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The 2017 outbreak of Mycoplasma bovis in New Zealand deeply impacted rural communities, particularly cattle farmers. In 2018, the Ministry for Primary Industries (MPI) implemented an eradication programme that involved herd testing, stock culls, restriction of stock movements, decontamination of affected farms, and compensation to farmers for losses associated with the eradication programme. New Zealand news media reported widely on the emotional trauma experienced by affected farmers and MPI was criticised for poor management of the outbreak. We interviewed nineteen farmers and farming couples affected by M. bovis in Southern New Zealand to gain insight into their experiences of the outbreak. In this paper, we present the findings pertaining to one dominant thematic: that of farmers' interactions with the bureaucracy associated with the management of the outbreak. The farm appeared to quite literally represent a site of collision between farming values of stock welfare and practical and relational forms of knowledge; and policy, regulation, compliance and technical instrumental forms of knowledge. For these reasons, Habermas’ theory of lifeworld and system presented itself as a particularly salient framework for interpreting our data. Participants experienced the eradication programme as intrusive, impractical, and inhumane; while their situated local knowledge and pragmatism were ignored in favour of adherence to wasteful and inefficient bureaucratic processes that while compliant with policy, made no sense to the farmers. We suggest that biosecurity threats such as M. bovis might be more effectively managed when the bureaucracy is attentive to the rural lifeworld and responsive to the situated knowledge of farmers.

Drawing has played a key role in the development and dissemination of Medicine and Surgery, such as to share anatomy, pathology, and techniques for clinical interventions. While many of the visuals used in medicine today are created by medical illustration professionals, and by imaging techniques such as photography and radiography; many doctors continue to draw routinely in their clinical practice. This is known to be valued by patients, for example when making informed decisions about care. We surveyed doctors in New Zealand online regarding their use of drawing to explore the prevalence of this practice. 472 complete responses were obtained over 3 months. There were very high rates of drawing among responding doctors practicing in both medical and surgical specialties. Reasons for drawing are explored and included professional, collegial, and patient communication, supporting informed consent, clinical documentation, and for planning procedures. Widespread use of drawing in clinical practice, almost non-existent training or support for this in digital workflows, and high interest in resources to develop clinical drawing skills, suggest unmet training needs for this practical clinical communication tool.

Little is known about the experiences of ethnic Chinese accessing mental health services in Aotearoa New Zealand, resulting in uncertainty around their service preferences, and facilitators or barriers to their mental health help-seeking. This paper investigated the experiences of providers of specific mental health services for ethnic Chinese in Aotearoa, their opinions regarding their patients' experience, and their suggestions to improve the system.Sixteen health professionals with experience and expertise delivering mental health services for ethnic Chinese were interviewed at 12 organisations across Aotearoa. Interviews were recorded, transcribed and analysed using general inductive methods and thematic analysis.Practitioners' experiences revolved heavily around cultural brokerage, which is vital for culturally appropriate care, but this is time-consuming and receives little formal support. Practitioners thought the patient experience was inadequate, with a lack of language- and culturally appropriate services leading to delays in help-seeking. Practitioners' suggestions for system improvement included increasing resourcing for research, and for expanding the availability of language and culturally appropriate services.Current mental health service provision is inadequate for ethnic Chinese seeking help in Aotearoa, and is causing harm by delaying mental health help-seeking. Decisive Government leadership and deeper collaboration between non-Government organisations (NGOs) will be key to improving mental health service accessibility and outcomes.

Mycoplasma bovis, a disease affecting cattle worldwide, was first reported in New Zealand in 2017. Classed as an unwanted organism, the Government attempted eradicating it via culling of infected h...

People most commonly pray because of their belief in a God or higher power that can hear and respond to these prayers. Patients may ask their physicians to join with them in prayer for many reasons...

This study examined the challenges for supervisors and managers of managing sick leave within a New Zealand university. We used a qualitative research design, interviewing 20 university staff across the academic and service divisions who had managerial roles. We applied Habermas’ distinctions of technical instrumental, practical relational, and emancipatory critical transformative interests, and his twofold distinction of system and lifeworld to our analysis. The primary findings suggest that while the technical instrumental discourses were dominant within the university bureaucracy, managers (particularly front line managers) drew upon practical relational and emancipatory critical transformative discourses to justify the considerable discretion they exercised in managing sick leave. Far from being incidental, these humanistic elements are as much a part of the bureaucracy as the rational elements and are fundamental to the system’s equilibrium.

