Competence, respect and trust: key features of successful interprofessional nurse-doctor relationships.

Professional relationships between doctors and nurses have often been seen as problematic, a barrier to effective collaborative practice, yet little is known about the intrinsic nature of such relationships in the primary care context. This study set out to explore roles of, and relationships between, nurses and doctors currently working in New Zealand primary care settings. Using a qualitative methodology, data were collected using in-depth interviews with 18 individual nurses and doctors working in primary care settings in Wellington, New Zealand. Doctors' and nurses' perceptions of their own and each others' roles, and the perceived relationships between individuals from both disciplinary groups were explored, using principles of naturalistic enquiry in a mixed method of analysis. The study findings indicate that effective interprofessional relationships between individual doctors and nurses can, and often do, exist in New Zealand primary care settings, although they are not universal. The identification and separation of vocational and business roles, and the development of professional identity, form the basis for a theory of trust development in nurse-doctor interprofessional relationships in New Zealand primary care. Professional identity is related to demonstration of professional competence, in turn related to development of mutual interprofessional respect and enduring interprofessional trust.

Interprofessional postgraduate education in primary health care: is it making a difference?

This paper explores attitudes to, and perceptions of, the impact of interprofessional postgraduate education for primary health care professionals, based on a postal survey of 153 primary health care professionals undertaking postgraduate qualifications in New Zealand. The response rate was 75% (114/153 responses); comprising 79 doctors, 28 nurses, 7 other health professionals. As a result of their postgraduate education, 92% (104/113) reported improvement in their own practice; 68% (72/106) reported a positive influence on their workplace practice. Forty-eight percent (53/111) increased their understanding of their own professional role; 79% (77/98) increased their understanding of another professional groups' skills and competencies. Twenty-two percent (25/114) perceived increased career opportunities within a year; 56% (64/114) in the longer term. Only 12% (14/114) perceived future increases in income as a result of their study. Interprofessional postgraduate qualification study for primary health care professionals in New Zealand resulted in personal and professional benefit for individuals and their clinical practice, and increased understanding about their own and other health professionals' roles. The interprofessional nature of the education was seen as positive, contributing to a modest increase in collaboration between health professional groups. Barriers to furthering participation in interprofessional learning and increasing intersectorial collaboration in the workplace are identified and discussed.

Early clinical exposure to people who are dying: learning to care at the end of life.

BACKGROUND: The nature of medical care at the end of life and, in particular, the way in which caring is learned remain problematic for medical educators and the profession. Recent work has indicated that doctors learn to care, in an emotional and intimate way, from people who are dying. METHODS: This paper reports on the development of a programme designed for medical students in their first clinical year who spend time with a person who is dying and their family. The students are required to produce a portfolio assignment that includes a personal reflection of the experience. The findings from a phenomenological study undertaken using these personal reflections are reported. These reflections and comments are interpreted as being embedded in five key themes. RESULTS: The actual encounters differed from the medical students' anticipation of them. Students identified an emotional component to the experience; they explored their own and the patient's understandings of spirituality; they reflected on personal meanings of the encounter and they suggested ways in which they might learn to care more effectively for people who are dying. DISCUSSION: The way in which many of these students approach end-of-life care has been altered through a transformative educational experience that encouraged them to draw on their own experiences and skills. Their learning was facilitated by the writing of accounts and the discussion that each group held with teaching staff at the conclusion of the programme.

Issues relating to early detection and diagnosis of breast cancer in New Zealand general practice.

