Preventing childhood obesity in general practice: a qualitative study of GPs, practice nurses, and practice managers.

BACKGROUND: General practitioners (GPs) in Australia have an important role to play in preventing childhood obesity. Activities such as growth monitoring and promotion of healthy behaviours can contribute to obesity prevention efforts; however, the practicalities of how this is done are poorly documented. OBJECTIVES: Objectives were to understand current attitudes and practices regarding promoting healthy childhood growth and development and preventing childhood obesity in general practice, and identify practical barriers and enablers to routinely incorporating this into general practice based on the observations and personal experiences of general practice staff. METHODS: A descriptive qualitative study was undertaken with Australian general practice staff. Barriers and enablers underwent thematic analysis and mapped to the ecological model. RESULTS: Interviews were conducted with 9 GPs, 4 nurses, and 2 practice managers. Participants agreed that growth monitoring and healthy behaviour promotion should be done for children with a healthy weight. However, the thematic analysis indicated that obesity prevention in clinics is not supported well by the broader general practice system, there are complexities associated with obesity prevention discussions, and the COVID-19 pandemic has intensified challenges in general practice. Two themes for obesity prevention enablers were identified; these related to bridging the implementation gap and the need for changes outside the clinic to support behaviour within the clinic. Ecological model mapping implicated multiple ecological levels for each theme. CONCLUSION: Childhood obesity prevention through growth monitoring and healthy behaviour promotion is relevant to general practice; however, more support is needed to enable implementation and embed these practices day-to-day.

Behaviour change for type 2 diabetes: perspectives of general practitioners, primary care academics, and behaviour change experts on the use of the 5As framework.

BACKGROUND: The 5As framework is a recognized underpinning of behaviour change guidelines, teaching, and research in primary care. Supporting patients to improve their lifestyle behaviours, including diet and physical activity, is a common aspect of type 2 diabetes mellitus (T2DM) management. The 5As framework often informs behaviour change for patients with T2DM. OBJECTIVE: To explore the experience and perspectives of general practitioners (GPs) and primary care academics and behaviour change experts regarding using the 5As framework when caring for patients with T2DM to better understand how and why the 5As are effective in practice. METHODS: We recruited 20 practising GPs, primary care academics, and behaviour change experts for an individual semistructured interview and analysed the data using a realist evaluation approach. RESULTS: There were diverse accounts of how GPs use the 5As in practice and few of the participants could name each "A." The 5As were commonly regarded as a framework best suited to beginners and although GPs expressed they followed the broad direction of the 5As, they did not consciously follow the framework in an instructive manner. Elements that could enhance the 5As included more emphasis on motivational interviewing, changing how "Ask" is included in the consultation, and increased person-centredness. CONCLUSION: Although it is a ubiquitous framework in primary care, the 5As are understood in diverse ways and applied variably in practice. There is room to enhance how the 5As support behaviour change consultations to optimize outcomes in primary care.

General practitioners (GPs) are usually involved in helping patients with diabetes to improve their diet, physical activity, and other lifestyle behaviours. The 5As are a framework designed to be used to structure behaviour change conversations­5As stand for Ask, Assess, Advise, Assist, and Arrange. We interviewed 20 people who were either GPs or experts in behaviour change. They had different ways of explaining the intent and usage of the 5As but consistently saw them as a framework for new practitioners. No one used the 5As consciously in their consultations with patients. The participants had multiple suggestions for how the 5As could be enhanced to support better care for patients living with diabetes. These included: more focus on motivational interviewing techniques, changing the number or order of the 5As steps, more focus on teamwork as well as the individual cultural needs of the patients. This work can inform further research on how patients can be better supported by GPs through evidence-based behaviour change care.

OPTIMISE: a pragmatic stepped wedge cluster randomised trial of an intervention to improve primary care for refugees in Australia.

