A qualitative study of the barriers and enablers to fertility-awareness education in general practice.

AIMS: To understand the barriers and enablers to fertility-awareness education in general practice. BACKGROUND: Most women along with their primary care practitioners - general practitioners and practice nurses - believe that women should be educated about fertility-awareness when first reporting trouble conceiving. To date, no in-depth study has examined the enablers and challenges of this type of education in general practice. DESIGN: A descriptive exploratory qualitative study using deductive content analysis. METHODS: General practitioners (N = 11) and practice nurses (N = 20) were recruited from general practices in three socioculturally diverse areas in Victoria, Australia. Data were collected through semistructured interviews based on the 12 domains of a theoretical behaviour change framework from April-August 2012. The participants' responses were organized into themes that fall under the framework domains. FINDINGS: The biggest barriers to fertility-awareness education in general practice were short consultations and time constraints faced by general practitioners together with a lack of patient educational materials and remuneration to support its delivery. The biggest enablers were a greater use of nurses trained in fertility-awareness in a collaborative team care arrangement with general practitioners. CONCLUSION: This study has identified several important barriers and enablers to fertility-awareness education in general practice. Translation into practice of our findings is imperative as the first step in establishing a primary care model in fertility-awareness. This would fill an important gap in the primary care of infertile women and build capacity in general practice to reduce infertility through women's enhanced fertility knowledge.

'Catching chlamydia': combining cash incentives and community pharmacy access for increased chlamydia screening, the view of young people.

In Australia and elsewhere, chlamydia screening rates for those aged between 16 and 30 years continue to be low. Innovative, age-appropriate approaches are necessary to increase chlamydia screening among this target group to prevent short- and long-term consequences of the infection such as pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy and infertility. Studies have demonstrated that offering chlamydia screening in community pharmacies may be a useful adjunct to current screening services. Approximately 90% of Australians visit a pharmacy at least once a year. Chlamydia screening and education in community pharmacies with remuneration may provide another option for opportunistic testing as part of a national chlamydia screening scheme. Compensation is an accepted practice in the field of research and has been demonstrated to improve adherence to health promotion activities. In 2011, a cross-sectional study of community pharmacy-based chlamydia screening offered in conjunction with an A$10 cash incentive to participate was conducted in the Australian Capital Territory. As part of this study young people were asked about their experience of, and views about, pharmacy-based chlamydia screening. The views of consented participants were collected using the one-page questionnaire consisting of 10 closed questions and one open-ended question. Participants completed the questionnaire when they returned their urine sample and before being given the cash incentive. Overall participants were highly satisfied with the pharmacy-based chlamydia screening service. Over 60% of questionnaire respondents felt that the payment did affect their decision to have the chlamydia test, and 23% stated that it made no difference. Young people reported that pharmacy-based screening is acceptable and convenient. Accessibility and the small cash incentive played significant roles in increasing participation.

What primary health-care services are Australian consumers willing to accept from nurse practitioners? A National Survey.

BACKGROUND: Nurses are becoming increasingly important as providers of primary health care in Australia. In November 2010, Medicare provider rights and Pharmaceutical Benefits Scheme rights for nurse practitioners, working in private practice and in collaboration with a medical practitioner, were introduced in Australia. Although international evidence suggests that nurse practitioners would be appropriate and acceptable providers of care at the first point of contact, such as primary health care, there is little Australian evidence about what care consumers are willing to accept from nurse practitioners. OBJECTIVES: To ascertain what care Australian health-care consumers would accept from nurse practitioners in this setting. PARTICIPANTS: Australian adults over 18 years of age. METHODS: National Survey delivered online. Information about the survey was disseminated through a media campaign, stakeholder engagement and through the health-care consumer networks nationally. RESULTS: The total number of respondents that started the survey was n = 1883. Ninety-five percentage (n = 1784) of respondents completed the survey. The majority of respondents were women, aged 25-54 years, had completed tertiary education and had an annual household income of more than A$80,000. The majority of the respondents (n = 1562, 87%) said they would be prepared to see a nurse practitioner for some of their primary health-care needs. CONCLUSIONS: The findings of this study suggest consumers are accepting of a range of activities undertaken by nurse practitioners in primary health care and this has relevance for primary health-care workforce mix and organization, particularly for areas that are underserved by medical practitioners.

