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IntroductionDiscussions of integrated care have ranged in focus from large-scale health system transformations, to discrete interventions intended to enhance local continuity of care. Beyond these variations in scale and focus, literature on integrated care has used a variety of conceptual frameworks to explain various activities and elements necessary to achieve integrated care. Existing frameworks have helped to advance research and practice; yet the complexity of changing practice required to achieve integrated care across the policy, organizational, and clinical levels complicates efforts to represent or implement these innovations in straightforward ways.Aims Objectives Theory or MethodsIn this paper, we present a novel strategy for conceptualizing integrated care as developing through a series of milestones observable at the organizational level. Based on analysis of four integrated care organizational case studies in Canada and New Zealand, we outline how this approach to conceptualizing integrated care both resolves the tension of crossing the macro, meso, and micro levels of analysis, and generates new practical insights to guide policy and practice. Methods consist of qualitative interviews, observation, and document analysis across cases, and qualitative data were analyzed temporally to identify milestones as indicated by participants over time.Highlights or Results or Key FindingsWe define a milestone as the occurrence of a salient event that is perceived by respondents to facilitate or disrupt efforts towards the development of integrated care. We synthesize these events at the organizational level, suggesting that the organizational level of analysis is the most appropriate level to represent the significance of these milestones. Our analysis identified six categories of milestone: (1) Strategic relational milestones, referring to building relationships between stakeholders.(2) Strategic process change milestones, referring to efforts to improve quality in practice.(3) Structural (intra-organizational) milestones, referring to changes in organizational structure.(4) Structural (inter-organizational) milestones, referring to changes in the legal, operational, or leadership structures that facilitate relationships between organizations.(5) Environmental milestones, referring to changes in the social or natural environment.(6) Political milestones, referring to changes in the control and allocation of resources.ConclusionsOur results generate a new conceptual framework for understanding the achievement of integrated care as occurring through a series of milestones. This approach enhances the focus on achieving integrated care “in the wild”, in the actual environments in which leaders, clinicians, policymakers, patients, and caregivers work to implement integrated care.Implications for applicability/transferability sustainability and limitations Our model emphasizes two practical points. First, that there is no single series of sequential steps that must be taken to achieve integrated care. Second, that policy efforts to support integrated care ought to encourage organizations and their collaborators to work toward milestones that facilitate the development of integrated care.

In many countries, including New Zealand, recruitment of medical practitioners to rural and regional areas is a government priority, yet evidence for what determines career choice remains limited. We studied 19 newly qualified medical practitioners, all of whom had participated in a year-long undergraduate rural or regional placement (the Pūkawakawa Programme). We explored their placement experiences through focus groups and interviews and aimed to determine whether experiential differences existed between those who chose to return to a rural or regional location for early career employment (the Returners) and those who did not (the Non-Returners). Focus group and interview transcripts were a mean (range) length of 6485 (4720–7889) and 3084 (1843–4756) words, respectively, and underwent thematic analysis. We then used semiquantitative analysis to determine the relative dominance of themes and subthemes within our thematic results. Placement experiences were overwhelming positive – only four themes emerged for negative experiences, but five themes and nine subthemes emerged for positive experiences. Many curricular aspects of the placement experience were viewed as similarly positive for Returners and Non-Returners, as were social aspects with fellow students. Hence, positive experiences per se appear not to differentiate Returner and Non-Returner groups and so seem unlikely to be related to decisions about practice location. However, Returners reported a substantially higher proportion of positive placement experiences related to feeling part of the clinical team compared with Non-Returners (11% vs 4%, respectively) – a result consistent with Returners also reporting more positive experiences related to learning and knowledge gained and personal development.

Background:Staff nurse clinical leadership is a relatively new concept that includes the elements of collaboration, coordination, patient advocacy, and often quite autonomous decision-making required of palliative care nurses. Staff nurses need structural and psychological empowerment to develop as clinical leaders.Aims:The aim of this study was to establish baseline data regarding the self-perceived structural and psychological empowerment experienced by New Zealand hospice staff nurses and their ability to practise as clinical leaders.Methods:An explanatory sequential mixed-methods design was used, which included questionnaires measuring structural and psychological empowerment and clinical leadership behaviours and focus group discussions.Findings:Survey respondents reported that they were moderately psychologically and sometimes or rarely structurally empowered and felt that they can practise as clinical leaders most of the time. Two themes were identified from the focus groups.Conclusion:New Zealand staff hospice nurses felt that—despite feeling only moderately psychologically empowered, and only sometimes or rarely structurally empowered—they practise as clinical leaders most of the time.

ObjectiveTo develop a multidimensional framework representing patients’ perspectives on comfort to guide practice and quality initiatives aimed at improving patients’ experiences of care.DesignTwo-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients’ perspectives of comfort in an acute care setting.SettingCardiac surgical unit in New Zealand.ParticipantsCulturally diverse patients in hospital undergoing heart surgery.Main outcomesA definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort.ResultsComfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients’ personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment.ConclusionsThese findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

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.