OBJECTIVES: To examine whether primary care outreach facilitation improves the quality of care for general practice patients from refugee backgrounds. DESIGN: Pragmatic, cluster randomised controlled trial, with stepped wedge allocation to early or late intervention groups. SETTING, PARTICIPANTS: 31 general practices in three metropolitan areas of Sydney and Melbourne with high levels of refugee resettlement, November 2017 - August 2019. INTERVENTION: Trained facilitators made three visits to practices over six months, using structured action plans to help practice teams optimise routines of refugee care. MAJOR OUTCOME MEASURE: Change in proportion of patients from refugee backgrounds with documented health assessments (Medicare billing). Secondary outcomes were refugee status recording, interpreter use, and clinician-perceived difficulty in referring patients to appropriate dental, social, settlement, and mental health services. RESULTS: Our sample comprised 14 633 patients. The intervention was associated with an increase in the proportion of patients with Medicare-billed health assessments during the preceding six months, from 19.1% (95% CI, 18.6-19.5%) to 27.3% (95% CI, 26.7-27.9%; odds ratio, 1.88; 95% CI, 1.42-2.50). The impact of the intervention was greater in smaller practices, practices with larger proportions of patients from refugee backgrounds, recent training in refugee health care, or higher baseline provision of health assessments for such patients. There was no impact on refugee status recording, interpreter use increased modestly, and reported difficulties in refugee-specific referrals to social, settlement and dental services were reduced. CONCLUSIONS: Low intensity practice facilitation may improve some aspects of primary care for people from refugee backgrounds. Facilitators employed by local health services could support integrated approaches to enhancing the quality of primary care for this vulnerable population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 (retrospective).

Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study.

BACKGROUND: Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention. METHODS: The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention. RESULTS: Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier. CONCLUSIONS: In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP's opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services.

Turnover among Australian general practitioners: a longitudinal gender analysis.

BACKGROUND: Little is known about gender differences in general practitioner (GP) turnover. It is important to understand potential divergence given both the feminization of the Australian GP workforce and projected shortages of GPs. OBJECTIVE: There is increasing evidence that national health outcomes are related to the extent to which health care systems incorporate high quality primary care. Quality primary care is, in turn reliant on a stable general practice (GP) workforce. With the increasing feminization of medical schools, we sought to identify correlates of turnover in the GP workforce, separately for women and men, focusing particularly on part-time employment and child-rearing, and distinguishing effects related to either planned or unplanned turnover. METHODS: Annual responses from cohorts of at least 1900 women GPs and 2000 men GPs are used for up to eight waves of the Medicine in Australia-Balancing Employment and Life (MABEL) longitudinal survey of doctors. Descriptive and bivariate correlations are provided. Random effects ordered logit is applied to dependent variables for turnover intentions measuring intent to "leave direct care" or "leave medicine". A behavioral measure of turnover is used in random effects logit regressions, with the exclusion or inclusion of the confounding intentions variables revealing correlates of unplanned or planned turnover. RESULTS: Part-time employment is associated with turnover intentions among both women (84% or 94% increase in the odds ratios or ORs) and particularly men (414% or 672%), and with actual turnover for women (150% or 49%) and for men (160% or 107%). Women GPs engage in more unplanned turnover than men: they are 85% more likely to engage in turnover after controlling for intentions. Unplanned turnover is concentrated among women below 40 years of age and with young children, even though both groups report below average turnover intentions. CONCLUSION: Although further studies are needed to identify specific factors associated with GP turnover among women, the analysis highlights the need to focus on women GPs who are either young or have young children. Given the substantial personal and social investment required to produce GPs, it is wasteful to lose so many young women early in their careers.

The OPTIMISE project: protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia.