Nurse practitioners in aged care: documentary analysis of successful project proposals.

Meeting the primary health care needs of an aging population is an increasing challenge for many Western nations. In Australia, the federal government introduced a program to develop, test, and evaluate nurse practitioner models in aged care settings. In this article, we present a documentary analysis of 32 project proposals awarded funding under the Nurse Practitioner-Aged Care Models of Practice Program. Successfully funded models were diverse and were operated by a range of organizations across Australia. We identified three key priorities as underlying the proposed models: "The right care," "in the right place," and "at the right time." In this article, we explore how these priorities were presented by different applicants in different ways. Through the presentation of their models, the program's applicants identified and proposed to address current gaps in health services. Applicants contrasted their proposed models with available services to create persuasive and competitive applications for funding.

A tool to evaluate patients' experiences of nursing care in Australian general practice: development of the Patient Enablement and Satisfaction Survey.

Australian health policy initiatives have increasingly supported the employment of nurses in general practice. An understanding of the impact of nursing care on patients in this setting is integral to assuring quality, safety and a patient-centred focus. The aim was to develop a survey to evaluate the satisfaction and enablement of patients who receive nursing care in Australian general practices. The survey was to be simple to administer and analyse, ensuring practicality for use by general practice nurses, doctors and managers. Two validated instruments formed the basis of the Patient Enablement and Satisfaction Survey (PESS). This survey was refined and validated for the Australian setting using focus groups and in-depth interviews with patients, and feedback from general practice nurses. Test-retest and alternate form methods were used to establish the survey's reliability. Feedback resulted in 14 amendments to the original draft survey. Questions that demonstrated a strong positive correlation for the test-retest and alternate form measures were included in the final survey. The PESS is a useful, practical tool for the evaluation of nursing care in Australian general practice, its validity and reliability established through a patient-centred research approach, reflective of the needs of patients accessing nursing services in this setting.

Community pharmacy and cash reward: a winning combination for chlamydia screening?

OBJECTIVES: To date, the uptake of chlamydia screening in community pharmacies has been limited. The objective of this cross-sectional study was to determine if a cash reward, offered to both the provider and the consumer of chlamydia screening, increased the uptake of screening in community pharmacies. METHODS: During 4 weeks in 2011, chlamydia screening and education were offered in four city and two suburban pharmacies to people aged 16-30 years. Those who provided a urine sample for testing, contact details, and completed a brief questionnaire were rewarded with $A10. Positive participants, and their nominated contacts, were offered treatment. RESULTS: Over a period of 751.5 h, 979 testing kits were requested, and 900 (93%) urine samples returned. Using probabilistic linkage methods, we determined that 671/900 (75%) urine samples were from unique individuals. 0.9 unique samples were obtained/hour of screening, 63% of which were provided by men. 19/671 (2.8%; 95% CI 1.7% to 4.4%) people tested positive, 5.2% (95% CI 2.8% to 8.8%) of women, and 1.4% (1.4 0.5 to 3.1) of men. 11/19 (58%) people were contacted and treated-two for suspected pelvic inflammatory disease. CONCLUSIONS: Providing a cash reward to encourage chlamydia screening in community pharmacies resulted in greater participation rates than previously reported pharmacy-based studies, particularly among men. Easily implemented mechanisms to reduce inappropriate repeat screening, incorrect contact details and effects on pharmacy work flow may enhance the efficiency of this approach.

Addressing chronic and complex conditions: what evidence is there regarding the role primary healthcare nurses can play?

Primary healthcare services in Australia need to respond to the needs of an ageing population and the rising prevalence of chronic and complex conditions in that population. This paper reports on the results of a comprehensive Australian and international literature review on nurse-led and nurse-involved primary healthcare interventions with a particular focus on those serving people with chronic and complex conditions and hard to reach populations. The key question this review addresses is: what role can nurses play in primary healthcare to manage people with chronic and complex conditions? International evidence demonstrates that nurses working in primary care provide effective care, have high patient satisfaction and patients are more likely to comply with nurse instructions than general practitioner instructions. Nurses can provide care equivalent to doctors within their scope of practice but have longer consultations. Lifestyle interventions provided by nurses have been shown to be effective for cardiac care, diabetes care, smoking cessation and obesity. The nursing workforce can provide appropriate, cost-effective and high-quality primary healthcare within their scope of practice.

