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Purpose: This article aims to explore the meanings of positionality and demonstrate how reflective memos can illustrate positionality in a constructivist grounded theory (CGT) study. Design/methodology/approach: Acknowledging the positionality of the researcher through a reflective approach is an essential element of CGT studies. The first author (IS) used reflective memoing in her CGT study on Indian immigrant children's asthma to practice reflexivity and make her positionality explicit. Through memos, IS acknowledges her knowledge, beliefs, practices, experience and pre-existing assumptions about the research topic. This article is a compilation of the reflective memos that IS wrote during the initial phase of her research and draws on her motivations as they relate to the topic under study in the context of current literature. Findings: The reflective accounts of a researcher's background and experience can act as a lens for understanding the research question and the choice of methodology. Practical implications: This article may be useful to novice qualitative researchers who are struggling to define and establish their own positionality. John Dewey's and David Schon's works on reflective thinking serve as valuable tools to practice reflexivity. Philosophically underpinned reflections in the form of memos, employed from the outset and throughout the study, can enhance the study rigour by making research decisions transparent. Originality/value: This article provides practical guidance on how to outline positionality at the outset of a CGT study.

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. [ABSTRACT FROM AUTHOR]

Background: Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. Methods: We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. Results: The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. Conclusions: Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care. [ABSTRACT FROM AUTHOR]

Symbolic interactionism (SI), a perspective used to understand human conduct, is commonly said to underpin grounded theory methodology (GTM). However, the purpose of GTM is to produce substantive explanatory social theory from data without reliance on prior assumptions. Therefore, some argue that SI is an unnecessary theoretical constraint on the principal aim of GTM--the free conceptualization of data. In this article we use examples from an ongoing constructionist grounded theory study into the negotiation of nurses' roles in general practice in New Zealand, to demonstrate how SI can inform GTM regarding conceptual development and context. We argue that by asking three questions from a symbolic interactionist perspective, at each stage of the research process, freedom of conceptualization may be enhanced and awareness of contextual matters promoted to better bridge world views. [ABSTRACT FROM AUTHOR]

There has been a growing interest in giving voice to children in response to the introduction of the United Nations Convention on the Rights of the Child and evolving sociological discourses on childhood. Using child‐sensitive methodologies such as constructivist grounded theory (CGT) enables children's voices to contribute authentic, meaningful, and eventually more actionable data, capable of informing policies and practices in children's best interests. In this article, we discuss how researchers using CGT can privilege children's voices through effective knowledge coconstruction by creating a child‐sensitive research space and using methods that are appropriate to their abilities and interests. We draw on selected data from the first author's (I. S.) PhD project that explores Indian immigrant children's and their family carers' beliefs, practices, and experiences of asthma in New Zealand. We encourage researchers to consider CGT as one of the appropriate methodological choices to explicitly promote the voice of the child. [ABSTRACT FROM AUTHOR]

This study assessed the physical activities of Mental Health Nurses (MHN) in New Zealand against the 2018 World Health Organization recommended minimum levels of moderate‐to‐vigorous physical activity. The research design was exploratory and descriptive as there were no previous studies about physical activity levels of MHNs in New Zealand. Quantitative and qualitative data were collected using the International Physical Activity Questionnaire (IPAQ, Long Version) which included options for free‐text responses. Data were analysed using descriptive and inferential statistics. A total of 266 participants returned the survey, a response rate of 4%, and a limitation of the study. More than 50% of MHNs reported <150 min of moderate‐to‐vigorous exercise per week for each of the four physical activity domains. When individual physical activity domains were combined, only 10% spent <150 min on moderate‐to‐vigorous physical activity. Work‐related physical activities were higher for those working in the inpatient area than in community settings. Transport‐related physical activities were higher for those working in community settings. Participants registered from 6 to 20 years had more time sitting than other groups. Nurses aged 55 years and above showed the highest total physical activity levels. Moreover, healthcare organizations and nurse leaders need to promote physical activity and provide wellness intervention for their staff. Nurses who are physically active may be more effective in supporting their patients to increase their physical activity. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to determine whether targeted interventions, proven to be effective at improving evidence‐based bronchiolitis management, changed factors previously found to influence variation in bronchiolitis management. Methods: This survey assessed change in factors influencing clinicians' (nurses and doctors) bronchiolitis management at baseline and post‐intervention in a cluster randomised controlled trial of targeted, theory‐informed interventions aiming to de‐implement non‐evidence‐based bronchiolitis management (no use of chest X‐ray, salbutamol, antibiotics, glucocorticoids and adrenaline). Survey questions addressed previously identified factors influencing bronchiolitis management from six Theoretical Domains Framework domains (knowledge; skills; beliefs about consequences; social/professional role and identity; environmental context and resources; social influences). Data analysis was descriptive. Results: A total of 1958 surveys (baseline = 996; post‐intervention = 962) were completed by clinicians from the emergency department and paediatric inpatient units from 26 hospitals (intervention = 13; control = 13). Targeted bronchiolitis interventions significantly increased knowledge of the Australasian Bronchiolitis Guideline (intervention clinicians = 74%, control = 39%, difference = 34.7%, 95% confidence interval (CI) = 25.6–43.8%), improved skills in diagnosing (intervention doctors = 89%, control = 76%, difference = 12.6%, 95% CI = 6.2–19%) and managing bronchiolitis (intervention doctors = 87%, control = 76%, difference = 9.9%, 95% CI = 3.7–16.1%), positively influenced both beliefs about consequences regarding salbutamol use (intervention clinicians = 49%, control = 29%, difference = 20.3%, 95% CI = 13.2–27.4%) and nurses questioning non‐evidence‐based bronchiolitis management (chest X‐ray: intervention = 71%, control = 51%, difference = 20.8%, 95% CI = 11.4–30.2%; glucocorticoids: intervention = 64%, control = 40%, difference = 21.9%, 95% CI = 10.4–33.5%) (social/professional role and identity). A 14% improvement in evidence‐based bronchiolitis management favouring intervention hospitals was demonstrated in the cluster randomised controlled trial. Conclusion: Targeted interventions positively changed factors influencing bronchiolitis management resulting in improved evidence‐based bronchiolitis care. This study has important implications for improving bronchiolitis management and future development of interventions to de‐implement low‐value care. [ABSTRACT FROM AUTHOR]

