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A mixed-methods evaluation of an intervention for enhancing alcohol screening in adults aged 50+ attending primary health care
(CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners, 2025-01-02) Towers A; Newcombe D; White G; McMenamin J; Sheridan J; Rahman J; Moore A; Stokes T
Introduction Adults aged 50 years and over are drinking more than ever but primary health care (PHC) professionals find it challenging to screen them for alcohol-related harm, despite being at greater risk for harm than younger drinkers. Aim This intervention aimed to enhance alcohol screening for this cohort by (a) introducing an algorithm in the patient management system to automate detection of alcohol risk in patients and (b) providing training to support health professionals' practice of, knowledge about, and comfort with alcohol screening in this cohort. Methods Eleven PHC practices in Aotearoa New Zealand took part in this intervention, including 41 PHC health professionals. Development and integration of the automated alcohol screening process within PHC patient management systems was undertaken in parallel with health professional training approaches. Results Screening rates increased substantially at intervention initiation but fell immediately with the onset of the New Zealand COVID-19 national lockdown. Two-thirds of health professionals identified the system screening prompts, over 40% felt this changed their screening practice, and 33% increased their awareness of - and felt more comfortable screening for - alcohol-related risk in those aged 50+. Discussion We illustrated an initial increase in alcohol screening rates in those aged 50+ as a result of this intervention, but this increase could not be sustained in part due to COVID-19 disruption. However, health professionals indicated that this intervention helped many change their practice and enhanced their awareness of such risk and comfort in screening for alcohol-related risk in those aged 50+.
The key factors driving successful improvement in primary care : a mixed methods investigation of the determinants of quality improvement success in Aotearoa New Zealand : a thesis with publication presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, Aotearoa New Zealand
(Massey University, 2023-11-30) Cullen, Jane
Primary care is where the population receives most of their health care and where successful quality improvement (QI) can have the biggest impact on health, wellbeing, equity, and health system performance. A better understanding of the factors that influence QI in primary care is urgently needed to support a high-performing primary healthcare system. Most prior studies into the determinants of effective QI have focused on secondary care organisations and large-scale collaborative efforts. Primary care services such as general practice present a different set of challenges. Various key contextual factors have been identified in the literature, but few studies explain how they relate to each other and QI success. This study sought to answer the following questions: 1. What are the contextual factors influencing primary care improvement interventions? 2. How do the contextual factors, improvement content (topic and planned changes) and the implementation process influence each other and the improvement outcomes in primary care? 3. How applicable for primary care assessment is the Model for Understanding Success in Quality (MUSIQ), a tool for assessing modifiable contextual factors developed in secondary care? This research was an explanatory sequential mixed methods study based in the Aotearoa, New Zealand (NZ) primary care setting of general practice and Primary Health Organisations (PHOs). Amulti-case mixed methods approach was followed in the first stage. Mainly qualitative data were collected from primary care interviews guided by the Consolidated Framework for Implementation Research (CFIR). This was compared with quantitative data from the MUSIQ survey. The second stage consisted of a national survey where emerging theory was tested by partial least squares structural equation modelling (PLS-SEM). The findings revealed that most teams did not use formal QI methods, instead relying on their people-centred relationship skills and networks to drive QI via distributed leadership. Teams were intrinsically motivated by community and patient need and drew on strengths developed within the complexity and uncertainty of the primary care settings to drive QI. The collaborative skills which are increasingly required in the modern primary care setting support the shared social processes of sensemaking for enacting change. The key success factors driving QI in primary care are identified and how they relate to each other explained. A primary care adaptation of MUSIQ has been proposed that may aid improvement practitioners and researchers to assess primary care contexts. The key strengths should be developed and supported across primary care services and capability, capacity and resources supported centrally to increase the ability of primary care to improve services more easily and effectively.