Aged care nurse practitioners in Australia: evidence for the development of their role.

AIM: To consider evidence surrounding the emerging role of nurse practitioners in Australia with a particular focus on the provision of healthcare to older people. METHODS: Methods used included keyword, electronic database and bibliographic searches of international literature, as well as review of prominent policy reports in relation to aged care and advanced nursing roles. RESULTS: This paper reports on evidence from systematic reviews and international studies that show that nurse practitioners improve healthcare outcomes, particularly for hard to service populations. It also maps out the limited Australian evidence on the impact of nurse practitioners' care in aged care settings. CONCLUSIONS: If Australia is to meet the health needs of its ageing population, more evidence on the effectiveness, economic viability and sustainability of models of care, including those utilising nurse practitioners, is required.

Feasibility and acceptability of nurse-led youth clinics in Australian general practice.

Internationally, youth access to primary health care is problematic due to documented barriers such as cost, concerns about confidentiality, and knowledge about when to attend and available services. The treatment of health problems earlier in life together with engagement in prevention and health education can optimise youth health and maximise the potential of future wellbeing. This study investigated the feasibility, acceptability and cost of establishing nurse-led youth clinics in Victoria, Australia. Three general practices in rural and regional areas of Victoria implemented the nurse-led youth health clinics. The clinics were poorly attended by young people. Practice nurses identified several barriers to the clinic attendance including the short timeframe of the study, set times of the clinics and a lack of support for the clinics by some GPs and external youth health clinics, resulting in few referrals. The clinics cost from $5912 to $8557 to establish, which included training the practice nurses. Benefits of the clinics included increased staff knowledge about youth health issues and improved relationships within the general practice staff teams. The implementation of youth health clinics is not feasible in a short timeframe and to maximise use of the clinics, all members of the general practice team need to find the clinics acceptable.

Health promotion by primary care nurses in Australian general practice.

The pressures brought about by the increasing prevalence of poor health among some population groups as well as the rise in prevalence of chronic and complex conditions requires a nursing workforce skilled in health promotion. Primary care nurses have increasingly important roles in general practice settings but there is little exploration of the nature or extent of their health promotion work. This paper reports on a survey that investigated primary care nurses' perceptions of their current and potential roles in health promotion in general practice settings. The survey respondents were primary care nurses in general practice. 78 nurses responded to advertisements seeking participation, and 58 surveys were completed and returned. Data were analyzed through a framework of downstream-upstream health promotion actions. We found that the health promotion practices of primary care nurses were most commonly in the downstream realm of disease prevention and health education but nurses aspired to take on roles in more upstream work of partnerships and collaboration. Nurses' opportunities are undoubtedly constrained by both the general practice setting and their educational preparation. However, nurses were very positive about the opportunities that their role and position offered for expansion of their health promotion work.

How acceptable are primary health care nurse practitioners to Australian consumers?

International evidence indicates that nurses working in primary care can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurse practitioners employed in primary health care perform some tasks previously exclusive to the GP role due to their advanced skills, knowledge and training. In November 2010 Medicare provider rights and Pharmaceutical Benefits Scheme rights were provided for nurse practitioners working in private practice, and in collaboration with a medical practitioner. However, there is limited evidence about how acceptable nurse practitioners are to Australian consumers and what knowledge consumers have of the nurse practitioner role in the delivery of primary health care. The aim of this study was to examine Australian health care consumers' perceptions of nurse practitioners working in primary health care. This paper reports on the results of seven focus groups (n = 77 participants) conducted around Australia. Focus groups participants were asked how acceptable nurse practitioners are as provides of primary health care. Although there was some confusion about the role of nurse practitioners and how this role differed from other primary health care nurses, participants in the focus groups were very positive about nurse practitioners and would find them acceptable in providing primary health care.