Introduction: Health systems are striving to design and deliver care that is ‘person centered’—aligned with the needs and preferences of those receiving it; however, it is unclear what older people and their caregivers value in their care. This paper captures attributes of care that are important to older people and their caregivers. Methods: This qualitative descriptive study entailed 1–1 interviews with older adults with multimorbidity receiving community based primary health care in Canada and New Zealand and caregivers. Data were analyzed to identify core attributes of care, important to participants. Findings: Feeling heard, appreciated and comfortable; having someone to count on; easily accessing health and social care; knowing how to manage health and what to expect; feeling safe; and being independent were valued. Each attribute had several characteristics including: being treated like a friend; having contact information of a responsive provider; being accompanied to medical and social activities; being given clear treatment options including what to expect; having homes adapted to support limitations and having the opportunity to participate in meaningful hobbies. Conclusions: Attributes of good care extend beyond disease management. While our findings include activities that characterize these attributes, further research on implementation barriers and facilitators is required.

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.

Summary Background The dynamic nature of healthcare ensures that early career nurses enter an uncertain and complex world of practice and consequently require support to develop their practice, build confidence and reach their potential. The New Zealand Nurse Entry to Practice programme for registered nurses in their first year of practice has been operating since 2005 to enable safe and confident practice, improve the quality of care, and positively impact on recruitment and retention. This academic and clinical programme was offered as a partnership between a university and a clinical provider with postgraduate academic credits gained. Aim The aim of this study was to explore the perceived impact of postgraduate university education for early career nurses in one regional health area of New Zealand. Methods Participants were registered nurses who had completed the early career nurse programme and their clinical preceptors. The research was conducted via an online survey of 248 nurses and three focus groups to explore how the programme was experienced and its impact on knowledge and practice. Results Early career nurses and their preceptors found that the programme enables improved knowledge and skills of patient assessment, application of critical thinking to clinical practice, perceived improvement in patient care delivery and outcomes, enhanced interprofessional communication and knowledge sharing, and had a positive impact on professional awareness and career planning. Conclusions This clinical–academic partnership positively impacted on the clinical practice and transition experience of early career nurses and was closely aligned to an organization's strategic plan for nursing workforce development.

IntroductionA recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.MethodsOur research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6 ResultsThe key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9 DiscussionAs is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10

Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is “What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?” and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Québec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.

Access to health care as near to where people live as possible is desirable. However, not enough medical graduates choose to work in rural and regional areas, especially in general practice. The career decisions of recent medical graduates are known to be affected by a variety of professional, societal and personal factors. Internationally, medical programmes have exposed students to regional and rural experiences partly to encourage them to seek employment in these areas after graduation. As such, the Pūkawakawa Programme is a year-long regional and rural experience for selected Year 5 students from the University of Aucklandlsquo;s Medical Programme in New Zealand in partnership with the Northland District Health Board and two Primary Health Organisations. A lack of clarity about the drivers of rural and regional career decisions underpinned this study, which aimed to explore the barriers and encouragers for students of the programme to return as resident medical officers to the regional hospital where they had gained clinical experience.A mixed-method, descriptive design was used, including a short survey, followed by participation in a focus-group discussion or a one-on-one interview. Survey data were summarised in tabular form and inductive, thematic analysis was applied to transcripts of focus groups and interviews.Nineteen doctors in their first or second year following graduation participated: 15 who had returned to the hospital where they had clinical experience in the programme and four who were employed elsewhere. 'A match of personal goals and intended career intentions' was the reason most frequently selected for junior doctorsrsquo; choice of early career employment. Other frequently selected reasons were lifestyle, friends and family close by, and the reputation and experience of the Pūkawakawa Programme. Qualitative data revealed that the learning experience, the unique design of the curriculum and associated support from clinicians were identified as important factors in encouraging students to work in regional and rural environments. However, discouraging factors included separation from friends and families, geographical isolation and the lack of opportunities for partners to find work.This study has confirmed the value of the Pūkawakawa Programme as an important contributor to the regional and rural workforce of the Northland District, New Zealand. The value of an academic‑clinical partnership has been shown to support a regional and rural clinical learning environment. Evidence is provided of one way of having overcome barriers to building regional and rural workforce capacity in this district.

Introduction Access to health care as near to where people live as possible is desirable. However, not enough medical graduates choose to work in rural and regional areas, especially in general practice. The career decisions of recent medical graduates are known to be affected by a variety of professional, societal and personal factors. Internationally, medical programmes have exposed students to regional and rural experiences partly to encourage them to seek employment in these areas after graduation. As such, the Pūkawakawa Programme is a year-long regional and rural experience for selected Year 5 students from the University of Aucklandls Medical Programme in New Zealand in partnership with the Northland District Health Board and two Primary Health Organisations. A lack of clarity about the drivers of rural and regional career decisions underpinned this study, which aimed to explore the barriers and encouragers for students of the programme to return as resident medical officers to the regional hospital where they had gained clinical experience. Methods A mixed-method, descriptive design was used, including a short survey, followed by participation in a focus-group discussion or a one-on-one interview. Survey data were summarised in tabular form and inductive, thematic analysis was applied to transcripts of focus groups and interviews. Results Nineteen doctors in their first or second year following graduation participated: 15 who had returned to the hospital where they had clinical experience in the programme and four who were employed elsewhere. 'A match of personal goals and intended career intentions' was the reason most frequently selected for junior doctorsr choice of early career employment. Other frequently selected reasons were lifestyle, friends and family close by, and the reputation and experience of the Pūkawakawa Programme. Qualitative data revealed that the learning experience, the unique design of the curriculum and associated support from clinicians were identified as important factors in encouraging students to work in regional and rural environments. However, discouraging factors included separation from friends and families, geographical isolation and the lack of opportunities for partners to find work. Conclusions This study has confirmed the value of the Pūkawakawa Programme as an important contributor to the regional and rural workforce of the Northland District, New Zealand. The value of an academic‑clinical partnership has been shown to support a regional and rural clinical learning environment. Evidence is provided of one way of having overcome barriers to building regional and rural workforce capacity in this district.

