Sizing Up General Practice Environments for Big-Bodied Patients: An Environmental Assessment of Three Facilities in Aotearoa New Zealand.

OBJECTIVES: This research describes the physical environments of and equipment in Aotearoa New Zealand (NZ) general practices in relation to available standards for big-bodied people (BBP) seeking healthcare. BACKGROUND: The prevalence of BBP both in NZ and globally has increased over the last 30 years and is expected to increase further. As the first and most utilized point of contact for patients in NZ and many countries, it is essential that general practices provide suitable environments to cater for and meet the needs of big-bodied patients seeking healthcare. METHODS: An exploratory study utilizing an environmental investigation was undertaken in three diverse general practices. Data collection consisted of direct observation and physical measurements of practice layout and equipment. Findings were compared to the existing guidelines or standards for the healthcare of BBP. RESULTS: The analysis identified most environmental facets and equipment in all three general practices did not meet published guidelines for the care of BBP. CONCLUSIONS: In the global context of increasing and sustained prevalence of BBP, this exploratory study highlights it is crucial that general practices and similar community-based facilities review their physical environments and equipment and consider modifications to improve accessibility, inclusivity, and comfort for BBP.

"It was a very awkward consultation because I didn't know"-general practice staff experiences and challenges in providing healthcare to gender and sexual minority youth in Aotearoa New Zealand.

BACKGROUND: Rainbow young people (RYP; people of diverse genders, sexualities, and variations in sex characteristics) face barriers accessing primary care, often report negative experiences and the need to educate clinicians on rainbow-specific issues. This study explores general practice staff views and experiences of providing care to RYP. METHODS: Three focus groups were held with staff from 5 general practices in an urban area of Aotearoa New Zealand (25 participants in total). Practices were purposively selected to include some known to be more "rainbow-friendly" seeing larger numbers of RYP and some with no particular focus on RYP. All members of each practice were invited to participate, including administration and reception staff. Focus groups were audio-recorded, transcribed, and analysed in NVivo using inductive thematic analysis. RESULTS: Four main themes were identified: (i) Practice experience, (ii) Feeling awkward, (iii) Knowledge and training, and (iv) Structural barriers. Differences were apparent in health provider knowledge, comfort, and experience in providing care to RYP. Participants identified a lack of knowledge and training and wanted more resources and education. Systems limitations were common (e.g. with IT systems for recording gender) and often contributed to awkward clinical encounters. CONCLUSIONS: Participants recognized shortcomings in their training, knowledge, and level of confidence providing care to RYP and expressed a desire to improve their competency. Further work is needed to identify and trial practical strategies that help improve communication skills, knowledge, and the delivery of more equitable healthcare to RYP.

Uncertainty and certainty: perceptions and experiences of prediabetes in New Zealand primary care – a qualitative study.

Introduction Prediabetes is the asymptomatic precursor to type two diabetes mellitus, a significant and growing public health problem in New Zealand (NZ). Little is known about how general practitioners (GPs) and nurses view prediabetes care, and similarly little is known about how people with prediabetes view their condition and care. Aim This study aimed to investigate the views of NZ GPs and nurses, and people with prediabetes about prediabetes and its management. Methods This was a mixed qualitative methods study that is part of a randomised control trial of a prediabetes intervention. Results Three key themes emerged from the health professional data (GPs and nurses) and another three themes emerged from people with prediabetes data. GPs and nurses were uncertain about the progression of prediabetes; they felt prediabetes was not a priority and they were unsure about what to advise. People with prediabetes were uncertain about the diagnosis and information given to them; they were unsure about what to do about prediabetes and they found lifestyle change hard. Discussion GPs, nurses and people with prediabetes, expressed much uncertainty, but also some certainty about prediabetes. All were certain that prediabetes is common and increasing and that sustained lifestyle change was very difficult. But uncertainty prevailed about whether, in reality, prediabetes could be stopped, who would be most likely to benefit from lifestyle interventions and how best to achieve these. Older Maori and Pacific women were keen to promote lifestyle change and this appeared best done through Maori and Pacific peoples' organisations by means of co-designed interventions.

Experience of Sexual Healthcare by Maori and Non-Maori Young People: An Online Survey of 15-24 Year Olds in Hawkes Bay, New Zealand.

Objectives: To understand young people's expectations of, and experience with sexual healthcare in New Zealand. Methods: Online survey of 15-24 year olds in a region with high socioeconomic deprivation, with selected outcomes compared for Maori and Europeans. Results: Of 500 respondents, 60% had received sexual healthcare (74.3% in general practice) and 81% were happy with care received. Fewer Maori and people not in education, employment, or training reported positive experiences of sexual healthcare on arrival and in the consultation. Conclusions: Findings highlight the need for equitable delivery of youth-friendly, culturally safe, sexual and reproductive healthcare in general practice settings.

