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    The process of nurses' role negotiation in general practice: A grounded theory study.
    (John Wiley and Sons Ltd, 2023-11-06) Hewitt SL; Mills JE; Hoare KJ; Sheridan NF
    AIM: To explain the process by which nurses' roles are negotiated in general practice. BACKGROUND: Primary care nurses do important work within a social model of health to meet the needs of the populations they serve. Latterly, in the face of increased demand and workforce shortages, they are also taking on more medical responsibilities through task-shifting. Despite the increased complexity of their professional role, little is known about the processes by which it is negotiated. DESIGN: Constructivist grounded theory. METHODS: Semi-structured interviews were conducted with 22 participants from 17 New Zealand general practices between December 2020 and January 2022. Due to COVID-19, 11 interviews were via Zoom™. Concurrent data generation and analysis, using the constant comparative method and common grounded theory methods, identified the participants' main concern and led to the construction of a substantive explanatory theory around a core category. RESULTS: The substantive explanatory theory of creating place proposes that the negotiation of nurse roles within New Zealand general practice is a three-stage process involving occupying space, positioning to do differently and leveraging opportunity. Nurses and others act and interact in these stages, in accordance with their conceptualizations of need-responsive nursing practice, towards the outcome defining place. Defining place conceptualizes an accommodation between the values beliefs and expectations of individuals and pre-existing organizational norms, in which individual and group-normative concepts of need-responsive nursing practice are themselves developed. CONCLUSION: The theory of creating place provides new insights into the process of nurses' role negotiation in general practice. Findings support strategies to enable nurses, employers and health system managers to better negotiate professional roles to meet the needs of the populations they serve, while making optimum use of nursing skills and competencies. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Findings can inform nurses to better negotiate the complexities of the primary care environment, balancing systemic exigencies with the health needs of populations. IMPACT: What Problem Did the Study Address? In the face of health inequity, general practice nurses in New Zealand, as elsewhere, are key to meeting complex primary health needs. There is an evidence gap regarding the processes by which nurses' roles are negotiated within provider organizations. A deeper understanding of such processes may enable better use of nursing skills to address unmet health need. What Were the Main Findings? Nurses' roles in New Zealand general practice are determined through goal-driven negotiation in accordance with individual concepts of need-responsive nursing practice. Individuals progress from occupying workspaces defined by the care-philosophies of others to defining workplaces that incorporate their own professional beliefs, values and expectations. Negotiation is conditional upon access to role models, scheduled dialogue with mentors and decision-makers, and support for safe practice. Strong clinical and organizational governance and individuals' own positive personal self-efficacy are enablers of effective negotiation. Where and on Whom Will the Research Have Impact? The theory of Creating Space can inform organizational and individual efforts to advance the roles of general practice nurses to meet the health needs of their communities. General practice organizations can provide safe, supported environments for effective negotiation; primary care leaders can promote strong governance and develop individuals' sense of self-efficacy by involving them in key decisions. Nurses themselves can use the theory as a framework to support critical reflection on how to engage in active negotiation of their professional roles. REPORTING METHOD: The authors adhered to relevant EQUATOR guidelines using the COREQ reporting method. PATIENT OR PUBLIC CONTRIBUTION: Researchers and participants currently working in general practice were involved in the development of this study. By the process of theoretical sampling and constant comparison, participants' comments helped to shape the study design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: An understanding of the processes by which health professionals negotiate their roles is important to support them to meet the challenges of increased complexity across all health sectors globally.
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    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.
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    GPs’ awareness of car driving among oldest patients: exploratory results from a primary care cohort
    (Royal College of General Practitioners, 2021-04) Leve V; Pentzek M; Fuchs A; Bickel H; Weeg D; Weyerer S; Werle J; König H-H; Hajek A; Lühmann D; van den Bussche H; Wiese B; Oey A; Heser K; Wagner M; Luppa M; Röhr S; Maier W; Scherer M; Kaduszkiewicz H; Riedel-Heller SG; for the AgeCoDe/AgeQualiDe Study Group
    Background Increasingly more very old people are active drivers. Sensory, motor and cognitive limitations, and medication can increase safety risks. Timely attention to driving safety in the patient–doctor relationship can promote patient-centred solutions. Aim To explore the following questions: do GPs know which patients drive a car? Is fitness to drive addressed with patients? Design & setting Cross-sectional data from patient interviews and GP survey in the ninth follow-up phase of a prospective primary care cohort (the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) and the Study on Needs, Health Service Use, Costs and Health-Related Quality of Life in a large sample of ‘oldest-old’ primary care patients (≥85 years; AgeQualiDe)) . Method The sample consisted of patients in the age group ≥85 years and their GPs. Independent reports were gathered on driving activity from the GP and the patient, and information was gained from GPs on whether driving ability was discussed with the patient. Statistical analyses included validity parameters and bivariate characterisation of subgroups (non-parametric significance tests, effect size). Results Self-reports of 553 patients were available (69.5% female; mean age 90.5 years; 15.9% drive a car). For 427 patients, GP data were also available: GPs recognised 67.1% correctly as drivers and 94.9% as non-drivers. GPs said that they had discussed fitness to drive with 32.1% of potentially driving patients. Among drivers who were not recognised and with whom driving had not been discussed, there were more patients with a low educational level. Conclusion The GP’s assessment of driving activity among very old patients showed moderate sensitivity and good specificity. Driving ability was seldom discussed. Asking an appropriate question during assessment could increase GPs’ awareness of older patients’ automobility.
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    Mindful Self-Care and Resiliency (MSCR): protocol for a pilot trial of a brief mindfulness intervention to promote occupational resilience in rural general practitioners
    (BMJ Publishing Group Ltd, 2018-06-30) Rees C; Craigie M; Slatyer S; Heritage B; Harvey C; Brough P; Hegney D
    Introduction The Mindful Self-Care and Resiliency (MSCR) programme is a brief psychosocial intervention designed to promote resilience among various occupational groups. The intervention is based on the principles of mindfulness and also incorporates an educational self-care component. The current paper presents the protocol for a pilot study that will evaluate the effectiveness of this programme among general practitioners working in rural Queensland, Australia. Methods and analysis We will measure the impact of the MSCR programme on levels of employee resilience (Connor-Davidson Resilience Scale; State-Trait Assessment of Resilience STARS), compassion satisfaction and compassion fatigue (Professional Quality of Life Scale), self-compassion (Self-Compassion Scale) and mood (Positive and Negative Affect Scale). We will also assess the impact of the programme on job satisfaction (The Abridged Job in General Scale), absenteeism/presenteeism (The WHO Health and Work Performance Questionnaire) and general well-being (WHO Five Well-being Index). Repeated measures analysis of variance will be used to analyse the impact of the intervention on the outcome measures taken at pre, post, 1-month, 3-month and 6-month follow-ups. We will conduct individual interviews with participants to gather data on the feasibility and acceptability of the programme. Finally, we will conduct an initial cost-effectiveness analysis of the programme. Ethics and dissemination Approval for this study was obtained from the Curtin University Human Research ethics committee and the study has been registered with the Australian Clinical Trials Registry. Results will be published and presented at national and international congresses. Trial registration number ACTRN12617001479392p; Pre-results.