Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care.

BACKGROUND: There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children. METHODS: We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18-65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years. DISCUSSION: The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000105246. Registered on 23 January 2018.

Correction to: Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care.

In the original publication of this article [1], the first name of the 3rd author is wrong.

A case-study of the experiences of junior medical officers in the emergency departments of a metropolitan hospital and rural hospital.

OBJECTIVE: Increased exposure to post-graduate rural medical training is associated with increased likelihood of future rural practice. Training rotations in rural emergency departments provide a possible avenue for such exposure, but have been under-investigated. This study aimed to compare junior medical officers' emergency department experiences in a metropolitan and a rural hospital to inform rural health workforce initiatives. DESIGN: Mixed-method case-study design. SETTING: Two 10-week periods in the respective emergency departments. PARTICIPANTS: Four junior medical officers at the rural site and 22 junior medical officers at the metropolitan hospital. MAIN OUTCOME MEASURES: Caseloads extracted from electronic medical records and training experience. RESULTS: Data were collected over 142 days. The average number of patients seen per day, per junior medical officer, was significantly higher at the rural hospital emergency department (7.2 patients per day) in comparison with the metropolitan hospital (4.3 patients per day). Junior medical officers at the rural hospital saw relatively more lower acuity patients. The seven junior medical officers who were interviewed provided consistently positive responses regarding their training experiences in both locations. This was particularly evident in the rural hospital and was attributed to one-on-one supervision. CONCLUSIONS: Most junior medical officers agreed that their expectations for support and learning opportunities were met and/or exceeded. However, junior medical officers reported feeling more supported at the rural hospital due to direct contact and communication with senior medical officers. Placement in a smaller hospital emergency department did not disadvantage the junior medical officers' training in this case-study and provided a positive rural training experience. These findings support workforce policies which encourage rural hospital emergency department training.

Surviving, not thriving: a qualitative study of newly qualified midwives' experience of their transition to practice.

AIM AND OBJECTIVES: The study explored the experiences of newly qualified midwives and described the factors that facilitated or constrained their development during the transition from student to registered midwife. BACKGROUND: Knowledge of the transition to midwifery practice remains limited. DESIGN AND METHOD: A qualitative descriptive approach was used. Sixteen graduates from one Australian University participated in a tape-recorded interview. Thematic analysis was used to analyse the data set. RESULTS: The metaphor of 'The Pond', an environment that consists of layers of life and can be both clear and peaceful or murky and infested, was used to describe new midwives perceptions of the context and culture of hospital-based maternity care. For some, 'The Pond' was a harsh environment that often became toxic. The 'Life-raft' metaphor was used to describe the importance of midwife-to-midwife relationships. The theme of 'Swimming' captured the consequence of positive interactions with colleagues and a supportive environment, whilst 'Sinking' described the consequence of poor relationships with midwives and a difficult working environment. CONCLUSION: The study highlights the importance of positive midwife-to-midwife relationships on the transition from student to registered midwife. There was also evidence that continuity with women and midwifery colleagues enhanced confidence and restored faith in normal birth. At the same time, it was clear that the midwifery culture of some institutions remains highly contested with midwives struggling to provide woman-centred care and often challenged by the risk-averse nature of maternity care. RELEVANCE TO CLINICAL PRACTICE: Whilst further work is required, the findings provide a deeper understanding of individual midwives' transition period. The importance of forming longitudinal relationships not only with women but with midwifery colleagues is highlighted. Developing continuity models that adequately support graduates and student's needs are likely to assist in addressing practices issues in both the academic and clinical setting.

Improving women's experiences of perineal suturing: A pragmatic qualitative analysis of what is helpful and harmful.

BACKGROUND: Perineal trauma requiring suturing is increasing, along with the associated physiological and psychological morbidities for women. Provider training appears to focus more on technical aspects rather than respectful, relational care for women. Studies exploring women's experiences have identified that how women are cared for can significantly impact upon overall experiences. AIM: To identify areas of improvement to the perineal suturing process and provide robust recommendations for urgent change by investigating what aspects are most traumatic to women and which are most supportive. METHODS: A pragmatic qualitative analysis of data generated from 15 in-depth interviews with women who were sutured following birth. FINDINGS: Regardless of tear severity, what was identified as helpful included anything that made the process better by increasing feelings of trust and reassurance, and providing women with a sense of being seen and heard. Harmful experiences were identified as those that worsened the experience, by increasing feelings of fear and vulnerability and leaving women with a sense of being disregarded or disrespected. CONCLUSION: The study confirmed that how the suturing process is conducted can have a significant detrimental impact upon women's short- and longer-term physical and psychological well-being. IMPLICATIONS FOR PRACTICE: An improved experience for women is most likely with kind professionals who explain the process as it goes along, check-in regularly and validate how the women feel. Women prefer to be sutured by a known professional, only if this provider is also kind and respectful.

