MAPPING A NEW FUTURE:
PRIMARY HEALTH CARE NURSING
IN NEW ZEALAND
Nicolette Fay Sheridan
A thesis submitted in partial fulfilment of the requirements
for the degree of Doctor of Philosophy,
The University of Auckland, 2005
Thesis Consent Form
This thesis may be consulted for the purpose of research or private study provided that
due acknowledgement is made where appropriate, and that the author’s permission is
obtained before any material from the thesis is published.
I agree that The University of Auckland Library may make a copy of this thesis for
supply to the collection of another prescribed library, on request from that library; and
I agree that this thesis may be photocopied for supply to any person in accordance
with the provision of Section 56 of the Copyright Act 1994.
Signed:
Date:
Abstract
The aim of the study was to determine the practice of nurses employed in integrated
care projects in New Zealand from late 1999 to early 2001. Integrated care was a
major health reform strategy that emphasised primary health care as a means to
improve service provision between the health sectors. An investigation of nurses’
practice sought to determine the extent to which primary health care principles had
been adopted in practice, as a comprehensive primary health care approach has been
advocated globally in the management of chronic conditions; the leading cause of
disability throughout the world and the most expensive problems faced by health care
systems.
The philosophical basis of the research was postpositivism. The study employed a
quantitative non-experimental survey design because it allowed numeric descriptions
of the characteristics of integrated care projects to be gained for the purpose of
identifying nurses’ practice. The unit of inquiry was the integrated care project, and
80 comprised the study population. Data were obtained on projects from expert
informants (n=27) by telephone survey using a structured interview questionnaire
developed by the researcher.
Data obtained from interviews were statistically analysed in two stages. First, data
were produced to comprehensively describe the characteristics of integrated care
projects and nurses practice. The ‘Public health interventions model’ was used as a
framework to analyses the interventions (activities) and levels of population-based
practice of nurses. Following this, the social values embedded in nurses’ practice
were determined using ‘Beattie’s model of health promotion’ as a framework for
analysis.
A strong association was found between nurses’ practice in projects and strategies
used in integrated care, such as information sharing, guideline development and
promotion, and case management, and projects with an ethnic focus, low income
focus, chronic condition focus, and well-health focus.
Whilst nurses undertook
interventions most frequently at the individual practice level they were also strongly
i
associated with the small proportion of interventions that were undertaken at the
community level.
The majority of interventions by nurses reflected the health
promotion value of health persuasion, indicating a paternalist and individual-oriented
philosophy. Nurses were engaged in two interventions that indicated a collectiveoriented philosophy - coalition building and community development, the latter
reflecting health promotion values of negotiation, partnership and empowerment.
The study demonstrated that nurses’ practice in projects was predominantly centred
on individual-focused population-based practice suggesting the need for a framework
to assist nurses to transition their practice to include more activity at the community
and systems levels. Without a reorientation of practice, nurses will remain limited in
their ability to achieve health gains for populations. In response to this conclusion,
and drawing on research results and reviewed literature, a new model, The ‘Primary
Health Care interventions model’ was constructed.
Recommendations include
advocacy for the acceptance of the model by the health funder, professional nursing
bodies, health organisations, educational institutions, nurses, communities, and
individuals.
ii
Dedication
To my mother and father who taught me to care and reason,
and whose experiences of illness gave new insights into the emerging model,
with love
iii
Acknowledgements
During the years that led up to this thesis, I have drawn often and long upon the time,
advice, wisdom and good will of Jennifer Hand.
Margaret Horsburgh has also
provided significant help, and I thank both sincerely. For similar favours granted at
more select points in time warm thanks go to Paul Brown, Barbara Smith, Val Grey,
Warren Jones, Wendy Diamond, Sarah Lovell and Ivana Nakarada-Kordic.
I owe a depth of gratitude to Lorraine Nielsen for her enduring kindness and
generosity, and to Mary Finlayson who encouraged and believed in me. I am likewise
grateful to Matthew Parsons and work colleagues who provided good cheer.
Marjorie Schaffer, Linda Olson Keller, Sue Strohschein and Ron Labonte provided
gracious hospitality and ready knowledgeable assistance; without them this would be
a lesser work.
Thanks also go to the New Zealand Ministry of Health for assisting with scholarship
funding and Judy Kilpatrick, School of Nursing, University of Auckland who
graciously allowed me to organise my days to complete this project. I am obliged to
these institutions for their assistance.
For all kinds of things having to do less directly, but no less essentially with this thesis
completion, my fondest appreciation goes to Vicki Newton, friends and family.
Finally, my gratitude extends to all those participants who stimulated my
understanding of health and care; and how we, as nurses and health professionals, can
assist clients in meeting their needs for health and wellness in a rapidly changing
society.
iv
Table of Contents
ABSTRACT
I
DEDICATION
III
ACKNOWLEDGEMENTS
IV
TABLE OF CONTENTS
V
LIST OF TABLES
XIII
LIST OF FIGURES
XV
INTRODUCTION
XVI
1Chapter 1
Public health and generations of health reform
1
1.1
Introduction
1
1.2
Public health in context
1
1.3
Health systems and health reform
5
1.3.1
Three generations of health system reform
8
1.3.1.1 First generation health system reform
1.4
9
1.3.1.2 Second generation health system reform
10
1.3.1.3 Third generation health system reform
11
Public health developments intersect generations of health reform
14
1.4.1
Era of indigenous control (pre-colonisation)
14
1.4.2
Colonial era (1840 to 1890)
16
1.4.3
Nation-building era (1890 to 1940)
17
1.4.4
Affluence, medicine and infrastructure (1950s to early 1970s)
18
1.4.5
Life-style era (late 1960s to mid-1980s)
20
1.4.6
New public health (1980 to 2005 and beyond)
22
2Chapter 2
Health promotion theory
27
2.1
Introduction
27
2.2
Health promotion and nursing
28
2.3
Beattie’s model of health promotion
30
2.3.1
Health persuasion
32
2.3.2
Personal counselling
33
2.3.3
Legislative action
34
v
2.3.4
Community development
34
2.3.5
Beattie’s model: Health promotion values in practice
36
2.4
Health promotion: Social theories and models
37
2.4.1
Social theories
37
2.4.2
Models of health education and health promotion
38
2.5
Beattie’s model: An analytic framework for use in the NICPS
40
2.6
In conclusion
41
3Chapter 3
Chronic Conditions
43
3.1
Introduction
43
3.2
Chronic conditions challenge the health care system
44
3.2.1
Categorising countries
46
3.2.2
The reasons chronic conditions are escalating in New Zealand
46
3.2.2.1 Demographic trends and population ageing
47
3.2.2.2 Consumption patterns and life-style changes
49
3.2.3
Economic impact
51
3.2.3.1 New Zealand: Health care costs
3.2.4
3.3
Impact on the poor
55
Changing the systems of care
3.3.1.1
57
Community resources and policies
60
3.3.1.2 Health system organisation of care
60
3.3.1.3 Self-management support
60
3.3.1.4 Delivery system design
61
3.3.1.5 Decision support
61
3.3.1.6
61
Clinical information systems
Risk prevention
3.4.1
3.5
53
Current health systems are not designed for chronic problems
3.3.1
3.4
52
62
Government responsibility for health
64
In conclusion
65
4Chapter 4
Primary health care nursing
67
4.1
Introduction
67
4.2
The current PHC nursing workforce
68
4.2.1
Primary health care and community survey 2001
69
vi
4.2.2
4.3
Education preparation
70
Nursing groups in communities
71
4.3.1
Community nurses in early New Zealand
71
4.3.2
District Nursing
72
4.3.3
Public Health Nursing
73
4.3.4
Plunket Nursing
74
4.3.5
School Nursing
75
4.3.6
Practice Nursing
77
4.3.7
Other community nursing groups and new strategies
79
4.3.8
The historical legacy of community nursing
79
4.4
Contemporary PHC nursing developments
82
4.4.1
Background
82
4.4.2
PHC Nursing scholarships and innovative models of practice
83
4.4.3
Nurse Practitioner scope of practice
85
4.5
A model for PHC Nursing: The public health interventions wheel
4.5.1
87
Describing the Public Health Intervention Wheel
89
4.5.1.1 Population-based
90
4.5.1.2 Individual and family, community, and systems levels of
practice
91
4.5.1.3 Seventeen public health interventions
93
4.5.2
Validated and evidence-informed
96
4.5.2.1 Findings of the review of the intervention wheel
4.6
96
In conclusion
97
Chapter 5
5 Integrated Care
99
5.1
Introduction
99
5.2
Recent background
100
5.3
Central problem: Fragmentation between services
101
5.4
Integrated care: Different definitions and meanings
104
5.4.1
NICPS definition of integrated care
105
5.4.2
Perspectives of Ministers, advisors and purchasers
107
5.4.3
Types of integrated care
109
5.4.4
Strategies for integrated care
110
5.4.4.1
Collaboration
5.4.4.2 Case management
110
111
vii
5.4.4.3 Guideline development
5.4.5
5.5
Implications of integrated care for Maori
New Zealand integrated care demonstration pilot projects
112
113
116
5.5.1
Conceptual development
116
5.5.2
Potential risks in integrated care
118
5.5.3
Implementation: What actually happened?
119
5.5.4
Evaluation findings
123
5.6
In conclusion
Chapter 6
6 Methods: Nurses in integrated care projects study
125
127
6.1
Introduction
127
6.2
Research questions
128
6.3
A framework for the study design
129
6.3.1
6.4
Quantitative and descriptive: The survey
Study Methods
6.4.1
Study population
132
133
133
6.4.1.1
Eligibility
133
6.4.1.2
Sampling
134
6.4.1.3 Procedures for the recruitment of projects
135
6.4.2
Ethical considerations
136
6.4.3
Data collection
136
6.4.3.1 Interview questionnaire
136
6.4.3.2 Question form and content
139
6.4.3.3
Pilot-testing the instrument
141
6.4.3.4
Reliability and validity
142
6.4.3.5 The role of the interviewer
6.4.4
Organising the data for analysis
6.4.4.1 Constructing a code and assigning to survey data
144
147
147
Ethnic group
152
Low income
153
Age group
153
Disease or condition
154
6.4.4.2 Data entry
157
6.4.4.3 Coding and data reduction as a source of errors
158
6.4.5
Data analysis
158
viii
6.4.5.1 Stage one analysis
159
6.4.5.2 Stage two analysis
160
Chapter 7
7 Results: Nurses in integrated care projects study
162
7.1
Introduction
162
7.2
Study results
162
7.2.1
Survey respondents
162
7.2.2
Integrated care projects
163
7.2.3
Organisational structure
163
7.2.4
Funding
165
7.2.5
Type of service integration
165
7.2.6
Strategies for integration
166
7.2.7
Project level of population-based practice
167
7.2.8
Age group
168
7.2.9
Ethnic group
168
7.2.10 Low income
169
7.2.11 Disease, condition, or other focus
169
7.2.12 Non-nursing personnel
171
7.2.13 Nursing
171
7.3
Projects employing nurses
7.3.1
177
Planning a new health service and delivering an existing health
service differently by projects employing nurses
177
7.3.2
Funding by projects employing nurses
178
7.3.3
Type of service integration by projects employing nurses
178
7.3.4
Strategies of integration by projects employing nurses
178
7.3.5
Project level of population-based practice by projects employing
nurses
180
7.3.6
Age group by projects employing nurses
180
7.3.7
Ethnicity by projects employing nurses
181
7.3.8
Low income by projects employing nurses
181
7.3.9
Disease, condition or other by projects employing nurses
182
7.3.10 Chronic or acute condition, well-health, or other by projects
employing nurses
183
7.3.11 Non-nursing personnel by projects employing nurses
183
7.4
Chronic or acute condition, well-health, or other
7.4.1
Health service by chronic or acute condition, well-health, or other
183
183
ix
7.4.2
Project level of population-based practice by chronic or acute
condition, well-health, or other
184
7.4.3
Age group by chronic or acute condition, well-health, or other
185
7.4.4
Age group by disease, condition or other
186
7.4.5
Ethnicity by type of disease, condition or other
187
7.5
Age group
187
7.5.1
Ethnicity by age group with and without disease or condition
187
7.5.2
Income by age group, with or without disease or condition
188
7.6
Nursing interventions
189
7.7
Social values embedded in the practices of nurses employed in projects
192
7.8
Summary of study results
195
Chapter 8
8 Discussion
199
8.1
Introduction
199
8.2
Which characteristics of integrated care are more strongly associated
with projects that employ nurses?
200
8.2.1
Organisation
200
8.2.1.1 Delivering an existing service differently and planning a new
service
200
8.2.1.2 Health care services provided by projects
201
8.2.1.3 Incentives and costs for general practice to be a project
partner
203
8.2.1.4 Material incentives to clients
204
8.2.1.5 Incentives and costs for the hospital to be a project partner
205
8.2.2
Funding
206
8.2.3
Type of service integration
207
8.2.4
Strategies for integrated care
208
8.2.4.1 Information sharing
208
Building relationships
209
Peer advice, education and referral
210
Client education
210
Development of a database
211
8.2.4.2 Guideline development and promotion
211
8.2.4.3 Case management
212
8.2.4.4 New coordination strategies
214
8.2.5
Level of population-based practice approach of projects
214
x
8.2.6
Age group focus
217
8.2.7
Ethnic group focus
219
8.2.8
Low income focus
221
8.2.9
Health, disease, condition or other focus
222
8.2.10 Non-nursing personnel
8.3
Population-based interventions and levels of practice undertaken by
nurses in integrated care projects
225
227
8.3.1
Intervention: Surveillance
228
8.3.2
Intervention: Disease and health event investigation
228
8.3.3
Intervention: Outreach
229
8.3.4
Intervention: Screening
230
8.3.5
Intervention: Referral and follow-up
231
8.3.6
Intervention: Case management
231
8.3.7
Intervention: Delegated functions
232
8.3.8
Interventions: Health teaching
232
8.3.9
Intervention: Counselling
233
8.3.10 Intervention: Consultation
234
8.3.11 Intervention: Collaboration
234
8.3.12 Intervention: Coalition building
235
8.3.13 Intervention: Community organising
236
8.3.14 Intervention: Advocacy
236
8.3.15 Intervention: Social marketing
237
8.3.16 Intervention: Policy development and enforcement
238
8.4
What underlying values are made explicit when interventions undertaken
by nurses are analysed?
238
8.4.1
Beattie’s model of health promotion
239
8.4.2
The four approaches to Beattie’s model
239
8.4.2.1 Authoritative or negotiated modes of interventions
241
8.4.2.2 Individual and collective focus of interventions
242
8.4.2.3 The challenge for nursing
242
8.5
Study findings provide new insights and direction
244
8.6
The Primary Health Care Interventions Model
245
8.6.1
Strengths of the PHCI model
250
xi
Chapter 9
9 Conclusion: Mapping a new future
252
9.1
Introduction
252
9.2
Strengths and limitations of the study
253
9.2.1
Study design
253
9.2.2
Study population
255
9.2.3
Questionnaire design
256
9.2.4
Data collection procedures
257
9.2.4.1 The interview
9.2.5
Data analysis procedures
257
258
9.2.5.1 Organising data analysis
258
9.2.5.2 Data analysis
258
9.3
Implications of the PHCI Model for nursing practice
259
9.4
Recommendations
262
9.5
Conclusion
264
References
266
Appendices
303
Appendix 1
Structure of the New Zealand Health and Disability Support Sector 1999
304
Appendix 2
Structure of the New Zealand Health and Disability Support Sector 2005
306
Appendix 3
Questionnaire
308
Appendix 4
Interventions undertaken by nurses in integrated care projects: Frequency tables
315
xii
List of Tables
Table 1: New Zealand public health developments and health reforms
25
Table 2: Studies addressing costs related to chronic conditions
52
Table 3: New Zealand studies addressing costs related to chronic conditions
53
Table 4: Milestones for PHC nursing development
87
Table 5: Definitions of public health interventions
95
Table 6: Risks
119
Table 7: Integrated care demonstration pilot projects
121
Table 8: Research approach to the Nurses in Integrated Care Projects Study
132
Table 9: Variables, research questions and items on the survey
138
Table 10: Question form of items on the survey
141
Table 11: Interviewer approaches to contacting respondent
145
Table 12: Codes assigned to questions 1 to 3
148
Table 13: Codes assigned to questions 4 to 9
149
Table 14: Codes assigned to question 10
150
Table 15: Codes assigned to questions 11 and 12
150
Table 16: Codes assigned to questions 13 to 15
152
Table 17: Codes assigned to question 17
154
Table 18: Codes assigned to question 18
155
Table 19: Codes assigned to questions 19 to 23
156
Table 20: Codes assigned to question 24
157
Table 21: Codes assigned to question 25 and 26
157
Table 22: Total interventions and levels of population-based practice by
wedge undertaken by nurses in projects
176
Table 23: Project level of population-based practice by projects employing
nurses
180
Table 24: Disease or condition or other by projects employing nurses
182
Table 25: Health service by chronic and acute condition, well-health, or other
184
xiii
Table 26: Project level of population-based practice by chronic or acute
condition, well-health, or other
185
Table 27: Age group by chronic or acute condition, well-health, or other
186
Table 28: Ethnicity by age group with or without disease or condition
188
Table 29: Health teaching intervention undertaken by nurses in projects
190
Table 30: Community organising intervention undertaken by nurses in
projects
190
Table 31: Coalition building intervention undertaken by nurses in projects
191
Table 32: Surveillance intervention undertaken by nurses in projects
191
Table 33: Summary of research questions and evidence informed responses
195
xiv
List of Figures
Figure 1: Beattie’s model of health promotion
31
Figure 2: The Chronic Care Model
59
Figure 3: The Public Health Interventions Wheel
89
Figure 4: Population-based systems level of practice
91
Figure 5: Population-based community level of practice
92
Figure 6: Population-based individual and family level of practice
93
Figure 7: Knowledge claims, strategies of inquiry, and methods leading to
approaches and the design process
130
Figure 8: Incentives to clients and project partners and new costs to hospitals
and general practices
165
Figure 9: Organisational relationships based on vertical and/or horizontal
integration
166
Figure 10: Strategies for integration
167
Figure 11: Project level of population-based practice
168
Figure 12: Projects by specific disease or condition
169
Figure 13: Chronic or acute condition, well-health or other
171
Figure 14: Total interventions undertaken by nurses in projects
172
Figure 15: Total interventions and levels of population-based practice
undertaken by nurses in projects
173
Figure 16: Total interventions and levels of population-based practice by
wedge undertaken by nurses in projects
174
Figure 17: Interventions and levels of population-based practice undertaken
by nurses in projects
192
Figure 18: An adaptation of Beattie’s model of health promotion situating
total interventions by nurses in projects
194
xv
Introduction
The task is not so much to see what no one else has seen, but to think what no
one yet has thought, about that which everyone sees.
(Arthur Schopenhauer, 1788-1860, Philosopher)
Nurses are the largest health professional group working in the New Zealand health
sector and have the potential to make an extensive and profound contribution to
reducing health inequalities. Over the last 50 years, average life expectancy at birth
has increased globally by almost 20 years (World Health Organization, 2003).
However, there are major disparities in the health of people within New Zealand and
between countries, as these disparities continue to grow (Ministry of Health, 2001c;
Pomare et al., 1995; World Health Organization, 2003). Primary health care nursing
in New Zealand is a new specialty area of practice that combines many different
nursing groups who have traditionally worked in communities. These nurses have a
central role in health promotion driven by primary health care principles, such as,
social justice, equity and community participation.
In 2004, primary health care nurses represented 10.6 per cent (n=3672) of the
registered nursing workforce in New Zealand (New Zealand Health Information
Service, 2004). The New Zealand Ministry of Health is investing in primary health
care as a health reform strategy and nursing has received NZ$8.1 million for
workforce development (A. King, 2005). The New Zealand Primary Health Care
Strategy (Ministry of Health, 2001c) signposted the way forward, but as yet a national
framework to guide primary health care (nursing) practice has not been articulated.
The purpose of this thesis is to establish the current position of primary health care
nursing in New Zealand, and to identify areas for future nursing development in line
with the PHC Strategy. This thesis has produced a unique and innovative model for
implementing primary health care nursing practice, developed from public health and
nursing literature, health promotion theory, and research on nurses’ practice. The
research investigated the practice of nurses employed in 80 New Zealand integrated
care projects in the late 1990s during the third generation of health reform.
xvi
Primary health care is not a new concept and has been promoted in two earlier
generations of health reform occurring within the period 1940 to 1980 (see p. 9-11,
25) as a way to provide health care to the majority of the world’s poor. This approach
failed on both occasions because the care was “primitive rather than primary” (World
Health Organization, 2000, p. 15). Health workers did not have the requisite skills,
resource allocation was insufficient to meet the need, and health services had a prorich bias due to the disproportionate use of hospital services by the well off. The
current generation of health reform in New Zealand and globally, is adopting primary
health care for a third time. There is now a greater likelihood for success as a
consequence of previous experience and learning, better knowledge about health and
its determinants, improved information systems, ‘consumer voice’, and integrated
approaches to health promotion. Today, a primary health care approach advocates a
balanced system of treatment and disease prevention, through affordable, accessible
and appropriate services. At the same time, there is recognition that health services
alone are not the answer, and that a major re-orientation is needed in the way that
health is considered, and health issues are acted upon (Talbot & Verrinder, 2005).
Pressure also exists on all health systems to develop a response to the escalation of
chronic conditions, which by 2020 will contribute to more than 60 per cent of the
global burden of disease and be the leading cause of disability throughout the world
(World Health Organization, 2001a; World Health Organization). In New Zealand,
demographic transitions, population ageing, changing life-styles, consumption
patterns, and risk behaviours are clear determinants of this trend. Internationally,
chronic conditions disproportionately affect the poor, economically challenge families
and governments, and jeopardise the sustainability of health care systems. Chronic
conditions are lengthy and require continuity of care, demonstrating a mismatch with
current health care systems that provide episodic acute care. A comprehensive health
care system that assures ongoing support for chronic conditions is essential, as
technological advances alone will not stop conditions such as heart disease, acquired
immune deficiency syndrome, diabetes and depression (World Health Organization,
2000).
Successful chronic care management requires the same fundamental changes as health
systems, that is, a shift to effective prevention strategies. This has not been core
xvii
business, as the focus has traditionally been strongly placed upon curing people.
Improving health requires a major emphasis on intervention in the chain of disease
causation, with the underlying risks to health addressed, in addition to the treatment of
established diseases. Almost half the global mortality and much of the burden of
disease are attributed to the top 20 risk factors (World Health Organization, 2002b).
Tackling major risk has the potential to reduce inequalities worldwide, and
governments have a leading role in this risk reduction.
Contemporary health promotion and public health theory can play a significant part in
repositioning the focus from the medical ethics of the individual to one that considers
the social ethics of the population (Lamm, 1994). Beaglehole and Bonita (1997)
argue that “Public health is the collective action taken by society to protect and
promote the health of entire populations; in contrast, clinical medicine deals only with
the problems of individuals” (p. xiii). Accordingly, health care systems and health
workers have tended to take a narrow view of what contributes to health, and focused
on health service issues.
Nurses who have historically provided care to sick
individuals in bed-based institutional settings are being challenged to practice in new
ways (Porter-O'Grady, 1999).
The Ministry of Health in New Zealand has funded scholarships for postgraduate
nursing education and the development of ‘innovation projects’ in an attempt to build
a primary health care nursing workforce. However, situating various nursing groups
under the umbrella title of primary health care does little to facilitate a primary health
care philosophy linked to ideas of social justice and equity. At present, there is no
commonly agreed core knowledge attributed to the specialty of primary health care
nursing.
The diverse range of interventions undertaken by the different nursing
groups has not been well-defined, nor has the level/s at which nurses undertake
population-based practice (individual and family, community, system). For nursing to
take a leading role in “reducing health inequalities, achieving population health gains
and promoting and preventing disease” (Ministry of Health, 2003b. p. vii), work with
communities and systems has the potential to achieve greater improvements in
population health than work exclusively focused on individuals and families (Keller,
Strohschein, Lia-Hoagberg, & Schaffer, 2004a). An analysis of New Zealand nurses’
in integrated care projects actual practice can identify the particular interventions and
xviii
levels of practice that need to be strengthened, “as interventions at each level of
practice contribute to the overall goal of improving population health” (Keller et al.,
2004a, p. 457) .
Integrated care was considered a major public sector reform strategy initiated from
central government (Wells, 1998) that engaged health professionals, including nurses,
in efforts to improve the coordination of care between health sectors and strengthen
primary health care. The thesis research, ‘Nurses in integrated care projects study’
was conducted during this period.
The study design was quantitative and the
philosophical basis of the research was postpositivism (see pp. 130-131).
The
research aimed to describe the characteristics of integrated care projects to create a
context within which nurses’ practice could be situated. Nurses’ practice was then
assessed to determine the range of interventions and related levels of population-based
practice routinely undertaken, and the health promotion values embedded within this
practice were identified.
Finally, the research findings in combination with the literature provided the basis for
the construction of a model to guide the implementation of future primary health care
nursing practice. The model provides a strong framework to develop primary health
care practice, and nurses whose work impacts on health, can use this framework in a
manner that both strengthens the relevance of health promotion work, and allows
them to be accountable for their practice.
Enabling insights for practitioner
development at a personal level, the model can also be used by the nursing profession
as an analytic framework to assess overall primary health care nursing practice, and
inform national strategic direction.
xix
1
Chapter 1
Public health and generations of health reform
1.1
Introduction
“Public health is an approach that aims to promote health, prevent disease, treat
illnesses, prolong valued life, care for the infirm and to provide health services”
(Laverack, 2005, p. 1). Historically, public health centred on preventing the spread of
infection and protecting the general population.
Today, public health is also
committed to reducing inequalities in health, and the development of health public
policy is an essential component of this approach (Baum, 1998). With such a broad
focus, it is not surprising that the term ‘public health’ is used to cover a wide range of
specialist areas that include water supply and sanitation, environmental health,
nursing and health promotion. Predictably, public health remains a contested and
disputed area of practice knowledge, priorities, and the services it claims to deliver.
This chapter describes the past and present public health developments and
accompanying perspectives, as a basis for understanding and situating the practice of
nurses in community settings. Section 1.2 highlights the various conceptions of
public health and introduces the ‘new public health’ agenda. Sections 1.3 and 1.4
describe three generations of health care reform, and six distinct periods of public
health identifying the dominant ideologies and interventions of each era. The tensions
that exist in public health philosophy and practice are discussed. Laverack (2005)
claims these tensions belong principally to people employed in the health sector who
have vested interests in “conceptual models, professional legitimacy and resources”
(p. 1). The chapter concludes with a summary table (see p. 25) that demonstrates
where public health developments intersect generations of health reform.
1.2
Public health in context
Definitions of public health have changed and evolved since the nineteenth century
when the main concern was the interface between the body and the environment, and
1
public health efforts sought to prevent the transmission of disease (D. Armstrong,
1988). In the early twentieth century Last (1998) suggests a greater emphasis was
placed upon the individual and on personal hygiene. The New Zealand Public Health
Association defines public health according to the Acheson Report1 as “the art and
science of preventing disease, prolonging life, and promoting the health of the
population through the organised efforts of society” (N. Holt, personal
communication, June 14, 2005). In New Zealand there may be confusion over the
term public health because it is often used to refer to the publicly funded health
service.
Baum (1998) maintains public health exists to make people and their communities
healthier through change, a definition that is consistent with the concept that “public
health is the collective action taken by society to protect and promote the health of the
entire population” (Beaglehole & Bonita, 1997, p. xiii). In contrast, clinical medicine
deals only with the problems of individuals and tends to take a narrow focus on health
service issues. Beaglehole and Bonita argue that the predominance of a narrow
medical focus by health systems is the reason for the failure by public health to
achieve its potential to improve the public’s health. They believe that until health in a
broad sense becomes a central concern of the policy making process, this situation
will not change. In most countries a narrow disease focused route prevails under the
influence of current social and economic ideology, and health is taken to be the
absence of disease attained by life-style changes that reduce an individual’s risk of
disease. In this approach the main public health activities are disease prevention,
targeting high-risk populations, and the emphasis in epidemiology is on method, and
on clinical and molecular studies that produce short-term benefits and do not address
fundamental threats to global health.
The general social climate of the 1980s shifted away from the notion that medical
progress would eventually cure most diseases (McKeown, 1979), and that individuals
were responsible for making life-style changes to advance health (Hetzel, 1976), to a
1
In 1988, the Department of Health and Social Security published ‘Public Health in England’, a report
of the Committee of Inquiry into the future development of the public health function. Sir Donald
Acheson chaired the Committee and the report was commonly referred to as the ‘Acheson Report’.
2
focus on ‘health for all by the year 2000’, promoting primary health care2 (World
Health Organization, 1978). This idea tied health improvement to overall social and
economic development, and primary health care stressed the importance of equity in
access to community-based services, encouraging a comprehensive, sustainable
approach to improving health. Such an approach, however, was soon replaced by
selective and targeted strategies to control disease, a major departure from the original
‘health for all’ concept (Rifkin & Walt, 1986).
Selective primary health care
emphasised medical interventions above measures such as housing, education and
nutrition, and resulted in a focus on particular diseases that once resolved were simply
replaced by another, as the underlying causes of ill health had not been dealt with
(Tarimo & Webster, 1994). Recognition that major health problems cannot be solved
by medical care (J. Ashton & Seymour, 1988; Lalonde, 1974) led to the most recent3
introduction of the term ‘new public health’.
The world’s first international conference on health promotion was held in Canada in
the mid-1980s and resulted in the development of the Ottawa Charter (World Health
Organization, 1986). Baum (1998) pointed out that ‘health for all’ had not been
adopted by wealthy countries, and the life-style and behavioural approaches were
increasingly being seen limited and requiring a new conceptualisation for health
promotion. She stressed that health budgets continued to grow in the 1980s and the
prospect of reducing these by improving the health of populations was of interest.
The Ottawa Charter approach to health promotion plays down the life-style (health
education) approach to health and emphasises the importance of social structures and
policy as key health determinants. Five areas for action include: building healthy
public policy; creating supportive environments; strengthening community action;
developing personal skills, and re-orienting health services.
Green and Raeburn
(1988) characterised two approaches to health promotion, the ‘individual’, and the
‘system’, “observing that these views led to divided ideology and theoretical
perspectives on health promotion” (p. 35).
Despite this, they suggested that in
practice, viewpoints were often more integrated. The life-style approach was not
2
The Joint WHO/UNICEF International Conference on primary health care held at Alma Ata, USSR
(now Almaty, Kazakhstan) in 1978, adopted primary health care as the strategy for achieving ‘health
for all’.
3
The term ‘new public health’ was first used in 1916 and its original use referred to a narrow view of
public health based on bacteriology (Hill, 1916).
3
rejected, but rather integrated under the ‘development of personal skills’ as one of
many strategies. The Ottawa Charter, based on the understanding that peace, shelter,
education, food, income, a stable ecosystem, social justice and equity are requisite for
health, sought a multi-pronged, multilevel health promotion strategy.
New public health overlapped and integrated with other health movements of the
1960s and 1970s, such as health promotion, primary health care, women’s health,
Maori health, worker’s health, and health education.
The new public health
movement set out an agenda for public action, initiating more social interventions,
community participation and policy change, in line with the activities of health
promotion (Downie, Fyfe, & Tannahill, 1990). Contemporary approaches to health
promotion:
disease
prevention;
health
education;
healthy
public
policy;
environmental4 protection, and community empowerment, are central to the practice
of public health. Yet despite new public health and the central strategy of health
promotion, which challenged the idea that health was just a medical issue and stressed
socio-environmental aspects, the mainstream debate of the 1980s focused on the
requirements of the curative services5.
The 1990s have been a period of international economic uncertainty and coincided
with less proactive public health action. Health promotion as a discrete activity has
met with limited success, although many have argued that it should have been central
to the development of social and economic policies. Free market thinking and neoconservative ideology have dominated making it difficult to advance strategies that
considered the determinants of health. Only by directing attention towards the socioenvironmental threats to health can the increasing inequality between and within
countries be addressed. Interestingly, however, there is also the risk of a shift in
public health interest to the potential of the human genome project and molecular and
genetic approaches to disease control (Beaglehole & Bonita, 1997).
A lack of attention to the major factors required to create healthy populations is of
great concern. The major contributions to the determination of overall population
4
The term ‘environmental’ refers to more than physical factors and is inclusive of social, cultural, and
economic factors.
5
Governments continued to be preoccupied with hospital issues, such as the size of waiting lists.
4
health status arise from public health measures aimed at the prevention of disease,
illness, disability, and the lowering of death rates, as opposed to the function of health
care (Frenk, 1993). Beaglehole and Bonita (1997) suggest the integration of medical
care under the public health umbrella would facilitate the process of setting broad
health goals and targets, and encourage resources to flow to prevention. As the
concept of population health becomes understood in policy decisions and there is a
major shift in focus to environmental sustainability, equity, and community, the
potential of public health may be realised.
Equity in health care has not been
achieved by health services and narrowly defined disease prevention and health
promotion activities. Recent estimates of the global burden of disease, the ageing of
the world’s population, and better knowledge of the determinants of health are
influencing the way countries are reforming health systems (World Health
Organization, 2002a).
A reintegration of the Ottawa Charter for health promotion and life-style approaches
beginning with a people centred approach (Raeburn & Rootman, 1997) sought to
build self-reliant local communities linked into a global system (World Health
Organization, 1992). A recent international health promotion conference attempted to
build new alliances for health, and included private sector partners (World Health
Organization, 1997). Future debates about the impact of globalisation, including the
growing influence of multinational companies and the declining influence of nation
states is important to public health development.
At present, addressing socio-
environmental factors poses a huge challenge, but also makes the new public health
agenda a more relevant guide for action (Baum, 1998).
1.3
Health systems and health reform
A health system includes “all the activities whose primary purpose is to promote,
restore or maintain health” (World Health Organization, 2000, p.5). This includes the
provision of professional medical attention, interventions by traditional healers and
home care of the sick, which is how 70-90 per cent of all sickness is managed
(Gwatkin & Guillot, 2000).
Traditional public health activities such as health
promotion, health education, and disease prevention, and other interventions that
5
promote health like environmental safety improvement are also included. Today, the
most fundamental objectives of the health system are: improving the health of the
population
they
serve
(attainment);
responding
to
people’s
expectations
(responsiveness and fairness), and providing financial protection against the costs of
ill-health (performance) (World Health Organization, 2000).
Governments have
become central to social policy and health care because to meet such objectives
requires decision making in managing resources equitably and ultimately, the
“responsibility for the overall performance of a country’s health system lies with
government” (World Health Organization, 2000, p. xiv).
Unfortunately, nearly all of the information about health systems refers only to the
‘health care system’, and describes either the provision of, or investment in health
services, such as preventative, curative, and palliative interventions provided to
individuals or populations.
Despite this more limited definition, health systems
represent one of the largest sectors in the world economy, with global spending on
health care in 1999 about $1.2 trillion, up 5.6 per cent from the previous year, and 13
per cent of world gross domestic product. A moderate acceleration in spending
growth of 6.5 per cent is expected from 2002 until 2010 (Heffler et al., 2001).
The health system represents governments’ formal commitment to the health of the
population, and commonly attempts to create and sustain the greatest good for the
largest group of people. There is, however, wide variability in the extent to which this
goal is achieved because diverse approaches are taken by governments in response to
needs or demands, and numerous programmes compete for government funding. In
addition, there is no single way to organise government departments, and these
structures often determine priorities. Political interest groups and consumers impact
on the strategic activities undertaken within the health system with regard to decision
making, where they place pressure on decision-makers to allocate resources
(McMurray, 2003). McMurray suggests tradition has a significant part to play in the
way health systems are shaped.
For example, two very different models are
demonstrated in the health systems of the United Kingdom and the United States. In
the United Kingdom, the national health services model is characterised by a
government-financed and operated system, whereas in the United States an
entrepreneurial market model driven by the private sector controls health care. By
6
contrast, New Zealand has a mix of public and private health services, and the extent
to which services are privatised represents another political element (Boyd &
Sheridan, 2000).
In health care, commercial partners expect returns on their
investments and this can conflict with the interests of other health professionals, who
may perceive limits to education, career advancement, and improved employment
conditions.
Health systems have undergone overlapping generations of reform in the past one
hundred years, and this is discussed more extensively in section 1.3.1. In summary,
health reforms have included the founding of national health care schemes, the
extension of social insurance schemes, and the promotion of primary health care as a
route to achieving universal coverage - the goal of health for all. In the last decade
there has been a gradual shift towards ‘new universalism’, the delivery of high quality
essential care to all people (World Health Organization, 2000). However, at the
national level in New Zealand, the ongoing debate about health reform has been
narrowly focused on medical care services and has not embraced the need for a reemphasis on public health services (Beaglehole & Bonita, 1997). This appears to be
the situation in most countries and the political motivations for reforming health
systems remain contradictory. Opinions on the drivers of health reforms include:
concern over inefficiencies in service delivery, which a devolved regional system is
considered better able to resolve, though this remains uncertain (Lomas & Rachlis,
1996; Reamy, 1995); concern over the ineffectiveness of many medical interventions
fuelling health system and academic collaborations to develop a more evidence-based
approach to resource allocation (Lomas, Woods, & Veenstra, 1997); a desire to shift
services from institutional to community settings, such as early discharge
programmes, outpatient day surgeries, and community based chronic care
management; for cost efficiency reasons; to provide more responsive services, and a
desire to increase individual and community participation in health decision making
and self-management (Lewis, 1997; Lomas, 1997; Lomas et al., 1997). Betkowski
(1996) maintains health reform should be based on asking whether there is a way to
get better value out of the money we spend on health, whilst Wilson (1996) argues
that the aim of reform has frequently been to accommodate to reduced government
funding.
7
In New Zealand, the government assumes a major part of the responsibility for health
care provision. Davis and Ashton (2001) described the New Zealand health reforms
during the 1990s as radical, ongoing and pervasive. According to Ashton (2005), the
most notable and most radical of the health reforms occurred in 1993 when marketlike incentives were introduced into the system. Public purchasers tended service
contracts to private and public providers who were then required to compete.
Beaglehole and Bonita (1997) agree the main drivers of the early 1990 reforms were
the introduction of the market into health services and separating the purchasers of
services from the providers. In 2000 health reforms led to the establishment of 21
district health boards and the recombined roles of purchasing and providing services.
The move to devolve to a regional system was a result of a labour-led coalition
government elected to power in 1999, and the waning of the market model. Health
policy began to reflect centre-left ideology and the emphasis was placed upon
‘patients not profit’, and cooperation rather than competition.
Today, more
information is available for services that require funding, new alliances have been
formed, and different styles of service provision have emerged (T. Ashton, 2001). In
the last decade Ashton contends strategies for improving health care provision have
included integrated care, evidence-based medicine, a greater reliance on democratic
and consultative processes, and an emphasis on primary health care with each
embodying specific values and bringing unanticipated problems.
1.3.1
Three generations of health system reform
Traditional practices and systems of promoting health have existed for thousands of
years and coexist today with organised health systems in the modern sense, which
have developed only over the last hundred years. The health system plays a more
influential role than ever before, affecting peoples’ lives and livelihoods throughout
the lifespan.
Perceived failures in health and the pursuit for greater efficiency,
fairness and responsiveness to people’s expectations of the health system have
prompted reforms. According to Frenk (1994) the course of reform determines “the
deeper meaning of the social effort to care for health….the health system can
reproduce inequalities, or it can assume a leading role in offering everyone an equal
opportunity to confront the challenges of life….reforms imply options” (p. 32). The
8
World Health Organisation (2000) describes three overlapping generations of health
system reform beginning in the twentieth century and moving into the twenty first.
1.3.1.1
First generation health system reform
The first generation of reforms saw the founding of national health care systems and
the extension to middle income nations of social insurance systems, mostly in the
1940s and 1950s in richer countries, and later in poorer countries (World Health
Organization, 2000). Rising costs placed stress on systems in the 1960s as the volume
and intensity of hospital-based care increased in all countries. The wealthy used
health services more heavily than the poor who were underserved by systems that
were technically universal in coverage.
The World Health Organisation (2000)
reported that too many people continued to depend upon their own resources to pay
for health services and could often get only ineffective or poor quality care.
Indigenous populations were frequently excluded from health services.
Countries like Africa, under British administration, implemented a European model of
health care intended for colonial administrators and expatriates, with second class or
no provision made for indigenous peoples. In New Zealand, John Hinds reported on a
six year study of bronciectasis (often a consequence of pertussis) in 1958, which
demonstrated a higher incidence in the indigenous Maori, “who were also less likely
to receive treatment” (Dow, 1995, p. 196). This was despite the British Crown and
New Zealand Maori signing the Treaty of Waitangi6, which conferred citizen rights to
Maori and should have afforded some protection.
In former colonies and poor
countries, the health system was unable to deliver the most basic services to people in
rural areas.
In most wealthy countries, major urban hospitals received around two-
thirds of all government health budgets and delivered care to less than 20 per cent of
the population (Barnum & Kutzin, 1993). Barnum and Kutzin also contended that 50
per cent of hospital inpatient funding went on treating conditions such as diarrhoea,
malaria, and tuberculosis, which could have been managed by ambulatory care.
6
The Treaty of Waitangi was signed in 1840 and provided for a transfer of sovereignty, and a
confirmation of existing property rights, in addition to conferring citizen rights to Maori (Boyd &
Sheridan, 2000).
9
1.3.1.2
Second generation health system reform
A second generation of radical reform introduced primary health care as the route to
achieving affordable universal coverage, as concerns centred on the need to make
systems more cost efficient, equitable, and accessible. Newell (1975) suggests that
this approach built on the experiences of disease projects in the 1940s7, and in some
countries, life expectancy at birth increased up to 20 years in a span of two decades.
The emphasis was placed upon “public health measures relative to clinical care,
prevention relative to cure, essential drugs, and education of the community by
community health workers” (World Health Organization, 2000, p. 14).
Primary
health care sought to bring basic health care to all people.
The term ‘primary’ acquired many meanings including: first contact with the health
system; first level of care; simple treatments by untrained providers; interventions
acting on primary diseases, and was also associated with political activity involving
multisectoral action and community involvement. This is arguably why no single
model of primary health care exists. Many primary health care programmes were
funded inadequately, workers did not focus on prevention and community outreach,
training and equipment was insufficient, and the care was often “primitive rather than
primary” (World Health Organization, 2000, p. 15). For example in India, community
workers were placed in over 100,000 health posts to deliver basic primary health care
to two-thirds of the population. Primary care was better integrated into the whole
system in wealthy countries. In New Zealand primary care was associated with
general medical practice, and a reliance on general practitioners has remained central
in current third generation reform.
The second generation health reform approach, emphasised in the primary health care
movement, gave too much attention to peoples’ demand for health care, instead of
concentrating on their presumed needs (World Health Organization, 2000). Systems
fail when these two concepts do not match, because the supply of services cannot
align with both demand and need. Poverty is one of a number of reasons that needs
7
These countries included “South Africa, the Islamic Republic of Iran, and former Yugoslavia…also
built on the successes and experiments of China, Cuba, Guatemala, Indonesia, Niger, the United
Republic of Tanzania, and Maharashtra State in India” (World Health Organization, 2000, p. 14).
10
may not be expressed in demand. Both first generation and second generation reform
have been supply-oriented.
Primary health care has achieved an unprecedented degree of international consensus
since the Alma Ata Conference of 1978 (Frenk, 1994), although poor organisation of
programmes during the second generation of reform often led to failure. Aligned with
the concept of new universalism (see p. 7), primary health care was characterised by
the principle of ‘cost-effectiveness for everyone’, as opposed to all possible care for
the whole population, or only the simplest and most basic care for the poor (World
Health Organization, 2000). An emphasis was placed on public funding, though
delivery of services could be both public and private, and rationing services was
considered necessary as long as whole groups of the population were not excluded. In
general, it was easier to define interventions that would benefit the poor if applied to
the whole population, than to assure that the poor benefited, or that most of the
beneficiaries were poor (World Health Organization, 2000). Publicly funded health
services targeted to reach the poor were more often used by the rich, and this pro-rich
bias was due largely to the disproportionate use of hospital services by the well off.
Gwatkin (1998, as cited in World Health Organization, 2000) argues that “the
distribution of primary care is almost always more beneficial to the poor than hospital
care is….the poor sometimes obtain less of the benefit of primary care than the rich”
(p. 16).
The poor obtain much of their personal ambulatory care from private
providers. This accounts for the bulk of their use of the health system and is paid for
by out-of-pocket expenditure (Berman, 2000).
1.3.1.3
Third generation health system reform
Current third generation reform is responding more to demand. Efforts to improve
access for the poor, and the provision of subsidies, rather than just service provision
within the public sector characterise third generation reform. There is a move away
from allocating providers budgets to determine ‘supposed needs’ to reforms that
attempt to make the money follow the patient. Third generation reform throughout
the 1990s saw a greater shift to new universalism, and an understanding that assessing
needs alone does not provide a sound basis for planning and purchasing health
11
services, when the severity or priority of needs cannot be ascertained (Petrou, 1998).
The political focus accompanying this bottom up approach is to establish clear
indications of financial limitations, particularly in light of a potentially infinite
demand for care. The World Health Organisation (2000) maintains that if services are
to be provided to all, then not all services can be provided. Third generation reform
has been motivated by a number of reasons (see p. 7) and includes more
experimentation in approach. There has been increased reliance on the market since
the 1980s, with the promotion of competition, more explicit rationing criteria, and a
reduction in government regulation and control. In addition, individual choice and
responsibility have been emphasised.
Focusing on the commercial performance of government-owned organisations in New
Zealand was balanced ahead of the millennium by the government promoting provider
and community cooperation in the interests of more effective services. The new
centre left government merged central agency roles, promoted local collaborative and
accountability cultures, as well as community involvement in decision making
through district health boards. The overarching objective was to reduce inequalities
(Boyd & Sheridan, 2000). Globally, governments attempted to establish realistic
expectations about what they should do with general revenues within their financial
capacity (World Health Organization, 2000). These changes have impacted on health
systems, and one consequence has been an increase in insurance mechanisms.
In New Zealand, a country with universal coverage, over one third of the population is
covered by private health insurance, “which has a history of meeting the cost of
services outside the taxpayer-funded health system” (Boyd & Sheridan, 2000, p. 309).
Universal health insurance has been introduced to varying degrees in the Republic of
Korea, Malaysia, Singapore, and China and reforms to extend or merge insurance
coverage for greater risk sharing have also occurred in Argentina, Chile, Colombia,
and Mexico (World Health Organization, 2000). A mix of insurance and out-ofpocket health care has replaced much of the public system throughout the former
communist countries.
In New Zealand, general practitioners as gatekeepers to the health system have been
made accountable for their patient’s health and resource usage when prescribing
12
interventions. This role was formalised in New Zealand through budget holding for
general practitioners in Independent Practitioner Associations. Similarly in the United
Kingdom, general practice fund holding occurred, and in the United States, Health
Maintenance Organisations acted as the vehicle for budget holding (Wilton & Smith,
1998). In the United States, there has also been a “shift in power from providers to
insurers, who now largely control the access of doctors and patients to one another”
(World Health Organization, 2000, p. 17).
Third generation reforms have required countries like New Zealand to rethink the
demands, issues and incentives that drive health service priorities. Emphasis is being
placed on population health policies to improve the health of all New Zealanders,
especially the poor, as it is no longer assumed that delivering personal health services
will result in population health (Marmor & Mashaw, 2001). A paradigmatic change
of this nature creates tension between the medical ethics of the individual and the
social ethics of the health system and population (Lamm, 1994).
Participating
communities, self-management, and effective primary health care are the bases of
such a model. To support community knowledge and self-determination, nurses,
dieticians, physiotherapists, occupational therapists, counsellors, traditional healers,
community workers and clients may increasingly be included in primary health care
teams. There are currently opportunities for more appropriate utilisation of nurses.
Government subsidies of NZ$30 million a year for nurses who work with general
practitioners were expected to better align incentives for collaborative practice (Boyd
& Sheridan, 2000).
Seamless care for clients entering the health care system has been identified as an
important area in which to improve quality. Strengthening partnerships between
providers and investing in integrated information systems were recognised first steps.
At the end of the 1990s the government invested NZ$4 million on trials of health
information systems to support integrated providers (Boyd & Sheridan, 2000). All
major providers are currently engaged in the ongoing development of effective
information systems, and leadership in this area “could ensure national standards,
appropriate methods, and commonality among clinical computing systems, electronic
records, and clinical messaging” (Boyd & Sheridan, p. 312), although privacy issues
are a major concern.
13
1.4
Public health developments intersect generations of health reform
Section 1.4 draws attention to the importance of the linkages between public health
and health system reform in order to establish a context within which contemporary
and future developments can be placed. Whilst cost affects the kind of health care
system a country can afford, the impact of politics and culture is of no less importance
(Lassey, Lassey, & Jinks, 1997).
Prevailing social and economic ideology has
bearing on the emphasis given to health promoting strategies, and recurrent themes in
the history of public health, such as collective responsibility for health, population
focus, primary prevention, and government action play an important part in the debate
about health system reform. All current challenges have historical antecedents and
there are many lessons for this century.
Contemporary public health practice in New Zealand reflects six distinct periods of
development since the time of British colonisation and settlement. The most recent
era ‘new public health’, represents the contribution of the past, and also a departure
from it (Baum, 1998).
To track this development, six periods of public health
thinking and practice are outlined separately, although in reality these are overlapping
eras of practice. The six periods are: the era of indigenous control; the colonial era;
the nation-building era; the era of affluence, medicine and infrastructure; the life-style
era, and the era of new public health8. It is interesting that the three most recent
periods of public health development are in step with the three generations of health
system reform.
Health reform, placed within a public health context, can be
considered in relation to particular dominant policies, ideologies and typical (health)
interventions. Table 1 provides a summary of this information (see p. 25).
1.4.1
Era of indigenous control (pre-colonisation)
The era of indigenous control is estimated to be in excess of 700 years in New
Zealand (M. King, 2004). In history, many forms of collective public health activity
8
Baum (1998) identifies these six eras in relation to public health development in Australia. These
periods, along with dominant ideology and policies, and typical intervention models have been applied
to public health developments in New Zealand.
14
have been identified in diverse societies (Brockington, 1975; Rosen, 1958; W.
Wilkinson & Sidel, 1991). Examples include: the isolation of people with leprosy
(ngerengere) by Maori in New Zealand (Buck, 1949); the regulation of prostitution in
Ancient Rome and Greece, and inoculation against smallpox in India and China
before the common era (Baum, 1998).
Maori in New Zealand recognised the importance of healthy communities and a
public health system evolved, based on values that reflected the relationship between
people and the natural environment. Health for early Maori was integral to survival
and therefore demanded a united approach to every-day existence.
Society was
communal, families lived together and the natural environment was a source of food,
shelter, clothing and identity (Durie, 1998). The “underlying philosophical basis for
public health was linked to a division of people, places or events as either tapu or noa”
(Durie, 1998, p. 7).
Tapu is a sacred state or condition in which a person, place or thing is set aside by
dedication to the gods and thereby removed from common use (Marsden, 1975).
Conferring tapu was a measure of protection that invoked caution and warned of
danger, in contrast to noa, which implied no restriction or scarcity, but rather safety,
freedom and abundance. The work of the tohunga (traditional healer)9 depended on
drawing distinctions between tapu and noa and re-establishing balance between the
two. The concepts tapu and noa are embodied in separating clean from unclean,
replacing a dangerous situation with a safe one, and distinguishing pure water from
contaminated water.
These are all recognisable as public health practices.
Brockington (1975) points out religions may also be seen as public health measures as
they encourage sobriety, cleanliness, isolation of people with infectious disease, and
ritual abstention from food likely to convey parasites.
9
Traditional Maori communities recognised two classes of leaders, rangatira and tohunga. Within both
classes hereditary and ascribed roles were important, and together they covered political, spiritual, and
professional dimensions. Rangatira were the political leaders, while tohunga were the professional
experts in a variety of pursuits including agriculture, warfare, weaving, decorative arts, fishing,
environmental conservation, and healing. From an early age tohunga were immersed in tribal ritual
and tradition, and inevitably became the carriers of tribal culture, science, and technology (Durie,
1998).
15
Durie (1998) maintains there is a failure to appreciate the transcultural nature of
health and the shared experiences of most tribal and urban cultures. He suggests the
major differences between traditional Maori and scientific, western approaches to
health, is related as much to time and to balance as to irreconcilable belief systems.
The dominant ideologies of the indigenous era include strong links with land,
traditional healers, an emphasis on spirituality, and the integration of health and life
(Baum, 1998).
1.4.2
Colonial era (1840 to 1890)
The colonial era focused public health effort on the control of infectious disease in
order to create healthier environments.
Whilst New Zealand was portrayed to
prospective emigrants as a society free from disease, sanitation and water supply
caused concern in towns and smaller settlements.
New Zealand’s geographic
isolation afforded the greatest protection from infectious disease coming ashore, and
the vigilance of quarantine officials, and good fortune played a lesser role (Dow,
1995). New Zealand’s public health legislation was inspired by the fear of cholera
(1842), smallpox (1872), plague (1900) and influenza (1920) (MacLean, 1964). Dow
noted other factors, such as the impact of chronology, financial considerations, local
rivalries and developments beyond New Zealand as also playing a part in public
health legislation.
New Zealand was significantly influenced by Britain with regard to the establishment
of quarantine acts, public health acts, and the provision of clean water and sanitation.
The Public Health Act of 1872 sought to organise a system of public health. Central
boards of health in each province networked with local boards, before the abolition of
provinces in 1876 and a new Act that required one central board to be established
(Dow, 1995). The Board however, met infrequently, dealt with matters of quarantine
on rare occasions, and provided little support for local boards. The result was that
almost nothing was done to improve public health in the colony prior to 1900
(MacLean, 1966).
16
Colonisation saw the introduction of measles, influenza, whooping cough, typhoid,
scarlet fever and mumps, which had devastating consequences for Maori who had no
‘population’ immunity. This was compounded by Maori relocating from hill top
kainga and pa (settlements) to live in coastal areas where there were opportunities for
trade, education and employment. As new settlements frequently lacked public health
amenities such as clean water, sanitation10 and drainage, the health of Maori declined.
1.4.3
Nation-building era (1890 to 1940)
Public health promoted nation-building in line with an overarching government
intention to strengthen the nation, which was seen as possible by improving the health
and fitness of white citizens (Powles, 1988). ‘Improving the race’ was linked to
eugenics, and consistent with the notions of vitality, efficiency, purity and virtue.
Powles contended that the period of nation-building was characterised by two main
ideas.
The first, ‘progressivism’, sought to modify the effects of capitalism,
motivated by Utopian views that governments were responsible for improving
peoples’ health. The second idea, ‘national efficiency’, was based on the assumption
that strong nations were essential for national protection. The pursuit of a ‘pure race’
became part of the public health agenda, demonstrating the influence of dominant
political and social attitudes.
While the concept of nation-building was evolving, public health efforts in New
Zealand in the early 1900s concentrated on poor nutrition, inadequate sanitation,
tuberculosis11 and infectious diseases. Maori Councils12 developed links between Iwi
(tribes) and the government, and were attributed with a 70 per cent vaccination uptake
of the entire Maori population. Maori community health workers improved housing,
sanitation, and water supplies until the positions were disestablished in 1909, and
10
Old hill top sites with organised sanitation were abandoned and indiscriminate defecation on the
lowlands led to the pollution of pools and springs (Buck, 1949).
11
Tuberculosis was the main cause of disease in New Zealand in 1900 (Dow, 1995).
12
Maori Councils established in 1900 delivered government prevention and health promotion
programmes but were unable to introduce Maori policy perspectives, limiting their ability to improve
Maori health.
17
district nurses were recruited to work in Maori communities with typhoid and other
acute illnesses (Dow, 1995). Despite a number of community based approaches, in
1909 the Department of Public Health amalgamated with the Department of
Hospitals, and an emphasis was placed on hospital services, rather than the health of
the entire population. The Tohunga Suppression Act of 1907, two years earlier, also
gave a clear indication that the government intended to base health care services on
solely western concepts. Smallpox, the influenza epidemic of 1918, and campaigns
for cancer detection assumed priority at the end of this period.
Within the third era the health of citizens became a legitimate concern of
governments, who also promoted the individual’s responsibility for their own health.
Raising the standard of child health assumed a priority, and the New Zealand
government funded routine medical examinations of schoolchildren, and also selected
‘squads of children’ to participate in special physical exercises (Dow, 1995).
Internationally, comparisons were made between the average height and weight of
schoolchildren throughout the first half of the century, as improving national physique
was a common priority in all wealthy countries. Accompanying this focus were
interests in dental health and diet. Dow describes experimental programmes such as
‘toothbrush drill’ (schoolchildren brushed, rinsed and spat in unison), and ‘open-air
schools’ (classrooms maximised fresh air and sunlight) being implemented in multiple
sites. These activities benefited children in the main centres who were nearly all
European. It is not surprising that the focus of public health activities differed for
Maori and non-Maori/European in light of the ideology linking health to pure race. It
is even less surprising that many ‘White Australians’ (and New Zealanders) believed
their civilised role was to smooth the pillow of the dying race (Baum, 1998).