BACKGROUND: Australia is one of many nations struggling with the challenges of delivering quality primary health care (PHC) to increasing numbers of refugees. The OPTIMISE project represents a collaboration between 12 organisations to generate a model of integrated refugee PHC suitable for uptake throughout Australia. This paper describes the methodology of one component; an outreach practice facilitation intervention, directed towards improving the quality of PHC received by refugees in Australian general practices. METHODS: Our mixed methods study will use a cluster stepped wedge randomised controlled trial design set in 3 urban regions of high refugee resettlement in Australia. The intervention was build upon regional partnerships of policy advisors, clinicians, academics and health service managers. Following a regional needs assessment, the partnerships reached consensus on four core areas for intervention in general practice (GP): recording of refugee status; using interpreters; conducting comprehensive health assessments; and referring to refugee specialised services. Refugee health staff trained in outreach practice facilitation techniques will work with GP clinics to modify practice routines relating to the four core areas. 36 general practice clinics with no prior involvement in a refugee health focused practice facilitation will be randomly allocated into early and late intervention groups. The primary outcome will be changes in number of claims for Medical Benefit Service reimbursed comprehensive health assessments among patients identified as being from a refugee background. Changes in practice performance for this and 3 secondary outcomes will be evaluated using multilevel mixed effects models. Baseline data collection will comprise (i) pre-intervention provider survey; (ii) two surveys documenting each practices' structure and approaches to delivery of care to refugees. De-identified medical record data will be collected at baseline, at the end of the intervention and 6 and 12 months following completion. DISCUSSION: OPTIMISE will test whether a regionally oriented practice facilitation initiative can improve the quality of PHC delivered to refugees. Findings have the potential to influence policy and practice in broader primary care settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 , 05/12/2018, Retrospectively registered. Protocol Version 1, 21/08/2017.

Mindfulness-based lifestyle programs for the self-management of Parkinson's disease in Australia.

Despite emerging evidence suggesting positive outcomes of mindfulness training for the self-management of other neurodegenerative diseases, limited research has explored its effect on the self-management of Parkinson's disease (PD). We aimed to characterize the experiences of individuals participating in a facilitated, group mindfulness-based lifestyle program for community living adults with Stage 2 PD and explore how the program influenced beliefs about self-management of their disease. Our longitudinal qualitative study was embedded within a randomized controlled trial exploring the impact of a 6-week mindfulness-based lifestyle program on patient-reported function. The study was set in Melbourne, Australia in 2012-2013. We conducted semi-structured interviews with participants before, immediately after, and 6 months following participation in the program. Sixteen participants were interviewed prior to commencing the program. Of these, 12 were interviewed shortly after its conclusion, and 9 interviewed at 6 months. Prior to the program, participants felt a lack of control over their illness. A desire for control and a need for alternative tools for managing the progression of PD motivated many to engage with the program. Following the program, where participants experienced an increase in mindfulness, many became more accepting of disease progression and reported improved social relationships and self-confidence in managing their disease. Mindfulness-based lifestyle programs have the potential for increasing both participants' sense of control over their reactions to disease symptoms as well as social connectedness. Community-based mindfulness training may provide participants with tools for self-managing a number of the consequences of Stage 2 PD.

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions.

Background: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. Results: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach.

Background: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective: To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. Methods: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. Results: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.

Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Health seeking narratives of unwell Sri Lankan Tamil refugees in Melbourne Australia.

Sri Lankan Tamil refugees are among the largest group of refugees to resettle in Australia in the last decade. The aim of this study is to characterise the narratives of health-seeking among unwell Sri Lankan Tamil refugees in Melbourne, Victoria, Australia. Drawing on a qualitative, phenomenological perspective, we conducted in-depth interviews in Tamil and English with 12 participants who identified as being unwell for 6 months or more. Findings revealed three narratives of health-seeking: the search for the 'good life' that was lost or never experienced, seeking help from familiar channels in an unfamiliar context, and the desire for financial and occupational independence. These three narratives are undergirded by the metanarrative of a hope-filled recovery. These narratives of Tamil refugees' lived experience provide new insights into clinical care and health service delivery.

Acceptability of general practice services for Afghan refugees in south-eastern Melbourne.

