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Item Who rules the centre of care? : an institutional ethnography exploring patient experiences within the New Zealand primary care setting : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Manawatū, New Zealand(Massey University, 2022) Webster, RachelImproving ‘patient experience’ is at the forefront of international quality improvement agendas and is prioritised by dominant frameworks such as the Institute for Healthcare Improvement’s ‘Triple Aim.’ To gather knowledge of this priority measure, New Zealand developed a set of ‘system level measures’ to benchmark and compare data between local, national and international health systems. The primary care patient experience survey, introduced as a system level measure, is purported to measure ‘patient experience.’ The survey produces official reports of a person/patient-centred primary care system. However, the findings in this report differ from what I learned talking with patients about their actual experience. This project uses the tools of institutional ethnography to begin an inquiry from the accounts of patients. To generate these accounts, I asked people about their experience of being a patient (N = 10). The intention is to learn about what patients say, know and do. I then asked seven clinicians (general practitioners, nurse practitioners, and registered nurses) about their experience, again focusing on what they say, know and do. The analysis reveals that some frontline patients and clinicians reported care practices that explicitly challenge their ability to be at or put patients at the centre of care. In some instances, practices purported to enhance person-centred care instead appear to place the person at an even greater distance from the centre, generating new work for patients without a clear benefit for the patient doing such work. Examples investigated include ‘GP triage’ and ‘team-based practice.’ From these findings, I followed what patients and clinicians say, know and do into the institution of primary care. At this level I talked with other key stakeholders of primary care and patient experience; people in management and governance, practice owners, strategy writers, survey writers, and primary care researchers (N = 11). I asked people in these positions about what they say and know, with the intention of using this knowledge to make sense of what can be said and done at the frontline of primary care. I found that standardising practices (e.g. 15 minute appointments, consultations limited to one issue per appointment, fee for service) constrain the clinician (and by proxy the patient) to what can be said and done during an episode of primary care. These practices are powerfully controlled by the private business model of primary care despite significant public funding. I found that patients and clinicians undertake significant workarounds to support care priorities such as continuity of care and timely access to care. Yet, the measurement of the “person-centredness” of primary care (the survey), renders invisible these actions of both patients and clinicians. The implications of these findings suggest that primary care, as it is presently organised, reorganised and protected by its principle protagonists, shifts the work of person-centred practices onto the frontline of primary care. The frontline of primary care is, at present, invisibly attempting to save this system from failure through their best efforts at addressing patient need.Item Multidisciplinary, multiple risk factor cardiovascular disease primary prevention programme in community pharmacy : a feasibility study : a thesis presented in partial fulfilment of the requirements for the degree of MSc Programme in Nutrition & Dietetics, School of Sport, Exercise and Nutrition, Massey University, Albany, New Zealand(Massey University, 2020) Alsford, Dave PeterBackground: Community pharmacy cardiovascular disease (CVD) primary prevention interventions, led by pharmacists, are effective. However, the majority of these have targeted single CVD risk factors and most have not adequately assessed the impact of dietary and physical activity behaviour. A multidisciplinary and multi- risk factor approach that involves collaboration between dietitians (dietary and physical activity consultations) and pharmacists (pharmacological treatment) may provide additional risk reduction benefits for participants. Objective: To assess the feasibility of implementing a community pharmacy-based CVD primary prevention programme using a multidisciplinary approach to motivate lifestyle behaviour change in participants at risk of CVD. The primary outcome was change in estimated five-year CVD risk. Methods: A 16-week single cohort pre- and post-test study was undertaken in two community pharmacies with twelve participants aged 40-74 years who had risk factors associated with increased CVD. Participants received dietary and physical activity advice at baseline and every four weeks by a student dietitian as well as pharmacological management assessment at baseline, 16 weeks and as needed by a pharmacist. Biochemical (blood lipids, blood pressure, HbA1c) and anthropometric (body composition, weight, height, waist and hip circumference) measures were compared at baseline, eight and 16 weeks. Behavioural measures (diet, physical activity and medication use) were compared between baseline and 16 weeks. Results: Eleven participants (68±5.2 years) completed the programme. Significant reductions from baseline to 16 weeks were observed for mean systolic and diastolic blood pressure (-5.47, p = 0.04 and -4.06mmHg, p = 0.01 respectively) and mean total cholesterol reduced significantly from baseline to eight weeks, (-0.43mmol/L; p = 0.005) but not between baseline and 16 weeks. The average diet quality score significantly improved by 12.6% from 65.9 to 74.2 out of 100 during the intervention period (p = 0.007). Other CVD risk factor measures showed a trend towards improvement. Five-year CVD risk did not significantly improve. Conclusions: Results are comparable to existing literature on interventions to reduce CVD in the community pharmacy setting. Findings within this small cohort, particularly the improvements seen in diet, support the inclusion of dietitians for the primary prevention of CVD in community pharmacies. A larger scale, controlled study will help in determining the extent of efficacy with this approach.Item The nurse practitioner-led primary health care clinic : a community needs analysis : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University(Massey University, 1999) Clendon, JillAim. To determine the feasibility of establishing a nurse practitioner-led, family focused, primary health care clinic within a primary school environment as an alternate or complementary way of addressing the health needs of 'at risk' children and families to the services already provided by public health nurses. Method. Utilising needs analysis method, data was collected from three sources - known demographic data, 17 key informant interviews and two focus group interviews. Questions were asked regarding the health needs of the community, the perceptions of participants regarding the role of the public health nurse in order to determine if a public health nurse would be the most appropriate person to lead a primary health care clinic, and the practicalities of establishing a clinic including the services participants would expect a clinic to provide. Analysis was descriptive and exploratory. Results. A wide range of health needs were identified from both the demographic data and from participant interviews. Findings also showed that participants' understanding of the role of the public health nurse was not great and that community expectations were such that for a public health nurse to lead a primary health care clinic further skills would be required. Outcomes from investigating the practicalities of establishing a nurse practitioner-led clinic resulted in the preparation of a community-developed model that would serve to address the health needs of children and families in the area the study was undertaken. Conclusion. Overall findings indicated that the establishment of a nurse practitionerled, family focused, primary health care clinic in a primary school environment is feasible. While a public health nurse may fulfil the role of the nurse practitioner, it was established that preparation to an advanced level of practice would be required. It is likely that a similar model would also be successful in other communities in New Zealand, however the health needs identified in this study are specific to the community studied. Further community needs assessments would need to be completed to ensure health services target health needs specific to the communities involved.