Exploring consumer perspectives about the Health Care Home model of primary care provision: A qualitative study.

BACKGROUND AND OBJECTIVES: Australia's health system faces challenges in the management and prevention of chronic disease. Models of primary care delivery, such as the Health Care Home (HCH) model, have been proposed to help meet these challenges. The aim of this study was to explore pre-implementation consumer perspectives of the HCH model. METHOD: Qualitative data were collected from focus groups and semi-structured interviews with 38 general practice patients diversified across rural and urban areas and patient demographics. RESULTS: The qualitative findings revealed that consumers were confused about the name of the model. They were sceptical about potential hidden costs associated with the model and concerned about hidden agendas and where things in general practice are headed. DISCUSSION: The findings indicate that consumers may not readily embrace the HCH model. To aid consumer acceptance, the authors recommend the terminology be clarified and the concepts, financial implications and expected outcomes of the model be clearly communicated.

Same same but different: expectations of graduates from two midwifery education courses in Australia.

AIMS AND OBJECTIVES: To identify the expectations and workforce intentions of new graduate midwives from two different pre-registration educational courses at one Australian university. BACKGROUND: In Australia there are two different educational pathways to midwifery qualification, one offered for registered nurses, commonly at a postgraduate level and the other for non-nurses, at an undergraduate level. The knowledge about midwifery graduates in general is reasonably limited and there is no specific research that examines the similarities and differences between graduates from the two different courses. DESIGN: A cross-sectional design was used. METHOD: Data were collected by questionnaire from both undergraduate and postgraduate midwifery graduates in 2007 and 2008 at one Australian university. Data were analysed using descriptive statistics. RESULTS: Almost all the graduates from the two different pre-registration courses intended to enter the midwifery workforce with both groups rating the factors that influenced this decision similarly. There were, however, significant differences in graduates age and their intention to work part time. Their views of their ideal roles and subsequent uptake into formal new graduate transition programmes differed. Graduates from the two courses also reported philosophical differences regarding their concepts of job satisfaction and ways their jobs could be improved. CONCLUSIONS: The graduates from the two different courses showed sufficient significant differences to warrant consideration in current workforce planning for midwifery. RELEVANCE TO CLINICAL PRACTICE: The factors that influence the career decisions of new graduate midwives can positively impact educational and workforce planning. The findings may be able to help inform strategies to address turnover and attrition in midwifery.

General practitioners' attitudes towards acne management: Psychological morbidity and the need for collaboration.

METHOD: A qualitative descriptive study collected data via telephone interviews with 20 purposively sampled GPs working in New South Wales. A thematic analysis guided by the study objectives was undertaken. RESULTS: The participating GPs had divergent management approaches to acne treatment, infrequently provided acne patients with written resources, and would value additional dermatological support. Furthermore, the GPs recognised psychosocial ramifications and patient distress as drivers for treatment and expedited referral to dermatologists. DISCUSSION: Avenues for improved patient outcomes include explicit attention to psychological morbidity beyond treatment of the acne itself and improved use of patient educational materials, along with consistent collaboration between GPs and dermatologists.

Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.

OBJECTIVE: to identify and describe the design characteristics of hospital birth rooms that support midwives and their practice. DESIGN: this study used a qualitative exploratory descriptive methodology underpinned by the theoretical approach of critical realism. Data was collected through 21 in-depth, face-to-face photo-elicitation interviews and a thematic analysis guided by study objectives and the aims of exploratory research was undertaken. SETTING: the study was set at a recently renovated tertiary hospital in a large Australian city. PARTICIPANTS: participants were 16 registered midwives working in a tertiary hospital; seven in delivery suite and nine in birth centre settings. Experience as a midwife ranged from three to 39 years and the sample included midwives in diverse roles such as educator, student support and unit manager. FINDINGS: three design characteristics were identified that supported midwifery practice. They were friendliness, functionality and freedom. Friendly rooms reduced stress and increased midwives' feelings of safety. Functional rooms enabled choice and provided options to better meet the needs of labouring women. And freedom allowed for flexible, spontaneous and responsive midwifery practice. CONCLUSION: hospital birth rooms that possess the characteristics of friendliness, functionality and freedom offer enhanced support for midwives and may therefore increase effective care provision. IMPLICATIONS FOR PRACTICE: new and existing birth rooms can be designed or adapted to better support the wellbeing and effectiveness of midwives and may thereby enhance the quality of midwifery care delivered in the hospital. Quality midwifery care is associated with positive outcomes and experiences for labouring women. Further research is required to investigate the benefit that may be transmitted to women by implementing design intended to support and enhance midwifery practice.

