The process of nurses' role negotiation in general practice: A grounded theory study.

AIM: To explain the process by which nurses' roles are negotiated in general practice. BACKGROUND: Primary care nurses do important work within a social model of health to meet the needs of the populations they serve. Latterly, in the face of increased demand and workforce shortages, they are also taking on more medical responsibilities through task-shifting. Despite the increased complexity of their professional role, little is known about the processes by which it is negotiated. DESIGN: Constructivist grounded theory. METHODS: Semi-structured interviews were conducted with 22 participants from 17 New Zealand general practices between December 2020 and January 2022. Due to COVID-19, 11 interviews were via Zoom™. Concurrent data generation and analysis, using the constant comparative method and common grounded theory methods, identified the participants' main concern and led to the construction of a substantive explanatory theory around a core category. RESULTS: The substantive explanatory theory of creating place proposes that the negotiation of nurse roles within New Zealand general practice is a three-stage process involving occupying space, positioning to do differently and leveraging opportunity. Nurses and others act and interact in these stages, in accordance with their conceptualizations of need-responsive nursing practice, towards the outcome defining place. Defining place conceptualizes an accommodation between the values beliefs and expectations of individuals and pre-existing organizational norms, in which individual and group-normative concepts of need-responsive nursing practice are themselves developed. CONCLUSION: The theory of creating place provides new insights into the process of nurses' role negotiation in general practice. Findings support strategies to enable nurses, employers and health system managers to better negotiate professional roles to meet the needs of the populations they serve, while making optimum use of nursing skills and competencies. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Findings can inform nurses to better negotiate the complexities of the primary care environment, balancing systemic exigencies with the health needs of populations. IMPACT: What Problem Did the Study Address? In the face of health inequity, general practice nurses in New Zealand, as elsewhere, are key to meeting complex primary health needs. There is an evidence gap regarding the processes by which nurses' roles are negotiated within provider organizations. A deeper understanding of such processes may enable better use of nursing skills to address unmet health need. What Were the Main Findings? Nurses' roles in New Zealand general practice are determined through goal-driven negotiation in accordance with individual concepts of need-responsive nursing practice. Individuals progress from occupying workspaces defined by the care-philosophies of others to defining workplaces that incorporate their own professional beliefs, values and expectations. Negotiation is conditional upon access to role models, scheduled dialogue with mentors and decision-makers, and support for safe practice. Strong clinical and organizational governance and individuals' own positive personal self-efficacy are enablers of effective negotiation. Where and on Whom Will the Research Have Impact? The theory of Creating Space can inform organizational and individual efforts to advance the roles of general practice nurses to meet the health needs of their communities. General practice organizations can provide safe, supported environments for effective negotiation; primary care leaders can promote strong governance and develop individuals' sense of self-efficacy by involving them in key decisions. Nurses themselves can use the theory as a framework to support critical reflection on how to engage in active negotiation of their professional roles. REPORTING METHOD: The authors adhered to relevant EQUATOR guidelines using the COREQ reporting method. PATIENT OR PUBLIC CONTRIBUTION: Researchers and participants currently working in general practice were involved in the development of this study. By the process of theoretical sampling and constant comparison, participants' comments helped to shape the study design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: An understanding of the processes by which health professionals negotiate their roles is important to support them to meet the challenges of increased complexity across all health sectors globally.

Nurse rostering: understanding the current shift work scheduling processes, benefits, limitations, and potential fatigue risks.