AIM: This study describes current practice in New Zealand general practice with emphasis on identifying problem areas in the early detection of breast cancer. The study is focused on women outside the age group for the New Zealand breast screening programme (50-64 years). METHOD: Thirty selected general practitioners throughout New Zealand were interviewed in depth to identify the key issues relating to the early detection and diagnosis of breast cancer in the primary care setting. Attitudes to key issues were quantified in a later postal survey of 656 general practitioners randomly sampled from the RNZCGP database. RESULTS: The response rate to the quantitative study was 82%. General practitioners were generally well informed about risk factors for breast cancer and the relative sensitivity and specificity of screening and diagnostic tools. Diagnosis and management were influenced by the limitations of screening and diagnostic tools, as well as access to, and confidence in, services. The appropriate level of investigation and follow-up for young women was an area of uncertainty. CONCLUSION: The study provided data to inform guideline development and a baseline measure of current practice against which the impact of the implementation of guidelines could be measured.

Trainee interns in general practices.

AIM: To determine the impact of trainee interns (sixth year medical students) on general practices involved in medical student teaching. METHOD: Postal questionnaires were sent to general practitioners, nurses and receptionists in each of 30 general practices throughout New Zealand. Questionnaires were also sent to patients in practices where a trainee intern was present during the study period. RESULTS: Nearly all of the general practitioners, receptionists and nurses found advantages in having trainee interns. Advantages included enjoyment of teaching and personal satisfaction from student involvement in the practice. Two thirds felt that the advantages would increase if the attachment duration was extended. General practitioners reported an increased level of stress and decrease in productivity, with greater hours at work per week. Remuneration was considered inadequate by a third of the general practitioners. Patients found trainee intern involvement advantageous, with improvement in quality of both care and communication. Disadvantages included longer waiting time and longer appointment time. Younger patients were more likely to find disadvantages than older patients. CONCLUSION: Trainee interns in general practices can have a beneficial impact on the quality of primary care. There are disadvantages for health care professionals and patients, and appropriate compensation (in money or time) is important for community undergraduate medical education to continue to be acceptable.

Baby feeding: the thoughts behind the statistics.

AIM: To investigate attitudes towards baby feeding and to identify reasons why women stop breast feeding. METHOD: A series of six focus groups were held with thirty eight mothers with babies aged between 3 and 18 months, who had been breast and/or bottle fed. RESULTS: The discussions identified a number of significant themes. Decisions on baby feeding were made before birth. Women felt under considerable pressure to breast feed and felt guilty about bottle feeding. Information available about baby feeding was generally inconsistent, unrealistic and incomplete although all women were well informed about the benefits of breast feeding. Most women found breast feeding more difficult than anticipated and needed more help with common problems. A number of difficulties were identified with bottle feeding. Those women who enjoyed breast feeding were most likely to continue. The best support for breast feeding came from other mothers and supportive partners. Ceasing breast feeding was difficult for some women. CONCLUSION: Exploring mothers' attitudes to breast feeding highlighted the need for non judgemental attitudes to baby feeding and consistent information and support on both breast and bottle feeding. Duration of breast feeding is likely to be improved if problems can be addressed. A larger, more detailed prospective study would more accurately identify problem areas and suggest ways of solving them.

Premenstrual syndromes defined by symptom-sets.

An analysis is made of the pattern of presenting premenstrual symptoms in randomly selected general practice patients from the Wellington region, New Zealand. Participants, 1826 healthy women 16-54 years old whose characteristics were reasonably representative of the adult female population, were asked about their general, obstetrical and gynaecological health. For the 1456 women who had menstruated within the last month or so, detailed questions were asked about the last menstrual cycle. Each woman was assigned to one of seven premenstrual symptom sets. Three groups had 'pure' symptoms, ie a predominant single symptom (breast tenderness, bloating or irritability). Three groups had 'mixed' symptom-sets. The largest of the 'mixed' groups was formed by the women who reported breast tenderness, bloating and irritability together with tension and depression. Women in this group were most likely to rate their symptomatology as severe. The last group contains a large number of women with miscellaneous symptoms. Characteristics of these groups are outlined. The study highlights the importance of distinguishing among premenstrual syndromes as this can foster more effective clinical management.

Treatment of premenstrual symptoms in Wellington women.

