“WHAT ARE PATIENTS’ PERCEPTIONS OF
THE NURSING CONTRIBUTION THROUGH
THE MINISTRY OF HEALTH FUNDED
SEMI-STRUCTURED PROGRAMME
CURRENTLY KNOWN AS CAREPLUS?”
Playing the advantage:
2011 Conference for General Practice,
Langham, Auckland
Ebbett J F RGON, RSCN (UK), BN, PGDip HSM, PGDip PHC,
MPHC
McKinlay E RN, MA (App), Adv Dip Nurs
Titchener J MD MSPT MA
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Researcher interest and background
 CarePlus Coordinator Health Hawkes Bay July 2005present
 Other related professional roles include; Nursing Council
(NZ) Convenor, Professional Conduct Committee,
RNZCGP Cornerstone Assessor, MoH Primary Health
Care Nursing Expert Advisory Committee member
 Models of long term condition management grew out of
PGDip
 Thesis requirement for Mphc
 Ministry of Health intentions July 2007
 Patient narrative
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Introduction
 CarePlus- a NZ chronic care initiative
 Funding for extra primary care visits
 Aims to improve chronic care management,
primary health care teamwork and reduce
health inequalities (MoH, 2004)
 Focus on education, self-management and
linkage with related chronic care programmes
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Research Aim
 Develop
a
practical
and
theoretical
understanding of what the patient understands
the nursing contribution to be in a NZ chronic
care programme (CarePlus)
 To ascertain from patients those elements of
the overall nursing contribution they find
helpful and why
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Background: the literature
 Limited literature on patient perception of nursing
contribution particularly in primary care
 Gaps in literature around how patients perceive
the role of nurses in long-term conditions
programmes
 Most of the literature on patient perception:
-Older
-Secondary care based
-Physician based
-Nurse specialist/Case management
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Literature summary
 Accessibility, advice, technical support (Lloyd-Williams et
al.,2005; Patterson & Britten, 2000; Phillips et al., 2007; Wiles, 1997;
Wright, et al., 2007).
 Knowledge/social/communication and emotional skills
of nurse (Balint, 1957; Fox & Chelsla, 2008; Lloyd-Williams et al.,
2005; Wiles, 1997, Wright et al, 2007).
 Teamwork and roles of nurses (Carryer, Snell, Perry, Hunt &
Blakey, 2008; Lupton, 2003; Miles, 1991; Robison & Wiles, 1994;
Wiles, 1997).
 Lifestyle advice and behaviour (Haidet, Krol, Sharf, 2006;
Lloyd-Williams et al., 2005; McDonald & Rogers, 2008; Page,
Lockwood & Conroy-Hiller, 2005).
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Methodology
 Methodology: qualitative, descriptive, interpretive
 Central Region Ethics committee approval:
 CEN08/24/EXP
 Purposeful sampling
 Individual interviews with patients in CarePlus programme
August 2008-July 2009
 Semi structured, iterative depending on
responses). Audio taped, transcribed verbatim
respondent
 Analysis: Inductive thematic, data management supported
by NVivo
 Researcher conflict of interest
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
14 Participants: summary
 <3 months to 2 years in
Care Plus programme
 Ethnicity:
Pakeha,
Maori, Pacific
 Age: 20 - 80 (majority
between 60 and 80
years)
 Employed, unemployed,
sickness
beneficiary,
student, retired
Conditions:
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Asthma
Hypertension
Type 1 Diabetes
Type 2 Diabetes
IHD
Schizophrenia
Asbestosis
Gout
Polycystic ovary
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Initial (unexpected) finding
 Participants had a limited view of what CarePlus
was;
- Lowered GP fees
- Initially unsure of purpose of nurse consultation
 Narrow view-initially restricted perception of the
nursing contribution
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Emergent findings and results
Interpersonal
communication
Clinical
Support
Guide/
Interpreter
Patient
perception of
nurses
Self
management
support
Coaching
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Clinical support
Sub themes:
 Technical skills
 Cholesterol advice, BP/WT
monitoring, smoking cessation,
pain management, foot care, diet
advice
 Planning care
 Early diagnosis, goal setting, follow
up care, referral, initiator of clinical
programmes
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What the participants said about
‘clinical support’
Just mainly watch my weight, which is really down. I
was a big person. I was round 130kg. And I was
weighed on Monday, which was the third, and I’m
down to 98…er, 89.