In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent, is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives follo...

BACKGROUND The undergraduate curriculum tends to focus on how individuals can cope with stress especially when transitioning from the classroom to the clinical workplace environment. Often this carries the message that stress is bad, yet little attention has been paid to the influence of one's belief regarding the value of stress for learning. Because stress is often perceived as bad, we chose to use the term 'challenge' in exploring the associations amongst belief of the value of challenge, the challenge experienced, the perceived learning, affect and staff support. METHODS At the end of each clinical module within a medical curriculum, medical students rated the perceived learning, degree of challenge, affect, support and the value of challenge for learning. The value and associations amongst these variables were analysed. RESULTS The challenge for students varied according to the type of module. Students generally considered that challenge promoted rather than hindered learning. The level of challenge experienced may influence the perception of the value of challenge for learning. However, when challenge was regarded as beneficial, this was strongly, positively associated with perceived learning, positive affect and support. DISCUSSION Students who believe challenge is positive also perceive that such challenges promote learning. Likewise students who regard challenge as negative are less likely to learn from such challenges. The positive relationship between the belief of the value of challenge with affect and support may have positive implications for well-being. It is contended that curriculum planners should acknowledge the potential positive influence of stressors in clinical education and that challenge can be seen as valuable when there is student support and measures associated with maintaining a positive affect.

In this article, we argue that sick leave and its management within the university involves exchanges of moral capital. The circulation of moral capital supports a moral economy, in turn underpinning the political economy of the corporate university. The forms of moral capital are diverse, sometimes easily recognized as such, more often hidden in plain sight. Like other forms of capital, moral capital can be accrued, depleted, and exchanged as it is paid forward. The exchanges between employers and employees within this moral economy represent trading of moral capital over and above contractual exchanges of income and other benefits for labor. Sick leave transactions illustrate the many forms this moral capital can take: values and principles, entitlements and accruals of sick leave, bureaucratic compliance, discretion, vulnerability and deservingness, employment history, and work ethic.

Background Challenge, sometimes perceived as stress, may be beneficial or detrimental to learning but the circumstances when it may be beneficial are not clear. This study looks at the association of challenge with perceived learning and how this might be influenced by affect, context or the type of learning. Method The participants, medical students in their first years of experiential clinical exposure, rated specified learning episodes (LEs) on the perceived learning (low to high), challenge (low to high) and affect (feeling positive to negative). Such learning episodes were self-identified or identified by course organisers. Correlations, using Kendall’s tau-b test, were conducted to explore the associations among learning, challenge and affect. In the second stage the types of LEs were then thematically classified in order to determine those that were positive for learning and challenging and/or associated with positive affect. Result There were positive correlations between perceived learning and challenge, and between perceived learning and affect for both types of LEs. The circumstances in which challenge (stress) promoted learning were authentic environments, authentic tasks and simulated clinical activities; most requiring a degree of social interaction. Conclusion Challenge and positive affect are beneficial in the perception of discrete learning, but are two separate constructs. Ideally both challenge and affect need to operate alongside authentic supportive clinical activities, that by their nature involve others, to maximise perceived learning.

Implementing newly legalized euthanasia or assisted dying presents challenges. The procedure is high-stakes and irreversible and the context is controversial and associated with high emotions and strong opinions. This qualitative study reports unexpected experiences of twenty-one medical doctors who provided Medical Assistance in Dying (MAID) in the first years after legalization in Canada. The phrase 'because it was new' occurred multiple times as doctors attributed unanticipated experiences to the lack of individual and collective experience or knowledge. Positively viewed surprises included increased awareness of palliative care and an unexpected personal sense of fulfillment from helping others. Negative surprises were attributed multiple factors including ambiguously phrased legislation, systems issues and individual inexperience. Participants described issues such as technical difficulties around provision, provider anxiety, logistical snags and inability to adequately counsel and guide families. Participants expressed desire for more guidance, mentoring, training, and team communication. This article draws on phenomenological analysis of data to present providers' accounts of their experiences in the Canadian context. This will assist new providers and jurisdictions in anticipating and preparing for circumstances that were unexpected for the first cohort.