Stakeholder perceptions of a nurse led walk-in centre.

BACKGROUND: As many countries face primary care medical workforce shortages and find it difficult to provide timely and affordable care they seek to find new ways of delivering first point of contact health care through developing new service models. In common with other areas of rural and regional Australia, the Australian Capital Territory (ACT) is currently experiencing a general practitioner (GP) workforce shortage which impacts significantly on the ability of patients to access GP led primary care services. The introduction of a nurse led primary care Walk-in Centre in the ACT aimed to fulfill an unmet health care need in the community and meet projected demand for health care services as well as relieve pressure on the hospital system. Stakeholders have the potential to influence health service planning and policy, to advise on the potential of services to meet population health needs and to assess how acceptable health service innovation is to key stakeholder groups. This study aimed to ascertain the views of key stakeholders about the Walk-in Centre. METHODS: Stakeholders were purposively selected through the identification of individuals and organisations which had organisational or professional contact with the Walk-in Centre. Semi structured interviews around key themes were conducted with seventeen stakeholders. RESULTS: Stakeholders were generally supportive of the Walk-in Centre but identified key areas which they considered needed to be addressed. These included the service's systems, full utilisation of the nurse practitioner role and adequate education and training. It was also suggested that a doctor could be available to the Centre as a source of referral for patients who fall outside the nurses' scope of practice. The location of the Centre was seen to impact on patient flows to the Emergency Department. CONCLUSION: Nurse led Walk-in Centres are one response to addressing primary health care medical workforce shortages. Whilst some stakeholders have reservations about the model others are supportive and see the potential the model has to provide accessible primary health care. Any further developments of nurse-led Walk-in Centres need to take into account the views of key stakeholders so as to ensure that the model is acceptable and sustainable.

Nurse-led primary healthcare walk-in centres: an integrative literature review.

AIMS: This paper is a report of an integrative review of the international literature examining established nurse-led primary healthcare walk-in centres and their outcomes to understand whether they are effective in improving access to primary health care. BACKGROUND: Reviews of nurse-led primary care walk-in centres have included centres staffed by family physicians and general practitioners. There is a paucity of evidence about walk-in centres staffed solely by nurses. DATA SOURCES: Studies were identified through an electronic search using the databases Medline, Cinahl and EBSCO from 1990 until July 2010. Papers were included if they examined walk-in centres providing nurse-led primary care for the general community. Only peer reviewed studies published in English were included. REVIEW METHODS: An integrative approach utilizing Bowling's checklist facilitated a systematic appraisal of studies in regard to clarity of aims, objectives, methods and appropriate analysis of data. RESULTS: Thirteen publications were categorized into five themes: 'users of walk-in centres', 'quality of care provided at walk-in centres', 'impact on other healthcare providers', 'perceptions of walk-in centres' and 'satisfaction with walk-in centres'. CONCLUSION: The possibility that walk-in centres create demand highlights the need for clearer evidence of the drivers of demand for health care in walk-in centres. Innovations in healthcare provision need to be matched with adaptation to nursing education to ensure an adequately prepared nursing workforce. Improvement in access to primary healthcare needs to be measured in terms of equity and the capacity this access has to fill identified gaps in primary healthcare provision in the community.

Potential roles for practice nurses in preventive care for young people - a qualitative study.

BACKGROUND: Increasing numbers of practice nurses and their expanding roles in Australian general practice suggest they can contribute to quality primary healthcare for young people. METHODS: Seventeen health and community professionals and a purposefully selected group of 12 practice nurses were interviewed about the role of the practice nurse in young people's healthcare. A directed content approach to analysis was applied. RESULTS: Participants recognised the psychosocial health burdens young people experience and the barriers they perceive in accessing healthcare. With good communication skills and appropriate training, practice nurses were perceived to be able to have an important role in the preventive care of young people. DISCUSSION: Practice nurses can contribute to breaking down barriers to healthcare for young people. This study is being reported on at an opportune time, considering the implications for young people of the 'Practice Nurse Incentive Program'.