1.4.4
Affluence, medicine and infrastructure (1950s to early 1970s)
In this post war period, economic affluence and government intervention in health,
housing and education aimed to improve the quality of life of the population.
Clinical medicine was associated with new technologies, such as organ transplants.
This was the golden age for medicine, with finance available for medical research on
the prevention of disease and illness, fuelled by the belief that medicine would
18
conquer disease. Investments in hospitals grew and health budgets expanded. The
growth of medicine coincided with a period of affluence, rising living standards and
life expectancy13.
Consistent with first generation reforms, “a social security scheme launched in 1939
provided New Zealanders with free medicines, free hospital care, and a universal
subsidy for primary care physician visits for over twenty years” (Boyd & Sheridan,
2000, p. 305). Public health developments in New Zealand were closely aligned with
health care services and focused on selected diseases and technological solutions,
consistent with the approaches taken in other wealthy countries during this era
(Beaglehole & Bonita, 1997). Planning and constructing hospitals saw costs escalate,
and the idea of ‘capping costs’ was not strongly held. Efforts to stop escalating costs
included domiciliary care advocated as an alternative to hospitalisation, and the
amalgamation of psychiatric and general hospitals (Dow, 1995). Dow suggests these
diversionary strategies had little impact on reducing overall hospital sector costs.
Maori health problems were related to under privilege at a time when most had
‘plenty’ (Dow, 1995). Maori did not receive necessary care and in many cases were
excluded from care, a common experience shared by other indigenous peoples (see p.
9) and a driver for the first generation of health reform. In 1951, life expectancy at
birth was 14 - 17 years less for Maori than non-Maori, and Maori infant mortality was
also much higher than that of non-Maori. The incidence of preventable conditions,
such as bronchiectasis was higher in Maori (see p. 9), who also suffered
disproportionately from tuberculosis, after it had been largely eradicated from the
non-Maori population (Dow, 1995).
“By the 1960’s, public hospital waiting lists were long, and medical insurance
schemes grew to help people pay for private hospital admissions, particularly for nonacute surgery” (Boyd & Sheridan, 2000, p. 305).
Hospital care continued to
dominate, and like other wealthy countries, New Zealand’s health costs increased
more rapidly than the gross domestic product. Scepticism about the cost and promise
13
The greatest gains in life expectancy were made in an earlier period before medical therapies were
available. Changes to social, economic and environmental conditions appear to have had a much
greater effect on mortality rates (McKeown, 1979).
19
of medicine was growing with McKeown (1979) challenging the notion that scientific
medicine was responsible for extending the average life expectancy and others
describing the limits of medicine’s contribution to health (Powles, 1973). Health
education gained momentum through public exhibits, print, film, public meetings, and
radio broadcasts. During this period the first anti-smoking campaign was launched
and nurse training transferred from hospital schools to technical institutes, making it
education-based rather than service-based14. The era of affluence, medicine and
infrastructure that coincided with first generation reforms, which sought to address
inequalities in access to health services for the poor, failed both in New Zealand and
globally. Hospital care predominated, health system costs rose as the volume of
hospital care increased, and efforts to reach the poor were either non-existent or very
limited.
1.4.5
Life-style era (late 1960s to mid-1980s)
The life-style era saw public health developments focus on the effects of affluence, in
terms of chronic disease. Highly individual, behavioural approaches to life-style
diseases such as diabetes, cancer and cardiovascular disease drew almost exclusively
on psychological theory15 and had little regard for individuals’ social and economic
circumstances, despite an increasing awareness of the structural causes of illness. The
notion of primary health care (World Health Organization, 1978) was embraced, but
unfortunately, selectively applied to the management of specific diseases (see p. 3).
This encouraged the view that medical interventions are the most crucial to health,
usually to the detriment of other measures such as housing, sanitation, education and
food production (Rifkin & Walt, 1986). Termed ‘selective primary health care’
(Walsh & Warren, 1979), this approach was criticised by advocates of a more
comprehensive community development approach for not addressing the root causes
of illness (Rifkin & Walt, 1986; Werner, Sanders, Weston, Babb, & Rodriguez, 1997).
14
This action was intended primarily to reduce the high withdrawal among trainee nurses, which ran at
45 per cent (Dow, 1995), to support the new technical Institute movement (M. Brown, Masters, &
Smith, 1997), and to encourage a community focus (M. Horsburgh, personal communication, July 15,
2005).
15
Theories developed in this decade included the health belief model (Becker, 1974), the theory of
reasoned action (Ajzen & Fishbein, 1980), social learning theory (Bandura, 1977) and in the next
decade, the stages of change model (Prochaska & DiClemente, 1984).
20
Targeted national public health programmes based on behavioural theories attempted
to persuade people to stop smoking, improve their nutrition, practise breast selfexamination - exercise and health were deemed the individual’s responsibility.
Programmes, such as these, focusing solely on individual behaviour change were
widely criticised for ignoring the lack of opportunities for people who were
disadvantaged to be healthy (Crawford, 1977; J. French & Adams, 1986; Naidoo &
Wills, 1994; Rodmell & Watt, 1986; Tesh, 1988; B. Tones, 1986). Disease focused
associations, such as the Heart Foundation, were active in their campaigns to change
risk factors and population surveys of risk factors were commonly conducted.
Prevention was rediscovered in an attempt to control health costs.
Economic rationalism became a central discourse in New Zealand political life. The
cost of medicine was questioned as New Zealand hospitals simultaneously succeeded
in gaining a larger proportion of the health budget. The cost of health care increased
during the 1960s, with a comparison of spending for the years 1961 and 1972
revealing an increase of 45 per cent (Dow, 1995). Consistent with second generation
reforms, attempts to make efficient use of the reduced health budget throughout the
1980s focused on the transition to a population-based formula and an emphasis on
primary care, synonymous in New Zealand with general medical practice. General
practitioners “function as independent, fee-for-service practitioners receiving some
government subsidies” (Boyd & Sheridan, 2000, p. 305) and provide clinical care,
cure relative to prevention, and essential drugs.
During the life-style period ‘Maori identity’ was asserted beyond the marae and into
areas such as law, medicine and education.
A resurgence of interest in Maori
language and culture combined with new insights into the Treaty of Waitangi as a
living social document relevant to contemporary life. An important earlier report on
the Department of Maori Affairs examined issues such as land, housing, and
education, concluding that integration should replace the former policy of
assimilation, and differences based on inequality or discrimination should be
eliminated (Hunn, 1961). While these findings had direct implications for health,
nearly two decade passed before State sector reform in the 1980s reactivated the
formal recognition of the Treaty and its integration into health services. Health
21
became a topic for discussion on the marae, rivalling land as the central focus of
Maori concern.
Maori health models were developed and articulated, reaffirming spirituality as a
basis for health and well-being (Durie, 1998).
Statistical information on socio-
economic, self-esteem and cultural factors noted a further narrowing of the gap
between Maori and non-Maori health, with differences attributed in part, to the
monoculturalism of health services (Pomare et al., 1995). The life-style period was
not discrete, and significant developments, such as indigenous peoples’ health
movements and women’s health movements, coincided, contributing to the evolution
of ‘new public health’. Second generation reform overlapping the life-style era, was
as unsuccessful as the first generation of reform had been in improving the health of
the poor.
1.4.6
New public health (1980 to 2005 and beyond)
The most recent era, new public health, is based on the Ottawa Charter (see p. 3) and
seeks to direct resources into a positive approach to health, placing a greater emphasis
on health promotion. Baum (1998) suggests the driving forces behind the Charter
result from the limited effectiveness of the ‘health for all by the year 2000’ strategy in
wealthy countries, and the limitations of the life-style and behavioural approaches,
requiring a new notion for health promotion.
New public health has developed strategies that are integrative, combining some
elements of past strategies and new ideas.
Previous eras focused on physical
infrastructure in order to provide clean water and sanitation, whilst new public health
complements this focus also advocating social support, and behaviour and life-styles
approaches. Legislation and policy, key mechanisms in the nineteenth century were
rediscovered as important tools for modern public health. Intersectoral action is
recognised as crucial to success, a shift from the time when medicine had centre
place.
Current philosophy promotes community participation, whereas ‘experts’
drove public health during the twentieth century. New public health considers many
methodologies to be legitimate, not just epidemiology and is concerned with all
22
threats to health, including chronic conditions, and the sustainability of the physical
environment.
This is in contrast to earlier public health concerns that focused
predominantly on infectious disease. New public health has established an agenda for
action and policies are influenced by notions of poverty and social justice (Baum,
1998).
The Healthy Cities programme in 1986 (J. Ashton, 1992; Tsouros, 1995) was a
collaboration between different sectors of government and communities to create an
environment conducive to good health. This early initiative saw cities as the units for
public health planning, rather than individuals. Healthy cities varied between and
within countries, although common aims included: promoting equity and reducing
inequities in health status; recognising the importance of the determinants of health;
fostering intersectoral collaboration; aligning with new public health thinking;
partnering with community, and encouraging innovation.
The healthy cities
programme attempted to tackle complex public health issues at city, community and
regional levels. Baum (1993) maintained that by focusing on individual cities, wider
social, economic and political factors were ignored. Whilst this criticism may be
justified, the healthy cities programme was an innovative experiment that led the
healthy settings approach, which saw hospitals, schools and workplaces become
centres for health promotion.
The importance of policy as a tool of public health was agreed at the second
international health promotion conference where the theme was healthy public policy.
The purpose of healthy public policy is to create the preconditions for healthy living
through: closing the health gap between social groups and between nations;
broadening the choices of people to make the healthy choice the easier and most
possible, and ensuring supportive social environments (Mahler, 1988). Implementing
primary health care policy in New Zealand is necessary, partly because the
community care sector has long been neglected, and policies of de-institutionalisation
and changes to hospital procedures (day surgery, shorter average lengths of stay) have
increased the demand for care in the community. New Zealand does not have a
universal primary medical care system free at the point of use, and this circumstance
23
led to the development of third sector16 primary care (Crampton, Dowell, &
Woodward, 2001).
Successive governments have sought to improve access to
primary medical care for low-income families by manipulating the primary care
subsidy scheme, and attempts to limit the amount charged by general practitioners
have failed (M. Brown & Crampton, 1997; Health Benefits Review, 1986).
Experimental funding mechanisms such as capitation and budget-holding sought to
increase control over demand-driven expenditure in the early 1990s (Malcolm &
Shalowitz, 1997). Third sector primary care organisations - union health clinics,
tribally based Maori health providers, and community-based primary care providers,
established a formal network in 1994, Health Care Aotearoa, to serve populations that
were largely non-European and lived in deprived areas. Population approaches to
funding and service provision were consistent with the intention of integrated care
(see p. 106), whereas projects in the late 1990s targeted defined populations, for
example with chronic conditions.
Since 2001 primary health organisations
comprising collective groups of general practices and other primary care providers
have sought to deliver population-based services to enrolled populations.
Opportunities exist for primary health organisations to work in innovative ways with
consumers to address inequalities in health and health care service provision.
The linking of national strategies provides the opportunity for New Zealand public
health to become more innovative, as patchy innovation has been evident throughout
developments in community health.
The Primary Health Care Strategy (PHC
Strategy) seeks to tackle inequalities in health and emphasises population health, the
role of community, health promotion, and preventive care. However, the continued
reliance on goals and targets and measurable health outcomes as a means of
monitoring (forcing a focus on disease), and the investment in general practice rather
than broader primary health care services, strongly suggest a continued medical and
behavioural focus. In New Zealand the debate between selective and comprehensive
primary health care approaches mirrors that of other wealthy countries (Baum &
Saunders, 1995).
16
The term third sector has been adopted internationally to describe organisations that are nongovernment and non-profit.
24
Table 1: New Zealand public health developments and health reforms
Era
Dominant policies and
ideologies
Typical intervention
model
Era of indigenous
control (estimated
in excess of 700
years )
Strong links with land,
traditional healers,
emphasis on spirituality
and health was integral
to life. Maori public
health concepts – tapu
and noa
Public health practice
was part of accepted
culture, Maori
knowledge was
transferred through
oral tradition. Tohunga
protected Iwi survival.
Colonial era (1840
to 1890s)
Control of infectious
disease, public health
was strongly influenced
by British settlers.
Emphasis on sanitation.
Maori re-settlement saw
increased illness/death
Quarantine Acts.
Public Health Acts in
colonies. Provision of
clean water and
sanitation.
Nation-building era
(1890 to 1940)
Government action to
strengthen the nation
through health and
fitness ‘Improve the
(white) race’. Health
linked to ideas of vitality,
efficiency, purity and
virtue. The focus was
national protection and
progress
Medical inspections
and organised
exercise programmes
aimed to improve the
national physique of
schoolchildren. Maori
health received limited
attention. Hygiene
advice was given to
the population
Economic affluence
sees governments
committed to improving
quality of life (post war).
Investment in clinical
medicine aligned with
the belief ‘medicine
would conquer disease’
Government involved
in housing, education,
and health. Hospitals
and budgets expand.
First organ transplant.
Public health is linked
to health services and
disease prevention
Affluence,
medicine, and
infrastructure (1950
to early 1970s)
Life-style era (late
1960s to mid-1980)
New Public Health
era (1980 to 2005
and beyond)
Chronic disease focus –
effects of affluence.
Economic rationalism.
Individual responsibility.
Epidemiological
methods. Assertion of
Maori identity in the
professions, health
models are developed
Selective primary
health care – illness
causes not addressed.
Individual behavioural
approaches to care.
Life-style projects.
Population surveys.
Treaty of Waitangi
impacts health system
Ottawa Charter:
collective action; healthy
public policy, and health
promotion. Issues of
poverty, social justice,
equity, effect policies.
Market economies,
competition, reduced
government expenditure
Healthy public policy –
ie. smoking legislation.
Innovative healthy
cities approach.
Intersectoral action
with community
participation. Creating
supportive social and
physical environments
Generation of
health reform
st
1 generation
1940s to 1950s
Health care to the
underserved/poor
(indigenous/Maori)
Hospital care had
a pro-rich bias. In
New Zealand free
hospital care,
medicines,
subsidies for all
nd
2 generation
1960s to 1980s
Primary health
care strategy
sought to bring
basic health care
to all people.
Supply-driven
rd
3 generation
1980 and beyond
Demand-driven.
Better access,
services/subsidies.
Experimentation.
Less regulation by
government.
Interest in health
insurance
mechanisms
25
It is ironic that during the new public health era, the World Health Organisation was
advocating a broader agenda for public health, and simultaneously promoting a
methodology that was essentially reductionist. The mismatch of philosophy and
strategy (the broad social, economic and environmental agenda set by the Ottawa
Charter) and the mechanism to achieve this mismatch (mainly behavioural and
medically defined goals and targets) encapsulated the tensions and forces within
public health itself.
Medicine and epidemiology were, and remain, dominant
professional groupings within public health, and the approaches of these groups dealt
best with the behavioural and medical aspects. Third generation reform has not yet
demonstrated sustainable improvement in the health and well-being of the poor.
However, as this generation of reform continues, both the challenge and opportunity
to improve population health through advocating health promotion exist.
Chapter two introduces health promotion theory in order to shed light on the ways in
which public health can be improved. “Health and its promotion…(must be) built
into the consciousness of the public and professionals in order that change and
improvement can be continually effected” (Downie et al., 1990, p. vi). The following
chapter proposes that health promotion should be considered an important and crucial
element of contemporary public health. As health promotion has acquired many
meanings, Beattie’s model of health promotion (Beattie, 1991)17 provides a useful
framework to explore underlying values.
17
Beattie’s model also provides a framework for analysing the NICPS results that determine the health
promotion values embedded within nurses’ practice (see p. 192, chapter seven).
26
2
Chapter 2
Health promotion theory
2.1
Introduction
Section 2.1 explicates a central model of health promotion from a variety of others,
establishing the theoretical perspective for the study (see p. 127). Health promotion
theory is discussed in a separate chapter to distinguish it from other public health
literature, although it is clearly a logical extension of the former discussion. This
approach also isolates health promotion theory from other components of the research
process enabling the reader to better identify and understand the theory base and its
use in the thesis research, the ‘Nurses in integrated care projects study’ (NICPS).
Attempts to conceptualise health promotion have given rise to a range of different
models and approaches. For the purpose of this thesis, health promotion is defined as
any activity that encourages health (B. Tones, 1986) including chronic care
management. Although Tones and Tilford (1994) have more recently suggested
health promotion is health education and healthy public policy, and taken account of
the concept of empowerment, the earlier definition is less bounded and therefore
allows for a wider range of possible activities.
The inclusion of chronic condition
management, with its emphasis on disease reduction, prevention and health protection
to maximise positive health, as an adjustment to this definition is becoming less
contentious. The continuing debate over territory, challenging the nature of health
promotion activities, is a feature of the history of health promotion. French (1990)
has questioned why disease management should not be included, whereas Downie et
al. (1990) explicitly removed curative and acute services from definitions of health
promotion.
Chapter 2 is presented in four parts. First, section 2.2 health promotion and nursing,
is briefly discussed to establish a context for the professions’ approach to health
promotion practice. Beattie’s model of health promotion is then described, and other
models and related conceptions of health promotion are compared and contrasted in
sections 2.3 and 2.4, respectively. Beattie’s model provides the framework for the
analysis of study results in order to identify the health promotion values embedded
27
within nurses’ practice in section 2.5. Finally, summary comments draw together the
central and related ideas expressed in chapters one and two.
2.2
Health promotion and nursing
Health promotion is a contested area. This is partly because it is a very broad field of
action, its focus has changed over time, and terms used such as ‘health education’ and
‘health promotion’ have shifted their meaning. There is no easy consensus about the
ideas that underpin health promotion and protagonists hold very different views about
priorities and strategies, which reflect their underlying values (Downie et al., 1990; J.
French, 1990; J. French & Adams, 1986; B. Tones, 1986; K. Tones & Tilford, 1994).
Nursing as a profession has contributed to the individualisation of health, views the
client as a victim of his or her behaviour, and “encourages a form of health promotion
which focuses on the individual and ignores or decontexualizes social problems”
(Caraher, 1994, p. 465). Attempts to link health with structural or social issues were
met with resounding disapproval in the 1980s (Beattie, 1991) at a time when health
status focused on individuals and their beliefs (W. Rogers, 1991). Caraher (1994)
pointed out that “viewing the individual as the focus of interventions is not in itself an
inappropriate approach, depending on the context within which this happens” (p.
466). However, if the focus is solely on the individual and their behaviour it can lead
to ‘victim-blaming’ (Crawford, 1977). Even within a health-promoting environment,
which attempts to make healthy choices easier (World Health Organization, 1985)
victim blaming can occur and people may choose to behave in ways determined as
unhealthy. Hamilton and Bhatti (1996) maintain a population health promotion model
that calls for action on the full range of factors that determine health shifts the focus
away from victim blaming individuals.
The way health is viewed influences the interventions undertaken. Factors causing
disease, such as germs, were considered external to the individual and treated with
antibiotics. The emphasis has moved towards individuals taking control over health
and disease, “now, the healthful behaviour is the accepted standard and the
unhealthful
behaviour
[excessive
drinking
and
smoking]
is
socially
28
deviant….concepts about health, physical fitness, and personal responsibility have
been fused with popular culture” (Guidotti, 1989, p. 402). The focus on individuals
having control of their health, as opposed to social and economic factors,
individualised the problem and poverty for example, became an issue individuals had
to manage. This is given further emphasis by the claims of nursing to a health
promotion capability. As Beattie (1991) contended
The established and mainstream professions have become increasingly interested
and involved in health promotion at a time when independently of one another,
each of the professions has been vigorously examining and seeking to consolidate
their own knowledge base, their definitions of professional competence…(p. 185).
The nursing profession engaged in the development of individual practitioner’s skills,
initially focusing on communication for the purpose of health teaching (Beattie, 1990;
Coutts & Hardy, 1985; Gott & O'Brien, 1990).
This proved to have limited
effectiveness because nurses could advise, inform, and direct, but changing a client’s
behaviour was something only the client could do. This realisation resulted in a shift
to personal counselling as a more effective method of achieving health behaviour
change (Wilson-Barnett, 1988). Personal counselling, like health persuasion, focuses
on the individual and encourages them to be responsible for their own health.
Nurses and other health professionals continue to use the strategies of health
persuasion and personal counselling in efforts to encourage individuals to change their
life-styles. Caraher (1994) contends “links between health and social structure are
relegated to a position of areas we must use in targeting groups in society” (p. 467)
with groups often deemed vulnerable to their own behaviour and not vulnerable to
social and structural elements, such as occupation, social class and income. Any
personal counselling intervention by nurses that teaches individuals to cope with their
circumstances and to accept structural limitations can create victims and in itself can
be a cause of ill health.
Increasingly the social and economic determinants of health are identified in New
Zealand national strategies as areas of focus in the interests of improving population
health (Ministry of Health, 2001c). There is a strong argument that it will prove
29
difficult to advance health promotion practice unless an understanding of how broader
social, political and cultural values are developed and this knowledge is translated into
health promotion practice. For this reason Beattie’s model of health promotion was
selected to make explicit the values in nurses’ practice when employed in integrated
care projects (see p. 194, chapter seven).
2.3
Beattie’s model of health promotion
Beattie’s analytical model of health promotion allows the foundation for practice to be
investigated. By making explicit the links between core values and different practices
a greater understanding of the philosophy and priorities of health promotion can be
derived (Naidoo & Wills, 1994). Beattie’s model is not bounded by current practice
and can describe a vision of health promotion practice not yet in operation. In this
sense, theory may drive practice leading to new discoveries.
Adapted from an earlier framework (Beattie, 1986), the dimensions of the crossclassification are adapted in figure 1 to examine the theoretical underpinnings of
health promotion (Beattie, 1991). Beattie’s model is explicit in saying that health
promotion is embedded within wider social and cultural practices, in ideologies and
political struggles that include power, control, autonomy and authority. Various
accounts of health promotion are positioned within a broad socio-cultural dimension,
making this the most important feature of the model.
Beattie’s model provides a range of approaches that may comprise an intervention:
health persuasion, a traditional health education practice; personal counselling where
individuals are assisted to find solutions to their health issues; legislative action,
which develops activities to protect the public’s health, and community development,
enabling groups of people to identify and meet their needs through education, support,
or services.
The specific approach to an intervention depends upon “bipolar
dimensions namely ‘mode of intervention’ and ‘focus of intervention” (Beattie, 1991,
p. 167) that invoke two well-known and established dichotomies in the analysis of
social policy.
30
Figure 1: Beattie’s model of health promotion
From “Knowledge and control in health promotion: A test case for social policy and social theory” by A. Beattie,
1991, p.162-202. In The Sociology of the Health Service. Chapter 7. Eds J. Gabe, M. Calnan, and M. Bury.
Copyright 1991 by Routledge: London. Reprinted with permission of the author.
Mode of intervention results from views about power and control. The authoritative
mode is characterised by ‘top-down’ forms of interventions, led by experts who
encourage individuals or communities to adopt behaviours perceived as good for them
reflecting paternalism and prescription.
This versus the negotiated mode
characterised by ‘bottom-up’ forms reflecting participation, where health workers act
as facilitators and people themselves lead, identifying their own needs. Beattie (1986;
1991) among others (Hardy, 1981; Room, 1979), has shown how top down and
bottom up health interventions come to be polarised by degrees within the
authority/negotiation dimension. Focus of intervention results from views about the
causes of ill health, improving the health of individuals versus the health of
communities or entire populations. “The individual/collective dimension stands in its
own right as one of the most stable and enduring axes of conflict in social theory and
social policy” (Taylor-Gooby & Dale, 1981, p. 168).
31
2.3.1
Health persuasion
Beattie’s model assists us to reflect upon the social and political perspective
underlying health promotion approaches and to recognise related social values. The
‘conservative’ model of health persuasion, for example, is based on a bio-pathological
model of health. Health persuasion “has long historical roots, including temperance
campaigns in the nineteenth century, anti-venereal disease propaganda at the time of
the 1914 - 18 war and better-eating campaigns on the ‘home front’ during the 1939-45
war” (Beattie, 1991, p. 168). The strategy is associated with clinical preventative
medicine, individual subjects, and a system of care primarily concerned with illness
views health promotion as attempting to repair weaknesses or deficits and solve
problems. The health persuasion strategy relates to individual responsibility, topdown authority by a health professional or outside agent and has been described by
Crawford (1977) as paternalistic, favouring a culture of victim blaming.
The health persuasion strategy has reinforced the idea of risk factors to health and
“concepts about health, physical fitness, and personal responsibility have been fused
with popular culture, so that the message is continually reinforced by peer pressure,
advertising and the approval of the medical community” (Guidotti, 1989, p. 402). On
the surface this social intervention appears straightforward to plan, such as a review of
medical literature about the risks related to behaviour before delivering a message
targeting a specific audience using selected media. However, the effectiveness of the
health persuasion strategy has repeatedly been shown to be unsuccessful on its own in
bringing about life-style changes (Gatherer, Parfit, Partner, & Vessey, 1979). Beattie
(1991) contends “the dubious and discredited strategy of health persuasion regularly
finds enthusiastic champions in Parliament” (p. 170) suggesting that many in
governmental positions with power have ignored the lack of scientific justification for
health persuasion campaigns and have even suppressed evidence of ineffectiveness.
Gradually new knowledge has led to personal counselling being considered a more
effective way of working with individuals to change their behaviour (Beattie, 1990;
1991; K. Tones, Tilford, & Robinson, 1990; Wilson-Barnett, 1988).
32
2.3.2
Personal counselling
The realisation that bio-medicine with its emphasis on treatment and care was labourintensive and high cost led to an increased interest in an approach that persuaded
individuals to change their life-styles (Guidotti, 1989). Personal counselling adopted
counselling, group-work techniques and personal development programmes for the
purpose of health promotion. The theories and models associated with this work have
their origins in psychodynamic and post-Freudian humanistic psychology and social
psychology, emerging within the context of the mental health movement.
This
strategy was apparent in biographical medicine within psychiatry, general practice,
psychiatric nursing (D. Armstrong, 1979); pupil-centred education in schools and
subsequently in personal tutoring (Walkerdine, 1984), and individual case work
among social workers, probation officers, marriage guidance counsellors, hospital
chaplains and other therapists (A. Campbell, 1984). Like health persuasion, the focus
is on the individual, but in this situation does not necessarily imply paternalism.
Personal counselling is client-led, relies on the health worker acting as a facilitator
rather than an expert, and involves creating autonomy so that the client can make
informed choices.
The central precept in much personal counselling is ‘self-empowerment’ and the nondirective and client-orientation of the process is valued by its proponents (C. Rogers,
1969). Blackham (1978) suggests clients favour this strategy because it promises
personal autonomy and self-determination.
Criticisms of personal counselling
include: the invasion of a private domain; professionals not expert in techniques
(Halmos, 1965); emphasis on self-conscious verbalisation and disclosure; futureoriented life planning; the premium placed on middle-class values, potentially
creating problems of access for the client who is poor (Bernstein & Henderson, 1974),
and raising hopes which cannot be met within the present context of the client’s life
(Radical Therapist-Rough Times Collective, 1974).
Beattie (1991) argues the
“emphasis is clearly and almost exclusively on helping individuals to learn to cope
(rather than to change their circumstances)” (p. 175) and in this respect does not
escape the charge of victim blaming (Pattison, 2000; Pearson, 1973). Both health
persuasion and personal counselling approaches to health promotion place the
33
responsibility on the individual, and the health professional is not held accountable for
any subsequent outcome.
2.3.3
Legislative action
The social change approach of Ewles and Simnett (2003) assumes a concomitant
philosophy of collective (or community) action, whilst Beattie’s model demonstrates
that collective action can be participative and community-based or paternalistic and
state directed.
Beattie’s framework for analysis helps to tease out some of the
complexities underlying health action. Legislative action seeks to direct behaviour
towards achieving health at a macro-level using a top-down process to improve
health.
This strategy has a lengthy history, which includes environmental
interventions, such as clean water, sanitation, improved diet, and better housing
(Beattie, 1991), air pollution legislation (Scarrow, 1972), seat belt regulation, and
smoke-free legislation in public places. Improving health by enforcing legislation has
been argued with increasing force (Doyal & Pennell, 1979; Draper, Best, & Dennis,
1977; Kennedy, 1983) and recent evidence of the growing social and economic
inequalities in health support this case (National Health Committee, 1998). Garside
(1987) argued the need to understand the cultural and ethical issues related to
legislative action, pointing out the “dangers of ‘collectivist authoritarianism’ in social
reform focused too exclusively on health itself (as against ‘the problems of the
community at large’)” (p. 173), an issue of no less importance today. Legislative
action is a strategy led by professionals, intended to protect communities. This topdown approach, however, may be viewed as inappropriate or irrelevant by
communities because of the limited or non-existent input they have had into processes
that determine health promotion interventions directed at them.
2.3.4
Community development
Community development is a more recent health promotion strategy that has been
termed self-help health, community-oriented health education, health outreach, and
community health action (Somerville, 1984).
Like personal counselling, it has
34
emerged in different contexts with some similarities of ideas, such as selforganisation, mutual assistance within the group, and expertise external to the group
being a less urgent requirement (Beattie, 1986). Groups form to discuss common
concerns, establish mutual issues, clarify options and work collectively.
Underlying a community development strategy are assumptions about empowerment,
equity and the mobilisation of communities to work together to change their
environment using a bottom-up process. The concept of empowerment in health
promotion began with the emergence of the community health movement, which tried
to stem the flow of authoritarianism and individualism that had come to dominate the
political agenda (Beattie, 1991).
The World Health Organisation (1986)
acknowledged that health developments in communities should not only be developed
for the people, but rather by the people. Tones (1990) and others (Hamilton & Bhatti,
1996) argue that if root causes of ill health are not addressed, an individually-oriented
approach leading to victim blaming may occur.
The role of the health worker in community development may include: identifying
potential groups through community surveys or consultation processes; facilitating a
group coming together; assisting the process of debate; mobilising community
resources; linking the group with key people in positions of power; advocating for the
group to wider audiences, and networking to bring the group together with others who
can act as resources (Chaplin & Adams, 1986; Laverack, 2005). Beattie (1991)
suggests community development has often been misunderstood as a way of getting
prescribed health agendas and messages to groups considered hard-to-reach (health
persuasion) through health and welfare services (personal counselling), made
available at the local level (legislative action).
In such a context, community
development is assimilated into another health promotion strategy and that has
assumed priority.
Community development has an explicit purpose, to bring about social and political
change, and can be supported by partnerships with health workers. John Raeburn
(personal communication, April 30, 2003) suggests it is necessary for health workers,
such as nurses, involved in community development to be able to make distinctions
between the different models of partnership, a requirement for community
35
development. For example, a community involvement model is applied when the
nurse determines the agenda and attempts to get the community on side, a community
participation model is applied when the nurse gives the major role of the programmes
design and implementation to the community but remains in control, and a community
controlled action model is applied when the nurse acts as a guide and educator of
community members who learn skills to undertake their own (health promotion)
programme.
Community controlled action is concerned with empowerment and can “support the
community in the identification of issues that are important and relevant to their lives”
(Laverack & Labonte, 2000, p. 256).
Laverack & Labonte view community
empowerment as more than a means to an end of health behaviour change, and
recommend the goals of community empowerment are considered in parallel to the
goals of top-down18 health promotion programmes.
This idea prevents the
assimilation of community empowerment into other health promotion agendas, by
clarifying the criteria for its attainment. Programmes negotiated with well established
communities may require a commitment of only six to 12 months, whilst nonestablished communities have been reported as taking no less than two years and up to
seven years to develop (Raeburn, 1996). According to Laverack and Labonte “too
short a programme time frame runs the real risk of initiating healthy community
changes, only to end before such changes have reached some degree of sustainability”
(p. 258). Examples of community development programmes designed and managed
in negotiation with communities range from anti-poverty or housing development
programmes to community gardens, and advocacy support (Labonte, 1996).
2.3.5
Beattie’s model: Health promotion values in practice
Foucault (2002) recognised the importance of trying to understand the relationship
between values (ways of thinking) and practice (ways of doing). Beattie’s model
enables practitioners to identify the values and assumptions underlying different
18
Top-down programmes are conventional, solve a problem or deficit, focus on individual
responsibility, are controlled by an outside agency and have low community ownership (Laverack &
Labonte, 2000).
36
forms of practice and to assess practice from the point of view of others, such as
policy makers and clients. Health professionals, including nurses, are influenced by
socialisation into a family, a social class, a cultural group, and through values
developed in professional training and experience. If for example, nurses’ values are
not congruent with their professional role, or interventions overlap quadrants, the
model may reveal only some of the formulation. However, as Beattie’s model is
abstract and highly complex, it is anticipated that changing social values will be
identified in the analysis of health promotion practice.
2.4
Health promotion: Social theories and models
Health promotion has come to refer to a movement that challenged the medicalisation
of health, stressing the importance of socio-environmental aspects to health and wellbeing. The theoretical base was derived principally from social and philosophic
theory, with other contributions from the behavioural and educational sciences,
epidemiology and clinical practice. In this section, social theories are outlined and
links are drawn to behavioural psychology and education, amongst other disciplines.
Health education and more comprehensive health promotion models are discussed as
descriptive or analytical, and compared in relation to Beattie’s model.
2.4.1
Social theories
Health promotion has drawn on perspectives found in sociology and social policy
(Bunton, 1992), adopting a structural analysis that focuses on the physical and social
influences, including relationships, that impact health and inequalities in health
(Townsend, Phillimore, & Beattie, 1988). The social change or healthy public policy
approach, synonymous with the period of new public health, owes much to a political
economy analysis of how ill health is generated by poverty, poor housing and work
environments, pollution, discrimination and unemployment (Doyal & Pennell, 1979).
Health promotion has also adopted a post-modern notion of fragmentation, in the
sense that it has attacked the objective, science-driven model of medicine and
37
embraced the diversity of lay accounts of health, subjectivity, social movements,
community action and empowerment (Kelly & Charlton, 1995). Social policy has
provided analytical frameworks for thinking about policy-making and policy-change.
Examining shifts in policies for health, and wider political ideologies such as New
Right perspectives on the sovereign consumer helps to explain recent shifts in health
promotion. Other theories and models adopted by health promotion from social
psychology and education include: locus of control; reasoned action; health belief,
and behavioural change (Ajzen & Fishbein, 1980; Becker, 1974; Prochaska &
DiClemente, 1984; Rotter, 1966).
Sociologists have argued that health promotion, embedded in contemporary society,
emerged as a persuasive discourse about risk, change, life-style and consumption, and
its messages reflect fundamental shifts in the ways of seeing and practising health
care. For example in India, rapid social change has led to an expanding human
immunodeficiency viral epidemic (J. Armstrong, 1995).
This is an important
justification for developing analytic models such as Beattie’s model of health
promotion that attempt to represent the tensions and oppositions by demonstrating the
ways in which health promotion is embedded in wider social and cultural practices
and political struggles.
2.4.2
Models of health education and health promotion
Health education was a central health promotion activity undertaken in the 1980s and
models proliferated, although there was no consensus on core activities (Downie et
al., 1990).
Health education activities, such as teaching attitude and behaviour
change, informing and educating people about health issues, and empowering clients
to set their own agendas, were undertaken alongside medical interventions that
persuaded people to seek early treatment and approaches focused on changing the
physical and social environment (Ewles & Simnett, 2003). The different approaches
had distinctive priorities and reflected different views of clients. Unlike Beattie’s
model these frameworks did not demonstrate what motivated health professionals to
select one approach over another, and could only describe current practice.
Descriptive models of health education and promotion activities can highlight issues,
38
but do not provide reliable models of real practice, and are not necessarily transferable
to other settings. Describing how health promotion occurs rather than analysing the
values and conflicts that underpin it does little to help practitioners reflect upon the
approaches they adopt within their practice.
French and Adams (1986), in contrast to Ewles and Simnet (2003) identified
collective action, self-empowerment and behaviour change, as social values
underpinning different approaches. Like Beattie (1991) others identified collective
action and empowerment as effective and desirable concepts in health promotion (J.
French & Adams, 1986; K. Tones & Tilford, 1994), proposing that through health
education, communities and health professional bodies could influence public policy
to address health inequalities and improve health (K. Tones & Tilford, 1994).
Downie et al. (1990) identified traditional, transitional and modern approaches to
health education. The first two approaches do not address positive health, life skills,
self-esteem, participation, constraints to freedom of choice and collective dimensions
of health and behaviour. In the modern or contemporary approach, health promotion
work does not focus on prevention and disease reduction or on structural and social
change, exclusively. Instead, this model offers combinations of approaches, and when
compared to Beattie’s model does not make explicit the political or social values
underlying each approach, or reveal the author’s preferences as to methods.
Other models have attempted to link health promotion to social and political
structures and to frameworks of social knowledge.
Caplan and Holland plotted
theories of knowing (conflict or consensual) against ways of knowing about the social
world (subjective or objective) (Caplan, 1993). Collins (1993) has attempted to link a
micro model of a person’s health beliefs, constraints and actions to a macro model,
which analyses health promotion at a societal level. Like Beattie, these authors agree
that when practitioners do not make their assumptions explicit they have not
acknowledged the political nature of health promotion practice. Beattie’s definitive
model assists the reflective practitioner to go beyond description to analysis (Schon,
1983).
39
The health promotion models discussed are not mutually exclusive, and being either
descriptive or analytical, can demonstrate diversity and its potential conflicts.
Diversity may be, but is not always, explained by trends and changing ideas over
time. Conversely there are considerable differences between an approach based on
bottom-up negotiation, one that utilises a regulatory framework and legislative
changes, and one that relies on professional dominance. The increasing development
of analytical models in health promotion suggests a greater awareness of the
importance of making explicit the values within the society in which health promotion
is undertaken. Models such as these present new possibilities for improving practice
and provide opportunities to review ideas and actions. However, it is interesting that
older, seminal work by Beattie (1991) is more relevant for the contemporary analysis
of nurses’ practice than other models developed more recently.
2.5
Beattie’s model: An analytic framework for use in the NICPS
Section 2.5 presents Beattie’s model of health promotion as a framework to both
understand health promotion and analyse health promotion values within practice.
Downie et al. (1990) argue health promotion reflects the values of society, which must
be widely shared for the continuance of that society.
Beattie’s model is firmly
oriented towards advancing health promotion practice because it makes explicit the
assumptions within the society (or profession) in which activities are undertaken. Of
the health promotion models and theories that have been more generally discussed
(see section 2.4), none provide the broad theoretical perspective that allows systematic
analysis, as Beattie’s does.
For this reason, Beattie’s model was adopted to
investigate the health promotion interventions undertaken by nurses in integrated care
projects (see p. 160).
Alongside the investigation of types of investigations such as case management, there
was a place for a more theoretical inquiry into the health promotion (social) values
embedded within this practice. Beattie’s model, because of its cross-classification
matrices is a highly suitable tool for such an analysis. The consensus values of health
promotion within the era of new public health (see section 1.4.6) are represented in
the model, as are the principles of primary health care (see p. xiv). The analysis of
40
interventions undertaken by nurses, using Beattie’s model will establish whether these
values and principles are embedded within nurses’ actual practice.
In addition,
because the model is conceptual and therefore not bounded by existing practice,
desired values for future primary health care nursing can be contemplated and in this
sense, theory may transform contemporary practice leading to new discoveries.
2.6
In conclusion
This chapter has shown that all current challenges have historical antecedents.
Consideration of history, crucial philosophies, and practices that have been
representative of public health are important in assisting an understanding of
contemporary public health.
New public health has been described as both a
continuation of the past and a departure from it (Baum, 1998). The claim to be ‘new’
derives from having pulled together numerous, diverse movements into a cohesive
whole that has the potential to radically define the future direction of public health.
Combining many methodologies has also served to make health promotion, a key
strategy of public health, a legitimate and respectable part of the wider health scene.
Commentators like Alan Beattie have sought to develop models of health promotion
that portray the differing philosophies embedded within understandings of what health
is, and how health can be best promoted. Beattie’s classic model has made explicit
the theoretical propositions embodied in public health practice, which can be assessed
in any health system context.
Beaglehole and Bonita (1997), among other observers of the historical and
contemporary health system in New Zealand, agree that more emphasis should be
placed on public health and primary health care activities. There is practically no
disagreement in the literature on this view, yet achieving it is proving difficult in the
face of an intransigently curative health system. Since the millennium, New Zealand
has advocated primary health care as a central approach underpinning health reform.
National strategies, restructuring, and an accompanying investment in the health
workforce herald fundamental change in the culture of the health system. Even
though in many countries public health practice has been reduced to a series of
specific interventions far removed from the broad social movements that historically
41
have had the greatest effect on the public’s health, rethinking health promotion and
primary health care has been apparent in all three generations of reform.
Decreased interest in the broader agenda established by the Ottawa Charter is partially
a consequence of a tight fiscal environment, and a return to the earlier core business
of ‘curing people’. Cost containment is clearly a key motivation of third generation
reform.
The resources devoted by government to public health services in all
countries are only a fraction of those spent on medical care, whilst the costs of
medical care inspired by technological developments, the ageing population, and
epidemics of non-communicable diseases (Evans & Stoddart, 1990) are the critical
concern of governments.
These issues are outlined in the next chapter, which
discusses the pressure on health systems to respond to the global burden of disease,
caused by an escalation of chronic conditions.
42
3
Chapter 3
Chronic Conditions
3.1
Introduction
Most New Zealanders now die from chronic conditions, which are increasing
globally. People are living longer with chronic illnesses and with more complex comorbidities (National Health Committee, 2005). Unhealthy life-style choices such as
tobacco and excessive alcohol consumption, physical inactivity, and unhealthy
nutrition are known risk factors for heart disease, diabetes, and stroke
(cerebrovascular disease). By 2020 chronic conditions will be the leading cause of
disability throughout the world and the most expensive problems faced by health care
systems (World Health Organization, 2002a). At present, health care systems around
the world are organised to provide acute illness care, despite the global disease burden
having shifted towards chronic conditions. Health care services are fragmented, focus
on acute and emergent symptoms, and often provide care without the benefit of
complete clinical information. The client’s role in management is not emphasised,
follow-up care can be sporadic, and community services tend to be ignored. There is
pressure on all health systems to develop a response to the escalation of chronic
conditions, which has grown as a result of demographic transitions and ageing,
changing life-styles, consumption patterns and urbanisation (World Health
Organization, 2002a). Action taken today can prevent and reduce the leading risks to
health and avoid the burden of disease in future decades.
The purpose of this chapter is threefold. Section 3.2 presents the challenge chronic
conditions pose to countries from a health and economic standpoint, the reasons for
this rapid growth, and the bi-directional relationship between chronic conditions and
poverty. Section 3.3 considers the deficits in the New Zealand acute health care
system when faced with managing chronic conditions, and introduces the ‘Chronic
Care Model’, as a blueprint for a more comprehensive system of care. Section 3.4
outlines the risks to health and discusses risk prevention. Actions to lower the burden
of disease, the role of government’s in tackling major risks, and promoting health are
identified.
43
3.2
Chronic conditions challenge the health care system
The importance of chronic conditions to the health of society has been of international
concern since the 1940s (Commission on Chronic Illness, 1957) and primary
prevention in chronic condition management was emphasised in the 1970’s (Benjamin
& Newcomer, 1997). Chronic conditions are persistent health problems that never
completely resolve and require differing degrees of health care management over
time. Considered from this perspective, chronic conditions cover a wide spectrum of
different health concerns. Persistent communicable (e.g., human immunodeficiency
virus (HIV) / acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB))
and non-communicable (e.g., cardiovascular disease, cancer and diabetes) diseases,
specific mental disorders (e.g., depression and schizophrenia), and ongoing
impairments in structure (e.g., amputations, blindness and joint disorders) are defined
as chronic conditions (World Health Organization, 2002a). Persistent pain problems
are also included within the chronic conditions category. Chronic conditions can be
effectively managed for years, may be more severe at times, and require life-style
changes.
No longer considered in isolation, similar management strategies are
effective across chronic conditions.
Non-communicable conditions accounted for almost three-quarters (32 million) of the
deaths among adults aged 15 years and over in 2002, nearly four times the number of
deaths caused by communicable disease and maternal, perinatal and nutrition
conditions combined (8.2 million, or 18% of all causes) (World Health Organization,
2003). Non-communicable diseases kill nine out of 10 people in wealthy countries
compared with poor countries like Africa, where approximately one in three adult
deaths result. In Latin America, Asia, and the Western Pacific Region three in four
deaths are caused by non-communicable disease, “reflecting the relatively advanced
stage of the epidemiological transition achieved in these populations and the
emergence of the double burden of disease” (World Health Organization, 2003, p.
13).
The burden of non-communicable diseases is increasing and accounts for almost half
of the global burden of disease (all ages), a 10 per cent increase from estimated levels
in 1990. The proportion of burden from non-communicable diseases in wealthy
44
countries remains stable at over 80 per cent in adults aged 15 years and over, while in
middle-income countries it has already exceeded 70 per cent, and in poor countries
almost 50 per cent of the adult disease burden is now attributable to noncommunicable diseases.
Cardiovascular diseases account for 13 per cent of the disease burden among adults
over 15 years of age. The two leading causes of mortality and disease burden among
older adults (over age 60) are ischaemic heart disease and stroke. These two diseases
are responsible for 36 per cent of all deaths in wealthy countries (World Health
Organization, 2003).
“Ischaemic heart disease and stroke…are two of the three
leading causes of burden of disease in adult males globally. HIV/AIDS is the leading
cause for males and the second leading cause for females, accounting for around 6%
of the global burden of disease. Unipolar depressive disorders are the leading cause
of burden for females, reflecting their higher prevalence in women” (World Health
Organization, 2003, p. 14).
Of the 7.1 million cancer deaths estimated to have occurred in 2002, 17 per cent were
attributable to lung cancer alone and of these, three-quarters occurred among men
(Shibuya, Mathers, Boschi-Pinto, Lopez, & Murray, 2002). An increase of nearly 30
per cent over the preceding 10 years reflected the emergence of the tobacco epidemic
in low and middle income countries. Stomach cancer causes 850,000 deaths yearly,
followed by liver and colon/rectal cancers, the third and fourth leading causes of
cancer deaths, with over half of the liver cancer deaths occurring in the Western
Pacific Region. Breast cancer is the leading cause of cancer among women, with
breast cancer survival rates improving where there is coverage and access to
secondary prevention. Globally, neuro-psychiatric conditions19 account for 19 per
cent of disease burden among adults.
19
“More than 150 million people suffer from depression at any one point in time; nearly 1 million
commit suicide every year; and about 25 million suffer from schizophrenia, 38 million from epilepsy,
and more than 90 million from an alcohol or drug use disorder” (World Health Organization, 2003, p.
190).
45
3.2.1
Categorising countries
Globally, the health of people is variable between, and to a lesser extent, within
countries. Differing classification systems are used to group countries, but no system
is fully satisfactory. The World Bank (1993) categorises countries according to their
gross national product and by eight demographic regions. The regional categories can
be divided into the former socialist economies of Europe and the established market
economies where uniform age distributions are leading to older populations, and the
other six regions where the age distributions are younger. “These latter countries
correspond to the low and middle income countries and contain 85 per cent of the
world’s population” (Beaglehole & Bonita, 1997, p. 5).
The terms ‘developed’ and ‘less developed’ or ‘developing’ are used by the United
Nations, and falsely allude to a continuum. However, developing countries will not
inevitably follow the wealth generation of the small number of developed countries.
Other terms include ‘North’ and ‘South’, ‘First World’ and ‘Third World’ countries,
‘industrialised’, ‘non-industrialised’, and ‘newly industrialising’ and are also
unsatisfactory because within broad groups of countries there is enormous diversity in
social, economic and health characteristics. Instead, the terms ‘rich’ or ‘wealthy’, and
‘poor’, have been adopted throughout this thesis because they emphasise an important
distinction and remind us that “rich countries have achieved and maintained their
position largely at the expense of poor countries” (Beaglehole & Bonita, 1997. p. 6).
3.2.2
The reasons chronic conditions are escalating in New Zealand
Despite the decrease in the number of communicable diseases, the rise in noncommunicable conditions and mental disorders has far-reaching implications. In New
Zealand chronic conditions make up the major health burden and reasons for this
rapid growth include demographic trends, population ageing, consumption patterns
and life-style changes (World Health Organization, 2002a).
46
3.2.2.1
Demographic trends and population ageing
Populations are living longer due to nutrition, public health developments during the
last one hundred years, and advances in science and technology (World Health
Organization, 2002b). Average life expectancy at birth has increased globally almost
20 years in the last 50 years (World Health Organization, 2003).
In 2005 life
expectancy at birth for New Zealand males is 76.7 years and for New Zealand females
81.2 years (Statistics New Zealand, 2005a). Despite major improvements for Maori
over the last 40 years, life expectancy is lower than the New Zealand average,
although the gap in life expectancy at birth between Maori and non-Maori, reduced by
0.6 years in the five years to 2000-2002 (Ministry of Social Development, 2004).
Ethnic differences in death and disease rates are associated with differences in the
socio-economic status of the different groups (National Health Committee, 1998).
Similar to other wealthy countries, New Zealand is experiencing changes in the age
structure of its population characterised by fewer children and an increase in the older
population. Projections indicate that the New Zealand population will increase from
4.06 million in 2004 to 5.05 million by 205120 (Statistics New Zealand, 2004) and
there will be 1.14 million people aged 65 years and over, representing an increase of
166 per cent since 1996. People aged 85 and over will number 290,000 in 2051, a
six-fold increase since 2000 (Khawaja & Thomson, 2000).
Fertility levels will continue to decrease for New Zealand women until 2010 and will
then level off to 1.9 children on average. The population under 15 years is expected
to continue to decline, with children comprising 22 per cent of the population in 2004,
and 16 per cent, in 2051 (Statistics New Zealand, 2004). There were 57,630 live
births registered in New Zealand in the March 2005 year, 1.8 per cent higher than the
annual average over the last decade (56,630), although this is, as in other wealthy
countries, below the level required for a population to replace itself without migration
(Statistics New Zealand, 2005a). A net migration gain of 5000 people each year (the
average annual level for the last 100 years) will comprise approximately 4000 Asian
20
This is based on the medium projection series, which assumes medium fertility, medium mortality
and a net gain from migration of 5,000 people per year over the intervening period.
47
people and 1000 Pacific people each year from 2000 until 201621 (Khawaja &
Dunstan, 2000; Ministry of Health, 2002d; Statistics New Zealand, 2005b).
The age structure of the New Zealand population will undergo significant changes in
the future, because like other wealthy countries, the New Zealand population is
ageing. People aged 65 and over will make up one-quarter of the population in 2039,
compared with 12 per cent in 2004. The median age of the population is projected to
rise from 35 years in 2004 to 45 years by 2045, reflecting the combined impact of
sub-replacement fertility, increased longevity, and the transition of baby boomer22
cohorts into the older ages (Statistics New Zealand, 2004).
Increasing longevity does not inevitably mean higher rates of chronic conditions, as
there is growing evidence that successive cohorts of older people are living longer
than their predecessors and are also healthier. Considerable debate surrounds whether
increasing life expectancy will be largely healthy, with ill health and disability
compressed into the last years of life. A ‘selective survival effect’ reported in very
old people, is associated with health status in earlier years (Grundy, 1997). However,
the sheer increase in numbers of older people in New Zealand will lead to an increase
in chronic conditions and associated disability. Future increases in the incidence and
prevalence of chronic conditions will be strongly influenced by the approaches to
prevention that are undertaken by the New Zealand government today.
Health expectancy is a summary measure of population health that captures the
quantity and quality dimensions of physical health and is defined as the number of
years a person could expect to live independently, without functional limitation and
requiring assistance. In 2001, ‘independent life expectancy at birth’23 was 64.8 years
for New Zealand males and 68.5 years for New Zealand females. There were large
differences between Maori and non-Maori in their probability for living a long and
healthy life (Ministry of Social Development, 2004).
21
Actual population numbers will depend on fertility and migration decisions that have not yet been
made, and on mortality patterns that may be subject to change.
22
The baby-boom era refers to the post-war increase in fertility rates. Spanning from 1946 to 1965,
New Zealand experienced the longest and most intense baby boom amongst wealthy countries.
23
Independent life expectancy at birth is a measure that reflects changes in social and economic
conditions, life-style changes, medical advances and better access to health services.
48
3.2.2.2
Consumption patterns and life-style changes
Life-style and behaviour are primary determinants of conditions such as heart disease,
diabetes, and many cancers, and have the potential to prevent, initiate, or advance
chronic conditions and their associated complications. Major causes and risk factors
for chronic conditions are life-styles that adopt unhealthy behaviours such as tobacco
use, physical inactivity, excessive alcohol use, unmanaged stress, and prolonged and
unhealthy nutrition.
The consumption of cigarettes, other tobacco products, and exposure to tobacco
smoke is the world’s leading preventable cause of death, responsible for five million
deaths a year (World Health Organization, 2003).
Tobacco smoking is a well
recognised risk factor for many cancers and respiratory and cardiac conditions, as well
as exposure to environmental tobacco smoke (particularly maternal smoking), an
identified risk factor for Sudden Infant Death Syndrome (SIDS) and respiratory
problems in children. Brundtland (2001) contends “Tobacco will cause more of them
to die than any other single reason - and health systems will not be able to afford the
long and expensive care in its wake” (p. 14).
In a 2001 comparison of adult smoking prevalence rates, New Zealand had a rate of
25 per cent, ranking eighth out of 17 OECD countries, ahead of the Netherlands
(34%) and the United Kingdom (27%), but well behind Australia (19.8%), the United
States (18.5%), and Canada (18%) (Ministry of Social Development, 2004). When
compared to other wealthy countries, New Zealand smoking levels are relatively low
for males and relatively high for females (Ministry of Health, 2003f), and smoking is
more prevalent among those with lower incomes, beneficiaries, and those living in the
most deprived areas (Howden-Chapman & Tobias, 2000).
Smoking is most prevalent among people aged 25-34 years, followed by those aged
15-24 years, and those aged 35-54.
Maori women have the highest smoking
prevalence (52%) followed by Maori men (39%). Among Pacific peoples smoking is
more prevalent among men (35%) than among women (29%) (Ministry of Social
Development, 2004). Peto, Lopez, Boreham, Thun, and Heath (1994) suggest 50 per
cent of smoker’s who die prematurely die on average 14 years earlier than non49
smokers. In New Zealand about 4700 people die each year as a result of tobacco
smoking ("Tobacco in New Zealand," n.d.).
Unhealthy changes in dietary patterns, reduced physical activity, and increased illicit
drug use may seem minor compared to the destruction caused by tobacco, however,
these negative changes in life-style are increasing globally and are associated with
chronic health problems. In 1997, 35 per cent of New Zealand adults aged 15 and
over were overweight and 17 per cent were obese (15% of adult males and 19% of
adult females) (Ministry of Health, 1999).
New Zealand has a relatively high
prevalence of obesity compared to an OECD median of 11.5 per cent24 (Ministry of
Social Development, 2004). In 2002, 10 per cent of children aged 5-14 years were
obese (Ministry of Health, 2003d).
Obesity increases with age, peaking in the 45-64 year age group, and adult females
are more likely than adult males to be obese. For females there is an association
between obesity and the level of deprivation in the area where people live, and Maori
and Pacific people have higher rates of obesity than other ethnic groups. Obesity is
associated with heart disease, diabetes, stroke, high blood pressure and some cancers
(Ministry of Social Development, 2002). Globally, increasing levels of obesity are
related to social changes, including convenience foods high in fat and energy, passive
leisure, less physically demanding work, greater use of automated transport, and
labour-saving technology in the home.
Twelve per cent of New Zealand adults have never experienced stress that has a
negative effect, whilst 88 per cent have experienced stress that has a negative effect in
the last 12 months, with three per cent always experiencing this negative stress
(Gravitas Research and Strategy Limited, 2005). Half of all New Zealand adults
(57% males and 48% females) take part in 30 minutes or more of physical activity a
day, on five or more days a week and three out of four adults take part in more than
2.5 hours of physical activity each week. Overall, men are more active than women,
24
The United States has the worst prevalence rate of obesity (31% in 1999), with the United Kingdom
(22% in 2001) and Australia (21% in 1999) higher than New Zealand. The rate in Canada was slightly
lower (15% in 2001) than New Zealand and Japan (3% in 2001) had the lowest prevalence of obesity
(Ministry of Social Development, 2004).
50
and Asian people, particularly Asian women, are the least physically active (Ministry
of Health, 2004d). The Ministry of Health (2003c) estimated that as many as 11,000
deaths in 1997 (40% of all deaths) may have been attributable to the joint effect of
sub-optimal diet and physical activity levels. This includes over 85 per cent of
ischaemic heart disease, 70 per cent of stroke mortality, 80 per cent of diabetes
mortality and six per cent of all cancer mortality.
Alcohol is the most commonly used recreational drug in New Zealand and excessive
consumption of alcohol is a major personal and public health issue. Heavy drinking
over a long period of time is associated with causing cirrhosis of the liver,
pancreatitis, endocrine disorders, cardiomyopathy, gastritis, high blood pressure,
haemorrhagic stroke, cancers of the mouth, pharynx, larynx, oesophagus, breast and
liver.