A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher’s role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.

INTRODUCTION: This project aimed to identify the support needs of older people living in rural Central Otago, Aotearoa New Zealand and to ascertain if a pilot social work position was meeting these needs. METHODS: Data were collected during December 2019. Twelve semi-structured qualitative interviews were conducted with the social worker, referrers of the social worker’s clients, key community stakeholders, and the older rural residents supported by the social worker. FINDINGS: An interpretive analysis of the data identified two key thematics: 1) being older in Central Otago; and 2) providing aged social work services in this region. CONCLUSION: Despite the positive impact that the Age Concern Otago social work position is having for clients of the service, the need for social support for older rural people in Central Otago continues to grow. In addition to increasing social worker resourcing, better coordination and linking between the government and non-government agencies operating in this space would improve the effectiveness of aged social work services, as would improved visibility of these services within the community.

Introduction Learner neglect is a relatively new concept in education and no suitable framework for its exploration has been devised. The aim of this study was to determine whether an existing framework, Glaser's framework of child neglect, could be applied to learner neglect in clinical learning environments. This was a retrospective analysis of data obtained as part of a related study. Method Six focus groups were conducted with medical students in their early clinical years to explore their views of what experiences in medical education were challenging and why they presented a challenge. The transcript data were analysed using inductive content analysis, within an interpretivist approach in the development of categories. The identified categories were cross referenced with Glaser's framework categories replacing the carer with the teacher and the child with the learner. Results Glaser's classifications of teacher (parent) behaviours were all identified in the negative aspects of medical learner clinical education including: emotional unavailability/unresponsiveness, acting in a hostile manner, inappropriate inconsistent developmental interaction, failure to recognise individuality and failure to promote social adaption. Physical unavailability was identified as an additional category and is included in our proposed framework of learner neglect. Discussion Adapting Glaser's framework was useful in considering learner neglect. Medical schools have a role in ensuring learning experiences are positive across contexts and to make explicit to teachers any behaviours that may appear as learner neglect. Applying this framework has the potential to make more explicit any subtle undermining teacher behaviours. Once explicit, there is a greater likelihood that behaviours may be reappraised both by the teacher and learner and modified to promote a more effective clinical learning experience.

This paper examines the role of sick leave in constructing the identity of a good worker. The setting is a public funded New Zealand university. Within a qualitative research design, interviews were conducted with a range of employees and managers about their use and management of sick leave. Sick leave entitlements, use, and management encompass moral discourses that impact upon worker identity. Normalising discourses generated by compliance to bureaucratic demands and norms of productivity and performance in the neoliberalised workplace are constitutive to the construct of the good employee as reflected by the appropriate use and recording of sick leave. Conversely, the respectful, authentic, compliant and productive worker is constitutive of its opposite - the difficult employee. The construct of the difficult employee positions conformity and self-management of sick leave as strong moral imperatives. Managers were generally supportive of workers' efforts to self-manage sick leave with consideration for university commitments and were flexible around work hours, but this would in turn position them as deviant to institutional pathways of managing sick leave, with tensions between humanistic and authoritarian management.

In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives following a high-profile court case afforded an opportunity for examining how assisted dying was discussed in the public sphere. In this article, we report on a discourse analysis of a selection of social media to illustrate the ways in which citizens participate in the voluntary euthanasia debate. The volume of social media posts that made up our data set suggests that the legalisation of assisted dying is a highly topical and deeply salient societal issue. Social media postings represent the voices of ordinary citizens who may not participate in formal public consultation processes. Based on our analysis, the assignment of binary conclusions about public opinion is simplistic and fails to adequately represent the intricacies of public debate. Contributors’ posts reveal deeply held sociocultural values, as well as tensions about the relationship between citizens and the apparatus of government.