'Be nice to us, we're still learning': an online survey of young people in Hawkes Bay, New Zealand, about unmet need for sexual health care and improving access to services.

Background Young people need equitable access to high-quality sexual and reproductive health care to enjoy good sexual health. Methods This online survey of people aged 15-24years in a defined region of New Zealand asked about unmet need for sexual health care and sought views on improving access to sexual health care. Results Fivehundred participants took part in the study between August and October 2020, of whom 60% were female, 25% were of Maori (indigenous) ethnicity, and 21.4% were gender and/or sexuality diverse. Sixty percent had ever received sexual health care (300/500), and 74.3% received it from a general practice clinic (223/300). Overall, 41% (204/500) reported they needed, but had not received sexual health care in the past ('unmet need'). Reasons for unmet need included being shy, embarrassed or ashamed (74.5%, 152/204), fear of judgment by clinic staff (42.6%, 87/204), cost (32.8%, 67/204), concerns about confidentiality (28.9%, 59/204), and not knowing where to go (24%, 49/204). Maori participants were more likely to report not knowing where to go (32.1% vs 20%, P=0.04). Participants identified the need to reduce stigma, normalise sexual health care, improve convenience, affordability and awareness of services as key to improving access. Reassurance about confidentiality and being treated with kindness, empathy and respect were deemed critical to service acceptability. Conclusions Action is urgently needed at policy, funding and practice levels to improve access to services by: reducing societal stigma, normalising discussions around sexual health, improving affordability and raising awareness of services. Quality improvement is also needed in general practice to ensure young people can routinely access youth-friendly sexual and reproductive health care.

Young peoples' perspectives about care in a youth-friendly general practice.

INTRODUCTION Youth health outcomes are poor in New Zealand and have a life-long impact on individuals, whanau (family) and society. Little is known about how young people view their experiences of general practice care despite it being the most common place to access health care. AIM This study sought to explore young peoples' experiences of care in a selected, youth-friendly general practice. METHODS In-depth individual interviews with six young people. RESULTS Four themes were identified from young peoples' narratives in relation to their experiences of general practice care: going to the doctor is not easy for a young person; the attributes of staff make all the difference; specific youth-friendly consultation practices help young people; and a youth-friendly physical environment can help young people access services and feel safe. DISCUSSION Even though the study general practice had explicitly instituted youth-friendly initiatives, including offering no-charge consultations and specialist staff members, young people still described considerable barriers to attendance. Many barriers are practice-based and could be modified by staff training, provision of further youth care staff roles and consideration of environmental changes. Other barriers such as waiving prescription costs need government funding.

Access to sexual healthcare during New Zealand's COVID-19 lockdown: cross-sectional online survey of 15-24-year-olds in a high deprivation region.

BACKGROUND: New Zealand's response to the COVID-19 pandemic involved a nationwide stay-at-home lockdown in March-April 2020 that restricted access to primary healthcare services. METHODS: An online survey of 15-24-year-olds in a high deprivation region of New Zealand asked about the need for, and receipt of, sexual healthcare during lockdown. Experience of telehealth and preferences for future receipt of sexual healthcare were also explored. Social media advertising was used to recruit participants over five weeks in August and October 2020. RESULTS: The survey sample included 500 respondents comprising 58.8% females, 25.4% Maori (indigenous) ethnicity and 21.4% LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex +) young people. During lockdown, 22.2% of respondents reported sexual health needs (111/500), but fewer than half this group got help (45%, 50/111), believing their issue could wait, or due to barriers contacting services and lack of information about service availability. Experience of telehealth consultations (by 28/50 participants) was mostly favourable though only 46% agreed it was easier than going to the clinic. Telehealth methods were the preferred option by some participants for future receipt of sexual healthcare; but for most scenarios suggested, respondents favoured in-person clinic visits. CONCLUSIONS: Young people experienced unmet need for sexual healthcare during lockdown in New Zealand, but not because services were unavailable. Findings point to the need for targeted information dissemination to young people about available services and the importance of seeking help during lockdown. More research is needed to understand the advantages and disadvantages of sexual healthcare delivered via telehealth to inform future service provision.

Collaborative Care in Primary Care: The Influence of Practice Interior Architecture on Informal Face-to-Face Communication-An Observational Study.