Over 750000 refugees have resettled in Australia since 1945. Despite complex health needs related to prior traumatic experiences and the challenges of resettlement in a foreign country, refugees experience poor access to primary care. Health and settlement service providers describe numerous cultural, communication, financial and health literacy barriers. This study aimed to investigate the acceptability of general practitioner (GP) services and understand what aspects of acceptability are relevant for Afghan refugees in south-eastern Melbourne. Semi-structured interviews were conducted with two Afghan community leaders and 16 Dari- or English-speaking Afghan refugees who accessed GP services. Two distinct narratives emerged - those of recently arrived refugees and established refugees (living in Australia for 3 years or longer). Transecting these narratives, participants indicated the importance of: (1) a preference for detailed clinical assessments, diagnostic investigations and the provision of prescriptions at the first consultation; (2) 'refugee-friendly' staff; and (3) integrated, 'one-stop-shop' GP clinic features. The value of acceptable personal characteristics evolved over time - GP acceptability was less a consideration for recently arrived, compared with more, established refugees. The findings reinforce the importance of tailoring healthcare delivery to the evolving needs and healthcare expectations of newly arrived and established refugees respectively.

When colocation is not enough: a case study of General Practitioner Super Clinics in Australia.

Developed nations are implementing initiatives to transform the delivery of primary care. New models have been built around multidisciplinary teams, information technology and systematic approaches for chronic disease management (CDM). In Australia, the General Practice Super Clinic (GPSC) model was introduced in 2010. A case study approach was used to illustrate the development of inter-disciplinary CDM over 12 months in two new, outer urban GPSCs. A social scientist visited each practice for two 3-4-day periods. Data, including practice documents, observations and in-depth interviews (n=31) with patients, clinicians and staff, were analysed using the concept of organisational routines. Findings revealed slow, incremental evolution of inter-disciplinary care in both sites. Clinic managers found the facilitation of inter-disciplinary routines for CDM difficult in light of competing priorities within program objectives and the demands of clinic construction. Constraints inherent within the GPSC program, a lack of meaningful support for transformation of the model of care and the lack of effective incentives for collaborative care in fee-for-service billing arrangements, meant that program objectives for integrated multidisciplinary care were largely unattainable. Findings suggest that the GPSC initiative should be considered a program for infrastructure support rather than one of primary care transformation.

The effects of a mindfulness-based lifestyle program for adults with Parkinson's disease: a mixed methods, wait list controlled randomised control study.

BACKGROUND: Parkinson's disease (PD) is the second commonest neurodegenerative disease in developed countries. Current treatment for PD is pharmacologically focused and can have significant side-effects. There is increasing interest in holistic approaches including mindfulness to help manage the challenges associated with living with PD. We hypothesised that there would be an improvement in PD associated function and wellbeing in participants after participating in a 6-week mindfulness-based lifestyle program, and that these improvements would be sustainable at 6 months. Our primary objective was to determine changes in function and wellbeing associated with PD. METHODS: An exploratory prospective, mixed-method, randomised control trial incorporating a before and after design with a waitlist control, with an embedded qualitative component was conducted in 2012-2013. Participants included community living adults with disability congruent to H&Y Stage 2 PD, aged 18-75, fluent in spoken and written English and able to attend at least four of six sessions of the program. Participants were randomised to the intervention or wait-list control groups at two locations. All participants in the wait-list control group eventually received the intervention. Two randomisation codes were created for each location. Allocation to the intervention or wait-list control was by random number generation. The program facilitator and participants were blinded to participant data. RESULTS: Group 1 included 35 participants and group 2 (the waitlist control), 37. Data was analysed from 24 (group 1) and 33 (group 2) participants. The intervention group, compared to the waitlist control, showed a small improvement in function and wellbeing associated with PD immediately after the program (t-score = -0.59) and at 6-month post intervention (t-score = -1.42) as reported by the PDQ-39 SI. However this finding was not significant (p = 0.56 and 0.16 respectively). A small yet significant effect size (ß = 0.23) in PDQ-39 ADL was reported in group 1 after 6-months post-intervention. This showed a positive improvement in the ADL as reported by group 1 after 6-months (t-score -1.8, p = 0.04). Four secondary measures are reported. CONCLUSIONS: Our findings suggest mindfulness-based lifestyle programs have potential to assist participants in managing the ongoing difficulties associated with a neurological condition such as Parkinson's disease. Importantly, our study shows promise for the long term benefits of such programs. Improvements to participant activities in daily living and mindfulness were retained at 6-months post intervention. A more definitive study should be conducted in a larger sample of PD patients to further explore these findings and their impact on reducing stress and anxiety in PD patients. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612000440820 , 17(th) April 2012.