Background Assisted dying (AD) is currently of wide interest due to legislative change. Its relationship to other end-of-life practices such as palliative sedation (PS) is the subject of ongoing debate. The aim of this article is to describe the perspectives of a group of New Zealanders with life-limiting illness, who want or would consider AD, on the provision of end of life services, including assisted death, withdrawal of lifeprolonging treatment and symptom management with opioids or PS. Methods We recruited 14 people with life-limiting illness and life expectancy of less than a year. Their mean age was 61 (range, 34-82) years and half were enrolled in Hospice. An additional six family members were also interviewed and included in analysis. We asked them about why they would consider AD if it was available. Interview transcripts were inductively analyzed consistent with thematic analysis. We compared the findings to prevailing ethical frameworks. Results Most of the participants viewed current palliative care practices, such as pain relief with opioids and symptom management with PS, as hastening death, in contrast to some medical research which concludes that proportional therapeutic doses do not hasten death. Some participants did not agree with the 'doctrine of double effect' ('DDE') and saw such practices as 'slow euthanasia' and 'covert euthanasia'. They implied such practices were performed without patient consent, though they did not conceive of this as murder. Participants asserted that active and passive practices for ending life were morally equivalent, and preferred to choose the time of death over other legal means for death. Conclusions This article contributes to what is known about how patients perceive end-of-life practices that potentially hasten death. There is a divide in what medical ethics and most health professionals and what some patients consider active hastening death. Participants' perspective was consistent with a consequentialist framework whereas deontology often guides medical ethics at the end of life. Participants' challenge to the interpretation of legal end-of-life practices as AD represents an epistemic contest to the foundation of medical knowledge, authority and ethics and therefore carries implications for preferences in care, communication and palliative care practice.

There is very little literature on the actual decision-making frameworks used by general practitioners with respect to ethical issues and virtually none on the impact of personal experiences of illness on this. This study aimed to investigate what these frameworks might be and if and how they were altered by doctors’ own illness experience. Twenty general practitioners were recruited, 10 having had a previous serious medical illness and 10 having no such history. They participated in a semi-structured interview, including case vignettes, recorded and analysed using qualitative thematic analysis. Being a patient themselves altered general practitioners’ decision-making by enhancing physician empathy, increasing ease at discussing difficult topics, having a greater willingness to support patient choice and a wider ability to provide a greater diversity of therapeutic strategies, with the role of empathy being the most noticeable difference between the groups. Doctors who had not had a severe personal illness showed difficulty in anticipating how this might change their decision-making. Virtue ethics was most commonly used for decision-making by both groups. There was considerable divergence of opinion on the ethics and usefulness of self-disclosure of personal illness in both groups of doctors. These findings have implications for the teaching and learning of medical ethics at both undergraduate and postgraduate level.

Individual agency is central to late modern and neoliberal concepts of the self and notions of a good death. Assisted dying can be understood as a reflection of these ideas in that control over death resides with the individual. The aim of this article is to explore individual agency and control and employ concepts of biopower and freedom to illustrate the paradoxes inherent within assisted dying. Assisted dying is currently of wide interest due to legislative change. At the time of research, the New Zealand Parliament was passing the End of Life Choice Act, yet there had been no research with people approaching the end of life about assisted dying. Through the media we recruited and interviewed 14 people approaching the end of life who would have considered choosing assisted dying if it were available to them. Interviews were analyzed using an immersion/crystallization thematic analysis. Assisted dying appealed to participants because it offered control. This article examines the discursive context of control as well as the participants’ perception of control to offer insights into how paradoxically, a medical regime of assisted dying reinforces health professionals as in control of the circumstances of dying. We argue that although legalized medical assisted dying is highly regulated and monitored, thus limiting freedom, the option of assisted dying also increases freedom for the dying person. Within this paradox of control, there is still scope for choice and an ethical making of the self, although limited by the biopolitical regime, that equates to a degree of freedom for participants.

What does the term ‘healthy lifestyle’ mean to middle-aged adults (54–65 years)? Participants in an interview study about longevity described the ‘healthy lifestyle’ largely in terms of diet, exercise and prevention, and avoidance behaviours. It was evident that the healthy lifestyle was an ideal that required participants to make many choices in their daily lives based on what they considered to be ‘right’ and ‘good’. In describing their adherence to a healthy lifestyle, we argue that participants’ perspectives reveal contemporary discourses of healthism that are characterised by self-responsibility, as well as notions of risk and consequence. These discourses represent normalising moral technologies that shape citizens’ behaviours and reflect Liechter’s (1997) new secular morality. Participants engaged variously with these technologies ranging from ambivalence, zealousness, negotiation, bargaining, and resistance. Family doctors play a critical role in helping people to navigate the disciplinary apparatus of normalising moral technologies that underpin the healthy lifestyle.