Alcohol dependence and abuse are related to high levels of alcohol
consumption, and alcohol during pregnancy can lead to birth defects in infants
(Ministry of Health, 2004d).
In New Zealand eight out of 10 adults reported having a drink that contained alcohol
in the last year. One-sixth of adult drinkers (17.2%) had a potentially hazardous
drinking problem, and male drinkers (27.1%) were more likely than female drinkers
(11.4%) to display drinking patterns that put them at risk of negative health effects.
The proportion of adult drinkers with a potentially hazardous drinking problem was
highest in the 15-24 year age group, and decreased with age (Statistics New Zealand,
2004).
3.2.3
Economic impact
Health care costs become excessive when chronic conditions are poorly managed.
However, the impacts of chronic health problems extend beyond the expenses
associated with medical treatment. Individuals pay the measurable costs of clinical
interventions, reduced workdays, and lost employment. Other costs that are difficult
to measure precisely include condition-related disability, shortened lifespan, and
lowered quality of life. Governments and health care organisations pay the direct and
indirect costs associated with medical care. Health professionals and families can find
51
it frustrating and difficult to provide care across settings, time, and within available
resources and governments, employers, and societies suffer the loss of productivity
associated with chronic conditions. Table 2 cites studies in different countries that
vary in method and degree of rigor but consistently demonstrate the high economic
costs related to chronic conditions.
Table 2: Studies addressing costs related to chronic conditions
Asthma
Total estimated cost (direct & indirect) in 1999
Direct cost:
Germany
Diabetes
India
United States
Obesity
3.2.3.1
United Kingdom
Heart Disease
Inpatient (hospital) Є$48.2 million;
Rehabilitation Є$62.5 million;
Total drug prescription Є$6,411 million
NZ$4.71853
(Є$2.74 billion)
(Stock et al., 2005)
Indirect cost:
Sickness benefit payments Є$1,194.8 million
Lost years of productivity/early retirement Є$610.2 million
Lost years of productivity/premature death Є$244.5million
Total estimated direct cost to patient in the
management of diabetes mellitus
(direct cost included medicines, laboratory costs, doctors
fees, hospitalisation, surgery, and transportation in the last
year)
*20 million people have diabetes in India
Total estimated cost (direct & indirect) in 2001
Direct cost:
NZ$3.14332 billion
(US$2.2 billion)
(Shobhana et al., 2000)
NZ$167.167 billion
(US$117 billion)
Health care costs: $61 billion
Indirect cost:
Loss of production
Total costs of CVD and CHD in 2003
Direct cost:
(Weight-control Information
Network, 2004)
NZ$86.9646 billion
(UK£33.709 billion)
Health care costs: CVD: £14,732 million; CHD: £3,527 million
Indirect cost:
Productivity losses due to mortality:
CVD: £3,677 million; CHD: £2,173 million
Productivity loss due to morbidity:
CVD: £2,556 million; CHD: £961 million
Informal care: CVD: £4,835 million; CHD: £7,910 million
(Petersen, Peto,
Scarborough, & Rayner,
2005)
New Zealand: Health care costs
Health expenditure is the result of a mix of social, political and economic factors.
Although there is no ‘right’ amount to spend on health, health expenditure as a
proportion of ‘Gross Domestic Product’ (GDP) is often used in international
52
comparisons25. In New Zealand total health expenditure in 2000/01, as a percentage
of GDP, was 8.8 per cent, increasing to 9.2 per cent when the funding for non-health
items (mostly disability support activities) was included. Public health expenditure
accounts for about three-quarters of total health expenditure (Ministry of Health,
2004c). Expenditure on health care in New Zealand is similar to that which could be
expected for another OECD country with a similar level of GDP.
Table 3
demonstrates the high costs associated with chronic conditions that cause the burden
of disease in New Zealand.
Table 3: New Zealand studies addressing costs related to chronic conditions
Asthma
Total estimated cost (direct & indirect) late 1990s NZ$825 million
Direct cost:
Pharmaceuticals $50.0
(Holt & Beasley, 2001)
Hospital inpatient $14.0 million;
Emergency Department services $6.7 million
Primary care services $19.3 million
Specialist services $0.8 million
Patient costs $25.6 million
Others $8.8 million
Indirect cost:
Work loss $105 million
Premature death $254 million
Disability adjusted life years $340 million
Diabetes
Total estimated cost (direct & indirect) 1999
Direct cost:
NZ$540 million
$270 million
(Protemix, 2003)
Indirect cost:
At least $270 million
Obesity
Direct costs to the health sector in 2000/1
NZ$247.1 million
$274.1 million
(A. King, 2003)
Heart Disease
Direct costs
1999: Hospital cardiac services: >$150 million
2001/02: Cardiovascular drugs: $110 million
3.2.4
NZ$260 million
(Health News, 2004)
Impact on the poor
The relationship between poverty and chronic conditions can be described as complex
and interdependent. Chronic conditions disproportionately affect the poor who are
25
Reasons for differences in international health spending include: health service cost variations;
higher costs of medical care consumed, given higher labour costs and prices for services; intensity of
treatments; rates at which invasive procedures are performed; rapid and extensive introduction of new
medical technologies; demographic characteristics; cultural and religious factors; welfare philosophies;
private insurance coverage; origin of funding, and the incidence of litigation.
53
caught in a cycle of poverty and poor health. The poor may lack knowledge about
ways to protect themselves from disease or when to seek health services, lack power
to protect their rights, and lack income to access services or obtain coverage for
essential interventions. In fact, interventions that could significantly reduce deaths
and disease burden and improve health do not reach the world’s poorest populations
(World Health Organization, 2001b).
The path from poverty to chronic conditions involves a number of socioenvironmental factors that are critical determinants of health status. These include
prenatal factors, age, education, environment, and access to care. Mothers who are
malnourished are more likely to bear children who experience chronic conditions such
as diabetes, hypertension, and heart disease in adulthood (Law et al., 2001). Poverty
and poor health in childhood has been associated with cancer, pulmonary disease,
cardiovascular disease and arthritis in adulthood (Blackwell, Hayward, & Crimmins,
2001; Law et al., 1993). In the United Kingdom, impoverished elderly were at high
risk of physical dysfunction and unable to afford care for chronic conditions (Lynch,
Kaplan, & Shema, 1997) and in Brazil, receiving less education was linked with
higher rates of mental disorders (Ludermir & Lewis, 2001).
Unemployment has been associated with health problems and morbidity, and
mortality rates are higher in the unemployed than the general population (Buffat,
2000). The poor tend to work in more physically demanding roles increasing the risk
of injury due to accidents (Marmot & Bobak, 2000; Warden, 1998) and in poor
countries hazardous chemical exposure has been linked with local prevalence rates of
cancer, cardiovascular, and respiratory diseases (Mengesha & Bekele, 1998). The
poor frequently lack access to health care or preventative measures that, in turn, have
been associated with poor health outcomes and exacerbations of chronic conditions.
Care is often delayed because of cost for indigent groups. In New Zealand cost,
transport, acceptability of the provider, and the Maori concept of whakama26 have
been identified as barriers to Maori accessing services (Pomare et al., 1995). Changes
to the cost structure of services can affect utilisation, which was evidenced when
levels of utilisation fell by 15 per cent after the New Zealand government introduced a
26
Whakama is a term used to describe embarrassment, losing face and shyness.
54
new charging regime in general practice. Beneficiaries were the group most affected,
even though this group was supposedly the focus of increased assistance (P. Davis,
Gribben, Lee, & McAvoy, 1994). In Vietnam the poor are often observed to delay
treatment, use less government provided health services, and pay more for each
episode of care compared with the rich (Ensor & San, 1996). In Mexico the poor
experience inadequate care because of restricted access to medications and health
professionals due to unavailability or expense (Leyva-Flores, Kageyama, & ErvitiErice, 2001).
The path from poverty to chronic health problems is bi-directional and the ‘chronic
conditions – poverty’ relationship also requires consideration. Loss of income, the
costs of interventions and marginalisation because of chronic health problems
negatively affect the economic status of those with chronic conditions. Chronic
conditions have been linked to work disability, early retirement, and reduced
productivity placing employees at risk of premature job termination (Dooley,
Fielding, & Levi, 1996; Herrin, Cangialose, Boccuzzi, Weintraub, & Ballard, 2000)
and treatment costs can be prohibitive when conditions are initially not managed well
or prevented (Rice, Kelman, & Miller, 1992). People with chronic conditions are also
at risk of stigmatisation, which can result in limiting employment opportunities and
causing an exacerbation of chronic problems (Alem, 2001).
3.3
Current health systems are not designed for chronic problems
The World Health Organisation (2000) has described a health system as including “all
the activities whose primary purpose is to promote, restore or maintain health” (p. 5).
Controversy has always surrounded the central objectives of health systems, however
there is general consensus that health promotion and health restoration are
overarching purposes. The World Health Organisation contend that improving the
health of the population, responding to peoples expectations, and providing financial
protection against the costs of ill-health are fundamental objectives.
Medical
attention, interventions by traditional healers, and home care of the sick, which is how
70-90 per cent of all sickness is managed (Kleinman, 1978) are services provided
within the health system, in addition to public health activities such as health
55
promotion and disease prevention, and environmental safety improvement.
In
general, however, information about health systems refers to either the provision or
investment in health services, which relates to the ‘the health care system’27 as
opposed to the wider ‘health system’. Global spending on health care alone in 1997
was approximately $2985 billion, almost eight percent of world GDP, and represents
only a part of the cost of population health (World Health Organization, 2000).
Historically, the New Zealand health care system evolved around identifying
infectious diseases, treating symptoms, and sometimes producing cures, and today
performs best when addressing individual episodic and urgent concerns. The acute
care approach, appropriate in the past, cannot successfully manage the burden
presented by chronic conditions. The acute care approach still permeates the thinking
of clients, the public, health organisations, health workers, and governments.
It
affects all levels of the health care system, and is perpetuated by out-dated health
training and education, and workforce employment practices (World Health
Organization, 2002a). This is because health professionals learning and formative
experiences were in hospitals, as opposed to less acute settings, and knowledge,
beliefs and methods were aimed at achieving outcomes in this intense, acute setting.
Currently the New Zealand health care system is difficult to characterise because it
includes a wide and diverse range of organisations, health professionals/workers and
consumers. Financial arrangements underpinning the health care system are complex
and include combinations of funding from public, private, and not-for-profit
organisations (Boyd & Sheridan, 2000).
Nevertheless, there is an increased
recognition of the importance of a comprehensive approach to health care services
and longer-term outcomes as a consequence of health care costs, population focused
information, and outcomes based knowledge. The New Zealand Health Strategy
(Ministry of Health, 2000) provided the direction for government action on health,
identifying the need to prevent and manage chronic diseases and their disabling
consequences, and acknowledged the importance of an adequate support workforce.
The newly established Health Workforce Advisory Committee reported “…past
health workforce structures are not an adequate guide as we look to the future…new
27
The health care system includes preventative, curative, and palliative interventions for individuals or
populations.
56
models of clinical practice to manage continuity of care for people experiencing
chronic conditions have become a major challenge and opportunity for workforce
development” (Ministry of Health, 2002e, p. 16). Nursing in a review of practice and
education identified that chronic care and increased screening and prevention needs as
influencing future primary health care roles for nurses (Nursing Council of New
Zealand, 2001a).
Reform within the New Zealand health care system is occurring on many levels.
Information and skills are recognised as essential for clients to manage their
conditions and client behaviours and provider communications are receiving increased
attention.
Coordinated approaches are evidence-informed, consumer voice and
participation is greater, and the need to maximise community resources is
acknowledged (Ministry of Health, 2001c). Globally, health care organisations are
challenged to streamline services, up-skill health professionals/workers, focus on
prevention, and continue ongoing development of information systems to enable
planned care for predictable complications. Without an investment in considerable
change, the New Zealand health care system, like that of other countries, will remain
inefficient and ineffective as the prevalence of chronic conditions rises. Unnecessary
hospital admissions, expensive technologies, and the collection of useless clinical
information will continue to cost millions, and improvements in population health
status will not keep pace (World Health Organization, 2002b). An important role for
governments includes setting standards for quality, aligning financial incentives with
the development and strengthening of intersectoral partnerships, and establishing
policies that encourage the coordination of care. Clearly the most fundamental issue
highlighted by this discussion is the urgent need to shift away from an acute, reactive,
episodic model of care that is unable to achieve the necessary population health
outcomes that are possible.
3.3.1
Changing the systems of care
“Current care systems cannot do the job. Trying harder will not work. Changing the
systems of care will” (Institute of Medicine (U.S.) Committee on Quality of Health
Care in America, 2001, p. x). In New Zealand important changes to health policy and
57
legislation, and the reorganisation of health care financing to support care for chronic
conditions is occurring (Ministry of Health, 2001b, 2001c, 2004a). Developing a
more comprehensive system of care is aligned to the realisation that simple unidimensional solutions do not work for complex problems.
No longer are conditions such as asthma, diabetes, arthritis and depression being
considered in isolation.
Awareness is growing that similar strategies can be as
effective in managing many different conditions (R. Davis, Wagner, & Groves, 2000).
Improving the care of the chronically ill begins with primary care, where the large
majority of patients receive the bulk of their care and are likely to do so for the
foreseeable future (Hiss, 1996). “The defining characteristics of primary care (that is,
continuity, coordination, and comprehensiveness) are well suited to care of chronic
illness” (Rothman & Wagner, 2003), suggesting the redesign of the system of care is
the primary determinant of chronic care quality. Primary care can only expand and
strengthen the role in chronic illness care with system support. The Chronic Care
Model, which addresses necessary health system changes for improving chronic
illness care, was developed as a framework to guide quality improvement, particularly
within primary care (Bodenheimer, Wagner, & Grumbach, 2002a, 2002b). Changes
necessary to reorient the current acute health system include refocusing on the
delivery of effective preventative care, which is fundamentally what is recommended
by the chronic care model of effective chronic-disease management. For this reason,
the model is presented as a blueprint for changing the current system of care.
The chronic care model constitutes a major rethinking of primary care practice, based
on the knowledge that chronic care takes place within the entire community, the
health care system, and the provider organisation (Bodenheimer et al., 2002a).
Endorsed by the World Health Organisation as a framework to guide practice, the
model has been implemented in more than 300 health care organisations in the United
States (Bodenheimer et al., 2002a; Glasgow, Orleans, & Wagner, 2001). The extent
to which the model can improve the management of chronic conditions, such as
diabetes, asthma, congestive heart failure, and depression, and reduce health care
costs has been demonstrated (Bodenheimer et al., 2002b). Recently, the chronic care
model was adopted by several district health boards in New Zealand as a generic
58
template, applicable across diseases and health care organisations within regions (J.
Wellingham, personal communication, November 11, 2004).
The chronic care model seeks systems change to enable improved patient outcomes,
which occur when patients are informed and activated, and health professionals
comprise prepared, proactive teams.
The interaction between the two groups is
intended to improve functional and clinical outcomes (see Figure 2).
Figure 2: The Chronic Care Model
From “A survey of leading chronic disease management programs: Are they consistent with the literature?” by
E.H. Wagner, C. Davis, J. Schaefer, M. Von Korff, and B. Austin, 1999, Managed Care Quarterly, 7,3, p.56-66.
Copyright 1999 by Aspen Publishers Incorporated. Reprinted with permission of the author.
The model recommends evidence-based interventions within six areas known to
improve processes of care and patient outcomes. These are described in the sections
following.
59
3.3.1.1
Community resources and policies
The health care system can enhance care for its patients by looking outside itself.
Health organisations and health professionals are often poorly organised to use
community resources. Community resources support community care for chronic
illnesses and include both government and community-based voluntary programmes.
Mobilising community resources to meet the needs of patients involves partnerships
with community organisations to assist the development of interventions in needed
services. Other strategies include encouraging patient participation in community
programmes, creating linkages to community resources through resource directories,
referral pathways and joint programmes, and advocating for policies that improve
patient care.
3.3.1.2
Health system organisation of care
Health care systems create an environment in which organised efforts to improve
health care for chronic illness occurs. Critical elements include a coherent approach
to system improvement, leadership committed to improving clinical outcomes and
incentives to providers and patients to improve care. A system must be motivated and
prepared for change throughout the organisation. The systematic handling of errors
and quality problems, and the prevention of breakdowns in communication and care
coordination can be resolved through agreements that facilitate information sharing.
3.3.1.3
Self-management support
Self-management support empowers and prepares patients to take responsibility for
their health and the management of their chronic conditions in ways that reduce
symptoms, complications, and disability. Strategies include assessment, goal setting,
action planning, problem solving and follow-up. Skills training and psychosocial
support interventions are central components of a delivery systems self-management
support structure.
60
3.3.1.4
Delivery system design
Delivery system design focuses on the delivery of effective, efficient clinical care and
self-management support. An interdisciplinary team with defined roles carries out the
tasks required to manage complex conditions. Planned visits, continuity of care and
regular follow up are important components. Clinical case management services are
recommended for complex patients and the care that the patient understands, and that
is appropriate to their cultural background, is advocated.
3.3.1.5
Decision support
Treatment decisions need to be based on explicit, proven guidelines underpinned by
research.
Evidence based guidelines embedded in routine practice supported by
reminders, effective provider education, and collaborative support from relevant
clinical specialists, including primary care, along with patient preferences are
recommended.
3.3.1.6
Clinical information systems
Timely information about patients and populations with chronic conditions ensures
efficient and effective care. Disease registers, for example, can include information
about the performance of elements of care and can be accessed by health care teams to
track and plan care, monitor performance and provide reminders about needed
services. Sharing information with patients and providers to coordinate care is a
critical feature.
61
3.4
Risk prevention
Improving health requires a major emphasis on the prevention of disease causation,
with the underlying risks28 to health treated in addition to established diseases.
Almost half of global mortality is attributed to 20 risk factors and managing these
risks effectively may result in as many as 10 extra years of healthy life expectancy.
Reducing risk by 25 per cent will result in the avoidance of much of the burden of
disease29, and in human terms, millions of premature deaths may be averted, and
many more millions of people may be spared years of disease, disability and ill health
(World Health Organization, 2002b). Quantifying the burden of disease attributable
to major risk factors, and estimating the potentially avoidable burden, if the
population distribution of risk is reduced across the board, are the first steps.
Following, an assessment of the types of interventions available to decrease exposure
to risks or minimise the impact of exposure on health, the extent to which
interventions can improve population health singly and in combination, and the
resources to implement them are required.
“Reducing risks to health is the responsibility of governments” (World Health
Organization, 2002b, Message from the Director-General, p. ix), who need to invest
heavily in risk prevention to contribute substantially to future healthy populations and
sustainable development.
Health policies for the prevention of well-known risks
require choices to be made between different strategies. In most cases it is more
effective to give priority to population-based interventions rather than those aimed at
high risk individuals, to give priority to primary over secondary prevention, and to
control distal, rather than proximal risks to health.
Population wide interventions have the greatest potential for prevention. For example
in reducing risks from blood pressure and cholesterol, shifting the mean of the whole
population will be cost effective in avoiding future heart attacks and strokes, rather
than screening programmes that identify and treat people with defined hypertension or
28
‘Risk’ is the probability of an adverse outcome, or a factor that raises this probability.
A prediction of the measure of inaction suggests that by the year 2020 there will be nine million
deaths caused by tobacco worldwide, compared to almost five million a year now (World Health
Organization, 2002b).
29
62
raised cholesterol levels. The more immediate risks for major disease have been the
focus of most epidemiological research and interventional analysis. Tackling distal
factors such as reducing poverty and improving access to education is well-known to
have a positive impact on health and survival, and there is potential for major health
gains through sustained intersectoral collaboration across ministries concerned with
policy development and implementation.
Primary prevention targets well populations and keeps problems from occurring in the
first instance, promoting resiliency and protective factors, or reducing susceptibility
and exposure to risk factors (Minnesota Department of Health, 2001). Immunisation
is an example of risk reduction through primary prevention as it lowers future
exposures, and therefore the incidence of new disease episodes over time. Primary
prevention must consider how common and widely distributed the risk is and the
availability and costs of effective interventions.
Significant health gains can be
achieved through inexpensive treatments when primary prevention has failed.
Secondary prevention detects and treats problems in the early stages, preventing
serious or long-term effects or from affecting others (Minnesota Department of
Health, 2001). Targeting problems with common risk factors, secondary prevention
screens exposed populations for the early onset of sub-clinical illness and offers
treatment.
If disease processes are reversible, valid screening tests exist, and
treatments are available, secondary prevention is effective.
Identifying and preventing risks to health is a political process (Dowie, 2001) and
factors that influence whether policies are adopted include the public’s perception of
the risk, scientific uncertainty, distribution of risk, and inequity of health outcomes
(Slovic & Gregory, 1999). The success of risk prevention is determined by the
strength of the political leadership and support by sectors of society concerned with
promoting health.
63
3.4.1
Government responsibility for health
Governments in all wealthy countries play a major role in the funding30 of health care.
The New Zealand Government purchases public health services directly, but has
devolved purchasing responsibility to district health boards for most health care
provision. The extent to which a government is involved in health care is often a
result of decisions made in response to economic, political, technical and
demographic pressures, combined with the social and cultural preferences of a
society. The World Health Organisation (2002b) maintains that governments should
take a greater role in tackling major risks to health because: reducing major risks to
health will promote sustainable development; reducing major risks can reduce
inequalities in society; government’s need to prioritise and focus on the most
important risks, and exercising stewardship means fulfilling the government’s
responsibility to protect its citizens.
Population-based strategies directed by
government benefit entire communities and the poor, who experience the greatest
risks, usually benefit most thereby reducing inequalities. Tackling major risk has the
potential to reduce inequalities globally.
Actions that governments can take in risk reduction include: formulating risk
reduction policies, including more support for scientific research, improved
surveillance systems and better access to global information; prioritising the
development of policies for the prevention of large risks to health; prioritising highest,
interventions that are cost-effective and affordable in preventing and reducing risks;
collaboration to reduce major risks to health such as unsafe water, sanitation and lack
of education; collaboration to improve risk management and increase public
awareness and understanding of risks to health, and encouraging the actions of
communities and individuals to achieve a balance among all groups (World Health
Organization, 2002b). The world faces some large, common, and certain risks to
health, which are generally well understood scientifically, with estimates of risk
probability and consequence, available. The cost-effectiveness of many interventions
is also known and can inform policy decisions. Focused government-led action to
30
The term funding applies to the insurance function, that is, the raising of revenue to be spent on
health services.
64
reduce risks to health, address determinants of health and promote healthy life is
essential.
3.5
In conclusion
The global burden of disease has shifted from acute conditions towards chronic
conditions worldwide, although the New Zealand health system, like that of other
countries has not changed accordingly.
Current health care systems continue to
provide episodic, acute care, demonstrating a mismatch with chronic conditions,
which are lengthy and require continuity of care. Without a system that assures
ongoing support, technological advances will not stop heart disease, acquired
immunodeficiency syndrome, diabetes, and other chronic conditions.
By 2020
chronic conditions will contribute to more than 60 per cent of the global burden of
disease (World Health Organization, 2001a).
In New Zealand demographic
transitions and population ageing, consumption patterns and risk behaviours, are clear
determinants in this trend. Chronic conditions disproportionately affect the poor,
economically challenge patients, families, and governments and jeopardise the
sustainability of health care systems.
The changes necessary to improve the health care systems delivery of effective
preventative care are fundamentally the same as those recommended in the chronic
care model of effective chronic-disease management. If improvements in chronic care
prevention and management follow a common set of system changes and
improvement strategies, progress will be faster, more efficient, and less confusing.
The chronic care model provides a functional template, as well as a set of organised
principles, for basic changes to support care that is evidence-based, population-based
and patient-centred. Defining broad areas, it is a framework in which improvement
strategies can be adapted to local conditions. This is probably the reason why it is
advocated by the World Health Organisation.
Improving health requires a major emphasis on the prevention of disease causation,
with the underlying risks to health treated in addition to established diseases. The 20
top risk factors are attributed to almost half of global mortality and much of the
65
burden of disease.
Tackling major risk has the potential to reduce inequalities
globally, and governments have a central role in leading action that reduces risks,
promotes health and protects populations. In addition, health provider organisations,
health professionals such as nurses, and the wider society, have roles in reducing risk.
The following chapter discusses nursing and the development of primary health care.
The management of chronic conditions is a burden to the individual and state, and
tackling major risks poses a challenge to health professionals. Much of this work will
be undertaken in the community, by those (nurses) involved in primary health care.
66
4
Chapter 4
Primary health care nursing
4.1
Introduction
Nurses are the largest health professional group working in the health sector and
number approximately 38,000 people (Health News, 2004).
The New Zealand
government has committed resources to the development of primary health care
(PHC) nursing, a recently defined specialty area of practice (Hughes, 2003; Ministry
of Health, 2002a; Ministry of Health). The PHC nursing workforce comprises nurses
working outside of hospitals in community settings and the Ministry has stated “The
extensive contribution that PHC nursing can make to reducing health inequalities,
achieving population health gains and promoting and preventing disease is yet to be
realised” (Ministry of Health, 2003b, p. vii, Executive Summary). The most widely
used definition, constructed by a Ministry appointed expert nursing advisory group,
states primary health care nurses are:
…registered nurses with knowledge and expertise in primary health care
practice. Primary health care nurses work autonomously and collaboratively
to promote, improve, maintain and restore health. Primary health care nursing
encompasses population health, health promotion, disease prevention,
wellness care, first-point-of-contact care and disease management across the
lifespan. The setting and the ethnic and cultural grouping of the people
determine models of practice. Partnership with people - individuals, whanau
(family), communities and populations - to achieve the shared goal of health
for all, is central to primary health care nursing (Ministry of Health, 2003b, p.
9).
The overarching ‘primary health care specialty’ encompasses many groups of nurses
who have historically worked in community settings, developing various nursing roles
that have focused on different activities or interventions, and individuals or groups.
Bringing these groups together and establishing a common ‘core knowledge’ as the
basis for PHC nursing practice has in part been a response to the New Zealand Public
Health and Disability Act (Ministry of Health, 2001b).
The Act, requiring the
67
development of national strategies, was accompanied by health care system
restructuring to achieve the overall vision of improving population health through the
activation of the PHC strategy (see section 4.4.1).
The purpose of this chapter is two fold. First, to describe the diverse nursing groups
that now comprise the PHC nursing workforce, their different historical backgrounds,
and recent developments to promote the combining of these groups under a new title
and specialty area of practice.
Second, to present a model, which expands the
understanding of the range of interventions, and levels of population-based practice
that are available to PHC nurses. The model is also used to analyse nurses’ practice in
the ‘Nurses in integrated care projects study’ (see chapter 6). Concepts underpinning
the model are explained and have additional relevance to the implementation of
population-based practice (see section 4.5.1.1).
4.2
The current PHC nursing workforce
“The term ‘primary health care workforce’ covers the collective practice of registered
nurses providing care in the community….public health nurses, Plunket nurses31,
practice nurses32, district nurses, rural nurses, nurses providing care to specific groups
(e.g., respiratory and diabetic patients) and nurses working in Maori and Pacific health
provider organisations” (Ministry of Health, 2003b, p. 11).
Community settings
include urban and rural general practices, community-based clinics, (situated on
marae, in schools or workplaces) and in peoples homes. Many nurses practice within
relatively narrow areas of practice, such as wound management, and some clients may
receive care from several practitioners at one time. Other practitioners, such as those
working in rural communities, generally adopt a wider field of practice, responsive to
the needs of clients in an effort to achieve integrated care (Litchfield, 2001).
The Nursing Council of New Zealand (Nursing Council), who governs the practice of
nurses and midwives by monitoring standards of registration and enrolment,
31
Plunket nurse is a title used in New Zealand to describe nurses who initially provided care to mothers
and their newborn babies, and later expanded services to include older children (see pp. 74-75).
32
Practice nurse is a title used in New Zealand to describe nurses who work alongside general practice
physicians, who are generally their employer (see pp. 77-78).
68
completes a workforce survey each year, which provides statistical information about
the active registered nurses and midwives in New Zealand. As of 31 March, 2004
there were 34,660 practising registered nurses in New Zealand, of whom 91 per cent
were female, over a third were aged between 40-50 years, 68.3 per cent were New
Zealand European, 7.5 per cent were New Zealand Maori, and 2.9 per cent were
Pacific peoples (New Zealand Health Information Service, 2004).
The Nursing Council survey collects statistics on employment settings and types of
work, although this does not always capture the number and range of nurses working
in the community and primary health care. In 2004, registered nurses or midwives
identified as working in primary health care, including practice nursing, numbered
3672 (10.6%). Many other nurses may work in PHC or community settings but are
classified in other categories, such as, public health (1.5%); palliative care (1.7%);
child health (5.4%); district nursing (2.6%); occupational health (0.9%); assessment
and rehabilitation (3.0%) (New Zealand Health Information Service, 2004).
4.2.1
Primary health care and community survey 2001
A voluntary survey sent to 7617 registered nurses who had indicated in the 2000
workforce survey that their type of work or employment setting could include PHC,
had a response rate of 47.9 per cent (n=3562). Results from the survey found the
‘work type’ of the majority of the PHC nursing workforce was classified as practice
nursing33 (45%). Other nursing categories included: health education and promotion
(28%); specialist PHC (28%); well child or child health (21%); district (18%); mental
health (16%); family planning/sexual health (12%); public health (10%); rural health
(8%); Maori health (7%); occupational health (6%); Pacific health (3%) and other
(9%). Other results revealed the average age of a PHC nurse was 48 years, the main
ethnic group was New Zealand European (80.5%), with 7 per cent of nurses selfidentifying as Maori. The two main employer groups were general practice (32%)
and district health boards (32%), with the majority of Maori nurses employed by
Maori providers (5%) and 140 nurses worked on a marae. The three main settings of
33
Respondents could indicate more than one work type.
69
service delivery were the home, a clinic, or general practice. When asked if specific
strategies to reduce inequalities in health outcomes were part of their work, 44 per
cent of respondents reported they were (Ministry of Health, 2003e).
4.2.2
Education preparation
Registered nurses in New Zealand are educated to baccalaureate degree level today,
although, this has not always been the case. Nursing training was undertaken in
hospitals until the late-1980s, when an amendment to the Nurses Act of 1977
provided for polytechnics (later called technical institutes) to offer nursing education
and award diplomas. This accompanied a transfer of nursing education from hospitals
to technical institutes, although for a number of years hospital-based nursing training
programmes overlapped with those taught in technical institutes. The reasons for the
transition of nursing education from hospitals to technical institutes included:
reducing the high rate of withdrawal among trainee nurses (Dow, 1995); supporting
the new technical institute movement (M. Brown et al., 1997), and shifting the focus
from a service-based model, dominated by the secondary sector (hospital) to an
education-based model that presented the opportunity for primary sector (community)
influence (M. Horsburgh, personal communication, July 15, 2005). A review of
nursing education commissioned by the Nursing Council found that the location of
nursing education within a technical institute had not resulted in the adoption of a
community or primary health care nursing orientation (KPMG Consulting, 2001).
In the early 1990s, with the introduction of baccalaureate and graduate education in
technical institutes and universities, opportunities for nurses began to develop.
Currently, there are six approved clinical masters in nursing programmes in New
Zealand, assisting nurses to prepare for nurse practitioner status (see section 4.4.3). In
the specialty area of primary health care, nurse practitioner development has been
slow. Judy Kilpatrick, Head of the School of Nursing, the University of Auckland,
suggests this is because the primary care sector has undergone significant
restructuring, whilst the focus has been placed on the development of new primary
health care organisations. She also contends nurse practitioner roles and positions
have not been clearly identified or resourced, and there has been resistance by some
70
general practice physicians to accept this role as complementary (J. Kilpatrick,
personal communication, July 21, 2005).
The Ministry of Health (2003b) has
proposed an education and career pathway in primary health care nursing. This
framework links education programmes with generic New Zealand Nursing Council
competencies, but does not identify knowledge that is specific to primary health care.
In fact, the Ministry of Health (2003b) states “most programmes include reflection on
practice and self-development in the area of clinical practice, but are not specific to
primary health care nursing” (Ministry of Health, 2003b, p. 38).
4.3
Nursing groups in communities
Historically, a number of different nursing groups have worked in New Zealand
communities, and these combined groups now comprise the PHC nursing workforce.
Not surprisingly, the differences in histories have had a significant bearing on the
cultures that exist within the distinct nursing groups. The challenge for advancing a
PHC agenda is the development of a common knowledge and culture, whilst building
on past developments and strengths. The roles of community nurses in early New
Zealand are discussed first, and include the district nurse, public health nurse, Plunket
nurse and school nurse. Following on, the more recent practice nurse role situated in
the domain of general practice is discussed. Finally, PHC nursing roles, such as
disease-state management, Maori health, Pacific health, Asian health, migrant health,
older persons’ health, child health and occupational health are identified. Most of
these roles undertake practice interventions consistent with those undertaken by
public health, district and practice nursing roles.
4.3.1
Community nurses in early New Zealand
In the 1800s nurses were mostly untrained and unskilled and care was provided by
male attendants and older women from the domestic classes (Burgess, 1984). In early
New Zealand pioneering life, local women also carried out nursing work. Nursing as
a profession that required training is related to the dominance of the medical
profession. Women of higher social standing considered nursing because it was seen
71
as a legitimate charitable activity and an excellent preparation for marriage and
motherhood. Alternatively, it was also seen as a substitute for a large number of
women that statistically, were unlikely to marry (McKegg, 1991).
The first nursing training programme in New Zealand was established at Wellington
Hospital in 1883 with an intake of ‘lady nurses’ (Burgess, 1984). Community nursing
in New Zealand was strongly influenced by two women, Suzanne Aubert de Laye
(1835-1926) and Sibylla Maude (1862-1935). Aubert de Laye later became Mother
Mary Joseph Aubert, founder of the Congregation of the Daughters of Our Lady of
Compassion, and is claimed to be the first trained community nurse (public health) in
New Zealand. She trained in Paris under the Sisters of Charity, and secretly followed
a complete medical course of lectures at Lyons. In the late 1800s, early in her nursing
career, she worked with Maori in Hawkes Bay and the poor in Wellington (McKegg,
1991). Maude travelled to London in 1889 and trained for a year as a ‘paying lady
probationer’ at the Middlesex Hospital (Burgess, 1984) and on her return to New
Zealand became the matron at Christchurch Hospital. She had an interest in older
people’s health and left her position to become the first district nurse in New Zealand,
later founding the Nurse Maude District Nursing Service in Christchurch (Stonehouse,
1972). The four early divisions of labour for community health nursing in New
Zealand were district nursing, public health nursing, Plunket nursing and school
health nursing (Durkheim, 1984).
4.3.2
District Nursing
In addition to the Nurse Maude District Nursing Service and the District Nursing
Association of New Zealand also established in the early 1900s (Stonehouse, 1972),
the district nursing service developed under sponsorship of the Saint Johns
Ambulance Association with nurses appointed in Dunedin and Palmerston North in
1906 and 1909 respectively (Blue, 1995). Care for the sick outside of the hospital
became possible in 1909 with the introduction of the Hospital and Charitable
Institutions Act. Backblocks district nursing schemes developed and by 1913, nine
district nurses were employed by Hospital Boards in rural areas. The introduction of
the Government social security benefit for district nursing services in the 1940s
72
resulted in a major expansion of services (Burgess, 1984). District nursing roles today
can be very specialised centring on for example, ulcer management, or can be more
widely oriented in rural communities where there is a limited availability of other
services within the region.
4.3.3
Public Health Nursing
Public health nursing developed in New Zealand at the turn of the century when major
threats to health were communicable disease and malnutrition. After an outbreak of
dysentery in Papawai, the Chief Health Officer, Doctor Mason, recommended to the
Native Department that a nurse be sent to assist the local doctor and teach the Maori
women food preparation and care of the sick. Under the Native Department a native
health nursing scheme developed with Maori women trained as nurses. Akenehi Hei
and Heni Whangapirita were the first two Maori registered nurses to graduate as part
of the scheme in 1909, although several others had previously gained partial
registration by way of nursing certificates (McKegg, 1992).
The service developed in response to concerns for the future of the Maori race as a
result of reduced immunity to newly acquired diseases such as tuberculosis, influenza,
enteric fever and small pox. McKegg (1991) argues nurses work reflected unspoken
agendas, which included removing the threat that contagious diseases in Maori posed
to the European community, and as “forces for assimilation” (p. 4).
Nurses
responsibilities included relaying the notions of ‘scientific motherhood’ to Maori by
providing advice on hygiene, food preparation, care of their children, pregnancy,
childbirth, inspecting kainga and native schools, and keeping a record of Maori births
and deaths in the district (Burgess, 1984). Reluctance by hospital authorities to train
Maori women as nurses prevented the scheme expanding, and in 1911 when the
Native Department was transferred to the Department of Health the majority of nurses
employed to work in the service were non-Maori (McKegg, 1992).
The native health nurses were increasingly expected to attend to Europeans living in
the backblocks. The title ‘district health nurse’ was adopted and the special nurse to
Maori ceased to exist (Blue, 1995).
At this time nurses were undertaking
73
interventions related to venereal disease, tuberculosis, child health, immunisation,
health education, Maori health, and school health (Department of Health, 1986). Such
activities suggest a distinct nursing role with a primary health care orientation, which
is consistent with McKillop’s proposition that by 1930, native nurses who provided
care specifically for Maori were superseded by public health nursing for all Maori and
non-Maori in a geographically defined area (McKillop, 1998). In 1953, the service
combined with Industrial Health Nursing and the title changed to ‘public health nurse’
as it remains today.
Blue (1995) contends that because of the traditional conceptions of the native health
nurse working with Maori, for many years a segregated system of delivery of child
health services existed in New Zealand. Many Maori opted for care by a public health
nurse (formerly a native health nurse), and most non-Maori utilised the services of the
Plunket nurse. In the late 1980s Plunket nurses in mutual agreement with Area Health
Boards assumed primary responsibility for the well childcare of all pre-schoolchildren
leaving public health nurses with assigned responsibility for children under five,
considered to be at risk or living in rural areas (Ministry of Health, 1996). Later in
1995, the demise of the Public Health Commission was labelled a “…retrograde step
for the advancement of public health and population based health” (Carryer, Dignam,
Horsburgh, Hughes, & Martin, 1999, p. 6). It was suggested that this would become
evident over time with declining population health, or more immediately “as in a
national emergency” (W. Armstrong & Bandaranayake, 1995, p. 23). Since this time
the number of nurses has significantly reduced and the emphasis has been placed on
communicable disease screening and management, health promotion, and less on
family oriented health services (Martin, 2002).
4.3.4
Plunket Nursing
In 1907, Doctor Truby King founded the Royal Society for the Health of Women and
Children, a service which became known as the Plunket Society following the
personal support of Lady Plunket, wife of the then Governor General (Parry, 1982).
Concerned with the high rate of infant mortality, King promoted breast-feeding,
improved methods of bottle-feeding, and mother-craft. Under the patronage of the
74
society, Plunket Nursing was established, and across New Zealand Karitane Hospitals
and Karitane nurses developed with nursing services offered to all women with
newborn babies.
In the 1950s, 1960s and 1970s Plunket restructured both the organisation and services
provided by the nurse. Karitane Hospitals closed and home visiting was negatively
impacted. Over time the Plunket Society has initiated health prevention programs,
household help, well child checks and crisis groups. Community health had been
promoted through activities such as immunisation, water safety education, the
provision of safety guards for heaters, information on poisons, safety about children’s
clothing, and education on human relationships. Until the early 1990s public health
nurses had provided similar services to Plunket nurses leading to a duplication of
services in some areas and no services in others (Dow, 1995).
In 1993 a national schedule for well childcare outlined an expectation of integrated
and coordinated well child service provision, which included health education and
promotion, health protection, clinical assessment, and family/whanau care and support
(Ministry of Health, 1996). Today, this schedule directs the work of Plunket nurses.
A number of health providers, including general practice physicians, nurses, social
work services, voluntary and self-help groups continue to deliver well childcare
(Malcolm, 1997) and both the duplication and fragmentation of services continue to
occur. The Plunket Society has remained a national non-governmental organisation
receiving significant funding from government and fundraising to provide well
childcare34 to children under five and their mothers.
4.3.5
School Nursing
In 1917 the first school nurses were appointed to work alongside four medical officers
of health to conduct compulsory medical inspections of children in state schools
because there were concerns about the health of schoolchildren. Termed the School
Medical Service, the emphasis was on disease control, for example taking throat
34
‘Well childcare’ is a current term used in New Zealand to describe routine health screening
and surveillance interventions provided for children.
75
swabs during diphtheria epidemics, and conducting health and development
assessments (Blue, 1995). The service grew to 31 nurses and 12 medical officers of
health by 1930. The Maori schools were worst affected by diseases such as diphtheria
and received the minimum of care, as only 18 Maori health nurses were in post in
1918. Consequently, much of the responsibility for the health care of schoolchildren
was devolved to the 250 teachers in the native schools (Dow, 1995). In 1921 school
health, which had been the responsibility of the Department of Education was
devolved to the Department of Health (Burgess, 1984). The School Medical Service
promoted immunisations amidst public opposition and anti-vaccinationist opinion
within the Department, with estimates that 83 - 85 per cent of all schoolchildren were
not vaccinated in 1924-5. Nurses active in school health were titled ‘district health
nurses’ (see section 4.3.2).
The School Dental Service was established in 1919, with about 30 dental nurses
completing their training each year in the 1920s. In 1947 dental care extended to
adolescents as well as schoolchildren, and fluoridation was a key health issue for
nurses.
The health camp movement was established in 1919 to combat the
malnutrition traditionally associated with tuberculosis, and by the 1930s had been
embraced by a number of voluntary agencies working with the Department. During
the 1950s there was friction over child health between the Department of Health, the
medical and dental professions and voluntary organisations such as Plunket and the
new parents centre movement.
Public health nurses supported controversial
departmental efforts to promote immunisation, sex education, pasteurised milk and
fluoridation of water supplies (Dow, 1995).
Today public health nurses have a presence in schools but are often less available due
to the reallocation of public health services to competing areas.
Schools have
independently employed nurses to support the health of schoolchildren, although the
range of interventions school nurses undertake has not been well reported (Alcorn,
2002). Generally, there is a belief that school nurses promote health. This is apparent
in the statement “School Principals and Boards of Trustees that support an on-site
nursing service believe that an accessible and free primary health care service has the
potential to promote student health and well-being and improve educational outcomes
for students” (Alcorn, 2002, p. 30).
76
4.3.6
Practice Nursing
Practice nursing is the most dominant of the nursing groups in the New Zealand
community, with over three thousand nurses working alongside general practice
physicians (S. French, Old, & Healy, 2001). Based on a United Kingdom funding
model, practice nursing received government subsidies.
In the United Kingdom
however, the funding mechanisms established for practice nurses provided the
opportunity for education to guide the development of the specialty’s practice. In
New Zealand no provision was made to fund education, which was seen as a lack of
commitment to the development of the practice nurse role (B. Docherty, personal
communication, May 13, 2005).
The practice nurse role has principally complemented primary care provided by
general practice physicians (Minto, 2004). The origins lie in the development of
general practice services in the 1970s when rural general practice physicians received
a 50 per cent subsidy from the government as an incentive for practice nurse services,
which aimed to relieve the general practice physician of activities that could be
undertaken just as adequately by the nurse. The subsidy has been subject to several
changes since its introduction, and in 1974 was increased to 100 per cent in an attempt
to extend the role to include urban as well as rural practice settings. The full subsidy
enabled practice nurse services to be provided at no cost to the client. As a ‘first point
of contact’ with the health care system, nurses provided health advice and conducted
clinical assessments and interventions. Despite the full subsidy, it was common for
general practice physicians to insist on seeing the client in addition to the nurse,
claiming a general medical services subsidy, with the result that the government paid
twice for health care (Blue, 1995).
The practice nurse subsidy was altered again in 1991 to NZ$11 per hour for up to a
maximum of 32 hours per week (75%). This arrangement resulted in most practice
nurses being employed part time and an increasing number of practice nurse services
were charged to the client as general practice (physician) employers argued the need
to pay for overheads such as dressings, equipment, reception staffing, power, and
goods and services tax (Blue, 1995). The practice nurse subsidy has been viewed by
many nurses as problematic in that general practice physicians have determined the
77
activities undertaken by the nurse outside of a nursing framework (College of Nurses
Aotearoa (NZ) Inc., 2001). As a consequence of the PHC Strategy in 2001, the
practice nurse subsidy along with the general medical services subsidy for laboratory
and pharmaceutical costs was placed under a capitated funding formula managed by
the Primary Health Organisation (see section 4.4.1) and representing general practice
interests.
In addition, the Accident Corporation Compensation pays the general
practice physician NZ$15 for practice nurse interventions such as suturing a wound,
with the doctor receiving a further NZ$28 for reviewing the same injury (B. Docherty,
personal communication, May 13, 2005).
Atkin and Lunt (1996) perceive the practice nurse role to have more flexibility than,
for example the role of the district nurse. Other authors have described the practice
role as predominantly task-oriented (Toop, Nuthall, & Hodges, 1996) with tasks
delegated by general practitioners (Docherty, 1996; Michel, 1997). General practice,
being located within clinical medicine, deals with the problems of individuals and
does little to protect and promote the health of society (Beaglehole & Bonita, 1997), a
construct that bounds the potential practice of practice nurses. Docherty contends
practice nurses adopt one of two roles, either the ‘hand maiden’ role where the
activities are delegated by the general practitioner, or a more autonomous role where a
nurse uses a wide range of skills, makes decisions within a field of practice, and runs
clinics focused on health education topics such as weight management and chronic
diseases management.
Carryer et al. (1999) go further, suggesting that nurses
understand a strategy of health promotion that addresses the social and environmental
determinants of health.
It is often perceived that the general practitioner sublimates the ability of the practice
nurse to contribute as a full and independent team member (Martin, 2002). Docherty
(2004) maintains “…it has always been difficult for practice nurses to provide a true
nursing service within a team when most of the ‘service’ has been defined and
financially determined by the employer” (p. 10). Consistent with this perspective,
Minto (2004) argues the capacity for expanding nursing services has been limited by
the structural arrangement that place general practitioners as employers of practice
nurses. Other factors that have affected practice nurses ability to contribute as equal
team members include limited access to resources, physical workspace, postgraduate
78
education (Ministry of Health, 1998), and the nurses own view of their role and lack
of confidence about the contribution they can make (Williams, 2000).
4.3.7
Other community nursing groups and new strategies
A number of other nursing groups such as occupational health nurses, disease-state
management nurses (including diabetes nurse educators and COPD case managers),
Maori and Pacific health nurses, and rural health nurses have evolved. These groups
commonly adopt the same types of interventions as Plunket, district, public health and
practice nurses. In addition, combinations of nurses from the various groups have
contributed to strategies like integrated care (see chapter 5), which required
collaboration within and across the professions.
Similarly, ‘Community FIRST’, which is a new service and funding model, is being
evaluated by the ‘ASPIRE’35 study and engages nurses36 to lead a case management
team of physiotherapists, occupational therapists, general practitioners and support
workers to provide restorative and rehabilitative services to older people living in
their own homes in five New Zealand cities (Ministry of Health, 2004b; Parsons et al.,
2004). This model is being assessed for application in a multicultural population of
all ages, with nurses again managing complex rehabilitation packages (Baird, 2004).
4.3.8
The historical legacy of community nursing
The work of nurses in communities in the early 1900s reveals the development of a
profession under the watchful eye of medicine. Doctors fiercely guarded clinical
knowledge and clear divisions existed between nursing and medicine, with the
idealised nurse one trained to take orders rather than follow her initiative (McKegg,
1991).
Interestingly however, without the support of a hospital and working in
isolated backblock areas far from the support of other health care workers, community
35
ASPIRE is the acronym for the ‘Assessment of Services Promoting Independence and Recovery in
Elders’.
36
Community nurses who undertook lead case management roles in ASPIRE, completed a master
programme of study in gerontology and rehabilitation (Parsons, Anderson, Senior, & Jacobs, 2004).
79
nurses were faced with the choice of leaving clients without treatment or taking on
responsibilities outside their designated role. Most chose to provide treatment.
Because it was dominated by medicine, community nursing in New Zealand did not
develop autonomously as compared with primary health care practitioners such as
‘barefoot doctors’ in China and community nurses working in health centres in
Sweden and Finland who were largely autonomous (Blue, 1995). New Zealand
public health nurses did not commonly work from a community base, but remained
attached to urban-based units of the Department of Health. Blue contends that the
roles and responsibilities delegated to the public health nurse were strongly influenced
by traditional gender roles and power differentials between nursing and medicine. For
example, only in recent times have public health nurses been able to immunise
without the supervision of a medical practitioner.
Practice nursing may have
developed because public health nurses did not offer ‘first point of contact’ services in
primary health care in the 1970s. Autonomous decision-making by practice nurses is
still limited by their need to defer to general practice physician employers, and the
cost effectiveness of the service is impeded by the dual claiming of subsidies for
clients by both nurses and doctors.
While community nursing groups such as district nurses, public health nurses and
school nurses overlap in terms of the populations they serve and the interventions they
undertake, they are separate entities and do not share a common public health
philosophy.
Knowledge of primary health care principles (see p. xiv) and an
understanding of the social and economic determinants of health would be required.
Instead, many nurses appear to practice within a medical paradigm that focuses on
acute symptom management (B. Docherty, personal communication, May 13, 2005).
Constructing a collective primary health care workforce able to meet the diverse
needs of individuals and populations poses a real challenge to the nursing profession.
In particular, developing a more client centred orientation in health care requires
nurses to build requisite partnerships with key providers to achieve a more
comprehensive, integrated health-based delivery system.
Zerwekh (1992) describes the practical wisdom of public health nurses in the 1890s
who undertook a case load in the community, promoted self-management, and
80
acquired skills in clinical decision making through experience. In contrast to these
early days where cases were found through inquiries in neighbourhoods,
contemporary case loads result from referrals by a variety of agencies, such as schools
and general practice physicians, which require a wider range of partnerships and
collaboration. Collaboration produces “action that results in the attainment of mutual
goals for the patient’s needs….it excludes unilateral, isolated or independent actions
by professionals as a general style” (Ministry of Health, 2002f, p. 21).
The nursing profession believes there is a need for more intersectoral partnerships and
community development (J. Carryer, 2004). Porter-O’Grady (1999) has said
“Nursing has a history of pulling together the many and disparate resources, players,
and processes in health care around patients…. [and] is perhaps the only profession
whose focus is the patient’s journey rather than any one given clinical event” (p. 9).
However, if nursing is to play a significant role in building relationships and
community development, distinctions between different models of partnership among
professionals and the community must be understood. For example, a community
involvement model is applied when the nurse determines the agenda and attempts to
get the community on side, a community participation model is applied when the
nurse gives the major role of the projects design and implementation to the
community but remains in control, and a community controlled action model is
applied when the nurse acts as a guide and educator of community members who
learn skills to undertake their own project (J. Raeburn, personal communication, April
30, 2003).
If nursing is to contribute to improving population health outcomes, nursing groups
and in particular practice nurses, are well placed to promote health (Docherty, 2004;
Minto, 2004). Implementing population-based practice on all levels will require an
expansion of generic skills and the development of new knowledge and expertise.
The PHC Strategy provides the context for change and PHC nurses have been
identified as crucial to the successful implementation of the Strategy (Ministry of
Health, 2001c). Section 4.4 describes the planned approach taken nationally to align
and develop the PHC nursing workforce between 2002 and 2005.
81
4.4
4.4.1
Contemporary PHC nursing developments
Background
The New Zealand Labour government was elected to power in 1999 and introduced
the New Zealand Public Health and Disability Act in 2000, which regulated the
provision of health and disability services for New Zealand. Two key strategies set
the overarching direction for the development of services, the New Zealand Health
Strategy (Ministry of Health, 2001b) and the New Zealand Disability Strategy
(Ministry of Health, 2001a). Fostering cooperation and collaboration between health
and social sectors, and encouraging community voice in health and disability service
decisions were central notions. Other documents were developed to provide greater
detail of service, health issue, or population group specific strategies and/or action
plans, such as, the New Zealand PHC Strategy (Ministry of Health, 2001c).
Structural reforms to the health care system in 2001 accompanied the new strategic
directions for health and disability service provision. District Health Boards were
responsible for the purchasing and provision of primary, secondary and tertiary health
services for defined populations.
The population-based formula now used for
determining a region’s share of public funding considers the demographic
characteristics of each region, and adjusts for unmet need, overseas visitors and the
degree of rurality (T. Ashton, 2005). Primary Health Organisations (PHOs) were the
vehicle for District Health Board provision of population-based health care. PHOs are
local health provider organisations that provide population-based and personal first
line general practice services. In January 2005 there were 77 PHOs (A. King, 2005).
The central aim of the PHO is to improve health and reduce health inequalities by
targeting populations with poor health, or who are underserved. PHOs are required
to: collaborate with other providers and coordinate care; demonstrate community, Iwi
(tribal), and consumer participation in governing processes; respond to the needs of
the community; demonstrate provider and practitioner influence in organisational
decision making; apply a population needs-based formula (capitation), and
demonstrate accountability for public funds, as they are ‘not-for-profit’ organisations
(Ministry of Health, 2002b).
82
The PHC Strategy sought to identify and remove health inequalities and improve
health through focusing on population health, health promotion and preventative care;
community involvement; multidisciplinary approaches to decision making; improving
accessibility, affordability and appropriateness of services; improving coordination
and continuity of care and quality information; and funding, and providing services
according to the population’s needs as opposed to fee-for-services when people are
unwell (Ministry of Health, 2001c). In total the Government intends to commit just
over NZ$1.7 billion over six years starting 2002/03 specifically for implementing the
PHC Strategy using the PHO model (Ministry of Health, 2004e).
The level of
funding indicates a genuine attempt to establish a stronger PHC orientation within the
New Zealand health care system. Existing PHC services include generalist first level
services, such as general practice services, mobile nursing services, community health
services for certain conditions (maternity, family planning and sexual health, mental
health, dentistry, and pharmacy) or for particular therapies (physiotherapy,
chiropractic, and osteopathy). Development of a PHC workforce that includes nurses
has been central to achieving the Strategy (Ministry of Health, 2001c).
4.4.2
PHC Nursing scholarships and innovative models of practice
The PHC Strategy required the MOH to facilitate a national approach to PHC nursing,
which addressed capabilities, professional practice, educational and career
frameworks, and employment arrangements (Ministry of Health, 2001c). Nursing
received NZ$8.1 million of the funding committed to PHC for workforce
development. Primary health care nursing scholarships were established to assist
nurses working in the sector to gain postgraduate qualifications. Initially in 2003/04,
about 390 scholarships were allocated.
In early 2005, further scholarships were
allocated, and the total cost so far stands at NZ$850,000. In another nursing initiative,
11 innovative models of PHC nursing were selected from over 130 proposals at a cost
of NZ$7.25 million including the evaluation (Hughes, 2003; A. King, 2005).
The 11 models focused on population strategies that fell under the New Zealand
Health Strategy and assisted in the implementation of the PHC Strategy, over a four
year period. Almost half of the innovative nursing models sought to reduce the
83
fragmentation and duplication of services, which had also been a feature of integrated
care, and to support the transition of PHC service provision through PHOs (Hughes,
2003; Ministry of Health, 2004e). Selected from across New Zealand, examples
included: coalition of nursing groups aiming to reduce inequalities (Northland District
Health Board); Tuwharetoa health services partnership with whanau to reduce
inequalities (Lakes District Health Board); combined PHC nursing groups to support
nurses in the transition to PHOs (Mid-Central District Health Board); expanding
nursing services to improve access to care, early interventions, and disease
management (West Coast District Health Board), and a kupapa Maori PHC nursing
service to develop nurse practitioner roles (Auckland District Health Board) (H.
Hunter, personal communication, June 25, 2003).
The decision to allocate the majority of the funding to PHC nursing innovations
resulted from earlier findings by the Ministerial Taskforce on Nursing (Ministry of
Health, 1998). The Taskforce identified few established nursing structures for entry
into community practice, under-developed community nursing leadership, and no
systematic approach to transition into practice for new graduates. Recommendations
of the Taskforce included the development of a framework to guide PHC nursing over
the next decade, which resulted in a national advisory group publication, ‘Investing in
health: A framework for primary health care nursing’ (Ministry of Health, 2003b).
This PHC nursing framework suggested: the need for developing innovative methods
of service delivery; improving coordination of care across services; strengthening
collaboration in multidisciplinary teams, and building stronger links across sectors.
Funding streams, employment practices, and coordinated service provision that
incorporated population and personal health strategies were advocated. Emphasis was
placed on new models of PHC nursing practice that improved access to PHC services,
health outcomes and reduced inequalities. PHC nurses were expected to be active in
the governance of PHOs and hold leadership positions, and the framework highlighted
a need for postgraduate education to support the development of PHC nursing
practice. These recommendations were acted upon by the Ministry, represented in the
funding of innovative nursing practice models and postgraduate nursing education.
84
4.4.3
Nurse Practitioner scope of practice
The Health Practitioners Competence Assurance Act 2003 came into effect in
September 2004 replacing the Nurses Act 1977 (Nursing Council of New Zealand,
2004). The term ‘nurse practitioner’ is protected under the new Act and is registered
as a distinct ‘scope of practice’37. The Ministry of Health (2002f) stated “nurse
practitioners are the highest level of clinical expert within nursing” (see p. v, preface).