A national survey of general practitioners' experiences of patient-initiated aggression in Australia.

OBJECTIVE: To determine the prevalence of patient-initiated aggression toward general practitioners in Australia. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional national survey, conducted during February-May 2010, of 3090 GPs in 19 Divisions of General Practice, purposively sampled to represent urban, rural and remote areas. MAIN OUTCOME MEASURE: Proportion of GPs experiencing patient-initiated aggression. RESULTS: Eight-hundred and four GPs returned completed surveys (response rate, 26.3%). In the previous 12 months, 58% of GPs had experienced verbal abuse and 18% had experienced property damage or theft. Very few GPs had experienced physical abuse (6%), stalking (4%), sexual harassment (6%) or sexual assault (0.1%). After controlling for other demographic variables, GPs with fewer years of experience (P = 0.003), or who worked full-time or in larger practices (both P = 0.03) experienced significantly more verbal abuse than their counterparts, and GPs who worked full-time (P = 0.004) or in metropolitan areas (P = 0.01) experienced significantly more property damage or theft. Female GPs experienced significantly more sexual harassment than male GPs (P < 0.001). CONCLUSIONS: This is the first national evidence of the prevalence of patient aggression toward GPs in Australia, which could inform the development of policies and guidelines that aim to reduce the prevalence of patient aggression toward GPs.

Patient initiated aggression - prevalence and impact for general practice staff.

BACKGROUND: Patient initiated aggression toward general practice staff can cause distress among staff, however, it is unknown how frequently practice staff experience patient aggression in the workplace. The aim of this study is to determine the national prevalence of patient aggression toward general practice staff. METHOD: A clustered cross sectional survey involving general practice staff working in Australia. RESULTS: A questionnaire was posted to 1109 general practices nationally and 217 questionnaires were completed and returned (19.6% response rate). It was found that verbal aggression is commonly experienced by practice staff, particularly receptionists, whereas physical aggression is infrequent. Staff working in larger practices experience more verbal aggression and property damage or theft and it was reported that verbal aggression has a greater impact on staff wellbeing than physical aggression. DISCUSSION: This study provides some national evidence of the prevalence of patient aggression toward general practice staff. This may inform the development of policy and procedures.

The work, education and career pathways of nurses in Australian general practice.

There is little understanding about the educational levels and career pathways of the primary care nursing workforce in Australia. This article reports on survey research conducted to examine the qualifications and educational preparation of primary care nurses in general practice, their current enrolments in education programs, and their perspectives about post-registration education. Fifty-eight practice nurses from across Australia completed the survey. Over 94% reported that they had access to educational opportunities but identified a range of barriers to undertaking further education. Although 41% of nurses said they were practising at a specialty advanced level, this correlated with the number of years they had worked in general practice rather than to any other factor, including level of education. Respondents felt a strong sense of being regarded as less important than nurses working in the acute care sector. Almost 85% of respondents reported that they did not have a career pathway in their organisation. They also felt that while the public had confidence in them, there was some way to go regarding role recognition.

Experiences and outcomes of partner notification among men and women recently diagnosed with Chlamydia and their views on innovative resources aimed at improving notification rates.

OBJECTIVE: To describe the partner notification experiences of individuals diagnosed with chlamydia and to determine what supports might best assist them. GOAL: To determine what supports might best assist chlamydia infected individuals to notify their partners. STUDY DESIGN: A telephone survey was undertaken with men and women recently diagnosed with chlamydia across 3 Australian jurisdictions between August 2007 and January 2008. RESULTS: Of the 286 individuals who agreed to be contacted about the study, 202 (71%) completed the survey. Twenty-three percent (333/1458) of recent partners were notified: men who had sex with men (MSM) notified 15% (133/880) of their partners, heterosexual men 31% (114/370), and women 46% (86/188) of their partners (P < 0.001). Overall, 84% (169/202) of individuals notified at least one partner. The main reasons for informing partners were out of concern for them (44%) or because it was considered "the right thing to do" (37%). The preferred methods for contacting partners were telephone (52%) and face-to-face (30%). E-mail (8%) and short message service (SMS) (11%) were less commonly used; however, if offered a website with anonymous e-mail and SMS services, nearly half of individuals indicated they would find this useful. Of those who had not informed all partners with known contact details (n = 94), 34% reported that if web-based tools were available they would have contacted more partners. Over half of participants would like to have been given antibiotics to give to their partner. CONCLUSION: The availability of tailored resources may assist in improving partner notification for chlamydia.