Background: Studying implementation of integrated models of community-based primary health care takes a “whole systems” multidisciplinary approach to capture micro (patient/carer and provider), meso (organization) and macro (system/policy) factors. In new research studying the implementation of these integrated models intended to improve care for older adults with complex care needs, our project team adopted four theoretical perspectives to capture micro, meso and macro factors influencing implementation.Problem Statement: Four theoretical and disciplinary perspectives were adopted to guide data collection and analysis. These perspectives were guided by 1) Wagner’s Chronic Care Model as related to Ham’s 10 Dimensions of High Performing Chronic Care Systems addressing patient/caregiver and provider level perspectives; 2) the Organizational Context and Capabilities for Integrating Care framework capturing organizational and provider level perspectives; and 3) the Health Policy Monitor survey methodology covering system and policy level perspectives. The different perspectives capture a wide breadth of concepts; however there is also significant conceptual overlap across those frameworks. The nature of this overlap requires clarification in order to: 1) ensure efficient data collection at the case sites; and 2) guide inter-disciplinary data analysis.Theory/Methods: Concept mapping was used to identify connections between the concepts across perspectives. Novak and Canas (2007)’s methods and software CmapTools were used to first generate a descriptive map. We explored the conceptual links of the map using data from 1 case studies in Ontario collected as part of the iCOACH project.Results: The concept map reveals many links across policy/system, organizational, provider and patient/carer theoretical perspectives. Examination of the overlap between concepts related to care coordination reveals different meanings, approaches, and implementations, depending on from which perspective you start. For instance, from a policy perspective care coordination is related to how services are delivered and delivery arrangements, the organizational perspective highlights inter-organizational linkages and collaboration, the provider perspective focuses on teamwork and community linkages, and the patient and carer perspective emphasizes the experience of coordinated care.Conclusions: Our analysis reveals that while concepts from different theoretical perspectives and disciplines may be similar in definition, each perspective offers a different meaning, value and driver associated with similar concepts. This analysis highlights the importance of developing a “whole system” perspective, and how concept mapping can be used to guide this approach to data collection and analysis.Lessons Learned: Concept mapping was a critical and foundational step towards a cross-disciplinary “whole system” analysis of integrated models of community-based primary health care. Collaboration between scholars familiar with concepts at different levels aided in the development of the map and proved valuable in supporting inter-disciplinary analysis of data.Limitations: The concept map will be directly relevant to the iCOACH project; however, additional work remains to be done to expand its utility to other projects and jurisdictions. Still, the methodology presented may be useful to other researchers engaging in whole-systems research on integrated care.Suggestions for future research: We will explore other areas of conceptual overlap using case study data to develop a complete conceptual map of the relevant theoretical domains.

Introduction: Patient self-management support is central to care for long term conditions and for integrated care. Patients and their carers are the final arbiter of whether support for self-management has been effective. A new taxonomy lists 14 categories of provider activities that support patient self-management (Practical Reviews in Self-Management Support, PRISMS). We asked whether we could recognise these provider activities in narratives from patients and carers. We sought to extend the theoretical framework of the taxonomy to include the view from patient and carers. Methods: We interviewed 28 patients and family carers in a case study of primary health care in New Zealand in 2015 to determine which components of the taxonomy were visible. We drew on interviews with clinicians and organisation persons to explain case study context. Results: We found, within patient and carer data, evidence of all 14 components of provider self-management support. The overarching dimensions of the taxonomy helped reveal an intensity and consistency of provider behaviour that was not apparent considering the individual components. Conclusions: Patient and carer data mapped to provider activities. The taxonomy was not explicit on provider relationships and engagement with, or separate support needs of, patients and carers.