Similar to registered nurses, nurse practitioners do not require supervision by other
disciplines. However, they differ from registered nurses in that they are required to
have a clinically focused masters degree or equivalence, and a minimum of four years
experience at an advanced level in a specific specialty area (Ministry of Health,
2002f). As at July 2005, there were 17 nurse practitioners registered in a range of
specialty areas, which included neonatology, mental health, diabetes and related
conditions, wound care, urology, gerontology, child and youth health, and whanau ora
- family health (P. Renouf, personal communication, July 29, 2005).
The majority of the nurse practitioners work in primary health care settings. The
nurse practitioner with a sub-specialty in child and youth health is currently the only
nurse in New Zealand to have prescribing authority38. The nurse practitioners in the
whanau ora specialty have a Maori health focus. Prescribing is an important tool for
nurse practitioners and over time it is envisaged that the majority will need
prescribing competencies (Ministry of Health, 2002f). “The introduction of the role
of the primary health care nurse practitioner is a fundamental opportunity to showcase
their expert practice and leadership qualities, and to be inspirational role-models for
primary health care nurses” (Ministry of Health, 2003b, p. 32).
Competencies for the nurse practitioner scope of practice include: the ability to
articulate a specialty area of practice and advancement; demonstrate expert practice
across settings and within interdisciplinary environments; provide effective nursing
leadership and consultancy; conduct scholarly research inquiry into nursing practice;
37
In 2004 four areas of registration were defined as ‘scopes of practice’, nurse practitioner, registered
nurse, nurse assistant, and enrolled nurse (Nursing Council of New Zealand, 2004).
38
In 2003 Paula Renouf was registered as the first nurse practitioner with prescribing authority by the
Nursing Council of New Zealand. She had worked for the previous ten years in California as a nurse
practitioner in primary care.
85
develop and influence health and socioeconomic policies and nursing practice at local
and national levels, and prescribe interventions, appliances, treatments and authorised
medicines within a specialty area of practice. “Advocating health promotion and
disease prevention, nurse practitioners will look beyond treating the ailment and
consider non-medical interventions and encourage self-care. They will also be able to
diagnose, evaluate health problems, including prescribing and monitoring medication”
(Ministry of Health, 2002f, p. v, preface).
In summary, New Zealand has planned and invested in the development of a PHC
nursing workforce. Funding has been available for nurses to experiment with
innovative models of nursing practice and the evaluation of these models is in
progress. A number of PHOs have nurses represented in governance positions and
further postgraduate scholarships are being allocated to nurses. Workforce surveys
are informing nursing recruitment and retention strategies, and the first nurse
practitioners in PHC are demonstrating advanced practice. In order to progress PHC
nursing in the period 2002 to 2005, an incremental plan of action was proposed (see p.
87, Table 4). Most of the 2002 to 2004 milestones have been achieved, although
areas that continue to be developed include: the registration of nurse practitioners,
particularly in relation to prescribing and attaining a wider authority; leadership
structures; credentialing PHC teams, and integrating new knowledge into primary
health care nursing practice.
86
Table 4: Milestones for PHC nursing development
2002/3
•
•
•
•
•
•
•
•
Development of the framework for PHC nursing
Innovative models of PHC nursing practice funded by the MOH
Funding for postgraduate education accessed by PHC nurses
First PHOs established and nurses represented in governance positions
PHC leadership structure developed in district health boards and PHOs
PHC education framework established
PHC nursing resources focus on needs analysis as a basis for service
planning
PHC workforce analysis and recruitment and retention strategies
developed
Nurse practitioners implemented in PHC
2003/04
•
•
•
•
•
Innovative models of PHC nursing practice funded by the MOH
Beginning evaluation of innovative models of PHC nursing practice
Introduction of PHC nurse practitioners
Nursing leadership positions in place in district health boards and PHOs
PHC education framework in place
2004/05
•
Continue evaluation of innovative models and promulgate successful
models
PHC nurses supported to gain competency based annual practicing
certificates
Evaluation of initial gains to community - satisfaction surveys
PHC nursing framework fully implemented
PHC nurses have access to appropriate postgraduate education
PHC nurses credentialed and functioning in PHC nursing teams
•
•
•
•
•
•
From “Investing in Health: Whakatohutia te Oranga Tangata: A framework for activating primary health care nursing
in New Zealand,” by the Ministry of Health, 2003, p.8. Wellington: Ministry of Health.
4.5
A model for PHC Nursing: The public health interventions wheel
The public health interventions wheel (interventions wheel or wheel) is a public
health model that has the capacity to demonstrate PHC nursing as a specialty area of
practice. Initially developed as a means of identifying and documenting interventions
undertaken by nurses in the United States, the intervention wheel became a tool for
enabling practitioners to articulate their practice. The intervention wheel identifies
population-based practice at three levels – individual and family, community, and
systems and recognises 17 public health interventions. The concept is that each
intervention and level of practice contributes to improving overall population health.
The intervention wheel can describe nurses’ practice, despite the different locations
nurses work in because a core set of interventions are commonly used, and the wheel
87
clarifies what is similar across settings (Keller, Strohschein, Lia-Hoagberg, &
Schaffer, 1998).
The intervention wheel was first introduced in 1998 by public health nurses in the
Minnesota Department of Health (Keller et al., 1998).
The wheel has been
disseminated widely throughout the United States and is also used by disciplines39 in
public health, other than nursing. Interest in the model has been influenced by the
move towards population-based practice and the intervention wheel provides a guide
for public health orientation, documentation, job descriptions, performance
evaluations, programme planning and evaluation, and budgeting. Presented to boards
and legislators, it has also provided a policy structure for health decision making, and
is currently a component of nursing education programmes (Keller, Strohschein,
Schaffer, & Lia-Hoagberg, 2004b).
The author visited the United States in 2003 to explore the intervention wheel’s
multiple applications to nursing practice, education, research and management.
Public health nurses in Minnesota, working in the counties of Bloomington and
Carver were observed applying the intervention wheel to the planning and evaluation
of population health programmes. It formed the basis of job descriptions and was
used to support pay equity adjustments.
Student nurses at Bethel College,
Minneapolis-Saint Paul attributed their understanding of population-based nursing
practice to the wheel, which was introduced as a learning tool in year one of the
undergraduate program. Postgraduate nursing students at the University of Minnesota
used the wheel as a framework for critically analysing their practice. Nurses from the
Shiprock Community Health Service Unit integrated Navajo values into the
intervention wheel as a guide to both clinical and cultural practice. Overall, the
intervention wheel appeared versatile and adaptable.
39
The intervention wheel describes the breadth of public health work, so nutritionists, health educators,
planners, physicians, and epidemiologists may use the same interventions within interdisciplinary
teams.
88
Figure 3: The Public Health Interventions Wheel
From “Population-Based Public Health Nursing Interventions: A Model from Practice,” by L. Keller, S.
Strohschein, B. Lia-Hoagberg, and M. Schaffer, 1998, Public Health Nursing, 15, p.208. Copyright 1998 by
Blackwell Science Incorporated. Printed with permission of the author.
4.5.1
Describing the Public Health Intervention Wheel
The intervention wheel shown in Figure 3 comprises three distinct elements of equal
importance. The wheel is population-based, encompasses three levels of practice
(community, systems, individual and family), and defines 17 public health
interventions. The three elements are described successively.
89
4.5.1.1
Population-based
According to the Minnesota Department of Health (2001), five criteria determine
population-based practice.
First, population-based practice focuses on entire
populations and interventions are not restricted to those who seek service, are poor, or
otherwise vulnerable. This is consistent with the concept ‘new universalism’, which
infers high quality essential care, defined by the criteria of effectiveness, cost, and
social acceptability that are available to the entire population. It implies explicit
choice of priorities among interventions, respecting the ethical principle that it may be
necessary and efficient to ration services, but that it is inadmissible to exclude whole
groups of the population (World Health Organization, 2000).
Population-based
practice identifies everyone who is in the population-of-interest40 or the population-atrisk41.
Second, population-based practice is guided by an assessment of population health
status, which is determined by a community health assessment.
Risk factors,
problems, protective factors, and assets within populations that impact health status
are analysed, priorities are established, and interventions are planned, implemented
and evaluated.
The focus on community needs allows programmes to remain
responsive. Third, population-based practice considers the determinants of health,
such as income and poverty, employment and occupation, education, housing, social
cohesion, culture and ethnicity (National Health Committee, 1998), which promote or
prevent health (R. Wilkinson & Marmot, 2003). Fourth, population-based practice
considers all levels of prevention and prioritises primary prevention, promoting health
and preventing problems before they occur. Prevention is an action taken to prevent
the occurrence of an event or to reduce the effect after it has occurred (Turnock,
2001).
Population-based practice presumes that prevention may occur before a
problem occurs, when a problem has begun but before signs appear, or after a
problem has occurred.
40
“A population-of-interest…is essentially healthy, but who could improve factors that promote or
protect health” (Minnesota Department of Health, 2001, p. 2).
41
“A population-at-risk…has a common identified risk factor or risk-exposure that poses a threat to
health” (Minnesota Department of Health, 2001, p. 2).
90
Finally, population-based practice considers interventions at all levels of practice.
Interventions may be directed at entire populations within a community, the system
that affects the health of those populations, and/or the individuals or families within
those populations known to be at risk. Interventions at each of these levels of practice
contribute to the overall goal of improving population health status. Public health
professionals determine the most appropriate level/s of practice based on community
need and the availability of effective strategies and resources (Keller, Schaffer, LiaHoagberg, & Strohschein, 2002).
4.5.1.2
Individual and family, community, and systems levels of practice
Nurses, where possible are expected to use interventions at all three levels of practice,
although traditionally nurses have documented their work with individuals and
families for reimbursement, reporting and productivity purposes (Keller et al., 2004a).
Keller et al. contend work with communities and systems has equal if not greater
importance compared to work with individuals and families, when considering the
goal of improving population health. This principle is central to the intervention
wheel.
Figure 4: Population-based systems level of practice
91
Population-based systems practice has the potential to change organisations, policies,
laws, and power structures (Keller et al., 2004a). At the systems level the focus is on
the systems that impact health, not directly on individuals and communities.
Changing systems is considered a more effective and sustainable way of impacting on
population health than requiring change from every individual in a community. An
example of systems level practice is demonstrated when a nurse who works with a
network of health provider organisations establishes best practice standards around
depression management and all parties adopt these guidelines.
Figure 5: Population-based community level of practice
Population-based community practice changes community norms, community
attitudes, community awareness, community practices, and community behaviours. It
is directed towards entire populations within a community or occasionally towards
targeted groups within this population. Community practice is measured in terms of
what proportion of the population actually changes (Keller et al., 2004a). An example
of community level practice is demonstrated by a nurse who works with community
agencies and health provider organisations to increase community awareness of
mental illness, seeking to change community attitudes and behaviours and thereby
reduce the stigma of mental illness experienced by many people.
92
Figure 6: Population-based individual and family level of practice
Population-based individual practice changes knowledge, attitudes, beliefs, practices,
and the behaviours of individuals. This practice level is directed at individuals, alone
or as part of a family, class or group. Services to individuals and families are
population-based if they meet specific criteria, such as individuals receiving services
because they are members of an identified population, and those services clearly
contribute to improving the overall health status of the population (Keller et al.,
2004a). An example of individual level practice is demonstrated by a nurse who case
manages health care services on behalf of a frail older person with chronic mental
health problems.
In summary nurses determine the most appropriate level/s of practice based on
community need and the availability of effective strategies and resources. All levels
of practice are important and as shown can address an issue simultaneously.
4.5.1.3
Seventeen public health interventions
Interventions are actions taken on behalf of communities, systems, and individuals
and families to improve or protect health status. The 17 interventions comprise
surveillance, disease and other health investigation, outreach, screening, case finding,
93
referral and follow-up, case management, delegated functions, health teaching,
consultation, counselling, collaboration, coalition building, community organising,
advocacy, social marketing, and policy development and enforcement (see p. 95,
Table 5).
These interventions can be implemented at all three levels, with the
exceptions of case finding, which occurs only at the individual level, and coalition
building and community organising, which occurs only at the community and systems
levels.
Related interventions have also been grouped into ‘wedges’. Surveillance, disease
and health investigation, outreach, screening, and case finding comprise one wedge.
Interventions comprising other wedges are: referral and follow-up, case management,
and delegated functions; health teaching, consultation, and counselling; collaboration,
coalition building, and community organising, and finally advocacy, social marketing,
and policy development and enforcement. The wedges are placed on the wheel in an
order that reflects their relationship, with surveillance placed at the top of the wheel
because it is the place where most public health work begins (Keller et al., 2004a).
94
Table 5: Definitions of public health interventions
Intervention
Definition
Surveillance
Describes and monitors health events through ongoing and systematic
collection, analysis, and interpretation of health data for the purpose of planning,
implementing, and evaluating public health interventions
Disease &
health event
investigation
Systematically gathers and analyses data regarding threats to the health of
populations, ascertains the source of the threat, identifies cases and others at
risk, and determines control measures
Outreach
Locates populations-of-interest or populations-at-risk and provides information
about the nature of the concern, what can be done about it, and how services
can be obtained
Screening
Identifies individuals with unrecognised health risk factors or asymptomatic
disease conditions in populations
Case-finding
Locates individuals and families with identified risk factors and connects them
with resources
Referral &
follow-up
Assists individuals, families, groups, organisations, and/or communities to
identify and access necessary resources in to prevent or resolve problems or
concerns
Case
management
Optimises self-care capabilities of individuals and families and the capacity of
systems and communities to coordinate and provide services
Delegated
functions
Direct care tasks a registered professional nurse carries out under the authority
of a health care practitioner as allowed by law. Delegated functions also include
direct care tasks a registered nurse entrusts to other appropriate personnel to
perform
Health teaching
Communicates facts, ideas and skills that change knowledge, attitudes, values,
beliefs, behaviours, and the practices of individuals/families, systems,
communities
Counselling
Establishes an interpersonal relationship with a community, a system, family or
individual intended to increase or enhance their capacity for self-care and
coping. Counselling engages the community, system, family or individual at an
emotional level
Consultation
Seeks information and generates optional solutions to perceived problems or
issues through interactive problem solving with a community, system, family or
individual. The community, system, family or individual selects and acts on the
option best meeting the circumstances
Collaboration
Commits two or more persons or organisations to achieve a common goal
through enhancing the capacity of one or more of the members to promote and
protect health
Coalition
building
Promotes and develops alliances among organisations or constituencies for a
common purpose. It builds linkages, solves problems, and enhances local
leadership to address health concerns
Community
organising
Helps community groups to identify common problems or goals, mobilise
resources, and develop and implement strategies for reaching the goals they
have agreed
Advocacy
Pleads someone’s cause or act on someone’s behalf, with a focus on
developing the community, system, individual or family’s capacity to plead their
own cause or act on their own behalf
Social
marketing
Utilises commercial marketing principles and technologies for programmes
designed to influence the knowledge, attitudes, values, beliefs, behaviours, and
practices of the population-of-interest
Policy
development &
policy
enforcement
Places health issues on decision-makers’ agendas, acquires a plan of
resolution, and determines resources. Policy development results in laws, rules,
regulations, ordinances, and policies. Policy enforcement compels others to
comply with the laws, rules, regulations, ordinances and policies.
From “Population-Based Public Health Nursing Interventions: A Model from Practice,” by L. Keller, S. Strohschein, B. LiaHoagberg, and M. Schaffer, 1998, Public Health Nursing, 3, p.210. Copyright 1998 by Blackwell Science Incorporated. Adapted
with permission of the author.
95
4.5.2
Validated and evidence-informed
The idea of the intervention wheel began in 1994 with a collection of practice
examples from over 200 experienced public health nurses in Minnesota. A panel of
practice experts identified common themes from the examples, which were then
depicted as spokes of the wheel. Numerous copies of the interventions were critiqued
throughout the nation. A federal research grant in 1998 enabled a systematic review
of the evidence relating to the interventions, and this information combined with
theory and expert opinion informed the intervention wheel. The process involved
hundreds of public health nurses in the United States over an 18 month period (Keller
et al., 2004a; Minnesota Department of Health, 2001).
The following six questions guided the review process:
1.
Did the 17 interventions encompass the breadth of public health practice?
2.
Did the interventions occur at all levels of practice?
3.
Were there missing interventions, or public health nursing activities that
could not be classified into existing interventions?
4.
Were there overlaps or duplications among the interventions?
5.
Did the evidence support the original interventions?
6.
How could these interventions be implemented with excellence?
4.5.2.1
Findings of the review of the intervention wheel
The intervention wheel was found to capture the breadth and scope of populationbased nursing, and provided a solid foundation for nursing practice and research. The
original assumption that the interventions occurred at all levels was revised to reflect
the three interventions that were exceptions to this assumption (see p. 94). There
were no missing interventions, although there was a recommendation that the original
‘policy development’ be expanded to include ‘policy development and enforcement’
to reflect the expert consensus that without enforcement, policy development is
ineffective. The interventions were found to be distinct and separate, although many
were interrelated or occurred simultaneously or sequentially.
This resulted in a
96
reordering of the interventions on the outside of the wheel to reflect relatedness. In
addition, several interventions were modified, such as provider education, which was
integrated into health teaching, because of the recognition that provider education was
actually health teaching at the systems level. Other modifications included ‘delegated
medical’ being expanded and renamed ‘delegated functions’ to reflect nursing
responsibility for delegating to others as well as accepting delegation, and ‘disease
investigation’ was expanded to ‘disease and other health investigation’ to encompass
other threats to health including acts of bio-terrorism, chemical or other hazardous
waste spills, and natural disasters. The evidence confirmed the definitions of the
interventions and was used to identify basic steps and recommend best practices for
each intervention. A significant challenge to documenting best practices was a lack of
evidence, so best practices were a combination of research, other evidence from the
literature and practice expertise (Keller et al., 2004a).
In 1999, a 46-member panel of public health nurse experts and academics from
several states participated in a consensus meeting and agreed the set of interventions.
These regional recommendations were reviewed by a national panel of public health
nurse experts who required few changes to the original set of 17 interventions
presented in Figure 3 (see p. 89) (Keller et al., 2004a; Minnesota Department of
Health, 2001).
4.6
In conclusion
The New Zealand PHC nursing workforce is a collection of nursing groups with
differing historic experiences and knowledge. Building a combined workforce with
expertise in primary health care will require more than “ongoing education…in
specific practice areas (e.g., district nursing, practice nursing) or for additional skills
(e.g., asthma management, immunisation)” as suggested by the Ministry of Health
(2003b, p. 9). Repositioning the PHC nursing workforce to work with communities,
improve population health outcomes and reduce health inequalities to meet the
objectives of the PHC Strategy will require new public health knowledge and a way to
integrate these concepts into PHC nursing practice.
97
The New Zealand Government has identified the potential future contribution PHC
nursing can make in reducing inequalities, and to this end has invested in PHC
nursing workforce development through the funding of postgraduate education and
innovative models for nursing practice. The direction is clear and the road map
drawn, however, access to education does not necessarily translate into major shifts in
nursing practice and the culture surrounding practice, just as new models of practice
(of varying degrees of innovation) may not necessarily result in a redesign of service
delivery. Whilst Government has progressed important nursing initiatives, without a
common core PHC nursing knowledge and an understanding of how to implement
community care and promote community development, in addition to the
conventional care provided to individuals and families, the potential contribution of
PHC nursing will be limited.
The public health interventions wheel provides a vision of the range and levels of
future population-based practice.
Presented as a model that has the capacity to
demonstrate PHC nursing as a specialty area of practice, it can assist nurses to
understand practice at the community and systems levels, in addition to the individual
and family level. Each intervention and level of practice contributes to improving
overall population health making the wheel a useful tool in the implementation of
PHC nursing practice. To date, New Zealand has not articulated a national framework
for guiding population-based practice and this model has the potential to contribute to
meet that challenge.
Chapter five presents integrated care, a public health reform strategy of the 1990s as
an outcome of the socio-political environment that aimed to promote primary health
care. The notion of integrated care was tested by the government funding of a number
of national experimental, demonstration pilot projects, within which health
professionals including nurses were employed. The purpose, design, and evaluation
of demonstration pilot projects are comprehensively described.
98
5
5.1
Chapter 5
Integrated Care
Introduction
In New Zealand the duplication and fragmentation of health care services during the
twentieth century was in part due to the way services were provided. Independent
general practice physicians provided primary care, public hospitals provided
community services, secondary and tertiary care, and various other providers provided
community care services (Russell, Cumming, Slack, Paterson, & Gilbert, 2003). They
suggested integrated care was not a new strategy, and for more than a decade had
been considered a solution to the fragmentation of service delivery between primary
and secondary care. In 1975 the government identified the need for closer liaisons
between general practices and hospital services and favoured the strategy of integrated
care (Department of Health, 1974). A health system review in 1986 advised on
changes to better integrate care (Health Benefits Review, 1986), and this theme was
again followed up in the 1990s linking integrated care with the total management of
an individual’s health care, including the funding of all services by the purchasing
authorities (Upton & New Zealand Department of Health, 1991). Integrated care, by
the mid-1990s, was also strongly associated with the idea of ‘chains of care’
(Ovretveit, 1998) and the containment of health care costs (Russell et al., 2003).
Internationally, a central purpose of integrated care was the development of a systems
approach, maximising health gain from targeted resources, effective interventions,
and emphasising care and prevention in the management of chronic conditions
(Bringewatt, 1997; Ovretveit, 1998). Integrated care was a consistent objective of
health reforms in the 1990s in Australia, the United States, Canada, the United
Kingdom, Scotland, and New Zealand, although there were a number of reasons for
seeking integrated care and many methods for achieving it. In recent times the New
Zealand health system has restructured more rapidly than any other system in the
world (T. Ashton, 1998), and despite the successive bouts of semantic redesign, it is
not clear that either those in the health sector or the public agree precisely what
integrated care is. The risk of this uncertainty is that advocates and opponents of
99
specific approaches to integrated care can pursue individual agendas within an
environment of confusion.
The purpose of this chapter is twofold. First, the background and environment within
which integrated care developed is discussed and the various meanings attributed to
integrated care, including beliefs by Maori, are identified. This is followed by a
description of national demonstration pilot projects that sought to test the strategy of
integrated care.
As the planning and implementation of these projects was
documented, the context and understanding of integrated care in New Zealand during
this time is illustrated. The chapter concludes with the identification of the need for
research to clarify aspects of integrated care. In particular, the need for research on
the practice of nurses in integrated care projects is highlighted.
5.2
Recent background
In New Zealand, in December 1996, the coalition Government announced changes to
the health sector. In just 18 months (July 1998) one funding body was to replace the
four regional health authorities and regional hospital and community services. The
assets and liabilities of the four regional health authorities were vested in a transitional
health authority one year earlier (Health Funding Authority, 1998). Lack of the
migration of ideas across regional health authorities is the major reason for
restructuring (Scott, 1997). At this time integrated care was recognised as critical to
the development of an effective and efficient health care system (Entwistle, 1997) and
as a health reform strategy, was inherited by the transitional health authority.
The steering group advising Government on changes to the coalition agreement
considered integrated care one of the most promising developments in contracting in
New Zealand and internationally in regard to coordination, cost-effectiveness of
treatments and improved health and independence outcomes (New Zealand Steering
Group to Oversee Health and Disability Changes, 1997). Integrated care policy had
100
been actively supported by regional health authorities and health provider
organisations since the early nineties, with the northern regional health authority
focusing on improved integration and population purchasing in 1993 (Boyd, 1998).
Issues for ongoing discussions included implementation issues, such as provider
behaviour, public lack of understanding, political actions, levels of provider trust, and
the coordination of care. Fiscal risks, such as limited budgets, cash flow, and risks of
provider failure, and information systems were also concerns on the same agenda.
Integrated care was a strategic objective in the Transitional Health Authority’s
‘statement of intent’, tabled in the House of Representatives as a purchasing method
to develop appropriate services that bridge the interface between primary, secondary
and tertiary health services, and health and disability support services, ensuring
coordinated care and intersectoral collaboration (Scott, 1997). In January 1998 the
Transitional Health Authority became the Health Funding Authority, responsible for
purchasing all publicly funded personal health and disability services within a capped
annual budget (see Appendix 1).
Ashton (1998) suggests the Health Funding
Authority viewed integrated care as a mechanism for aligning both clinical and
financial objectives. More specifically, the aim was to integrate care for patients by
addressing the linkages between the chains of service providers, and provide solutions
to the management of financial risk in the funding of health services.
5.3
Central problem: Fragmentation between services
In New Zealand, consumers move through a chain of providers42 for diagnosis and
treatment. The fragmentation of service delivery between primary and secondary care
has been noticeable for two main reasons. Historically, primary and secondary care
has been funded and organised in different ways. General practice physicians are
commonly self-employed and paid on a fee-for-service basis, and consultations are
time-limited with clients frequently referred on to other services. In contrast, public
42
For the purpose of this thesis, providers are defined as entities that provide health and disability
support services either directly or indirectly through, for example, subcontracting type arrangements.
101
hospitals have generally been paid by block budgets with hospital doctors on salaries.
This arrangement provides little incentive to increase throughput or speed service
delivery and because of the lack of integrated care, both primary and secondary
providers have the incentive to cost shift to each other43 (T. Ashton, 1998).
A second reason for fragmentation of patient care is because general practice
physicians act as gatekeepers for referral to publicly funded hospital specialists and
services, and cannot admit their patients to public hospitals or provide care in the
hospital setting44. Links between general practice physicians and hospital specialists
have depended primarily upon the exchange of records, letters and telephone calls,
and whilst these types of arrangements constitute simple forms of shared care
(Hickman, Drummond, & Grimshaw, 1994), integrated care is more than provider
cooperation, centring on changing the way services are organised (Central Health,
1997a).
In 1993 the introduction of a quasi-market for health services necessitated contracting
between purchasers and providers, and the problem of fragmentation of services was
exacerbated. Many services were broken down into separate packages, and single
provider organisations would often hold a range of contracts with the same purchaser
for a related set of services. Breaking services down in this way could increase
competition and consumer choice because it encouraged smaller providers to offer
particular components of care rather than a whole spectrum of services. However,
this method of contracting created new service boundaries and had the potential to
negatively affect the way patients’ moved between services.
Fragmentation of service delivery not only reduces the quality of care, but also is
likely to be inefficient. Fragmentation produces both a duplication of services and a
lack of necessary services to patients who falls though the gaps between services.
43
Another influential factor in this pattern of service use has been the fact that patients must pay a copayment for general practice consultations and also pharmaceuticals, whereas specialists and hospital
services are free of charge. Therefore, patients have an incentive to choose hospital services whenever
possible, and general practice physicians may also seek hospital care as a means of reducing out-ofpocket payments for their patients.
44
There are some exceptions, most notably for maternity services, and in some rural hospitals.
102
Providers referring patients on to other providers have no incentive and often little
information to consider the marginal costs of that referral in relation to the value of
the expected outcome. The purchaser, on the other hand, has more information about
service costs, but has no information about the potential value of a service for
individual patients, and is largely responsible for determining the level of services.
This situation is based upon historical utilisation patterns and fiscal capacity rather
than upon any analysis of the correct level and mix of services.
General practice fund-holding was a main response to the dual problems of costshifting and service fragmentation in the United Kingdom. In New Zealand almost 70
per cent of general practice physicians are involved in budget holding arrangements
for pharmaceuticals. However, incentives to promote integrated care or to contain
expenditure have been limited because: budgets are held by organisations called
Independent Practitioner Associations, rather than by individual general practice
physicians or groups of practices; budgets do not cover hospital services, and are
limited to pharmaceuticals, laboratory tests, and sometimes selected community
services; budgets are nominal rather than real, so money does not change hands unless
there is a surplus at the end of the contract period45, and any budget constraint on
general practice physicians is weakened by the fact that patients must pay a copayment for consultations.
New Zealand Independent Practitioner Associations were expected to play an
important role in promoting integrated care, although the Health Funding Authority
considered a wider range of options. Most notably, Aetna Incorporated, a United
States insurance company, established a network of general practices throughout
northern New Zealand and offered medical services to the Health Funding Authority
at a discounted rate. Aetna held the full risk for primary care, pharmaceuticals, and
laboratory services, supplied by member general practice physicians, and the shift of
financial risk to private insurers proved attractive to the Health Funding Authority.
45
Surpluses are usually shared between the budget holder and the purchaser, with any losses usually
taken by the purchaser.
103
5.4
Integrated care: Different definitions and meanings
International literature reveals that in different countries a range of terms have been
attached to integrated care (Anderson, 1998; Feek, 1998; Kodner & Spreeuwenberg,
2002) and the lack of a commonly accepted definition has been a barrier to the
promotion of integrated care theory and practice (Kodner & Spreeuwenberg, 2002).
In the United States ‘managed care’ is used, whereas ‘coordinated care’ has been
adopted in Australia, and ‘shared care’ is the preferred term in the United Kingdom.
Other terms in usage in Europe include ‘seamless care’, ‘continuous care’ and
‘chronic care management’ (Schrijvers, 2001).
As previously stated, the ideas behind integrated care in New Zealand were not new
(Russell et al., 2003). In the early 1990s, politicians, health professionals, managers
and policy-makers commonly used the term integrated care interchangeably with
‘coordinated care’ (Ministry of Health & Coopers & Lybrand, 1995) and ‘managed
care’ (Marwick, 1996). Malcolm and Shalowitz (1997) argued managed care had
been led in New Zealand by Independent Practitioner Associations and was linked to
the commercialisation of the health system. Independent Practitioner Associations
promoted the benefits of managed care to clients and practitioners, and their
involvement with large American insurance companies such as Aetna Incorporated
generated concern because of the possible prioritisation of profit before care.
However, after the 1996 general elections in New Zealand, ‘managed care’ was
replaced by the euphemism ‘integrated care’.
This change was in response to
negative publicity in New Zealand surrounding the failure of the United States health
care system to contain costs and provide adequate access to services (D. Armstrong,
1988; Pert, 1998). Like Malcolm and Shalowitz (1997), they proposed that managed
care and coordinated or integrated care were synonymous and the name change was
purely to remove the stigma attached to United States managed care models. Wano
(2003) contended integrated care was never fully embraced by Maori because it was
identified as synonymous with managed care and cost cutting. The notion that the
central purpose of integrated care was to accommodate to reduced government
funding had been argued a few years earlier in countries such as Canada (Wilson,
1996). In 1999, Wyatt Creech, the acting New Zealand Minister of Health, officially
104
grouped managed care and coordinated care approaches under the banner of
integrated care (Creech, 1999), although the meaning remained contested. Wood
(2001) argues that the adoption of the term integrated care in New Zealand as in
Scotland, represented a decisive shift against competition as the mechanism for
service quality and cost control.
It has been strongly argued that integrated care in New Zealand placed an emphasis
on intersectoral collaboration for the purpose of coordinating clinical care and
producing better patient outcomes (R. McCormick, 1997; R . McCormick & Ranger,
1997), whereas managed care emphasises containing health care costs (Ovretveit,
1998). This understanding is similar to one proposed in a position paper for the
World Health Organisation, in which integrated care is defined as “a concept bringing
together inputs, delivery, management and the organisation of services related to
diagnosis, treatments, care, rehabilitation and health promotion” (Grone & GarciaBarbero, 2001, p. 4).
The following section 5.4.1 identifies the definition of
integrated care for use in the NICPS before discussing various other meanings and
definitions attributed to integrated care.
The practice environment of health
professionals can be better understood by clarifying the complexity of integrated care.
5.4.1
NICPS definition of integrated care
Integrated care is the “methods and type of organisation which will provide the most
cost effective preventative and caring services to those with the greatest health needs
and which will ensure continuity of care and coordination between different services”
(Ovretveit, 1998, p. 1). This understanding of integrated care is used in the study of
nurses in integrated care projects and describes integrated care in terms of working
collaboratively whilst also focusing on positive economic outcomes.
Ovretveit’s definition contrasts with that of McCormick and Rainger (1997) who
argue integrated care stresses processes and agreements, unlike managed care which
begins by defining structures for health provision and agreeing financial incentives.
105
Cost effectiveness is a central requirement in the definition of integrated care
(Ovretveit, 1998), as are notions of continuity and coordination. In the New Zealand
health care system, which has a public market46, the term integrated care can describe
both managed care ideas applied within public systems and other ideas such as ‘chains
of care’ or ‘care pathways’.
The aim of integrated care within this definition is to
maximise health gain from a defined resource by targeting populations, applying
effective interventions and linking different services. The focus is placed on the most
serious health needs to create an effective health care system that includes prevention
and health promotion, with interventions working synergistically.
Ovretveit (1998) maintains that within the New Zealand public market system the
objectives are to: increase access to care for those most in need and who can benefit;
improve the continuity of care and coordination between services for individuals;
reduce costs by reducing inappropriate use of services, influencing the choice of
interventions, introducing cost-saving substitution, shifting resources from tertiary
and secondary care to primary and preventative services, overcoming financial
barriers to effective interventions, and creating financial risk-sharing arrangements
with providers to encourage more cost-effective actions. The methods for achieving
this include: agreements and contracts, improved information systems, guidelines and
protocols, utilisation controls such as gate-keeping, and discharge planning, pooling
finance from separate sources, financial incentives (removing financial disincentives),
new organisation, and integrated care. These methods assist in the management of a
complete episode of care, and combined with an overview of the populations needs
can lead to improving the range of services designed to meet those needs over the
longer term. Integrated care and devolved purchasing is potentially a way to increase
systems quality.
46
Health systems in both the United Kingdom and Sweden have also introduced public markets,
whereby a public purchaser or funder contracts services from separate and often competing
organisations. This system often results in professions and services concentrating upon the elements of
service that they are contracted to provide, despite consumers needing a range of services provided by
different organisations.
106
5.4.2
Perspectives of Ministers, advisors and purchasers
Previous Ministers of Health described integrated care in terms of new provider
relationships and strategic alliances (Shipley, 1995) and as a process driven from the
grassroots, starting with communities and individuals working in partnership (English,
1997). These ideas are similar to those held by regional health authorities, who stated
integrated care was the coordination of primary and secondary health and disability
support services, and providers would partner patients in their journey through the
health care system (Central Health, 1997b; Coster, 1998; Crombie & Gedye, 1997).
Such statements implied integrated care was about people, partnerships and services
to improve health, although they revealed little about the processes required to
achieve integrated care.
Davies (1999) suggests that there are two separate but potentially complementary
aspects to integrated care, service coordination and devolution of purchasing
responsibilities. Keating (1998) conceives integrated care provides services to meet
peoples’ needs, improves coordination and communication between providers and
reduces the duplication of administrative and clinical procedures, a notion
synonymous with service coordination. Marwick (1996) maintains integrated care
includes the management of budgets for the care of a population, consistent with the
devolution of purchasing responsibilities. Whilst these perspectives are potentially
complementary and Davies, Keating and Marwick are all senior employees within the
Ministry of Health, it is interesting that they are not expressed in any related way.
Karen Wells, the national integration manager for the Health Funding Authority in
1997, stated integrated care was a policy solution to manage resource allocation and
systematically devolve economic decision-making, or rationing decisions, to the
providers of services. Implementation was to result in structural reform of the New
Zealand public health system, and integrated care was the key reform strategy (Wells,
1998). The reason for devolving decision making to providers related to the health
professional (rather than the Health Funding Authority) having consumer level
information, necessary for determining appropriate service decisions. In addition,
107
providers were also considered able to better determine specific service levels and
where to make trade-offs between services (McKenzie, 1997).
Whilst these are
advantages, there were also accompanying risks for providers who had to provide
specified services within restricted budgets. As a contracting strategy, integrated care
used incentives to: align clinical decision making with the right mix of health and
disability support services, purchase services on an outcome basis, influence provider
responsiveness to consumers, and manage risks related to increased demand and
reduced utilisation. The scope of integrated care ranged from a group of related
services currently contracting with the funder using shared guidelines and information
systems, to a capitation payment for wide scale integrated care between primary and
secondary services (McKenzie & Webster, 1997).
If the implementation of integrated care was to result in reform of the public health
system as suggested by Wells (1998) it is difficult to see how this would have
occurred given the predominant focus on health care provision. A public health
system requires consideration of the social and economic determinants of health
(Beaglehole & Bonita, 1997). Definitions of integrated care previously referred to
partnerships with health providers and clients within the primary and secondary care
sectors, rather than intersectoral partnerships with for example, housing, education,
and welfare.
However, integrated care could potentially have adopted a wider
approach across other sectors and have directed attention to inequalities in housing,
employment, and education, factors known to impact upon health (R. Davis, Wagner,
& Groves, 1999). Such an approach is consistent with the public health concept of
primary health care, and accords closely with the views of some Maori (Russell et al.,
2003). Feek (1998) suggests the allocation of health resources in integrated care is an
important ethical issue, and it becomes even more complex when social services and
providers in sectors other than health are included. Changes to the New Zealand
Public Health and Disability Act 1999 resulted in the development of national
strategies including the PHC Strategy, which signposted a way to improve the primary
health care of New Zealanders and was accompanied by structural reforms. District
health boards and primary health organisations (see p. 82) were established (see
Appendix 2), building on the strengths of earlier integrated care developments, which
108
had encouraged intersectoral collaboration and in particular, health provider
partnerships.
5.4.3
Types of integrated care
The direction of organisational relationships across and within sectors has been
differentiated as either vertical or horizontal (Shortell, Gillies, Anderson, Erickson, &
Mitchell, 1996). Vertical integration occurs between organisations in different sectors
such as general practice (primary) and the hospital (secondary).
In contrast,
horizontal integration occurs between organisations within the same sector, such as
general practice and other primary health care organisations. Both horizontal and
vertical integration were promoted by the Health Funding Authority (1998) as a
means of reducing the fragmentation of services by improving collaboration and
coordination between providers. Critics such as Anderson (1998) however, suggest
viewing integrated care in this way is not useful because it is constrained by primary
and secondary care boundaries.
Anderson’s interpretation attributes considerable
weight to a description that has sought only to define the direction of the relationship.
In addition to the idea of vertical and horizontal integration, Shortell et al. (1996)
described three components of integrated care - functional, physician-system, and
clinical, maintaining all were important.
Functional integration referred to
organisations having shared systems, such as, information, financial management, and
quality, and also engaging in strategic planning.
Physician-system integration
referred to the need for physicians to be actively involved in the planning,
management, and governance of integrated care, and clinical integration referred to
the coordination of health services delivered by provider organisations to clients. The
three components define ways of ‘doing’ integrated care and can relate to both
vertical and horizontal integration, allowing a fuller description of integrated care to
be ascertained in differing contexts.
109
5.4.4
Strategies for integrated care
A range of strategies for promoting integrated care were advocated, with collaboration
the most widely discussed overarching strategy (Health Funding Authority, 1998).
Specifically, strategies of case management and guideline development were
encouraged and promulgated as a means of achieving integrated care by the Health
Funding Authority.
Literature relating to these key ideas is outlined in sections
5.4.4.1 to 5.4.4.3.
5.4.4.1
Collaboration
Collaboration commits more than one person or organisation to achieve a common
purpose through enhancing the capacity of one or more people or organisations to
promote and protect health (Henneman, Lee, & Cohen, 1995). Promoted as a strategy
for integrated care (Health Funding Authority, 1998), collaboration was tested in the
early 1990s by Independent Practitioner Associations. Woods (2001) observed,
New Zealand GPs who participate in associations of independent practitioners
have had budgets for an expanded range of services devolved to them….the
trick appears to be to develop an approach that builds on professional
relationships by progressively extending the influence of primary care
practitioners over other parts of the health care system as reward for
demonstrable competence in their discharge of increased management and
financial autonomy (p. 9).
Malcolm (1997) suggests “professional incentives, based on collaboration, can be
much more effective than market and commercial incentives in modifying
professional behaviour…” (p. 4).
Integrated care presented an opportunity for
medical clinicians to develop professional relationships in the interests of longer term
clinical outcomes, and the devolution of services benefited general practice physicians
110
financially without any loss incurred by hospital clinicians who were generally on
salaries.
By contrast, there have not been professional incentives based on collaboration for the
expansion of nurses’ practice, which also has the ability to influence clinical
outcomes. Within the primary sector, (practice) nurses roles have been described as
assistive and compensatory (to general practice physicians) with limitations to the
access of resources, physical workspace, and postgraduate education, preventing their
potential contribution (College of Nurses Aotearoa (NZ) Inc., 2001).
Although
collaboration between general practice physicians and nurses is critical to the success
of primary health care teams, nurses have not been supported by general practice
physician colleagues to contribute at a governance level influencing funding and
service delivery.
5.4.4.2
Case management
The Minnesota Department of Health (2001) contend that “case management
optimises self-care capabilities of individuals and families and the capacity of systems
and communities to coordinate and provide services” (p. 93). Case management has
similarly been defined as a “purposeful interaction coordinated among multiple
providers and vendors with the intention of meeting the client’s needs effectively”
(Weil & Karls, 1985, p. 123).
Numerous case management models are described in literature relating to social
services, health care, and nursing (Brault & Kissinger, 1991; DeSimone, 1988;
Papenhausen, 1990; Weil & Karls, 1985). Two common case management models
are the ‘brokerage model’ and the ‘clinical case management model’. Facilitating
access, brokering, and coordinating services are features of the brokerage model,
emphasising the “coordination and organisation of services for clients” (Kanter, 1989,
p. 114). The term care management rather than case management is used by the
British Social Services with regard to the brokerage model (Burns, 1997). Providing
clinical care and delegating and supervising other nurses with clinical care are
features of a clinical case management model, which follow the ‘Assertive
111
Community Treatment (ACT) model’ emphasising assertive outreach (Stein & Test,
1980). Assertive outreach involves the case manager maintaining contact with the
client over the long-term (Ford, Beadsmoore, Ryan, Repper, & Mattmuijen, 1995) and
there is wide consensus that all models should include this element. Maurin (1990)
maintains “that assertive outreach helps clients to achieve maximum levels of
functioning in the least restrictive settings” (p. 115). Marshall, Gray, Lockwood and
Green (1998) noted the ACT model utilised multidisciplinary case management teams
that provided interventions in the community and clients homes, held case loads of 10
- 15 clients, and the team undertook most of the interventions as opposed to referring
onto other services.
There is mounting evidence of clinical case management models being more effective
than the brokerage type of model in maintaining a client’s health in a primary health
care setting (Thomas & Lovell, 1999). The clinical case management model overlaps
with certain aspects of other models, such as, the development of an individual’s
strengths (Modrcin, Rapp, & Poertner, 1988), rehabilitation, medication management
and social skills (Goering, Wasylenki, Farkas, Lancee, & Ballantyne, 1988), or the
coordination of services (Kanter, 1989). Marshall et al. (1998) in reviewing case
management found the ACT model was the only model to have been used as an
alternative to acute hospital admissions.
Hospitalisation as an outcome measure has received criticism (Bachrach, 1982), but
remains the most frequently reported variable. Other variables include economic
analysis, symptom reduction, compliance with medication, quality of life measures,
and social functioning, which have been more difficult to compare across studies due
to the differences in client groups, methodology, case loads, assessment tools, period
of follow-up and case management models (Thomas & Lovell, 1999).
5.4.4.3
Guideline development
Clinical or practice guidelines, pathways, care maps and protocols are referred to
collectively as guidelines. Guidelines can be statements that assist practitioners and
112
clients make decisions about health care in specific clinical circumstances or can be
detailed information on health care provision to assist client journeys. Guidelines
cover a variety of topics including treatment, prevention and screening, and provide
physicians, nurses, other health professionals, and clients with a resource for
obtaining information on clinical practices. Jensen and Koerner (1999) suggest
As hospital-based care moves into the community, longitudinal clinical
pathways, with greater emphasis on health maintenance and self-care of
chronic conditions, help to focus attention on longitudinal outcomes. In the
future, visual trajectories from these outcomes may be consumer-friendly tools
to help client-provider partnerships to understand and manage self-care and
health maintenance (pp. 154-155).
Nurses were found to champion integrated care pathways, viewing them as a tool to
assist clinicians achieve a balance between the “clinical and resource dimensions of
care and between the requirements of both clinical autonomy and transparent
accountability” (p. 651) in a recent cross-national survey of 3065 healthcare
professional’s attitudes to health reforms (Degeling, Maxwell, Kennedy, & Coyle,
2003). This seminal study found that nurse managers and nurse clinicians in four
countries, including New Zealand, held systematised conceptions of clinical work,
and supported multidisciplinary team based systems. This was in contrast to medical
managers and medical clinicians who favoured individualist conceptions of clinical
work and opposed multidisciplinary teams. Nurses, rather than doctors perceived
guideline development as valuable in guiding practice decisions.
5.4.5
Implications of integrated care for Maori
Jansen (1998) argues that the Treaty of Waitangi and subsequent Crown legislation
established a framework for the response of providers to the Maori dimension of
every (health) issue. In the case of integrated care this infers the Crown, or its agent
the Health Funding Authority, is obliged to ensure Maori benefit, and Maori
expectation is met, such as, the planning and provision of integrated care by Maori for
113
Maori (rangatiratanga - authority over their own affairs). As Durie (1998) suggests
“central to the notion of Maori health is Maori control” (p. 1). The Health Funding
Authority’s obligation to actively protect Maori interests and improve health status
relates to the Treaty guarantee of equality and equity between Maori and other New
Zealanders.
For the period 1999-200247, a New Zealand government goal for Maori development
was extending “economic and social opportunities by significantly improving the
health, employment, education and housing status of Maori” (Ministry of Maori
Development, 1999, p. 12). Integrated care was an opportunity for Maori provider
organisations (MPOs) to address Maori/non-Maori disparities. Kiro (1997) suggests
however, that there are also increasing inequalities among Iwi (tribes) that effect
Maori health. The funding by government of integrated care raises issues about the
way in which Maori health policy reflects other government processes for Treaty
settlement with Maori, where dominant views of Iwi and Maori have been reinforced.
Kiro strongly contends that these views can lead to a rigid policy approach that
continues to disadvantage Maori48 most in need of help.
Kelsey (1993) asserts that at the time of integrated care, the National Government’s
social policies reflected underlying assumptions about: the need for government to get
out of delivering social services, including health; the inherent superiority of market
mechanisms for promoting efficiency and effectiveness; the need to reinforce
individual responsibility (and family responsibility), and the need to reinforce the
nuclear family as basic unit for social support. Commonly referred to as ‘New Right’,
this thinking resembles some of the mechanisms utilised by Maori seeking
rangatiratanga.
A convergence of interest between Iwi Maori, and Government
seemed apparent in the conceptualisation of integrated care (see p. 17, hypothesis 7),
which sought to test the notion of by Maori for Maori.
However, Kiro (1997)
maintains the key disagreement was the extent and means to which the Health
Funding Authority made provision for Maori health.
47
This timeframe coincided with the recruitment period of the NICPS, December 1999 to February
2001.
48
Pan tribal Maori who live in poor urban areas are a population that is often disadvantaged.
114
Integrated care was never fully embraced because its potential benefits were offset by
arguments (within Maori) that it was another way of cutting costs and marginalising
Maori based on a strategy that was set to fail (Wano, 2003). Many Maori providers
associated integrated care with a capitation-based payment system and were cautious
of agreeing to manage a defined Maori population’s health with very restricted
funding. Jansen (1998) maintained integrated care purchased in this way would drive
providers to focus on disease management because this approach could be assessed in
relation to specified outcomes, limiting the financial risk to providers.
Whilst numerous risks were identified, integrated care also presented prospects
operationally for Maori providers such as, investing in information technology,
standardising data, and developing patient management systems. New agreements
with partners were considered when they enabled for example, discount benefits from
bulk purchasing (Wano, 2003). Integrated care required collaboration, which often
led to a change in organisational structure. Agreeing on the structure and legal entity
for an integrated care organisation, and in some cases deciding on the shareholder or
owner of the entity posed difficulties.
Wano contends that a critical factor in
developing integrated care was the lack of a clear funding path in which to develop
the capacity and infrastructure of an integrated care entity. There were significant
risks for many Maori health providers as they were relatively immature49 from an
organisational development perspective, despite the potential benefits that collective
provider arrangements can bring.
With the development of organisational structures and processes, such as patient
management systems, many Maori provider organisations were better able to contract
with the purchaser to provide disease management services.
In general, disease
management approaches have an individual biomedical orientation, which can
conflict with Maori perspectives of health that embrace family, mental, social, bodily,
and spiritual well-being (Durie, 1998). A Maori view of health incorporates overall
Iwi development and relationships to the environment and is more than an
aggregation of individual health (Durie, 1985). Iwi-based health providers delivering
49
Maori health development came into focus during the 1990s, and Maori health providers grew from
20 in 1993 to more than 220 by the end of the decade (Ministry of Health, 2002c).
115
kaupapa (agenda) Maori services require a broad, inclusive integrated care approach
even though this means greater financial risk.
This broad inclusive integrated care approach was demonstrated in the Aboriginal
coordinated care trials50 in Australia.
The Aboriginal coordinated care trials
demonstrated a positive or well-health focus, and included prevention and health
promotion. It is difficult to say with any certainty why this occurred, although one
factor of influence is an Aboriginal view of health that stresses the wider physical,
social and spiritual environment (Saggers & Gray, 1991), a perspective common to
other first nation people such as Maori. However, it was predicted (Jansen, 1998) that
Maori integrated care projects, like the majority of non-aboriginal Australian trials
studied (Baum, 1998) would adopt a focus on people with common diseases and
medical management (Baum, 1998). This prediction was based on the belief that
Maori provider organisations would have to specify the integrated care services
provided and those services would demonstrate clinical outputs relating to disease
management, as this had been the experience of Maori providers when holding other
health contracts. Integrated care projects that were narrowly defined were easier to
cost and Maori provider organisations had to manage financial risk for economic
survival. Uncertain financial risk prevented wider integrated care experimentation
despite Maori provider organisations understanding the philosophical and cultural
parameters that also influence health status (Durie, 1998).
5.5
New Zealand integrated care demonstration pilot projects
5.5.1
Conceptual development
The conceptualisation and subsequent implementation of integrated care in New
Zealand is clearly illustrated in the development of the national demonstration pilot
projects.
This provides a useful context for situating the NICPS.
The general
objective of the demonstration projects was to test whether integrated care made a
50
Coordinated care trials in Australia paralleled integrated care in New Zealand with regard to the
development of ‘chains of care’.
116
difference in the provision of cost-effective health and disability support services that
improved health and independence of New Zealanders (Health Funding Authority,
1998). The demonstration projects sought to test a range of models, although the
selection of projects was based upon the ability of an organisation to provide four core
competencies considered by the Health Funding Authority as essential for integrated
care.
These competencies were: service management and coordination; provider
coordination through appropriate incentives; accountability to community, providers
and purchasers, and continuous quality improvement.
Demonstration projects were seen as an opportunity to learn about aspects of
integrated care such as costs, benefits and risks (Transitional Health Authority, 1997).
Guidelines for projects outlined eight hypotheses that tested the strategy of integrated
care (Health Funding Authority, 1998). These were:
1. Decision making guidelines for service provision improve health outcomes
and are cost-effective;
2. Contracting strategies that align incentives and promote collaboration across
traditional service boundaries improve health outcomes and are cost-effective;
3. Integrating service delivery is dependent upon integrating funding streams;
4. Budget responsibility for a wide range of primary care services improves
health outcomes and is cost-effective;
5. Budget responsibility for a specified bundle of services (e.g., mental health or
disease states such as asthma or diabetes) improves health outcomes and is
cost- effective;
6. Budget responsibility for a full range of services improves health outcomes
and is cost-effective;
7. Integrated services networks run by Maori for Maori are more effective and
efficient in contributing to improved health outcomes than mainstream
integrated service networks, and
117
8. Consumers who make a choice about health service options have improved
health outcomes and make more cost-effective choices.
In addition, health and independence gain targets for integrated care projects were
outlined. Various integrated care strategies became the intervention to be evaluated
relative to the hypothesis being tested. The following example was provided.
A ‘by Maori for Maori’ organisation forms relationships with a primary health care group and a
Crown Health Enterprise (CHE) to integrate services in a region with 50,000 people. They
want to create an integrated service network and apply for and become a national
demonstration project. For the first 24 months of their development project they decide to test
the following hypothesis:
Integrated service networks run by Maori for Maori are more effective and efficient in
contributing to improved health outcomes than mainstream integrated service networks.
They select their priority population: Maori diagnosed with diabetes.
They specify the national health and independence gain goal: To reduce the agestandardised diabetes mortality rate among Maori to 30 per 100,000 or less by the year 2002.
They specify their health and independence indicator targets for the demonstration period.
For example:
Improve control of blood glucose levels by x% in year 1 and y% in year 2
Improve control of serum lipid levels by x% in year 1 and y% in year 2
Improve control of blood pressure levels by x% in year 1 and y% in year 2
From: “Service Integration: Guidelines for the development of integration demonstration projects,” by The Health Funding
Authority, 1998, p. 10.
5.5.2
Potential risks in integrated care
Some of the potential risks in undertaking integrated care were identified by the
Transitional Health Authority (see p. 119, Table 6). The purpose of undertaking
demonstration projects was to explore, and ultimately manage these risks. Nine
integrated care demonstration pilot projects were selected, funded and evaluated,
118
whilst other integrated care projects developed simultaneously, but from the
grassroots, initiated by providers.
Table 6: Risks
Conceptual
risk
1. Potential gains from integrated care are not pursued effectively due to
insufficient incentives and there is no large improvement in the status
quo.
2. The costs of change could outweigh the gains. The resulting noise
surrounding the large shifts for the providers, such as loss of
autonomy, reduction in income for some, loss of employment for poor
quality practitioners, reductions in staff at hospitals and large hospital
reconfigurations driven from changes in referral behaviour, may create
an expensive resistance to change.
3. Providers forming large monopolies, particularly by vertically integrating
with Crown Health Enterprises (CHEs), resisting releasing surpluses to
consumers and wide-scale bilateral negotiation problems developing of
the sort experienced with the CHEs and Regional Health Authorities
(RHAs) in recent years.
4. Labour market and occupational regulation constraints on the supply of
health professionals impeding progress.
5. Consumer resistance from provider choice being constrained by
integrated care organisations (ICOs) or consumer resistance to having
to choose an ICO and be enrolled.
Implementation
risk
1. The capacity of the Transitional Health Authority (THA) / Health
Funding Authority (HFA) and providers to undertake integrated care
arrangements.
2. Resistance from providers to engage in proposals that are not as
favourable to them in the long term as current arrangements, such as
general practice physicians on fee-for-service for general medical
subsidy payments.
3. The lack of ability to deal adequately with the large scale proposals
which are not well developed but have considerable traction in
communities or in the political arena.
4. The ability of the THA to cancel the pilots if they do not succeed.
From “Discussion paper on integrated care”, by The Transitional Health Authority, 1997.
5.5.3
Implementation: What actually happened?
The Health Funding Authority identified two types of integrated care proposals,
existing projects that had already received contracts, and new projects. Eighteen
demonstration projects were then selected that varied greatly in size, scope and
intention.
Three projects were intended to focus on child and youth services.
119
Eventually, however eleven projects were finally selected and two of these did not
proceed as demonstration projects. One project, ‘South Auckland chronic obstructive
pulmonary disease’51 developed as an integrated care project independent of the
demonstration projects, after partners decided against compromising the project’s
design.
The second, ‘Women’s reproductive health in Tairawhiti’ was never
implemented.
Of the final nine demonstration projects the Health Funding Authority was unable to
prove the majority of the hypotheses (see pp. 117-118) because they did not undertake
integrated care in the way that had been conceptualised. For example, four of the
eight hypotheses referred to budget responsibility or funding mechanisms, but
demonstration projects did not hold budgets as had been originally intended. The
Health Funding Authority decided against experimenting with this type of funding
arrangement. Similarly, all projects selected were mainstream (did not have a specific
ethnic focus), which precluded the seventh hypothesis that related to integrated care
for Maori by Maori being tested. A brief description of the nine integrated care
demonstration pilot projects that were implemented is reported in Table 7 (see pp.
121-122).
51
The South Auckland chronic obstructive pulmonary disease (COPD) project successfully achieved a
number of positive health outcomes with partners contributing financially to the projects sustainability.
120
Table 7: Integrated care demonstration pilot projects
New Traditions
Hamilton ($150,000)
Diabetes Management
Mangere ($125,000+$36,000)
Diabetes Management
North Habour ($172,000)
($150,000 funded earlier project
work)
Family/Whanau Support Service
of Westkids Limited
West Auckland ($373,350)
Eldercare Canterbury
Christchurch ($450,000)
Development of an integrated network to provide
health care to children (0-14) within the Hamilton area
by: improving communication and coordination of
services between primary and secondary sectors;
developing best practice standards within secondary
services; improving case-coordination for children with
comprehensive health needs; improving data quality
on child mortality and morbidity rates to inform future
service provision, and identifying health needs and
health care services.
Integrated care for clients of the Mangere Health
Centre with diabetes, this project built on earlier project
work with a public health and health promotion
emphasis. Integrated care focused on the use of care
pathways, referral protocols, best practice guidelines,
information sharing between providers, and
establishing a diabetes register. A new diabetes care
coordination service was also established and a
randomized controlled trial of this service was
conducted with clients (n=177) participating. The
intervention group received education, support, and
help with diabetes when home visits were provided.