Background: Bronchiolitis is the most common reason for hospitalisation in infants. All international bronchiolitis guidelines recommend supportive care, yet considerable variation in practice continues with infants receiving non-evidence based therapies. We developed six targeted, theory-informed interventions; clinical leads, stakeholder meeting, train-the-trainer, education delivery, other educational materials, and audit and feedback. A cluster randomised controlled trial (cRCT) found the interventions to be effective in reducing use of five non-evidence based therapies in infants with bronchiolitis. This process evaluation paper aims to determine whether the interventions were implemented as planned (fidelity), explore end-users' perceptions of the interventions and evaluate cRCT outcome data with intervention fidelity data.Methods: A pre-specified mixed-methods process evaluation was conducted alongside the cRCT, guided by frameworks for process evaluation of cRCTs and complex interventions. Quantitative data on the fidelity, dose and reach of interventions were collected from the 13 intervention hospitals during the study and analysed using descriptive statistics. Qualitative data identifying perception and acceptability of interventions were collected from 42 intervention hospital clinical leads on study completion and analysed using thematic analysis.Results: The cRCT found targeted, theory-informed interventions improved bronchiolitis management by 14.1%. The process evaluation data found variability in how the intervention was delivered at the cluster and individual level. Total fidelity scores ranged from 55 to 98% across intervention hospitals (mean = 78%; SD = 13%). Fidelity scores were highest for use of clinical leads (mean = 98%; SD = 7%), and lowest for use of other educational materials (mean = 65%; SD = 19%) and audit and feedback (mean = 65%; SD = 20%). Clinical leads reflected positively about the interventions, with time constraints being the greatest barrier to their use.Conclusion: Our targeted, theory-informed interventions were delivered with moderate fidelity, and were well received by clinical leads. Despite clinical leads experiencing challenges of time constraints, the level of fidelity had a positive effect on successfully de-implementing non-evidence-based care in infants with bronchiolitis. These findings will inform widespread rollout of our bronchiolitis interventions, and guide future practice change in acute care settings.Trial Registration: Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415 . [ABSTRACT FROM AUTHOR]

Co-designed research is gaining prominence within the health care space. Community engagement is a key premise of co-design and is also particularly vital when carrying out kaupapa Māori research. Kaupapa Māori describes a "by Māori, for Māori" approach to research in Aotearoa/New Zealand. This article discusses the research process of Hā Ora: a co-design project underpinned by a kaupapa Māori approach. The objective was to explore the barriers to early presentation and diagnosis of lung cancer, barriers identified by Māori. The team worked with four rural Māori communities, with whom we aimed to co-design local interventions that would promote earlier diagnosis of lung cancer. This article highlights and unpacks the complexities of carrying out communityengaged co-design with Māori who live in rural communities. In particular, we draw attention to the importance of flexibility and adaptability in the research process. We highlight issues pertaining to timelines and budgets, and also the intricacies of involving co-governance and advisory groups. Overall, through this article, we argue that health researchers need to prioritise working with and for participants, rather than on them, especially when working with Māori communities. [ABSTRACT FROM AUTHOR]

Limited knowledge about the nursing workforce in New Zealand general practice inhibits the optimal use of nurses in this increasingly complex setting. Using workforce survey data published biennially by the Nursing Council of New Zealand, this study describes the characteristics of nurses in general practice and contrasts them with the greater nursing workforce, including consideration of changes in the profiles between 2015 and 2019. The findings suggest the general practice nursing workforce is older, less diverse, more predominately New Zealand trained and very much more likely to work part-time than other nurses. There is evidence that nurses in general practice are increasingly primary health care focused, as they take on expanded roles and responsibilities. However, ambiguity about terminology and the inability to track individuals in the data are limitations of this study. Therefore, it was not possible to identify and describe cohorts of nurses in general practice by important characteristics, such as prescribing authority, regionality and rurality. A greater national focus on defining and tracking this pivotal workforce is called for to overcome role confusion and better facilitate the use of nursing scopes of practice. Little is known about the New Zealand general practice nursing workforce, yet it is pivotal to the delivery of effective care in this complex environment. Analysis of available data suggests it is an aging workforce with a lack of diversity, but there is also evidence of nurses enthusiastically embracing primary health care principles and broadening their scope. Greater national effort to understand and sustain the workforce is required to nurture this enthusiasm and to help improve health outcomes. [ABSTRACT FROM AUTHOR]

Background: Bronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework.Methods: Semi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis.Results: Between July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse's reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of 'paediatric confident' nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources).Conclusions: Factors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions. [ABSTRACT FROM AUTHOR]

Background: The impact of long‐term conditions is the "healthcare equivalent to climate change." People with long‐term conditions often feel they are a problem, a burden to themselves, their family and friends. Providers struggle to support patients to self‐manage. The Practical Reviews in Self‐Management Support (PRISMS) taxonomy lists what provider actions might support patient self‐management. Objective: To offer providers advice on how to support patient self‐management. Design: Semi‐structured interviews with 40 patient‐participants. Setting and participants: Three case studies of primary health‐care organizations in New Zealand and Canada serving diverse populations. Participants were older adults with long‐term conditions who needed support to live in the community. Main outcome measures: Qualitative description to classify patient narratives of self‐management support according to the PRISMS taxonomy with thematic analysis to explore how support was acceptable and effective. Results: Patients identified a relationship‐in‐action as the mechanism, the how by which providers supported them to self‐manage. When providers acted upon knowledge of patient lives and priorities, these patients were often willing to try activities or medications they had resisted in the past. Effective self‐management support saw PRISMS components delivered in patient‐specific combinations by individual providers or teams. Discussion and conclusions: Providers who establish relationships with patients can support them to self‐manage and improve health outcomes. Delivery of taxonomy components, in the absence of a relationship, is unlikely to be either acceptable or effective. Providers need to be aware that social determinants of health can constrain patients' options to self‐manage. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]

