Search

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’.

There is an increasing emphasis on interprofessional education for health professional students. However, exercises at the immersion level – where students are embedded in their professional roles – are challenging to design. We investigated the feasibility of running a series of simulated pharmacies alongside an existing simulated medical clinic. Students enjoyed the added authenticity of interprofessional simulation, but that this made them feel they had to represent their profession well. Simulation suites for different health professions should be co-located where possible.

ABSTRACTGeneral practitioners are increasingly approached to participate in research and share de-identified patient information. Research using electronic health records has considerable potential for improving the quality and safety of patient care. Obtaining individual patient consent for the use of the information is usually not feasible. In this article we explore the ethical issues in using personal health information in research without patient consent including the threat to confidentially and the doctor-patient relationship, and we discuss how the risks can be minimised and managed drawing on our experience as general practitioners and researchers.

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.

INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.

Learning environments are a significant determinant of student behaviour, achievement and satisfaction. In this article we use students' reflective essays to identify key features of the learning environment that contributed to positive and transformative learning experiences. We explore the relationships between these features, the students' sense of safety in the learning environment (LE), the resulting learning challenge with which they could cope and their positive reports of the experience itself. Our students worked in a unique simulation of General Practice, the Safe and Effective Clinical Outcomes clinic, where they consistently reported positive experiences of learning. We analysed 77 essays from 2011 and 2012 using an immersion/crystallisation framework. Half of the students referred to the safety of the learning environment spontaneously. Students described deep learning experiences in their simulated consultations. Students valued features of the LE which contributed to a psychologically safe environment. Together with the provision of constructive support and immediate, individualised feedback this feeling of safety assisted students to find their own way through clinical dilemmas. These factors combine to make students feel relaxed and able to take on challenges that otherwise would have been overwhelming. Errors became learning opportunities and students could practice purposefully. We draw on literature from medical education, educational psychology and sociology to interpret our findings. Our results demonstrate relationships between safe learning environments, learning challenge and powerful learning experiences, justifying close attention to the construction of learning environments to promote student learning, confidence and motivation.

McCartney’s call for reflection on the status of social care and its integration with the health system will resonate with many.1 Our recent, modest innovation might facilitate mutual awareness of the various people who support and care for patients. We have been investigating the concept of a “community of clinical practice”2 (adapted from Wegner’s community of practice …

Targeted postgraduate training increases the likelihood young doctors will take up careers in rural generalist medicine. This article describes the postgraduate pathways that have evolved for these doctors in New Zealand. The Cairns consensus statement 2014 defined rural medical generalism as a scope of practice that encompasses primary care, hospital or secondary care, emergency care, advanced skill sets and a population-based approach to the health needs of rural communities. Even as work goes on to define this role different jurisdictions have developed their own training pathways for these important members of the rural healthcare workforce. In 2002 the University of Otago developed a distance-taught postgraduate diploma aimed at the extended practice of rural general practitioners (GPs) and rural hospital medical officers. This qualification has evolved into a 4-year vocational training program in rural hospital medicine, with the university diploma retained as the academic component. The intentionally flexible and modular nature of the rural hospital training program and university diploma allow for a range of training options. The majority of trainees are taking advantage of this by combining general practice and rural hospital training. Although structured quite differently the components of this combined pathway looks similar to the Australian rural generalist pathways. There is evidence that the program has had a positive impact on the New Zealand rural hospital medical workforce.

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.

ABSTRACT INTRODUCTIONVery little is known how patients react to learning about their own doctors’ illnesses. Doctors can be uncertain if and when such disclosures can be helpful, and in what way, to patients. This paper attempts to bridge this gap by providing an in-depth analysis of one group of patients’ experiences with this type of disclosure. AIMTo understand from patients’ perspectives, the effects on them of doctors disclosing their own illnesses, to provide guidance concerning the uses of this disclosure for general practitioners. METHODSThis qualitative study was an exploration of 13 patients’ reactions to receiving such information, using semi-structured interviews and thematic analysis. RESULTSThe major themes were the emotional dimensions of illness and patienthood, the doctor–patient relationship and patients’ concerns about disclosures. Disclosures can have profound effects on patients with both negative and positive consequences. CONCLUSIONWe present suggestions about how to use such disclosures in primary care to minimise potential harms and emphasise potential benefits, based on these patients’ perspectives and the current literature.

Background: This article describes a simulated General Practice clinic for medical students, which incorporates specific features to aid learning of clinical problem solving. Description: We outline the overall objectives of the simulation, explain the concept, and describe how the clinic works. The clinic is novel in that it utilises clinical outcomes as measures for student success in the consultation. There are no time restrictions on a consultation. Students are unobserved and have open access to clinical information and telephone advice from a senior colleague. Evaluation: The achievement of the case-specific outcomes is assessed by reference to students’ clinical notes and the responses of the simulated patients to specific scenario-related questions. Following the clinic there is a debrief session, and students are provided with the evidence base and outcomes for each scenario. Conclusions: The clinic has been part of our undergraduate curriculum since 2004. Collectively, students rate it as their ...

An interview study of participants in primary health carebased CoCPs highlighted their potential complexity. We found that the visual representation of CoCPs as maps facilitated the assimilation of this complexity. Each patient was shown their map to confirm whether they agreed that it represented their care world. The optimal care and wellbeing of the patient at the centre of the CoCP is the common purpose of its participants. CoCPs are dynamic: the composition changes as the patient’s needs change. Participants have varying roles and levels of engagement (Figure 1).5 CoCP maps include family, social clubs, community and health care services. They articulate the formal and informal care networks that sustain individuals in the community.