BACKGROUND: Quality patient care in primary care settings, especially for patients with complex long-term health needs, is improved by interprofessional collaborative practice. Effective collaboration is achieved in large part by frequent informal face-to-face "on-the-fly" communication between team members. Research undertaken in hospitals shows that interior architecture influences informal communication and collaboration between staff. However, little is known about how the interior architecture of primary care practices might facilitate or hinder informal communication and collaboration among primary care staff. OBJECTIVES: This research explores the influence of primary care practice interior architecture on face-to-face on-the-fly communication for collaborative care. METHODS: An observational study was undertaken to compare face-to-face informal interactions between staff in three primary care practices of differing interior architecture. Data collected from practices included: direct observations floor plans, photographs, interviews, and surveys. RESULTS: Most primary care staff engaged in frequent, brief face-to-face interactions, which appeared to be key to the delivery of effective collaboration. Features of primary care practice designs that were associated with increased frequency of staff interaction included shared spaces, staff proximity/visibility, and the presence of convenient circulatory and transitional spaces where staff were able to easily engage in timely on-the-fly communication with colleagues. CONCLUSIONS: The interior architecture of primary care practices has an important impact on staff collaboration. Although more research is needed to investigate further details in more practices, close attention should nevertheless be paid to maximizing opportunities for brief face-to-face communication in well-designed shared spaces in primary care practices.

Collaborative care in 'Youth One Stop Shops' in New Zealand: Hidden, time-consuming, essential.

Young people in New Zealand have high morbidity but low service utilization rates. Dedicated youth services 'Youth One Stop Shops' provide 'wraparound' health and social care. However, little is understood about how staff within these services interact with each other or with external agencies to provide this specialist care. This article reports on volume and type of internal and inter-agency health and social service staff-staff interactions, to better understand elements of potential collaboration in day-to-day practice. An observational, case-study approach was utilized. Four dedicated youth services recorded data over three-month periods about a selected number of high-use clients. Youth service staff recorded all interactions with colleagues within their organization and staff from external services. A large volume of non-patient contact work was revealed, with a high proportion of 'complex/involved' interactions recorded. The range and diversity of external agencies with which youth service staff interacted with to meet the needs of young people was extensive and complex. The focus on 'information sharing' and 'complex/involved' interactions demonstrates a well-coordinated, wraparound service delivery model. Current funding formulae take inadequate account of the volume of non-patient contact work that youth services provide for high-needs young people.

What does palliative care look like in a New Zealand aged residential care facility when patients are admitted to die?

AIMS: New Zealanders dying in public hospitals or hospices are increasingly being discharged and admitted-to-die in aged residential care (ARC) facilities as hospitals and hospices struggle to meet demand. This study sought to investigate how care is delivered to patients admitted-to-die in an ARC facility. METHODS: A mixed-methods case study including a clinical notes review of seven patients who died in one ARC facility within three months of admission and a focus group with ARC facility staff and visiting professionals from other organisations. RESULTS: The clinical notes review showed a high burden of palliative care symptoms that constituted specialist palliative care, provided by ARC staff plus professionals from other organisations. Focus group data showed those involved were willing, but expressed significant concern about lack of structure and funding. CONCLUSIONS: As our increasing and aging population reaches end-of-life, New Zealand hospitals/hospices will not be able to provide ongoing specialist palliative care and admission-to-die in ARC facilities may be a viable alternative. However, ARC facilities are not set up or staffed to provide specialist palliative care of those admitted-to-die. A specific model of care that is funded appropriately is required.

Interagency collaborative care for young people with complex needs: Front-line staff perspectives.

Worldwide, a growing burden of health and social issues now affect young people. Interagency collaboration and the "integration" of health and social care services are advocated to address the increasingly complex needs of at-risk youth and to reduce barriers to accessing care. In New Zealand, Youth-One-Stop-Shops (YOSSs) provide integrated health and social care to young people with complex needs. Little is known about how YOSSs facilitate collaborative care. This study explored the collaboration between YOSSs and external agencies between 2015 and 2017 using a multiple case study method. This paper reports qualitative focus group and individual interview data from two of four case sites including six YOSS staff and 14 external agency staff. Results showed participants regarded collaboration as critical to the successful care of high needs young people and were positive about working together. They believed YOSSs provided effective wraparound collaborative care and actively facilitated communication between diverse agencies on behalf of young people. The main challenges participants faced when working together related to the different "world views" and cultures of agencies which can run contrary to collaborative practice. Despite this, some highly collaborative relationships were apparent and staff in the different agencies perceived YOSSs had a lead role in co-ordinating collaborative care and were genuinely valued and trusted. However without the YOSS involvement, collaboration between agencies in relation to young people was less frequent and rarely went beyond limited information exchange. Establishing and maintaining trusting interpersonal relationships with individual staff was key to successfully negotiating agency differences. The study confirms that collaboration when caring for young people with high needs is complex and challenging, yet agencies from diverse sectors value collaboration and see the YOSS integrated wraparound approach as an important model of care.

