Search

Objectives: This research describes four aspects of the development of the Sense of Safety Theoretical Framework for whole person care: exploring the meaning of the phrase "sense of safety"—the whole person language ; the range of human experience that impacts sense of safety—whole person scope ; the dynamics that build sense of safety—the healing goals ; and the personal and cross-disciplinary trauma-informed practitioner skills and attitudes that facilitate sense of safety. Methods: This qualitative participatory study was conducted in two phases. Researchers iteratively explored the concept of sense of safety using focus groups and semi-structured interviews. Overarching research questions were: "Does the transdisciplinary concept of Sense of Safety make sense as an approach to the whole person in distress?"; "How do participants describe the meaning of the phrase "sense of safety"?"; "What does a person experience when they feel safe?" and "What can practitioners do to facilitate a sense of safety?" Phase One involved rural and urban family doctors, mental health clinicians across multiple disciplines, people with lived experience of mental distress, and Indigenous Australian academics. Phase Two widened the scope of disciplines involved to iteratively reflect on their clinical and personal experience with "sense of safety" and included international family doctors, physiotherapists, occupational therapists, social workers, teachers, multidisciplinary rural clinicians and multidisciplinary clinicians with a lived experience of physical trauma, grief, and severe mental illness. Results: The everyday language "sense of safety" was found to describe a whole person experience that integrates awareness of self, others, and context. The scope of human experience that impacts sensed safety was found to include seven domains: Environment, Social Climate, Relationships, Body, Inner Experience, Sense of Self and Spirit/Meaning (Whole Person Domains). Five dynamic healing goals were identified that build sense of safety: Broad Awareness; Calm Sense-Making; Respectful Connection; Capable Engagement; and Owning Yourself (Sense of Safety Dynamics). Five practitioner skills and attitudes that facilitate sense of safety were named: Valuing the Whole Picture; Holding Story Safely; Being with You; Learning Together; and Validating Dignity (Sense of Safety Practitioner Skills). Conclusion: The Sense of Safety Theoretical Framework developed in this study focusses on an experience that is a fundamental prerequisite of health. Sense of safety is affected by, and influences, life story, relationships, meaning, sense of self, and – physical health: the whole person. The language "sense of safety" communicates an integrative experience that can help clinicians to see the whole person and describe a cross-disciplinary goal of care. The Whole Person Domains clarify the scope of care required, while the Sense of Safety Dynamics offer practical processes of care. The Sense of Safety Practitioner Skills describe trauma-informed skills and attitudes that facilitate a sense of safety. Each of these parts of the Sense of Safety Theoretical Framework translate practitioner, lived experience, and First Nations wisdom and a wide existing transdisciplinary literature into a framework and language ready for practice. Assessing and building sense of safety prioritizes a healing-oriented and trauma-informed approach. The Sense of Safety Theoretical Framework facilitates a paradigm shift that towards integrating sensation, subjective experience, physiology, and social determinants into everyday quality care in health, education and public policy. [ABSTRACT FROM AUTHOR]

Background and objective Tuberculosis infection (TBI) screening and treatment delivered from primary care could hold the key to achieving tuberculosis (TB) elimination in lowTB burden countries. This scoping review was undertaken to understand how elements of the cascade of care for TBI screening and treatment have been implemented in primary care settings globally. Methods For this review, eight databases were searched, including PubMed, Embase, CINAHL, Global Index Medicus, Scopus, Web of Science, ProQuest Dissertations & Theses Global and the Cochrane Library, to examine models of care for TBI screening and treatment in primary care. Results Eight articles were included from the 7207 articles screened. These eight articles describe models of care that are varied in their aim, design and focus and elements of the TBI cascade of care. Discussion Although primary care is well placed to offer TBI screening and treatment, robust referral, community mobilisation and systems support are critical. Further research is necessary for Australia to deliver on the elimination target of the World Health Organization. [ABSTRACT FROM AUTHOR]