Integrated care for clients (n=2092) with diabetes
registered with Comprehensive Health Services (IPA)
in the North Habour area. This project built on an
earlier diabetes project work. Integrated care focused
on: developing relationships between clients and
providers, including Maori; implementing a clinical
pathway and referral guidelines; establishing
(diabetes) registers and audits; training general
practice physicians and practice nurses in diabetes
management to enable more complex care to be
undertaken in the primary sector and by practice
nurses.
‘Westkids’ is an integrated care organisation of all
major primary and secondary providers in West
Auckland, including Maori providers and Pacific
providers. Westkids approach to integrated care in
one service, the Family/Whanau Support Service,
which provides a community health worker service for
sick children (0-17) and their families in need. This
project included: conducting research on service users
(429 case studies on children and families), developing
a new service, use of care pathways, and developing
new partnerships at both governance and operational
levels.
‘Eldercare’ comprised a number of primary, secondary
and tertiary care providers who collaborated and
explored ways of integrating funding and improving
services for older people (75+) in the areas of: hip
fracture, stroke, and acute confusion. Generic projects
arose out the three areas, such as, discharge planning,
ongoing care in the community, health and home
services, co-ordination of services to the elderly, and
others with a health promotion component.
121
Congestive Heart Failure
Christchurch ($59,800 and funding
from another source)
Kaipara Care Incorporated
Dargaville ($65,000 initially)
ProCare Paediatric Asthma
Auckland ($581,407)
Mental Health Integration
Taskforce
Auckland ($282,626)
A collaborative trial (n=202) that built on earlier project
work and tested: the use of best practice guidelines for
cardiac failure treatment, and integrated care. The
integrated care approach was client-centered and care
was shifted from the secondary (hospital) sector to the
primary (general practice) sector. Primary care
providers gained access to specialist secondary care
advice, mobile echocardiograms, and home visits for
clients from a specialist (cardiac) nurse.
Development of an integrated network of providers
(general practice physicians, nurses, pharmacists) in
Northland who enrolled and case managed the care of
people with diabetes, childhood asthma (under 14
years of age) and the frail elderly, in a rural bicultural
environment. Activities included: developing clinical
pathways, adapting and utilising diabetes guidelines,
and establishing a database of the enrolled population.
Integration of paediatric (2-15 years of age) asthma
care between general practice and hospital services
was tested by conducting a randomized controlled trial.
A clinical pathway and guidelines were developed and
ProCare general practice physicians were assigned to
either the intervention (trained on the use of the
guideline) or control (usual asthma care) group.
Participants (n=1200) completed a self-administered
questionnaire. The aim was to implement a clinical
pathway and guideline in general practice and reduce
acute episodes of asthma needing hospitalisation.
A randomized controlled trial compared the
effectiveness of ‘liaison attachment shared care’ with
existing models of community mental health care for
clients with serious / long-term mental health problems.
The intervention used guidelines and a clinical
pathway for care managed by a team that included a
general practice physician, specialist mental health
nurse and medical specialist. This contrasted with the
existing model of care in which discharged clients have
little or no contact with the general practice physician
and no access to specialist mental health nurses.
122
5.5.4
Evaluation findings
An evaluation was planned along the lines broadly described in intensive evaluation
briefs prepared for each project by KPMG Consulting52 in 1998. The election in 1999
of a Labour (centre-left) government appeared to lessen the political interest in
integrated care and the Health Funding Authority contracted the Health Services
Research Centre (HSRC), Victoria University, Wellington, instead to conduct a
process evaluation of each demonstration project. The HSRC evaluators contended
the evaluation was subject to a number of constraints. Apart from being unable to test
all hypotheses, the evaluation occurred well after projects had begun, precluding the
collection of baseline data and ongoing systematic data. An economic evaluation
could not be undertaken because quantitative economic data was not available.
In
addition, some projects did not collect data, or were unwilling to provide data (Russell
et al., 2003).
In designing individual project evaluation briefs, the HSRC evaluators considered:
project aims; project approach to integration; measures of success as perceived by
project personnel and the Health Funding Authority, and the eight hypotheses
identified by the Health Funding Authority to test integrated care. Overall, the results
of the evaluation were mixed. Most projects could only be assessed on a small
number of stated hypotheses, and the approaches to integration varied considerably.
A number of these projects were self-evaluated. Aspects evaluated depended upon
perceived relevance by stakeholders, project capability, and the available resource.
All projects were expected to align with the Health Funding Authority’s commitment
to the Treaty of Waitangi, and evidence of the implementation of Treaty principles
was assessed.
During the evaluation process the evaluators developed a model of integrated care as a
guide to assessing integration. The models key concepts included: cooperation and
collaboration; Treaty of Waitangi; tools or rules for implementing integration;
implementing actions; outcomes of implemented actions, and evaluation (Health
52
KPMG Consulting was also involved in the evaluation of Coordinated Care Trials in Australia.
123
Services Research Centre & Te Ropu Rangahau Hauora a Eru Pomare, 2001). These
concepts were evaluated to varying degrees in the nine demonstrate project evaluation
reports. Overall, the following key findings and project examples were identified:
1. Successful integrated care projects worked on cultural and attitudinal change
with providers.
New Traditions, Eldercare Canterbury and Kaipara Care
projects used an integrated approach and processes, and projects focusing
mainly on implementing guidelines were less well integrated.
2. North Harbour Diabetes Management, Kaipara Care, New Traditions and
Westkids showed a strong commitment to the Treaty of Waitangi and
supported a bicultural service, responsive to Maori. These projects placed
importance on formal agreements and developed focused objectives. The
remaining five projects were at varying stages of relationship building.
3. Relationships were enacted or formalised around ‘tools or rules’ such as, bestpractice guidelines, clinical guidelines, referral protocols or care pathways,
new information systems and new services.
4. Self-evaluation was a high priority in many of the projects. Congestive Heart
Failure, Mangere Diabetes Management, ProCare Paediatric Asthma, and the
Mental Health Integration Taskforce conducted trials to assess progress. Some
projects incorporated, for example, before-and-after measures to assess the
impact of integrated care on diabetes. Some projects lacked the mechanisms
or expertise to assess their own work, and external evaluation consultants were
contracted by Kaipara Care and Eldercare Canterbury.
5. Data were insufficient to assess whether integrated care results in cost savings
or better cost-effectiveness, and improved health outcomes outweigh cost
increases.
124
5.6
In conclusion
Overall, integrated care demonstration projects did not prove the majority of
hypotheses set by the Health Funding Authority. The hypotheses were clearly too
ambitious for the majority of projects, as five of the eight hypotheses were unable to
be tested due to the design of projects.
The integrated care demonstration projects that were implemented did not hold budget
responsibility for a range of services, and were not reliant upon contracting strategies
to gain incentives, promote collaboration, or integrate funding. The cost effectiveness
of new ways of purchasing or providing services could not be ascertained and
sufficient data were not collected to access if integrated care improved health
outcomes. Service networks for Maori by Maori were also not tested to determine
improved effectiveness compared with mainstream approaches.
Interestingly, the
South Auckland COPD project that did not continue as a demonstration pilot held a
budget and successfully produced clinical and financial outcome data (Rea et al.,
2004).
The Health Funding Authority’s initial intentions, evidenced by the
hypotheses, were retrenched not only because projects were unable to test the
hypotheses, but also because the Health Funding Authority perceived some risks, such
as providers creating large monopolies, were too great.
Integrated care demonstration pilot projects, however, established the foundations for
developing more comprehensive primary health care by starting to change the culture
and attitudes relating to working together across sectors and building relationships.
The development of guidelines and information systems were tangible activities that
offered opportunities for collaboration with financial benefits.
During the time of the pilot projects, district health boards were maturing and most
were carrying considerable debt. Little additional financial support for integrated care
was available outside of the demonstration project funding restricting the scope of the
evaluation. Consequently, the roles of health professionals such as nurses were not
125
assessed. Nurses participated in all pilot projects, and little data exists to define their
roles within pilot projects.
Chapter six outlines the methods for studying integrated care projects that include the
nine demonstration pilots, in order that nurses’ practice can be assessed.
The
importance of such research is to identify how best to develop more effective and
predictive primary health care nursing practice for the future. Information of this
nature can inform funding strategies, which impact directly upon health care and
service provision.
126
6
6.1
Chapter 6
Methods: Nurses in integrated care projects study
Introduction
In New Zealand integrated care was considered a major public sector reform strategy
initiated from central government (Wells, 1998) that engaged health professionals,
including nurses, in efforts to improve primary health care services. Demonstration
pilot projects tested innovations in integrated care (Health Funding Authority, 1998).
Non-demonstration integrated care projects also evolved directing attention to the
provision of health care services in the primary sector. This chapter outlines the New
Zealand NICPS (Nurses in integrated care projects study). The aim of the study was
to determine the practice of nurses in integrated care projects in New Zealand from
1999 to early 2001. The characteristics of integrated care projects are described to
create a context within which nurses’ practice can be situated. Nurses’ practice is
assessed to determine the range of interventions and related levels of population-based
practice nurses routinely undertake before the health promotion values embedded
within this practice are identified. This special-purpose study employed a quantitative
non-experimental survey design as the strategy of inquiry. The philosophical basis of
the research was postpositivism.
The survey design was chosen because it allowed a quantitative or numeric
description of the characteristics of integrated care projects for the purpose of
identifying the practice of nurses. By studying nurses in integrated care projects,
generalisations can be made about this sample population that can be extrapolated
more widely to primary health care nursing. A survey questionnaire was used for data
collection. In recent times, the survey has become the most commonly used method
of data collection in public health research because descriptive data can establish
meaning by contrasting, comparing, or identifying relationships (Creswell, 2003).
The descriptive survey, like the experiment, can also identify a sample and generalise
to a population, but does not seek to test the impact of a treatment on an outcome, as
in an experiment (Keppel, 1991).
127
The NICPS examined integrated care project characteristics in an attempt to identify
factors that could potentially impact on the practice of nurses in projects.
The
following variables were investigated: organisational structure; funding; type of
service integration; strategies for integration; project approach to level of populationbased practice; age group targeted; ethnic group targeted; low income group targeted;
health or disease/condition focus targeted; practice of non-nursing personnel, and the
practice of nurses. Two frameworks, the ‘Public health intervention wheel’ and
‘Beattie’s model of health promotion’ were used to analyse nurses’ practice. The
former provided a standard against which to assess the range of interventions and the
related levels of population-based practice undertaken by all nurses in projects, whilst
the latter illustrated the health promotion values inherent within these interventions.
The chapter has three distinct components: section 6.2 research questions; section 6.3
framework for the study design, and section 6.4 study methods.
6.2
Research questions
Survey data on 80 New Zealand integrated care projects and the practice of nurses in
projects was collected and analysed to answer the following research questions:
1. 1. Which characteristics of integrated care are more strongly associated with
projects that employ53 nurses?
2. What types of population-based interventions were undertaken by nurses in
integrated care projects?
3. What population-based levels of practice (individual-focused, communityfocused, and systems-focused) did nurses demonstrate in integrated care
projects?
4. What underlying values are made explicit when interventions undertaken by
nurses are analysed?
53
The term ‘employ’ in this thesis means to ‘provide work for’.
128
The NICPS used these research questions to shape the study. The first question
investigated ten characteristics or variables of integrated care to determine the context
within which nurses practiced. These are:
1. organisational structure
2. funding
3. type of service integration
4. strategies for integration
5. population-based level/s of approach
6. age group targeted
7. ethnic group targeted
8. low income group targeted
9. health or disease/condition targeted
10. non-nursing personnel
The second and third questions sought to determine the range of interventions
undertaken by nurses, and the extent nurses intervened with communities, the systems
that impacted on the health of communities, and/or the individuals and families that
comprised communities. The third question applied a theory as a standard against
which to measure underlying health promotion values apparent in the practice of
nurses in integrated care projects. Collectively, the four research questions sought to
describe the practice and values of nurses in integrated care projects.
6.3
A framework for the study design
Since many different research approaches are available to investigators, a general
framework was adopted to guide the research process (see p. 130, Figure 7).
Preliminary steps in designing this study included: assessing the knowledge claims
brought to the study, considering the strategy of inquiry to be used, and identifying
specific methods.
129
Elements of inquiry
Alternative knowledge claims
Approaches to research
Design processes
of research
Qualitative
Quantitative
Mixed Methods
Strategies of inquiry
Questions
Translated
into practice
Conceptualised
By the researcher
Methods
Theoretical lens
Data collection
Data analysis
Write up
Validation
Figure 7: Knowledge claims, strategies of inquiry, and methods leading to
approaches and the design process
From “Research design: Qualitative, quantitative, and mixed methods approaches” by J.W. Creswell, 2003, p.5. Copyright 2003
by Sage Publications: California. Reprinted with permission of the author.
Three specific questions developed by Creswell (2003) were considered in relation to
the NICPS and established the basis of the study design. They are:
1. What knowledge claims54 were made by the researcher?
The NICPS adheres to the major elements of postpositivism55.
This position
challenges the traditional notion of absolute truth and knowledge (Phillips &
Burbules, 2000), recognising that it is not possible to be ‘positive’ about claims of
knowledge when studying the practice of nurses.
Postpositivism reflects a
deterministic philosophy therefore the problems studied examine issues that influence
outcomes, such as the approach taken to health promotion and the practice of nurses.
It is also reductionist because broader concepts are reduced to ideas that can be tested,
such as the research questions. Knowledge developed through a postpositivist lens is
based on the measurement of objective reality, such as the interventions of nurses in
projects. Recording numeric measures of the practice of nurses was essential. The
approach began with the theory of health promotion, and was followed by the
54
Knowledge claims have been referred to as paradigms (Lincoln & Guba, 2000; Mertens, 1998);
philosophical assumptions, epistemologies, and ontologies (Crotty, 1998), or broadly conceived
research methodologies (W. Neuman, 2000).
55
Postpositivism is often called quantitative research, positivist/postpositivist and empirical science.
130
collection of data on the practice of nurses. The theory provided the standard against
which practice was examined.
The process was about making claims and then
refining or abandoning some of them for other claims more strongly warranted.
Information was collected using a survey instrument based on measures obtained from
participants. The study sought to develop true statements that could explain the
relationships of interest, posed in terms of research questions.
Objectivity was
necessary to the inquiry, with methods and conclusions examined for bias. Standards
of validity and reliability were important.
2. What strategies of inquiry inform the procedures?
The NICPS employed a quantitative research design as the strategy of inquiry.
Traditionally, strategies of inquiry associated with quantitative research were those
that invoked the postpositivist perspectives56. More recently quantitative strategies
have involved surveys that seek to address more complex problems, such as those
raised in the NICPS. In the present study a telephone interview was used for data
collection. The intent was to generalise the findings of the practice of nurses in
integrated care projects to primary health care nursing more widely.
3. What methods of data collection and analysis were used?
Study data were collected using a predetermined instrument based on questions.
Performance data and attitudinal data were statistically analysed. These practices are
consistent with accepted quantitative research methods (Creswell, 2003, p. 17).
The knowledge claims, the strategies, and the methods contribute to the overall
research approach, which tends to be more quantitative.
The research approach for
the NICPS is described in Table 8 (see p. 132).
56
These include true experiments, quasi-experiments and correlational studies (D. Campbell &
Stanley, 1963), and specific single subject experiments (Cooper, Heron, & Heward, 1987; S. Neuman
& McCormick, 1995).
131
Table 8: Research approach to the Nurses in Integrated Care Projects Study
Knowledge Claims
Strategy of Inquiry
Pre-determined
Quantitative
Postpositivism
Determinism
Reductionism
Methods
Non-experimental design:
Survey
Instrument based questions
Statistical analysis
Empirical measurement
Theory verification
6.3.1
Quantitative and descriptive: The survey
The present quantitative study is descriptive and cross-sectional. Descriptive crosssectional surveys can occur at a fixed point in time or within a specific timeframe
(Hennekens & Buring, 1987), like the present study. Descriptive studies provide an
account of the characteristics of individuals, groups, organisations, and situations for
the purpose of discovering new meaning. Such studies describe what exists, the
frequency of occurrences, and categorise information. Descriptive research can be
classified as exploratory in that a process of discovery underpins the research
enterprise.
From data generated through the process of discovery, meaning is
ascribed and interpreted, allowing for the identification of concepts and themes
associated with the phenomena under study.
Hopkins (1980) maintains that a
descriptive study is particularly appropriate when, as in the present study, the
interaction of a number of independent variables, such as ‘organisational structure’ or
‘low income targeted’, and their effects on one dependent variable, the ‘practice of
nurses’ is investigated. The NICPS had two distinct intentions. The first was to
provide data about the practice of nurses within an integrated care environment and
the second, to establish meaning by contrasting, comparing or identifying
relationships. Hopkins maintains that commonly the first phase is purely descriptive,
while in the second phase correlational techniques are used, resulting in knowledge
that is generalisable.
132
The survey was selected because this strategy allows the collection of data by asking
respondent’s questions and analysing their answers for the purpose of producing
statistics. Surveys can be either mailed, delivered self-administered questionnaires, or
face-to-face surveys. Better access to certain populations is an advantage of telephone
studies (Fowler, 2002) and such surveys are also generally considered by respondents
to be less intrusive than those conducted face-to-face (Robson, 1993). The survey can
enable comprehensive information to be obtained, obvious misunderstandings to be
corrected during interview, and the use of probes to gain fuller answers to survey
questions. The survey enables the meaning of a question or any other aspect of the
questionnaire to be clarified. Bradburn & Sudman (1979) contend rapport can be
more difficult to achieve in telephone surveying compared with face-to-face
surveying, although this can be compensated for by smaller interviewer effects and a
lower tendency towards socially desirable responses.
Overall, the survey was
recognised as a strategy of inquiry that from a single source of data could provide new
insights into the complexity of health service provision and primary health care
nursing practice.
6.4
Study Methods
6.4.1
6.4.1.1
Study population
Eligibility
The unit of inquiry in the NICPS was the integrated care project. Integrated care
projects were classified as two or more New Zealand organisations57 that agreed to
plan and/or implement integrated care in the interests of improving the health of
identified individuals and populations. In the study integrated care “refers to the
methods and type of organisation which will provide the most cost effective
preventative and caring services to those with the greatest health needs and which will
ensure continuity of care and coordination between different services” (Ovretveit,
1998, p. 1). The inclusion criteria for the NICPS referred to New Zealand projects
57
The majority of organisations were located within the health sector.
133
defined as integrated care. Projects whose characteristics ruled them out as integrated
care were excluded. The eligibility criteria focused the survey on the provision of
accurate information about integrated care projects and the practice of nurses within
those projects.
Eighty projects met the eligibility criteria and comprised the sample population. Of
the 80 projects, the first 27 were identified from a list provided by the Ministry of
Health. Nine demonstration pilot projects were included in this initial 27. Following
up these newly identified projects resulted in a further 53 projects being identified,
and included in the overall sample. The study recruited projects between December
1999 and February 2001. The Ministry of Health appeared to be the only entity that
held a record, albeit a partial list, of the number of integrated care projects in
existence. No complete list of projects could be found.
Twenty-seven individuals, identified as holding a key role in either project planning
or implementation, were surveyed to provide data on the characteristics of the 80
projects. Some individuals provided information on several projects. Individuals
surveyed were recognised as having an overall and in-depth knowledge of projects.
6.4.1.2
Sampling
The study employed a non-probability or purposeful sampling method.
Non-
probability samples, such as integrated care projects, can be selected based on
judgements regarding the needs of the survey. Non-probability sampling has no set
rule regarding sample size. The 80 projects that met the study criteria within the
period the study had been granted ethical approval, were surveyed. Non-probability
samples do not guarantee that all eligible projects have an equal chance of being
included in the sample.
However, the follow-up of projects in the NICPS was
rigorous and painstaking, all eligible projects were included in the sample, and a 100
per cent response rate was achieved.
134
The technique snowball sampling involved individuals initially surveyed, identifying
new projects. This technique was appropriate as only a limited number of projects
were known, and expert informants with knowledge of specific projects became
resources in the discovery of new projects. With the NICPS representing projects
spread across New Zealand the sample became less vulnerable to selection bias.
6.4.1.3
Procedures for the recruitment of projects
Telephone contact was made with individuals in organisations identified as having a
lead role in projects for the purpose of verifying the project’s current status. This
inquiry revealed that some integrated care projects were in the planning phase, others
were being implemented, some existed in name only, and a number were not
eligibility for inclusion into the NICPS.
The lead organisation/s of projects
categorised as eligible were asked to identify an individual who held a key role within
the project. On several occasions two or more organisations in partnership on the
project reached agreement about who would respond to the survey. More than one
person was interviewed for some projects. This occurred in situations where key roles
were held by more than one person, and individuals had only partial knowledge. For
example, some interviewees held project roles that focused on clinical quality and best
practice, whilst others held project management roles that focused on costs and
outcomes, or information management and technology. Once identified, individuals
were contacted by telephone and their cooperation was sought by emphasising the
significance of the study and the importance of their contribution.
Following the initial contact by telephone, a letter of introduction outlining the study,
participant information sheet, and consent form were posted to individuals.
A
stamped addressed envelope was included for the return of the consent form. Ten
consent forms were received in the following week. Two non-respondents were
followed up with a phone call approximately two weeks after mailing. This group all
returned consent forms in the following week. A record was kept of participant’s
details. Upon receipt of the signed consent form, the interview questionnaire was
posted to respondents indicating the questions that would be asked in the telephone
135
interview.
Approximately one week after the posting of the questionnaire, a
telephone call was made to establish a date and time for the interview, and to answer
any questions the respondent had about this process.
From the initial twelve
telephone interviews, which obtained data on the first 27 projects, potential new
projects were also identified. The recruitment of new projects remained consistent
with the procedures adopted for the first cohort.
6.4.2
Ethical considerations
Written consent to participate was sought from all respondents prior to any
information being collected at interview. Approval by the Auckland Northern Region
Ethics Committee was granted for the conduct of the study between December 1999
and February 2001.
6.4.3
Data collection
Data were obtained on 80 integrated care projects from expert informants during a
telephone survey using a structured interview questionnaire.
Twenty-seven
interviews were conducted, which lasted between 50-65 minutes, with the average
interview taking about 60 minutes. Robson (1993) contends anything less than half
an hour is unlikely to be valuable. All respondents answered every question (item) on
the interview questionnaire (see Appendix 3). Data were collected on the respondent
and specific project characteristics. The extent of the data collected is indicated in
Table 9: Variables, research questions and items on the survey (see p. 138).
6.4.3.1
Interview questionnaire
No existing survey instrument was found that could collect data to answer the four
research questions. Instruments used to measure innovation and improvements in
performance across organisations were investigated and found unsuitable for use in
136
this study (Kaplan & Norton, 1997). This was because the present study needed
specific baseline data on the current environment and practice of nurses, which was
unknown. The information required about the practice of nurses was also specialised,
and could not be captured in non-occupational specific questions. Consequentially, a
specific instrument was developed to guide the content and structure of the interview.
Literature was extensively reviewed on public health, health reform, health
promotion, chronic conditions, integrated care, and primary health care nursing (see
chapters 2 to 5). The interview questionnaire developed as a result of frameworks and
central issues identified in the literature, expert advice, and the knowledge of the
researcher, who had a particular interest in integrated care. Experts were consulted
about the overall questionnaire design, question form and question content. As a
consequence, themes (question fields) and questions (items) were identified. The
themes selected were central to characterising the projects, became starting points for
generating specific questions, and are shown in Table 9 (see p. 138).
137
Table 9: Variables, research questions and items on the survey
Variable
Research question
Item on survey
Independent variable #1:
organisational structure
Research question #1:
Which characteristics of
integrated care are more strongly
associated with projects that
employ nurses?
See questions 8, 9, 10, 11,
12, 20, 21, 22 & 23: planning
new services, delivering
existing services differently,
health services provided,
general practice incentives,
hospital incentives, financial
incentives to project, material
incentives to clients, costs to
general practice, costs to
hospitals
Research question #2:
What types of population-based
interventions were undertaken by
nurses in integrated care
projects?
Research question #3:
What population-based levels of
practice did nurses demonstrate
in integrated care projects?
Independent variable #2:
funding
Research questions #1, #2, #3
See question 19: dedicated
funding, main funding source
Independent variable #3:
type of service
integration
Research questions #1, #2, #3
See question 5:
organisations in partnership
Independent variable #4:
strategies for integration
Research questions #1, #2, #3
See questions 6, 7 & 18:
purpose of project, measure
of achievement, project
strategies
Independent variable #5:
population-based level of
approach
Research questions #1, #2, #3
See question 17: level of
project approach
Independent variable #6:
age group targeted
Research questions #1, #2, #3
See questions 15: age
groups
Independent variable #7:
ethnic group targeted
Research questions #1, #2, #3
See questions 13: ethnic
groups, ethnic group only,
ethnic group and wider
population
Independent variable #8:
low income group
targeted
Research questions #1, #2, #3
See questions 14:
geographic area
Independent variable #9:
health, disease or
condition targeted
Research questions #1, #2, #3
See questions 16: disease,
condition, or another focus
Independent variable
#10: Practice of nonnursing personnel
Research questions #1, #2, #3
See question 24: practice of
non-nursing personnel
Dependent variable
#1: Practice of nurses
Research questions #1, #2, #3
See questions 25 and 26:
practice interventions of
nurses, levels of populationbased practice of nurses
Research question #4:
What underlying values are made
explicit when interventions
undertaken by nurses are
analysed?
138
6.4.3.2
Question form and content
In this survey, answers were of interest not intrinsically but because of their
relationship to the practice of nurses in projects, which was being measured. Most
questions were designed as measures and answers were valuable only when they
could be shown to have a predictable relationship to the area of interest, the practice
of nurses in projects. Each question attempted to maximise the relationship between
the answer recorded and what the researcher was trying to measure.
Individual
questions were assessed on their ability to uncover situational knowledge. Some
questions were discarded because they were too general and the range of
interpretation too wide, led in a particular direction, or demonstrated a bias. Finally,
from over 40 initial questions, 27 comprised the survey instrument and are presented
in a conventional58 sequence. A number of questions are complex and break down
into a set of simpler questions.
According to Fink (1995) questions take one of two primary forms. When they
require the respondent to use their own words they are called open. When they are
pre-selected for the respondent, they are called closed. The present survey used eight
open questions, 13 closed questions, and six that used a combination of both open and
closed (see p. 141, Table 10).
Several open questions appeared straightforward, like question two, “Who is your
employer?” Powney and Watts (1987) argued that simplicity is deceptive and draw
on the allegory of writing a book, in that most of us have basic literacy skills but few
attain literary art. The open questions permitted the researcher to obtain answers from
the respondent who answered questions using their own words. Open question three
“What is your primary role in the project?” could have been asked alternatively using
pre-selected answers. The list of possible answers, however, would likely have been
longer than what was feasible to present to respondents.
Despite this, closed
questions with a limited number of response alternatives can provide reliably answers.
Schuman and Presser (1981) suggested the researcher could interpret the meaning of
answers more reliably if alternatives were given to the respondent. Fowler (2002, p.
58
A conventional sequence begins with non-threatening questions, moving through the body of the
interview in a way that flows easily.
139
91) suggested the provision of a constrained number of answer options increased the
likelihood that there would be enough people giving any particular answer to be
analytically interesting.
In the NICPS, closed questions provided respondents with response alternatives in
one form, called categorical.
Categorical alternatives have no numerical or
preferential values. For example, question eight asks respondents to answer yes or no
regarding whether the project plans to deliver a new health service. “Yes” and “no”
are binary (dichotomous) categories from which a selection must be made. Question
17 asks respondents which level of approach has been adopted by the project and also
calls for categorical choices. This question, however, presents four categories:
individuals and families; communities; system, and a combination of any of these.
Fowler (2002) argued that four categories was a comfortable maximum on a
telephone, and suggested that for many telephone surveys two or three category
responses should predominate.
In addition to the number of categories, a second issue concerns how best to group the
categorical responses so that they are meaningful. Question 15 asks which age group
is targeted by the project and uses standard categories: 0-20, 21-55, over 55 and all
ages. These categories assumed that projects targeted different age groups within the
population and did not focus predominantly on one group. If for example, older
adults had been the focus of the majority of projects categories could have been
constructed differently, such as: 65-74, 75-84, 85-95 and over 95. Question 13 asks
about ethnicity through a series of three closed questions, and as each answer is
provided more comprehensive data becomes available.
Combining closed questions and open questions allowed data to be collected on a
single issue with increasing detail. For example, question 14 asks about geography
and combines categorical data obtained from a closed question and descriptive data
from a subsequent open question. The initial question seeks a categorical binary
(yes/no) response, with the follow-on question answered only when ‘yes’ is indicated.
Finally, the meanings of potentially ambiguous terms like condition, non-nursing
personnel, or nurse, were defined at the beginning of specific survey questions.
140
Table 10: Question form of items on the survey
Question form
Items on survey
Open
Descriptive
1, 2, 3, 4, 5, 6, 7 & 27
Closed
Categorical: 2 response choices
8, 10, 20, 22 & 23
Categorical: >2 response choices
17 & 26
Categorical:
Question 1: 2 response choices
Questions 2&3: 2 response choices
11, 12, 13, 15, 16 & 25
Categorical:
Question 1: 2 response choices
Question 2: Descriptive
9, 14, 18, 19, 21 & 24
Combination of open &
open
6.4.3.3
Pilot-testing the instrument
The pilot-test provided the opportunity to trial the instrument before it was made final.
Six practising health professionals with a sound knowledge of integrated care were
surveyed by telephone. Each had a copy of the survey questionnaire during the
interview. The interviewer read each question and asked the respondents to say in
their own words what they thought the question was asking. The interviewer sought
to determine if questions were understood and whether the wording in each question
was clear. Respondents were asked to explain how they chose a particular answer
when categorical alternatives were given and whether enough information was
provided to answer a question adequately.
Answers were repeated back to
respondents and they were asked if this accurately reflected what they had said.
Answers were then assessed to see if they had provided valid measures of what the
question had been designed to measure. Interviewees were also asked if they had felt
respected by the interviewer and if they perceived the interviewer had listened to them
and appeared friendly during the interview process. The time of the interview was
monitored. The interviewer identified suitable probes to encourage an interviewee to
answer a question, how to keep the interviewee on the topic, how to keep the
interview to the agreed time limit, and an effective method for recording information.
141
The results of the pilot test were used to revise the survey instrument and logistics.
After analysing data from the pilot test, seven previously open questions were
replaced by closed questions or combination closed and open questions. The question
form was altered to attain more predictable and reliable responses. Questions about
project funding, incentives, and costs, were identified as potential areas of sensitivity,
so were placed towards the end of the interview in an attempt to maintain the flow.
Minor changes to questions 25 and 26 resulted in interventions frequently
implemented in conjunction with one another, like health teaching, counselling, and
consultation, being grouped together. Respondents did not require the definitions to
be read as often, and appeared to answer more quickly after the categories were
grouped. Finally, an option for respondents to comment at the end of the interview
was included. Amending the final draft of the survey instrument was uncomplicated,
and an approximate timeframe of 60 minutes for the interview was established.
6.4.3.4
Reliability and validity
Reliability (repeatability) and validity (accuracy) described the quality of
measurements resulting from the questionnaire-based survey. Questions were reliable
when they provided consistent measures in comparable situations, and valid when the
answers corresponded to what they were intended to measure (Fowler, 2002). The
survey instrument used the same set of standardised questions for all interviews and
one interviewer asked the questions and recorded the answers (see pp. 145-146).
In order to provide a consistent data collection experience for all respondents the
question-and-answer process was entirely scripted, with questions written in full. The
questions were also reviewed by experts and pilot-tested to establish common
meaning. Respondents had expert knowledge of the survey topic and in addition,
closed questions provided answers that could be communicated consistently to all
respondents. Of the 27 survey items, 19 included closed questions. Twelve items
asked successive questions to gain greater detail and in doing so increased reliability.
142
Obtaining accurate information from the interview questions relied upon the use of
conventional language, complete sentences and the avoidance of abbreviations,
colloquialisms, and jargon. In early drafts of the questionnaire, biasing words and
phases, two-edged questions, and negative questions were eliminated. The use of
unclear terms, such as non-nursing personnel, was a more common error than the use
of unfamiliar words. The prevalence of misunderstanding of common wording has
been well documented (Belson, 1981; Fowler, 1992; Oksenberg, Cannell, & Kalton,
1991; Tanur, 1992).
Internal consistency reliability is applied to groups of items that are thought to
measure different aspects of the same variable. Internal consistency is an indicator of
how well the different items measure the same variable. A limitation of the survey
instrument was that internal consistency reliability had not been calculated, however,
this form of reliability was addressed by a number of survey questions measuring
aspects of the same variable.
For example, health services were measured in
questions eight, nine and ten.
Several types of validity are typically measured when assessing the performance of a
survey instrument: face, content, criterion, and construct (Litwin, 1995). Assessing
face validity involved discussing with colleagues the survey instrument for question
appropriateness. Content validity involved a more formal expert review of how good
a question or set of questions were, resulting in significant changes being made.
Pilot-testing also enabled respondents to offer additional perspectives.
Criterion
validity has two dimensions concurrent and predictive. Concurrent validity could not
be measured because an established gold standard did not exist. Predictive validity,
measuring how well a question predicts expected occurrences, was used to support
research questions. Peers who were unfamiliar with the research questions reviewed a
summary of data and drew conclusions. Because a number of individuals drew the
same conclusions a level of assurance could be inferred. Construct validity is a
theoretical measure of how meaningful the survey is. It is frequently seen as a gestalt
of how well a survey instrument performs in different settings, with different
populations, over a number of years.
143
Data collected in the study was mostly factual. Increasing the validity of reporting
factual data depends on what is being asked and how it is asked.
Reasons
respondent’s report events with less than perfect accuracy include: they do not
understand the question; they do not know the answer; they cannot recall information,
although they know it, and they do not want to report the answer in the interviewer
context (Fowler, 2002).
In the present study, to ensure that questions were
understood, definitions were provided to all respondents and category choices assisted
respondents to choose answers. Every effort was made to maximise the validity of
factual data by writing questions that would be consistently understood by
respondents. No respondent commented they could not recall information at the time
of the interview.
This may have been because the information sought by the
interviewer was familiar to the respondent and very recent. Lastly, all respondents
appeared interested to participate in the survey, perhaps because they perceived the
survey would generate information useful to them. Respondents were informed that
they could withdraw from the study after reviewing the questionnaire content, and
they were free to refrain from answering any question during the interview without
providing an explanation. Despite these reassurances a 100 per cent response rate was
obtained and all relevant questions were answered. In addressing issues that had the
potential to impact on the quality of data collected, internal validity was established.
The 80 integrated care projects investigated are likely to share certain essential
characteristics (see sections 5.4.3 and 5.4.4) with other projects in New Zealand that
developed during the same period. The findings of the NICPS can reasonably be
generalised to other New Zealand integrated care projects and primary health care
nursing practice at this time. Generalisability (external validity) is an important
feature of this study design.
6.4.3.5
The role of the interviewer
The survey employed one interviewer59 who had three major functions.
The
interviewer contacted respondents to enlist cooperation, motivated respondents to
59
The researcher conducted the survey interviews.
144
perform their role, and engaged in the interview process asking questions and
recording answers in a standardised way. Gaining the cooperation of respondents was
challenging. The style adopted for initially engaging people was personable and
professional.
The study was presented as if there was ‘no question’ that the
respondent would want to cooperate.
What was required from respondents was
clearly articulated and any issues raised were immediately addressed.
The interviewer attempted to standardise the interview by introducing a similar
process to all respondents about the study and its purpose (see Table 11). This was so
that the context of the interview would remain as constant as possible. Confidentiality
issues were discussed and the various people and organisations that might use the
study findings were identified.
Table 11: Interviewer approaches to contacting respondent
st
Telephone call was made to introduce the study and gain cooperation
nd
One week later a letter outlining the study purpose, a participant information
sheet, and consent form were posted out
rd
Two weeks following the 2 contact, a telephone call was made to nonrespondents to enlist cooperation/provide more information/address any issues
th
One week after receiving the signed consent form, the survey questionnaire was
posted out
th
One week after posting out the survey questionnaire a telephone call was made
to set an interview time. (Each interview collected data on one project. At the
completion of the first interview, a second interview was scheduled for those
providing data on >1 project)
1 contact
2 contact
3 contact
4 contact
5 contact
nd
Before the interview began, a standardised instruction (Fink, 1995) was used to
explain the respondents’ tasks to them, and to explain the question-and-answer
process. This instruction was given:
Before we start, let me tell you a little about the interview process, since most
people have not been in a survey like this before. You will be asked two kinds
145
of questions in this survey. In some cases, I will be asking you to answer
questions in your own words. In those cases, I will have to write down every
word you say, not summarising anything. For other questions, you will be
given a set of answers, and you will be asked to choose the one that is closest
to your own view. Even though none of the answers may fit your ideas
exactly, choosing the response closest to your views will enable us to compare
your answers more easily with those of other people.
Another standardised instruction (Fink, 1995) given to respondents was used to ensure
that they had a common understanding of their priorities.
It is very important that you answer as accurately as you can. Take your time.
Ask me to clarify if you have any question about what is wanted.
Since interviewer behaviour can reduce interviewer effects on data and increase
overall accuracy, the interviewer set the pace of the interview. Reading questions
slowly, the interviewer indicated to respondents they could take time to give
thoughtful, accurate answers. Survey questions were asked in the same way as they
were written, with no variation or wording changes.
Questions that required a
response alternative were read through a second time. Probes were used to encourage
the respondent to provide more information when a question had not been fully
answered. Standard probes, such as “Anything else?”; “Tell me more”, and “How do
you mean that?” were used in the interview. The interviewer was careful not to
communicate any judgement on an answer a respondent gave, did not express
personal views or opinions, and sought to minimise the personal side of the
communication in an effort to standardise the relationship across respondents.
The recording of answers was standardised.
Answers to open questions were
recorded in the respondent’s own words and for closed questions the respondent’s
choice was recorded. The interviewer entered data directly onto a coded survey
questionnaire. Whilst the interviewer had knowledge of integrated care, this was
different from respondents’ specific knowledge about projects. The interviewer did
not assume to know what the respondent was saying when the respondent had not
146
been clear, or to read anything more into what the respondent said. The interviewer
recognised that the interviewer role could potentially contribute to error in survey
data.
Fowler (2002) maintained it is unusual for researchers to make any efforts beyond
training and supervision to minimise interviewer effects. In the present study, the
interviewer had field experience and had received training and supervision in
interviewing.
These authors argue that although training and supervision are
important, so is a well-designed survey instrument. The more an interviewer has to
probe, explain, or clarify, the more likely they are to influence answers. The better
the survey instrument the more likely it is that the interviewer will conduct a robust,
standardised interview.
6.4.4
Organising the data for analysis
Survey answers were transformed into data files for computer analysis. This section
describes the practices used for code development and management, data format and
entry, and data checking procedures. There are two kinds of errors that can occur in
going from an answer to an entry in a data file. Transcription errors can occur when
an interviewer records an answer and errors can be made in regard to coding decision.
Quality control related to the data entry and coding procedures chosen in this study.
6.4.4.1
Constructing a code and assigning to survey data
Answers were translated into numeric codes by the researcher.
Codes were
unambiguous. In addition, codes were designed to minimise errors during coding and
analysis. For example, the same code (0) was consistently used for ‘no’ responses.
When response alternatives were provided to respondents, codes were assigned to the
given set of answers. When respondents were asked to answer questions in their own
words the range of answers could not be predicted ahead of time. For these questions,
code development became an interactive process whereby the researcher identified
147
categories that emerged from the answers, and imposed an order on the answers
obtained.
The purpose was to create categories that grouped answers, which were analytically
similar, and to distinguish between answers that were different. The researcher found
that when categorisation was too fine, a large number of categories with few entries
resulted, which made analysis more difficult. The researcher also found that large,
broad categories risked masking differences that may have been important. The
criterion was to place answers in analytically meaningful categories and assign one
code to each answer.
Constructing a code required documenting the differences across answers to each
question from the researcher’s perspective. A draft code for classifying these answers
was constructed, tested on another 15 interviews, and revised as necessary.
A
separate code for ‘other’ responses was assigned. Notes recorded on this category
were used to expand and clarify the code, and in some instances to add needed
categories.
As well, a record of answers included in the ‘other’ category was
obtained. These steps allowed the coder to identify and address any problems or
ambiguities that presented.
Table 12: Codes assigned to questions 1 to 3
Question
Code
1
Name
1=Name
2
Employer
1=Primary sector
2=Secondary sector
3=Other
3
Role
1=Financial management
2=Clinical management
3=Systems management
Questions one to three related to the respondent, with categories derived from the
respondent’s answers. The researcher sought to determine if informants located in
one health sector were more likely to undertake a specific role.
148
Table 13: Codes assigned to questions 4 to 9
Question
Code
4
Project title
1=Project title
5
Type of integration
1=Vertical
0=No
1=General Practice+Hospital
2=Hospital+PHC Provider60
3=Other
2=Horizontal
0=No
1=General Practice+PHC Provider
2=Hospital+Hospital
3=General Practice/PHC Provider+other sector
4=General Practice+General Practice
3=Vertical + horizontal
0=No
1=General Practice+PHC Provider+Hospital
2=Multiple Providers
6
Project purpose
1=Project purpose
7
Achieve purpose
0=No
1=Yes
8
New planning
0=No
1=Yes
9
Different delivery
0=No
1=GP delivering specialist care
2=Other type of different delivery
Questions four to 27 related to the project.
Data collected on organisations in
partnership measured the variable type of service integration.
Shortell (1996)
differentiates integration as either vertical or horizontal to describe the direction of
organisational relationships. Vertical integration occurs between organisations in
different sectors such as general practice (primary) and the hospital (secondary), and
horizontal integration occurs between organisations within the same sector, such as
general practice and other primary health care organisations. Question nine included
a successive question that required coding three categories derived from respondent’s
answers.
60
“PHC Provider” refers to primary health care organisations other than general practice.
149
Table 14: Codes assigned to question 10
Question
10
Code
Health service
0=No
1=Combination of all services
2=Screening and prevention
3=Health promotion
4=Diagnostic tests and expert advice
5=Treatment and follow-up
6=Rehabilitation
Question 10 classified the types of services projects provided. Projects that had
planned services or developed clinical guidelines but not implemented them were
classified 0 (No). Screening and prevention focused mostly on diseases, but also
included wider areas such as poverty by assessing housing, exercise programmes to
reduce the weight of obese groups, and community health checks for at risk
populations. Health promotion referred to services provided to people not known to
be at risk of a disease or condition and included asthma education, and the promotion
of health care services more broadly. Diagnostic tests and expert advice included
conducting echocardiograms and spirometry and advice by specialist nurses to
colleagues, or clients, by way of a nurse telephone triage system. Treatment and
follow-up referred to primary medical care post-discharge, community care pathways
and primary care follow-up services. Rehabilitation related to smoking cessation
programmes and improving physical function with input from physiotherapists.
Table 15: Codes assigned to questions 11 and 12
Question
Code
11
General practice incentive
0=No
1=Generate income
2=Plan new health services
3=Improve existing health services
4=Gain new skills
5=Reduce hospital service demand
6=Reduce hospital specialist time
12
Hospital incentive
0=No
1=Generate income
2=Plan new health services
3=Improve existing health services
4=Reduce hospitalisations
5=Reduce hospital specialist time
Question 11 classified the main incentive perceived by respondents to influence
general practice being a partner in a project. Generating income referred to activities
150
like enrolling new clients, and receiving payment to case manage or vaccinate clients.
Planning a new health service referred to, for example, new respiratory and cardiac
services that utilised clinical guidelines, and the establishment of equipment
coordination for client use. Improving an existing health service referred to, for
example, extending maternity services to provide additional care, case management
within mental health, and the coordination of child health services to improve access
to primary care.
Gaining new skills referred to, for example, general practice
accessing hospital specialist advice within 24 hours, case meetings, or co-working
arrangements. Reducing hospital service demand referred to services being shifted to
the primary sector from the secondary sector. Reducing hospital specialists’ time
referred to general practitioners and nurses’ case managing more complex clients in
the community, rather than admitting them to the secondary sector.
Question 12 classifies the main incentive perceived by respondents to influence a
hospital being a partner in a project. Generating income referred to integrated funding
generated by project services.
Planning a new health service frequently referred to
the development of databases. Improving existing health services referred to for
example, the integration of information systems between providers, expanding
services to provide more comprehensive primary health care, extending maternity
services to offer additional care, case management within mental health services and
enforcing the use of guidelines and protocols. Reduce hospitalisations referred most
often to the management of clients with chronic conditions in the primary sector, new
or improved screening and prevention services, and the implementation of clinical
guidelines.
Reduce hospital specialist time referred to advising and educating
colleagues in the primary sector about the management of chronic conditions.
151
Table 16: Codes assigned to questions 13 to 15
Question
Code
13
Ethnic group
0=No
1=Maori only
2=Maori and wider population
3=Pacific only
4=Pacific and Maori only
5=Pacific and Maori and wider population
6=Other
14
Low income
0=No
1=low decile area
15
Age group
1=0-20
2=21-55
3=over 55
4=all ages
16
Disease or condition
0=No
1=Diabetes
2=Chronic obstructive pulmonary disease
3=Acute confusion
4=Two or more chronic conditions
5=Mental health condition
6=Cardiac conditions
7=Sexual and reproductive health
8=Two or more acute conditions
9=Hip fracture
10=Asthma and other respiratory conditions
11=Cerebrovascular disease (stroke)
12=Dental health
13=Meningitis
14=Hepatitis
15=Obstetric health
16=Iron deficiency anaemia
17=Urinary tract infection
Health, disease or
condition, or other focus
0=Other
1=Chronic disease or condition
2=Acute disease or condition
3=Well-health
Ethnic group
Maori health was identified as an area for health gain to be addressed by integrated
care (Health Funding Authority, 1998).
Consequently, the researcher sought to
determine the proportion of projects that had an exclusive Maori focus, and a focus on
Maori and the wider population. This idea was further developed to explore the
relationship between integrated care and Pacific people, who have also been identified
as an underserved population (Ministry of Health, 2001c). The highest numbers of
Maori and Pacific people in New Zealand can be found in specific geographic
regions, so a classification that combined both ethnic groups was created.
152
Low income
Geography was used to determine low income. The New Zealand deprivation index
uses data from the Census to rank areas across the country according to relative
deprivation. Deprivation is measured using nine variables: access to a telephone,
income, employment, household income, access to a car, family unit support,
educational qualifications, home ownership and household occupancy levels. Each
geographical meshblock within New Zealand is assigned a deprivation score based on
the nine variables.
The meshblock scores are then divided into tenths with
meshblocks of the highest values representing the 10 per cent of most deprived
meshblocks in the country, and those in the lowest deprivation group representing the
10 per cent of least deprived areas.
For the purposes of this study, the most deprived 30 per cent of meshblocks were
coded as low decile, representing the 30 per cent most deprived areas in New Zealand.
The atlas “Degrees of Deprivation in New Zealand: An atlas of socio-economic
difference” (Crampton, Salmond, & Kirkpatrick, 2004) was used as a tool to identify
the deprivation figure for the client catchment area of health services identified within
this study. In instances where the catchment area covered more than one meshblock
the average deprivation rating was taken from all relevant meshblocks.
Age group
The codes were assigned to answers within the four closed-response categories:
children (including babies) and adolescence (0-20), adults (21-55), older adults (55+),
and all ages (0-55+). Literature on integrated care suggested the strategy would target
all ages (Health Funding Authority, 1998). For the purposes of this study, older adults
are classified as those 55 years and over, although 65 years is internationally
recognised as the point from which people are known as older adults. It is also the
age at which entitlement to retirement income in New Zealand was guaranteed in
2001 (Ministry of Health, 1997). However, the term ‘kaumatua’ refers to all Maori
aged 55 years and over. Kaumatua more traditionally refers to the status and role that
kuia (older people) and koroua/koro (older men) attain as recognition of their
contribution, leadership, knowledge and protection of whanau/hapu/iwi life (Barlow,
1991). This age range allows the flexibility to acknowledge that many Maori face
153
age-related disability and illnesses at a relatively younger age and have a shorter life
expectancy than non-Maori. From a Pacific people’s perspective status customarily
accorded to older Pacific peoples is not necessarily confined to chronological
considerations but can also be ascribed as a consequence of increased social status.
Many Pacific peoples face illness or limitation to physical participation and mobility,
typically associated with older people, at a younger age than the general population
(Ministry of Health, 1997).
Statistical data impose an age range on population
groups, which makes it necessary to adopt an age span to enable a meaningful
comparison of quantitative statistical analyses.
Therefore, the study adopted the
definition of the kaumatua age range.
Disease or condition
The researcher sought to determine the disease or condition focus of projects and
attributed codes accordingly. No specific condition was then reclassified. Some
projects, for example, classified as sexual and reproductive health focused on wellhealth in pregnancy or women’s health. The dental health classification also related
to well-health. Other classifications such as urinary tract infection were reclassified
as either acute or chronic dependent upon project data.
Table 17: Codes assigned to question 17
Question
17
Code
Level of project approach
1=Individual/family
2=Community
3=System
4=Individual/family and Community
5=Individual/family and System
6=Community/System
7=Individual/family and Community and System
Question 17 attempted to discover the overall level of the population-based approach
(see pp. 90-93) adopted by the project. For example, did the project attempt to change
the knowledge, attitudes, beliefs, and practices of individuals (and families) or
communities; or neither individuals or communities, but rather the systems that
impact health?
154
Table 18: Codes assigned to question 18
Question
18
Code
Strategies for integration
1=Clinical guideline development
0=No
1=Nurses
2=Others
2=Clinical guideline promotion
0=No
1=Case management
2=Audit
3=Information to clients
4=Information to peers
3=Case management
0=No
1=Nurse
2=General practice team
3=Clinical team
4=Other
4=Database development
0=No
1=Yes
5=Information sharing
0=No
1=Peer advice/education
2=Peer referral
3=Client education
4=Relationship building
6=New coordination strategy
0=No
1=Yes
Decision making guidelines, effective information systems and coordination activities
such as case management, has been promoted as strategies to be tested (Health
Funding Authority, 1998). These strategies formed the basis of question 18, which
required a binary response to specific strategies before successive questions sought to
uncover more detail. So, for example, after establishing guidelines were developed, a
following question asked who had developed them. The classification of data is
explicit and codes are generally predictable. The strategy case management uses the
code general practice team, which includes nurses, and others employed in general
practice, and the code clinical team refers to primary and secondary clinicians. Code
other, refers to administrators or information managers who case managed the client’s
care by coordinating different clinicians for direct service provision. Information
sharing used the code peer advice and/or education, for example, when hospital
specialists advised/educated general practice personnel, or when nurses with a
specialty area of practice like diabetes advised/educated practice nurses. Peer referral
most often referred to situations where hospital services were shifted to general
practitioners, such as conducting an echocardiogram, a task usually undertaken by the
cardiologist. Client education referred to education as a formal activity, rather than an
educational opportunity that happened in the course of a health professional/client
155
interaction.
Relationship building centred on both client and health provider
relationships and focused on improving access and quality of services.
New
coordination strategy referred to different means of coordinating and providing health
interventions (mouth guards and vaccines) and services (community health checks,
dental care, and maternity care).
Table 19: Codes assigned to questions 19 to 23
Question
Code
19
Project funding
0=No
1=Project partners
2=Government
20
Project financial incentive
0=No
1=Yes
21
Client material incentive
22
Costs to general practice
0=No
1=Yes
23
Costs to hospital
0=No
1=Yes
0=No
1=Yes
Question 19 asked initially if the project received new funding and who provided the
main funding. Financial incentive for organisations that are project partners included
general practice receiving additional payment for consultations with clients
(additional to fee-for-service client charges and the general medical subsidy from
government). Material incentive for clients included improvements to a home (see p.
164). Financial costs incurred by hospitals included transferring resources to general
practice for the provision of new primary health care services.
Question 24 asked if non-nursing personnel were employed in projects, and sought a
description of the practice.
The codes indicate the six main areas identified.
Information management referred to the development of a database and the
establishment of systems to share information.
Administration and coordination
referred to the organisation of personnel, services, clients, and data. Research and
audit referred to investigations into best practices, risk factors, immunisation rates,
and clinical case management.
Consulting referred to advice and information
provided to colleagues in the areas of clinical management and project management,
156
including evaluation.
Clinical guideline development referred to all activities
pertaining to the production of a guideline for a specific purpose and population.
Technical support referred to equipment management and maintenance.
Table 20: Codes assigned to question 24
Question
24
Code
Non-nursing personnel
0=No
1=Information management
2=Administration/coordination
3=Research and audit
4=Consulting
5=Clinical guideline development
6=Technical support
Question 25 asked if the project employed nurses and then sought to determine which
of the 17 interventions were undertaken by nurses. Question 26 determined the
level/s of population-based practice undertaken for each intervention previously
identified in question 25.
Table 21: Codes assigned to question 25 and 26
Question
Code
25
Intervention
26
Level of practice
0=No nurses
1=Surveillance
(interventions: continuous to 17)
0=No intervention
1=Individual/family
2=Community
3=Systems
4=Individual/family+Community
5=Individual/family+Systems
6=Community/Systems
7= Individual/family+Community+Systems
(0-7 scale measuring level of practice was applied to each intervention)
6.4.4.2
Data entry
Data were double entered into a Microsoft Excel spreadsheet and then converted to
SPSS. The study code for each interview was entered into the data for a particular
record61. The study code preserved the order of the data and was critical in checking
61
Record pertains to data collected at each interview about a specific project.
157
files for completeness. Data were coded in the order that questions appeared on the
survey instrument, in an attempt to reduce errors.
This process represented an
effective and relatively cost-free means of controlling quality. Multiple codes were
entered in a single column. Editing of the data was facilitated by the incorporation of
range and logic checks. Cross checking of the data was undertaken so that errors in
data entry could be rectified.
6.4.4.3
Coding and data reduction as a source of errors
Because coding and data reduction processes were checked thoroughly, there was
potential for this part of the survey process to be relatively free from errors. When
dealing with closed answers the rate of data entry should be less than one per cent
(Fowler, 2002). The quality of coding open questions is reported to vary with the
quality of the question, the quality of the code, and the experience of the coder. In the
present study, the open questions were focused and the coding categories were
conceptually clear. Fowler (2002) suggests in these circumstances coding should
exceed 90 per cent in reliability. Codes that depend on knowing complete definitions,
such as employment categories or health conditions, require particular attention. The
researcher, familiar with such definitions, maintained a level of accuracy in both the
coding and data entry process.
6.4.5
Data analysis
Data obtained from interviews lend themselves to extensive, descriptive statistical
analyses. The data analysis was conducted to reduce, organise and give meaning to
the data. The investigation aimed to establish if a relationship existed between the
characteristics of integrated care projects and the practice of nurses in projects.
Research questions sought to determine: the characteristics of integrated care more
strongly associated with projects that employ nurses; the interventions and levels of
practice undertaken by nurses, and finally the health promotion values embedded in
158
nurses’ practice overall. To achieve this two stages of interpretation were necessary,
and are presented as stage one and stage two analyses.
6.4.5.1
Stage one analysis
Simple frequency tables (see Appendix 4) were initially produced to describe the
characteristics of integrated care projects and the practice of nurses. Frequencies take
the form of numbers and percentages.
Data included: the respondent’s personal details; organisational structure; funding;
type of service integration; strategies for integration; level of project approach; age
group targeted; ethnic group targeted; low income targeted; health, disease or
condition targeted; practice of non-nursing personnel, and the practice of nurses. This
primary analysis was undertaken on all variables, but it was anticipated that this
would not fully address the research questions. Following several consultations with
statisticians Alastair Stewart and Elizabeth Robinson it was decided that for the
purpose of this research, cross tabulating primary analysis data was required.
Variable ‘projects employing nurses’ was cross tabulated by: planning a new health
service and delivering an existing health service differently; type of service
integration; strategies of integration; health service provided; level of project
approach; age group targeted; ethnic group targeted; low income targeted; disease or
condition targeted, and the practice of non-nursing personnel (see section 7.3).
Additional cross tabulations included: disease, condition or other focus by: health
service; level of project approach; age group, and ethnic group (see pp. 183-187), and
age group with or without disease or condition by: ethnic group and low income (see
pp. 187-189).
Nursing interventions (n=17) were cross tabulated by ethnic group (Maori); low
income (low decile area); health or disease/condition (chronic condition and well-
159
health); individual level of population-based practice; community level of populationbased practice, and by system level of population-based practice (see pp. 189-191).
6.4.5.2
Stage two analysis
Social values embedded within the practice of nurses were determined using Beattie’s
model of health promotion (see p. 31, Figure 1). Seventeen interventions and the
level of population-based practice approach most often undertaken by nurses relating
to that intervention are situated within Beattie’s model of health promotion, which has
been adapted for this purpose. The three levels, individual and family (individual),
community and systems, were reduced to individual and community to align with
Beattie’s model of health promotion (see p. 194, Figure 18). Individual and systems
levels were combined. This was possible because whilst systems interventions within
projects always related to data management, which has a system focus, subsequent
health impacts affected individuals.
