and assessment activities to the GPs. However, where GPs had significant training in CAM, the CAM practitioners role included both treatment and diagnostic activities.

Contested professional role boundaries in health care: a systematic review of the literature

BackgroundAcross the Western world, demographic changes have led to healthcare policy trends in the direction of role flexibility, challenging established role boundaries and professional hierarchies. Population ageing is known to be associated with a rise in prevalence of chronic illnesses which, coupled with a reducing workforce, now places much greater demands on healthcare provision. Role flexibility within the health professions has been identified as one of the key innovative practice developments which may mitigate the effects of these demographic changes and help to ensure a sustainable health provision into the future. However, it is clear that policy drives to encourage and enable greater role flexibility among the health professions may also lead to professional resistance and inter-professional role boundary disputes. In the foot and ankle arena, this has been evident in areas such as podiatric surgery, podiatrist prescribing and extended practice in diabetes care, but it is far from unique to podiatry.MethodsA systematic review of the literature identifying examples of disputed role boundaries in health professions was undertaken, utilising the STARLITE framework and adopting a focus on the specific characteristics and outcomes of boundary disputes. Synthesis of the data was undertaken via template analysis, employing a thematic organisation and structure.ResultsThe review highlights the range of role boundary disputes across the health professions, and a commonality of events preceding each dispute. It was notable that relatively few disputes were resolved through recourse to legal or regulatory mandates.ConclusionsWhilst there are a number of different strategies underpinning boundary disputes, some common characteristics can be identified and related to existing theory. Importantly, horizontal substitution invokes more overt role boundary disputes than other forms, with less resolution, and with clear implications for professions working within the foot and ankle arena.

Developing a viva exam to assess clinical reasoning in pre-registration osteopathy students.

BackgroundClinical reasoning (CR) is a core capability for health practitioners. Assessing CR requires a suite of tools to encompass a wide scope of contexts and cognitive abilities. The aim of this project was to develop an oral examination and grading rubric for the assessment of CR in osteopathy, trial it with senior students in three accredited university programs in Australia and New Zealand, and to evaluate its content and face validity.MethodsExperienced osteopathic academics developed 20 cases and a grading rubric. Thirty senior students were recruited, 10 from each university. Twelve fourth year and 18 fifth year students participated. Three members of the research team were trained and examined students at an institution different from their own. Two cases were presented to each student participant in a series of vignettes. The rubric was constructed to follow a set of examiner questions that related to each attribute of CR. Data were analysed to explore differences in examiner marking, as well as relationships between cases, institutions, and different year levels. A non-examining member of the research team acted as an observer at each location.ResultsNo statistical difference was found between the total and single question scores, nor for the total scores between examiners. Significant differences were found between 4th and 5th students on total score and a number of single questions. The rubric was found to be internally consistent.ConclusionsA viva examination of clinical reasoning, trialled with senior osteopathy students, showed face and content validity. Results suggested that the viva exam may also differentiate between 4th and 5th year students’ capabilities in CR. Further work is required to establish the reliability of assessment, to further refine the rubric, and to train examiners before it is implemented as a high-stakes assessment in accredited osteopathy programs.

Interprofessional collaborations in integrative medicine

OBJECTIVES Little is known about the implementation of integrative medicine (IM) in Australian health care and the nature of interprofessional collaborations that have been established in IM. The aim of this research was to examine the relationships among general medical practitioners (GPs) and complementary and alternative medicine (CAM) practitioners and their respective roles in co-located integrative practices. DESIGN This research adopted hermeneutic phenomenology as an effective methodology for revealing peoples experiences of IM and the meanings they attached to these experiences. Three (3) data collection methods were used: cumulative case studies, focus groups, and key informant interviews. Data analysis consisted of constant comparison of data from multiple sources to identify patterns and meta-themes. SETTINGS/LOCATION The setting for this research was Australian IM clinics where GPs and CAM practitioners were co-located. RESULTS Three (3) practice styles were identified among IM practitioners in this research: (1) mutually empowering when GPs and CAM practitioners regarded each other as peers, (2) GP-directed with varying levels of autonomy afforded CAM practitioners, and (3) limited collaboration where patients were offered mainstream medicine and CAM, which GPs performed themselves. CONCLUSIONS IM practice styles differed in terms of interprofessional power-sharing and roles assigned to CAM practitioners. Practice styles where CAM practitioners were highly valued and able to exercise high levels of professional autonomy were perceived as making effective use of the available CAM workforce. Both GP-directed and intragrative practice styles (where GPs practiced CAM themselves without referral to CAM practitioners) were perceived by many GPs and CAM practitioners as enhancing patient safety.