New graduate nurses are the future of nursing and the education they receive as they transition into the workforce as a newly registered nurse is critical for building a suitably qualified nursing workforce that will adequately serve the future population. Variation exists in education programmes for new graduate nurses in their first year of practice which is known to impact on transition experience. A qualitative study using focus groups and semi-structured interviews was undertaken to explore the experiences and perceptions of New Graduate Nurses undertaking a new graduate programme and Directors of Nursing supporting them to complete the programme which may or may not have been inclusive of a postgraduate course (Masters Level). The findings of this study are in line with previous research and support the value of new graduate programmes but did reveal a lack of consensus in regards to the structure and content of such programmes. This study revealed some commonalities and challenges between the differing programmes but has identified the need for further research to establish the impact of postgraduate education in the first year of practice and how this impacts on nursing practice and patient care. There are numerous terms in the literature with reference to new graduate programmes; transition to practice programme, nurse entry to practice programme, first year of clinical practice programme, new graduate programme and early career nursing programme. For the purpose of this article the term Nurse Entry to Practice (NETP) will be used in reference to any form of new graduate programme.

Introduction: Community Based Primary Health Care (CBPHC) is positioned as the foundation of integrated health systems, intended to support broader goals of population health and health system sustainability. CBPHC moves beyond traditional primary care (a physician visit) to team based care that spans organizational boundaries (such as primary care clinics + community care services). At the core of CBPHC are patients and their informal carers (family and friends) who can inform ongoing reforms in this sector by sharing their experience, particularly in areas that require improvement. The objective of this paper is to share the unmet needs of patients and caregivers within CBPHC. Methods: This study is part of a broader programme of research called, implementing integrated care for older adults with complex health needs (iCOACH). Semi-structured interviews are being conducted with older patients with complex care needs and with unpaid, informal carers across multiple CBPHC sites in Canada (Ontario and Quebec) and New Zealand. Interviews captured the roles, characteristics and needs of patients and carers, and were audio-recorded and transcribed verbatim. Interviews were reviewed by multiple team members and a consensus codebook was created. The code “unmet need” was extracted from the patient and carer transcripts, and analyzed for core themes using an inductive approach. Results: Unmet needs culminated into three broad themes across patient and carer interviews: Accessing Care; Quality of Care; and Missing Care. Many patients accessed care within CBPHC, but the model itself tended to be spread across multiple settings and providers. Patients and carers also required access to services that were outside the CBPHC model. Challenges arose due to lack of transportation, out-of-pocket expenses, limited availability of assistive devices to support mobility, and long wait times. Quality of care and relationships were compromised if there was a language barrier, and when services were misaligned with the preferences of patients and carers. Components of care were often missing, such as respite care for carers, supports for instrumental activities of daily living (e.g., home maintenance and transportation), and supports to reduce social isolation. Conclusions: Due to the complex health and social needs of patients and carers, they often require access to multiple services and providers who are seldom situated under the same roof . Finding ways to integrate across organizational boundaries may reduce areas of unmet need. Furthermore greater attention to the social determinants of health within CBPHC may create a more holistic experience for patients and carers. Lessons Learned: CBPHC is intended to deliver holistic integrated care but when situated within a fragmented health care system, challenges for patients and carers persist. Limitations: Further comparisons need to be made between the unmet needs between patients and caregivers in Canada and New Zealand. Suggestions for future research: Next steps will include the development of a framework that describes the policy and organizational context, and provider configurations in each of the study jurisdictions. How these factors relate to different patient and carer needs and experiences, including areas of unmet need, will be explored to inform the development of person centered CBPHC models.

Introduction: The implementation of integrated care involves efforts to engage health care providers in a vision of health care delivery that includes coordination and collaboration for the care of individual clients. The processes by which health care providers engage with an organizational vision for integrated care, and the challenges associated with encouraging health care providers to adopt integrated practices remain under-explored in the research literature. Theory/Method: This paper reports initial findings on health care provider engagement in efforts to implement integrated community-based primary health care from the iCOACH project (Integrated Care for Older Adults with Complex Health Needs). The research project draws on in-depth international case studies of organizations in 3 jurisdictions: Ontario, Canada (n=3), Quebec, Canada (n=3), and New Zealand (n=3). Drawing on the theory of institutional logics, this report will include data from health care provider and organizational management/leadership interviews across all 9 case studies. Results: Preliminary findings suggest that health care providers respond to organizations’ visions for integrated care differently depending on whether they feel supported to practice in more integrated ways. Even within a single organization, health care providers may enact or resist the organizational vision (and thus institutional logic) toward integrated care depending on the extent to which they feel engaged. Managerial approaches were found to be of central importance, helping to determine the extent to which health care providers adopted more integrated practices in the provision of everyday care delivery. These findings were illustrated across case studies in each of the 3 study jurisdictions. Discussion: Although these qualitative data only represent preliminary analysis, they point to the importance of managerial engagement strategies to promote health care provider buy-in to an organizational vision of more integrated care. These early findings suggest that managers within health care organizations can act as either barriers or facilitators to implementing integrated care depending on whether and how the interact and work with health care providers. Conclusions: Managerial approaches to the engagement of health care providers are of primary importance for the implementation of integrated care. Further analysis of the iCOACH study data will provide more detailed examination of which managerial approaches promote integrated health care provider practice, and those which act as barriers to integrated primary health care. Lessons Learned: The key lesson learned is that health care providers respond differently to a single managerial approach. Organizational leaders should anticipate different reactions from health care providers within a given organizational context, and anticipate the need for different engagement strategies when seeking to implement integrated care. Limitations: This abstract represents only preliminary analysis, and further analysis is required to provide a more detailed presentation of (a) specific health care provider reactions to managerial strategies, (b) the influence of other features of organizational contexts, and (c) how to promote better health care provider buy-in to organization vision. Future Research: Further analysis will examine in detail the reactions of health care providers to specific managerial strategies, presenting their adoption of more integrated ways of providing primary health care in different organizational contexts.