BACKGROUND: Implementing appropriate shift work schedules can help mitigate the risk of sleep impairment and reduce fatigue of healthcare workers, reducing occupational health and safety risks. In Australia, the organisation has a responsibility to make sure all reasonable measures are taken to reduce fatigue of staff. Therefore, it is important to assess what the current rostering processes is for staff responsible for creating the rosters for nurses. AIM: The aims of the project were to understand (1) who creates the rosters and what the process is, (2) what training and knowledge these staff have in establishing rostering schedules that optimise the sleep and wellbeing of staff, and (3) what the benefits and limitations are of current rostering practices. METHODS: Findings were generated through semi-structured interviews, using cluster coding to form categories. Twenty four nurses responsible for rostering staff were interviewed from three different sites in Victoria (one metropolitan and two regional/rural hospitals). Data was analysed using selected grounded theory methods with thematic analysis. RESULTS: The common themes that came out of the interviews were that rostering staff were under prepared, unaware of fatigue and safety guidelines and polices from governing bodies and had not received any education or training before taking on the role. The most common rostering style was self-rostering, where staff could submit preferences. However, there were concerns about staff fatigue but were divided as to who should be responsible, with many saying it was up to staff to preference shifts that they could cope with. The final theme was cultural barriers to change. CONCLUSION: While self-rostering resulted in staff having more freedom and flexibility,  shift preferences may be influenced more so by a need to fit with lifestyle rather than to minimise fatigue and increase safety in the workplace. Greater consideration of the impact of shift work schedules on fatigue is required to ensure that the layers of clinical governance in health care organisations minimise the risk of occupation health and safety issues for employees delivering direct patient care.

Differences in shift and work-related patterns between metropolitan and regional/rural healthcare shift workers and the occupational health and safety risks.

OBJECTIVES: To explore if there are differences in shift patterns and work-related factors between metropolitan and regional/rural healthcare shift workers and their risk of poor sleep and mental health. Furthermore, explore whether these factors impact on medical errors, workplace and car/near car accidents. DESIGN: A cross-sectional study. SETTING: An anonymous online survey of healthcare shift workers in Australia. PARTICIPANTS: A total of 403 nurses, midwives and paramedics completed the survey. MAIN OUTCOME MEASURES: Sample characteristics, employment location, shift work-related features, sleep and mental health measurements, workplace accidents, medical errors and car/near car accident post shift. RESULTS: Regional/rural healthcare shift workers were significantly older, had more years' experience, worked more nights, on-call and hours per week. Those in metropolitan areas took significantly longer (minutes) to travel to work, had higher levels of anxiety, increased risk of shift work disorder, reported significantly more workplace accidents and were more likely to have a car/near car accident when commuting home post shift. Both groups reported ~25% having a medical error in the past year. Workplace accidents were related to more on-call shifts and poor sleep quality. Medical errors were associated with fewer years' experience, more evening shifts and increased stress. Car accidents were associated with metropolitan location and increased depression. CONCLUSION: Differences in work-related factors between metropolitan and regional/rural healthcare shift workers were observed. Some of these factors contributed to occupational health and safety risks. Further exploration is needed to understand how to reduce occupational health and safety risks, and improve employee and patient safety both in both regional/rural and metropolitan areas.

Australian cancer nurses' experiences of burnout: Exploring the job demands and job resources of metropolitan cancer nurses during 2019-2020.

BACKGROUND: Existing studies that seek to understand nurses' experiences of burnout are dominated by cross-sectional, quantitative survey designs employing predetermined measures, often overlooking important job-related stressors that can be highly dependent on industry and professional contexts. Cancer nurses are a group of professionals who warrant special attention, as burnout in this profession is often attributed to high job demands and the challenge of caring for a vulnerable cohort of patients. A deeper understanding of the job demands associated with cancer nursing is required to provide insights about the work experiences of cancer nurses and identify aspects that mitigate burnout and stress. PURPOSE: This study describes the antecedents of burnout among Australian cancer nurses by focusing on the demands and resources inherent in their work. We aim to build on the existing literature by identifying job resources that may serve to mitigate the antecedents of burnout. METHODOLOGY/APPROACH: An in-depth interview study of cancer nurses across a spectrum of age and experience in Australian metropolitan public health care services was conducted over a 2-year period that coincided with the COVID-19 pandemic. The job demands and resources model framed this study of job-related factors associated with burnout and conversely job resources that may foster work engagement. RESULTS: Patient aggression, workload, emotional demands, and abusive peers and managers were reported as distinct job demands, whereas job significance and supportive peers who demonstrated leadership, along with task variety, were identified as job resources. CONCLUSION: Australian cancer nurses work in an environment where job demands are increasingly disproportionate to job resources, leading to significant risk of burnout. PRACTICE IMPLICATIONS: Our study identifies modifiable strategies for improving work conditions for this group who play a critical role in the health care system.