Building links between town and gown: an innovative organisation in south-eastern Melbourne.

Primary care is the foundation of a nation's health care system. Real world research is a requirement of a health system built to deliver the benefits of a strong primary care community. In the last decade, new approaches to optimising the impact of research on practice and policy have been formulated across disciplines. However, in Australia, the primary care research community remains small and primary care researchers are not well represented in either receiving support for or governing research. While practice-based research networks (PBRNs) have brought GPs and, sometimes, other clinicians together with academics, few have managed to bring local decision makers and other primary health care stakeholders into partnerships where they can work together on common problems. This paper outlines a novel three-way partnership between a health authority, a primary care organisation and a university in the south-eastern suburbs of Melbourne. A case study was undertaken based on author experience of the Southern Academic Primary Care Research Unit (SAPCRU) and semi-structured interviews with representatives from partner organisations. Interviews elicited perceived barriers and facilitators, including complex financial, human resources and governance challenges, associated with bridging the gap between research and practice. It was found that SAPCRU has been successful in engaging with research partners and has begun to develop links with policy makers and orient research themes to the needs of its varied communities. Especially with the introduction of Primary Health Networks (PHNs), the model has the potential to translate to different settings but barriers should be noted.

What next for behaviour change professional development in general practice? Insights from an environmental scan and workshops.

BACKGROUND: A key role of general practice professionals (that is, GPs, and general practice nurses [GPNs]) is to support patients to change behaviours. Traditional approaches to assisting patients with, and learning about, behaviour change have modest outcomes. AIM: To explore behaviour change with GPs and GPNs and the availability of related professional development (PD) opportunities. DESIGN & SETTING: Multi-methods study comprising an environmental scan survey of behaviour change tools and PD opportunities, and online workshops with Australian GPs and GPNs. METHOD: Survey data were analysed using qualitative content analysis, informing the design of the workshops. Workshop data included observation, note-taking, and collaborative reflection, which were analysed thematically and synthesised with survey data. RESULTS: The survey had 18 complete responses. For the two virtual workshops, workshop 1 had 16 participants and workshop 2 had eight participants. There was diversity in awareness of existing behaviour change tools and resources. Preferences for future tools and PD opportunities related to specific aspects of its design, content, activities, and delivery. The following three themes developed from the workshop data: recognising the importance of relationships; recognising the importance of continuity; and keeping context in mind. In the absence of tools and resources, GPs and GPNs discussed behaviour change as something that occurs best through a patient-centred alliance that is continuing, respectful, grounded in trust and an understanding of their patient, and prioritises patient autonomy. CONCLUSION: Future general practice behaviour change PD should support clinicians to 'assist' patients and recognise the social and contextual influences on behaviour.

Leading primary care under the weight of COVID-19: how leadership was enacted in six australian general practices during 2020.

BACKGROUND: The COVID-19 pandemic challenged health care delivery globally, providing unique challenges to primary care. Australia's primary healthcare system (primarily general practices) was integral to the response. COVID-19 tested the ability of primary health care to respond to the greater urgency and magnitude than previous pandemics. Early reflections highlighted the critical role of leaders in helping organisations negotiate the pandemic's consequences. This study explores how general practice leadership was enacted during 2020, highlighting how leadership attributes were implemented to support practice teams. METHODOLOGY: We performed secondary analysis on data from a participatory prospective qualitative case study involving six general practices in Melbourne, Victoria, between April 2020 and February 2021. The initial coding template based on Miller et al.'s relationship-centred model informed a reflexive thematic approach to data re-analysis, focused on leadership. Our interpretation was informed by Crabtree et al.'s leadership model. RESULTS: All practices realigned clinical and organisational routines in the early months of the pandemic - hierarchical leadership styles often allowing rapid early responses. Yet power imbalances and exclusive communication channels at times left practice members feeling isolated. Positive team morale and interdisciplinary teamwork influenced practices' ability to foster emergent leaders. However, emergence of leaders generally represented an inherent 'need' for authoritative figures in the crisis, rather than deliberate fostering of leadership. CONCLUSION: This study demonstrates the importance of collaborative leadership during crises while highlighting areas for better preparedness. Promoting interdisciplinary communication and implementing formal leadership training in crisis management in the general practice setting is crucial for future pandemics.