Exploring interprofessional, interagency multimorbidity care: case study based observational research.

BACKGROUND: The increase in multimorbidity or co-occurring chronic illnesses is a leading healthcare concern. Patients with multimorbidity require ongoing care from many different professionals and agencies, and often report a lack of integrated care. OBJECTIVE: To explore the daily help-seeking behaviours of patients with multimorbidity, including which health professionals they seek help from, how professionals work together, and perceptions and characteristics of effective interprofessional, interagency multimorbidity care. DESIGN: Using a case study observational research design, multiple data sources were assembled for four patients with multimorbidity, identified by two general practitioners in New Zealand. In this paper, two case studies are presented, including the recorded instances of contact and communication between patients and professionals, and between professionals. Professional interactions were categorized as consultation, coordination, or collaboration. RESULTS: The two case studies illustrated two female patients with likely similar educational levels, but with different profiles of multimorbidity, social circumstances, and personal capabilities, involving various professionals and agencies. Engagement between professionals showed varying levels of interaction and a lack of clarity about leadership or care coordination. The majority of interactions were one-to-one consultations and rarely involved coordination and collaboration. Patients were rarely included in communications between professionals. CONCLUSION: Cases constructed from multiple data sources illustrate the complexity of day-to-day, interprofessional, interagency multimorbidity care. While consultation is the most frequent mode of professional interaction, targeted coordinated and collaborative interactions (including the patient) are highly effective activities. Greater attention should be given to developing and facilitating these interactions and determining who should lead them.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus.

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin's 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

Observation of interprofessional collaboration in primary care practice: A multiple case study.

Interprofessional collaboration (IPC) is known to improve and enhance care for people with complex healthcare and social care needs and is ideally anchored in primary care. Such care is complex, challenging, and often poorly undertaken. In countries such as Canada, the United Kingdom, the Netherlands, Australia, and New Zealand, primary care is provided predominantly via general practices, where groups of general practitioners and nurses typically work. Using a case study design, direct observations were made of interprofessional activity in three diverse general practices in New Zealand to determine how collaboration is achieved and maintained. Non-participant observation of health professional interaction was undertaken and recorded using field notes and video recordings. Observational data were subject to analysis prior to collection of interview data, subsequently gathered independently at each site. Case-specific themes were developed before determining cross-case themes. Cross-case themes revealed five key elements to IPC: the built environment, practice demographics and location, practice business models, shared goals, and team structure and climate. The combination of elements at each practice site indicated that strengths in one area helped offset challenges in others. The three practices (cases) collectively demonstrated the importance of an "all of practice" commitment to collaborative practice so that shared decision-making can occur.

Observation of interprofessional collaborative practice in primary care teams: An integrative literature review.

BACKGROUND: Interprofessional collaboration improves patient care, especially for those patients with complex and/or chronic conditions. Many studies examining collaborative practice in primary care settings have been undertaken, yet identification of essential elements of effective interprofessional collaboration in primary care settings remains obscure. OBJECTIVE: To examine the nature of interprofessional collaboration (including interprofessional collaborative practice) and the key influences that lead to successful models of interprofessional practice in primary care teams, as reported in studies using direct observation methods. DESIGN: Integrative review using Whittemore and Knafl's (2005) five stage framework: problem identification, literature search, data evaluation, data analysis and presentation. Data sources and review method: Primary research studies meeting the search criteria were accessed from MEDLINE, PsycINFO, Scopus, King's Fund and Informit Health Collection databases, and by hand-searching reference lists. From 2005 to 2013, 105 studies closely examining elements of interprofessional collaboration were identified. Of these, 11 studies were identified which incorporated a range of 'real time' direct observation methods where the collaborative practice of health professionals was closely observed. RESULTS: Constant opportunity for effective, frequent, informal shared communication emerged as the overarching theme and most critical factor in achieving and sustaining effective interprofessional collaboration and interprofessional collaborative practice in this review. Multiple channels for repeated (often brief) informal shared communication were necessary for shared knowledge creation, development of shared goals, and shared clinical decision making. Favourable physical space configuration and 'having frequent brief time in common' were key facilitators. CONCLUSION: This review highlights the need to look critically at the body of research purported to investigate interprofessional collaboration in primary care settings and suggests the value of using direct observational methods to elucidate this. Direct observation of collaborative practice in everyday work settings holds promise as a method to better understand and articulate the complex phenomena of interprofessional collaboration, yet only a small number of studies to date have attempted to directly observe such practice. Despite methodological challenges, findings suggest that observation data may contribute in a unique way to the teamwork discourse, by identifying elements of interprofessional collaborative practice that are not so obvious to individuals when asked to self-report.