Background: Family carers, as a "shadow workforce", are foundational to the day-to-day integration of health service delivery for older family members living with complex health needs. This paper utilises Haggerty's model of continuity of care to explore the contribution of family carers' to the provision of care and support for an older family member's chronic condition within the context of health service delivery. Methods: We analysed data from interviews of 13 family carers in a case study of primary health care in New Zealand -- a Maori Provider Organisation -- to determine the alignment of family caregiving with the three levels of continuity of care (relational continuity, informational continuity, and management continuity). Results: We found alignment of family caregiving tasks, responsibilities, and relationships with the three levels of continuity of care. Family carers 1) partnered with providers to extend chronic care to the home; 2) transferred and contributed information from one provider/service to another; 3) supported consistent and flexible management of care. Discussion: The Maori Provider Organisation supported family carer-provider partnership enabled by shared Maori cultural values and social mandate of building family-centred wellbeing. Relational continuity was the most important level of continuity of care; it sets precedence for family carers and providers to establish the other levels -- informational and management -- continuity of care for their family member cared for. Family carers need to be considered as active partners working alongside responsive primary health care providers and organisation in the implementation of chronic care. [ABSTRACT FROM AUTHOR]

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence. [ABSTRACT FROM AUTHOR]

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of communitybased primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based. [ABSTRACT FROM AUTHOR]

This study uses conversation analysis to explore 'candidate obstacles', a practice observed in sequences of patient resistance to lifestyle advice within health professional consultations. This article presents illustrative analyses of selected data excerpts drawn from audio-visual recordings of 116 tracked consultations between health professionals and 34 patients newly diagnosed with type 2 diabetes mellitus in New Zealand. The analysis shows that in consultations where health promotion activities are central, patient resistance can provide space for patients to identify obstacles to their compliance with lifestyle advice. Identifying candidate obstacles provides opportunities for health professionals to align advice with concerns of patients and potentially improve patient outcomes. [ABSTRACT FROM AUTHOR]

AimTo identify shortcomings in existing models of patient behaviour change, and present the development and testing of a novel approach using practitioner facilitation and person-focussed conversations that identifies and addresses behaviours at an earlier stage than current models.BackgroundSystematic strategies used by health professionals to change patient behaviours began with motivational interviewing and brief intervention approaches for serious addictive behaviours. Practitioners typically presume they should drive the process of patient behaviour change. Attempts to transfer these approaches to primary care, and a broader range of health risk behaviours, have been less successful. The TADS programme (Tobacco, Alcohol and Other Drugs, later Training and Development Services) began teaching motivational interviewing and brief interventions to practitioners in New Zealand in 1996. Formal and informal evaluations showed that practitioners used screening tools that patients rejected and that led to incomplete disclosure, used language that did not engage patients, failed to identify the behaviours patients wished to address and therefore misdirected interventions.MethodsIterative development of new tools with input from patients and primary care clinicians.FindingsThe TADS programme developed a questionnaire whose results remained private to the patient, which enabled the patient to identify personal behaviours that they might choose to change (the TADS Personal Assessment Choice Tool). This was assisted by a brief conversation that facilitated and supported any change prioritised by the patient (the TADS Brief Opportunistic Interaction). The need for this approach, and its effectiveness, appeared to be similar across adults, youth, different ethnic groups and people in different socio-economic circumstances. Behaviours patients identified were often linked to other health risk behaviours or early-stage mental health disorders that were not easily detected by practitioner-driven screening or inquiry. The long-term effectiveness of this approach in different populations in primary health care settings requires further evaluation. [ABSTRACT FROM AUTHOR]

Background: Action research (AR) and randomized controlled trials (RCTs) are usually considered to be theoretically and practically incompatible. However, we argue that their respective strengths and weaknesses can be complementary. We illustrate our argument from a recent study assessing the effect of telemonitoring on health-related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals in two urban hospital services and one remote rural primary care service in New Zealand.Methods: Data came from authors' observations and field notes of discussions with three groups: the healthcare providers and healthcare consumers who participated in the research, and a group of 17 researchers and collaborators. The consumers had heart failure (Site A, urban), airways disease (Site B, urban), and diabetes (Site C, rural). The research ran from 2008 (project inception) until 2012 (project close-off). Researchers came from a wide range of disciplines. Both RCT and AR methods were recognised from early in the process but often worked in parallel rather than together. In retrospect, we have mapped our observed research processes to the AR cycle characteristics (creation of communicative space, democracy and participation, iterative learning and improvement, emergence, and accommodation of different ways of knowing).Results: We describe the context, conduct and outcomes of the telemonitoring trial, framing the overall process in the language of AR. Although not fully articulated at the time, AR processes made the RCT sensitive to important context, e.g. clinical processes. They resulted in substantive changes to the design and conduct of the RCT, and to interpretation and uptake of findings, e.g. a simpler technology procurement process emerged. Creating a communicative space enabled co-design between the researcher group and collaborators from the provider participant group, and a stronger RCT design.Conclusions: It appears possible to enhance the utility of RCTs by explicitly embedding them in an AR framework to shape stronger RCT design. The AR process and characteristics may enable researchers to evaluate telehealth while enhancing rather than compromising the quality of an RCT, where research results are returned to practice as part of the research process.Trial Registration: Australian New Zealand Clinical Trials Registry, reference ACTRN12610000269033 . [ABSTRACT FROM AUTHOR]