Nursing care for people living with diabetes and associated conditions in Fiji : an iTaukei community context : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, New Zealand
(Massey University, 2021) Ravono, Akisi Nailaba
This research examined the experiences of iTaukei (indigenous people of Fiji) patients and nurses in the context of the diabetes epidemic in Fiji. Vanua theory, which has some influence on iTaukei health beliefs and practices through its physical, social and cultural elements informed the design and conduct of the research. Despite the voluminous global literature on diabetes and non-communicable diseases (NCD), there was little written about the topic for Fiji and the Pacific. Fiji was among the first few countries to adopt public health initiatives that were developed to curb the incidence of NCD. However, such initiatives have faced a perpetual challenge in terms of implementation, monitoring and evaluation. The research used the Fijian Vanua Research Framework and veitalanoa, a data collection method, to gather information from twelve patients and eleven nurses from four medical areas in Fiji. The veitalanoa groups were complemented by four veitalanoa individual sessions and field observations. Findings revealed that patients struggled to cope with diabetes and associated complications while nurses were challenged to deliver best practice in inadequate nursing practice environments. Specifically, patients had difficulties both living with diabetes and accessing planned care and were culturally unlikely to question or challenge medical decisions, simply expecting safe and trustful care. Nurses were not able to nurse in the way they know is needed; they provided rudimentary and sometimes inappropriate care, and experienced extreme frustration while attempting to provide holistic care in a highly medicalised model of care. The nurses were aware of vanua etiquette and their connections with iTaukei patients, however, they could not apply such protocol. Despite study findings revealing significant challenges for patients and nurses, the participants suggested a way forward for the improvement of nursing care and primary health care in Fiji. Such changes may represent considerable challenge to the accepted hierarchies of power and decision making and will need to be strongly supported by a focus on patient centered care.
Marlborough Maori experience in accessing mental health services via primary health care : an exploratory study : Te Kura Hinengaro Tangata, School of Psychology, Massey University, Turitea, Palmerston North, February 2007, thesis submitted in partial fulfilment of the requirements for the degree of
(Massey University, 2007) Eade, Lorraine
National and Maori health policy: A background The New Zealand government has clearly recognised the disparities between Maori and non-Maori health (Te Puni Kokiri, 2000a; Te Puni Kokiri, 2000b; Ministry of Health, 2002a). This has contributed towards a number of health strategies and policy development designed to improve Maori health. The New Zealand Health Strategy (2000) is the government's overarching health strategy, which acknowledges a special relationship between Maori and the Crown under the Treaty of Waitangi. It identifies Maori health as one of its key priorities and several subsidiary strategies have been launched to assist meet its national objectives for achieving Maori health gain. Four subsidiary strategies play a pivotal role in terms of Maori mental wellbeing. The key objectives outlined in He Korowai Oranga - The Maori Health Strategy (2002) are to improve access to appropriate services for Maori, improve Maori health outcomes and support Maori health provider development. Te Puawaitanga Maori Mental Health National Strategic Framework (2002b) suggests that opportunities need to be maximised for intra and intersectoral co-operation. These include objectives to improve training for General Practitioners and other health workers providing primary health care to Maori tangata whaiora (users of mental health services), with a focus on depression, anxiety, youth suicide and addictions. The Primary Health Care Strategy (2001) aims to build a strong primary health care system that will improve the health of all New Zealanders and in particular will focus on reducing inequalities in health. Te Tahuhu - The Second New Zealand Mental Health and Addiction Plan (2005) has, as one of its ten challenges, a stronger emphasis on primary health care. This challenge aims towards "building and strengthening the capability of the primary health care sector to promote mental health and wellbeing for tangata whaiora", and for the New Zealand health system to "continue to broaden the range, quality and choice of mental health and addiction services accessible for Maori", (p. 13,14). [From Introduction]
Nurse practitioners in rural primary health care in New Zealand : an institutional ethnography : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Albany, New Zealand
(Massey University, 2017) Adams, Sue
Nurse practitioners are an effective and appropriate health workforce for delivering health services to underserved and rural populations. Since 2001, New Zealand has been registering nurse practitioners through a robust educational, regulatory, and legislative framework, and from 2014, all nurse practitioners are authorised prescribers. However, the numbers of nurse practitioners working in rural primary health care have been slow to materialise. Despite an ageing demographic, the increasing prevalence of long term conditions, ongoing health inequalities, and a declining rural medical workforce, there remains a persistence to pursue the general practitioner-led model of care. The purpose of this study was to critically examine the work required to establish nurse practitioner services in rural primary health care in New Zealand. Institutional ethnography, developed by Dorothy Smith, provided the overall approach to the inquiry. The activities and experiences of people in local settings are textually organised by the institutional ruling relations. This inquiry explored the work and experiences that nurses undertook on their journey to become nurse practitioners and deliver services in rural primary health care, and how these were institutionally shaped and coordinated. Interviews were initially conducted with nurse practitioners and nurse practitioner candidates as the primary informants. The interviews were analysed using a mapping technique to identify text-based work processes and show connections, tensions, and contradictions with authoritative or ruling texts. Further data was collected through secondary informant interviews and the tracing and identification of texts. The findings revealed that there were multiple texts and discourses being enacted locally, which facilitated or hampered their work to become nurse practitioners. The ongoing institutional domination of medicine retained general practitioner-led primary care, despite policy and nursing professional texts that promoted social justice. Service fragmentation and frequent changes in policy, structure, and management of organisations at local and national level, resulted in further challenges and work processes by the nurse practitioners to maintain and implement services. Together with the lack of a cohesive national policy and implementation framework for nurse practitioners, the opportunity for nurse practitioners to meet the health needs of the rural population of New Zealand continues to be discounted.