Introduction : An abundance of studies have investigated the many influences on the implementation of healthcare aimed at bridging the gap between recommended practice, what healthcare consumers want and need, and what they actually receive. Yet it is still not well known which implementation approaches work best in the use of knowledge, and the adoption and perpetuation of new ways of providing care in community-based settings.The metanarrative review will purposively inform implementation in the third phase of a programme of research, implementing integrated care for older adults with complex health needs (iCOACH) in New Zealand and Canada. Methods : This work reviewed what is known about implementation that may be suitable to guide the scaling up and evaluation phase of iCOACH. Metanarrative review methods were applied to systematic and narrative reviews of literature on implementation frameworks, theories and strategies. We synthesised heterogenous findings in a way that informs the practice of implementation. Results : Thirty-five systematic and narrative reviews met our inclusion criteria and were appraised, summarised, and qualitatively analysed. The various assumptions, worldviews and findings represented in the literature were subjected to high level analysis and interpretation that identified five metanarratives concerning the constructs, influencing factors, frameworks, and the effectiveness of interventions and strategies employed in implementation. Discussion : A wide range of people have a stake in how to implement what works best and matters most for older adults with chronic health care problems in various community-based settings, not least consumers themselves. We call for collaborative adaptation with stakeholders, most importantly the person receiving care and their family in the implementation of a new model. Conclusions and lessons learned : There is still no ‘silver bullet’ in implementation science in spite of abundant primary and secondary studies. People- and relationship-centred care is fundamental to integrated, community-based care at all levels in the broader health care delivery system. Yet many implementation theories and frameworks neglect these important considerations. All phases of implementation of a new model of care call for collaborative adaptation with stakeholders, the most important being the person receiving care in terms of what matters most to them. Limitations : While our search strategies were extensive we cannot guarantee that we located every systematic or narrative review on this topic. Suggestions for future research : Participatory research methods and realist evaluation approaches informed by this metanarrative review is required of the implementation of a new model of integrated, community-based care for older adults with chronic health problems to establish what has worked best, for whom and how.

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated community-based and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them.

This paper is a response to our recognition that approaches to equity and consumer involvement in research differed in emphasis between our researchers and jurisdictions. Whilst we shared common aspirations we varied in our priorities between equity groups and methods to represent consumer interests. New Zealand has a historical focus on equity for indigenous Maori and shares with Canada concern about enduring inequalities that affect people’s lives.

Purpose Comfort is central to patient experience but the concept of comfort is poorly defined. This review aims to develop a framework representing patients' complex perspective of comfort to inform practice and guide initiatives to improve the quality of healthcare. Data sources CINAHL, MEDLINE Complete, PsycINFO and Google Scholar (November 2016); reference lists of included publications. Study selection Qualitative and theoretical studies advancing knowledge about the concept of comfort in healthcare settings. Studies rated for methodological quality and relevance to patients' perspectives. Data extraction Data on design, methods, features of the concept of comfort, influences on patients' comfort. Data were systematically coded and categorized using Framework method. Results of data synthesis Sixty-two studies (14 theoretical and 48 qualitative) were included. Qualitative studies explored patient and staff perspectives in varying healthcare settings including hospice, emergency departments, paediatric, medical and surgical wards and residential care for the elderly. From patients' perspective, comfort is multidimensional, characterized by relief from physical discomfort and feeling positive and strengthened in one's ability to cope with the challenges of illness, injury and disability. Different factors are important to different individuals. We identified 10 areas of influence within four interrelated levels: patients' use of self-comforting strategies; family presence; staff actions and behaviours; and environmental factors. Conclusion Our data provide new insights into the nature of comfort as a highly personal and contextual experience influenced in different individuals by different factors that we have classified into a framework to guide practice and quality improvement initiatives.

Purpose Internationally there is no consensus on the indicators essential for determining safe recovery from anesthesia and patient readiness for discharge from the postanesthesia care unit (PACU). Design Integrative review. Methods Using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) as a search strategy, the literature related to PACU discharge scores were evaluated and organized into themes. Findings The traditional components of airway support, oxygenation, sedation, and circulation are common within many first stage PACU discharge scores. However, there is strong support from the literature for components such as heart rate, temperature, pain, postoperative nausea and vomiting (PONV), urine output, and surgical site assessment to also be included. The review revealed that there is no standardized time frequency in applying a first stage PACU discharge score to patients within the PACU environment. Conclusions There is a need for the development and trial of an evidence based first stage PACU discharge score.

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.