INTRODUCTION: The increasing prevalence of diabetes has led to expanded roles for primary health care nurses in diabetes management. AIM: To describe and compare anthropometric and glycaemic characteristics of patients with diabetes and their management by practice nurses, district nurses and specialist nurses. METHODS: Primary health care nurses in Auckland randomly sampled in a cross-sectional survey, completed a postal self-administered questionnaire (n=284) and telephone interview (n=287) between 2006 and 2008. Biographical and diabetes management details were collected for 265 (86%) of the total 308 patients with diabetes seen by participants on a randomly selected day. RESULTS: Nurses were able to access key clinical information for only a proportion of their patients: weight for 68%; BMI for 16%; HbA1c for 76% and serum glucose levels for 34% (for either measure 82%); although most (96%) records were available about whether patients self-monitored blood glucose levels. Most nursing management activities focused on giving advice on dietary intake (70%) and physical activity (66%), weighing patients (58%), and testing or discussing blood glucose levels (42% and 43%, respectively). These proportions varied by nurse group (p<0.05), generally being highest for specialist nurses and lowest for district nurses. DISCUSSION: Most practice and specialist nurses could access patients' weight and HbA1c levels and focused their clinical management on health education to decrease these if indicated. Communication and organisational systems and contracts that allow district nurses to work across both primary and secondary health services are necessary to improve community-based nursing services for patients with diabetes. [ABSTRACT FROM AUTHOR]

Background Primary health care does not adequately respond to populations known to have high needs such as those with compounding jeopardy from chronic conditions, poverty, minority status and age; as such populations report powerlessness. Objective To explore what poor older adults with chronic conditions who mostly belong to ethnic minority groups say they want from clinicians. Setting and Participants Participants were older adults whose chronic conditions were severe enough to require hospital admission more than twice in the previous 12 months. All participants lived in poor localities in Auckland, New Zealand's largest city. Methods Forty-two in-depth interviews were conducted and analysed using qualitative description. Results An outward acceptance of health care belied an underlying dissatisfaction with low engagement. Participants did not feel heard and wanted information conveyed in a way that indicated clinicians understood them in the context of their lives. Powerlessness, anger, frustration and non-concordance were frequent responses. Discussion and Conclusions Despite socio-cultural and disease-related complexity, patients pursue the (unrealised) ideal of an engaged therapeutic relationship with an understanding clinician. Powerlessness means that the onus is upon the health system and the clinician to engage. Engagement means building a relationship on the basis of social, cultural and clinical knowledge and demonstrating a shift in the way clinicians choose to think and interact in patient care. Respectful listening and questioning can deepen clinicians' awareness of patients' most important concerns. Enabling patients to direct the consultation is a way to integrate clinician expertise with what patients need and value. [ABSTRACT FROM AUTHOR]

The aim of this study was to explore the influences, processes and environments that shaped the practice of European nurses for indigenous New Zealand (NZ) Māori communities who were being overwhelmed by introduced infectious diseases. Historical data were accessed from multiple archival sources and analysed through the lens of colonial theory. Through their work early last century, NZ nurses actively gained professional status and territory through their work with Māori. By living and working alongside Māori, they learned to practise in new ways that influenced Māori health. By developing a new role in new professional territory, nurses extended their practice to include health promotion as well as disease prevention. Māori survival from epidemics improved, and the population grew over that period. For Māori, however, Eurocentric care alleviated their immediate health problems, but the detrimental impact of the mechanisms of colonisation overall has continued to the present day. [ABSTRACT FROM AUTHOR]

Comprehensive geriatric assessment ( CGA) is considered the cornerstone of good practice, as it identifies need across multiple domains such as social, physical and psychological. The interRAI home care ( interRAI- HC), probably the most well-researched and supported community-based CGA has been implemented globally, often at considerable expense. Policy-makers, managers and clinicians anticipate significant gains in health outcomes following such investment; however, the implementation of CGA is often undertaken in the absence of community service development. This study sought to compare the inter RAI- HC with an existing CGA [the Support Needs Assessment ( SNA)] in community-dwelling older people. A randomised controlled trial was undertaken from January 2006 to January 2007 comparing the interRAI- HC and the SNA in 316 people (65+) referred for assessment of needs with follow-up at 1 and 4 months. Outcomes included health-related quality of life, physical function, social support, cognitive status, mood and health service usage as well as identified need. The study found that significantly more support needs were identified using the interRAI- HC compared to the SNA. More social and carer support were recommended by SNA and more rehabilitation and preventive health screens were recommended by interRAI- HC. Despite these differences, the mean healthcare use was similar at 4 months, although interRAI- HC participants had more Emergency Department presentations and hospital admissions. No statistically significant differences between groups were reported in terms of outcomes. In conclusion, the interRAI- HC was found to identify more unmet support needs than the SNA though resulted in no favourable outcomes for the older person or their carer. The study highlights the need to invest attention around the service context to maximise outcomes based on identified needs. [ABSTRACT FROM AUTHOR]

INTRODUCTION: There is a worldwide trend for diabetes care to be undertaken in primary care. Nurses are expected to take a leading role in diabetes management, but their roles in primary care are unclear in New Zealand, as are the systems of care they work in as well as their training. AIM: To describe and compare demographic details, education and diabetes experience, practice set- ting and facilities available for the three main groups of primary health care nurses working in the largest urban area in New Zealand. METHOD: Of the total number of practice nurses, district nurses and specialist nurses working in Auckland (n=1091), 31% were randomly selected to undertake a self-administered questionnaire and telephone interview in 2006-2008. RESULTS: Overall response was 86% (n=284 self-administered questionnaires, n=287 telephone interviews). Almost half (43%) of primary care nurses were aged over 50 years. A greater proportion of specialist nurses (89%) and practice nurses (84%) had post-registration diabetes education compared with district nurses (65%, p=0.005), from a range of educational settings including workshops, workplaces, conferences and tertiary institutions. More district nurses (35%) and practice nurses (32%) had worked in their current workplace for >10 years compared with specialist nurses (14%, p=0.004). Over 20% of practice nurses and district nurses lacked access to the internet, and the latter group had the least administrative facilities and felt least valued. DISCUSSION: These findings highlight an ageing primary health care nursing workforce, lack of a national primary health care post-registration qualification and a lack of internet access. [ABSTRACT FROM AUTHOR]