(Participant 6: 46 years old, New Zealand European Female,
>12 Months Registered, Diabetes/Ischaemic Heart Disease)
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Coaching
Sub themes:
 Motivator
 Behaviour change, confidence
building, encouragement, nudging,
ongoing support, reinforcing.
 Skill development
 Breaking task down, education, goal
setting, help with early diagnosis.
 Assessment activity  Follow up care, maintenance.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What the participants said about
‘coaching’
They just went through everything within the first
day. But not too much, because … she could see
that I was … a bit dazed and confused, and going,
"Oh my God, this is too much information."
So that's why they had me back every day for the
week and a bit, to make sure that I was
understanding what was going on.
(Participant 13: 32 years old, New Zealand European Female, >12
Months Registered, Diabetes/Hypertension).
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Interpersonal communication
Sub themes:
 Communication
 Answers questions, confidencebuilding, confidential, talk therapy,
filter, listening, affirming, sounding
board.
 Attitude/humanness  Attentive, available, encouraging,
friendly, trusting.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What the participants said about
‘interpersonal communication’
I probably talk to the nurse about more things… And
then when you talk to the doctor…about specific
things… the nurse is probably more general, and
then if there's any problems that she sees, then
that's what I would talk to the doctor about [the
problems].
(Participant 13: 32 years old, New Zealand European Female, >12
Months Registered, Diabetes/Hypertension).
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Guide and interpreter
Sub themes:
 Guide
 Breaking news, help with early
diagnosis, breaking the task down,
future planning
 Interpreter
 Filter, analyst, judge
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What the participants said about
‘guide and interpreter’
… we talked about, goal-setting… And … doing
goals. So this is my first goal. We're going to look at
weight first…She thought this was a good way to
start things, and… then we can look at other
things…I thought it was a good idea… because
every time I'm going to get weighed, I'm going, "God,
I haven't lost anything. I haven't put anything on." I
says, "My God, but I know I'm overweight."
(Participant 12: 48 years old, New Zealand Maori Male, Less than 3
Months Registered, Gout/Valve Replacement).
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Self management support
Sub themes:
 Self care support –
skills and
techniques
 Practicing behaviours, care
planning, problem solving, self
efficacy, skills training,
monitoring/managing symptoms,
attends appointments.
 Partnerships and
teamwork
 Joint decision making, walking
alongside.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What the participants said about
‘self management support’
I've been trying … to weigh myself every Saturday
morning, before breakfast. I've started doing that
again … I bought myself a new set of scales, so that
I can read them properly, so that's made a big
difference, because I just had a set of scales with a
clock sort of thing, and they were hopeless. So I
bought myself a digital pair. Now I really know
whether I'm going up or down.
(Participant 8: 64 years old, New Zealand European Female, 12
Months Registered, Type 2 Diabetes/Arthritis).
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
What does this mean for general
practice?
Patients limited understanding of CarePlus
Overall:
 Patients feel “guided” through the
management of their long term conditions;
 Patients perceive the nurse works with them
(intentionally) to determine what they take to
the doctor.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
So what does this mean about the
nursing contribution?