Objectives This study describes the incidence, nature and cause of work-related injuries in older New Zealand workers to understand the risks of work-related injury in this rapidly aging population. Methods Data for the period 2009–2013 from 25,455 injured workers aged 55–79 years, extracted from national work-related injury entitlement claims, were stratified by age group and analysed by sex, industry, injury type and cause. Age-specific claims rates were calculated by year, sex and ethnicity. Results Patterns of injury differed by age: 70–79 year olds had the highest injury rates and proportion of claims due to falls (45%), for the self-employed (32%), for the agriculture sector (24%), and for fatal injuries (5%). Discussion The burden of work-related injuries in older workers, particularly in those aged over 70, will increase with their increasing participation in work. Workplace injury prevention strategies and interventions need to consider the specific characteristics and vulnerabilities of older workers.

This paper describes a qualitative survey of professional statisticians carried out in New Zealand in 2014. The aim of the study was to find out if the issues this group faced were consistent with those identified in the literature. The issues identified were integrity, legitimacy, isolation, workforce shortage, communication, and marginalisation. They represent points of frustration for statisticians that may impact on the future of the profession as it responds to increasing demands and higher expectations. We found that these issues resonated for many of the statisticians included in our study and we have discussed a number of strategies to address them. They include raising our profile, attracting a broader range of people to the profession, increasing our communication skills, raising the statistical literacy of the people we work with, and a commitment to making it easy to engage with our colleagues. First published November 2017 at Statistics Education Research Journal Archives

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient’s journey. The concept of moral capital offers another route into the “black box” of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Aims and objectives To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. Background To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own ‘Community of Clinical Practice’ of which they are the central member. Design Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine ‘Communities of Clinical Practice’ in one general practice setting. Method Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients’ medical records. Data were analysed using a template organising style. Findings Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between ‘Community of Clinical Practice’ members, frequently through informal communication and realised through respectful dialogue. These common values – respect, authenticity, autonomy, compassion, trust, care ethics, holism – underpin the development of a shared vision of care. Conclusions A patient's vision of care, if shared, provides a focus around which ‘Community of Clinical Practice’ members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. Relevance to clinical practice A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a ‘Community of Clinical Practice’.

While we know about lay attitudes towards death and dying, we understand little about the ways people estimate their overall personal risk of life-limiting disease and/or death. This study contributes to the limited literature on lay longevity reckonings, with a particular focus on how these reckonings may influence health behaviours. Semi-structured interviews were held with 21 young older adults (54–65 years), addressing the core questions of ‘What do you think you will die from, and how long do you expect to live?’ Participants indicated their longevity estimation was guided by three key frameworks: family history, environment and lifestyle factors and lived experience. The reckoning process was also moderated by assumptions about loci of control and self-efficacy and the information available to participants. A tripartite model of death risk assessment is proposed, extending the idea of ‘negotiated risk’ beyond the scope of family history where it has received most attention. We argue that by drawing on the three risk-assessment frameworks, determining patients’ predisposition for external/internal attributions of control and perceptions of self-efficacy, clinicians will be better equipped to understand – and thus guide – patients’ reckonings of longevity and health behaviours that are influenced by it.