Background: Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management. Methods: Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis. In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared. Results: This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses' clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations. Conclusions: Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review. [ABSTRACT FROM AUTHOR]

AimTo ascertain how new funding arrangements, introduced in New Zealand's 2001 Primary Health Care (PHC) Strategy, have impacted on the expansion of nurses’ role in general practice.BackgroundNurses are central to the new policy that was designed to improve the health status of New Zealanders and reduce inequalities in health. Nurses were to be a crucial part of the PHC team, expanding their current roles to provide increased access to appropriate services. This paper investigates how the new funding arrangements, introduced as part of the policy, have impacted on the expansion of nurses’ roles and consequently the realisation of the policy goals.MethodsSemi-structured interviews were undertaken with 128 key stakeholders five years after the introduction of the PHC Strategy, and surveys were completed by practice nurses, general practitioners and practice managers in purposively selected practices within the 20 participating Primary Health Organisations.FindingsThere has been substantial growth in the development of nursing roles for some nurses in general practice; however, this expansion has not been universal and one of the main reasons for this is the way funding devolves at the practice level. One of the consequences of the policymakers not taking into account the business model of the majority of general practices, is the resulting overarching goal of the strategy not being realised, and inequalities in health status remaining. [ABSTRACT FROM PUBLISHER]

Debates over issues of race, gender and class in Aotearoa / New Zealand, a small, relatively new nation located in the South West Pacific, reflect the racial complexity of its population and the fundamental allegiance of most of its people to ideas of fairness. We will discuss three major debates of particular relevance to Māori, the indigenous people of New Zealand: governance of health services, the governance of the largest city—Auckland / Tamaki Makaurau, and ownership / governance of the marine and coastal area. The contribution of Māori nurses who have worked with the most underserved in their own communities since European settlement in the early 1900s is not fully recognized and though they are acknowledged as a key workforce they struggle for institutionalized leadership and governance status. Ongoing controversy over Māori representation in the governance of Auckland illustrates the challenges attending Māori participation at the regional level. Just as both progressives and conservatives find the tax deal Obama struck in December 2010 with the Republicans unpalatable so in New Zealand two ideologically opposed groups, the Māori party and ACT, a conservative party, find themselves united against the Marine and Coastal Areas Bill / Takutai Moana Bill proposed by a centre right party. These current debates raise issues of equity, of the value of Treaties between settlers and indigenous peoples and related governance, and of property rights over public and natural resources. The New Zealand experience demonstrates a "backwards and forwards progression" in racial relations and partnership reflected in public sentiment and in unusual political alliances. We present data on the health system including the perspectives of Māori people with chronic conditions and assert the need for shared governance. We argue that New Zealand's approach to racial, gender and health equity has a basis in historic actions and pioneering attempts to create a fair society. These challenges, particularly in achieving equity for tangata whenua (indigenous Māori) are ongoing. [ABSTRACT FROM AUTHOR]

From a South Pacific perspective we see the Obama presidency as a symbol of optimism for public engagement and grassroots movements and as a model for new found power for marginalized peoples. New Zealand shares in the global issues of political representation and accountability, growing economic and social inequalities and increasing rates of chronic disease. We will describe the history and current situation of national political representation and discuss major current social and health issues. The discussion is illustrated by a case study and verbatim quotes from people with chronic disease drawn from research on consumer perspectives oil the services provided by the health system in one New Zealand city. We conclude by advocating for community organizing and empowerment resulting in many Obamas supporting the social and economic policies necessary to address the inequalities we hold to be fundamental to current social and health crises. Given the racial, social and political context of Aotearoa/New Zealand, yes, our Obarna could be a Pacific woman. [ABSTRACT FROM AUTHOR]

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally. [ABSTRACT FROM AUTHOR]

Introduction: Health systems worldwide are striving to provide care that is 'person centred'-- aligned with the needs and values of those receiving it. Partnerships and linkages between care settings such as primary care and the community sector (i.e., community based primary health care) has the goal of enabling better care and outcomes for people. It is unclear; however, if within these models, patients and caregivers perceive their care to be person-centered. In this study we capture what matters most to people with complex care needs and their caregivers (i.e., outcomes of importance) and second, we outline the conditions and activities associated with these outcomes. Methods: This is a qualitative descriptive study entailing one-to-one interviews with older adults with complex care needs receiving CBPHC in Ontario, Quebec and New Zealand and caregivers of these types of patients. The data were analyzed using inductive and deductive approaches by four researchers. Core categories were identified from the interviews, each representing an outcome of importance. Results: The majority of patients were female, 65+, with an average of 5 health conditions. A proportion spoke English as their second language. The majority of caregivers were female, a family member or partner of the patient and living in the same household. The outcomes of importance were: feeling heard, appreciated and comfortable; having someone to count on; understanding how to manage health and what to expect; being independent; feeling safe; and easily accessing health and social care. There were a number of activities associated with each outcome including (and not limited to): being treated like a friend; having the contact information of a dedicated and responsive provider; being given clear explanations of different treatment options and why these treatment options were being recommended; having the opportunity to partake in meaningful hobbies; having homes adapted to support physical limitations; and being accompanied to activities (ranging from doctors' appointments to grocery shopping). Discussion: Through a large international collection of interviews of culturally diverse patients with multi-morbidity and their caregivers, we outline what person centered care means to people as well as specific activities that support these outcomes. Conclusion (w/key findings): The importance of comfortable and reliable relationships, being independent, having access to social care resources and the trade-offs that patients and caregivers make as their needs change need to be considered as health care systems seek to better coordinate and integrate care for vulnerable populations and their families. Lessons learned: Key attributes of good care extend beyond the management of disease. While we focused on the experience of patients and caregivers receiving CBPHC, their experiences extended to other sectors and providers because not all care was available within the models studied. Limitations: We did not conduct a comparative analysis of attributes (e.g., ethnicities, geographies, etc.) which would help to answer important implementation questions including, what works for whom and in what conditions? Suggestions for Future Research: Examining how key attributes vary by sub-groups will provide insight into how to further tailor models of community base d primary health care. [ABSTRACT FROM AUTHOR]

