Adaption of the Cancer Information Overload Scale for pandemics and assessment of infodemic levels among nurses and midwives.

AIM: This study was conducted in three phases. Phase 1 aimed to adapt the Cancer Information Overload Scale and conduct content validity testing. Phase 2 aimed to conduct factorial validity testing of the scale. Phase 3 aimed to assess information overload and the sources of information used by nurses and midwives to keep up-to-date about COVID-19. DESIGN: A cross-sectional survey of nurses and midwives working in a metropolitan Local Health District in Sydney, Australia, was conducted from May to June 2020. METHODS: Adaptation of the Cancer Information Overload Scale and content validity of the modified scale (as the Pandemic Information Overload Scale) was undertaken by an expert panel comprising of senior nurses and researchers. Factorial validity and reliability of the Pandemic Information Overload Scale were evaluated using exploratory factor analyses using one subsample of the data. Using the second subsample of the data, information overload and sources of information used by nurses and midwives to keep up-to-date about COVID-19 were examined. RESULTS: The Pandemic Information Overload Scale is a reliable and valid instrument for measuring information overload among nurses during a pandemic. Its internal consistency was high (α = 0.81, M = 3.84). CONCLUSION: The 8-item PIO scale is a brief, reliable and psychometrically sound instrument for measuring nurses' and midwives' perceptions of information overload during COVID-19. Mean scores across this study indicated that participants were experiencing above average information overload. Implementing strategies to reduce this overload would optimize clinical decision making and promote patient safety.

COVID-19: Knowledge, anxiety, academic concerns and preventative behaviours among Australian and Indian undergraduate nursing students: A cross-sectional study.

AIMS AND OBJECTIVES: To compare knowledge, anxiety, academic concerns and preventative behaviours between undergraduate nursing students in Australia and India during the COVID-19 pandemic. BACKGROUND: Based on the World Health Organization's direction for containment of the novel coronavirus (COVID-19), countries implemented varying levels of restrictions including closure of university campuses and providing on line undergraduate education. METHODS: Students in NSW, Australia and Kerala, India completed an online survey assessing their (a) knowledge and source of information about COVID-19; (b) anxiety; and coping strategies; (c) academic concerns; and (d) preventative behaviours. Descriptive and inferential statistics were used to summarise the data. RESULTS: Data from 99 Australian and 113 Indian undergraduate nurses were analysed. Greater number of Indian students indicated having sufficient knowledge of COVID-19 (OR 0.22; 95% CI 0.08, 0.63), getting information about COVID-19 from social media (OR 0.03; 95% CI 0.01, 0.07) and being concerned about 'attending clinical placement' (MD-1.08; 95% CI -1.94, -0.23). Australian students reported significantly higher levels of anxiety (MD 1.99 95% CI 1.21, 2.78), difficulty sleeping (OR 18.00; 95% CI 6.76, 47.96), concentrating (OR 33.22; 95% CI 13.85, 79.67) and eating (OR 14.05; 95% CI 3.19, 61.84). Greater number of Australian students indicated that they would go to the University if they needed to meet with other students (OR 9.21; 95% CI 3.08, 27.55), had to access the library (OR 7.20; 95% CI 3.26, 15.90) or had a group assignment (OR 2.93; 95% CI 1.26, 6.77). CONCLUSIONS: Wide variations were present in knowledge, anxiety, academic concerns and preventative behaviours among undergraduate nursing students in two countries. RELEVANCE TO CLINICAL PRACTICE: Undergraduate students may benefit from additional support from the University and staff in the clinical setting with online learning and resources in order to adjust to the 'new normal' and enable them to achieve academic success.

Nonverbal communication between registered nurses and patients during chronic disease management consultations: Observations from general practice.