Miscommunication between patients and general practitioners: implications for clinical practice.

INTRODUCTION: Effective communication is integral to the general practice consultation, yet it is acknowledged that problems commonly occur. Previous research has shown that misunderstandings with potentially significant consequences occur frequently, but does not provide a clear picture of how and why miscommunication occurs, or how such problems can be prevented or resolved. This study explored the occurrence and management of specific examples of miscommunication in two routine general practice consultations. METHODS: A multi-method case study approach was used. The primary data collected for each case included a video-recorded consultation and post-consultation interviews with each general practitioner (GP) and patient. Instances of communication mismatch were examined using in-depth interaction analysis techniques. FINDINGS: GPs and patients may not be aware when misunderstandings have occurred. In-depth analysis of the case studies revealed the complexity of miscommunication: it was not a straightforward matter to locate when or why instances of communication mismatch had occurred, and each of the mismatches was quite distinctive: (1) they were identified in different ways; (2) they occurred at different points in the communication process; (3) they arose because of problems occurring at different levels of the communication, and (4) they had different consequences. CONCLUSION: Given the frequency and complexity of miscommunication in general practice consultations, GPs need to consider adopting various strategies, at both the practice/systems level and the level of the consultation interaction to minimise the risk of communication problems.

Interprofessional education for physiotherapy, medical and dietetics students: a pilot programme.

INTRODUCTION: Interprofessional education (IPE) has been shown to enhance interprofessional practice among health professionals. Until recently there has been limited opportunity to undertake such initiatives within existing pre-registration degree courses in New Zealand. AIM: This study aimed to test the feasibility of delivering an interprofessional component within existing health professional courses for medicine, physiotherapy and dietetics at the University of Otago, Wellington, New Zealand. METHODS: An interprofessional case-based course component (on chronic condition management) was developed by academic clinical teachers from schools of medicine, physiotherapy and dietetics at the same location. Evaluation was undertaken using a previously validated pre- and post-survey tool, to ascertain changes in attitude among students towards interprofessional practice, IPE and the effectiveness of health care teams. Focus groups were conducted with students and teachers. RESULTS: Survey results indicated pre-existing positive attitudes to interprofessional practice and education among students. There was a statistically significant increase in positive attitude towards such practice and education, and increased confidence in the effectiveness of heath care teams. Focus group findings were consistent with the survey results for students, and highlighted challenges experienced by the teachers. DISCUSSION: Students and teachers alike enjoyed the interprofessional interaction and benefited from a collaborative approach to chronic condition management. The timing and nature of learning activities and assessment methods created logistical challenges. Such course components have potential to improve collaborative practice and the quality and safety of health care among graduates. Interprofessional course components need to be equitable across disciplines and embedded in the unidisciplinary courses.

New Zealand general practitioners' non-urgent referrals to surgeons: who and why?

AIM: To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment. METHOD: During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral. RESULTS: 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in 73%, assistance with diagnosis and management was sought. In only 3% of eligible cases was no referral made. CONCLUSION: Elective surgical referral makes up a significant proportion of GP workload. In more than half of cases advice on diagnosis or management, rather than surgery, was sought, and in nearly two-thirds the patient was aged less than 65 years. Cancer control was a relatively frequent goal of referral. The very small number of cases where a desired referral was not made suggests that GP and patient expectations are adjusted to service capacity.

'It puts things out of your control': fear of consequences as a barrier to patient disclosure of mental health issues to general practitioners.

Research indicates that there is a high level of trust in health professionals but also a high level of non-disclosure of mental health issues to general practitioners (GPs). This paper explores the issue of patients' willingness to disclose mental health problems to GPs through interviews with 33 patients from the lower half of the North Island of New Zealand. Patients' willingness to disclose related to a range of factors but this paper focuses on fear and sense of control as these issues have received little attention in the extant literature and provide important discussion points for the conduct of consultations. Fear of the consequences of consultation warrants attention if general practice is to be promoted as the preferred point of contact for mental health consultations. The research reported here suggests that trust in a range of institutions and agencies, not just in the individual practitioner, would need to be achieved for the GP to be the preferred point of contact.