Purpose This report presents an evaluation of the implementation of a Best Practice Information Sheet related to tracheal suctioning of adults with an artificial airway. The Centre for Evidence-Based Nursing Aotearoa based in Auckland, New Zealand, conducted a systematic review of the evidence and produced a Best Practice Information Sheet. The present study is an evaluation of the impact of this information sheet. The study also describes the process used to implement the Best Practice Information Sheet at each of three study sites. Method A survey of 105 nurses was conducted at three sites: one in New Zealand and two in Australia. Using a before/after design, data were collected at the time of release of the Best Practice Information Sheet and then approximately 12 months later. Suctioning practice was observed with a focus on assessment of the patient by the nurse, the procedure used to suction and the bases for decisions made about suctioning. Before and after data were compared to capture the possible effects on practice of the recommendations in the Best Practice Information Sheet. Those involved in leading the implementation process at each site were interviewed by telephone, notes from the interviews were thematically analysed and comparisons were drawn. Results The degree of uptake of the evidence was variable across the three sites and across the recommendations. For a number of recommendations, there was a modest trend towards the uptake of the recommendations of the Best Practice Information Sheet. Other recommendations were congruent with existing usual practice and therefore no change was observed. Each study site employed a range of strategies to implement the Best Practice Information Sheet. Improved practice was seen in relation to a greater number of recommendations at one site. This site appears to have used more sources of information to evaluate the quality of practice, which may have raised the profile of suctioning and its impact on patients. Conclusions This study suggests a trend towards a modest uptake of best practice recommendations into nursing practice demonstrated by some behavioural changes within a 12-month period in the context of an implementation plan and a Best Practice Information Sheet.

The aim of the research project reported here was to evaluate the process and outcomes of the in‐depth training programme provided to primary and secondary schools’ boards of trustees by the Far North Rural Education Assistance Programme (REAP) in New Zealand. Practical research questions were developed from an analysis of the policy context and programme contracts. The international research literature on mentoring and effective support programmes was then examined. Data were collected using four methods: documentary analysis; case studies of eight selected school communities; a survey of all members of 24 participating boards’ of trustees; and a focus group interview of programme consultants. Construct validity, multiple data types and sources, reasonable survey response rates, bias control strategies and triangulation permitted tentative conclusions and provisional recommendations to be drawn. It was found that the REAP scheme was valued for three main reasons; it built governance capacity in school communities; delivered “free”, appropriately‐scaled, culturally sensitive and customized support on‐site; and it improved the ability of schools to self‐manage improvements. It was also found that the Far North REAP Office played a key role in conceptualizing, developing, brokering and managing these board mentoring services, and developed a model of brokerage that might be usefully replicated through the Ministry of Education’s contracting processes.

Introduction: Multimorbidity is often combined with functional limitations among older adults. It is therefore important to ensure the built and social environment encourages older adults to safely age while maintaining independence. Previous findings have focused on the impact of the built environment as a barrier to an active lifestyle, but not specific to accessing community-based health and social care (CHSC). We propose to investigate the impact of patient and caregiver limitations on accessing care, including the impact of the built environment. Methods: Secondary thematic coding analysis was undertaken with 53 patient and 38 informal caregiver interviews from communities in Canada and New Zealand. Reported findings are from a broader research program titled, Implementing integrated Care for Older Adults with Complex Health needs (iCOACH). Older complex seniors were recruited for participation from a community primary healthcare team if they were greater than 50 years of age, and managing ongoing chronic conditions. Caregivers were unpaid informal carers of older adults. A specific thematic code about unmet need was extensively reviewed for examples related to the built environment and access to care. Results: Functional limitations hindered self-management at home as well as accessing CHSC. Attributes of the physical environment at home impacted the use of assistive devices, and impaired the ability to leave the home. Physical barriers within the social environment included the inability to use public transportation, access community programs, and conduct daily living tasks. Consequences from not being able to access supports included greater financial strain, social isolation, poor safety at home, lack of independence, and greater caregiver strain. Older adults appeared to be less impacted by access barriers when living in supportive housing settings, where on-site staff were available to provide direct support, or initiate referrals for additional services. Discussions: Experiences of older adults and informal caregivers highlighted access to care issues specific to the immediate and external physical environment, and examples of when support was efficiently provided. When considering how to best deliver services to people with complex care needs and their caregivers, it is important to consider how those services can be accessed. Conclusions: When services cannot be easily accessed, patients and caregivers may make critical trade-offs. To maintain independence and safety, it is important to design services which consider the adaptations and supports that are required to support older adults both at home, as well as the environment they have to navigate to access care. Lessons learned: CHSC should be delivered to ensure increased accessibility. Providing health services which are close in proximity to primary care providers, or co-locating may be more efficient and accessible. Community programs should consider the broad range of limitations in designing holistic services for older adults and their caregivers. Limitations: Transferability of findings may be limited, as rural community-dwelling seniors and participants with cognitive decline were not included in the study. Suggestions for future research: Further explore the barriers to improving access to medical and social care from policy and provider perspectives, and create solutions that can be explored and implemented.