Introduction: Retention of general practice registrars in their training practices is important for addressing the GP workforce deficit and maldistribution of GPs. Given that rural and remote general practices are disproportionately affected by low retention, identifying the factors that promote retention may be as important as developing recruitment strategies in these areas. Quantifying the impact of relevant factors on registrar retention will enable a better understanding of how to incentivise retention and attenuate the loss of the rural workforce to other areas. We sought to establish the prevalence and associations of retention of general practice registrars in their training practices. Methods: This analysis was a component of the New alumni Experience of Training and independent Unsupervised Practice (NEXT-UP) study: a cross-sectional questionnaire-based study of early-career GPs in conjunction with evaluation of data contemporaneously recorded as part of vocational training. Participants were former registrars of three regional training organisations delivering general practice training in New South Wales, Tasmania, the Australian Capital Territory and Eastern Victoria, who had attained Fellowship of the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine between January 2016 and July 2018. The outcome measured was whether the registrar had previously worked at their current practice during vocational training. Multivariable logistic regression was used to estimate the association between relevant explanatory variables and the outcome. Results: A total of 354 alumni responded (response rate 28%), of whom 322 provided data regarding previous training practice retention, with 190 (59%) having previously worked at their current practice as registrars. Among respondents who reported currently working in a regional--rural practice location (n=100), 69% reported having previously worked at their current practice during training. GPs were more likely to be retained by a practice they had trained at if it was of lower socioeconomic status (adjusted odds ratio (aOR) 0.82 (95% confidence interval (CI) 0.73-0.91), p<0.001 for each decile of socioeconomic status) and if the practice provided two or more of home visits, nursing home visits or afterhours services (aOR 4.29 (95%CI 2.10-8.75), p<0.001). They were less likely to be retained by the practice if training was completed in a regional-rural area (aOR 0.35 (95%CI 0.17-0.72), p=0.004). Conclusion: Regional--rural training location is associated with reduced odds of subsequent retention of general practice registrars. This is occurring despite significant government investment in expansion of general practice training in regional and rural areas. The practice factor most strongly associated with GP retention was the provision of out-of-practice and after-hours care. There may be altruistic, rather than monetary, reasons that explain this finding. Such training opportunities, if provided to all trainees, especially in regional and rural areas, would be a learning opportunity, a way of promoting holistic community-based care and an incentive for subsequent retention within the practice and community as an established GP. [ABSTRACT FROM AUTHOR]

Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 x 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16-29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5-AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference -8.8%; 95% CI -10.5% to -7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference -7.1%; 95% CI -9.6% to -4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was -0.9% (95% CI -3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference -9.5%; 95% CI -11.7% to -7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference -6.4%; 95% CI -8.6% to -4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was -2.6% (95% CI -5.4% to -0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5-AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617, Author(s): Jane S. Hocking 1,*, Anna Wood 1,2, Meredith Temple-Smith 2, Sabine Braat 1, Matthew Law 3, Liliana Bulfone 4, Callum Jones 1, Mieke van Driel 5, Christopher K. Fairley [...]

Background: The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship. Aim: To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections. Design & setting: Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022. Method: Interviews were transcribed verbatim and analysed using a reflexive thematic approach. Results: We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth. Conclusion: Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections. [ABSTRACT FROM AUTHOR]

Introduction. In Australian general practitioner (GP) training, feedback and reflection on inpractice experience is central to developing GP registrars' (trainees') clinical competencies. Patient encounter tracking and learning tools (PETALs) that encompass an audit of consecutive patient consultations, feedback, and reflection are used to determine registrars' in-practice exposure and have been suggested as a tool for learning within a programmatic assessment framework. However, there is limited qualitative literature on the utility of PETALs in GP training. Aim. To provide greater understanding of how PETALs are used in GP training, using Registrars' Clinical Encounters in Training (ReCEnT) as a case study. Methods. Medical educators, supervisors, and registrars from two Australian regional GP training organisations participated in focus groups and interviews, designed to explore participants' perceptions of ReCEnT's utility. Data were analysed using reflexive thematic analysis. Results. Eight themes were identified that enhance our understanding of: how ReCEnT reports are used (reassuring registrars, facilitating self-reflection, identifying learning needs), what enables ReCEnT to reach its full potential (a culture of reflection, meaningful discussions with supervisors and medical educators, valuing objective data), and differences in understanding about ReCEnT's role in a programmatic assessment framework (as a tool for learning, as 'one piece of the puzzle'). Discussion. The findings were used to develop a Structure-Process-Outcomes model to demonstrate how ReCEnT is currently used and explores how it can be used for learning, rather than of learning, in a programmatic assessment framework for GP training. ReCEnT's longitudinal format has potential for enhancing learning throughout training. [ABSTRACT FROM AUTHOR]