For instance, a diabetes register collected
regional data that was used for case managing individuals. The researcher’s project
knowledge also informed classification processes.
Beattie’s model refers to a collective focus of intervention, described as either
participative and community-based or paternalistic and state-directed (Beattie, 1991).
Community level interventions by definition are directed towards entire populations
or groups within populations (Minnesota Department of Health, 2001), so are
considered community-based. Interventions at the community level attempt to change
community norms, attitudes, and practices, the means of which can be described as
paternalistic or state-directed. For the purposes of interpretation, ‘collective focus of
intervention’ translates to ‘community focus of intervention’.
Interventions are situated on the x-axis between individual focus of intervention and
community focus of intervention.
The specific location of each intervention is
determined by a simple formula measuring the degree of individual or community
focus:
160
Community – Individual (individual + systems) = Position
Measures of variables community, individual and systems, for each intervention were
taken from the total number of projects identified (see p. 192, Figure 17). The
formula was applied to provide a consistent, quantifiable total inclusive of all levels of
practice approach for each intervention.
The formula provided a rationale for
situating interventions numerically along the x-axis. The intervention is directed
along the y-axis, lying within the quadrant most representative of the approach
underpinning the intervention. In order to make Figure 18 (see p. 194) more easily
understood, the model was rotated 90° anti-clockwise from the original position (see
p. 31, Figure 1, Beattie’s model of health promotion).
161
7
7.1
Chapter 7
Results: Nurses in integrated care projects study
Introduction
Chapter seven provides an overview of the study results in two distinct sections.
Stage one presents descriptive statistics of the 80 integrated care projects and the
practice of nurses in these projects. Univariate analyses are presented initially, and
then selected variables are cross tabulated because of their potential to address the
research questions. Stage two presents the health promotion values seen to be driving
the overall practice of nurses in integrated care projects. Seventeen interventions and
the levels of population-based practice most commonly adopted by nurses employed
in these projects are situated within an adaptation of Beattie’s model of health
promotion. A summary of the results is presented in Table 33 (see pp. 195-198).
7.2
7.2.1
Study results
Survey respondents
Twenty-seven respondents were surveyed. A 60 minute telephone interview was used
to collect data on a single project. Overall, data were collected on 80 integrated care
projects (see section 6.4.1, p. 133). In summary:
Number of survey respondents
Number of projects
12
15
27
27
53
80
(Initial MOH list)
(Snowballing)
Of the 27 respondents, eight were interviewed on one project, six were interviewed on
two projects, and 13 were interviewed on three or more projects. Nine respondents
were registered nurses. Six respondents, who were not nurses, consulted nurses in
projects about their practice in order to answer interview questions 25 and 26.
Fourteen respondents were female and 16 were employed in hospitals. Twenty-one
respondents (78%) reported their main role as clinical management. Of these, nine
had trained in medicine, nine in nursing, and three in the allied health professions.
Four respondents (15%) reported their main role as financial management, whilst the
remaining two respondents (7%) reported their main role as systems management.
162
7.2.2
Integrated care projects
A profile of the 80 projects that comprise the NICPS is outlined below.
The
information is presented in the same sequence as the integrated care characteristics in
Table 9 (see p. 138), with data from survey questions relating to specific
characteristics reported in the same section. Bar graphs and frequency tables illustrate
the data and provide greater detail.
7.2.3
Organisational structure
Planning a new health service or delivering an existing service differently
Sixty per cent (48/80) of projects planned to deliver new health services. In addition,
63 per cent of projects also delivered existing health services differently. Of the
projects delivering existing health services differently, 60 per cent involved general
practice physicians providing services that had previously been provided by hospital
specialists, such as taking an echocardiogram.
Health care services provided by the project
Almost 70 per cent (n=55) of projects provided health care services.
Services
included screening and prevention (13%), diagnostic tests and expert advice (10%),
rehabilitation (6%), treatment and follow up (6%), health promotion (4%), and a
combination of these services (30%). Approximately 30 per cent of the projects did
not provide direct health care, but planned information systems such as databases for
disease management, and developed guidelines.
Incentives for general practice to be a project partner
Ninety per cent (n=72) of projects had general practice partners. Of these projects 84
per cent reported incentives for general practice to participate. Incentives included
163
improving existing health services (41%), generating income (19%), receiving
training (13%), planning and/or delivering new health services (10%), and reducing
demand for hospital services (1%).
Incentives for the hospital to be a project partner
Eighty-seven per cent (n=67) of projects had hospital partners. Of these projects 93
per cent reported incentives for hospitals to participate. Incentives included reducing
hospital admissions (63%), improving existing health services (21%), reducing
hospital specialist time (5%), planning and/or delivering new health services (3%),
and generating income (1%).
Financial incentives to project partners
Forty per cent (n=32) of projects had partners who received financial incentives when
they provided health services (see p. 165, Figure 8).
Material incentives to clients
Five per cent of projects had clients who received material incentives as a
consequence of their participation. Material incentives included: gifts, vouchers for
general practice consultations, housing brokered by the health organisation, and
building repairs to homes that included installation of amenities, such as ‘inside
toilets’ (see p. 165, Figure 8).
New cost incurred by general practices
General practices did not incur new costs as a result of participating in projects (see p.
165, Figure 8).
164
New cost incurred by hospitals
Hospitals incurred new costs (11%) as a result of participating in projects (see p. 165,
Figure 8).
Figure 8: Incentives to clients and project partners and new costs to hospitals
and general practices
7.2.4
Funding
Eighty-four per cent (67/80) of projects had a main source of new funding. These
projects received funding from either government (68%; n=54) or project partners
jointly (16%; n=13).
Sixteen per cent (n=13) of projects did not have a main source of new funding. These
projects were reported as either an alteration to an existing service, which used the
same resources, or a new service where project partners reallocated existing funding
from within their organisations.
7.2.5
Type of service integration
Projects were vertically integrated (40%; n=32), horizontally integrated (19%; n=15)
or both vertically and horizontally integrated (41%; n=33).
165
The most common organisational relationship of projects vertically integrated was
between general practice and the hospital (36%), with hospital and other primary
health care providers (4%) also vertically integrated.
Horizontal integration comprised relationships between general practice and primary
health care in sectors other than health (6%), hospital and hospital (6%), general
practice and general practice (4%), and general practice and primary health care in the
health sector (3%).
Of the projects that were both vertically and horizontally integrated organisational
relationships occurred between multiple providers across health and other sectors,
such as housing (23%), and general practice, primary health care and the hospital
(18%) (see p. 166, Figure 9).
Figure 9: Organisational relationships based on vertical and/or horizontal
integration
7.2.6
Strategies for integration
Six strategies for integration were identified (see p. 167, Figure 10) with the most
common strategy reported to be information sharing (65%). Information sharing,
included building relationships (31%), peer advice and education (16%), peer referral
166
(10%) and client education (8%). The development of a database to improve access
to information also occurred in 50 per cent of projects.
Developing a new coordination strategy occurred in 56 per cent of projects. This
strategy included coordinating health prevention and promotion activities with
community groups such as sports teams, and adopting new approaches.
Clinical guidelines were promoted in 36 per cent of projects and use by case managers
was found to be a central reason for promotion (26%).
Other reasons for the
promotion of clinical guidelines included information to peers (8%), use as an audit
tool (1%), and information to clients (1%). Clinical guideline development occurred
in 21 per cent of projects, with nurses the largest professional group involved in this
activity (10%).
Case management occurred in 33 per cent of projects, with nurses (20%),
multidisciplinary teams (8%), and general practice physicians and practice nurses
(5%) undertaking case management.
Figure 10: Strategies for integration
7.2.7
Project level of population-based practice
Twenty-three per cent of projects adopted an individual and family-focused level of
practice, with another 11 per cent adopting both individual and community level
167
practice.
Sixty-six per cent adopted a systems level practice, either exclusively
(32%), or in conjunction with another level of practice, such as, individual (29%), or
individual and community (4%) or community (1%). Overall, projects did not adopt a
community level of practice exclusively (see p. 168, Figure 11).
Figure 11: Project level of population-based practice
7.2.8
Age group
Twenty-eight per cent (n=22) of projects targeted people of all ages. Of the projects
that targeted specific age groups adults (21-55 years) were targeted in 29 per cent
(n=23) of projects, older people (>55 years) in 28 per cent (n=22), and children and
adolescents (0-20 years) in 16 per cent (n=13).
7.2.9
Ethnic group
Over half (53%; n=42) of the projects targeted Maori and/or Pacific peoples. Projects
targeting Maori included Maori exclusively (16%), Maori and the wider population
(10%), Maori and Pacific people exclusively (1%), and Maori and Pacific people and
the wider population (20%).
Five per cent of projects targeted Pacific people
exclusively.
168
7.2.10
Low income
Thirty per cent (n=24) of projects targeted populations in geographic areas defined as
low decile and representing the 30 per cent of most deprived areas in New Zealand.
7.2.11
Disease, condition, or other focus
Eighty-two per cent (n=66) of the projects targeted diseases or conditions and were
classified in relation to direct clinical intervention. Projects classified as ‘other’
(18%; n=14) included projects with a focus on well-health and the development of
information systems (see p. 154). Some of these projects had a disease or condition
focus, but the classification other sought to differentiate from chronic or acute
condition relating to direct clinical intervention.
Figure 12: Projects by specific disease or condition
169
Figure 13 (see p. 171) shows the percentage of projects that targeted chronic
conditions, acute conditions, well-health, or were classified as other. Fifty per cent
(n=40) of projects targeted chronic conditions. Chronic conditions included diabetes
(11%), two or more chronic conditions (8%), mental health conditions (8%), cardiac
conditions (6%), chronic obstructive pulmonary disease (6%), cerebrovascular disease
(stroke) (5%), asthma and respiratory conditions (5%), and urinary tract infections
(1%).
Ten percent (n=8) of projects targeted acute conditions, which included hip fracture
(3%), acute confusion (1%), acute conditions (1%), iron deficiency anaemia (1%),
obstetric health (1%), and dental health (1%).
Nineteen per cent (n=15) of projects targeted the well-health of either a population-ofinterest, such as pregnant women, or a population-at-risk, such as adolescents with
limited access to contraception, or adults with chronic obstructive pulmonary disease
at risk of exacerbations.
Projects targeted sexual and reproductive health (6%),
chronic obstructive pulmonary disease prevention (3%), outreach (3%), health
assessments (3%), meningitis prevention (1%), health screening (1%), exercise (1%),
and housing (1%). Projects targeting well-health included maintaining the health of a
‘well–ill’ population, such as those with chronic obstructive pulmonary disease, and
also maintaining the health of a population without any specific illness, at risk of
poorer health as a consequence of, for example, low income.
Twenty-one per cent (n=17) of projects did not target the direct clinical intervention
of a specific disease or condition, or have a well-health focus. Instead, these projects
developed databases (7%), partnerships (6%), guidelines, care maps, protocols,
frameworks for service delivery, and funding arrangements (6%), triaged services
(1%) and coordinated equipment (1%). A disease or condition focus was apparent in
some of these projects; for example, a care map was developed for hip fracture.
170
Figure 13: Chronic or acute condition, well-health or other
7.2.12
Non-nursing personnel
Thirty-seven per cent (n=30) of the projects employed non-nursing personnel. Project
coordination and administration was the most common main role (29%). Other main
roles included research and audit (5%), consulting (1%), technical support (1%), and
information (1%).
7.2.13
Nursing
Interventions
Over 80 per cent (n=65) of the projects employed nurses.
Of these projects, a
combined total of 411 interventions were undertaken by nurses from a range of 17
different types of interventions (see p. 95). In approximately 50 per cent (n=32) of the
projects only one type of intervention was undertaken suggesting a very restricted
range of practice. In 43 per cent (n=28) of projects nurses undertook nine or more
interventions, and in 26 per cent (n=17) of projects nurses undertook 13 or more
interventions, suggesting a more extensive range of practice.
The types of intervention undertaken included case management (9%; n=36);
consulting (9%; n=36); health teaching (7%; n=31); collaboration (7%; n=31); referral
171
and follow-up (7%; n=30); delegated functions (7%; n=29); counselling (7%; n=29);
advocacy (7%; n=29); coalition building (7%; n=28); screening (6%; n=26); policy
development and enforcement (6%; n=24); outreach (5%; n=23); disease and health
event investigation (5%; n=19); community organising (4%; n=15); social marketing
(3%; n=13), and surveillance (3%; n=12) (see Figure 14).
The seventeenth
intervention, case finding (10%; n=42), combines surveillance, screening, disease and
other health event investigation, and outreach, at the individual level of practice. No
distinction was made between the levels of population-based practice of the other
sixteen interventions.
Figure 14: Total interventions undertaken by nurses in projects
Almost 50 per cent of the total interventions undertaken by nurses comprise two
wedges or groups of interventions (see Figure 14).
The first wedge of related
interventions comprises health teaching, counselling, and consulting (23%, n=96),
172
with referral and follow up, case management, and delegated functions, comprising
the second wedge (23%; n=95).
Interventions by level of population-based practice
Of the total number of interventions (n=411) undertaken by nurses, a level of
population-based practice that was exclusive occurred at the individual level in 66 per
cent (n=270) of the interventions; community level in nine per cent (n=35), and
systems level in eight per cent (n=33).
Figure 15: Total interventions and levels of population-based practice undertaken
by nurses in projects
173
Eighteen per cent (n=73) of the total number of interventions by nurses were
undertaken on either two or three levels of practice. Most (13%; n=55) of these
interventions occurred at both the individual and community levels. A small number
of interventions occurred at the systems and individual levels (1%; n=3); systems and
community levels (2%; n=8); or the systems, individual, and community levels (2%;
n=7). Figure 15 (see p. 173) shows the percentage of total interventions undertaken
by nurses and the levels of the practice of each intervention.
Related interventions are grouped in wedges (see Figure 16 and p. 176, Table 22). An
individual level of practice occurred most in referral and follow-up, case management,
and delegated functions (21%; n=87), and health teaching, counselling and
consultation (19%; n=80). A community level of practice occurred most (8%; n=32)
in the wedge of interventions that included collaboration, coalition building, and
community organising. A systems level of practice occurred most (4%; n=18) in the
wedge of interventions that included surveillance, disease and health event
investigation, outreach and screening.
Figure 16: Total interventions and levels of population-based practice by
wedge undertaken by nurses in projects
Both individual and community levels of practice occurred in all wedges. These
approaches were more prominent in advocacy, social marketing and policy
174
development and enforcement (5%; n=19) and surveillance, disease and health event
investigation, outreach and screening (4%; n=16) wedges. Figure 16 (see p. 174)
shows the wedges that applied more than one level of practice such as, community
and systems levels, and individual, community and systems levels.
175
Table 22: Total interventions and levels of population-based practice by wedge undertaken by nurses in projects
Individual
Community
Systems
Individual &
Community
Individual
&
Systems
Community
& Systems
Individual &
Community
& Systems
Totals
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
Surveillance, Disease
& health event
investigating,
Outreach, Screening
42
10
2
0
18
4
16
4
0
0
0
0
2
0
80
19
Referral & follow-up,
Case management,
Delegated functions
87
21
0
0
6
1
1
0
1
0
0
0
0
0
95
23
Health teaching,
Counselling,
Consultation
80
19
0
0
5
1
8
2
2
0
0
0
1
0
96
23
Collaboration,
Coalition building,
Community
organising
18
4
32
8
4
1
11
3
0
0
8
2
1
0
74
18
Advocacy, Social
marketing, Policy
development and
enforcement
43
10
1
0
0
0
19
5
0
0
0
0
3
1
66
16
TOTALS
270
66
35
9
33
8
55
13
3
1
8
2
7
2
411
100
176
7.3
7.3.1
Projects employing nurses
Planning a new health service and delivering an existing health service
differently by projects employing nurses
Sixty per cent (48/80) of projects reported general practice physicians provided care
previously delivered by hospital specialists (classified as delivering an existing
service differently), and of these projects 41 (85%) employed nurses. In addition, 30
projects reporting general practice physicians provided care previously delivered by
hospital specialists planned a new service and nurses were employed in 29 (97%) of
these projects.
Health care services by projects employing nurses
Of the projects employing nurses (n=65), health care services provided included:
screening (12%; n=8); diagnostic testing and expert advice (9%; n=6); health
promotion (5%; n=3); treatment and follow-up (5%; n=3); rehabilitation (1%; n=1),
and a combination of these services (34%; n=22). Thirty-four per cent (n=22) of
these projects did not provide services.
Of the projects that did not employ nurses (n=15) all services were undertaken, with
the exception of health promotion. Rehabilitation was provided in 27 per cent (n=4)
of these projects and 24 per cent (n=3) did not provide services.
Incentives and costs by projects employing nurses
Eighty-four per cent (n=67) of general practices had incentives to participate and
nurses were employed in 78% (n=52) of these.
General practice did not incur
financial costs as a result of participating in projects.
Ninety-three per cent (n=74) of hospitals had incentives to participate in projects and
nurses were employed in all projects (80%; n=59). Eleven per cent (n=9) of hospitals
177
incurred financial costs as a result of participating in projects and nurses were
employed in 67% (n=6) of these projects.
Forty per cent (n=32) of projects had partners who received financial incentives when
they provided health services and nurses were employed in 75% (n=24) of these
projects.
7.3.2
Funding by projects employing nurses
Sixty eight per cent (n=54) of projects received their main source of new funding
from government and nurses were employed in 82% (n=44) of these projects.
7.3.3
Type of service integration by projects employing nurses
Forty-one per cent (n=33) of projects were both vertically and horizontally integrated
and 28 of these projects employed nurses. A further 40 per cent (n=32) of projects
were vertically integrated, with 22 of these employing nurses. Vertical integration
occurred most often between general practice and the hospital. The remaining 19 per
cent (n=15) of projects were horizontally integrated and all of these employed nurses.
Horizontal integration occurred most in the primary sector between general practices
and other primary health care providers.
7.3.4
Strategies of integration by projects employing nurses
Information sharing via other methods
Of the projects employing nurses (n=65), information sharing occurred in 71 per cent
(n=46) through relationship building (n=25), providing peer education and advice
(n=11), peer referral (4), and client education (n=6). Of the projects that did not
employ nurses (n=15), information sharing occurred in 40 per cent (n=6) through peer
referral (n=4) and peer education and advice (n=2).
178
Information sharing via database
Of the projects employing nurses (n=65), information sharing via a database was
undertaken in 52 per cent (n=34). Of the projects that did not employ nurses (n=15),
information sharing via a database was undertaken in 40 per cent (n=6).
New coordination strategy
Of the projects employing nurses (n=65), a new coordination strategy was undertaken
in 58 per cent (n=38). Of the projects that did not employ nurses (n=15), a new
coordination strategy was undertaken in 47 per cent (n=7).
Clinical guideline promotion
Of the projects employing nurses (n=65), clinical guidelines were promoted in 42 per
cent (n=27), for the purposes of case management (32%; n=21), information to peers
(6%; n=4), information to clients (1%; n=1), and auditing clinical practice (1%; n=1).
Of the projects that did not employ nurses (n=15), guidelines were promoted in 13 per
cent (n=2) of projects to provide information to peers.
Clinical guideline development
Of the projects employing nurses (n=65), clinical guidelines were developed in 25 per
cent (n=16) and half of the developers were nurses. Of the projects that did not
employ nurses (n=15), only one developed clinical guidelines.
Case management
Of the projects employing nurses (n=65), case management was undertaken in 38 per
cent (n=25) by nurses (25%; n=16), primary and secondary sector teams (9%; n=6)
179
and general practice teams (4%; n=3). Of the projects that did not employ nurses
(n=15), case management was undertaken once by a general practice team.
7.3.5
Project level of population-based practice by projects employing
nurses
Projects employing nurses (n=65) adopted overall, a level of practice that focused on
the individual (72%; n=47), either exclusively, or in combination with other levels,
such as community and/or systems.
Exclusive community level practice was not adopted by any project, although 20 per
cent (n=13) adopted a community level in combination with other levels.
Sixty-eight per cent (n=44) of these projects adopted a systems level of practice, with
26% (n=17) exclusively systems.
Exclusively individual or systems levels were
adopted only in projects that did not employ nurses (see Table 23).
Table 23: Project level of population-based practice by projects employing nurses
Project level of practice
No nurses
n (%)
Nurses
n (%)
Total
n (%)
Individual
6
(40.0)
12
(18.5)
18 (22.5)
Systems
9
(60.0)
17
(26.2)
26 (32.5)
Individual & Community
0
(0)
9
(13.8)
9
Individual & Systems
0
(0)
23
(35.4)
23 (28.8)
Community & Systems
Individual & Community &
Systems
0
(0)
1
(1.5)
1
(1.3)
0
(0)
3
(4.6)
3
(3.8)
Total
15 (100.0)
7.3.6
65 (100.0)
(11.3)
80 (100.0)
Age group by projects employing nurses
Of the 65 projects employing nurses, 28 per cent (n=18) targeted people of all ages.
Specific age groups, such as, adults (21-55 years) were targeted in 32 per cent (n=21)
180
of projects, older adults (>55 years) in 22 per cent (n=14), and children and
adolescents (0-20 years) in 18 per cent (n=12).
7.3.7
Ethnicity by projects employing nurses
Almost 60 per cent (n=38) of the projects employing nurses focused on Maori and/or
Pacific peoples. Of these projects, 52 per cent (n=34) included Maori, and 20 per cent
(n=13) were exclusively Maori. Twenty-six per cent (n=17) of the projects included
Pacific peoples and six per cent (n=4) were exclusively Pacific.
More than 40 per cent (n=27) of the projects employing nurses did not have an ethnic
focus. In comparison 73 per cent (n=11) of the projects that did not employ nurses
did not have an ethnic focus.
7.3.8
Low income by projects employing nurses
Seventy per cent of projects (n=56) did not have a low income focus. Nurses were
employed in 44 of these projects.
Of the 30 per cent (n=24) of projects that
demonstrated a low income focus, nurses were employed in the majority (n=21) of
these.
Whilst there were fewer (n=21) nurses employed in projects with a low income focus,
these nurses accounted for a greater proportion (88%) of the projects employing
nurses when compared with projects employing nurses that did not have a low income
focus (79%).
181
7.3.9
Disease, condition or other by projects employing nurses
Table 24: Disease or condition or other by projects employing nurses
Disease, condition or other
No nurses
n (%)
Other
2 (13.3)
Diabetes
Nurses
n (%)
Total
n (%)
12 (18.5)
14 (17.5)
0 (0)
9 (13.8)
9 (11.3)
Cardiac
1 (6.7)
4 (6.2)
5 (6.3)
Meningitis
1 (6.7)
0 (0)
1 (1.3)
Mental health
0 (0)
6 (9.2)
6 (7.5)
Asthma/respiratory
Chronic obstructive pulmonary
disease
Iron deficiency
0 (0)
4 (6.2)
4 (5.0)
2 (13.3)
5 (7.7)
7 (8.8)
0 (0)
1 (1.5)
1 (1.3)
Hip fracture
3 (20.0)
1 (1.5)
4 (5.0)
Hepatitis B
0 (0)
1 (1.5)
1 (1.3)
Cerebrovascular disease
1 (6.7)
3 (4.6)
4 (5.0)
Sexual & reproductive health
0 (0)
5 (7.7)
5 (6.3)
Urinary tract infection
0 (0)
1 (1.5)
1 (1.3)
Acute confusion
1 (6.7)
3 (4.6)
4 (5.0)
Acute conditions
0 (0)
1 (1.5)
1 (1.3)
Two or more chronic conditions
4 (26.7)
7 (10.8)
11 (13.8)
Dental health
0 (0)
1 (1.5)
1 (1.3)
Obstetric health
0 (0)
1 (1.5)
1 (1.3)
65 (100.0)
80 (100.0)
Total
15 (100.0)
Diabetes, two or more chronic conditions, mental health, chronic obstructive
pulmonary disease, sexual and reproductive health, cardiac conditions, and asthma
and respiratory conditions were targeted most often (n=36) by projects employing
nurses (n=65).
Projects that did not employ nurses (n=15) did not target diabetes, mental health,
sexual and reproductive health, or asthma and respiratory conditions. Whilst projects
targeted two or more chronic conditions, chronic obstructive pulmonary disease,
cerebrovascular disease and cardiac conditions (n=8), there was an also an emphasis
on hip fracture, meningitis and acute confusion (n=5) (see Table 24).
182
7.3.10
Chronic or acute condition, well-health, or other by projects
employing nurses
Of the projects employing nurses (n=65), over half (55%; n=36) targeted chronic
conditions. Twenty per cent (n=13) targeted well-health, 6 per cent (n=4) acute
conditions, and 19 per cent (n=12) were classified as other.
7.3.11
Non-nursing personnel by projects employing nurses
Of the 80 projects, almost 40 per cent (n=30) employed non-nursing personnel. A
higher percentage of non-nursing personnel were employed in projects that did not
employ nurses (47%; n=7) compared with projects that employed nurses (35%; n=23).
Project administration and service coordination was most often undertaken by nonnursing personnel in projects that did not employ nurses (40%; n=6) compared with
projects that employed nurses (26%; n=17). It is of note that non-nursing personnel
conducted research and audits in four projects, all of which employed nurses.
7.4
7.4.1
Chronic or acute condition, well-health, or other
Health service by chronic or acute condition, well-health, or other
A chronic condition focus was apparent in half of the 80 projects, with specific health
services, and combinations of services such as treatment and follow-up and
rehabilitation, provided in over 60 per cent of these projects. Screening and
prevention comprised almost half of the well-health projects (see p. 184, Table 25).
183
Table 25: Health service by chronic and acute condition, well-health, or other
Other
Acute
condition
n (%)
Well-health
Total
n (%)
Chronic
condition
n (%)
n (%)
n (%)
No health
services
7 (41.2)
15 (37.5)
1 (12.5)
2 (13.3)
25 (31.3)
Combination of
services
5 (29.4)
15 (37.5)
3 (37.5)
1 (6.7)
24 (30.0)
Diagnostic
testing & advice
2 (11.8)
3 (7.5)
0 (0)
3 (20.0)
8 (10.0)
Rehabilitation
1 (5.9)
2 (5.0)
1 (12.5)
1 (6.7)
5 (6.3)
Screening &
prevention
1 (5.9)
2 (5.0)
0 (0)
7 (46.7)
10 (12.5)
Health
promotion
1 (5.9)
1 (2.5)
0 (0)
1 (6.7)
3 (3.8)
Treatment &
follow-up
0 (0)
2 (5.0)
3 (37.5)
0 (0)
5 (6.3)
40 (100.0)
8 (100.0)
Total
7.4.2
17 (100.0)
15 (100.0)
80 (100.0)
Project level of population-based practice by chronic or acute
condition, well-health, or other
Of the projects with a chronic condition focus (50%; n=40), individual and systems
levels of practice were adopted either exclusively (n=20), or in combination (n=15)
and were clearly the preferred approach for these projects. Similarly, in projects with
an acute condition focus, system, and individual levels of practice were most often
adopted. A community level of practice was apparent in well-health projects, and
projects classified as other most often adopted a systems level of practice consistent
with the development of databases and disease-state registers (see p. 185, Table 26).
184
Table 26: Project level of population-based practice by chronic or acute condition, wellhealth, or other
Individual
Systems
n (%)
n (%)
Individual
&
Community
n (%)
Individual Community
&
& Systems
Systems
n (%)
n (%)
Individual
&
Community
& Systems
n (%)
Total
n (%)
11 (42.3)
1 (11.1)
4
(17.4)
1 (100)
0 (0)
17 (21.3)
Chronic
10 (55.6) 10 (38.5)
condition
2 (22.2)
15
(65.2)
0 (0)
3 (100)
40 (50.0)
Acute
condition
2 (11.1) 4 (15.4)
1 (11.1)
0 (0)
0 (0)
8 (10.0)
Wellhealth
6 (33.3) 1 (3.8)
5 (55.6)
3
(13.0)
0 (0)
0 (0)
15 (18.8)
Total
18 (100) 26 (100)
9 (100)
23 (100)
1(100)
3 (100)
80 (100)
Other
7.4.3
0 (0)
1 (4.3)
Age group by chronic or acute condition, well-health, or other
Children were the age group least represented in projects with a chronic condition
focus (n=5). Children were targeted in four well-health projects and three targeting
acute condition. Adults (21-55 years) were the age group best represented in projects
targeting chronic condition, acute condition, and well-health.
Older adults (>55
years) were targeted in projects focusing on acute condition, chronic condition, and
those classified as other.
Other included projects that targeted a disease or condition in the development of
databases and disease-state registers, which contrasted with projects classified as
chronic and acute where there was direct clinical intervention. Projects did not target
the maintenance of well-health in older adults (see p. 186, Table 27).
185
Table 27: Age group by chronic or acute condition, well-health, or other
All ages
n (%)
Other
Chronic condition
Children
n (%)
7 (31.8)
1 (7.7)
11 (50.0)
5 (38.5)
Adults
n (%)
0 (0)
Older adults
n (%)
9 (40.9)
17 (8.9)
15 (65.2)
9 (40.9)
40 (50.0)
8 (10.0)
Acute condition
0 (0)
3 (23.1)
1 (4.3)
4 (18.2)
Well-health
4 (18.2)
4 (30.8)
7 (30.4)
0 (0)
Total
7.4.4
22 (100.0)
13 (100.0)
Total
n (%)
23 (100.0)
22 (100.0)
15 (18.8)
80 (100.0)
Age group by disease, condition or other
Of the projects targeting children (n=13) approximately half (n=7) focused on a
specific disease or condition, with asthma and respiratory conditions and two or more
chronic conditions accounting for five of these projects.
Of the projects targeting adults (n=23), the majority (96%; n=22) focused on a
specific disease or condition. Diabetes, mental health, chronic obstructive pulmonary
disease and sexual and reproductive health accounted for the greatest number of
projects.
Of the projects targeting older adults (n=22), the majority (95%; n=21) focused on
specific diseases or conditions. Two or more chronic conditions, acute confusion, hip
fracture and cerebrovascular disease accounted for the greatest number of projects.
Of the projects targeting all ages (n=22), 64 per cent (n=14) focused on specific
diseases or conditions.
Diabetes, cardiac conditions and two or more chronic
conditions accounted for the greatest number of projects.
186
7.4.5
Ethnicity by type of disease, condition or other
Of the projects targeting Maori (48%; n=38) both exclusively or within the wider
population, and including Pacific people, 19 targeted diseases or chronic conditions
and 13 targeted well-health. Few projects targeted acute conditions (n=3) or were
classified as other (n=3).
Of the projects targeting Pacific peoples (26%; n=21) both exclusively or within the
wider population, and including Maori, eight targeted diseases or chronic conditions
and six targeted well-health. Only three projects targeted acute conditions and four
were classified as other.
Almost half of the projects (n=38) did not have an ethnicity focus, and more than 50
per cent (n=20) of these projects targeted chronic conditions.
7.5
7.5.1
Age group
Ethnicity by age group with and without disease or condition
Twelve of the 13 projects targeting children with or without a disease or condition had
a Maori and/or Pacific focus.
Thirteen of the 23 projects targeting adults with or without a disease or condition had
a Maori and/or Pacific focus. Of these projects, 12 targeted adults with a specific
disease or condition.
One of the 22 projects targeting older adults with or without a disease or condition
had a Maori and/or Pacific focus, and this sole project did not have a disease or
condition focus. Projects did not target older Maori or Pacific adults with a specific
disease or condition (see p. 188, Table 28).
187
Sixteen of the 22 projects targeting all ages with or without a disease or condition, had
a Maori and/or Pacific focus. Of these projects nine focused on Maori exclusively
and most also targeted a disease or condition.
Table 28: Ethnicity by age group with or without disease or condition
No
ethnicity
Maori
Maori &
wider
population
Pacific
Pacific
&
Maori
n (%)
n (%)
n (%)
n (%)
n (%)
All ages
4 (10.5)
2 (15.4)
0 (0)
0 (0)
All ages/
disease or
condition
2 (5.3)
7 (53.8)
3 (37.5)
Children
0 (0)
1 (7.7)
Children/
disease or
condition
1 (2.6)
Adults
Adults &
disease/
condition
Pacific &
Maori &
wider
population
n (%)
Total
n (%)
0 (0)
2 (12.5)
8 (10.0)
1 (25.0)
0 (0)
1 (6.3)
14 (17.5)
1 (12.5)
1 (25.0)
0 (0)
3 (18.8)
6 (7.5)
0 (0)
1 (12.5)
1 (25.0)
1 (0)
3 (18.8)
7 (8.8)
0 (0)
1 (7.7)
0 (0)
0 (0)
0 (0)
0 (0)
1 (1.3)
10 (26.3)
2 (15.4)
2 (25.0)
1 (25.0)
0 (0)
7 (43.8)
22 (27.5)
Older adults
0 (0)
0 (0)
1 (12.5)
0 (0)
0 (0)
0 (0)
1 (1.3)
Older adults
& disease/
condition
21 (55.3)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
21 (26.3)
Total
38 (100)
13 (100)
8 (100)
4 (100)
1 (100)
16 (100)
80 (100)
7.5.2
Income by age group, with or without disease or condition
Populations in low decile areas, classified low income, were targeted in 30 per cent
(24/80) of projects. Seventeen of these projects targeted a disease or condition in
people of all ages (n=9), adults (n=7), and children (n=1). It is important to note, that
projects with a low income focus did not specifically target older adults with or
without a disease or condition.
188
However, 22 projects that did not target low income, but focused on all older people,
targeted a disease or condition (n=21). This occurred similarly in projects focusing on
adults where 22 of 23 projects targeted a disease or condition.
Children were
represented in five projects targeting low income and an additional 13 projects
without this focus, included seven projects targeting a disease or condition. The
greatest proportion of projects with a low income focus (n=11) targeted all ages, and
in addition, a further 14 of 22 projects without an income focus, targeted a disease or
condition.
7.6
Nursing interventions
Seventeen nursing interventions are reported independently. The characteristic or
variable, level of population-based practice (individual, community, or systems), was
compared with a range of other variables of interest. This variable was manipulated
to create the categories of individual, community and systems.
The original
categories (see p. 154) were combined placing all categories with individual together,
with community together, and with systems together. Therefore, some of the original
categories are represented in one or more of the three new categories.
For each of the comparison variables, one or two categories were selected for
comparison: disease, condition or well-health; low income, and ethnic group (see p.
152, Table 16). The categories for ethnic group (see p. 152, Table 16 question 13)
were manipulated to create a category ‘Maori’ comprising all categories that included
Maori.
Individual
Thirteen of the 17 interventions were undertaken most often at the individual level,
relative to the community or systems level in projects. They were health teaching
(n=31) (see p. 190, Table 29), consultation (n=31), collaboration (n=30), referral and
follow-up (n=30), case management (n=30), delegated functions (n=29), counselling
(n=29), advocacy (n=29), policy development and enforcement (n=24), screening
189
(n=23), outreach (n=22), disease and health event investigation (n=14) and social
marketing (n=12) (see p. 192, Figure 17 and Appendix 4).
Table 29: Health teaching intervention undertaken by nurses in projects
Individual
Community
Systems
Ethnic Group
Low Income
Total No.
projects
Maori (%)
Low decile area (%)
31
4
1
21 (67.7)
3 (75)
0 (0)
16 (51.6)
2 (50)
0 (0)
Disease/Condition or Well-health
Chronic (%)
18 (58.1)
3 (75)
1 (100)
Well-health (%)
7 (22.6)
1 (25)
0 (0)
For categories Maori, low decile area, chronic (disease or condition), and well-health,
the individual level of interventions consistently contained more projects (see Table
29 and Appendix 4).
Community
Both the community organising and coalition building interventions were undertaken
most frequently at the community level, relative to the systems level. In fact, systems
level community organising interventions were not undertaken in any projects (see p.
192, Figure 17). Note individual level interventions are never undertaken in these
interventions (see p. 94). For categories Maori, low decile area, chronic, and wellhealth, the community level of both interventions consistently contained more projects
(see p. 190, Table 30 and p. 191, Table 31).
Table 30: Community organising intervention undertaken by nurses in projects
Community
Systems
Ethnic Group
Low Income
Total No.
projects
Maori (%)
Low decile area (%)
15
0
14 (93.3)
0 (0)
8 (53.3)
0 (0)
Disease/Condition or Well-health
Chronic (%)
7 (46.7)
0 (0)
Well-health (%)
6 (40)
0 (0)
190
Table 31: Coalition building intervention undertaken by nurses in projects
Community
Systems
Ethnic Group
Low Income
Total No.
projects
Maori (%)
Low decile area (%)
24
12
20 (83.3)
8 (66.7)
Disease/Condition or Well-health
Chronic (%)
11 (45.8)
4 (33.3)
13 (54.2)
6 (50)
Well-health (%)
7 (29.2)
3 (25)
Systems
The surveillance intervention was undertaken most often at the systems level relative
to the individual and community levels (see p. 192, Figure 17). For categories Maori,
low decile area, chronic, and well-health, the systems level of surveillance
intervention consistently contained more projects (see Table 32).
Table 32: Surveillance intervention undertaken by nurses in projects
Individual
Community
Systems
Ethnic Group
Low Income
Total No.
projects
Maori (%)
Low decile area (%)
1
2
11
1 (100)
2 (100)
9 (81.8)
0 (0)
0 (0)
3 (27.3)
Disease/Condition or Well-health
Chronic (%)
0 (0)
1 (50)
5 (45.5)
Well-health (%)
0 (0)
0 (0)
3 (27.3)
191
Figure 17: Interventions and levels of population-based practice undertaken by
nurses in projects
7.7
Social values embedded in the practices of nurses employed in projects
Beattie’s analytical model of health promotion (Beattie, 1991) allows links between
health promotion values and the practice of nurses employed in projects to be
identified. Figure 17 shows sixteen interventions62 and the level of population-based
practice most often undertaken by nurses with regard to each intervention.
Interventions are situated within Beattie’s model of health promotion, which has been
62
‘Case finding’ the seventeenth intervention is included within the interventions surveillance, disease
and health event investigation, outreach, and screening at the individual level.
192
adapted (see p. 194, Figure 18). The rationale for adapting the original model is
identified in chapter six, data analysis stage two (see pp. 160-161).
The majority (14/17) of the interventions are situated on the x-axis in the direction of
the individual focus of intervention, ranging numerically from the highest, case
management (n=37) to the lowest, social marketing (n=8).
Nine of these
interventions: social marketing; surveillance; disease and health event investigation;
policy development and enforcement; screening; delegated functions; health teaching;
referral and follow-up, and case management are situated within the quadrant titled
health persuasion, reflecting a paternalist and individual-oriented philosophy (Beattie,
1991).
The five remaining interventions: outreach, collaboration, advocacy,
counselling and consultation are situated in the personal counselling quadrant, which
highlights a negotiating approach, maintains an individual-oriented philosophy, but
does not necessarily imply paternalism.
Two interventions, coalition building and community organising are situated on the xaxis in the direction of the community focus of intervention. Community organising
is situated in the community development quadrant, reflecting collective action that is
participative and community based, whilst coalition building is situated mid-way
between legislative action and community development, reflecting collective action
that can be participative and community based or paternalistic and state-directed
(Beattie, 1991).
The authoritative mode of intervention was apparent in 10 of the 16 interventions
undertaken by nurses, with coalition building the only intervention to have a
collective focus.
A negotiated mode of intervention was apparent in seven
interventions that included coalition building, with only two having a community
focus.
193
Figure 18: An adaptation of Beattie’s model of health promotion situating
total interventions by nurses in projects
194
7.8
Summary of study results
The current study has four central research questions (see p. 128, section 6.2). A
summary of the results is included in Table 33, as a precise means of responding to
the research questions.
Question one precedes a list of the characteristics of
integrated care projects. Selected brief evidence informs the association between
project characteristics and projects employing nurses, before a rating of the strength of
this association is attributed. ‘Strong association’ equates to 85 per cent and over,
‘association’ to 16 - 84 per cent, and ‘weak association’ to 0 - 15 per cent. Questions
2, 3, and 4 are answered simultaneously. Each intervention is briefly identified, with
the most frequent level of practice and social values pertaining to that intervention,
ascribed.
Table 33: Summary of research questions and evidence informed responses
Research question 1:
Which characteristics of integrated care are more strongly associated with projects that employ nurses?
Characteristic
Evidence
Rating scale
Weak Association Strong
association
association
(0 - 15%) (16 - 84%) (85-100%)
Organisation
(see section 7.3.1)
√
Providing an existing
service differently and
planning a new
service
In 60% of projects general practice provided care
previously provided by hospital specialists and
nurses were employed in 85% of these projects.
In addition, 38% planned a new service and
nurses were employed in 97%.
Health services
provided by project
Almost 70% of projects provided health services
and nurses were employed in 78% of these
projects.
√
Incentives and costs:
General Practice
84% of general practices received incentives to
participate and nurses were employed in 78%.
√
General practice did not incur financial costs as a
result of participating in projects.
Incentives and costs:
Hospitals
Material incentives to
clients
√
11% of hospitals incurred financial costs as a
result of participating in projects and nurses were
employed in 67% of these projects.
√
93% of hospitals received incentives to participate
in projects and nurses were employed in 80%.
√
5% of projects provided material incentives to
clients and nurses were employed in all projects
(100%).
√
195
Funding
(see section 7.3.2)
Type of service
integration
(see section 7.3.3)
68% of projects received the main source of new
funding from government and nurses were
employed in 82% of these projects.
√
40% of projects were vertically integrated and
nurses were employed in 69% of these projects.
√
19% of projects were horizontally integrated and
nurses were employed in 100%.
√
41% of projects were vertically and horizontally
integrated and nurses were employed in 85%.
√
Information sharing
65% of projects undertook information sharing building relationships, peer advice & education,
peer referral, and client education, and nurses
were employed in 88% of these projects.
√
Database for
information sharing
50% of projects undertook database development,
and nurses were employed in 85%.
√
Guideline
development
21% of projects undertook guideline development
and nurses were employed in 94%.
√
Guideline promotion
36% of projects undertook guideline promotion and
nurses were employed in 93%.
√
Case management
33% of projects undertook case management and
nurses were employed in 96%.
√
New coordination
strategy
56% of projects undertook a new coordination
strategy and nurses were employed in 84%.
Strategies for
integrated care
(see section 7.3.4)
Project level of
population-based
practice
(see section 7.3.5)
√
√
67% of projects adopted an individual level of
practice and nurses were employed in 87% of
these projects.
√
16% of projects adopted a community level of
practice and nurses were employed in all (100%).
Age group focus
(see section 7.3.6)
66% of projects adopted a systems level of
practice and nurses were employed in 83%.
√
28% of projects targeted people of all ages and
nurses were employed in 82% of these projects.
√
16% of projects targeted children and adolescents
(0-20 years) and nurses were employed in 92%.
√
29% of projects targeted adults (21-55 years) and
nurses were employed in 91%.
√
28% of projects targeted older adults ( 55 years)
and nurses were employed in 64%.
√
196
Ethnic group focus
(see section 7.3.7)
Low income focus
(see section 7.3.8)
Chronic or acute
disease or condition,
well-health or other
focus
(see section 7.3.9)
53% of projects targeted Maori and/or Pacific
peoples exclusively or in combination with the
wider population and nurses were employed in
90% of these projects.
√
30% of projects targeted populations in geographic
areas defined as low decile and representing the
30% most deprived areas in New Zealand, and
nurses were employed in 88% of these projects.
√
50% of projects targeted chronic conditions and
nurses were employed in 90% of these projects.
√
√
21% of projects targeted ‘other’ (such as
information management) and nurses were
employed in 71%.
√
19% of projects targeted well or positive health
and nurses were employed in 87%.
Practice of nonnursing personnel
(see section 7.3.10)
10% of projects targeted acute conditions and
nurses were employed in 50%.
√
38% of projects employed non-nursing personnel
and nurses were employed in 77% of these
projects.
√
Research questions 2, 3, and 4:
What types of population-based interventions were undertaken by nurses in integrated care projects?
What population-based levels of practice did nurses demonstrate in integrated care projects?
What underlying values are made explicit when interventions undertaken by nurses are analysed?
Types of interventions
Levels of practice
most often
undertaken
Values made explicit in
interventions
Individual Community Systems
√
Surveillance
Collected and analysed data on health threats,
such as chronic disease
Health Persuasion
Authoritative mode
Individual focus
Disease and health event investigation
Focused on chronic diseases and other health
events, a key component of surveillance
√
Health Persuasion
Outreach
Informed those at risk, of risks to inform action,
used in conjunction with health teaching
√
Personal counselling
Authoritative mode
Individual focus
Negotiated mode
Individual focus
197
Screening
Preceded by outreach/social marketing, and in
conjunction with health teaching/counselling
√
Health Persuasion
Referral and follow-up
Nurses received referrals and referred on, always
linked with another intervention
√
Health Persuasion
Case management
Clinical case management model preferred,
emphasis on clients with chronic conditions
√
Health Persuasion
Delegated functions
Most often from GPs, and delegation to other
nurses, often related with case management
√
Health Persuasion
Health teaching
Most frequent intervention implemented
sequentially with counselling and consultation
√
Health Persuasion
Counselling
Aided problem solving, acknowledged feelings
√
Personal counselling
Consultation
Frequently a component of case management,
such ‘advice’ often followed health teaching
√
Personal counselling
Collaboration
Changed both the client and nurse, was linked
with concepts of empowerment and partnering
√
Personal counselling
Authoritative mode
Individual focus
Authoritative mode
Individual focus
Authoritative mode
Individual focus
Authoritative mode
Individual focus
Authoritative mode
Individual focus
Negotiated mode
Individual focus
Negotiated mode
Individual focus
Negotiated mode
Individual focus
√
Coalition building
Collective action that was mandated, but sought
to engage communities in projects
Legislative action and
Community
development Authoritative &
Negotiated modes
Collective focus
√
Community organising
With social marketing, activities sought to change
the health behaviours of communities
Community
development
Negotiated mode
Collective focus
Advocacy
Negotiated with clients, acting in a client’s interest
occurred in many related interventions
√
Personal counselling
Social marketing
‘Health information’ congruent with a client’s
values was aligned with other interventions
√
Health Persuasion
Policy development and enforcement
Occurred most frequently at the local level, with
enforcement occurring at the nation level
√
Health Persuasion
Negotiated mode
Individual focus
Authoritative mode
Individual focus
Authoritative mode
Individual focus
198
8
8.1
Chapter 8
Discussion
Introduction
In this thesis data from a descriptive survey were analysed to quantitatively profile the
characteristics of integrated care projects in order to identify the strength of the
relationship between specific characteristics and the practice of nurses in these
projects. The practice of nurses was investigated on three dimensions: the types of
interventions; individual, community and systems levels of practice, and the values
that could be identified from the manner in which nurses worked (see p. 128, section
6.2 research questions). Characteristics of integrated care refer to the following ten
variables: organisation; funding; type of service integration; strategies for integration;
level of project approach; age group targeted; ethnic group targeted; low income
group targeted; health, disease or condition targeted, and the practice of non-nursing
personnel, which were comprehensively discussed in chapter six (see p. 127).
Sections 8.2 to 8.4 answer the four research questions, with all sections beginning by
reporting relevant new findings. Section 8.2 analyses each characteristic of integrated
care and the strength of the association with projects employing nurses.
These
findings are discussed in light of the literature reviewed. Section 8.3 identifies the
interventions and population-based levels of practice undertaken by nurses and
analyses these by systematic reference to the ‘public health intervention model’
presented earlier. Practice examples illustrate the range and level of work undertaken
by nurses within the integrated care environment and enable deeper insights into the
nature of these practices. Section 8.4 explores the health promotion values embedded
within interventions and considers the implications of practice situated in a single
dominant paradigm. Health promotion theory, and in particular Beattie’s model of
health promotion (see pp. 30-36) is applied to help make the values within
interventions explicit and as a reference point for critical analysis. Finally, on the
basis of study findings the Primary Health Care Interventions Model (PHCI model), a
new framework to assist the implementation of PHC nursing practice, is presented.
199
8.2
Which characteristics of integrated care are more strongly associated with
projects that employ nurses?
The characteristics strongly associated with projects that employ nurses are: 1.
organisation: providing an existing service differently and planning a new service;
providing material incentives to clients; 2. type of integration: horizontal integration;
a combination of both horizontal and vertical integration; 3. strategy for integration:
information sharing; database for information sharing; guideline development;
guideline promotion; case management; 4. project population-based practice:
individual-level; community-level; 5. age group focus: children and adolescents;
adults; 6. ethnic group: Maori and Pacific; 7. low income: populations representing
the 30 per cent most deprived areas in New Zealand, and 8. health, disease/condition
or other focus: chronic conditions, and well-health. These characteristics, and other
characteristics not as strongly associated with projects employing nurses, are
described in relation to nurses’ practice (see pp. 195-198, Table 33).
8.2.1
8.2.1.1
Organisation
Delivering an existing service differently and planning a new service
A strong association was evidenced between general practices employing nurses and
delivering an existing service differently, such as a shift in services previously
provided by hospitals to general practice. This transition of existing services from
secondary to primary sectors also influenced the planning of new services within the
primary sector (see p. 163).
Services included administering ‘free’ influenza
vaccines, taking echocardiograms, sexual health management, providing (functional)
rehabilitation programmes, and conducting mental health assessments. The majority
of these services retained a narrow primary health care focus on individuals (see p.
184). This study identified that general practice operating within a clinical medical
paradigm constructed an environment where nurses undertook tasks delegated by their
employers and perpetuated a selective or narrow primary health care approach to the
delivery of existing services and the planning of new services. This is probably
because practice nurses have traditionally been employees of general practice
200
physicians who operate in privately owned businesses (Minto, 2004) and as Docherty
(2004) suggests it has always been difficult for nurses to provide a more
comprehensive nursing service when the ‘service’ is financially determined by the
employer.
The majority of projects employing nurses maintained a governance base, personnel,
and philosophy analogous to those of general practice. There was little evidence of
innovation in nurses’ approach to primary health care.
Overall, there was little
evidence of the primary health care approach described by the World Health
Organization (1986) and advocated in the PHC Strategy (Ministry of Health, 2001c).
These approaches are multi-level and comprehensive. For example, a primary health
care nurse working with older adults at risk of hip fracture in the future, for example,
could facilitate access to exercise programmes that improve strength, balance and gait
(individual level), advocate for traffic-free walking areas (community level), and
collaborate to promote the positive ageing strategy as a framework for health service
provision (systems level). This type of multi-level primary health care approach
develops personal skills, creates supportive environments and reorients health services
- health promotion strategies that go beyond healthy life-styles to overall well-being
(World Health Organization, 1986). The future contribution of nurses in primary
health care has “yet to be fully realised” (Ministry of Health, 2003b, Executive
summary, para. 1), with more comprehensive approaches to service provision
necessary.
8.2.1.2
Health care services provided by projects
An association was evidenced between health care services provided by projects, such
as screening and prevention, diagnostic tests and expert advice, health promotion,
treatment and follow-up, and rehabilitation, and nurses employed in projects.
Only projects employing nurses undertook health promotion.
The different
approaches adopted by projects reflected distinctive priorities and different
perspectives about clients. For example, health education that targeted children with
asthma was the sole health promotion activity in one project while another project saw
201
health promotion as creating a supportive environment for physical recreation. The
asthma education project was limited in scope to concepts of prevention and health
protection. The physical recreation project by comparison, attempted to promote
positive health and targeted people in a community setting. This project linked to
other services that could offer information and education about health and social
issues, empowering clients to set their own health agendas.
Health promotion was not defined in the questionnaire allowing for the widest
interpretation of this activity by respondents.
Internationally there has been a
continuing theoretical debate about whether health promotion should include disease
reduction and prevention, and health protection, or whether it should be concerned
solely with positive health (Downie et al., 1990; J. French, 1990). Similarly, a wide
variation in perspectives was reflected in project descriptions of health promotion
practice. In general an individualistic health education approach prevailed. Although
Carryer et al. (1999) suggest that nurses understand a strategy of health promotion
that addresses the social and environmental determinants of health (see p. 78), this
study found that very few projects attempted a comprehensive approach and that
nurses almost never addressed the determinants of health in health promotion
activities. This may be attributed to a lack of understanding of the broad strategies of
health promotion or to organisational characteristics discussed earlier that limited
nurses’ influence, or both. Beattie (1991) contends it is necessary to understand how
health promotion is connected to broader social, political and cultural values in order
to develop practice and improve health outcomes.
The absence of evidence of
engagement by nurses in health promotion activities indicates a need to address both
issues of understanding and governance (see p. 208).
Treatment and follow up and rehabilitation were undertaken least in projects
employing nurses. General practice physicians or hospital specialists saw clients most
often in their clinics or practices for medical treatments and/or follow up assessments
after discharge from hospital for conditions such as hip fracture or chronic obstructive
pulmonary disease. Rehabilitation was ‘functional’ seeking to improve the activities
of daily living for clients who had suffered a condition such as a cerebrovascular
disease.
Physiotherapists undertook most of the rehabilitation in projects, and
services were provided in hospital out-patient departments or client’s homes.
202
Treatment and follow-up assessments, and rehabilitation were undertaken by
individual clinicians, usually general practice physicians and physiotherapists, using
traditional bio-medical and mechanistic approaches to health care. The reason for
nurse’s limited participation is unclear, but may relate to a perception by project
planners that nurses had no distinct contribution to make.
Whilst nurses in integrated care projects had a lesser involvement in rehabilitation, it
is a potential area for future primary health care nursing development. Recognition of
the importance of the social and cultural environment to health (Ministry of Health,
2001c) has provided nurses with a legitimate framework in which to construct care
such as rehabilitation, and redefine the nursing contribution. For example in the field
of older people’s health, a new service and funding model ‘ASPIRE63’ is using nurses
to provide restorative and rehabilitative services to older people living in their own
homes (Parsons et al., 2004).
Nurses lead a case management team of
physiotherapists, occupational therapists, general practitioners and support workers in
five New Zealand cities and this model is currently being assessed for application in a
large multicultural population of all ages, with nurses again managing complex
rehabilitation packages (Baird, 2004).
Interestingly, whilst nurses employed in
integrated care projects undertook a limited role in rehabilitation, nurses were actively
engaged in case management, skills transferable to new primary health care nursing
roles.
8.2.1.3
Incentives and costs for general practice to be a project partner
An association was evidenced between general practice incentives and nurses
employed in projects with general practice partners. Overall, integrated care benefited
general practice partners financially by assisting them to develop new and/or existing
services or to pay for case management. Nurses did not benefit directly as they were
employees of general practice physicians and did not have a financial investment in
the business.
63
ASPIRE is the acronym for ‘Assessment of Services Promoting Independence and Recovery in
Elders’.
203
General practice did not incur financial costs as a result of participating in projects
(see Appendix 3, Question 20), although general practice partners contributed to the
funding of projects (see Appendix 3, Question 17). Investigation of these results
revealed the funding of projects was not considered a cost by respondents in the same
way as ‘lesser unanticipated costs’ arising in project planning and implementation,
which accounted for what initially appeared to be a discrepancy in responses.
8.2.1.4
Material incentives to clients
A strong association was evidenced between the projects offering material incentives
to clients and projects employing nurses. Material incentives to clients were only
offered in projects with a strong primary sector influence. Gifts, for example, were
donated by retail business when approached by nurses employed in a general practice,
and clients entitlement to gifts related, in one instance, to having achieved weight
loss. Vouchers for free monthly general practice consultations however, were offered
to people enrolled in the intervention group of a project that sought to test the strategy
of case management for people with chronic obstructive pulmonary disease64. This
incentive enabled the intervention group to attend the general practice for a routine
monthly health check and ultimately ensured the success of the project.
Other
incentives, such as building repairs to homes, and the installation of amenities, such as
inside toilets, resulted from projects that engaged both the health sector - nurses in
clinical health assessments, and the housing sector - builders in home assessments.
Material incentives to clients did not incur costs to project partners in the health
sector, except the project using vouchers, which included these costs at the planning
stage.
The incentives offered to clients in a small number of projects sought to encourage
people to change their health behaviours or participate in some form of health
promotion. This approach is consistent with international strategies that attempt to
help individuals become activated consumers (Bodenheimer et al., 2002a). In the
current study incentives were offered to clients who had chronic conditions and
64
The individuals with chronic obstructive pulmonary disease who were randomised into the control
group did not have access to vouchers.
204
resided in the poorest areas of New Zealand. This is a strategy similar to that of
providing benefits to poorer populations in the United States to promote active
participation (The Robert Wood Johnson Foundation, 2000).
8.2.1.5
Incentives and costs for the hospital to be a project partner
An association was evidenced between hospitals receiving incentives to participate in
projects and projects employing nurses. The most frequent incentive to participate
was to reduce hospital admissions. Like general practice, incentives also included
improving existing health services and planning and/or delivering new health services,
which resulted in financial gains. A number of nurses in hospitals worked between
the primary and secondary sectors in projects contributing, for example, to team case
management. Hospitals invested in this nursing role as part of a wider strategy to
prevent avoidable admissions for conditions such as diabetes, chronic obstructive
pulmonary disease, and cardiac conditions.
Unlike general practice however,
hospitals did not seek to generate revenue.