Nurses' contribution during inpatient rehabilitation is well documented. However, despite being the largest professional group in this setting, the specialty of rehabilitation nursing is poorly recognised. This article reports on the first of a four-phase study that aimed to clarify and develop the nursing contribution to inpatient rehabilitation for older persons. The aim of this study was to identify activity patterns and time use during daytime and evenings of older adult patients undergoing inpatient rehabilitation.Direct observation using behavioural modelling was undertaken of a convenience sample of 37 older people undergoing inpatient rehabilitation in a specialist unit of a large tertiary hospital in New Zealand. The primary outcome was the observation of meaningful activity. Binomial logistic regression was used to study the association between relevant variables.Meaningful activity was most likely to involve walking without assistance and to occur 08:00 to 14:00 h and 16:00 to 21:00 h during weekdays. Patients were more likely to receive treatment during the weekend. Irrespective of time, registered nurses were the health professionals most often present with patients.There is likely to be unrealised opportunities for registered nurses to support improved rehabilitation outcomes. Registered nurses' involvement in rehabilitation needs to be actively optimised.Nurses' engagement with older adults in rehabilitation settings is likely to be substantial, placing them as key members of the rehabilitation team. Nurses make a pivotal contribution to inpatient rehabilitation based on specialised knowledge and skills but this contribution is not well understood. Opportunities are likely, at times when allied health professionals are less often present, e.g. evenings and weekends, for registered nurses to more intentionally overlap rehabilitation activities with other care requirements.

Background. A programme of postgraduate study was developed in partnership between a health board and a university in New Zealand, having identified critical thinking and practice change as key determinants of good care delivery. Aim. To explore the impact after 12 months of a postgraduate programme for registered nurses on patient assessment and clinical reasoning, and the status of implementation plans for improved patient care. Design. Outcome evaluation using a survey and focus groups. Setting. On location at a hospital in a small city in New Zealand that provides healthcare services for 102,000 people across rural and urban areas. Participants. Registered nurses who had completed the programme (N=28) and seven clinical mentors. Methods. A survey, focus groups, and follow-up data about quality improvement projects were used to explore how the programme was experienced and its impact. Results. The survey revealed perceptions of improved knowledge and skills but a lack of confidence in communicating with medical staff. Of 28 quality improvement projects planned, all but three had been implemented and were still in use. Two themes were generated from focus group data: “new ways of thinking” and “doing things differently.” Conclusions. This academic/clinical partnership positively influenced nurses’ knowledge and skills, encouraged critical thinking and self-efficacy, and resulted in the sustained implementation of nurse-initiated projects intended to improve patient care.

To explore the impact of bariatric surgery on health-related quality of life (HRQoL).An audit of patients referred for bariatric procedures. Patients completed Short Form-36 questionnaires at their first pre-operative clinic and at their 6-month follow up appointment after surgery. SF-36 scores were compared with standard parametric tests.40 patients completed baseline SF-36 questionnaires and underwent bariatric surgery, 28 were surveyed again 6 months post-procedure during the audit period between December 2008 and December 2010. Twenty-three patients underwent laparoscopic Roux-en-Y gastric bypass and five underwent laparoscopic sleeve gastrectomy. The patients were predominantly New Zealand European, female, with a body mass index greater than 40 kg/m2. Significant improvements in health-related quality of life were observed. The physical and mental component summary scores were initially well below the population norms, but increased to the norm 6 months after surgery.The HRQoL of morbidly obese patients significantly improves after bariatric surgery. Services including the SF-36 in their measurement armamentarium can demonstrate the Service's impact on patient-perceived outcomes in addition to clinically-focused outcomes.

Purpose Oxidative stress has been implicated in Down syndrome (DS) pathology. This study compares DS individuals and controls on their urinary levels of allantoin and 2,3-dinor-iPF2α-III; these biomarkers have been previously validated in a clinical model of oxidative stress. Methods Urine samples were collected from 48 individuals with DS and 130 controls. Biomarkers were assayed by ultraperformance liquid chromatography-tandem mass spectrometry, normalized by urinary creatinine concentration. Results After adjusting for age and gender, mean allantoin levels were lower among DS individuals versus controls ( P = .04). The adjusted mean levels of 2,3-dinor-iPF2α-III were similar in DS individuals and controls ( P = .7). Conclusions Our results do not support the hypothesis that DS individuals have chronic systemic oxidative stress.

Since 2007, Health Workforce New Zealand has provided District Health Boards (DHBs) with funding to support nurses undertaking postgraduate education. As a result, a significant number of nurses, many working in general medical and surgical wards, have now completed a postgraduate qualification. Anecdotal evidence for one DHB indicated that there were mixed views with respect to how the increase in the number of nurses with postgraduate education had impacted on patient outcomes. Following a review of relevant literature the researchers aimed to ascertain from registered nurses working in acute medical and surgical wards their perception of the impact that further study had on their practice. A quantitative descriptive study was undertaken to answer the question of what impact postgraduate study had on the practice of those nurses working in medical and surgical wards of a District Health Board hospital? An anonymous postal survey was sent to registered nurses (N = 57), and senior nurses (N=25) working in acute medical and surgical areas of practice. The latter group consisted of 16 nurse managers and 9 nurse educators. The results showed that registered nurses, nurse managers and nurse educators all perceived the clinical practice of registered nurses as having improved in some degree as a consequence of postgraduate education. There is also a need for further research to be undertaken in other District Health Boards, especially in non-hospital based areas such as primary health care; and also to investigate ways of linking post graduate education with career pathways, as well as identifying and minimising potential barriers likely to prevent application of post graduate learning in the workplace.