Have farmers had enough of experts?

The exponential rise of information available means we can now, in theory, access knowledge on almost any question we ask. However, as the amount of unverified information increases, so too does the challenge in deciding which information to trust. Farmers, when learning about agricultural innovations, have historically relied on in-person advice from traditional 'experts', such as agricultural advisers, to inform farm management. As more farmers go online for information, it is not clear whether they are now using digital information to corroborate in-person advice from traditional 'experts', or if they are foregoing 'expert' advice in preference for peer-generated information. To fill this knowledge gap, we sought to understand how farmers in two contrasting European countries (Hungary and the UK) learnt about sustainable soil innovations and who influenced them to innovate. Through interviews with 82 respondents, we found farmers in both countries regularly used online sources to access soil information; some were prompted to change their soil management by farmer social media 'influencers'. However, online information and interactions were not usually the main factor influencing farmers to change their practices. Farmers placed most trust in other farmers to learn about new soil practices and were less trusting of traditional 'experts', particularly agricultural researchers from academic and government institutions, who they believed were not empathetic towards farmers' needs. We suggest that some farmers may indeed have had enough of traditional 'experts', instead relying more on their own peer networks to learn and innovate. We discuss ways to improve trustworthy knowledge exchange between agricultural stakeholders to increase uptake of sustainable soil management practices, while acknowledging the value of peer influence and online interactions for innovation and trust building.

Abnormal screens among nonmutation carriers in the High Risk Ontario Breast Screening Program.

BACKGROUND: The Ontario Breast Screening Program was expanded in 2011 to offer annual MRI and mammography to women with high-risk genetic mutations (e.g., BRCA1/2) and women with strong family histories and ≥25% estimated lifetime risk of breast cancer. Data to support high-risk screening is less clear in the nonmutation carrier group, as MRI has lower specificity among this population. The potential unintended consequences may be considerable and need to be explored. We aimed to describe the frequency of abnormal screens and biopsies. METHODS: Demographic surveys and chart review consent were sent to a sample of 441 individuals enrolled in a high-risk screening program at two tertiary care hospitals in Toronto, Ontario. Retrospective cross-sectional chart review was undertaken for clinicopathologic data. The frequencies of abnormal screens and biopsies were calculated. RESULTS: One hundred sixty-nine nonmutation carriers were included. The majority were white, employed, and highly educated. The median International Breast Cancer Intervention Study lifetime risk of breast cancer was 28.0% (range 24.5%-89.0%). 108 individuals (64%) experienced at least 1 abnormal screen and 13 (8%) had 3 or more over a median 3 years of screening (range 1-6 years). Of 55 biopsies, 3 (5.5%) were malignant. The cancer detection rate was 8.4/1000 screens (95% CI 3.2-22.4). CONCLUSIONS: An MRI-based screening program for nonmutation carriers was effective at diagnosing breast cancer. However, this population experienced a high rate of abnormal screens and intervention. Further research is needed to improve the performance of MRI-based screening in these women.

Genomic Literacy of Registered Nurses and Midwives in Australia: A Cross-Sectional Survey.