Telling partners about chlamydia: how acceptable are the new technologies?

BACKGROUND: Partner notification is accepted as a vital component in the control of chlamydia. However, in reality, many sexual partners of individuals diagnosed with chlamydia are never informed of their risk. The newer technologies of email and SMS have been used as a means of improving partner notification rates. This study explored the use and acceptability of different partner notification methods to help inform the development of strategies and resources to increase the number of partners notified. METHODS: Semi-structured telephone interviews were conducted with 40 people who were recently diagnosed with chlamydia from three sexual health centres and two general practices across three Australian jurisdictions. RESULTS: Most participants chose to contact their partners either in person (56%) or by phone (44%). Only 17% chose email or SMS. Participants viewed face-to-face as the "gold standard" in partner notification because it demonstrated caring, respect and courage. Telephone contact, while considered insensitive by some, was often valued because it was quick, convenient and less confronting. Email was often seen as less personal while SMS was generally considered the least acceptable method for telling partners. There was also concern that emails and SMS could be misunderstood, not taken seriously or shown to others. Despite these, email and SMS were seen to be appropriate and useful in some circumstances. Letters, both from the patients or from their doctor, were viewed more favourably but were seldom used. CONCLUSION: These findings suggest that many people diagnosed with chlamydia are reluctant to use the new technologies for partner notification, except in specific circumstances, and our efforts in developing partner notification resources may best be focused on giving patients the skills and confidence for personal interaction.

Better than nothing? Patient-delivered partner therapy and partner notification for chlamydia: the views of Australian general practitioners.

BACKGROUND: Genital chlamydia is the most commonly notified sexually transmissible infection (STI) in Australia and worldwide and can have serious reproductive health outcomes. Partner notification, testing and treatment are important facets of chlamydia control. Traditional methods of partner notification are not reaching enough partners to effectively control transmission of chlamydia. Patient-delivered partner therapy (PDPT) has been shown to improve the treatment of sexual partners. In Australia, General Practitioners (GPs) are responsible for the bulk of chlamydia testing, diagnosis, treatment and follow up. This study aimed to determine the views and practices of Australian general practitioners (GPs) in relation to partner notification and PDPT for chlamydia and explored GPs' perceptions of their patients' barriers to notifying partners of a chlamydia diagnosis. METHODS: In-depth, semi-structured telephone interviews were conducted with 40 general practitioners (GPs) from rural, regional and urban Australia from November 2006 to March 2007. Topics covered: GPs' current practice and views about partner notification, perceived barriers and useful supports, previous use of and views regarding PDPT.Transcripts were imported into NVivo7 and subjected to thematic analysis. Data saturation was reached after 32 interviews had been completed. RESULTS: Perceived barriers to patients telling partners (patient referral) included: stigma; age and cultural background; casual or long-term relationship, ongoing relationship or not. Barriers to GPs undertaking partner notification (provider referral) included: lack of time and staff; lack of contact details; uncertainty about the legality of contacting partners and whether this constitutes breach of patient confidentiality; and feeling both personally uncomfortable and inadequately trained to contact someone who is not their patient. GPs were divided on the use of PDPT--many felt concerned that it is not best clinical practice but many also felt that it is better than nothing.GPs identified the following factors which they considered would facilitate partner notification: clear clinical guidelines; a legal framework around partner notification; a formal chlamydia screening program; financial incentives; education and practical support for health professionals, and raising awareness of chlamydia in the community, in particular amongst young people. CONCLUSIONS: GPs reported some partners do not seek medical treatment even after they are notified of being a sexual contact of a patient with chlamydia. More routine use of PDPT may help address this issue however GPs in this study had negative attitudes to the use of PDPT. Appropriate guidelines and legislation may make the use of PDPT more acceptable to Australian GPs.