The aim of this qualitative inquiry was to explore older New Zealanders perspectives and experiences of food and nutrition intake, to gain insights to factors that influence vulnerability to malnutrition risk at older age. Participants represented an ethnically diverse group of nutritionally vulnerable older adults (five malnourished and nine at risk), with most participants identifying as having an illness severity of moderate or severe. Thematic content analysis was performed using an integrated approach and took into account participants' nutritional status as determined using the Mini Nutritional Assessment-Short Form. Six key themes emerged. Almost all participants reported they had reduced their food intake and felt that eating less, was the 'logical' thing to do as they were now undertaking less physical activity. They described eating as a chore; they ate because they 'had to keep going', but hardly ever felt hungry (low appetite); they had lost interest in eating, and no longer found food fanciful. Being in the company of others encouraged eating except in stressful situations such as caring for an ill spouse. They had a preference for foods they had grown up with but could no longer readily access or needed to avoid some foods because of coexisting conditions or illnesses, food intolerance and chewing difficulties. Finally, participants tried to eat foods best for their health. The notion of healthy eating as consuming "more vegetables" was widely held, with some participants explaining this meant "less fat and less sugar". Overall, the low food intake reported by these participants appears shaped by a myriad of sociocultural and health related factors. The findings can be used as a foundation to develop strategies for preventing vulnerability to malnutrition with advancing age. [ABSTRACT FROM AUTHOR]

Introduction: Health system restructuring has emphasized a shift from medical care to population health and primary health care in an attempt to reduce social exclusion and disparities in health. Broad notions of integrated care emphasize connections between health and social services. A population health approach demands operational commitment to reducing inequalities. The health system is recognized as a determinant of health interacting with other social determinants including, income, education, employment, housing and neighborhoods, and discrimination. In New Zealand, the Treaty of Waitangi signed in 1840 guarantees the rights of Māori (as indigenous peoples) and clearly implies equity of health outcomes. Description of policy, objectives and targeted population: In New Zealand, since the year 2000, health system restructuring has resulted in decentralization to regional District Health Boards and Primary Health Organizations. There was a strong initial focus on population health and an imperative to contain health-care spending strongly influenced by neo-liberal economics and politics. Internationally, other important drivers of health reform include a desire to shift services from institutions to primary health care, greater community participation in decisionmaking, a lack of integration between health and social services, and the ineffectiveness of medical interventions. The research presented here explores whether the values reflected in the original intentions of a population health approach have altered in over a decade of major restructuring. We interviewed managers, clinicians, government policy advisors and academics in 2007 and 2008 and reviewed major government health policies from 2009 to 2013 to establish which notions of population health were reflected. Key findings: Over the decade from 2000, population health shifted from a broad notion of health determinants to population health as the 'sum of the health of individuals' - where health was narrowly defined in terms of clinical conditions or need for health services. Participants recognized the impact of determinants on health, but most prioritized the work of health systems as clinical services. New Zealand was caught up in the international concern about safety, quality and variation in health service provision. An emphasis on 'quality and safety' impeded population health activities due to a focus on a small number of quantifiable health targets driven by financial incentives. District Health Board programs to identify high risk individuals diverted attention from broader population health outcomes. Boards were not held accountable for integrating a population health approach in service planning and did not initiate or lead intersectoral work. Participants reflected with disappointment that Boards appeared unable to break free of the constraints of national policy, even when narrowly focused on targets. Community consultation was limited. Primary Health Organizations mandated to address population health nevertheless aligned with the small-business model of general practice impeding service integration. 'Population health' dropped from favor in the mid -2000s, although many documents outside the health sector carried forward these values. Highlights: The ability of targets to focus provider attention appears so powerful as to eclipse attention to anything else. We know of no other health system with such a small number of targets. The narrowed focus on 6 targets limited attempts to integrate health services and completely undermined any understanding of integrated care as linking health and social services. The small-business model of primary care provision remains a perennial challenge to service integration. This model is readily compatible with a view of population health as the sum of individuals, who can be stratified and targeted, and for whom services can be counted and contracted. An emphasis on population health, followed by an emphasis on individual health, is a cycle repeated across decades. Conclusion: A progressively narrower focus on a small number of targets disrupted service integration, which in turn disrupted attention to determinants of health. Achieving integrated care that links health and social services is one pragmatic orientation that can support delivering population health care. [ABSTRACT FROM AUTHOR]

Background: Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption.Methods: We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis.Results: Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability.Conclusions: Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia. [ABSTRACT FROM AUTHOR]

Background: Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes., Methods: We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics., Results: Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree., Conclusions: Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients., (© 2024. The Author(s).)

Background: For more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by "failing to design and administer the current primary health care system to actively address persistent Māori health inequities". Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care., Methods: Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes., Primary Outcomes: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care., Results: A total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices. Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol., Conclusions: Māori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice., (© 2024. The Author(s).)