An association was also evidenced between hospitals incurring costs and the projects
employing nurses. Several projects reported hospital partners incurred costs when, for
example, they funded projects, paid for vaccines that were administered in general
practice, coordinated the database for projects that indicated they had not received
dedicated funding, developed guidelines, protocols and care maps for use in projects,
conducted smoking cessation programmes, and provided clinical and technical
personnel for work in primary and secondary sectors. Hospital partners supported
integrated care projects financially, motivated by the need to reduce hospital
admissions. This motivation influenced the part hospitals played in integrated care
and the predominant bio-medical focus of many projects to managing diseases or
conditions.
Particular costs incurred by hospitals, such as the development of guidelines and
protocols to guide best practice provided a professional incentive related in part to the
development of professional relationships across the health sector between those who
had shared interests in longer term clinical outcomes. Malcolm (1997) suggests
205
professional incentives can be much more effective than market and commercial
incentives in modifying professional behaviour. The effectiveness of professional
and/or financial incentives in encouraging project development is unclear, but an
investment in the primary sector by the secondary sector was apparent.
8.2.2
Funding
An association was evidenced between projects that received their main source of new
funding from government and nurses employed in these projects. Projects received
their main source of funding (new money) from either the Government or project
partners, or used existing resources from organisations partnering in projects.
Interestingly, the latter arrangement to resource projects by pooling existing
resources, rather than dedicating new money from a primary source, resulted in these
projects being identified as not having received funding. Direct government funding
was received by 70 per cent of the projects, and as the strategy of integrated care was
promoted by Government as a purchasing method to develop services that ensured
coordinated care between primary, secondary and tertiary sectors (Scott, 1997), this
was not unexpected. However, other than the allocation of more than NZ$1 million
for the development of nine demonstration integrated care pilot projects, the study
revealed new information about other projects that had received additional
government funding and were defined by stakeholders as integrated care projects.
Nurses employed in projects that received their main source of funding (new money)
from government were noticeably larger in scale than projects receiving funding from
other sources. It was not possible to establish the nature of the relationship between
receiving new money directly from government and projects employing nurses,
although it is likely that this additional resource was in part used to employ nurses.
One large-scale project, uncharacteristic of all other projects, received similar
amounts of new funding from both the Government and project partners and relied
heavily upon nursing. Involving 51 general practices and 135 patients with a clinical
diagnosis of chronic obstructive pulmonary disease, case management was undertaken
by practice nurses, general practice physicians, respiratory nurse specialists, and
respiratory physicians (Rea et al., 2004).
206
A small number of projects received their main source of funding from project
partners unable to gain additional financial support from government. A number of
these projects involved database development and the hospital partner was frequently
the greatest contributor. Such projects commonly employed nurses who received a
salary from the project partner who were their primary employer, which ensured no
direct cost to the project. For example, a nurse specialising in diabetes management
continued to be salaried by the hospital but worked in the project expanding the
nursing role to include case management. Project partners frequently committed
resources, such as nursing services, in addition to investing in the projects main
source of funding.
8.2.3
Type of service integration
A strong association was evidenced between projects that employed nurses and were
horizontally integrated, and also projects that were both horizontally and vertically
integrated. A lesser degree of association was evidenced between projects employing
nurses and projects vertically integrated.
Nurses were employed in all projects that were horizontally integrated with this type
of integration occurring most in the primary sector between general practice and other
primary health care providers. Nurses in the primary sector often refer clients to
services not provided by their organisation such as family planning, sexual health,
rehabilitation, mobile nursing, physiotherapy, osteopathy, chiropractic and pharmacy,
and the short time often allocated in general practice physician consultations is a
further reason for referral (T. Ashton, 1998). Consequently, collaborating with others
in the same sector is routine nursing practice.
Nurses were generally not involved in vertical integration without also engaging in
horizontal integration, although exclusive vertical integration occurred between
general practice physicians and hospital specialists who communicated over clients’
conditions and had authority to plan services and commit funding.
Nurses, in
contrast, did not have the authority to engage in planning services requiring the
commitment of funds, so frequently acted in a role scripted by their employer that
207
influenced the range of interventions undertaken. The College of Nurses Aotearoa
(NZ) Inc. (2001) contended that community nurses roles were assistive and
compensatory (to general practice physicians) limiting their contribution, and arguing
that more collegial collaboration is critical to the success of primary health care
teams.
They maintain that nurses need to be involved at a governance level,
influencing funding and service delivery.
An exception to this exclusion of nurses from governance was found in Maori
provider organisations. Nurses in Maori provider organisations were involved in
decision-making at a governance level and assisted projects to develop and maintain
vertical integration. These nurses collaborated with clinicians in the secondary sector
and with others in the primary sector (horizontal and vertical integration), during the
provision of mobile nursing services to people with chronic conditions. It is likely
that such roles enabled nurses to gain a wider understanding of both the health and
social needs of clients and the cultural and organisational differences of providers.
High visibility of new roles and knowledge appeared to influence nurse’s participation
at a governance level (S. Keown, personal communication, October 11, 2004).
Whilst projects employing nurses had a greater focus on horizontal integration, the
study has shown that nurses who were engaged in projects that were also vertically
integrated were involved in project governance, and this enabled them to be more
influential. Vertical integration remains important as resources are predicted to shift
toward primary and preventative services in an effort to reduce costs and prevent
hospital admissions (Ovretveit, 1998) and collaboration between providers will
remain a core function of nurses and other health professional’s roles (Ministry of
Health, 2001c).
8.2.4
8.2.4.1
Strategies for integrated care
Information sharing
Projects employing nurses were strongly associated with information sharing, which
included building relationships, peer advice and education, peer referral, client
208
education and the development of databases. Interestingly, building relationships and
client education was not undertaken in projects without nurses.
Building relationships
Nurses in the majority of projects that sought to build relationships between primary
and secondary sectors (vertical integration) undertook this activity alongside
relationship development within the same sector (horizontal integration). Vertical
integration and relationship building were actively promoted by project planners
because they aligned with the purpose of constructing a coordinated continuum of
care (Health Funding Authority, 1998).
A few projects employing nurses,
demonstrated complex relationships within the primary sector between general
practice, Maori provider organisations, Pacific provider organisations, the housing
sector, sports associations, and other community groups.
Porter-O’Grady (1999) maintains nursing has always pulled together disparate
resources, health workers, and processes and has focused on the client’s journey
rather than on specific clinical events. In New Zealand, Maori provider organisations
in over two decades of health reform have relied upon nursing to develop health care
services (Durie, 1998). So, it was not surprising that nurses employed in Maori
provider organisations, who were partners in projects, invested heavily in building
relationships.
The study demonstrated that projects with nurses built requisite
partnerships.
The nursing profession has argued the need for intersectoral partnerships and
community development (Carryer, 2004). However, if nursing is to play a significant
role in these areas a common understanding of the terms is necessary. For example,
distinctions between different models of partnership should be understood (see p. 81).
The majority of integrated care projects were designed and managed without any form
of community representation65 and the few projects employing nurses that built
relationships with individuals and communities applied a community involvement
model, where the nurses, acting as project advocates, determined the agenda and then
65
Community representation and in particular Maori representation at governance level was evaluated
in the demonstration pilot projects, signaling the expectation this would be a feature of integrated care
more generally.
209
attempted to get the community on side.
partnership was understood by nurses.
These projects illustrated the way
The interests of communities were not
paramount, or even equivalent, to those of the health professional.
Peer advice, education and referral
Peer advice, education and referral were activities that contributed to building
relationships and strengthening projects overall. Peer advice and education most
commonly occurred between hospital specialists, such as diabetes specialists and
general practice physicians, practice nurses or nurses in Maori or Pacific provider
organisations. In a smaller number of cases, nurses with a specialist area of practice,
such as mental health, advised and educated other nurses with a wider primary health
care focus. Peer advice and education acted as a vehicle for building relationships and
establishing trust in a context where all partners shared a common purpose. The
sharing of clinical knowledge changed relationships between project partners as they
established a team for undertaking functional activities and assessing clinical
outcomes. The success of projects depended upon the relatedness of partners who
agreed activities and outcomes. This behaviour has been described as an ‘issue of fit’
where the process of each of the partners and the comprehensiveness of the agreed
outcome are critical variables in the effectiveness of services (Porter-O'Grady, 1999).
Client education
Client education occurred in six projects, all employing nurses. Client education was
interpreted as a formal component of the project design, rather than an opportunistic
activity dependent upon other interventions. Informal client education occurred in
many projects and included timely information about the condition, human body,
effects of medications, interventions, and available services.
However, this was
random and the quality and reach of the education could not be established.
Client education has the potential to empower consumers to make informed decisions
and thereby shape the health care system. Internationally, consumers generally do not
think they receive enough information and that health care professionals do not
involve them in decisions about their own care (Golodner, 1999).
The formal
inclusion of client education in the design of relevant projects would have reduced the
210
issue of randomness and allowed assessment of quality and reach. The majority of
projects in the current study would have benefited from the inclusion of a formal
client education component. This study finding has implications for ensuring client
education is undertaken effectively in future projects.
Development of a database
Investment in information technology accompanied the legal, institutional and
functional changes that occurred in the New Zealand health care system during the
1990s.
New information allowed decision makers to describe their populations,
assess the effectiveness of interventions, and develop better practice.
Database
development occurred in half of the projects and nurses established a number of
health provider databases that required a comprehensive knowledge of the client
population. Several projects were related to the case management of clients with
chronic conditions where nurses were the sole case manager or had a central role in
case management. Nurses also developed databases to plan future services collecting
information on, for example: babies 0-24 months old at risk of recurrent urinary tract
infections; women with iron deficiency anaemia; children with chronic illnesses and
disabilities, and health services used by people residing in a defined geographic area.
8.2.4.2
Guideline development and promotion
A strong association was evidenced between guideline development and promotion
and projects employing nurses. Guidelines covered a variety of topics including
treatment, prevention and screening and provided physicians, nurses, other health
professionals, and clients with a resource for obtaining objective information on
clinical practices. Nurses were the ‘developer’ of guidelines in half of the projects that
undertook this strategy. In one project nurses developed guidelines for coronary heart
disease through a stringent process of reviewing literature, expert opinion, selected
references, peer review and critical appraisal, and in another project, participated in a
team developing a guideline for the management of chronic obstructive pulmonary
disease in primary health care settings. Guidelines were developed to clarify the
pathway for clients with conditions such as hip fracture, placing an emphasis on
211
rehabilitation to assist health professionals and clients identify available health
services as a foundation for integrated care, and later for outcomes management66.
Jensen and Koerner (1999) among others support guideline use for longitudinal
clinical management and the self-care of chronic conditions.
The most common reason for nurses in projects to promote guidelines was their use in
the case management of clients. This occurred whether guidelines were developed
within projects or externally. Other reasons for promotion included the provision of
information to peers and clients, and the benchmarking of clinical practice. Projects
without nurses had limited involvement in guideline development and promotion.
The study findings suggest nurses in projects developed and promoted guidelines
(systematising processes) to guide clinical practice. In contrast, projects without
nurses but with doctors had a lesser interest in systematised processes.
This
interpretation is supported by recent international research on healthcare
professional’s attitudes to health reforms (Degeling et al., 2003). These authors found
that in four countries, including New Zealand, nurses supported guidelines or
integrated care pathways because it enabled them to balance the clinical and resource
dimensions of care and the requirements of clinical autonomy and transparent
accountability. Nurses held systematised conceptions of clinical work, unlike doctors
who favoured individualist conceptions.
8.2.4.3
Case management
A strong association was evidenced between projects employing nurses and case
management. Nurses were the largest group of individual case managers (68%), also
undertaking case management as part of a multidisciplinary team or general practice
physician and practice nurse team. Case management occurred in less than half of the
projects employing nurses and was seldom undertaken in projects without nurses.
The most common case management role was the direct provision of clinical care by a
nurse within a specialty area, such as diabetes management. Other roles included
66
Outcomes management refers to a “technology of patient experience designed to help patients,
purchasers and providers make rational medical care-related choices based on insight into the effects of
these choices on the patient’s life” (Ellwood, 1988, p. 155).
212
facilitating access to services, brokering services, coordinating services, and
delegating and supervising other nurses providing clinical care.
Whilst numerous case management models exist (Brault & Kissinger, 1991;
DeSimone, 1988; Papenhausen, 1990; Weil & Karls, 1985), the key features of case
management in the projects investigated revealed similarities with either the ‘clinical
case management model’ (Stein & Test, 1980) or the ‘brokerage model’ (Burns, 1997;
Kanter, 1989), with the former model being most commonly identified. In the clinical
case management model the case manager maintained contact with the client over the
long-term. This was not a feature of the brokerage model, which emphasises the
“coordination and organisation of services for clients” (Kanter, 1989, p. 114), despite
wide consensus that all models should include this element (Ford et al., 1995).
International literature identifies additional features sometimes adopted into the
clinical case management model. Three such features include the development of an
individual’s strengths (Modrcin et al., 1988), a focus on rehabilitation medication
management and social skills (Goering et al., 1988), and an emphasis on the
coordination of services (Kanter, 1989).
A number of integrated care projects
demonstrated one or more of these additional features. For example, the ‘South
Auckland chronic obstructive pulmonary disease project’ and the ‘Eldercare
Canterbury community rehabilitation project’ both focused on rehabilitation and the
coordination of services, and the ‘Supportive recreation project’ (Tairawhiti) focused
on the development of an individual’s physical strength and social connectedness.
The clinical case management model is the only model to have been used as an
alternative to acute hospital admissions (Marshall et al., 1998) and there is mounting
evidence that this model is more effective in this respect than the brokerage model
(Thomas & Lovell, 1999). As integrated care projects sought to prevent avoidable
hospitalisations the adoption of a clinical case management model was predictable.
Integrated care also sought to coordinate services and whilst adopting the brokerage
model to achieve this end relied more heavily upon partnership arrangements as the
central vehicle for this activity.
Integrated care projects engaged a multidisciplinary health professional workforce and
interventions were often conducted in community facilities and client’s homes, similar
213
features to clinical case management in countries such as the United Kingdom
(Marshall et al., 1998), with the most striking difference being the case loads of nurse
case managers. Marshall et al. report case loads of 10 - 15 clients in the United
Kingdom, whereas nurses studied in integrated care projects in New Zealand often
held case loads well in excess of 15 clients, and sometimes reaching 80 or more
clients. In these situations nurses delegated functions and supervised other nurses as a
way of managing their work.
8.2.4.4
New coordination strategies
An association was evidenced between projects employing nurses and the
development of a new coordination strategy. New coordination strategies involved
working in non-traditional ways with project partners, such as sports organisations,
district councils and the housing sector.
Intersectoral collaboration influenced a
broader approach to health and new ways of coordinating and providing health
interventions. For example, in one project nurses, plumbers and builders visited
clients in rural and remote communities to provide health assessments, vaccinations,
maintain sewerage systems, and repair, insulate and adapt homes to improve the
quality of life for residents.
8.2.5
Level of population-based practice approach of projects
A strong association was evidenced between projects that adopted an individual or a
community level approach and projects that employed nurses. A lesser degree of
association was evidenced between projects that adopted a systems approach and
projects that employed nurses.
The study demonstrated overall that exclusive individual, and individual and systems
approaches were favoured over community approaches.
An individual level of
approach predominated in 72 per cent of the projects employing nurses, with an
exclusive approach occurring in one quarter of these projects and a further 50 per cent
adopted both individual and system approaches.
A community approach in
214
combination with an individual, or individual and system approach, occurred in about
a quarter of these projects.
Projects employing nurses adopted community and
systems approaches more often than projects without nurses.
Strengthening
community capacity and changing community norms, outcomes of community level
interventions, are essential requirements of primary health care and nurses in projects
contributed to the gradual development of a primary health care environment.
Historically,
person-to-person
and
individual-focused
interventions
have
predominated in nursing with the prevailing role, the care of the sick in bed-based
hospital institutions although important community roles have existed (PorterO'Grady, 1999). In New Zealand in the early 1900s for example, native health nurses
worked in remote areas with Maori communities caring for individuals with typhoid
and smallpox (see p. 73), shifting their focus a decade later to health promotion and
disease prevention. An individual approach continued into the 1950s and through the
1970s, initially reinforced by the health system focus on hospital care and biomedicine and then as a consequence of the life-style era, which sought to persuade
individuals to change their health-related behaviour (see p. 21).
The life-style approach has been widely criticised for ignoring the lack of
opportunities for disadvantaged people to be healthy (Crawford, 1977; J. French &
Adams, 1986; Naidoo & Wills, 1994; Rodmell & Watt, 1986; Tesh, 1988). For this
reason ‘new public health’ evolved advocating legislation and policy, intersectoral
action, community participation and equity (Baum, 1998). Whilst this represented a
different health promotion approach to that demonstrated in the life-style era, Green
and Raeburn (1988) maintained that in practice both approaches were often adopted.
The current study demonstrated this phenomenon when projects seeking to change the
behaviour of individuals with conditions such as diabetes, chronic obstructive
pulmonary disease and congestive heart failure, focused on interventions to change
diets, stop smoking, and reduce blood pressure and cholesterol levels respectively. In
addition, these projects undertook systems interventions, such as the establishment of
‘diabetes registers’, developed databases of people with chronic respiratory disease,
and provided influenza vaccinations to those at risk of an exacerbation of this
condition.
215
Community interventions in line with the increasing emphasis being placed on
primary health care, which promotes community empowerment (Ministry of Health,
2001b; 2001c; 2003b), were undertaken less frequently. A community level approach
was not undertaken by any project exclusively, however 16 per cent of projects
adopted a community approach in combination with another level of approach and
nurses were employed in all (100%) of these projects. Few projects demonstrated
community participatory approaches designed to empower communities and support
them to identify issues relevant to their lives. Laverack and Labonte (2000) maintain
that if health planners viewed community empowerment as more than a means to
achieve health behaviour change in top-down67 health promotion programmes, other
important outcomes such as a community’s capacity to influence it’s health, might
result.
One project that adopted both community and individual levels of practice was
directed at Maori women residing in a tribal region (rohe) who attended community
events collectively where information, health teaching and diagnostic testing was
available for cervical smears, breast examination and mammography.
A second
project adopted the same levels of approach targeting children and families at a
community fair, providing information on dental health. Children and adults were
offered free dental check ups in groups, with the nurse able to act as a broker for
ongoing dental care. In both projects nurses were Maori, worked and lived in their
tribal area, held cultural knowledge, encouraged clients to express their needs, and
were known as advocates for Maori rights.
Social justice through community
empowerment and advocacy were familiar concepts to these nurses, suggesting
confidence in a broader and more radical health promotion discourse compared to the
discourse of the 1970s that emphasised disease prevention through life-style
management (Feather & Labonte, 1995). Keller et al. (2004a) contend work with
communities has equal if not more impact on improving population health than work
with individuals and families. This is an area for future research, as the proportion of
the community that may actually change from community population-based practice
and the potential benefits from this approach has not yet been established.
67
Top-down programmes are conventional, solve a problem or deficit, focus on individual
responsibility, are controlled by an outside agency, and have low community ownership (Laverack &
Labonte, 2000).
216
Almost as many projects employing nurses adopted a systems level approach as
adopted an individual level approach. However unlike the latter group, only 26 per
cent adopted a systems approach exclusively, with most developing registers or
databases to detail the health status of individuals with chronic conditions, or to
record information such as immunisations for the purpose of sharing data across a
provider network. This exclusive systems approach was consistent with the aim of
integrated care to establish integrated networks (Health Funding Authority, 1998).
Systems-focused practice has the potential to change organisations, policies, laws and
power structures (Minnesota Department of Health, 2001).
Over half of the systems level projects employing nurses were undertaken
concurrently with individual level projects.
Most of these projects established
registers and databases to assist in the management of clients enrolled in disease state
management programmes. Nurses began by seeking to involve targeted groups and
individuals with chronic conditions in interventions largely defined by the project
planners, who regarded improvement in specified behaviours as important health
outcomes. Empowering individuals was viewed instrumentally, that is, as a means to
the end of health behaviour change.
Four projects employing nurses adopted
community and system, or individual, community and system levels of approach.
One multi-level project targeting chronic conditions involved the clinical case
management of individuals, the establishment of regional registers and databases,
advocacy for new marae-based services, and the detection of more cases within the
community. Some nurses reported a tension between representing a community’s
perspective and their inability to accommodate changes within the project.
8.2.6
Age group focus
A strong association was evidenced between projects employing nurses and projects
targeting children and adolescents, and adults. A lesser degree of association was
found in projects targeting older adults, and people of all ages.
Overall, fewer projects targeted children and adolescents compared with other age
groups, however almost all of these projects (92%) employed nurses. Children and
217
adolescents were the group in which primary prevention was most apparent, despite
the majority of these projects also demonstrating a disease or condition focus. For
example, mouth guards were provided to children playing sport to prevent meningitis,
and immunisation rates were improved in mobile populations through active casefinding by nurses. Both projects involved communities but did not adopt a negotiated
approach that built on community strengths and capacities, a starting place for distal
prevention.
The project that developed an electronic information network, which held data on a
large number of children for the purpose of managing morbidity relating to conditions
such as asthma and rheumatic fever, has the potential to develop anti-poverty or
housing development strategies. The ability to identify and tackle distal risks can
yield fundamental and sustained improvements to future health status. In general, few
projects included prevention strategies, and most focused on secondary rather than
primary prevention. This is of concern as New Zealand has increasing problems with
tobacco use (Peto et al., 1994) obesity and physical inactivity (Ministry of Health,
2003c, 2003d; Ministry of Social Development, 2004), and excessive alcohol use
(Statistics New Zealand, 2004), all major risk factors for chronic conditions.
Over a quarter of the projects targeted adults, with nurses employed in the majority
(91%) of projects, which focused on conditions, such as diabetes, chronic obstructive
pulmonary disease, and mental health. A similar percentage of projects targeted older
people, yet nurses were employed in fewer of these projects (64%) proportionally. Of
the 14 projects employing nurses that targeted older people, almost all adopted a
disease or condition focus.
The relationship between age group and disease or
condition reflected the integrated care intention to make services for people with
chronic disease more assessable (Health Funding Authority, 1998).
A further
intention to address health promotion and disease prevention was not met. All but one
project focused on existing diseases, and even secondary prevention such as the
maintenance of diabetic foot care was not included.
It was anticipated that integrated care in New Zealand would develop to prevent risks
to health and avoid future burdens of disease (Ovretveit, 1998). Latest population
projections indicate the New Zealand elderly population will grow 150 per cent by
218
2051 (see p. 47). With an increase in the actual numbers of older people combined
with populations throughout the world living longer, a dramatic rise in chronic
conditions and associated disability is expected (World Health Organization, 2002a).
Despite primary prevention being advocated over secondary prevention, few projects
targeting older adults were focused on positive or well-health or on preventing or
reducing risks.
8.2.7
Ethnic group focus
A strong association was evidenced between projects employing nurses and projects
targeting Maori and/or Pacific peoples. Over half of the projects targeted Maori
and/or Pacific peoples exclusively or in combination with the wider population, and
nurses were employed in 90 per cent of these projects.
The study demonstrated nurses worked with different ethnic populations and
commonly had a local knowledge of specific communities and families. The nursing
profession has contributed to the promotion of ‘cultural safety’68. In the late 1980s
changes to the education of nurses were made to support this concept. During the
time of integrated care, attempts to integrate health promotion, community
development, and primary health care into everyday practice assisted nurses to
acquire skills to care for people in ways that respected their culture.
Whilst
information was not specifically collected on the ethnicity of nurses employed in
integrated care projects, a number of nurses were known to self-identify as Maori,
Samoan, Tongan, and Cook Island and commonly worked alongside and served
people of the same ethnicity. When clinicians and patients are from the same cultural
background there is greater likelihood of accurate diagnosis and compliance (Durie,
2004), an association likely to be influenced by shared cultural understandings and
knowledge.
68
The New Zealand Nursing Council has defined cultural safety. Nursing Council states, “cultural
safety relates to the experience of the recipient of nursing or midwifery service and extends beyond
cultural awareness and cultural sensitivity” (Nursing Council of New Zealand, 2002, p. 7).
219
Improving Maori health was identified as a demonstration pilot hypothesis, and
sought to test the contention that services by Maori for Maori would produce the best
health outcomes (Health Funding Authority, 1998). Unfortunately, projects able to
test this hypothesis were not selected as demonstration pilots and the opportunity to
provide services by Maori for Maori was lost. If central to Maori health is Maori
control (Durie, 1998), rangatiratanga or Maori ownership and decision making was
not achieved through integrated care. Wano (2003) argues integrated care was never
fully embraced because it was seen (within Maori) as another way of cutting costs and
marginalising Maori. Ultimately, demonstration pilots and all other projects in the
NICPS bore no resemblance to the initial strategy, which sought to experiment with
cost, benefit, and risk arrangements.
Similarly, guidelines for demonstration pilots identified Pacific peoples as a ‘health
priority population’ (Health Funding Authority, 1998), a position the present New
Zealand government recently restated (Ministry of Health, 2001c).
However,
integrated care projects targeting Pacific peoples, like Maori, focused on disease or
condition management, rather than health more widely. Jansen (1998) argued this
was because a narrow disease management approach could be assessed in relation to
specified contract outcomes, and thereby limit financial risk to the provider
organisation.
Interestingly, of the 15 projects targeting prevention or promoting positive or wellhealth, 13 focused on Maori or Pacific peoples. Similarly, the coordinated care trials
in Australia focused on people with common diseases and medical management,
rather than prevention or health promotion, except for the Aboriginal trials (Baum,
1998). It is difficult to say with any certainty why projects with a positive or wellhealth focus occurred more frequently in Maori, Pacific and Aboriginal populations,
though, one factor of influence may be a view of health by these populations that
stresses the wider physical, social and spiritual environment (Durie, 1998; Saggers &
Gray, 1991). The values of project partners influenced the design of projects, and as a
general rule, projects targeting Maori and/or Pacific peoples were influenced by
project partners from the same ethnic background.
220
8.2.8
Low income focus
A strong association was evidenced between projects employing nurses and integrated
care projects targeting populations in geographic areas defined as low decile and
representing the 30 per cent of the most deprived areas in New Zealand. Of projects
targeting these areas, chronic conditions were also a focus. This is not surprising as
chronic conditions disproportionately affect the poor (World Health Organization,
2002a). Integrated care was intended to address the greatest and most serious health
needs (Bringewatt, 1997; Ovretveit, 1998), so it is alarming that only 30 per cent of
projects targeted people living in the most deprived areas in New Zealand, despite this
being a priority criterion (Health Funding Authority, 1998).
The strategy of
integrated care failed to implement its goal of improving the health of the poor and
underserved.
Three generations of health care reforms have been motivated by a desire to improve
the health of the poor and underserved. First generation reforms attempted to address
inequalities in access to health care at a time when hospital care predominated (see p.
9). Second generation reforms introduced primary or basic health care to all people,
which in poor countries was often considered primitive rather than primary. In New
Zealand general practice provided primary care and relied upon medical interventions
to gain health (Walsh & Warren, 1979), with the poor often getting less of the benefit
than the rich (Gwatkin, 1998, as cited in World Health Organization, 2000). The
technical, medical emphasis of primary care in New Zealand resulted in increased
hospitalisations and services targeted to reach the poor were often used more by the
rich due to the disproportionate use of hospital services by the well off. Public
hospital waiting lists grew and medical insurance schemes evolved to help (rich)
people pay for private hospital admissions (Boyd & Sheridan, 2000). First and second
generation reforms failed to improve the health of the poor.
Integrated care was located within the third generation of health reforms, coinciding
with the philosophy of new public health that promoted policies on poverty and social
justice. Third generation reforms responded more to demand by assuring access to
services for the poor and emphasised financing rather than service provision.
Integrated care planned to experiment with new ways to finance and deliver services
221
in the interests of addressing inequalities, such as access to services (Health Funding
Authority, 1998). Unfortunately, project performance relied upon the standard goals,
targets, and health outcome measures, familiar to both the health funder and providers
in the measurement of disease management, and forced attention back on disease.
Integrated care projects invested in general practice and its accompanying medical
construct of health.
This paradigm prevailed over broader primary health care
services and more diverse social understandings of health. It is unfortunate that at a
time when the World Health Organisation promoted equity in health care through
intersectoral collaboration and community participation integrated care developed as
an essentially reductionist strategy. Less than a third of projects targeted the poor,
and in this respect as a third generation reform that sought to improve the health of the
poor and underserved, integrated care had limited success.
8.2.9
Health, disease, condition or other focus
A strong association was evidenced between projects employing nurses and projects
targeting chronic conditions, other conditions, and well-health (see p. 183). A lesser
degree of association was evidenced between projects employing nurses and projects
targeting acute conditions.
Half of the projects targeted chronic conditions, including seven of the nine national
demonstration pilot projects. Nurses were employed in 90 per cent of the projects
targeting chronic conditions and only in these projects were diabetes, two or more
chronic conditions, mental health conditions, chronic obstructive pulmonary disease,
cardiac conditions, asthma and other respiratory conditions managed.
It is not
surprising that integrated care emphasised chronic conditions and care pathways
(Ovretveit, 1998) as pressure existed on the health system to find new ways to manage
the escalation of chronic conditions that comprised the burden of illness in New
Zealand (World Health Organization, 2002b).
A primary health care approach was selectively applied to the management of specific
diseases in these projects, narrowly focusing on medical care services and the
222
endeavours of health professionals, often nurses, to integrate such services. This is
concerning because it is well-known that major health problems cannot be solved by
medical care alone (Lalonde, 1974). Tarimo and Webster (1994) have suggested that
a selective approach to primary health care usually means that while a particular
problem may be resolved, it will be replaced by another problem as the underlying
cause of ill health has not been dealt with.
It is also commonly acknowledged that health care systems contribute to health status
but are not the major factor in the determination of overall population health status.
Rather, public health measures aimed at the prevention of disease, illness and
disability, and lowering death rates are increasingly understood as more important in
creating healthy populations (Frenk, 1994; Niessen, 2002). Beaglehole and Bonita
(1997) argue that the integration of medical care under a public health umbrella would
facilitate the process of setting broad health goals and targets and encourage resources
to flow to prevention.
Had integrated care projects been characterised by a
comprehensive primary health care approach, rather than a selective approach, more
sustainable health outcomes could have been expected. This raises the question of
how well current public health knowledge was understood and utilised in the
development of integrated care.
Wells (1998) perceived integrated care as a key public sector reform strategy that
would provide a solution to fragmented health care service provision. Integrated care
was envisaged to include partnerships across the housing, employment and education
sectors and to address inequality in relation to poverty when allocating health
resources (Davies, 1999; Feek, 1998; Wells, 1998).
These perspectives suggest
integrated care was viewed as more than medical service provision for chronic
conditions and implies a social and participatory approach to health, consistent with
the philosophy of new public health (Baum, 1998).
The New Zealand government has a central role in tackling major risks to reduce
inequalities in society.
While treating diseases and managing long-term health
problems is essential, the health system is also challenged to address the underlying
risks to health and adopt prevention and reduction strategies (World Health
Organization, 2002b).
It is therefore surprising that only 15 projects targeted
223
prevention and demonstrated a well-health focus. Nurses were employed in 87 per
cent of these projects, two of which considered distal risks and centred on the broader
dimensions of well-health through the promotion of exercise and improvements to
housing. In both projects nurses facilitated either sports people developing sport and
exercise programmes for youth or builders constructing ‘inside’ toilets, repairing
drainage and sewerage systems, upgrading electrical wiring, and insulating dwellings
for the poor. Maori health organisations were generally partners in the small number
of projects that worked with organisations outside the health sector, and were
instrumental in this happening.
Nurses were employed in the majority of projects that undertook primary and
secondary care, such as general health checks targeting whole populations - babies
under 12 months, women, or Maori residing in a specific geographic area. Other
activities included screening for hepatitis B or sexually transmitted infections in
populations-at-risk, and smoking cessation programmes for people with smoking
related illnesses.
For individuals with a respiratory condition, such as chronic
obstructive pulmonary disease, the smoking cessation programme attempted to
prevent secondary complications, thereby maintaining the health of the ‘well-ill’
individual.
Many nurses contributed to population health objectives through
involvement in immunisation and smoking cessation programmes, but consistent with
the literature, rarely participated in decisions about the distribution of resources and
benefits accrued from meeting targets (Carryer, 2004).
Acute conditions were targeted in ten per cent of projects and half of these projects
employed nurses.
The conditions targeted were disparate and included iron
deficiency anaemia, bleeding in the first trimester of pregnancy, and dental health
problems. All projects included Maori or Pacific project partners and nurses who
emphasised prevention. In contrast, the projects that did not employ nurses focused
on conditions requiring hospitalisation and medical technical support, such as acute
confusion and hip fracture. This study finding is reminiscent of the primary health
care approach in New Zealand during the second generation of reforms where medical
technical practices predominated.
224
Nurses were employed in 90 per cent of the projects classified as ‘other’ (see p. 182).
Most of these projects involved the development and implementation of health care
guidelines and care pathways to assist client journeys through the health system, and
memorandums of understanding or partnership protocols between organisations. The
emphasis was placed more generally on developing a seamless system of care
between services, with only a small number of projects selecting a specific condition,
such as hip fracture or stroke, to demonstrate this approach.
Ovretveit (1998)
maintains care pathways benefit all individuals, and in particular the increasing
number of individuals who experience acute exacerbations of a chronic condition over
a longer term. Nurses were involved in establishing databases of clients in a regional
area with, for example, chronic obstructive pulmonary disease or diabetes.
The
processes were active, ongoing and labour-intensive. The mobility of populations
concerns over undiagnosed or inaccurately diagnosed conditions, and clinical
management resulted in nurses undertaking this surveillance intervention for the
purposes of case-finding and identifying levels of disease. Projects without nurses
were principally involved in developing databases using a surveillance system that
could be described as passive, with the collection of hospital discharge data
comprising the main source.
8.2.10
Non-nursing personnel
An association was evidenced between projects employing nurses and non-nursing
personnel. Non-nursing personnel were employed in about 40 per cent of the projects
and nurses were employed in 77 per cent of these projects. A higher percentage of
non-nursing personnel were employed in projects that did not employ nurses.
Many projects appeared to delineate between nurses roles and those of non-nursing
personnel, and projects benefited from the employment of both. In other projects
there were overlaps in the roles of nurses and non-nursing personnel and there was no
clear reason for this overlap.
Reception and administration, including service
coordination, were the main roles undertaken by non-nursing personnel in projects
without nurses. In a number of projects nurses undertook receptionist/administrative
activities alongside, or in the absence of, non-nursing personnel. Practice nurses have
225
long been criticised for undertaking a receptionist role, rather than a clinical role in
general practice (Docherty, 2004) and some nurses in integrated care projects would
be subject to the same criticism.
Non-nursing personnel conducted research and audits in projects and nurses were not
engaged in these activities. In general, nurses engage in research utilisation, an
essential activity for maintaining best practice, and a competency of the nurse
practitioner scope of practice (Nursing Council of New Zealand, 2001b). Docherty
(2004) argues that nursing has a responsibility to provide primary health care nursing
research because it can influence a change in the current focus from ‘primary care’ to
‘primary health care’. In New Zealand these terms are often used interchangeably and
cause confusion. Docherty believes there is a risk that research will continue to focus
narrowly on primary (initial) care in for example the primary management of chronic
conditions, rather than taking a wider view of health care that includes individual and
community choice in an endeavour to sustain health and well-being. Primary health
care may include primary care to address a problem, but the main goal is to build
community capacity.
Nursing research in primary health care can involve
investigating the way health is determined through the exploration of social and
economic factors. Interestingly, all research conducted by non-nursing personnel in
the integrated care projects had a primary care focus, such as an audit of diabetes
management, and a randomised controlled trial of chronic obstructive pulmonary
disease case management.
226
8.3
Population-based interventions and levels of practice undertaken by nurses
in integrated care projects
What types of population-based interventions were undertaken by nurses in integrated
care projects?
This section systematically discusses the 17 types of interventions69 in the order they
appear on the intervention wheel (see p. 89) beginning with surveillance, so that
relationships between interventions comprising ‘wedges’ can be more easily shown.
This order does not reflect the interventions most frequently undertaken by nurses in
integrated care projects which were: case management; consulting; health teaching;
collaboration; referral and follow-up; delegated functions; counselling; advocacy;
coalition building; screening; policy development and enforcement; outreach; disease
and health event investigation; community organising; social marketing, and
surveillance (see p. 172, Figure 14).
Nurses undertook nine or more types of
intervention in almost half of the projects, but only one type of intervention was
undertaken in the remaining 50 per cent of projects.
What population-based levels of practice did nurses demonstrate in integrated care
projects?
Of a total 411 interventions undertaken by nurses, 66 per cent occurred exclusively at
the individual level, 9 per cent at the community level and 8 per cent at the systems
level. Less than a fifth of the total interventions were undertaken on either two or
three levels concurrently (see p. 173, Figure 15). This section provides examples of
interventions at differing practice levels70, offering deeper insights into nurses’
practice within the integrated care environment. Definitions of each intervention are
not restated and can be found in Table 5 (see p. 95).
69
‘Case-finding’, the seventeenth intervention is included within the interventions surveillance, disease
and health event investigation, outreach, and screening at the individual level.
70
This refers only to interventions and practice levels undertaken by nurses in the NICPS, and excludes
examples not undertaken, such as community and systems levels in referral and follow-up.
227
8.3.1
Intervention: Surveillance
Surveillance was the only intervention undertaken almost entirely at the systemsfocused level of practice (see pp. 191-192, Figure 17). Surveillance collects and
analyses data on health threats such as infectious diseases, but in projects was used
most with other health events such as chronic diseases. Unlike ‘disease and health
event investigation’ surveillance is ongoing, seeking to establish patterns and identify
changes in the incidence and prevalence of disease (Minnesota Department of Health,
2001). Surveillance involved assessing health before and after health events, and
whole populations were targeted (see examples following). Surveillance is different
from monitoring and screening71.
Individual example (Case-finding)
Health provider organisations in a region forwarded information on their clients, Pacific children, who
were scheduled to receive immunisations but could not be located. A project developed a Pacific
nursing service that acted as a broker for other health providers, such as general practices. Nurses used
their networks to locate families, conduct home visits to determine why the child had not been
immunised and provide the immunisation if requested. Immunisations were registered at the local
provider level and national level.
Community example
Nurses in a project that targeted chronic obstructive pulmonary disease management assessed the
health status of a group of enrolled clients before and after a case management intervention. Clients
initially completed a Short Form 36 (SF36), and Chronic Respiratory Questionnaire (CRQ), which was
repeated again at 12 and 24 months. Any presenting issues were addressed.
Systems example
Nurses in a collaborative project with many partners used random sampling to survey the population of
a geographic region to determine the prevalence of diabetes in order to establish baseline data.
Existing data sources were reviewed, such as, hospital discharge data, medical management
information, and other surveys. A regional register was developed for ongoing data collection of
diabetes cases in this population.
8.3.2
Intervention: Disease and health event investigation
Disease and health event investigation was undertaken approximately three-quarters
of the time at the individual level (see pp. 190, 192, Figure 17). Traditionally, disease
and health event investigation has focused on infectious diseases, however, study
71
Monitoring implies a constant adjustment of what is being done and looks at groups of individuals.
Screening detects previously unknown cases in a population and may serve as the method to find cases
(Minnesota Department of Health, 2001).
228
projects focused mainly on chronic conditions, injury, and other health events. This
investigation identifies “cases, their contacts, and others at risk, determining control
measures, and communicating with the public” (Minnesota Department of Health,
2001, p. 29). In the current study, investigation was a key component of surveillance,
frequently leading to case-finding and referral and follow-up. However, investigation
also stood alone when applied as a method for discovering new information.
Individual example (Case-finding)
Nurses initiated contact investigations of clients diagnosed with gonorrhoea, chlamydia, and other
sexually transmitted diseases. The nurse made visits to people identified as sexual contacts, providing
information and free primary care services.
Community example
Nurses were concerned with the assumed unmet health needs of children and their families with
chronic and terminal conditions, so selected one District Health Board area and applied a profiling
methodology to identify any existing need in this population. Unmet needs revealed by profiling
resulted in specific interventions being made available to children and their families. A second
profiling was planned to compare the quality of life of children and their families following
interventions and to establish their satisfaction with services.
Systems example
Specialist nurses and physicians worked with primary care providers to establish a system of
management for new cases of diabetes presenting with existing associated complications. The
specialist team trained practice nurses and general practitioners in the region to manage ‘complex’
diabetes cases via case studies and conferences conducted in primary health care settings.
8.3.3
Intervention: Outreach
Outreach was most frequently undertaken at the individual level with community
level interventions also occurring in almost half of the projects (see p. 192, Figure 17).
“Outreach success is determined by the proportion of those considered at risk who
receive information and act on it” (Minnesota Department of Health, 2001, p. 41).
Commonly outreach is undertaken with health teaching to inform those at risk, about
the risk, and how to get attention. At the community level, outreach messages were
often a precursor to screening, and disease and other health event investigation,
operating like social marketing.
229
Individual example (Case-finding)
A nurse conducted focus group interviews with Maori women concerned with the increasing incidence
of breast cancer, which assisted in the identification of potential barriers to screening and revealed
useful ways to encourage others to participate in screening programmes that were clinically and
culturally safe.
Community example
Maori nurses provided information on the need for mammography screening to Maori women over 50
years of age at a marae-based hui (conference). Women were enrolled with a Maori provider and
information was provided in te reo (Maori language) about the screening process, costs, and venues.
Women were followed up and those who had been screened determined the success of the outreach
message.
Systems example
A large project with multiple partners in west Auckland participated in the immunisation of children.
Nurses convinced pharmacies, community day cares and other community facilities visited by children
and their families to display information on immunisation, explaining how and where it could be
accessed. Immunisations were then undertaken by nurses at home visits or at a community outreach
well-child clinic.
8.3.4
Intervention: Screening
Screening was most frequently undertaken at the individual practice level with
community practice undertaken concurrently in about one third of the projects (see p.
192, Figure 17). Commonly, this intervention was preceded by outreach and social
marketing. Screening often occurred simultaneously with health teaching, and/or
counselling, and on several occasions transitioned into referral and follow-up for
those requiring a further assessment of presenting symptoms.
Individual example (Case-finding)
An older man who had many family members with diabetes, presented to his lead primary health care
provider for screening. The nurse performed urine and blood tests, and talked with the man about his
understanding of diabetes. The nurse also undertook a comprehensive health assessment as a
consequence of additional risk factors identified when taking his health history.
Community example
Nurses conducted general health checks at a community hall as a component of a collaborative project
targeting older people at risk of common conditions, such as diabetes, cardiac and respiratory
conditions. Nurses provided health teaching and counselling to all clients during the assessment, and
then preceded to enroll clients with a health provider to ensure referrals and follow-ups would be
undertaken.
Systems example
A rural community experienced an increase in the incidence (new cases) of diabetes. A project
comprising partners from the key health provider network supported nurses to screen the general
population in an attempt to identify cases, which were then referred on for follow-up.
230
8.3.5
Intervention: Referral and follow-up
Referral and follow-up occurred in 30 projects at the individual practice level only.
This intervention was always linked with another intervention, such as health
teaching, counselling, delegated functions, consulting, screening, case finding (as
related to surveillance, disease and health event investigation, or outreach), casemanagement or advocacy. Nurses were the recipients of referrals and also referred
clients on, the latter function reflecting their knowledge of resources and linkages
within communities.
When involved in referral systems, nurses developed and
implemented care pathways (see p. 192, Figure 17). As clients being case managed
were followed up the success of the referral (and the system) was assessed.
Individual example
Nurses in a rural town clinically case managed clients with a diagnosis of congestive heart failure upon
their discharge from hospital. Nurses conducted home visits to complete clinical assessments and
provide health and social support, referring clients on to general practice physicians and other
specialists when necessary, maintaining a central and ongoing role in case management.
8.3.6
Intervention: Case management
In the study the model of case management depended upon the skills of clinicians and
the ‘implementation’ context.
For example, nurses focusing on chronic disease
management were found to have adopted two case management models, one with a
predominant focus on brokering needed services and the other on the provision of
clinical care (see pp. 212-214).
Both models included prevention goals, health
teaching and counselling interventions, and considered the determinants that affected
a client’s quality of life. These characteristics suggest that elements of a public health
framework were embedded within case management models. This is not surprising as
the purpose of integrated care with it’s emphasis on primary health care, was to
improve the management of chronic conditions (Health Funding Authority, 1998).
Case management was undertaken at the individual and systems practice levels (see p.
192, Figure 17). The majority of projects applied a clinical case management model
focusing on individual clients with chronic conditions, such as diabetes (see p. 212).
231
Case-finding generally preceded case management, with health teaching, counselling,
consultation, advocacy and collaboration commonly occurring in the process of case
management.
Individual example
A general practice team comprising a practice nurse and general practice physician case managed the
clinical care of a client with chronic obstructive pulmonary disease. Scheduled monthly visits were
planned with the client to review their health status and revisit negotiated goals. Health teaching and
counselling were features of the case management interactions, and a referral to a pulmonary
rehabilitation programme was made and followed up.
Systems example
Nurses providing services to people with high needs and chronic conditions, such as chronic
obstructive pulmonary disease, collaboratively developed a central pathway to simplify access to
services for this population.
8.3.7
Intervention: Delegated functions
Delegated functions occurred most often when nurses undertook tasks delegated by
general practice physicians and hospital physicians, or when nurses with a specialist
knowledge delegated tasks to other nurses. Delegated functions were undertaken at
the individual level on all but one occasion (see p. 192, Figure 17). Critical decisions
were made every time nurses delegated to others or accepted delegation, with nurses
accountable for functions delegated by another nurse with the same licensure.
Individual example
A nurse undertook a comprehensive health assessment, which included the client’s clinical history,
blood tests, spirometry, shuttle walk test, and administered the Chronic Respiratory Questionnaire.
These functions were delegated by the general practice physician overseeing the client’s care.
Community example
Nurses administered immunisations to children in schools and other settings under standing orders
issued by the New Zealand Ministry of Health.
8.3.8
Interventions: Health teaching
Health teaching occurred at all levels, but overwhelmingly at the individual level (see
pp. 189-190, Table 29; p. 192, Figure 17). Health teaching was undertaken more than
any other intervention and occurred in conjunction with many other interventions, but
232
was most frequently implemented sequentially with counselling and consultation.
This was because health teaching influenced the knowledge, beliefs, and behaviours
of clients and systems, counselling focused on the emotional component of any
necessary change, and consultation offered solutions to problems. It is not surprising
that health teaching occurred in this context and the association between this
intervention and others is consistent with the literature (Minnesota Department of
Health, 2001).
Individual example
A nurse provided information and facilitated others providing education to 120 kuia (female elders),
who attended a hui (conference) on ‘women’s health’. Topics requested for the day included
menopause, nutrition, managing finance, and the dead (tu papaku), which included understanding the
roles of the doctor, police, coroner and funeral director.
Community example
Nurses collaborated with others to reduce smoking in older adults. The project developed posters in te
reo (Maori language), distributing them widely to sports clubs, marae, churches, bars and restaurants.
Systems example
Nurses case managing clients with mental health problems identified a need to advocate for their
clients rights, concerned at the stigma associated with mental illness. Nurses collaborated with others
in a campaign to reduce stigmatisation using the media (media advocacy).
8.3.9
Intervention: Counselling
Counselling occurred most at the individual level, but also at the community level
(see p. 192, Figure 17). This intervention sought to clarify issues, provide insight, and
facilitate problem management. Tschudin (1995) suggests counselling attempts to
help a person solve their problems through focusing on their feelings, and then on the
meaning of those feelings.
Individual example
A nurse facilitated a support group for families with children who have chronic illnesses and
disabilities. Health and social problems were discussed and potential solutions were explored in this
supportive environment.
Community example
The nurse worked with project partners and the Asthma Society to raise awareness about asthma
prevention. The goal was to raise community awareness about asthma and to change community
acceptance of asthma as a condition that is ‘not serious’ to a realisation that asthma is a life threatening,
preventable condition. Posters, local radio broadcasts, and articles in the newspaper, included peoples
personal stories relating to asthma as part of a wider strategy to disseminate this message.
233
8.3.10
Intervention: Consultation
Consultation occurred most frequently at the individual level, but also occurred at the
community and systems levels (see p. 192, Figure 17). This intervention was almost
always a component of case management, and often followed health teaching as a
problem solving process. Consultation is the provision of advice to others (Puetz &
Shinn, 1997), and nurses fulfilled multiple roles when consulting within projects. The
variety of roles included advocate, joint problem-solver, identifier of alternatives and
linker to resources, process consultant, information specialist (Ulschak & SnowAntle,
1990), coach, motivator, mentor, teacher, facilitator, confidant, sounding board,
change agent, fact-finder, expert, observer, and counsellor (Puetz & Shinn, 1997).
Individual example
A client who had suffered a stroke and lived alone, wanted to return home. The nurse discussed with
the client his needs, the options available, and together they identified financial issues before planning
an ‘assisted’ rehabilitation programme that could be undertaken at home.
Community example
An advisory group that included nurses provided expert advice to health professionals, providers, and
clients in a specific region around promoting the rehabilitation and recovery of people who had
recently experienced a stroke.
Systems example
Concerned about the rapid growth of a region and the settlement of new populations to the area, nurses,
other health professionals, and district councillors, worked on a health plan that proposed types and
locations of future health care services, and identified wider social and environmental health issues.
8.3.11
Intervention: Collaboration
Collaboration occurred at all levels, but most frequently at the individual level (see p.
192, Figure 17).
Even though collaboration, empowerment and partnering are
overlapping concepts, the intervention collaboration is distinguished by the potential
of transformation for both the nurse and client, which is attributed only to the client in
empowerment and partnering (Minnesota Department of Health, 2001).
234
Individual example
Over a two year period a nurse began to develop a relationship with a Maori client who had renal
failure. Through her interactions with the client, the nurse stated she better understood the client’s
values and practices and this had helped her to reassess and clarify her own practice and values.
Community example
Nurses collaborated with women’s groups, such as the Maori Women’s Welfare League and developed
strategies to assist women to care for themselves, such as having a cervical smear test or undertaking a
smoking cessation programme, and in doing so strengthened their families.
Systems example
A nurse clinically case managing clients with mental health problems became concerned that clients
were being evicted for unpaid housing rents during episodes of acute illness. The nurse and her
manager met with key decision-makers in the housing sector and negotiated to act as broker on behalf
of clients’ to ensure rents were paid. This changed the way nurses had traditionally case managed
clients and extended the model to include housing and attempt more holistic primary health care.
8.3.12
Intervention: Coalition building
Coalition building occurred most at the community level, but also at the systems level
(see pp. 190-191, Table 31; p. 192, Figure 17). Coalition building, like community
organising is an example of collective action, and empowerment, the process through
which individuals and communities take control of their lives and environment.
Coalition building can be brought about by organisations outside the community,
unlike community organising. Because coalition building does not require enhancing
the capacity of other organisations within the coalition, in this respect it is dissimilar
to collaboration (Minnesota Department of Health, 2001). Study projects considered
the impacts on partners, and focused on capacity building in the primary sector. This
intervention frequently resulted in nurses advocating for clients as groups at the
community level.
Community example
Nurses facilitated the development of a ‘parent’ coalition that influenced the approach to care and the
provision of services in the home for children with chronic illnesses and disabilities, creating a greater
awareness of the problems faced daily by children, families and carers.
Systems example
In a large region with a rapidly growing population comprising many young families, a coalition of
community organisations and individuals invited nurses from health organisations to assist in the
development of a plan for future community health and social services.
235
8.3.13
Intervention: Community organising
Community organising occurred only at the community level (see p. 190, Table 30; p.
192, Figure 17).
Community organising used social marketing in a number of
situations as a companion intervention to change the health behaviour of a population.
This intervention can also potentially be “implemented in conjunction with the policy
development intervention…when the organizing intent is to change policy at the
systems level” (Minnesota Department of Health, 2001, p. 237). In the current study,
however, community organising did not occur at the systems level.
Community example
A nurse facilitated a new approach to the annual review of diabetes by bringing together health
professionals, people with diabetes and their families, and the interested public. In a community centre
health assessments, including diagnostic tests such as retinal screening, were performed at no cost to
clients. A podiatrist provided services, and a cooking demonstration and ‘tasting’ was conducted to
encourage those with diabetes to consider new approaches to food.
8.3.14
Intervention: Advocacy
Advocacy occurred most at the individual and community levels and less frequently at
the systems level (see p. 192, Figure 17). Advocacy was explicit in case management,
when nurses acted in the interests of clients’ concerned with rights and entitlements.
Communication and negotiation skills were required when advocacy was associated
with referral and follow-up, community organising, policy development and
enforcement, and social marketing. In the process of advocating for clients, a number
of nurses encouraged clients to begin to assume this role for themselves.
236
Individual example
A nurse case managing a client with mental health problems discussed with the client their skills and
deficits, such as poor literacy, in order to provide assistance with employment. Having been told by the
client about preferred employment activities, the nurse negotiated with potential employers on the
client’s behalf. Upon gaining employment, the nurse continued to advocate for the client, whilst also
assisting the client to assume this role for themselves.
Community example
Nurses were concerned at the number of teeth extractions of very young children, adolescences, and
adults in a rural area with poor access to dental health services. A clinic was set up on the local marae
and dental health checks were performed at no cost to clients. Those needing further care were referred
to dentists and actively followed-up by nurses to ensure barriers, such as cost or access did not prevent
treatment being undertaken.
Systems example
Nurses participated in coalition building to bring together health professionals and organisations
concerned with the fragmented care people with chronic conditions often experienced. Collectively
they advocated for more seamless and comprehensive care, presenting to the Health Funding Authority
a new case management strategy for people with chronic obstructive pulmonary disease. Clinicians,
particularly nurses, were involved in media advocacy and the project received national funding.
8.3.15
Intervention: Social marketing
Social marketing occurred most often at the individual level, but also at the
community level (see p. 192, Figure 17), and like health teaching sought to change
attitudes and behaviours.
Social marketing has been described as a particular
application of health teaching (Minnesota Department of Health, 2001).
At the
individual level nurses framed information in a way that was congruent with clients’
values. Andreasen (1995) argued that measures taken to change behaviour must
consider demography and culture, as behaviours are learnt within family and social
environments.
Processes that are empowering and culturally sensitive were also
advocated.
Individual example
During a general health screen a man who was hypertensive, obese, and smoked heavily told the nurse
he had thought about joining a gym but had not because he was embarrassed about his weight and lack
of fitness. The nurse described a local walking group for people with varying health issues who met
daily. The client joined the group, was monitored regularly, lost weight and eventually chose to stop
smoking.
Community example
Nurses working in a rural area developed a communication plan with other health providers to
disseminate information on how to ‘live with diabetes’ in te reo (Maori language) via a local
community radio station. Community members with diabetes were interviewed about their lives, the
difficulties they experienced and the ways they coped with problems. In the weeks after the interview
series, local nurses and doctors reported an increase in the number of consultations about diabetes
management and health promotion.
237
8.3.16
Intervention: Policy development and enforcement
Policy development and enforcement occurred most at the individual level, but also at
the community level (see p. 192, Figure 17). Nurses influenced local policy by
developing regulations, mandates, guidelines, care pathways, and other resources to
guide client care practices.
Nurses involved in policy development also often
enforced or implemented the policy. National policies were enforced by nurses in the
interests of standardising processes in either the treatment or care pathway of clients
with a specific condition. Broader ‘healthy public policies’ were not developed but
rather enforced by nurses in projects (see community example).
Individual example
A nurse developed a primary health care pathway for clients who had recently suffered a stroke and
were returning home after hospitalisation. The nurse provided clients and their families with
information and a guide to the health and social services available, which included speech therapy,
physiotherapy, carer assistance, pharmacy, general practice advice, and welfare assistance.
Community example
A nurse investigated a public health concern raised by a kuia (female elder) about the quality of the
drinking water at a local kohanga reo (early childhood centre with a focus on Maori language and
culture) in a rural area. The water tank supplying the kohanga reo was tested and giardia was
identified. The nurse successfully worked with the health protection unit to get the tank emptied, water
blasted, re-filled and re-tested, before following up known or suspected cases of giardia.
8.4
What underlying values are made explicit when interventions undertaken
by nurses are analysed?
The health promotion values embedded in 14 interventions overall demonstrated an
individually oriented philosophy. Nine interventions reflected the values of health
persuasion - paternalism, authoritarianism, and prescription, and five interventions,
the values of personal counselling - self-empowerment and negotiation.
Two
interventions, namely coalition building and community organising, demonstrated a
collective oriented philosophy. Coalition building reflected the values of legislative
action, paternalism and state-directed authoritarianism. However, like community
organising, this intervention also reflected the values of community development,
namely participation, negotiation, and empowerment.
238
8.4.1
Beattie’s model of health promotion
Beattie’s model of health promotion (see p. 30, section 2.3) provides an
environmental-political framework for analysing the health promotion values
embedded within the overall practice of nurses employed in the 80 integrated care
projects. By situating 17 interventions by nurses within the model, each reflecting a
dominant focus72, particular health promotion values were identified. The mapping of
interventions in this way demonstrated the ethical and political tensions faced by
nurses in the projects studied. Stewart and Thomas (2004) suggest Beattie’s model
can show partnership with government in legislation and policy, and with individuals
and communities also taking an active role. Consistent with this finding, the current
study demonstrated both individual and community partnerships and revealed that
nurses invested most in individual partnerships.