Hospital-based spiritual care: what matters to patients?

Demographic changes in Australia have led to an increase in both religious diversity and the number of people who do not nominate a faith affiliation at hospital admission. Models of chaplaincy have shifted from clerical and largely male to an increasingly skilled and diverse spiritual care workforce appointed directly by health services. This study uses survey and in-depth interview methods at an inner-city Australian hospital to examine patient preferences for hospital chaplaincy provided by faith communities, and the importance of faith affiliation compared to other spiritual care provider characteristics. Survey results indicate that of 110 respondents, a high proportion (74%) prefer spiritual care to be provided by a person of the same faith. However, when considered relative to other characteristics, faith affiliation was not as important as kindness, listening skills and a non-judgmental attitude. Our findings have implications for workforce planning and educating. Further research in different settings and with different populations will make the findings more generalizable.

Exploring behaviour change in general practice consultations: A realist approach.

OBJECTIVES: While general practice involves supporting patients to modify their behaviour, General Practitioners (GPs) vary in their approach to behaviour change during consultations. We aimed to identify mechanisms supporting GPs to undertake successful behaviour change in consultations for people with T2DM by exploring (a) the role of GPs in behaviour change, (b) what happens in GP consultations that supports or impedes behaviour change and (c) how context moderates the behaviour change consultation. METHODS: Semi-structured interviews with academic clinicians (n = 13), GPs (n = 7) and patients with T2DM (n = 16) across Australia. Data were analysed thematically using a realist evaluation approach. RESULTS: Perspectives about the role of GPs were highly variable, ranging from the provision of test results and information to a relational approach towards shared goals. A GP-patient relationship that includes collaboration, continuity and patient-driven care may contribute to a sense of successful change. Different patient and GP characteristics were perceived to moderate the effectiveness and experience of behaviour change consultations. DISCUSSION: When patient factors are recognised in consultations, a relational approach becomes possible and priorities around behaviour change, that might be missed in a transactional approach, can be identified. Therefore, GP skills for engaging patients are linked to a person-centred approach.

Do preventative care guidelines emphasize behaviour change? A content analysis of three commonly used Australian general practice guidelines.

RATIONALE: Preventive health is a core part of primary care clinical practice and it is critical for both disease prevention and reducing the consequences of chronic disease. In primary care, the 5As framework is often used to guide behaviour change consultations for smoking, nutrition, alcohol use and physical activity. AIMS AND OBJECTIVES: Our objective was to analyze the emphasis placed on each 5As term in commonly used guidelines in Australian general practice and compare this to behaviour change terms/concepts essential to effective consultations. METHOD: A content analysis was undertaken to explore frequency of 5A terms and key behaviour change concepts/terms chapter-by-chapter across the three most commonly used guidelines in Australian general practice. RESULTS: The prevalence of each 5As term differed in all three guidelines, with 'Arrange' being mentioned the least often. Behaviour change concepts and terms, such as patient-centredness, listening, trust and tailoring, were infrequently used and were often confined to a separate chapter of the guidelines. CONCLUSION: The language and content of the guidelines contrast with known effective components of behaviour change consultations. Future revisions could reconsider emphasis of 5As terms to avoid paternalistic approaches, improve shared language across guidelines and incorporate behavioural science principles to enhance preventative care delivery.