Introduction Medical schools worldwide are playing a role in addressing the shortage of rural health practitioners. Selection of rural-origin students and long-term rural undergraduate placements have been shown to have a positive influence on a subsequent career choice of rural health. Evidence for the impact of short-term rural placements is less clear. In New Zealand, the Otago University Faculty of Medicine introduced a 7 week rural undergraduate placement at the Dunedin School Of Medicine, one of its three clinical schools, in 2000. A study of the first two annual cohorts showed a positive influence of the course on student attitudes to rural health and their intention to practise in a rural setting. The purpose of this study was to test whether or not these effects persisted into postgraduate years. Method The original study cohorts were posted a questionnaire (questions worded identically to the original survey) in 2009 (5th and 6th postgraduate years). Non-responders were followed up after 2 months. Graduates from the same year cohort at the two other Otago clinical schools (Christchurch and Wellington) were also surveyed. In addition to analysis by question, principal component analysis (PCA) identified 3 questions which represented the influence of the medical undergraduate program on students' attitudes towards rural general practice. This was used as an index of influence of the undergraduate curriculum. Results There was a statistically significant difference among graduates from Dunedin and the other two schools in reporting a positive influence towards rural practice from the undergraduate course.When asked how the medical undergraduate program influenced their attitude towards a career in rural practice, 56% of respondents from Dunedin reported a positive influence compared with 24% from Christchurch and 15% Wellington. This effect was less strong than that obtained immediately after the rural placement where 70% of Dunedin based students reported a positive influence. The index value for positive effect on attitudes was significantly higher for respondents who studied at Dunedin than at Wellington (mean index value 0.552 for Dunedin, -0.374 for Wellington t=4.172, p=0.000) or Christchurch (mean index value -0.083 for Christchurch t=2.606, p=0.011). There was no significant difference between Christchurch and Wellington (t=1.420, p=0.160). There was no significant difference among schools in the proportion of graduates who had worked or intended to work in rural general practice at any point in their career (24% Dunedin, 31% Christchurch, 16% Wellington (Phi=0.160, p=0.178). Conclusion Most of the literature on the influence of rural undergraduate placements, especially short term placements, examines immediate changes. This study adds to the evidence by showing that positive effects from a rural undergraduate placement persist into the postgraduate years, although that in isolation is unlikely to result in a significant workforce effect. Further investigation is warranted into which features of the undergraduate placement result in an extended positive effect on student attitudes.

To describe the variety and range of work that New Zealand rural hospitals perform, and to examine the factors that might influence either of these, including: the characteristics of the doctors who work in rural hospitals; the facilities available; and environmental factors (such as geographical isolation and the size of the catchment population).Structured postal questionnaire.There are about 44 rural hospitals in New Zealand, depending on definition. Catchment populations range from 750 to 45,000. They are staffed by either Medical Officers of Special Scale (MOSSes) or General Practitioners (GPs). They have varying levels of resources such as laboratory services and radiology services available on-site. They care for a wide range of patients and manage health conditions covering many different vocational areas of practice.Rural hospitals should be defined and recognised as a distinct entity to assist the development of appropriate vocational training pathways for their staff. They play an important and unique role in New Zealand's healthcare system which is currently unrecognised.

To provide a description of the role and function of Otago Province's three main rural hospitals, utilising analysis of hospital discharge data for the period July 2001 to June 2002.Calculation of hospitalisation rates based on analysis of information contained in the National Minimum Dataset (Hospital Events); Census data from Statistics New Zealand; and local knowledge of hospital utilisation by geographical district.A comparison between the rural Otago population and New Zealand (as a whole) show age-standardised hospitalisation rates of 19,847 vs 19,930 per 100,000, and a mean length of hospital stay of 4.5 days vs 6.8 days respectively. Patients aged over 75 years account for 49% of the work of rural Otago hospitals calculated by total bed days; 9% of patients account for 28% of the total discharges.Results show that Otago's rural hospitals (when compared to the New Zealand average) provide an efficient and appropriate service for their communities when judged by hospitalisation rates, mean length of stay, and patient groups cared for. There are serious difficulties encountered in using the National Minimum Dataset to analyse the workload of a rural hospital. An agreed methodology to overcome these difficulties is needed as they have significant implications for service planning and resource allocation for rural hospitals in New Zealand.

To evaluate the effect of the new fifth-year rural health curriculum developed at Dunedin School of Medicine on the attitudes of students to a career in rural general practice.A structured questionnaire was administered to all fifth-year medical students immediately before and after participation in the rural health curriculum at DSM during 2000 and 2001.There were statistically significant positive changes in the students' responses to each question regarding their attitudes towards rural general practice. Students identifying as being of rural origin were more likely to give positive answers both before and after the course. The numbers indicating that they will or probably will enter rural general practice increased from 1.1% (0% (n = 0) of urban and 6% (n = 1) of rural students) to 13% (10% (n = 6) of urban and 22% (n = 4) of rural), pre- to post-course.Students who identify their origins as rural are more likely to have a positive attitude towards rural general practice as a career choice. However, a rural curriculum can produce attitude changes in students, irrespective of origin. If medical schools wish to assist in addressing the needs of their rural communities they should consider selection of students from rural origin and ensure that rural health plays a significant part in the school curriculum.