AIMS AND OBJECTIVES: This study explores nonverbal communication behaviours between general practice nurses and patients during chronic disease consultations. BACKGROUND: Nonverbal communication is an important aspect of nurse-patient lifestyle risk reduction conversations. Despite the growing role of general practice nurses in lifestyle risk modification when managing chronic disease, few studies have investigated how this communication occurs. DESIGN: Observational study within a concurrent mixed methods project. METHODS: Thirty-six consultations by 14 general practice nurses were video-recorded between August 2017 and March 2018. Video analysis used the Nonverbal Accommodation Analysis System. The STROBE checklist was used to guide this paper. RESULTS: Joint convergence of nurse-patient behaviours such as laughing, smiling and eye contact was most common (44%; n = 157). Patient-nurse eye contact time decreased significantly across the consultation, while nurse gesturing increased significantly. No significant relationship between consultation length and convergent to divergent behaviour categorisation or nurse-computer use across the consultation was found. CONCLUSIONS: The high levels of convergent behaviours are promising for person-centred care. However, scope exists to enhance nonverbal interactions around lifestyle risk reduction. Supporting nurses with skills and improved environments for lifestyle risk communication has potential to improve therapeutic relationships and patient outcomes. RELEVANCE TO CLINICAL PRACTICE: These results indicate that nurses support patients through nonverbal interactions during conversations of lifestyle risk reduction. However, there are opportunities to improve this practice for future interventions.

Transitioning into new clinical areas of practice: An integrative review of the literature.

AIMS AND OBJECTIVES: To critically synthesise research related to the transition of registered nurses into new areas of clinical practice. BACKGROUND: Global workforce shortages and rising healthcare demands have encouraged registered nurses to move into new clinical settings. While a body of literature reports on the transition of newly qualified nurses, evidence surrounding the transition of more experienced registered nurses to new clinical areas remains poorly explored. DESIGN: An integrative review was conducted, guided by Whittemore and Knafl (Journal of Advanced Nursing, 52, 2005, 546) framework. METHODS: An electronic database search was conducted for papers published between 1996-2016. Papers were then subjected to a methodological quality appraisal, with findings synthesised using thematic analysis into core themes. RESULTS: Ten articles met the inclusion criteria. Three themes emerged, namely Support, Professional Development and Emotional Impact. These themes suggest that transitioning nurses experience challenges in adapting to new clinical areas and developing necessary skills. Such challenges prompted various emotional and physical responses. While formal and informal support systems were regarded as valuable by transitioning nurses, they were inconsistent across the new clinical areas. CONCLUSIONS: There is some evidence to highlight the initial shock and emotional stress experienced by registered nurses during transition to a new clinical area. However, the influence of formal and informal support systems for such registered nurses is far from conclusive. Further research is needed, to examine registered nurse transition into a variety of clinical areas to inform workforce support, policy and practices. RELEVANCE TO CLINICAL PRACTICE: The demand of health care is growing while global shortages of nursing workforce remain. To ensure retention and enhance the transition experience of registered nurses, it is important for nurse leaders, managers and policymakers to understand the transition experience and factors that impact this experience.

Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses.

BACKGROUND: Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role. OBJECTIVES: The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice. METHODS: Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention. RESULTS: Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified. CONCLUSION: The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time.

Quit in general practice: a cluster randomized trial of enhanced in-practice support for smoking cessation.

OBJECTIVES: To evaluate the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse (PN), and compare this to other forms of cessation support. METHODS: Three arm cluster randomized controlled trial conducted in 101 general practices in Sydney and Melbourne involving 2390 smokers. The Quit with PN intervention was compared to Quitline referral and a usual care control group. Smoking cessation pharmacotherapy was recommended to all groups. Outcomes were assessed by self-report at 3- and 12-month follow-up. Uptake of the interventions is also reported. RESULTS: The three groups were similar at baseline. Follow-up at 12 months was 82%. The sustained and point prevalence abstinence rates, respectively, at 3 months by group were: PN intervention 13.1% and 16.3%; Quitline referral 10.8% and 14.2%; Usual GP care 11.4% and 15.0%. At 12 months, the rates were: PN intervention 5.4% and 17.1%; Quitline referral 4.4% and 18.8%; Usual GP care 2.9% and 16.4%. Only 43% of patients in the PN intervention group attended to see the nurse. Multilevel regression analysis showed no effect of the intervention overall, but patients who received partial or complete PN support were more likely to report sustained abstinence [partial support odds ratio (OR) 2.27; complete support OR 5.34]. CONCLUSION: The results show no difference by group on intention to treat analysis. Those patients who received more intensive PN intervention were more likely to quit. This may have been related to patient motivation or an effect of PN led cessation support.