A survey of 1826 women in the Wellington region was carried out. Participants were asked about their general and gynaecological health, as well as detailed questions about their last menstrual cycle. The majority (1456) had had a menstrual period within the last month or so. Eighty five percent of these women noted premenstrual symptoms of some kind, and were asked about a variety of self-help measures, and medical help, for these, and whether the advice and/or treatment was in fact helpful. Nine hundred and ninety women had tried self-help while four hundred and sixteen had sought medical help. The most commonly tried self-help measures were exercise, rest and vitamin B6. Half the women had tried each of these. Overall, there was a marked placebo response, but exercise, rest and keeping a written diary of symptoms were all helpful in over eighty percent of those who tried them. Doctors offered a wide range of treatments, including vitamin B6, diuretics, oral contraceptives and mefanamic acid, but the effect of these was difficult to evaluate further. When the sample was subdivided into clusters of women who shared similar symptoms, significant differences in the effectiveness of different self help measures emerged. Four different premenstrual syndromes are suggested: PMS-breast, PMS-bloat, PMS-irritable and intolerant, and PMS-various.

Prevalence of dysmenorrhoea in Wellington women.

A survey of 1826 women in the Wellington region was carried out. Participants were asked about their general and gynaecological health and their menstrual, contraceptive and obstetric history. Detailed questions were asked about the menstruating women's last menstrual cycle. Half the women reported some dysmenorrhoea, and 520 had 'significant period pain.' Severity, duration and timing of pain were indexed. There was maximum prevalence at 20 to 24 years and positive associations with smoking, short cycles, and moderate to severe premenstrual symptoms. There was association with method of contraception but no association with sedentary occupation or body mass index. The apparent negative relationship with parity was not significant when age, smoking and premenstrual symptomatology were taken into account.

PIP: 1826 women in the Wellington region of New Zealand were surveyed to determine the prevalence and severity of dysmenorrhea. Study participants ranged in age from 16-54 years and had been recruited from the population of women who attended general practice surgeries for 1 week during June 1985. 30 general practice surgeons were randomly selected from a list of 190 doctors in general practice within the greater Wellington area. Questions were asked about several aspects of general health as well as about each woman's menstrual, contraceptive, and obstetrical history. 80% of the women surveyed were menstruating currently. The analysis was restricted to currently menstruating women to avoid any bias due to problems of longterm recall. 772 women (53%) responded that they experienced pain with their periods; 176 women (12%) reported discomfort severe enough to necessitate time off work or school. 12% of the total sample reported pain lasting 3 or more days; 36% reported pain lasting 2 or more days. 1/3 of all the women reporting period pain said the pain occurred only during menstruation; over half reported that it occurred both before and during menstruation. Some women experienced pain premenstrually only. Both prevalence and severity of dysmenorrhea were highest among women under age 25, with maximum prevalence and severity between 20-24 years (63% prevalence, 47% with significant period pain). The association with age was strong and was controlled for when considering other associations. Women with shorter menstrual cycles reported significantly more dysmenorrhea than those with average or long cycles. Smoking of cigarettes increased both prevalence and severity of dysmenorrhea. When smoking habits and age were controlled for, there was no consistent difference in prevalence or severity of dysmenorrhea with parity. Oral contraceptives (OCs) were seen to lessen both prevalence and severity of dysmenorrhea.

The prevalence of premenstrual symptoms in Wellington women.

A survey of 1826 women in the Wellington region was carried out. Participants were asked about their general and gynaecological health and their menstrual, contraceptive and obstetric history. Detailed questions were asked about the menstruating women's last menstrual cycle. Subjects were premenopausal women attending a random sample of general practice surgeries for any reason. The achieved sample is not intended as a cross-section of the Wellington community, but is nevertheless reasonably representative of the general adult female population aged 20 to 45. Most women volunteered one or more premenstrual symptoms; and about half of the women said these symptoms were such that they affected their lives.