Diabetic kidney disease : exploring factors that impede early detection and intervention in the primary care setting : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Wellington, New Zealand
(Massey University, 2015) Walker, Miranda
This thesis describes a study which aimed to identify factors which impede early detection and treatment of diabetic kidney disease (DKD) in primary care. Diabetic kidney disease is a common, harmful, and costly chronic healthcare condition. Despite long-established and evidence-based guidelines recommending early detection and treatment as the optimal management strategy, significant numbers of people continue to be either undetected or undertreated. Using a qualitative descriptive methodology, focus groups for primary care healthcare practitioners and semi-structured interviews with patients were conducted. Participants’ knowledge about DKD, its risk factors and management, and their perceptions about progression of the disease was collected. Content analysis extracted patterns of ideas from the data and then grouped them into key themes which were then interpreted from the perspective of Wagner’s Chronic Care Model. Two themes emerged from patient interviews: locating health within one’s lifestyle and motivators to change the priority of that position. Focus groups with health care practitioners revealed four themes: knowledge of best practice, screening and recall, models of primary care delivery, and factors which affect patients’ engagement with healthcare services. This study identified several factors which were found to impede the early detection and treatment of DKD in primary health. This thesis discusses those factors, placing them in the context of current literature on the topic, and from the perspective of effective provision of chronic care. Recommendations for possible improvements are offered, along with suggested directions for future research.
A single case study : an evaluation of the impact of the implementation of the primary health Care strategy on the primary health care nursing workforce in Tairawhiti : a thesis presented in total fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Manawatu, New Zealand
(Massey University, 2014) Robertson, Heather Ruth
In December 2000 the New Zealand Health Strategy was released closely followed by the Primary Health Care Strategy in February 2001. The Primary Health Care Strategy pledged a significant paradigm shift in health service funding and delivery and primary health care nurses were considered crucial to implementation. The intent of this study is to investigate the impact of implementation of the Strategy on primary health care nursing in Tairawhiti. Tairawhiti District Health Board (TDH) and the two Primary Health Organisations (PHOs) were central to the analysis. For my overarching research framework I employed a qualitative interpretive design informed by constructionism. The diffusion of innovation theory seeks to explain how, why, and at what rate new ideas are spread through cultures and provided the theoretical lens to collect the data and analyse the findings. Using a single instrumental case study design, data were collected from multiple sources including relevant policy documents and strategic plans as available on the TDH, Ngati Porou Hauora and Turanganui PHO websites. Qualitative data were obtained using in-depth individual interviews with managers at middle and senior levels at TDH and the two PHOs. Focus groups were held with primary health care nurses. The study concludes that investment in and the effective deployment of primary health care nurses in Tairawhiti did not occur as anticipated. A key finding was the lack of a whole of system strategic approach and poor diffusion processes meant widespread service change was undermined. The study also found that the Strategy met with multiple sources of resistance across the health sector, further exacerbated by existing structural barriers in the health system. This study brings together an increased understanding of the complexities that continue to disable a true primary health care approach and consequently restrict the potential gain the nursing workforce offers.