Telemonitoring can assist in managing cardiovascular disease in primary care: a systematic review of systematic reviews.

BACKGROUND: There has been growing interest regarding the impact of telemonitoring and its ability to reduce the increasing burden of chronic diseases, including chronic cardiovascular disease (CVD), on healthcare systems. A number of randomised trials have been undertaken internationally and synthesised into various systematic reviews to establish an evidence base for this model of care. This study sought to synthesise and critically evaluate this large body of evidence to inform clinicians, researchers and policy makers. METHODS: A systematic review of systematic reviews investigating the impact of telemonitoring interventions in the primary care management of CVD was conducted. Reviews were included if they explored primary care based telemonitoring in either CVD, heart failure or hypertension, were reported in the English language and were published between 2000 and 2013. Data was extracted by one reviewer and checked by a second reviewer using a standardised form. Two assessors then rated the quality of each review using the Overview Quality Assessment Questionnaire (OQAQ). RESULTS: Of the 13 included reviews, four focused on telemonitoring interventions in hypertension or CVD management and the remaining 9 reviews investigated telemonitoring in HF management. Seven reviews scored a five or above on the OQAQ evidencing good quality reviews. Findings suggest that telemonitoring can contribute to significant reductions in blood pressure, decreased all-cause and HF related hospitalisations, reduced all-cause mortality and improved quality of life. Telemonitoring was also demonstrated to reduce health care costs and appears acceptable to patients. CONCLUSION: Telemonitoring has the potential to enhance primary care management of CVD by improving patient outcomes and reducing health costs. However, further research needs to explore the specific elements of telemonitoring interventions to determine the relative value of the various elements. Additionally, the ways in which telemonitoring care improves health outcomes needs to be further explored to understand the nature of these interventions.

The evolution of nursing in Australian general practice: a comparative analysis of workforce surveys ten years on.

BACKGROUND: Nursing in Australian general practice has grown rapidly over the last decade in response to government initiatives to strengthen primary care. There are limited data about how this expansion has impacted on the nursing role, scope of practice and workforce characteristics. This study aimed to describe the current demographic and employment characteristics of Australian nurses working in general practice and explore trends in their role over time. METHODS: In the nascence of the expansion of the role of nurses in Australian general practice (2003-2004) a national survey was undertaken to describe nurse demographics, clinical roles and competencies. This survey was repeated in 2009-2010 and comparative analysis of the datasets undertaken to explore workforce changes over time. RESULTS: Two hundred eighty four nurses employed in general practice completed the first survey (2003/04) and 235 completed the second survey (2009/10). Significantly more participants in Study 2 were undertaking follow-up of pathology results, physical assessment and disease specific health education. There was also a statistically significant increase in the participants who felt that further education/training would augment their confidence in all clinical tasks (p < 0.001). Whilst the impact of legal implications as a barrier to the nurses' role in general practice decreased between the two time points, more participants perceived lack of space, job descriptions, confidence to negotiate with general practitioners and personal desire to enhance their role as barriers. Access to education and training as a facilitator to nursing role expansion increased between the two studies. The level of optimism of participants for the future of the nurses' role in general practice was slightly decreased over time. CONCLUSIONS: This study has identified that some of the structural barriers to nursing in Australian general practice have been addressed over time. However, it also identifies continuing barriers that impact practice nurse role development. Understanding and addressing these issues is vital to optimise the effectiveness of the primary care nursing workforce.

Socioeconomic status and heart failure in Sydney.