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.

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.

Aim: The aim of this study was to identify the enablers and barriers to guideline implementation in a primary healthcare setting by employing the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a template for data analysis and interpretation. Background: The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable, and, in spite of much investigation, remains resistant to explanation of what works and why. Optimising the enablers and minimising the barriers to implementation of a guideline for reducing cardiovascular disease risk has the potential to significantly reduce the burden of disease. The PARIHS framework has been successfully applied in a number of clinical contexts and has been found useful in illuminating the barriers and enablers to evidence implementation. Approach: This qualitative study involved focus groups with 20 primary healthcare nurses, 4 general practitioners, 5 managers, and individual interviews with 3 funder/planners who discussed their contribution to the use of a guideline for the assessment and management of cardiovascular risk. Template analysis based on the PARIHS framework was applied to semi-structured narrative data to provide an in-depth analysis of the barriers and enablers to implementation of the guideline. Conclusions: The lack of facilitation of the guideline into practice was a major barrier to implementation. Implementation plans that address the concerns and complexities of everyday practice are an essential aspect of guideline development. The PARIHS framework was found to be comprehensive and accommodating of the complexity of everyday practice associated with guideline implementation in primary health care. The pertinence of the framework confirms its usefulness as a tool to guide implementation. © 2011 Sigma Theta Tau International.

The aim of this study was to explore the realities of everyday nursing practice associated with the implementation of a guideline for the assessment and management of cardiovascular risk. The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable and, in spite of much investigation, remains resistant to explanation of what works and why. Exploration of the nature of guideline implementation has the potential to illuminate the complexities of guideline implementation by focussing on the nature of practice. Nurses are well placed at the front line of primary health care to contribute to an understanding of how guideline implementation plays out in their everyday practice. Qualitative description was used, involving focus groups and interviews with 32 participants (20 nurses, four doctors, five managers and three funder/planners), to explore the use of a guideline in everyday primary health-care practice. Thematic analysis of data was managed through an inductive process of familiarisation, coding, categorising and generation of themes. Four themes were generated from the data portraying the realities of guideline implementation for primary health-care nurses: self-managing patient, everyday nursing practice, developing new relationships in the health team and impact on health-care delivery. The findings reveal that, even with the best of intentions to implement the guideline, health professionals were frustrated and at a loss as to how to achieve that in practice. Consequently, cardiovascular risk assessment and management was uneven and fragmented. Primary health-care practice environments vary so much that solutions to the difficulties of implementing evidence into practice requires context-specific solution-finding through collaborative teamwork. Furthermore, the attention of guideline developers, health-care policymakers, funders and researchers requires direct focus on the 'how' and the 'what' of evidence implementation.

AIM: To describe and evaluate the implementation, effects and outcomes of a nurse-managed nocturnal enuresis treatment programme. METHOD: The research design comprised three data sources: focus group interviews with six public health nurses providing the nocturnal enuresis treatment programme, case notes of a convenience sample of 30 children who had completed the treatment programme and interviews with seven children who had completed the programme. RESULTS: The study showed a success rate of 87 per cent (n = 26). Success was defined as maintaining nocturnal continence for 14 consecutive nights. Key aspects in the programme's success and delivery included the child taking responsibility for the programme instead of the parent, the nature of the nurse-child interaction and the nurses' flexibility in adapting the programme for each child. CONCLUSION: The children had experienced low self-esteem as a result of nocturnal enuresis, but success on the programme dramatically improved their self-esteem and ability to socialise with other children. The study affirmed the value of the nurse as the facilitator of this programme. The study has contributed to the knowledge base on the management of nocturnal enuresis in a community-based nurse-managed programme.

Many higher plants, including Arabidopsis, transiently display purple anthocyanin pigments just after seed germination. We observed that steady state levels of mRNAs encoded by four flavonoid biosynthetic genes, PAL1 (encoding phenylalanine ammonia-lyase 1), CHS (encoding chalcone synthase), CHI (encoding chalcone isomerase), and DFR (encoding dihydroflavonol reductase), were temporally regulated, peaking in 3-day-old seedlings grown in continuous white light. Except for the case of PAL1 mRNA, mRNA levels for these flavonoid genes were very low in seedlings grown in darkness. Light induction studies using seedlings grown in darkness showed that PAL1 mRNA began to accumulate before CHS and CHI mRNAs, which, in turn, began to accumulate before DFR mRNA. This order of induction is the same as the order of the biosynthetic steps in flavonoid biosynthesis. Our results suggest that the flavonoid biosynthetic pathway is coordinately regulated by a developmental timing mechanism during germination. Blue light and UVB light induction experiments using red light- and dark-grown seedlings showed that the flavonoid biosynthetic genes are induced most effectively by UVB light and that blue light induction is mediated by a specific blue light receptor.