PURPOSE: Registered nurses and midwives require a degree of genomic literacy if they are to adequately communicate with other healthcare professionals and provide optimal care to patients, their families, and the community. Several studies have been conducted internationally to assess the genomic literacy of nurses; however, the genomic literacy of Australian registered nurses and midwives has not been investigated. The aim of this study was to measure the genomic literacy of Australian registered nurses and midwives through assessing participants' understandings of genomic concepts most critical to nursing and midwifery practice, as well as their perceived knowledge and attitude towards genomics in nursing and midwifery practice. DESIGN: Cross-sectional survey of Australian registered nurses and midwives using the Genomic Nursing Concept Inventory (GNCI© ), a 31 multiple-choice question survey instrument. Participants were recruited via two key Australian nursing and midwifery organizations over an 8-month period in 2016. METHODS: Descriptive and inferential statistical techniques were used to calculate the total GNCI© score and scores on individual subcategories, as well as relationships between demographic variables and GNCI© scores. FINDINGS: Most respondents worked as clinicians (71.4%) in a hospital or hospital-based setting (61.8%). Most registered nurses (80.5%) and midwives (97.2%) reported that genetics was relevant to clinical practice; however, over 80% of registered nurses and midwives believed their knowledge of genetics was poor or average. Genomic knowledge was assessed using the GNCI© . Scores ranged from 3 to 29 (out of a possible 31), with a mean score of 13.3 (SD 4.559) based on 253 (N = 253) respondents, indicating that genomic literacy is low. There was a significant difference between genomic knowledge scores and education and training level (p = .036). CONCLUSIONS: The genomic literacy of registered nurses and midwives in Australia is low. More must be done to ensure Australian registered nurses and midwives have an adequate level of genomic literacy to provide optimal care to patients, their families, and the community. CLINICAL RELEVANCE: Modern medicine requires a healthcare workforce that is literate in genomics. Findings from this study may serve as the catalyst to improve the genomic literacy of the Australian nursing and midwifery workforce, allowing for improved health outcomes for individuals and the wider Australian public.

Socio-economic composition of low-acuity paediatric presentation at a regional hospital emergency department.

AIM: Despite increasing rates of emergency department (ED) utilisation, little is known about low-acuity presentations in children ≤5 years. The aims of the study were to estimate the proportion and cost of low-acuity presentations in children ≤5 years presenting to the ED and to determine the relative effect of socio-economic status (SES) on paediatric low-acuity presentations at the ED. METHODS: This is a retrospective observational study of children ≤5 years presenting to the Cairns Hospital ED over 4 years. A multivariate logistic regression model was used to assess the association between SES and low-acuity presentations. Cost of low-acuity presentations was calculated based on triage score and admission status, using costs obtained from the National Hospital Cost Data Collection. RESULTS: A total of 23 086 children were included in the study, of whom 56.7% were male (mean age = 1.85 ± 1.63 years). Approximately one-third of ED visits were low-acuity presentations (32.4%), and low-acuity presentations increased progressively with SES. In multivariate analysis, children from families with very high SES were twice as likely to have a low-acuity presentation (odds ratio 2.17; 95% confidence interval, 1.66-2.85). Low-acuity ED presentations cost the health-care system in excess of A$895 000-A$1 110 000 per year. CONCLUSIONS: These findings demonstrate that a significant proportion of paediatric ED visits are of low acuity and that these visits yield a substantial cost to the health system. Further research is required regarding care givers' rationale and potentially other reasons underlying these low-acuity ED presentations.

Developing a positive patient experience with nurses in general practice: An integrated model of patient satisfaction and enablement.

AIM: To develop a conceptual model that provides a comprehensive understanding of the structures and processes underpinning patient enablement and satisfaction in general practice nurse consultations. BACKGROUND: Current evidence regarding patient satisfaction and enablement arising from general practice nursing care is either quantitative or qualitative. To date, no studies have integrated the results of mixed methods research to provide a deeper understanding of processes that facilitate their achievement. DESIGN: A concurrent mixed methods study. METHODS: Our 2013-2014 concurrent mixed methods study comprised a quantitative study that analysed variables identified in interviews with general practice nurses, patients and practice managers with data from a cross-sectional survey of 678 patients receiving nursing care in 21 general practices; and a qualitative study that used a grounded theory approach to in-depth interviews with nurses and patients from these same practices. Using joint displays, we compared and integrated the results of the multilevel analyses and the grounded theory model derived from these studies. FINDINGS: We conceptualized a model-'developing a positive patient experience with nurses in general practice'-in which time, continuity of care, nursing scope of practice and autonomy, and patients' health conditions provide platforms for the processes of triggering healthcare partnerships and tailoring care in nurse consultations. CONCLUSION: This model builds on previous evidence describing processes and characteristics that optimize the quality of care in general practice nurse consultations. It provides a practical tool to inform education and training for general practice nurses and other clinicians.