BACKGROUND: Socioeconomic disadvantage is associated with an increased risk of developing heart failure and with inferior health outcomes following diagnosis. METHODS: Data for hospitalisations and deaths due to heart failure in the Sydney metropolitan region were extracted from New South Wales hospital records and Australian Bureau of Statistics databases for 1999-2003. Standardised rates were analysed according to patients' residential local government area and correlated with an index of socioeconomic disadvantage. RESULTS: Eight of the 13 local government areas with standardised separation rate ratios significantly higher than all NSW, and those with the six highest standardised separation rate ratios, were in Greater Western Sydney. Rates of heart failure hospitalisations per local government area were inversely correlated with level of socioeconomic status. CONCLUSIONS: Higher rates of heart failure hospitalisations among residents of socioeconomically disadvantaged regions within Sydney highlight the need for strategies to lessen the impact of disadvantage and strategies to improve cardiovascular health.

The foster carer's experience: an integrative review.

BACKGROUND: Foster carers have a significant responsibility in caring for children who are unable to live with their birth families and represent a key determinant in child outcomes. Difficulties in recruiting and retaining quality foster carers have resulted in an increase in research investigating foster carers and their experiences in recent years. AIM: To synthesise current literature investigating foster carers and their experiences to enable a better understanding of their unique care-giving context. METHOD: The electronic databases CINAHL, Health Source, MEDLINE, Pscyh-articles, PsycINFO and socilNDEX were searched using the key terms; 'foster carer', 'foster parent', 'foster mother' and 'foster father'. Articles were included if they reported primary data about foster carers experiences in the English language. Papers published prior to 2000 were excluded in order to provide a contemporary perspective of the foster carer experience. Data was extracted, tabulated and thematically analysed. FINDINGS: The findings from this review revealed the provision of foster care to have both positive and negative effects on foster carers personal well-being. These effects are largely reliant of foster carers perception of their role as either parental or professional, the nature of their relationships with child welfare personnel, and their ability to manage children's difficult behaviours. CONCLUSION: It is important for nurses to understand caregiving as it occurs in a variety of contexts. Nurses need to have an awareness and understanding of the value and role foster carers have in the lives of vulnerable children. In so doing, nurses are well positioned to assist foster carers to identify and express their needs in relation to their important caregiving role.

A qualitative evaluation of New Zealand consumers perceptions of general practice nurses.

BACKGROUND: An important consideration in health service delivery is ensuring that services meet consumer needs and that consumers are satisfied with service delivery. Patient satisfaction can impact on compliance with suggested treatments and therefore impact on health outcomes. Comparatively few studies have explored consumer satisfaction with nurses in general practice. METHODS: A sub-group of 18 consumers from a larger quantitative evaluation of consumer satisfaction with New Zealand general practice nurses participated in semi-structured telephone interviews. Interview data was analysed using thematic analysis. RESULTS: Four major themes emerged from the data. These themes highlighted that, despite confusion experienced by some consumers regarding the practice nurse role, consumers were happy with the level of care provided by them. Consumers felt valued by Practice Nurses and considered them competent and highly knowledgeable. Findings also convey that consumers appreciate the accessibility and financial benefits of utilising the services of practice nurses. CONCLUSIONS: Consumers are highly satisfied with practice nurse service delivery and value their relationships with these health professionals. Consumers revealed that greater clarity around the practice nurse role and their scope of practice may enhance their utilisation. Spreading the message of practice nurses being the right person to deliver care, within their scope of practice, at the right time may have the potential to provide more timely care within the primary care setting.

Marginalised mothers: lesbian women negotiating heteronormative healthcare services.

Lesbian mothers share mainstream existence with other mothers by virtue of their motherhood, but remain marginalised by their non-heterosexual identity. This paper will draw on the qualitative findings of a recent Australian study that examined the experiences of lesbian mothers. Using a story-sharing method, data were collected using three methods; a demographic data sheet, in-depth semi-structured interviews and journaling. The findings demonstrated that participants experienced various forms of homophobia when interfacing with healthcare services and providers and included exclusion, heterosexual assumption, inappropriate questioning and refusal of services. Strategies used to avoid homophobia included screening and crusading.

Culturally and linguistically diverse general practitioners' utilisation of practice nurses.