ObjectiveTo explore the perspectives of primary healthcare (PHC) professionals providing care to refugees through mainstream general practice.DesignQualitative exploratory design with semistructured interviews subjected to inductive thematic analysis.Setting and participantsNine general practices enrolled in the Dunedin Refugee Resettlement Programme, in New Zealand (NZ)’s southern health region. Participants included nine general practitioners and six practice nurses.ResultsThree analytical constructs were identified: relational engagement with refugees, refugee healthcare delivery and providers’ professional role shaped by complexity. Building meaningful relational connections involved acknowledging refugees’ journeys by getting to know them as people. This was instrumental for the development of an empathetic understanding of the complex human trajectories that characterise refugees’ journeys to NZ. Participants encountered challenges in providing care to refugees with respect to time-limited consultations, variable use of interpreter services, fragmentation of care between agencies and need for improved health infrastructure to ensure a fluid interface between PHC, secondary care and community support services. The current business model of NZ general practice was perceived to interfere with value-driven care and discouraged tailoring of care to specific patient groups, raising concerns about the ‘fit’ of mainstream general practice to address the complex healthcare needs of refugees. Meeting the needs of refugees across the social determinants of health involved a lot of ‘behind the scenes work’ particularly in the absence of shared information systems and the lack of well-established referral pathways to connect refugees to services beyond the health sector. This led to providers feeling overwhelmed and uncertain about their ability to provide appropriate care to refugees.ConclusionsThis study provides rich context-specific findings that enhance PHC responsiveness to the needs of refugees in NZ.

Government responses and lockdowns, even done well, have also caused increased morbidity and mortality by a reduction in patients seeking treatment for non-COVID-19 conditions, and the postponement of therapy such as surgery and preventive screening. This opportunity cost of the lockdown also includes the morbidity and mortality induced by unemployment and mental health issues. Whether these risks of lockdown are outweighed by the projected lives saved from dying of COVID-19 has still to be adequately analysed both here and overseas, but such analyses are essential in understanding the circumstances under which such measures are ethically justified. Equity of information-provision has been problematic. There have been issues of access to digital information and telehealth, especially for people who are poor or homeless.29 Understanding the risks, benefits and ethics of virtual healthcare is evolving concurrently with its widescale implementation.

INTRODUCTION There has been increased interest in the utility of clinical pathways by primary health care in New Zealand, although evaluation of their use has been limited. AIM To identify barriers and facilitators for the use of clinical pathways in one health region. METHODS Interviews with 15 general practitioners in the Western Bay of Plenty. A qualitative thematic analysis was undertaken, informed by the Diffusion of Innovation Framework. RESULTS Four themes were identified: learning to use the pathways, persuasion and decision to use, implementation and sustainability. Barriers to using the pathways included time pressure; scepticism; difficulty in portraying patients’ clinical picture within a set pathway; technical difficulties and lack of support in obtaining knowledge; and practical implementation of the pathways in daily work. Facilitators included endorsement by opinion leaders; pathways directing workup and treatment stepwise towards referral; centralised information with resources available in the consultation; and reported increased acceptance of referrals by secondary care if pathways were used. DISCUSSION The development and implementation of health care initiatives requires an understanding of the local context. Knowledge about the specific, locally appreciated barriers and facilitators can inform future health-care developments. The Diffusion of Innovation Framework offers a practical model to understand effective implementation.

ObjectivesThere is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of ‘care maps’ – a patient-identified social network map of their care community – for health professionals in providing person-centred care.MethodsWe piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes.ResultsHealth professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients’ support networks, synthesising what is known and unknown. Health professionals understood patients’ perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice.DiscussionCare maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had ‘social function’ for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients’ lifeworlds.

A move to residential care represents a significant transition for older people, between their former independent and autonomous lives, and dependence, frailty and death. The concept of transition is valuable in considering the quality of care. We argue that a successful transition to residential care is one measure of quality in care. We used an ethnographic approach that emphasises participant-observation and qualitative interviewing. Analysis of the transcripts revealed several themes, one of which, transition, is discussed in this paper. Transition theory, along with the concept of liminality, i.e. the betwixt and between status of the mostly unanticipated move from home to Residential Aged Care Facilities identifies and explains the complexities involved in the move into residential care for older people and their families.

Cosmopolitanism speaks to pan-nationalist and pan-human experience. How can this be reconciled with the lived political economies of care across the formal and informal sectors? How do the critical and interpretive medical anthropological commitments to cultural critique and social justice articulate with cosmopolitanism? We examine these thematics through the contributions of Australian and New Zealand anthropologists. In both countries, paid and unpaid care work occurs within a neoliberal capitalist economy characterised by growing inequity between wealthiest and poorest citizens, privileging of autonomy and individualism over collectivist regimes of social organisation and resource allocation, transfer of assets and capital from the public to the private sector, and a significant shift in the balance of power toward employers in the labour marketplace. Each article illustrates the ways in which disability and care are constructed and contested, and the degree to which care exemplifies cosmopolitanism.