Nurses' competence in genetics: An integrative review.

The aim of this integrative review was to update a mixed method systematic review by Skirton, O'Connor, and Humphreys (2012) that reported on nurses' levels of competence in using genetics in clinical practice. Three electronic databases were searched using selected key words. Research studies published in English between January 2011 and September 2017 reporting levels of nurse competence in genetics or genomics were eligible for inclusion. The selected studies were subjected to thematic analysis. Three main themes were identified: (i) genomic knowledge and utilization, (ii) perceived relevance to practice, and (iii) genomic education. While the reviewed papers produced varied findings, many nurses were shown to have poor genomic knowledge and/or competency, and yet there was a consensus that most nurses believe genomics is important to their practice. The present review indicated that in the past 5 years nurses have made minimal progress toward achieving the core genomic competencies appropriate for clinical practice.

Implications of male circumcision for women in Papua New Guinea: a transformational grounded theory study.

BACKGROUND: Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences. METHODS: The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women's understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health. RESULTS: Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice. CONCLUSIONS: This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women's ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.

Assessing the link between implementation fidelity and health outcomes for a trial of intensive case management by community health workers: a mixed methods study protocol.

BACKGROUND: Better systems of care are required to address chronic disease in Indigenous people to ensure they can access all their care needs. Health research has produced evidence about effective models of care and chronic disease strategies to address Indigenous health, however the transfer of research findings into routine clinical practice has proven challenging. Complex interventions, such as those related to chronic disease, have many components that are often poorly implemented and hence rarely achieve implementation fidelity. Implementation fidelity is "the degree to which programs are implemented as intended by the program developer". Knowing if an intervention was implemented as planned is fundamental to knowing what has contributed to the success of an intervention. METHODS: The aim of this study is to adapt the implementation fidelity framework developed by Keith et al. and apply it to the intervention implemented in phase 1 of the Getting Better at Chronic Care in North Queensland study. The objectives are to quantify the level of implementation fidelity achieved during phase 1 of the study, measure the association between implementation fidelity and health outcomes and to explore the features of the primary health care system that contributed to improved health outcomes. A convergent parallel mixed methods study design will be used to develop a process for assessing implementation fidelity. Information collected via a questionnaire and routine data generated during phase 1 of the study will be used to explain the context for the intervention in each site and develop an implementation fidelity score for each component of the intervention. A weighting will be applied to each component of the intervention to calculate the overall implementation score for each participating community. Statistical analysis will assess the level of association between implementation fidelity scores and health outcomes. DISCUSSION: Health services research seeks to find solutions to social and technical problems to improve health outcomes. The development of a tool and methodology for assessing implementation fidelity in the Indigenous primary health care context will help address some of the barriers to the translation of research into practice. TRIAL REGISTRATION: ACTRN12610000812099 : 29.9.2010.

The process of patient enablement in general practice nurse consultations: a grounded theory study.

AIM: The aim of this study was to gain insight into the process of patient enablement in general practice nursing consultations. BACKGROUND: Enhanced roles for general practice nurses may benefit patients through a range of mechanisms, one of which may be increasing patient enablement. In studies with general practitioners enhanced patient enablement has been associated with increases in self-efficacy and skill development. DESIGN: This study used a constructivist grounded theory design. METHODS: In-depth interviews were conducted with 16 general practice nurses and 23 patients from 21 general practices between September 2013 - March 2014. Data generation and analysis were conducted concurrently using constant comparative analysis and theoretical sampling focussing on the process and outcomes of patient enablement. Use of the storyline technique supported theoretical coding and integration of the data into a theoretical model. FINDINGS: A clearly defined social process that fostered and optimised patient enablement was constructed. The theory of 'developing enabling healthcare partnerships between nurses and patients in general practice' incorporates three stages: triggering enabling healthcare partnerships, tailoring care and the manifestation of patient enablement. Patient enablement was evidenced through: 1. Patients' understanding of their unique healthcare requirements informing their health seeking behaviours and choices; 2. Patients taking an increased lead in their partnership with a nurse and seeking choices in their care and 3. Patients getting health care that reflected their needs, preferences and goals. CONCLUSIONS: This theoretical model is in line with a patient-centred model of health care and is particularly suited to patients with chronic disease.

Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes.

Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.

Sharing success - understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease.

BACKGROUND: Rheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor. METHODS: This qualitative study used semi-structured interviews with patients, parents/care givers and health professionals, to explore the enablers of and barriers to the uptake of secondary prophylaxis. Data from participant interviews (with 11 patients/carers and 11 health practitioners) conducted in four far north Queensland sites were analyzed using the method of constant comparative analysis. RESULTS: Deficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. There were also varying perceptions regarding responsibility for ensuring injection delivery. Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery. CONCLUSION: The study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD.

Effective pain management as part of palliative care for persons living with HIV/AIDS in a developing country: a qualitative study.

AIM AND OBJECTIVES: The aim of this research was to explore and understand nurses' experiences of managing pain for persons living with human immune virus/ acquired immune deficiency syndrome receiving palliative care at home in Botswana. BACKGROUND: Community palliative and hospice care in Africa and Botswana were developed for persons with end-stage acquired immune deficiency syndrome and other terminal illnesses being cared for at home. As antiretro viral therapies extend the lives of persons living with human immune virus/acquired immune deficiency syndromes, there is an increase in the chronic conditions associated with human immune virus/acquired immune deficiency syndrome. Despite a strong demand for care of persons living with human immune virus/acquired immune deficiency syndromes and other chronic illnesses, little is known about Botswanan community nurses' capacity to manage community-based end-of-life care for persons living with human immune virus/acquired immune deficiency syndromes. DESIGN: A qualitative study approach guided by van Manen's interpretive analysis was undertaken. METHODS: Data were collected using semi-structured interviews that were audio-recorded, transcribed and analysed using qualitative interpretive analysis. Thirteen nurses from 12 health districts in Botswana were recruited to the study using purposeful sampling. RESULTS: Participants identified that pain management was a significant issue. A lack of nurses' ability to advocate effectively for patients because of a lack of relevant skills and knowledge and poor availability of appropriate analgesics was a limiting factor along with doctors' reluctance to prescribe opioids to effectively manage pain. CONCLUSION: Lack of resources coupled with lack of training for nurses has a negative impact on palliative care and the delivery of care services to persons living with human immune virus/acquired immune deficiency syndromes in Botswana. RELEVANCE TO CLINICAL PRACTICE: Being attentive and listening to the nurses' voices in the provision of palliative care at home is an essential element in identifying the challenges they encounter. Lack of adequate palliative care training and a chronic shortage of resources have serious implications for the delivery of home-based palliative care in Botswana.

Retaining early career registered nurses: a case study.

BACKGROUND: A core objective of the Australian health system is to provide high quality, safe health care that meets the needs of all Australians. To achieve this, an adequate and effective workforce must support the delivery of care. With rapidly changing health care systems and consumer demographics, demand for care is increasing and retention of sufficient numbers of skilled staff is now a critical priority to meet current and future health care demands. Nurses are the largest cohort of professionals within the health workforce. Reducing the rates at which nurses leave the profession and supporting nurses to practice in their profession longer will have beneficial implications for the sustainability of a nursing workforce and, ultimately, to patient outcomes. The aim of the study was to describe and explain early career registered nurses' (ECRNs) experiences and support requirements during the first five years of practice for the purposes of identifying strategies that would support greater retention of ECRNs. METHODS: A single case study design focused on early career registered nurses (ECRNs) working in a hospital and health service in northern Australia. The research team adopted Djukic et al's definition of ECRNs as "RNs who have practiced for less than 5 years". Data was collected via three individual interviews and two focus groups. Thirty-five ECRNs participated in the study. RESULTS: Qualitative analysis of data generated during interviews and focus groups, identified the key themes of receiving career advice and choice or no choice. Analysis of study data in the context of the broader literature resulted in the researchers identifying six areas of focus for ECRN retention: 1) well-planned, supported and structured transition periods; 2) consideration of rotation through different areas with a six month minimum for skills development; 3) empowering decision making; 4) placement opportunities and choice in decisions of where to work; 5) career advice and support that considers ECRNs' personalities and skills; and 6) encouragement to reflect on career choices. CONCLUSIONS: Reducing turnover and improving retention relies on understanding the factors that influence nurses' decisions to leave or remain within an organisation and the profession. Ensuring nurses in the current workforce remain engaged and productive, rather than leave the profession, is reliant on addressing factors that cause attrition and implementing strategies that strengthen retention rates and workforce sustainability.