BACKGROUND: Practice nurses are primarily employed by general practitioners, however little is known about the barriers to practice nurse employment from the perspective of general practitioners (GPs). AIM: This paper seeks to explore solo, culturally and linguistically diverse (CALD) general practitioners' perceptions of the practice nurse role, and to identify the barriers and facilitators of these doctors employing nurses within their practice. METHODS: A descriptive study, using semi-structured interviews, was conducted from July to August 2010. Participants were CALD GPs working as solo practitioners who were members of a Division of General Practice in South Western Sydney. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using thematic analysis. RESULTS: The response rate was 51%, however no demographic differences were identified between responders and non-responders. The majority of participants (73%) agreed that practice nurses could perform vital sign measurements or spirometry. Fewer participants (52-63%) believed practice nurses could perform breast checks, pap smears, or assessment of medication regimes. Perceived barriers to employing a practice nurse included lack of space or equipment, legal implications, lack of a specific job description and language communication issues. Participants identified the need for greater financial rebates, assistance with training practice nurses and assistance with business modelling as facilitators to practice nurse employment. CONCLUSION: The feasibility of practice nurse employment in practices with solo, culturally and linguistically diverse general practitioners remains a challenge that needs further exploration. Employment of practice nurses may be a viable option for younger practitioners who have a desire to work in collaborative multidisciplinary models.

Caring for vulnerable children: challenges of mothering in the Australian foster care system.

Foster carers have a significant responsibility in caring for vulnerable children. In order to support and facilitate foster carers it is important to understand how they perceive and fulfil this responsibility. A qualitative story-telling study, informed by feminist perspectives, was used to conduct in-depth, semi-structured interviews with 20 women providing long-term foster care in Australia. Thematic analysis revealed these women characterised themselves as mothers, rather than paid carers, to the long-term foster children in their care. Using this maternal self-perception as the starting point, this paper reveals some of the challenges and difficulties participants encountered when mothering within the confines of the child protection system. Implications for nursing practice are discussed. These implications focus on ways that nurses can effectively support foster carers, thus optimising the health and well-being of the vulnerable children in their care.

Telehealth use in Australian primary healthcare during COVID-19: a cross-sectional descriptive survey.

OBJECTIVE: This study aimed to investigate Australian primary healthcare professionals' experiences of the rapid upscaling of telehealth during COVID-19. DESIGN: A cross-sectional survey. PARTICIPANTS AND SETTING: Two hundred and seventeen general practitioners, nurses and allied health professionals employed in primary healthcare settings across Australia were recruited via social media and professional organisations. METHODS: An online survey was disseminated between December 2020 and March 2021. The survey comprised items about individual demographics, experiences of delivering telehealth consultations, perceived quality of telehealth consultations and future perceptions of telehealth. RESULTS: Telephone was the most widely used method of providing telehealth, with less than 50% of participants using a combination of telephone and video. Key barriers to telehealth use related to the inability to undertake physical examination or physical intervention. Telehealth was perceived to improve access to healthcare for some vulnerable groups and those living in rural settings, but reduced access for people from non-English-speaking backgrounds. Quality of telehealth care was considered mostly or somewhat the same as care provided face-to-face, with actual or perceived negative outcomes related to missed or delayed diagnosis. Overwhelmingly, participants wanted telehealth to continue with guaranteed ongoing funding. Some 43.7% of participants identified the need to further improve telehealth models of care. CONCLUSION: The rapid shift to telehealth has facilitated ongoing care during the COVID-19 pandemic. However, further work is required to better understand how telehealth can be best harnessed to add value to service delivery in usual care.

Unveiling final-year students and new graduates' concerns, preparedness, and learning experiences during the pandemic in Qatar: A cross-sectional survey.