 Deficit in technical support
 Accessibility and sustained contact with
knowledgeable nurses with social and emotional
skill
 Lifestyle advice and interpersonal communications
 Relational continuity important
 Variation in delivery
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Limitations
 Project small and in one geographic location
 Those who chose not to participate may have
different thoughts about the nursing contribution
 Data collected from single point in time
 Favorable perceptions cannot be linked to
improved patient health outcomes
 Participants all English speaking
 Data collection by nurse
 Limited literature on the actual nursing
interventions in chronic conditions management
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Recommendations
 Review how general practice explains benefit of
CarePlus/frequency of follow up
 Enhance intentional patient centered goal setting
and care planning
 Development of nursing competency and
capability
 Protocol for follow up and discharge of patients
 Patient advisory
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Playing the advantage
 EIT evaluation of Nurse Healthy Lifestyle Clinics
 Purposeful and deliberate nursing consultation by:
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NursePoint Seminar Series;
Development of suite of assessment tools;
Nurse sensitive patient outcomes (DRINFO);
Structured supported self management;
Clinical supervision;
Nursing workforce development steering group
 HBDHB Long Term Conditions-Nursing Workforce
Development funding/CarePlus reserves.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Conclusion
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Establish what patients value and why;
Patient understanding of CarePlus is limited;
Patient motivation to engage;
Opportunities for nursing development: e.g. sleep, mental
health, and pain;
Patient world view vs: disease screening and monitoring;
Nurses need clinical skills to plan for right care and
communication skills for relational continuity
Patient increased confidence-especially when service is
recommended;
Patient preference with specialist need
Function of careplan questionable
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
References
 Balint, M. (1957). The doctor, his patient and the illness. New York:
International Universities.
 Carryer, J., Snell, H., Perry, V., Hunt, B., & Blakey, J. (2008). Long term
condition care in general practice: Patient perspectives. New Zealand
Family Practitioner, 35(5).
 Crowe, M., O'Malley, J., & Gordon, S. (2001). Meeting the needs of
consumers in the community: a working partnership in mental health in New
Zealand. Journal of Advanced Nursing, 35(1), 88-96.
 Fox, S., & Chesla, C. (2008). Living with chronic illness: A phenomenological
study of the health effects of the patient-provider relationship. Journal of the
American Academy of Nurse Practitioners, 20(3), 109-117.
 Guba, E., & Lincoln, Y., S. (1989). Fourth generation evaluation. . Newbury
Park, California: Sage Publications.
 Haidet, P., Kroll, T. L., Sharf, B. F., The complexity of patient participation:
Lessons learned from patients’ illness narratives. Patient Education and
Counselling 62, 323-329
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
References
 Lupton, D. (2003). Medicine as culture: Illness, disease and the body in
western societies. London: Sage.
 Lloyd-Williams, F., Beaton, S., Goldstein, P., Mair, F., May, C., & Capewell,
S. (2005). Patients' and nurses' views of nurse-led heart failure clinics in
general practice: a qualitative study. Chronic Illness, 1(1), 39-47.
 Macdonald, W., Rogers, A., Blakeman, T., & Bower, P. (2008). Practice
nurses and the facilitation of self-management in primary care. Journal of
Advanced Nursing, 62(2), 191.
 Paterson, C., & Britten, N. (2000). Organising primary health care for
people with asthma: the patient’s perspective. British Journal of General
Practice 50, 299-303.
 Robison, J., & Wiles, R. (1994). Teamwork in Primary Care: Do Patients
Benefit? , University of Southampton, Southampton.
 Wiles, R. (1997). Empowering practice nurses in the follow-up of patients
with established heart disease: lessons from patients' experience. Journal of
Advanced Nursing, 26(4), 729-735.
 Wright, K., Ryder, S., & Gousy, M.(2007) Community Matrons improve
health: patients’ perspectives. British Journal of Community Nursing,
12(10), 453-459.
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand
Acknowledgements
 Research Supervisors: McKinlay, E. & Titchener, J.
 Department of Primary Health Care and General
Practice, Otago University, Wellington
 Chair of General Practice Trust Postgraduate Study
Fees Scholarships: Wellington Faculty
 Hawkes Bay Medical Research Foundation Inc.
 College of Nurses Aotearoa (NZ) Inc.,
Putiputi O’Brien Scholarship
 Health Hawke’s Bay-Te Oranga Hawke’s Bay
 Research participants
Department of Primary Health Care and General Practice
University of Otago – Wellington – New Zealand