Sue Pullon

Early clinical exposure to people who are dying: learning to care at the end of life

Background  The nature of medical care at the end of life and, in particular, the way in which caring is learned remain problematic for medical educators and the profession. Recent work has indicated that doctors learn to care, in an emotional and intimate way, from people who are dying.

Factors Influencing Continuation of Breastfeeding in a Cohort of Women

The objective of this studywas to prospectively explore the influence ofwomen’s experiences in preparing for and establishing breastfeeding on the duration of breastfeeding. A cohort of 490 women was surveyed at intervals during pregnancy and after giving birth. Data were collected on breastfeeding outcomes and experiences and analyzed using multiple logistic regression. After controlling for sociodemographic variables, women were less likely to be still fully breastfeeding at 6 to 10 weeks postpartum if they believed they needed more breastfeeding information prior to delivery or had experienced breastfeeding problems. Women were less likely to be fully breastfeeding at 4 months postpartum if they had experienced breastfeeding problems. This prospective study demonstrated the influence ofwomen’s preparedness for breastfeeding and their experiences in establishing breastfeeding on breastfeeding duration. Improvements in prenatal education about breastfeeding and management of breastfeeding problems are likely to increase breastfeeding duration.

The midwife's role in facilitating smoking behaviour change during pregnancy

OBJECTIVE To explore the midwifes role in providing education and support for changes in smoking behaviour during usual primary maternity care. DESIGN A qualitative study using a thematic approach to analysis of data collected in face-to-face interviews. SETTING AND PARTICIPANTS Eleven women who had participated in the intervention groups of the MEWS Study, a cluster randomised trial of education and support for women who smoke, and 16 midwives from the intervention and control arms of the trial. The trial was set in the lower North Island of New Zealand in 2000. FINDINGS Midwives acknowledged that asking women about smoking was part of their role as maternity care providers. However, many found it difficult to know how to ask women about their smoking, how to identify the women who would be receptive to advice and how to support them to make changes to their smoking. Midwives were also concerned about making women feel guiltier than they already did about their smoking, and about the impact of providing smoking cessation on their relationship with women. In contrast, women expected their midwife to ask them about their smoking. When women wanted to quit their midwife was an extremely valuable source of information and support. Midwives were also in a position to help women who did not want to quit to make other changes to their smoking behaviour. Even women who did not want to quit were prepared to be asked about their smoking. Problems arose when the way the midwife asked and the frequency of her enquiries were not appropriate for the stage of the change cycle the woman was in. IMPLICATIONS FOR PRACTICE Midwives can effectively provide education and support for smoking change during pregnancy if they match the womans readiness to make changes with the type of advice and support they provide.

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.

Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care

OBJECTIVE To test the hypothesis that appropriate interventions delivered by midwives within usual primary maternity care, can assist women to stop or reduce the amount they smoke and facilitate longer duration of breast feeding. DESIGN, SETTING AND PARTICIPANTS In a cluster randomised trial of smoking education and breast-feeding interventions in the lower North Island, New Zealand, midwives were stratified by locality and randomly allocated into a control group and three intervention groups. The control group provided usual care. Midwives in the intervention groups delivered either a programme of education and support for smoking cessation or reduction, a programme of education and support for breast feeding or both programmes. Sixty-one midwives recruited a total of 297 women. INTERVENTIONS Structured programmes provided by midwives. FINDINGS Women receiving only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and 36 weeks gestation. Women receiving both the smoking cessation and breast-feeding education and support programmes were significantly more likely than women in the control group to have changed their smoking behaviour at 36 weeks gestation. There was no difference in rates of cessation or reduction between the groups in the postnatal period. There was no difference in rates of full breast feeding between the control and intervention groups for women who planned to breast feed. KEY CONCLUSIONS Education and support by midwives, as part of primary midwifery, can facilitate smoking cessation and reduction during pregnancy.

How well do medical students rate and communicate clinical empathy

Background: This article presents findings from a prospective, longitudinal cohort educational study investigating empathy communication in clinical consultations. It reports on changes in students’ self-report empathy during medical undergraduate training, investigates how well peers can assess student competence in motivational interviewing/brief interventions (MI/BI) skills and explores the relationship between students’ self-report empathy and peer- or tutor-assessments of competence. Methods: 72 medical students completed the Jefferson Scale of Physician Empathy at three time points: at the beginning of their fifth year medical training (Time 1), after a specific MI/BI training session during their fifth year medical training (Time 2) and 1 year later during a revision session in year 6. Competence in BI/MI consultation was assessed using the validated tool Behaviour Change Counselling Index. Results: A significant decline in medical students’ empathy scores was observed from year 5 to year 6, consistent with international findings. Peer assessments and tutor ratings of competence in MI/BI skills performance were moderately correlated, but peer assessments were negatively correlated with medical students’ self-rated empathy. Senior medical students who self-rated as more empathic received lower competence evaluations of MI/BI skills from their peers. Interventions to further investigate teaching and learning of empathy are discussed.

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.

An interprofessional community education project as a socially accountable assessment.

Abstract As part of a clinically based rotational undergraduate interprofessional programme, an assessment was devised which was construed as being socially accountable. An interprofessional programme, with cohorts of students from six different health professions, was evaluated in a number of ways. Students completed pre and post questionnaires about many aspects of the programme and also participated in focus groups. The social accountability of the key assignment emerged as important for both students and the community agencies that provided the clinical experience for students. Students implicitly and explicitly reported that their awareness of the need for health professionals to be socially accountable was heightened as a result of the assignment task. This article indicates that with creativity and perseverance an assessment can be devised that is relevant both to the student and the community, and is a powerful learning exercise for all involved.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus.

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin’s 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

What makes an interprofessional education programme meaningful to students? Findings from focus group interviews with students based in New Zealand

ABSTRACT It is important to understand what an interprofessional education (IPE) experience means to students and what makes it meaningful so that optimal use can be made of IPE opportunities and resources. This article reports qualitative data from a larger study evaluating an 11-hour IPE programme which focused on long-term condition management. Qualitative analysis aimed to explore students’ perspectives of the programme. Forty-one students from dietetics, medicine, physiotherapy, and radiation therapy were invited to participate in interprofessional focus groups. Data gathered from 34 students who participated in two focus groups were analysed inductively using thematic analysis. Three key themes emerged related to (i) learning, (ii) perceived long-term professional benefits, and (iii) the structure and content of the programme. Participants considered the programme to be a valuable learning opportunity with direct relevance to their future clinical careers. Findings indicated that providing students with an opportunity to learn about each other should be prioritised within IPE programmes and that this process should be student-led. This may help students to effectively learn with and from each other. Students perceived active learning activities, including interviewing a patient in their home and presenting findings to their peers, to be particularly valuable.