Background: The emergence of COVID-19 interrupted education worldwide and educational institutions were forced to switch to an online learning (E-learning) environment. Objectives: To explore the perceived educational experiences, worries, and preparedness to enter clinical practice among final-year nursing students and new graduate nurses after studying during the COVID-19 pandemic. Design: A cross-sectional survey design. Setting: and participants: An online survey of final-year undergraduate bachelor of nursing students at a single university in Qatar and new graduates across 14 health facilities in Qatar was undertaken between May 2022 and July 2022. Methods: Participant demographics, experiences of E-learning and perceptions of readiness for practice were collected using validated instruments and open-ended questions. Descriptive statistics and thematic exploration were used to analyze the data. Results: Fifty-nine final-year students and 23 new graduates with an average age of 23.95 years (SD = 3.89) responded to the survey. Face-to-face clinical placement learning was preferred by 50 % of students and 66.1 % of graduates. During COVID-19, the majority of the participants indicated that strategies like practice kits and online simulations were implemented. While 61 % of new graduates felt well-prepared in their nursing skills, and 87 % felt confident, less than half of the students still in their final year of education felt prepared or confident. Increased stress and a perceived impact on education quality were reported due to changes in learning modalities. Despite these challenges, 81.1 % of students and 95.7 % of graduates felt they had developed sufficient professional values, with most looking forward to becoming registered nurses. The qualitative themes that emerged related to 1) adjusting to online learning, 2) experiencing restrictions in clinical learning skills, 3) feeling less confident and 4) experiencing increased stress. Conclusions: Despite experiencing emotional and educational challenges, the participants in this study felt that their education prepared them for clinical practice. Innovative strategies and unique educational experiences used by educators enhanced participants' clinical skills and readiness for practice.

Graduating nursing students' perceived preparedness for working in critical care areas.

AIMS: This article reports a study examining the relationships between undergraduate students' demographics, educational preparation and clinical experience and their self reported preparedness for employment in critical care. BACKGROUND: Increasing demand for critical care services internationally, creates a need to grow the critical care nursing workforce. Limited data are available on factors affecting new graduate nurses' career choices. METHODS: Final year nursing students from a multi-campus Australian University were surveyed during 2009. RESULTS: Over half of the participants were interested in seeking employment in critical care following graduation. Main reasons for choosing critical care nursing were: (i) like varied and challenging work; (ii) opportunities for professional development; and (iii) like working one-on-one with patients. The main barriers identified by participants were related to the lack of knowledge and clinical skills required to work in critical care. Using the 9-item confidence and interest in critical care nursing scale, the study revealed that male participants and those who spent more than 1 week clinical placement in critical care were significantly more likely to report greater confidence and interest in seeking employment in critical care areas. CONCLUSIONS: The value of placing nursing students in critical care areas for more than 1 week during undergraduate clinical placements is affirmed. Whilst most final year students report feeling prepared to work in critical care areas, the next step is to explore the transition of students as new graduates in critical care to identify professional and educational issues that impact on their retention.

The stigma of being a long-term foster carer.

Stigma is a powerful social phenomenon with insidious health implications. Understanding stigma as it applies to various populations is imperative for nurses as it enables nurses to enhance individual patient care and nurses are well positioned to influence both social and health care policies which may exacerbate the experience of stigma. This article is a report of a study to explore the experiences of women who provide long-term foster care. Interviews were conducted with 20 women who provided long-term foster care in Australia. Data were coded according to the components of stigma described by Link and Phelan (2001). Findings reveal participants rejected the label of foster carer to avoid the negative stereotype. When unable to conceal their foster carer label, participants experienced social isolation and status loss. Moreover, participants felt marginalized and disempowered within the governing systems.

Understanding nursing students' perceptions of the general practice environment and their priorities for employment settings.

AIM: To explore final year nursing students' perceptions of the general practice environment and their priorities when choosing a workplace. DESIGN: Online survey, reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. METHODS: The validated Profession Scale from the Scale on Community Care Perceptions (SCOPE) tool was used to identify characteristics within the general practice environment and the importance of these in choosing a workplace. To explore the factor structure, exploratory factor analysis was undertaken which was used to revise the survey language and flow before widespread dissemination. RESULTS: Three hundred and fifty-five responses were received. Factor analysis revealed three factors: Provision of care, Employment conditions and Nature of work. Respondents exposed to general practice in the Bachelor of Nursing program or who had a general practice clinical placement had significantly different perceptions across all factors. Although wages, advancement opportunities, work pressures and the physical nature of work were perceived as important in choosing a workplace, they were seen as only moderately present in general practice.