In this essay I contend that the aged care sector not only constitutes a political economy, but is at the same time a moral economy containing multiple contested moral spaces, purposes and standpoints. Global processes of cosmopolitanisation contain moral agendas that link macro level structures with local communities, families, individuals, workplaces, and organisations. The aged residential care (ARC) facility as a moral economy exemplifies vernacular cosmopolitanisation. The State shapes the moral economy of the New Zealand aged care sector through enforceable policies and regulations, while organisations and facilities compete in a neoliberal consumption-oriented marketplace. Those employed in the sector such as nurses and careworkers seek a living. Residents must find home within ARC, while their families expect they receive quality care from ARC facilities.

Informal caregiving encompasses the motivations and practices of relatives in looking after family members of all ages with long-term illnesses and disabilities. Only recently has it been differentiated as a distinct role within the nurturance obligations of familial roles. As such, informal caregiving has been recognised through contemporary social movements in many countries, such as Australia, New Zealand, the United Kingdom and the United States. At the same time, there is an increasing interest in caregiving in history which elucidates the care needed and offered at different historical moments. Our aim here is to examine the minutiae and intimacies of care practices between caregiver and the recipient of care in two different periods of time, seventeenth century England and colonial America. We suggest that these data support the notion that care is a fundamental social human dynamic, connecting caregivers from early to contemporary times. Caregivers can be viewed as a shared global community, transcending community and time; at the same time acts of caregiving represent the humanitarian ideals of cosmopolitanism.

Advance care planning (ACP) has been framed as best practice for quality palliative care, yet a growing body of literature affirms the need for an early iterative ACP process to begin when people are young and healthy. A significant gap appears to exist in the literature regarding the utility of death conversations outside the end-of-life context. Could 'death conversations' early in life be an effective tool by which doctor and patient can co-construct a more healthful way of life, and realistic relationship with death? And what variables must be taken into account for these conversations to proceed successfully? This paper provides a narrative exploration of the value of death conversations in the clinical context in New Zealand. Five exemplars are discussed, drawn from a sample of 21 semi-structured interviews with young older adults (54-65 years old) not receiving palliative care or diagnosed with a terminal illness. Together, these narratives indicate that further community consultation is required to determine culturally appropriate ways to initiate productive conversations around aging, death and dying and how to build patient/practitioner/family relationships which allow these conversations to happen safely. There is a need to acknowledge the important factor of culture related to age, generation, sex, faith and ethnicity when engaging in conversations about aging, death and dying. By doing so, health professionals will be best equipped to assist their patients to live well into death.

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient’s well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients’ medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice’s repertoires are characterised by care and are driven by the moral imperative to care. They do ‘whatever it takes’, although there is a cost to this form of care. Well-functioning communities of clinical practice use patient’s well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the ‘messiness’ of community-based care.

Objective:International studies have shown that patients want their spiritual needs attended to at the end of life. The present authors developed a project to investigate people's understanding of spirituality and spiritual care practices in New Zealand (NZ) hospices.Method:A mixed-methods approach included 52 semistructured interviews and a survey of 642 patients, family members, and staff from 25 (78%) of NZ's hospices. We employed a generic qualitative design and analysis to capture the experiences and understandings of participants' spirituality and spiritual care, while a cross-sectional survey yielded population level information.Results:Our findings suggest that spirituality is broadly understood and considered important for all three of the populations studied. The patient and family populations had high spiritual needs that included a search for (1) meaning, (2) peace of mind, and (3) a degree of certainty in an uncertain world. The healthcare professionals in the hospices surveyed seldom explicitly met the needs of patients and families. Staff had spiritual needs, but organizational support was sometimes lacking in attending to these needs.Significance of results:As a result of our study, which was the first nationwide study in NZ to examine spirituality in hospice care, Hospice New Zealand has developed a spirituality professional development program. Given that spirituality was found to be important to the majority of our participants, it is hoped that the adoption of such an approach will impact on spiritual care for patients and families in NZ hospices.