BSMC : is there room for me? : an exploration of nursing leadership in primary health care : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Auckland, New Zealand
(Massey University, 2012) Calverley, Rachael
The unpredictability of health in a dynamic climate can result in a multiplicity of challenges. Indeed unpredictability has been referred to as the essence of creativity. Strong leadership in healthcare and importantly nursing is crucial to seeking solutions to organizational change especially when decision making will impact on the population’s health. By influencing policy objectives through leadership, nurses have the opportunity to develop strategies that make a difference to future complex problems. With the implementation of the Governments Better Sooner More Convenient (BSMC) policy agenda and principles underway from 2008 onwards, to reframe primary health care services, a series of key principles emerged including: a more personalized primary health care system with services moved closer to home; reduction in demand on hospitals and a package of services centred on integrated family health centres, with nurses taking a key role in shifting services from the secondary to primary care needs of patient support. From seventy health collective submissions positioning themselves to address these principles, nine were selected to move through to the next stage of development. The applications from all of the successful organizations referred to the need for improved multi-professional working and/or the importance of the nursing workforce to the BSMC agenda. Importantly, it would appear that a high quality nursing leadership function within the BSMC health collectives developing BSMC service configurations would be required to meet their goals. The purpose of this study was to explore with nurse leaders how they were able to contribute to these evolving primary health care collectives and changes that influenced the development of new or reviewed services, in addition to gaining insight into their challenges and opportunities as nurse leaders. The literature suggests a move away from the post heroic model of leadership and refers more frequently to coalitions of experts or leaders as a collective intelligence. These emerging characteristics represent a distributed leadership model that is leadership shared across varying people, professions and roles. It is this distributed model of leadership that provided a conceptual framework and a clear point of reference for this study. A qualitative approach derived from an interpretive perspective was the methodology chosen for this research. Eight out of nine potential nurse leaders involved in each of the regional health collectives participated in telephone interviews and communicated with the researcher via email networks. Theme identification was the essential task for the analysis process. Four key themes were identified with subthemes: politicization (power to influence), infrastructure (teams and education/training), coalitions of leaders (communication and relationships) and resilience (battling and visibility). The findings suggest on-going challenges to nurses leading in primary health care which include fragmentation among nurses, variable investment in regional nursing infrastructure, interdisciplinary relationship issues and limited training to develop future nurse leaders. Addressing these results requires clinical, strategic and professional nursing leaders to work within fora that are unified, cohesive and collectively agreed on their purpose.
Living large : the experiences of large-bodied women when accessing general practice services : a thesis presented in partial fulfillment of the requirements for the degree of Master of Philosophy (Nursing) at Massey University, Palmerston North, New Zealand
(Massey University, 2011) Russell, Nicola
The ‘obesity epidemic’ of the past two decades has resulted in numerous studies reporting higher levels of stigma and discrimination experienced by obese/overweight women, both within the health care system and society in the main. Despite general practice being the most utilised point of access for health care services, there has been very little international or national exploration of the experiences of large-bodied women accessing these services. Utilising a qualitative, descriptive research design, this post-structuralist feminist study has enabled a group of large-bodied women to express their stories of accessing general practice services. Eight self identified large-bodied women volunteered to participate in semi-structured face-to-face interviews. Thematic analysis identified seven themes: Early experiences of body perception, Confronting social stereotypes, Contending with feminine beauty ideals, Perceptions of health, Pursuing health, Respecting the whole person and Feeling safe to access care. The women in this study articulated broader interpretations of health and well-being than those teachings reproduced within dominant bio-medical and social discourses of obesity. When these women’s personal context, beliefs and values are silenced by the health care provider, the rhetoric of health care professional claims of patient-centred care has given way to these women experiencing stigmatisation and a sense of ambiguity about general practice services. However, when space is given for multiple interpretations of obesity to exist within the patient-health care provider relationship, these women feel respected, their health needs are satisfied and they are more comfortable to engage in health screening services. Resisting the powerful socio-cultural milieu which supports the superiority of a slim female body as a signifier of both health and beauty presents a challenge for health care professionals to negotiate. I contend however, that giving consideration to the perspectives of large-bodied women and critically reflecting upon one’s own personal beliefs and attitudes about the overweight/obese, presents an opportunity to ensure clinical practice for this population is truly patient-centred.
Tauiwi general practitioners explanations of Maori health: Colonial relations in primary healthcare in Aotearoa/New Zealand?
(SAGE Publications, 2002) McCreanor T; Nairn R
This article reports initial findings from qualitative research investigating how general practitioners talk about Maori health. Transcripts of semistructured interviews with 25 general practitioners from urban Auckland were subjected to critical discursive analyses. Through this process of intensive, analytic reading, interpretative repertoires—patterns of words and images about a particular topic—were identified. This article presents the main features of one such repertoire, termed Maori Morbidity, that the general practitioners used in accounting for poor Maori health status. Our participants were drawing upon a circumscribed pool of ideas and explaining the inequalities in health between Maori and Tauiwi in ways that gave primacy to characteristics of Maori and their culture. We discuss the implications of this conclusion for relations between Maori patients and Tauiwi doctors in primary healthcare settings.

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