The hardware and software implications of hospital birth room design: a midwifery perspective.

OBJECTIVE: to explore the impacts of physical and aesthetic design of hospital birth rooms on midwives. BACKGROUND: the design of a workplace, including architecture, equipment, furnishings and aesthetics, can influence the experience and performance of staff. Some research has explored the effects of workplace design in health care environments but very little research has examined the impact of design on midwives working in hospital birth rooms. METHODS: a video ethnographic study was undertaken and the labours of six women cared for by midwives were filmed. Filming took place in one birth centre and two labour wards within two Australian hospitals. Subsequently, eight midwives participated in video-reflexive interviews whilst viewing the filmed labour of the woman for whom they provided care. Thematic analysis of the midwife interviews was undertaken. FINDINGS: midwives were strongly affected by the design of the birth room. Four major themes were identified: finding a space amongst congestion and clutter; trying to work underwater; creating ambience in a clinical space and being equipped for flexible practice. Aesthetic features, room layout and the design of equipment and fixtures all impacted on the midwives and their practice in both birth centre and labour ward settings. CONCLUSION AND IMPLICATIONS FOR PRACTICE: the current design of many hospital birth rooms challenges the provision of effective midwifery practice. Changes to the design and aesthetics of the hospital birth room may engender safer, more comfortable and more effective midwifery practice.

Messages from Space: An Exploration of the Relationship between Hospital Birth Environments and Midwifery Practice.

OBJECTIVE: To explore the relationship between the birth environment and the practice of midwifery using the theoretical approach of critical realism. BACKGROUND: The practice of midwifery has significant influence on the experiences and health outcomes of childbearing women. In the developed world most midwifery takes place in hospitals. The design and aesthetics of the hospital birth environment have an effect on midwives and inevitably play a role in shaping their practice. Despite this, knowledge about midwives' own thoughts and feelings regarding the design of hospital birth environments is limited. METHODS: An exploratory descriptive methodology was used and 16 face-to-face photo-elicitation interviews were conducted with practicing midwives. Audio recordings were made of the interviews and they were transcribed verbatim. Thematic analysis, informed by the theoretical framework of critical realism, was undertaken. RESULTS: Midwives identified cognitive and emotional responses to varied birth environments and were able to describe the way in which these responses influenced their practice. The overarching theme of "messages from space" was developed along with three sub-themes: messages, feelings, and behaviors. Midwives' responses aligned with the three domains of a critical realist world-view and indicated that a relationship existed between hospital birth environments and midwifery practice. CONCLUSIONS: The design of hospital birth rooms may shape midwifery practice by generating cognitive and emotional responses, which influence the activities and behaviors of individual midwives. KEYWORDS: Hospital, midwifery, quality care, staff, women's health, work environment.

Space, place and the midwife: exploring the relationship between the birth environment, neurobiology and midwifery practice.

BACKGROUND: Research indicates that midwives and their practice are influenced by space and place and that midwives practice differently in different places. It is possible that one mechanism through which space and place influence midwifery practice is via neurobiological responses such as the production and release of oxytocin, which can be triggered by experiences and perceptions of the physical environment. AIM: To articulate the significance of space and place to midwifery and explore the relationship between the birth environment, neurobiology and midwifery practice. DISCUSSION: Quality midwifery care requires the facilitation of trusting social relationships and the provision of emotionally sensitive care to childbearing women. The neuropeptide oxytocin plays a critical role in human social and emotional behaviour by increasing trust, reducing stress and heightening empathy, reciprocity and generosity. PRINCIPLE CONCLUSION: Through its role as a trigger for oxytocin release, the birth environment may play a direct role in the provision of quality midwifery care.