When chronic conditions become emergencies - a report from regional Queensland.

OBJECTIVE: To describe chronic conditions and injuries as a proportion of total emergency presentations to a large public hospital in regional Queensland, and to investigate differences in presentation rates associated with Indigenous status. DESIGN: Cross-sectional analysis using Emergency Department Information System data between 1 July 2012 and 30 June 2014. SETTING: Regional Queensland, Australia. PARTICIPANTS: A total of 95 238 emergency presentations were generated by 50 083 local residents living in the 10 statistical local areas (SLAs) immediately around the hospital. MAIN OUTCOME MEASURES: Emergency presentations for chronic conditions and injuries identified from discharge ICD-10-AM principal diagnosis. Age-standardised presentation rates were calculated using the Australian 2001 reference population. RESULTS: Approximately half of all presentations were for chronic conditions (20.2%) and injuries (28.8%). Two-thirds of all chronic condition presentations were for mental and behavioural disorders (34.6%) and circulatory diseases (33.2%). Head injuries accounted for the highest proportion of injuries (18.9%). Age-standardised rates for major diagnostic groups were consistently higher for Indigenous residents, whose presentations were lower in mean age (95% CI) by 7.7 (7.3-8.1) years, 23% less likely to be potentially avoidable GP-type presentations [RR (95% CI) = 0.77 (0.75-0.80)], 30% more likely to arrive by ambulance [1.31 (1.28-1.33)] and 11% more likely to require hospital admission [1.11 (1.08-1.13)]. CONCLUSIONS: Opportunities exist to enhance current coordinated hospital avoidance and primary health services in regional Queensland targeting common mental and circulatory disorders, especially for Indigenous Australians.

Regional health workforce planning through action research: lessons for commissioning health services from a case study in Far North Queensland.

Creating a stable and sustainable health workforce in regional, rural and remote Australia has long been a challenge to health workforce planners, policy makers and researchers alike. Traditional health workforce planning is often reactive and assumes continuation of current patterns of healthcare utilisation. This demonstration project in Far North Queensland exemplifies how participatory regional health workforce planning processes can accurately model current and projected local workforce requirements. The recent establishment of Primary Health Networks (PHNs) with the intent to commission health services tailored to individual healthcare needs underlines the relevance of such an approach. This study used action research methodology informed by World Health Organization (WHO) systems thinking. Four cyclical stages of health workforce planning were followed: needs assessment; health service model redesign; skills-set assessment and workforce redesign; and development of a workforce and training plan. This study demonstrated that needs-based loco-regional health workforce planning can be achieved successfully through participatory processes with stakeholders. Stronger health systems and workforce training solutions were delivered by facilitating linkages and planning processes based on community need involving healthcare professionals across all disciplines and sectors. By focusing upon extending competencies and skills sets, local health professionals form a stable and sustainable local workforce. Concrete examples of initiatives generated from this process include developing a chronic disease inter-professional teaching clinic in a rural town and renal dialysis being delivered locally to an Aboriginal community. The growing trend of policy makers decentralising health funding, planning and accountability and rising health system costs increase the future utility of this approach. This type of planning can also assist the new PHNs to commission health services that meet the needs of the population and contribute to service and system improvement and innovation.