Introduction. Patient encounter tools provide feedback and potentially reflection on general practitioner (GP) registrars' in-practice learning and may contribute to the formative assessment of clinical competencies. However, little is known about the perceived utility of such tools. Aim. To investigate the perceived utility of a patient encounter tool by GP registrars, their supervisors, and medical educators (MEs). Methods. General practice registrars, supervisors and MEs from two Australian regional training organisations completed a cross-sectional questionnaire. Registrars rated how Registrar Clinical Encounters in Training (ReCEnT), a patient encounter tool, influenced their reflection on, and change in, clinical practice, learning and training. Supervisors' and MEs' perceptions provided contextual information about understanding their registrars' clinical practice, learning and training needs. Results. Questionnaires were completed by 48% of registrars (n = 90), 22% of supervisors (n = 182), and 61% of MEs (n = 62). Most registrars agreed that ReCEnT helped them reflect on their clinical practice (79%), learning needs (69%) and training needs (72%). Many registrars reported changing their clinical practice (54%) and learning approaches (51%). Fewer (37%) agreed that ReCEnT influenced them to change their training plans. Most supervisors (68%) and MEs (82%) agreed ReCEnT reports helped them better understand their registrars' clinical practice. Similarly, most supervisors (63%) and MEs (68%) agreed ReCEnT reports helped them better understand their registrars' learning and training needs. Discussion. ReCEnT can prompt self-reflection among registrars, leading to changes in clinical practice, learning approaches and training plans. Reaching its potential as an assessment for learning (as opposed to an assessment of learning) requires effective engagement between registrars, their supervisors and MEs. [ABSTRACT FROM AUTHOR]

Aim. The aim of the study was to establish whether two previously described barriers to effective in-consultation assistance-seeking by general practice (GP) vocational specialist trainees (ie concern about patient impressions of their competence, and discomfort presenting to supervisors in front of patients) influenced the frequency of trainee in-consultation assistanceseeking from their supervisor. Methods. This was a cross-sectional study nested in the Registrar Clinical Encounters in Clinical Training ongoing cohort study of Australian GP trainees. Trainee participants completed contemporaneous records of 60 consecutive patient consultations, including whether supervisory assistance was sought. Trainees also completed a cross-sectional survey including items eliciting their beliefs about patient impressions and their own discomfort in seeking in-consultation supervisory assistance. These were factors of interest in multivariable logistic regression analyses; the outcome factor in both regression models was the seeking of inconsultation supervisory assistance. Results. In 2018, 778 trainees (778/876, response rate 89%) completed the cross-sectional survey. No association was found between the odds of inconsultation help-seeking and perceived decrease in patient impressions of trainee competence (OR = 1.09; 95% CI: 0.91, 1.31; P = 0.36) or higher comfort presenting outside patients' hearing (OR = 0.9; 95% CI: 0.77, 1.05; P = 0.19). Discussion. Contrary to expected utility models of helpseeking, trainees may not consider personal discomfort or impression management to be important enough, compared to patient safety and other considerations, to influence decisions regarding in-consultation help-seeking. Clinical supervisors should, nevertheless, consider the potential personal costs to trainees and maintain trainee self-esteem and confidence by providing in-consultation assistance in front of patients as comfortably and effectively as possible. [ABSTRACT FROM AUTHOR]