Understanding clinical reasoning in osteopathy: a qualitative research approach

BackgroundClinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions.MethodsThis study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories.ResultsAccording to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions.ConclusionsThe use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care.Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines.

Identifying common values among seven health professions: An interprofessional analysis

ABSTRACT This article reviews the competency frameworks of seven Australian health professions to explore relationships among health professions of similar status as reflected in their competency frameworks and to identify common themes and values across the professions. Frameworks were compared using a constructivist grounded theory approach to identify key themes, against which individual competencies for each profession were mapped and compared. The themes were examined for underlying values and a higher order theoretical framework was developed. In contrast to classical theories of professionalism that foreground differentiation of professions, our study suggests that the professions embrace a common structure and understanding, based on shared underpinning values. We propose a model of two core values that encompass all identified themes: the rights of the client and the capacity of a particular profession to serve the healthcare needs of clients. Interprofessional practice represents the intersection of the rights of the client to receive the best available healthcare and the recognition of the individual contribution of each profession. Recognising that all health professions adhere to a common value base, and exploring professional similarities and differences from that value base, challenges a paradigm that distinguishes professions solely on scope of practice.

Ethical experiential learning in medical, nursing and allied health education: A narrative review

Students enrolled in medical, nursing and health science programs often participate in experiential learning in their practical classes. Experiential learning includes peer physical examination and peer-assisted learning where students practise clinical skills on each other. OBJECTIVES To identify effective strategies that enable ethical experiential learning for health students during practical classes. DESIGN A narrative review of the literature. DATA SOURCES Pubmed, Cinahl and Scopus databases were searched because they include most of the health education journals where relevant articles would be published. REVIEW METHODS A data extraction framework was developed to extract information from the included papers. Data were entered into a fillable form in Google Docs. Findings from identified studies were extracted to a series of tables (e.g. strategies for fostering ethical conduct; facilitators and barriers to peer-assisted learning). Themes were identified from these findings through a process of line by line coding and organisation of codes into descriptive themes using a constant comparative method. Finally understandings and hypotheses of relevance to our research question were generated from the descriptive themes. RESULTS A total of 35 articles were retrieved that met the inclusion criteria. A total of 13 strategies for ethical experiential learning were identified and one evaluation was reported. The most frequently reported strategies were gaining written informed consent from students, providing information about the benefits of experiential learning and what to expect in practical classes, and facilitating discussions in class about potential issues. Contexts that facilitated participation in experiential learning included allowing students to choose their own groups, making participation voluntary, and providing adequate supervision, feedback and encouragement. CONCLUSION A total of 13 strategies for ethical experiential learning were identified in the literature. A formal process for written consent was evaluated as effective; the effectiveness of other strategies remains to be determined. A comprehensive framework that integrates all recommendations from the literature is needed to guide future research and practise of ethical experiential learning in health courses.

Diabetes educator role boundaries in Australia: a documentary analysis

BackgroundDiabetes educators provide self-management education for people living with diabetes to promote optimal health and wellbeing. Their national association is the Australian Diabetes Educators Association (ADEA), established in 1981. In Australia the diabetes educator workforce is a diverse, interdisciplinary entity, with nurses, podiatrists, dietitians and several other health professional groups recognised by ADEA as providers of diabetes education. Historically nurses have filled the diabetes educator role and anecdotally, nurses are perceived to have wider scope of practice when undertaking the diabetes educator role than the other professions eligible to practise diabetes education. The nature of the interprofessional role boundaries and differing scopes of practice of diabetes educators of various primary disciplines are poorly understood. Informed by a documentary analysis, this historical review explores the interprofessional evolution of the diabetes educator workforce in Australia and describes the major drivers shaping the role boundaries of diabetes educators from 1981 until 2017.MethodsThis documentary analysis was undertaken in the form of a literature review. STARLITE framework guided the searches for grey and peer reviewed literature. A timeline featuring the key events and changes in the diabetes educator workforce was developed. The timeline was analysed and emerging themes were identified as the major drivers of change within this faction of the health workforce.ResultsThis historical review illustrates that there have been drivers at the macro, meso and micro levels which reflect and are reflected by the interprofessional role boundaries in the diabetes educator workforce. The most influential drivers of the interprofessional evolution of the diabetes educator workforce occurred at the macro level and can be broadly categorised according to three major influences: the advent of non-medical prescribing; the expansion of the Medicare Benefits Schedule to include rebates for allied health services; and the competency movement.ConclusionThis analysis illustrates the gradual movement of the diabetes educator workforce from a nursing dominant entity, with an emphasis on interprofessional role boundaries, to an interdisciplinary body, in which role flexibility is encouraged. There is however, recent evidence of role boundary delineation at the meso and micro levels.