Aim: The following article reports an audit, conducted between July 2014 and July 2017, of adherence to best practice in medication administration and documentation by nurses., Method: A sample of 47 registered nurses' (RNs') documentation relating to the administration of 939 medications using standing order directives were examined and scored by seven senior nurses and a medical practitioner against an audit tool. The scores were divided into four quartiles with the top two quartiles demonstrating best practice in adherence to safety standards for the administration of medication., Results: Forty-three RNs (91.5%) scored in the top two quartiles. The remaining four RNs (8.5%), following supervision by a senior nurse, subsequently demonstrated improvement in their documentation to the quartile one range of the audit tool. This audit demonstrates that, following education in diagnosis and treatment of common childhood conditions, the majority of nurses who were audited could diagnose simple conditions of childhood and safely administer medications to them. Moreover, two years after the programme was introduced, the serious sequelae of acute rheumatic fever (ARF) reduced in children aged 5-12 years., Conclusion: RNs who took part in the audit used standing order directives to safely administer medications to children. RN prescribing throughout New Zealand should be explored as an effective means to provide timely treatment and improve patient outcomes., Competing Interests: Nil.

Importance: In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care., Objective: To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis., Design, Setting, and Participants: This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020., Interventions: Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback., Main Outcomes and Measures: The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions., Results: A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001)., Conclusions and Relevance: Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care., Trial Registration: Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.

Introduction: Asthma is one of the most common diseases in the world and is a global public health burden. There is an urgent need for research that leads to evidenced-based primary prevention strategies to reduce the prevalence of asthma. One novel risk factor that might have a role in the pathogenesis of asthma is the use of paracetamol in early life. This trial aims to determine if paracetamol, compared with ibuprofen use, as required for fever and pain in the first year of life, increases the risk of asthma at age 6 years., Methods and Analysis: The Paracetamol and Ibuprofen in Primary Prevention of Asthma in Tamariki trial is a multicentre, open-label, two-arm parallel randomised controlled trial. 3922 infants born at ≥32 weeks' gestation will be randomly allocated to receive only paracetamol or only ibuprofen for treatment of fever and pain, if required in the first year of life. The primary outcome is asthma at 6 years of age, defined as the presence of wheeze in the preceding 12 months. Secondary outcomes include hospital admissions for bronchiolitis, wheeze or asthma in the first year of life, and within the first 6 years of life; wheeze at 3 years of age; eczema within the first year and at 3 and 6 years of age; atopy at 3 and 6 years of age., Ethics and Dissemination: The trial has been approved by the Northern A Health and Disability Ethics Committee of New Zealand (17/NTA/233). Dissemination plans include publication in international peer-reviewed journals, and presentation at national and international scientific meetings, assimilation into national and international guidelines, and presentation of findings to lay audiences through established media links., Trial Registration Number: ACTRN12618000303246; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand)., Methods: In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC., Results: We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions., Conclusions: We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

Objectives: To assess the effect of telecare on health related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals., Methods: Patients were randomly assigned either to usual care or to additionally entering their data into a commercially-available electronic device that uploaded data once a day to a nurse-led monitoring station. Patients had congestive heart failure (Site A), chronic obstructive pulmonary disease (Site B), or any long-term condition, mostly diabetes (Site C). Site C contributed only intervention patients - they considered a usual care option to be unethical. The study took place in New Zealand between September 2010 and February 2012, and lasted 3 to 6 months for each patient. The primary outcome was health-related quality of life (SF36). Data on experiences were collected by individual and group interviews and by questionnaire., Results: There were 171 patients (98 intervention, 73 control). Quality of life, self-efficacy and disease-specific measures did not change significantly, while anxiety and depression both decreased significantly with the intervention. Hospital admissions, days in hospital, emergency department visits, outpatient visits and costs did not differ significantly between the groups. Patients at all sites were universally positive. Many felt safer and more cared-for, and said that they and their family had learned more about managing their condition. Staff could all see potential benefits of telecare, and, after some initial technical problems, many staff felt that telecare enabled them to effectively monitor more patients., Conclusions: Strongly positive patient and staff experiences and attitudes complement and contrast with small or non-significant quantitative changes. Telecare led to patients and families taking a more active role in self-management. It is likely that subgroups of patients benefitted in ways that were not measured or visible within the quantitative data, especially feelings of safety and being cared-for., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000269033.

Aims: To identify factors associated with patients receiving foot examinations by primary health care nurses., Methods: A cross-sectional survey of 287 randomly sampled primary health care nurses, from a total of 1091 in Auckland, completed a postal self-administered questionnaire and telephone interview. Biographical and diabetes management details were collected for 265 diabetes patients consulted by the nurses on a randomly selected day., Results: A response rate of 86% was achieved. Nurses examined patient's feet in 46% of consultations. Controlling for demographic variables, foot examinations were associated with age, odds ratio (1.25, 95% CI 0.57-2.74) for patients aged 51-65 years and >66 years (2.50, 1.08-5.75) compared with those ≤50 years, consultations by district compared with practice nurses (14.23, 95% CI 3.82-53.05), special programme consultations compared with usual follow-up consults (8.81, 95% CI 2.99-25.93) and length of consultation (1.89, 0.72-4.97) for 15-30 min and (4.45, 95% CI 1.48-13.41) >30 min compared with consultations ≤15 min, or for wound care (2.58, 1.01-6.61)., Conclusions: Diabetes foot examinations by primary health care nurses varies greatly, and are associated with characteristics of the patient (age, need for wound care) and the consultation (district nurses, diabetes programme and duration)., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Aim: To describe primary health care (practice and specialist) nurses involvement in the government-funded annual diabetes review 'Get Checked' programme and the division of care between nurses and general practitioners in Auckland, New Zealand., Method: Of the total 911 practice and specialist nurses identified and working in the greater Auckland region, 276 (30%) were randomly selected and invited to undertake a self-administered questionnaire and telephone interview in 2006-8., Results: An 86% response rate was achieved. Over 60% of practice nurses and over half of specialist nurses participate in 'Get Checked' reviews. Of those nurses, 40% of practice and 70% specialist nurses, reported completing over half of the total number of 'Get Checked' reviews at their practice. Of the nurses sampled who work in general practice (n=198), 38% reported that 'nurses mostly complete' the reviews, 45% stated that 'nurses and doctors equally complete' them and 17% reported that only 'doctors' did so. For the nurses who reported that 'nurses and doctors equally complete' the reviews (n=89), most nurses undertake blood pressure measurements (90%), weigh patients (88%), give lifestyle advice (87%), examine patient's feet (73%), and 44% carried out the complete review of the patients they consult., Conclusion: These findings show the 'Get Checked' programme was successful in engaging practice and community-based specialist nurses in the community management of diabetes and has revealed positive relationships between nurses and doctors, extended roles for nurses and the importance of engaging nurses in the design of health care programmes.

Objective: To determine the impact of a restorative model of home care on social support and physical function among community-dwelling older people., Design: Cluster-randomized controlled trial., Setting: Home care in an urban area., Participants: Participants (N=205) were randomly assigned to an intervention group (n=108; mean age, 79.1y; 71.3% women; 81.5% New Zealand European [NZE]; 50.8% residing in areas of the highest levels of social deprivation) or a usual care group (n=97; mean age, 76.9y; 60.8% women; 73.2% NZE; 53.5% in the highest levels of social deprivation)., Intervention: Participants randomly assigned to the intervention group completed a goal facilitation tool with a needs assessor to determine their needs and to establish the aims for the episode of care. Services were structured according to the principles of restorative home care (independence focused with individually tailored activity programs). Usual care participants received a standard needs assessment that informed the delivery of home care services., Main Outcome Measures: Short Physical Performance Battery (SPPB), Dukes Social Support Index (DSSI)., Results: There was greater change over time in physical function (measured by SPPB: F=8.30, P=.003) but no associated increase in social support (as determined by DSSI: F=2.58, P=.09)., Conclusions: Significant improvements in physical function were observed after a period of restorative home care services. The absence of an associated change in social support may have been the result of a combination of factors, including the threshold of physical function required for community ambulation, the low rate of allied health service provision, and the time required to reestablish social ties. The findings contribute to a greater understanding of factors necessary to refocus home-based services to emphasize improvements in physical function and independence., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the usefulness of a national and a local system dynamics model of cardiovascular disease to planning and funding decision makers., Methods: In an iterative process, an existing national model was populated with local data and presented to stakeholders in Counties Manukau, New Zealand. They explored the model's plausibility, usefulness and implications. Data were collected from 30 people using questionnaires, and from field notes and interviews; both were thematically analysed., Results: Potential users readily understood the model and actively engaged in discussing it. None disputed the overall model structure, but most wanted extensions to elaborate areas of specific interest to them. Local data made little qualitative difference to data interpretation but were nevertheless considered a necessary step to support confident local decisions., Conclusion: Some limitations to the model and its use were recognised, but users could allow for these and still derive use from the model to qualitatively compare decision options., Implications: The system dynamics modelling process is useful in complex systems and is likely to become established as part of the routinely used suite of tools used to support complex decisions in Counties Manukau District Health Board., (© 2012 The Authors. ANZJPH © 2012 Public Health Association of Australia.)

Introduction: Chronic illness is the leading cause of morbidity, mortality, and inequitable health outcomes in New Zealand. The ABCCNZ Stocktake aimed to identify extent of long-term conditions management evidence-based practices in stroke, cardiovascular disease, chronic obstructive pulmonary disease and congestive heart failure in New Zealand's District Health Boards (DHBs)., Methods: Eleven 'dimensions' of care for long-term conditions, identified by literature review and confirmed at workshops with long-term conditions professionals, formed the basis of the Stocktake of all 21 DHBs. It comprised two questionnaires: a generic component capturing perceptions of practice; and a disease-specific component assessing service provision., Results: Fifteen DHBs completed all or parts of the questionnaires. Data accrual was completed in July 2008. Although most DHBs had developed long-term conditions management strategies to a moderate degree, there was considerable variability of practice between DHBs. DHBs thought their PHOs had developed strategies in some areas to a low to moderate level, though cardiovascular disease provision rated more highly. Regarding disease-specific services, larger DHBs had greater long-term conditions management provision not only of tertiary services, but of standard care, leadership, self-management, case-management, and audit., Conclusions: There is considerable variability in perceptions of long-term conditions management service provision across DHBs. In many instances variability in actual disease-specific service provision appears to relate to DHB size.

Aim: To assess whether spirometry done in hospital during an admission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is clinically useful for long-term management., Methods: Patients admitted to hospital with a clinical diagnosis of AECOPD had spirometry post-bronchodilator at discharge and approximately 4 weeks later., Results: Spirometry was achieved in less than half of those considered to have AECOPD. Of 49 patients who had spirometry on both occasions, 41 met the GOLD criteria for COPD at discharge and 39 of these met the criteria at 1 month. For the 41, spirometry was not statistically different between discharge and 1 month but often crossed arbitrary boundaries for classification of severity based on FEV(1). The eight who did not meet GOLD criteria at discharge were either misclassified due to comorbidities that reduce FVC, or they did not have COPD as a cause of their hospital admission., Conclusion: Spirometry done in hospital at the time of AECOP is useful in patients with a high pre-test probability of moderate-to-severe COPD. Small changes in spirometry at 1 month could place them up or down one grade of severity. Spirometry at discharge may be useful to detect those who warrant further investigation.

Adult patients who are very high intensity users of hospital emergency departments (VHIU) have complex medical and psychosocial needs. Their care is often poorly coordinated and expensive. Substantial health and social resources may be available to these patients but it is ineffective for a variety of reasons. In 2009 Counties Manukau District Health Board approved a business case for a programme designed to improve the care of VHIU patients identified at Middlemore Hospital. The model of care includes medical and social review, a multidisciplinary planning approach with a designated 'navigator' and assertive follow-up, self and family management, and involvement of community based organisations, primary care and secondary care. The model has been organised around geographic localities and alongside other initiatives. An intermediate care team has been established to attend to the current presenting problems, however the main emphasis is on optimising ongoing care and reducing subsequent admissions especially by connecting patients with primary health care. This whole process could be driven by the primacy care sector in due course. The background and initial experience with implementation are described.