Section 8.4 analyses the interventions undertaken by nurses in light of the four health
promotion strategies - health persuasion, personal counselling, legislative action, and
community development.
Following this, the prevailing mode (authoritative/
negotiating) and focus (individual/collective) of each intervention is attributed. This
is determined by the way interventions are made operational by nurses in projects (see
p. 160, section 6.4.5.2). Finally, new knowledge and the challenge this poses to future
primary health care nursing practice is summarised.
8.4.2
The four approaches to Beattie’s model
The majority of interventions undertaken by nurses in integrated care projects reflect
the strategy of health persuasion. Case management, referral and follow-up, health
teaching, delegated functions, screening, policy development and enforcement,
disease and health event investigation, surveillance and social marketing, all reflected
the social values within health persuasion, which are based on a bio-pathological
model of health that views health promotion as attempting to repair weaknesses and
deficits (Beattie, 1991). Health persuasion, a strategy led by professionals and in this
72
These 17 types of interventions are derived from the total (n=411) interventions undertaken by nurses
in projects.
239
case nurses, has been described as paternalistic and favouring a culture of ‘victim
blaming’ (Crawford, 1977).
Dealing with risk factors to health, the limited
effectiveness of health persuasion as a single strategy has been well documented
(Beattie, 1991). Whilst nurses in projects clearly favoured this traditional strategy,
they also frequently used it in conjunction with other strategies.
The health promotion value of autonomy was demonstrated in five interventions,
namely consultation, counselling, advocacy, collaboration and outreach, which relate
to the strategy of personal counselling.
Personal counselling is client-led, often
centres on personal development, and requires the health professional to act as a
facilitator rather than an expert. The central precept in personal counselling is selfempowerment and the client-orientation of the process is valued by its proponents (C.
Rogers, 1969).
The study demonstrated that nurses undertook ‘counselling’ to
facilitate problem solving, ‘consultation’ to identify alternatives or link to resources,
and ‘advocacy’ to negotiate issues the client wished to address. In all of these
interventions nurses identified the importance of the clients’ participatory role and the
creation of autonomy through enabling clients to make their own choices.
Coalition building was the only intervention to reflect the values within the strategy of
legislative action, which directs behaviour towards achieving health at a macro-level,
using top-down processes. Led by health professionals, this strategy seeks to protect
communities (Beattie, 1991).
Coalition building, an intervention of collective
action73, was bought about through legislative action and community development,
the former strategy directed by the government’s integrated care policy, which
required projects to build partnerships, a role nurses were active in (see pp. 178-179).
Coalition building was further mandated at the organisational level by local policies
such as partnership charters, memorandums of understanding, and joint venture
contracts, established within projects to govern the type of partnership arrangement.
Two interventions, community organising and coalition building74 reflected the values
within the strategy of community development, which enhances the skills of a group
73
Coalition building is only ever undertaken at community and systems levels (see p. 94).
Coalition building overall reflected equally both the social values of legislative action and
community development (see p. 194, Figure 18).
74
240
or community to work together to change the environment using bottom-up processes.
The World Health Organization (1986) contended that health developments in
communities should not only be developed for the people, but rather by the people. In
general, nurses in the study undertaking community organising and coalition building
facilitated groups coming together, linked the group with key people who could assist
the project, and acted more widely as a resource. Chaplin and Adams (1986) confirm
these are usual functions for health workers in community development.
8.4.2.1
Authoritative or negotiated modes of interventions
Beattie, among others, has shown how ‘top down and bottom up’ health interventions
come to be polarised by varying degrees at opposite ends of the authority-negotiation
continuum (Beattie, 1986, 1991; Hardy, 1981). Ten interventions undertaken by
nurses were situated in the health persuasion and legislative action quadrants
suggesting they were imposed by institutions of authority, namely nurses, other health
professionals, project planners, and government agents.
Authoritative modes of
intervention are top-down, which implies they promote individual or community
responsibility, start with problems defined by health educators, clinicians and policy
makers, and focus on education, improved services, and life-style (Laverack &
Labonte, 2000).
Seven interventions situated in the personal counselling and community development
quadrants were negotiated from within the affected communities concerned.
Negotiated modes of intervention are bottom-up, which implies they enable
individuals and can promote empowerment, starting with health priorities defined by
either individuals or communities, and in the case of communities build on
community control, resources and capabilities towards economic, social and political
change (Laverack & Labonte, 2000).
241
8.4.2.2
Individual and collective focus of interventions
The individual/collective dimension is one of the most stable and enduring axes of
conflict in social theory and social policy (Taylor-Gooby & Dale, 1981). Nursing has
traditionally emphasised the care of individuals who are experiencing illness or some
condition viewed as a deficit that requires medical interventions (Porter-O'Grady,
1999).
The study revealed that fifteen75 interventions undertaken by nurses
demonstrated an individual focus and only two interventions a collective focus. The
overwhelming individual focus of nurses’ practice, with the particular emphasis on
the use of a health persuasion strategy, suggests that contemporary practice is still
grounded in individualism, paternalism, authoritarianism and prescription.
Authoritarianism and individualism dominated political agendas in the 1980s. This
orientation was challenged as leading to victim blaming and strategies that failed to
address the root causes of ill health. The challenge contributed to the emergence of
the community health movement and empowerment as a central concept (Beattie,
1991).
The study showed that the maintenance of an individual focus perpetuated an
approach that had proved inadequate in addressing the inequalities known to
contribute to poor health (K. Tones et al., 1990). If interventions undertaken by
nurses had sought to reduce inequalities a focus on the causes of ill health, such as
housing, would have been more widely apparent. Instead the focus remained on
individuals and changing behaviour, demonstrating no real capability to address the
determinants of poor health.
The skills required by nurses to practice using a
collective orientation were rarely evidenced in integrated care projects.
8.4.2.3
The challenge for nursing
In general, nurses exerted power over individuals and communities through top down
approaches to interventions. Individualism dominated. Although health promotion
75
Case management is included within the sum of fifteen.
242
practice involving communities was undertaken, community control of resources and
community ownership was minimal. This was because integrated care policy had
been determined nationally; project funding was primarily approved by government,
and the condition of partnering with clients including communities, was imposed.
Coalition building demonstrated a convergence of approaches between those
developed by project planners with authority influenced by national policy and those
emerging in communities. Unsurprisingly, intersectoral collaboration a feature of
coalition building often resulted in opposing and competing viewpoints, which in a
number of projects restricted development.
Coalition building, like community organising also reflected a negotiated approach,
however nurses always had a predetermined agenda and were more interested in
gaining community involvement (see p. 36, section 2.3.4) than in empowering
communities.
Communities were not enabled in ways that encouraged building
capacity or improving competence, metaphors of empowerment. In general, nurses in
projects did not appear to have an understanding of how community empowerment
could be practically accommodated within projects. Laverack and Labonte (2000)
suggest community empowerment goals must be developed alongside typical
approaches to programming for a systematic change in practice to occur, and this was
not observed in these projects.
Care of the individual is a legitimate practice focus for nurses and when undertaken in
conjunction with interventions that maintain a community focus, has the potential to
address inequalities in health (Ministry of Health, 2001c).
Nurses in projects
undertook individual and community interventions, but only in a limited number of
projects.
Interestingly, a sequential effect between several interventions where
progress in one area facilitated progress in another was evidenced in projects. For
example nurses’ success in collaboration with clients and health providers at the
individual level influenced coalition building (see section 8.3.11 intervention:
collaboration, systems example). In this sense interventions at differing levels of
practice were often complementary, a highly positive outcome.
Insights into the health promotion values embedded within nurses’ practice have
proved valuable in revealing the width of the gap between the ideal of integrated care
243
and primary health care and the actuality of practice. The context within which nurses
currently work is conventional or top down, retains an individual-focus, and relates to
disease management and prevention.
Moving from this traditional authoritative
position to a more negotiated position that promotes community participation and
empowerment raises the prospect of new solutions to relevant, complex health and
social issues.
Section 8.5 proposes a model to guide primary health care nursing practice76 transition
from individual level practice to increase the commitment to practice at the
community and systems levels. The framework will assist nurses to reflect upon the
interventions, associated population-based levels of practice, and distinct health
promotion values embedded within that practice. In this way nurses can evaluate their
current practice in relation to achieving primary health care outcomes and decide the
focus and direction for structuring future practice.
8.5
Study findings provide new insights and direction
The study demonstrated that PHC nursing as undertaken by nurses in integrated care
projects, could not address the inequalities in health care provision experienced by
underserved populations, principally because of its central reliance upon individuallyfocused population-based practice. There is wide recognition of the need to address
health determinants, and consensus this is to be undertaken by nurses and other health
professionals in partnership with consumers (Ministry of Health, 2001c). Nurses in
the study negotiated health care interventions with individual clients, however when
the client was the group or collective, notably fewer interventions were evidenced
suggesting this focus was less important or practitioners did not have the required
skills to practice at this level.
Over several years, national strategies and international frameworks have directed
attention towards working with communities and advocated the inclusion of
community-focused population-based practice (Beattie, 1991; Ministry of Health,
76
Health workers other than nurses can use the model as a framework for reflecting upon, and
reorienting practice.
244
2001b, 2001c, 2003b; Minnesota Department of Health, 2001).
Translating
overarching strategic directions into primary health care practice is an important
function of the nursing profession. Recent scholarships available for the postgraduate
education of primary health care nurses represented an attempt at strengthening this
workforce (Ministry of Health, 2003a, 2005). However, there has not been nationally
agreed core knowledge of primary health care, so it cannot be assumed that
community-focused population-based practice is a feature of this education.
The challenge for nursing is to understand and accept the reality that current practice
defined as ‘primary health care’, which it is suggested is akin to that of nurses studied
in integrated care projects, is predominantly authoritative and individually-focused. A
shift is needed from health persuasion to community development, and the values
associated with the strategy of community development must be embedded within
nurses’ practice if primary health care is to be achieved.
At the individual-focused practice level a negotiated approach results in improved
health outcomes (Beattie, 1991), but even this approach, which shifts away from an
authoritative position is limited. Nursing must take a collective, negotiated approach
placing a greater emphasis on supporting communities to build control, resources, and
capacities (see pp. 34-36, section 2.3.4) if the goal is to improve the overall health of
the population.
Study findings provide the basis for advocating this ideological
position which is articulated in the design of a new model that brings together current
public health ideas, placing an emphasis on the values intrinsic to health promotion
and its central strategy ‘primary health care’ (see p. 249). Termed the ‘Primary
Health Care Interventions Model’ (PHCI model), this framework can assist New
Zealand nurses evaluate their practice, and implement interventions in ways that
enable more comprehensive primary health care practice in the future.
8.6
The Primary Health Care Interventions Model
The PHCI model was developed as a response to the current study findings and
reviewed literature, most importantly the Intervention Wheel (Keller et al., 1998) and
Beattie’s model of health promotion practice (Beattie, 1991). The purpose of the
245
model is to demonstrate the links between values and interventions thereby assisting
nurses to reflect upon their actual practice and intrinsic values. The model allows for
insights at a personal level, necessary for any practitioner contemplating practice
development in primary health care. The range of interventions includes all the
activities of primary health care nurses’ practice, and the framework is a guide for
action as well as a tool for reflection. The profession can apply the model to the
analysis of overall PHC nursing practice data to guide action about the development
of this specialty.
New Zealand nurses have often experienced tensions in practice that surround how to
include the concerns and issues of community in top down practice approaches, such
as those characteristic of the majority of integrated care projects. Laverack and
Labonte (2000) contend “the dichotomy between top down disease prevention and
life-style change and bottom up community empowerment approaches is not as fixed
as it is sometimes portrayed” (p. 256), or as exclusive, and that community
empowerment goals can be accommodated within usual approaches to practice. For
nurses, who are grappling with how to implement primary health care practice, the
PHCI model can describe a vision of health promotion practice not yet in operation.
In this sense, theory may advance practice through critical reflection of existing
practice and values, and engage nurses in the act of planning new practice, which
leads towards more certain ends.
The PHCI model comprises elements from the Intervention Wheel (Keller et al.,
1998), defining a comprehensive set of interventions and three levels of populationbased practice, which have intrinsic values related to population-based practice and
public health nursing. These elements form the foundation of the PHCI model and
have been adapted to explicitly identify Beattie’s theory of health promotion. Future
adaptations to the model may include new primary health care interventions as they
are identified. The PHCI model also identifies changes in societal values because like
Beattie’s model of health promotion, it is embedded in wider social and cultural
practices, in ideologies and political struggles (see p. 30). The model has the ability
to run in parallel with other frameworks, such as ‘Whare Tapa Wha’, a contemporary
model that expresses a Maori perspective of health (Durie, 1998) or ‘empowerment
246
tracks’ that can systematically accommodate community empowerment goals within
usual approaches to projects (Laverack & Labonte, 2000).
The PHCI model was adapted as an instrument to guide the implementation of New
Zealand primary health care nursing practice, although the model is not exclusive to
nursing and can be used by other disciplines. Situating the framework within a
pikopiko frond, the native fern, is an expression of growth and renewal, in this case
symbolising a new framework created from the rejuvenation of two well-established
models.
The model integrates four separate components:
1. The population-basis of all public health/health promotion interventions
2. Three levels of public health/health promotion practice:
Community
Systems
Individual and family
3. The 17 public health/health promotion interventions
Surveillance
Disease and health event investigation
Outreach
Screening
Case-finding
Referral and follow-up
Case management
Delegated functions
Health teaching
Counselling
Consultation
Collaboration
Coalition building
Community organising
247
Advocacy
Social marketing
Policy development and enforcement
4. The four public health/health promotion strategies
Health persuasion
Personal counselling
Legislative action
Community development
The model comprises an outer ring of 16 interventions, with the 17th intervention case
finding, occurring only at an individually-focused level of practice in surveillance,
disease and health event investigation, outreach, and screening. For this reason the
label case-finding is not apparent in the model, whilst the intervention itself is
represented within the four interventions listed previously. The three inner rings
indicate distinct levels of population-based practice labelled ‘systems-focused’,
‘community-focused’, and ‘individual-focused’. These components, based upon the
Intervention Wheel (Keller et al., 1998) correspond to each of the 17 interventions in
the PHCI model’s ‘spoke-less or disc wheel’, and similarly can be undertaken at all
three population-based levels of practice.
The PHCI model embodies the same
population-based concepts as the Intervention Wheel (Minnesota Department of
Health, 2001).
248
y
Policpment Survei
llanc
o
l
e
e
He
Devforcement
a
n
E
Dislth E
l
&
a
I
nv
ci
g
es eas ve
tig e nt
So etin
k
at
ar
io
F
O
S
C
M
M
U
E
SE
T
O
h
He
a
t
M
an Cas
ag e
em
en
t
Re
ferr
Foll al &
ow-up
ng
lli
L
g
eenin
nity Develop
m
en
A
lative ction
s
i
eg
Scr
mu
n
tio
ra
bo
lla
Co
C
om
on
Coaliti
ng
Buildi
SED
CU
O nal Counse
o
Com
munity
Orga
nizing
INDIVI
ersu DU
P
h
as
t
l
C
NITY-FOCUS
U
M
ED
OM
C
/ FAMILYL
A on Pers F
i
ac
re
ut
Ad
vo
c
D
n
ac
y
S
SY
on
su
lt a
tio
n
Co u
nsellin
g
Health g
n
Teachi
ed
a t ns
g
le o
De nct i
Fu
Primary Health Care Interventions Model
From "Population-Based Public Health Nursing Interventions: A Model from Practice," by L. Keller, S. Strohschein, B. Lia-Hoagberg, and M. Schaffer,
1998, Public Health Nursing, 15, p. 208. Copyright 1998 by Blackwell Science Incorporated. Adapted with permission of the author.
From "Knowledge and Control in Health Promotion: A Test Case for Social Policy and Social Theory," by A. Beattie, 1991, in J. Cabe, M.Calnan, and
M. Bury (Eds.), The Sociology of the Health Service, p. 167. Copyright 1991 by Routledge. Adapted with permission of the author.
Within the two most inner rings, the four health promotion strategies, components
from Beattie’s model of health promotion (Beattie, 1991) are situated.
Health
persuasion and personal counselling are situated in the ‘individual-focused’ ring as
they represent strategies focused on individuals, the former utilising an authoritative
mode of intervention, and the latter a negotiated mode.
Legislative action and
community development, situated in the ‘community-focused’ ring represent
strategies focused on communities or groups, the former utilising an authoritative
mode of intervention, and the latter a negotiated mode. At a systems-focused level of
practice, all four strategies of health promotion are relevant. The specific formulae
developed for analysing the values embedded in nurses’ practice in integrated care
projects (see p. 161) linked systems-focused practice with individuals.
In other
contexts however, a link between systems-focused practice and communities
exclusively, or in combination with individuals would require the formulae to be
adapted as discussed under study limitations (see section 9.2.5.2). It was decided to
refrain from situating the four strategies on the system-focused ring because, for the
purpose of assigning overall values to practice, systems-focused practice was aligned
with either individuals or communities and it appeared to make the model
unnecessarily complex. Further, as Beattie’s four strategies (see p. 32-36) embody
distinct modes and focuses of interventions, these labels were not included in the
PHCI model.
8.6.1
Strengths of the PHCI model
Beattie’s model has limitations for those who want to take action (Beattie, 1991). In
the PHCI model, however, this is not a limiting factor because the incorporation of
interventions and levels of practice provide a clear guide to the type of activities and
embedded values that distinguish the different approaches to advancing primary
health care practice.
For example, interventions located in the community
development quadrant are related to concepts of empowerment, equity, and the
mobilisation of communities to effect change (see section 234). Therefore, if nurses
select to reorient their practice in line with these values, interventions will need to be
undertaken at community and systems levels, in addition to the individual level.
250
Beattie’s environmental-political model is characterised by content rather than by
processes or objectives.
This has implications when seeking to understand
information, for example, if interventions overlap quadrants the model may not allow
an adequate interpretation of new formulations (Beattie, 1991). The PHCI model
however captures descriptions of interventions allowing for the provision of more
detail, which enables greater depth and clarity in the analysis. The PHCI model has
the ability to assess interventions and values to assist nurses and others tease out some
of the complexities underlying health action.
Chapter nine concludes the thesis by identifying the implications of the PHCI model
for future primary health care nursing practice and offers recommendations for
stakeholders in advocating acceptance of the model.
251
9
9.1
Chapter 9
Conclusion: Mapping a new future
Introduction
The purpose of this thesis was to discover the practice of nurses within the context of
integrated care projects implemented in the late 1990s.
Integrated care projects
intended to experiment with different methods and types of health care organisation in
an attempt to better coordinating care, whilst also focusing on positive economic
outcomes (Ovretveit, 1998). The NICPS found that nurses employed in projects
focused most of their practice at the individual-level. Population-based individualfocused practice cannot address inequalities in health care alone. Community and
systems-focused approaches are also required if improvements are to be seen in the
health of the population. The use of health promotion theory in the analysis of nurses’
practice has led to the further proposition that expanding nurses’ practice to include a
focus on collective groups or communities will require the adoption of health
promotion values consistent with such an approach. Consequently, the PHCI model
(see p. 249) was developed to assist nurses to transition their practice from an
individual-level to include a greater focus on communities and community-focused
population-based practice.
This final chapter outlines the strengths and limitations of the study methods before
discussing in section 9.3 the implications of accepting the PHCI model as a platform
for practical action - a framework to advance future primary health care nursing
practice. Section 9.4 offers recommendations as a means for progressing nursing
practice. Recommendations are directed at six stakeholder groups who have varying
roles in advocating for the acceptance of the PHCI model.
Finally, summary
comments are proffered in conclusion.
252
9.2
Strengths and limitations of the study
The discussion of the strengths and limitations of the current study is organised under
the following headings: study design; study population; questionnaire design; data
collection procedures and data analysis procedures.
9.2.1
Study design
The cross-sectional survey design was considered an appropriate methodology for
investigating the practice of nurses in integrated care projects because it allowed a
quantitative description of project characteristics (see p. 129). The current study has
the ability to describe what existed, the frequency of occurrences, and to categorise
information. Survey data derived from interviews on 80 integrated care projects were
reduced numerically, allowing broader concepts to be tested by the research questions.
The effect of reducing the perceptions of respondents to a set of numbers, a method
also used in randomised controlled trials, has been criticised for over simplifying
information in line with the positivistic conventions of an established (quantitative)
agenda (Oakley, 1981). Whilst this perspective is not uncommon among qualitative
researchers, synthesising data enabled a macro-perspective to be gained, which was a
central purpose of the study. The survey also employed detailed categorisation and
coding processes to ensure the quality of data were maintained (see pp. 147-158,
section 6.4.4).
As a strategy of inquiry, surveys have been criticised because they do not have the
same power as laboratory experiments to establish causality. However, surveys were
developed for a different purpose, as a precise means of measuring social
phenomenon (Creswell, 2003), with the ability to identify associations between
variables such as organisation, and consequently produce useful descriptive data.
Unlike an experiment the researcher does not control the environment, therefore each
respondent answers in different circumstances bringing to the study a diverse set of
assumptions, history and values.
253
It has been argued that aggregation77 of data from surveys means making assumptions
that might not be justified. This is because a particular variable is rarely considered in
the context of the respondent’s wider set of ideas and values (Oakley, 1981). In the
current study, interviewees shared many common features, such as, significant health
sector knowledge; work in integrated care, and a high level of interest in the research
subject. In addition, the survey questions were pilot-tested on a comparable health
professional audience to find out if they were well understood and to ensure that the
answers would provide meaningful information (see pp. 141-142, section 6.4.3.3).
The descriptive survey has the ability to identify a sample and generalise to a
population, but does not seek to test the impact of a treatment or intervention on an
outcome, as in an experiment (Keppel, 1991).
Theoretically, the current study
findings about the practice of nurses in projects can be extrapolated to a wider
primary health care nursing population. The interventions and levels of practice
undertaken by nurses in projects occurred during a particular health reform, which the
author argues was a starting place for more recent primary health care activity.
Therefore, when reviewing the study findings, and disseminating to a wider primary
health care nursing audience, consideration must be in the context of more recent
developments in the field. Both nursing and health care policy has moved on since
integrated care. For example, nursing policy led to the development of scholarships
for primary health care nursing education, and pilot innovation nursing projects, and
health care policy has continued to assist the maturation of PHOs. An investment in
policy implementation is most notable in these areas.
Of these, education provides the most likely opportunity for developing the health
promotion values and philosophy that are necessary for the adoption of communityfocused practice.
At present despite the availability of postgraduate nursing
education, there is little evidence to demonstrate that current programmes are
influencing a shift from conventional individual-focused practice to include a
community-focused approach. As a consequence, the researcher has confidence in
generalising the study findings to primary health care nurses more broadly. A paucity
of research on the health promotion values within nursing practice is acknowledged,
77
Aggregation assumes that words have uniform and agreed meanings that are not contingent upon
their context.
254
as most research on primary health care nursing has focused on the activities of nurses
in different environments (Ministry of Health, 2003b) and not on the underpinning
values, beliefs and culture of the nursing groups who now comprise the new primary
health care nursing workforce. The NICPS, despite the use of a robust research
methodology, can only draw tentative conclusions. Future research is needed to
demonstrate the level of consistency of these findings.
9.2.2
Study population
The unit of inquiry was the integrated care project, with projects eligible for inclusion
in the study if they met the established criteria (see pp. 133-134, section 6.4.11). The
non-probability sampling method employed by the study did not guarantee that all
eligible projects had an equal chance of being included in the sample78, although all
eligible projects were rigorously followed up. The snowballing technique used to
identify projects also risked selection bias. However, as a complete list of projects
was unavailable, this method was the most suitable.
The issue of bias by recall can be a feature of any research that asks respondents to
provide information retrospectively.
In the current study the respondents were
identified as having a professional knowledge of integrated care developments, and
because the information sought was recent, the margin for error was considered to be
relatively small. All respondents were contacted in the workplace so potential bias
relating to the ‘inability to be contacted’ did not present as an issue.
Concerns initially existed that in some projects an expert informant whilst having
knowledge of a project at the macro level may not have had the detailed knowledge of
nursing practice sought in interview questions 23 and 24. Nurses, however, were
expert informants in over 50 per cent of the interviews where specific information was
sought on nursing practice, and the questionnaire was available to respondents before
the interview, allowing time for the clarification of any details. A 100 per cent
response rate was achieved and all questions were answered.
78
This was because only those projects identified by respondents could be followed up. Eligible
projects may have existed that were not identified by respondents.
255
9.2.3
Questionnaire design
No survey instrument was found to exist that could collect data to answer the four
research questions, so a questionnaire was developed that used a standardised set of
questions for the interview. Open-ended questions, reducing complex questions into
sets of simpler questions, and choosing the correct category from options provided by
the interviewer were strategies employed to ensure data collected had depth and
accuracy. Groves (1989) suggests variations in question form are necessary to make
sure questions are answerable in a telephone survey.
Detailed numerical
categorisation and coding processes ensured data were standardised and quality was
maintained. Internal consistency reliability was addressed by a number of survey
questions measuring aspects of the same variable. For example, health services were
measured in questions eight, nine and 10. As the review was conducted by experts
and pilot-tested on health professionals, predictive validity, rather than concurrent
validity was established (see p. 143). Overall, pilot-testing suggested the questions
were understood and provided consistent measures in comparable situations. Sets of
questions were found to be appropriate and provided useful data, indicating validity.
Internal consistency reliability, an indicator of how well different items measure the
same variable, was weak in questions 17 and 20. Question 17 asked who funded the
project and question 20 asked if general practice incurred financial costs as a result of
participating in the project. Some responses indicated general practice had funded
projects (incurring costs), whilst also indicating no costs had been incurred. Further
investigation revealed that the funding of projects was often not considered a cost in
the same way as the funding of lesser costs relating to project implementation (see p.
204).
256
9.2.4
Data collection procedures
The survey has become the most widely used method of data collection in public
health research as descriptive data can establish meaning by contrasting, comparing,
or identifying relationships (Creswell, 2003). The telephone survey was preferred as
a method of data collection over face-to-face surveying by the researcher because it
was less intrusive than face-to-face interviewing and importantly, enabled lower
financial costs to be incurred as respondents represented a range of projects across
New Zealand. A further advantage of this survey was the ability to collect detailed
data in pre-selected categories within a relatively short time. Data on a large number
of projects were collected in a systematic and organised manner, a feature of the
telephone survey that enabled potentially better quality control than the use of a selfadministered questionnaire (Fowler, 2002). Acceptability of the telephone interview
by respondents appeared to result from a perception that this was work-related and
was of limited inconvenience requiring only a 60 minute interview during the work
day. Whilst surveys have been criticised for constituting a ‘data raid’ with little
benefit to the respondents (Wadsworth, 1997), the researcher offered interviewees
access to the study results upon completion of the research. The study findings
provide a source of data and insights into the complexity of health service provision,
including nursing practice, that can assist these key informants as well as health
policy development and action generally.
9.2.4.1
The interview
The interview was fully structured as it sought to obtain “research-relevant
information…on content specified by the research objectives of systematic
description, prediction or explanation” (Cohen & Manion, 1989, p. 307). This style
has been criticised as detached (Oakley, 1981) and telephone interviews as more
difficult than other methods at building rapport (Bradburn et al., 1979). However,
Bradburn et al. suggested the drawbacks of the telephone interview were compensated
for by smaller interviewer effects and a lower tendency towards socially desirable
responses. In the current study the researcher was not detached but rather sought to
develop a friendly, interested, and professional style of relating in an attempt to build
257
rapport. Fowler and Mangione (1990) report that interviewers who take steps to relax
respondents, without detracting from a professional interaction, may be able to
produce a more effective interview. On occasions interviewees asked questions of the
interviewer who was flexible and responded with honesty. Oakley (1981) maintains
this approach ensures integrity in the interview process, although others have argued
the “lack of standardisation that this implies raises concerns about reliability”
(Robson, 1993, p. 229). Standardisation was ensured by the use of one interviewer
who conducted all interviews. The interviewer knew several of the respondents so
attempts were made to minimise personal communication in an effort to standardise
the interview. Other measures to standardise the interview process were discussed in
section 6.4.3.5 (see pp. 144-147).
9.2.5
9.2.5.1
Data analysis procedures
Organising data analysis
Two types of errors were potential issues in organising data for analysis. The first
involved transcribing a response onto the questionnaire at the time of the interview.
Responses perceived by the researcher to be ambiguous were clarified at this point,
with the majority of questions ‘closed’ to reduce the risk of error (see p. 141, Table
10). The second type of error related to the coding of responses. Significant effort
went into constructing codes that placed answers in analytically meaningful categories
(see pp. 147-157, section 6.4.4.1).
9.2.5.2
Data analysis
The second phase of the analysis involved the development of a formula (see p. 161)
for the specific purpose of locating variables on a health promotion grid (see p. 194,
Figure 18).
This formula was developed for the current study, in which all
interventions related to populations of individuals, rather than communities or groups.
258
To extrapolate this formula to other situations where systems include communities
will require amendments to be made to the formula79.
The process of attributing values to nurses practice using the frameworks of the public
health intervention wheel (Keller et al., 1998) and Beattie’s model of health
promotion (Beattie, 1991) is open to challenge. This is solely because the collective
range of interventions that constitute health promotion practice can be contested
(Beattie, 1991; Downie et al., 1990; B. Tones, 1986; K. Tones & Tilford, 1994). The
definition of health promotion that was adopted for use in the thesis (see p. 27) was
deliberately broad, allowing for the inclusion of activities such as ‘delegated
functions’ that may be associated with illness management, which remains
contentious.
The interventions undertaken by nurses in projects represented a
comprehensive range of activities. Analysis of these interventions undertaken by
nurses studied in integrated care projects provided new insights into what was
conceived as primary health care practice.
9.3
Implications of the PHCI Model for nursing practice
Nursing practice is challenged with being responsive to the changing health needs of
individuals and populations. The importance of addressing health disparities caused
by social, economic, cultural and structural inequalities has increasingly been realised
and strengthening primary health care, a vehicle for improving population health
outcomes, has been mandated (Ministry of Health, 2001b). Integrated care projects, a
health reform of the 1990’s, provided a primary health care context within which
nurses’ practice could be assessed. During the last four years an increased focus on
primary health care has influenced national strategies and continuation of structural
health reform. Many contemporary projects, such as Care Plus, which targets people
with chronic conditions (Ministry of Health, 2004a) have benefited from antecedent
strategies, such as integrated care. New primary health care nursing initiatives are
underway although to date, a national framework that demonstrates the interventions
and health promotion philosophy required to advance primary health care practice has
79
A possible adaptation could be:
Community (community + systems) – Individual (individual + system) = Position
259
yet to be mandated. This study has shown the reality of nurses’ practice to be
restricted within a primary care environment that focused on the acute care
management of an individual’s problems. Nurses appeared ill-equipped to promote
primary health care in a broader community sense.
Study findings indicate that integrated care, which planned to work in ‘innovative
ways’ to improve the health of populations characterised by being Maori, Pacific, low
income, or with chronic conditions, was exceedingly limited. In the main, nurses, like
the projects they were employed in, practiced from a traditional, individually oriented
paradigm. It seems apparent that the next step in advancing a primary health care
nursing agenda is to identify a framework that explains current practice and can
demonstrate a way to reorient future practice to achieve greater improvement in the
health of groups and communities, in addition to individuals.
Nursing has an
important role to play in the activities of health promotion - the provision of care, the
prevention of illness, and the promotion of positive health. Caraher (1994) maintains
“the attempt to create a healthy population is a worthy one” (see p. 467) and nursing
because of its role in health promotion, must determine the most effective way to
achieve this end. Health promotion, at any level of population-based practice cannot
be divorced from politics and ideology, and implementing primary health care is at
present a central issue.
As there is no common approach to implementation,
fragmentation of health care services remains a risk.
In the current study health persuasion and personal counselling strategies were
adopted in the majority of interventions undertaken by nurses employed in integrated
care projects.
Personal counselling was considered by health promotion
commentators, and health professionals including nurses, to be a more effective way
of working with clients (Beattie, 1990, 1991; K. Tones et al., 1990; Wilson-Barnett,
1988). Nurses employed in projects appeared to locate health within a political
agenda that was largely individualistic. Nurses did not appear to understand that this
strategy could also create victims (Crawford, 1977). Interventions by nurses that
target individuals is appropriate from a health promotion perspective when combined
with interventions at the community and systems levels, and when the emphasis
includes a wider socio-environmental perspective.
Overall, nurses employed in
projects did not often use the strategies of legislative action or community
260
development in promoting the health of communities. This is of note, as two decades
of the ‘New public health’ have attempted to introduce these concepts and they have
become increasingly visible in national strategies and advisory reports (Ministry of
Health, 2001b, 2001c, 2003b). Consistent with this, structural reforms to the health
care system have attempted to shift the focus from primary care to more
comprehensive primary health care.
More recently, nursing has received funding for scholarships and innovative projects
in a concerted effort to advance primary health care (Ministry of Health, 2003a,
2005). Scholarships for post-graduate education have focused predominantly on the
development of clinical skills, rather than on the relationship between the nurse and
client where issues of power and control are examined and health promotion practice
comes to be understood as more than a benign encounter.
The shift from an
individual-focus to include a community-focus is anticipated. However, without a
map to guide the journey, progress is likely to be slow. The implication of this
finding is the need to transition primary health care nursing from essentially,
individual encounters in primary care to more comprehensive primary health care
practices.
The PHCI model can guide the implementation of primary health care practice in New
Zealand.
The Model can be used to explain and evaluate nursing practice in
operation, identify gaps, and plan future practice. A strong ideological position,
commonly held by all primary health care nurses is intrinsic to the development of a
skilled workforce able to integrate individual and community empowerment goals
within health care practice. As stated previously, the PHCI model has the ability to
run in parallel with other cultural frameworks (Durie, 1998) or empowerment models
(Laverack & Labonte, 2000).
Research to evaluate the effectiveness of the PHCI model as a tool to guide the
implementation of primary health care is recommended in settings, such as the current
PHO environment. Nurses’ perceptions regarding the degree to which the model is
useful in assisting them to advance their practice must also be surveyed. Future
research into the range of interventions, levels of population-based practice, and
health promotion values within nurses’ practice is required.
As societal values
261
change, the values embedded in nurses’ practice will also change. Finally, and most
importantly, the effect of community population-based practice, in conjunction with
systems and individual levels of practice must be studied to determine the degree of
impact a multilevel approach has on the total outcome: the health of the population.
9.4
Recommendations
Advocacy for the acceptance of this model is expected to be a complex process and
will have implications for health policy. Stakeholders will include: The Ministry of
Health; The Nursing Council of New Zealand; health organisations such as, District
Health Boards and Primary Health Organisations; educational institutions; nurses;
communities, and individuals.
The following recommendations are offered to facilitate this process:
1.
The Ministry of Health
1.1
Formally advocate the PHCI model as a framework for implementing
primary health care nursing practice.
1.2
Support individual and community empowerment approaches in
primary health care policies and programmes funded by the state.
1.3
Affirm the Treaty of Waitangi by ensuring that whanau, hapu, and iwi
are active in the design and delivery of primary health care
programmes.
1.4
Implement national conventions for the promotion of health and the
equal status of all people.
1.4
Continue to resource innovations in primary health care and to develop
a skilled, competent workforce.
2.
The New Zealand Nursing Council
2.1
Adopt the PHCI model as the central framework for implementing
primary health care nursing practice.
262
2.2
Ensure that ‘essential knowledge’ in primary health care is defined and
included in the prescribed curricula for the education of nurses at
undergraduate and postgraduate levels.
2.3
Conduct ongoing research into the interventions, levels of practice, and
health promotion values within primary health care nursing practice
and the association with health outcomes at individual, community and
population levels.
3.
Health provider organisations
3.1
Formally adopt the PHCI model as a framework for implementing
primary health care practice.
3.2
Ensure health professionals working in primary health care understand
how to accommodate both individual and community empowerment
goals within typical approaches to health promotion.
3.3
Incorporate this knowledge and appropriate practice in training and
accreditation systems.
3.4
Develop strategies to promote health in partnership with clients,
relevant to local conditions, and communities.
Share information
across health provider organisations and coordinate projects where
possible.
3.5
Promote the message that individuals and communities have the right
and responsibility to be involved in their own health care.
4.
Educational institutions
4.1
Provide educational programmes at undergraduate and postgraduate
levels for nurses that build primary health care knowledge and offer
strategies for clinical practice.
4.2
Introduce the PHCI model as a conceptual framework for analysing
primary health care nursing practice.
4.3
Research ways to deepen discussions with communities about health
issues and acceptable, relevant, health promotion practice.
263
5.
Primary health care nurses
5.1
Adopt the PHCI model as a framework for implementing primary
health care nursing practice.
5.2
Evaluate the effectiveness of practice, including information on health
outcomes, and client and community feedback.
5.3
Promote the PHCI model and education about health promotion
concepts to nurses, other health professionals/workers and consumers.
6.
Communities and individuals
6.1
Collaborate with Government and health provider organisations in
identifying and prioritising health need and approaches to health and
health care.
6.2
Advocate with Government and health provider organisations for the
promotion of individual and community empowerment.
6.3
Participate in implementing health interventions with nurses, health
professionals/workers and others to improve health outcomes.
9.5
Conclusion
The contribution of this research has been to provide an understanding of the practice,
and values within that practice, of nurses in integrated care projects. Theoretical
frameworks provided tools for analysis in combination with a postpositivist research
philosophy to clarify types of interventions and levels of population-based practice.
From insights gained about this nursing practice reality, a new model has been
developed to assist nurses and others to implement primary health care in New
Zealand and elsewhere.
This work began in 1999 in the midst of more than a decade of health reforms and has
ended, contributing to sector knowledge that supports the need to transform the acute
care system to one that has a chronic care focus and emphasises primary health care.
Nurses as the largest health professional group demonstrated only a small measure of
practice innovation in integrated care projects and little evidence exists of their
collective efforts in advancing this strategy. Since 2001 the Government has invested
264
in PHC nursing and attempted to create an environment that fosters innovation. If
nurses however, cannot envisage a future where interventions are directed at
communities and entire populations, innovations in practice will continue to centre on
individuals, predictive of the past. A major paradigmatic shift from individuals to
groups and communities and an acceptance of the health promotion values associated
with community development challenges nurses to turn new ideas into a working
reality. The Government, health provider organisations, and nursing professional
bodies, whilst espousing the rhetoric of primary health care have not advocated for a
health promotion ideological and practice approach for implementation. This remains
the greatest challenge because without leadership PHC nursing practice will remain
inconsistent and under-developed, and will not be able to meet the needs of
populations experiencing the increasing burden of illness and disability associated
with chronic conditions.
The journey of changing the paradigm of nursing practice to reflect a truly primary
health care orientation has only just begun. There will be further changes to the
structure of the health care system and the roles of the different health professional
groups in New Zealand, and these changes will provide a challenge to the ongoing
practice development of PHC nursing. Future research is required to understand both
new health system contexts and the evolution of PHC nursing practice as it pursues a
more comprehensive primary health care path that is less constrained and offers
greater opportunity for both nurses and their clients.
265
References
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social
behavior. Englewood Cliffs, NJ: Prentice-Hall.
Alcorn, G. D. (2002). Giving voice to school nursing as a primary health care
specialty. Unpublished master's thesis, Victoria University of Wellington,
Wellington, New Zealand.
Alem, A. (2001). Mental health services and epidemiology of mental health problems
in Ethiopia. Ethiopian Medical Journal, 39(2), 153-165.
Anderson, S. (1998, 1 September). Thoughts on integrated care. Health Care &
Informatics Review Online, 2(11). Retrieved June 17, 2004, from
http://hcro.enigma.co.nz/website/index.cfm?fuseaction=articledisplay&Featur
eID=48
Andreasen, A. R. (1995). Marketing social change: Changing behavior to promote
health, social development, and the environment. San Francisco: Jossey-Bass.
Armstrong, D. (1979). The emancipation of biographical medicine. Social Science &
Medicine - Medical Psychology & Medical Sociology, 13A(1), 1-8.
Armstrong, D. (1988). Historical origins of health behaviour. In R. Anderson, J.
Davies, I. Kickbusch, D. McQueen & J. Turner (Eds.), Health behaviour
research and health promotion (pp. 8-21). Oxford, United Kingdom: Oxford
University Press.
Armstrong, J. (1995, September 3). India faces AIDS explosion. The Guardian
Weekly, p. 17.
Armstrong, W., & Bandaranayake, D. (1995). Public health in New Zealand: Recent
changes and future prospects. Wellington, New Zealand: Department of
Public Health.
266
Ashton, J. (1992). Healthy cities. Philadelphia: Open University Press.
Ashton, J., & Seymour, H. (1988). The new public health: The Liverpool experience.
Milton Keynes, United Kingdom: Open University Press.
Ashton, T. (1998, June 29-July 1). Development of integrated care initiatives in New
Zealand: Incentives and risks. Paper presented at the Health and Risk: An
International Symposium, St Catherine's College, Oxford University, England.
Ashton, T. (2001). The influence of economic theory. In P. Davis & T. Ashton (Eds.),
Health and public policy in New Zealand (pp. 107-126). Auckland, New
Zealand: Oxford University Press.
Ashton, T. (2005). Recent developments in the funding and organisation of the New
Zealand health system. Australia and New Zealand Health Policy, 2(1), 9-15.
Atkin, K., & Lunt, N. (1996). The role of the practice nurse in primary health care:
Managing and supervising the practice nurse resource. Journal of Nursing
Management, 4(2), 85-92.
Bachrach, L. L. (1982). Assessment of outcomes in community support systems:
Results, problems, and limitations. Schizophrenia Bulletin, 8(1), 39-61.
Baird, J. (2004). Community based support services for older people: Draft
discussion. Hamilton, New Zealand: Presbyterian Support Services.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Barlow, C. (1991). Tikanga whakaaro: Key concepts in Maori culture. Auckland,
New Zealand: Oxford University Press.
Barnum, H., & Kutzin, J. (1993). Public hospitals in developing countries: Resource
use, cost, financing. Baltimore: Johns Hopkins University Press.
267
Baum, F. E. (1993). Healthy cities and change: Social movement or bureaucratic tool?
Health Promotion International, 8(1), 31 - 40.
Baum, F. E. (1998). The new public health: An Australian perspective. Melbourne,
Australia: Oxford University Press.
Baum, F. E., & Saunders, D. (1995). Can health promotion and primary health care
achieve health for all without a return to their more radical agendas? Health
Promotion International, 10(2), 149-160.
Beaglehole, R., & Bonita, R. (1997). Public health at the crossroads: Achievements
and prospects. Cambridge, England: Cambridge University Press.
Beattie, A. (1986). Community development for health: From practice to theory?
Radical Health Promotion, 4, 11-16.
Beattie, A. (1990). Teaching and learning about health education: New directions for
curriculum development. Edinburgh, United Kingdom: Health Education
Board for Scotland.
Beattie, A. (1991). Knowledge and control in health promotion: A test case for social
policy and social theory. In J. Gabe, M. Calnan & M. Bury (Eds.), The
sociology of the health service (pp. 162-202). London: Routledge.
Becker, M. H. (Ed.). (1974). The Health belief model and personal health behavior.
Thorofare, NJ: Charles B. Slack.
Belson, W. A. (1981). The design and understanding of survey questions. Aldershot,
England: Gower.
Benjamin, A. E., & Newcomer, R. J. (1997). Community level indicators of chronic
health conditions. In R. J. Newcomer & A. E. Benjamin (Eds.), Indicators of
chronic health conditions: Monitoring community-level delivery systems (pp.
1-14). Baltimore, MD: Johns Hopkins University Press.
268
Berman, P. (2000). Organization of ambulatory care provision: A critical determinant
of health system performance in developing countries. Bulletin of the World
Health Organization, 78(6), 791-802.
Bernstein, B. B., & Henderson, D. (1974). Social class differences in the relevance of
language to socialization. In B. B. Bernstein (Ed.), Class, codes and control:
Vol. 2. Primary socialization, language and education (pp. 24-47). London:
Routledge & Kegan Paul.
Betkowski, N. (1996). Preface. In M. Stingl & D. Wilson (Eds.), Efficiency versus
equality: Health reform in Canada (pp. ix-xi). Halifax, Nova Scotia, Canada:
Fernwood Publications.
Blackham, H. J. (Ed.). (1978). Education for personal autonomy: An inquiry into the
school's resources for furthering the personal development of pupils. London:
Bedford Square Press.
Blackwell, D. L., Hayward, M. D., & Crimmins, E. M. (2001). Does childhood health
affect chronic morbidity in later life? Social Science & Medicine, 52(8), 12691284.
Blue, R. G. (1995). "A new net goes out fishing": Options for change within the public
health nursing service. Unpublished master's thesis, University of Auckland,
Auckland, New Zealand.
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002a). Improving primary care
for patients with chronic illness. JAMA, 288(14), 1775-1779.
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002b). Improving primary care
for patients with chronic illness: The chronic care model, Part 2. JAMA,
288(15), 1909-1914.
Boyd, M. (1998). Handover briefing: Integration initiatives Auckland localities.
Auckland, New Zealand: Health Funding Authority.
269
Boyd, M., & Sheridan, N. F. (2000). New Zealand. In W. W. Wieners (Ed.), Global
health care markets: A comprehensive guide to regions, trends, and
opportunities shaping the international health arena (pp. 304-313). San
Francisco: Jossey-Bass.
Bradburn, N. M., Sudman, S., & Blair, E. (1979). Improving interview method and
questionnaire design. San Francisco: Jossey-Bass.
Brault, G. L., & Kissinger, L. D. (1991). Case management: Ambiguous at best.
Journal of Pediatric Health Care, 5(4), 179-183.
Bringewatt, R. J. (1997, December 9-19). Integrating for person-centered care. Paper
presented at the Second Annual Washington Conference on Integrated Patient
Care, Washington, DC.
Brockington, C. F. (1975). The history of public health. In W. Hobson (Ed.), The
theory and practice of public health (4th ed., pp. 1-7). London: Oxford
University Press.
Brown, M., & Crampton, P. (1997). New Zealand policy strategies concerning the
funding of general practitioner care. Health Policy, 41(2), 87-104.
Brown, M., Masters, D., & Smith, B. (1997). Nursing education in New Zealand:
Hospital vs polytech vs university. Professional Leader, 4(1), 7-11, 14.
Brundtland, G. H. (2001). Bridging the health divide: The way forward. In Address:
Fifty-fourth World Health Assembly, Geneva. Retrieved July 15, 2003, from
http://66.102.7.104/search?q=cache:PHgQxtL3a94J:www.who.int/directorgeneral/speeches/2001/english/20010514_wha54.html+%22world+health+ass
embly%22+brundtland+2001+%22tobacco+will+cause%22&hl=en
Buck, P. H. (1949). The coming of the Maori. Wellington, New Zealand: Maori
Purposes Fund Board/Whitcombe and Tombs.
270
Buffat, J. (2000). Unemployment and health. Revue Medicale de la Suisse Romande,
120(4), 379-383.
Bunton, R. (1992). Health promotion as social policy. In R. Bunton & G. Macdonald
(Eds.), Health promotion: Disciplines and diversity (pp. 129-152). London:
Routledge.
Burgess, M. E. (1984). Nursing in New Zealand society. Auckland, New Zealand:
Longman Paul.
Burns, T. (1997). Case management, care management and care programming. British
Journal of Psychiatry, 170(5), 393-395.
Campbell, A. (1984). Moderated love: A theology of professional care. London:
SPCK.
Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental
designs for research. In N. L. Gage (Ed.), Handbook of research on teaching
(pp. 1-76). Chicago: Rand-McNally.
Caplan, R. (1993). The importance of social theory for health promotion: From
description to reflexivity. Health Promotion International, 8(2), 147-157.
Caraher, M. (1994). Nursing and health promotion practice: The creation of victims
and winners in a political context. Journal of Advanced Nursing, 19(3), 465468.
Carryer, J. (2004). Nursing participation and governance in primary health
organisation or talking primary health care, thinking primary care. Vision EIT,
12(1), 4-9, 13-14.
Carryer, J., Dignam, D., Horsburgh, M., Hughes, F., & Martin, J. (1999). Locating
nursing in primary health care: A report for the National Health Committee.
Wellington, New Zealand: National Health Committee.
271
Central Health. (1997a). Integrated care: A beginner's guide. Wellington, New
Zealand: Transitional Health Authority.
Central Health. (1997b). Integrated care: Project and policy information pack: Draft
report. Wellington, New Zealand: Transitional Health Authority.
Chaplin, J., & Adams, D. (1986). London health action network. London: London
Community Health Resource.
Cohen, L., & Manion, L. (1989). Research methods in education (3rd ed.). London:
Routledge.
College of Nurses Aotearoa (NZ) Inc. (2001). The nursing answer to inequalities in
primary health care. Palmerston North, New Zealand: Author.
Collins, R. (1993). Emotional energy as the common denominator of rational action.
Rationality and Society, 5(2), 203-230.
Commission on Chronic Illness. (1957). Chronic illness in the United States,
prevention of chronic illness. Cambridge, MA: Harvard University Press.
Cooper, J. O., Heron, T. E., & Heward, W. L. (1987). Applied behavior analysis.
Columbus, OH: Merrill Publications.
Coster, G. (1998, August 1). An academic perspective on the development of
integrated care. Health Care & Informatics Review Online, 2(10). Retrieved
November 25, 2004, from
http://www.enigma.co.nz/hcro/website/results/2005011212043011900977.pdf
Coutts, L. C., & Hardy, L. K. (1985). Teaching for health: The nurse as health
educator. New York: Churchill Livingstone.
Crampton, P., Dowell, A., & Woodward, A. (2001). Third sector primary care for
vulnerable populations. Social Science & Medicine, 53(11), 1491-1502.
272
Crampton, P., Salmond, C. E., & Kirkpatrick, R. (2004). Degrees of deprivation in
New Zealand: An atlas of socioeconomic difference (2nd ed.). Auckland, New
Zealand: David Bateman.
Crawford, R. (1977). You are dangerous to your health: The ideology and politics of
victim blaming. International Journal of Health Services, 7(4), 663-680.
Creech, W. (1999). The Government's medium-term strategy for health and disability
support services, 1999. Wellington, New Zealand: Ministry of Health.
Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed
methods approaches. Thousand Oaks, CA: Sage Publications.
Crombie, D., & Gedye, C. (1997). Integrated care plan for North Health. Auckland,
New Zealand: Northern Regional Health Authority.
Crotty, M. (1998). The foundations of social research: Meaning and perspective in
the research process. London: Sage.
Davies, P. (1999). Making sense of integrated care in New Zealand. Australian Health
Review, 22(4), 25-44; discussion 45-27.
Davis, P., & Ashton, T. (2001). Health and public policy in New Zealand. Auckland,
New Zealand: Oxford University Press.
Davis, P., Gribben, B., Lee, R. L., & McAvoy, B. (1994). The impact of the new
subsidy regime in general practice in New Zealand. Health Policy, 29(1-2),
113-125.
Davis, R., Wagner, E. G., & Groves, T. (2000). Advances in managing chronic
disease. Research, performance measurement, and quality improvement are
key. BMJ, 320(7234), 525-526.
Davis, R., Wagner, E. H., & Groves, T. (1999). Managing chronic disease. BMJ,
318(7191), 1090-1091.
273
Degeling, P., Maxwell, S., Kennedy, J., & Coyle, B. (2003). Medicine, management,
and modernisation: A "danse macabre"? BMJ, 326(7390), 649-652.
Department of Health. (1974). A health service for New Zealand. Wellington, New
Zealand: Government Printer.
Department of Health. (1986). Public health nursing: Report of the review Committee
to the Director-General of Health. Wellington, New Zealand: The Committee.
DeSimone, B. S. (1988). The case for case management. Continuing Care, 7(6), 2223.
Docherty, B. (1996). Nursing in general practice: A New Zealand perspective.
Christchurch, New Zealand: Author.
Docherty, B. (2004). Nursing participation and governance in primary health
organisation or talking primary health care, thinking primary care:
Commentary 1. Vision EIT, 12(1), 10-11.
Dooley, D., Fielding, J., & Levi, L. (1996). Health and unemployment. Annual
Review of Public Health, 17, 449-465.
Dow, D. A. (1995). Safeguarding the public health: A history of the New Zealand
Department of Health. Wellington, New Zealand: Victoria University Press.
Dowie, J. (2001). Towards value-based, science-informed public health policy:
Conceptual framework and practical guidelines: Background paper for The
World Health Report 2002. Geneva, Switzerland: World Health Organization.
Downie, R. S., Fyfe, C., & Tannahill, A. (1990). Health promotion: Models and
values. Oxford: Oxford University Press.
Doyal, L., & Pennell, I. (1979). The political economy of health. London: Pluto Press.
274
Draper, P., Best, G., & Dennis, J. (1977). Heath & wealth. Royal Society of Health
Journal, 97(3), 121-126.
Durie, M. H. (1985). Maori health institutions. Community Mental Health in New
Zealand, 2(1), 64-69.
Durie, M. H. (1998). Whaiora: Maori health development (2nd ed.). Auckland, New
Zealand: Oxford University Press.
Durie, M. H. (2004, April 26-30). An indigenous model of health promotion. Paper
presented at the 18th World Conference on Health Promotion and Health
Education, Melbourne, Australia.
Durkheim, E. (1984). The division of labor in society (W. D. Hall, Trans.). New York:
Free Press.
Ellwood, P. M. (1988). Shattuck lecture--outcomes management. A technology of
patient experience. New England Journal of Medicine, 318(23), 1549-1556.
English, B. (1997). Keynote Address. Paper presented at the Annual Conference of the
Association of Salaried Medical Specialists, Wellington, New Zealand.
Ensor, T., & San, P. B. (1996). Access and payment for health care: The poor of
Northern Vietnam. International Journal of Health Planning & Management,
11(1), 69-83.
Entwistle, M. (1997, September 1). Co-ordinated contracting: An enabling strategy
for the development of integrated care presented to the NZIHM & NZHA
Conference. Health Care & Informatics Review Online, 2(2). Retrieved May
4, 2004, from
http://www.enigma.co.nz/hcro/website/results/2005011213541860300981.pdf
Evans, R. G., & Stoddart, G. L. (1990). Producing health, consuming health care.
Social Science & Medicine, 31(12), 1347-1363.
275
Ewles, L., & Simnett, I. (2003). Promoting health: A practical guide (5th ed.).
Edinburgh: Baillière Tindall.
Feather, J., & Labonte, R. (1995). Sharing knowledge from health promotion practice:
Final report. Saskatoon, Canada: University of Saskatchewan, Prairie Region
Health Promotion Research Centre.
Feek, C. (1998, May 1). Policy and ethics. Health Care & Informatics Review Online,
2(7). Retrieved May 4, 2004, from
http://www.enigma.co.nz/hcro/website/results/200501121349064100980.pdf
Fink, A. (1995). How to sample in surveys. Thousand Oaks, CA: Sage.
Ford, R., Beadsmoore, A., Ryan, P., Repper, J., & Mattmuijen, C. (1995). Providing
the safety net: Case management for people with a serious mental illness.
Journal of Mental Health, 4(1), 91-97.
Foucault, M. (2002). Archaeology of knowledge. London: Routledge.
Fowler, F. J., Jr. (1992). How unclear terms affect survey data. Public Opinion
Quarterly, 56(2), 218-231.
Fowler, F. J., Jr. (2002). Survey research methods (3rd ed.). Thousand Oaks, CA:
Sage Publications.
Fowler, F. J., Jr., & Mangione, T. W. (1990). Standardized survey interviewing:
Minimizing interviewer-related error. Newbury Park, CA: Sage Publications.
French, J. (1990). Boundaries and horizons: The role of health education within health
promotion. Health Education Journal, 49(1), 7-10.
French, J., & Adams, L. (1986). From analysis to synthesis: Theories of health
education. Health Education Journal, 45(2), 71–74.
276
French, S., Old, A., & Healy, J. (2001). Health care systems in transition: New
Zealand. European Observatory on Health Care Systems, 3(19), 1-136.
Frenk, J. (1993, May). The new public health. Annual Review of Public Health, 14,
469-490.
Frenk, J. (1994). Dimensions of health system reform. Health Policy, 27(1), 19-34.
Garside, P. (1987, July). History of public health. Paper presented at the Rethinking
public health, Birmingham, United Kingdom.
Gatherer, A., Parfit, J., Partner, E., & Vessey, M. (1979). Is health education
effective? London: Health Education Council.
Glasgow, R. E., Orleans, C. T., & Wagner, E. H. (2001). Does the chronic care model
serve also as a template for improving prevention? Milbank Quarterly, 79(4),
579-612.
Goering, P. N., Wasylenki, D. A., Farkas, M., Lancee, W. J., & Ballantyne, R. (1988).
What difference does case management make? Hospital & Community
Psychiatry, 39(3), 272-276.
Golodner, L. (1999). Consumer voice. In E. L. Cohen & V. De Back (Eds.), The
outcomes mandate: Case management in health care today (pp. 20-26). St.
Louis, MO: Mosby.
Gott, M., & O'Brien, M. (1990). The role of the nurse in health promotion. Health
Promotion International, 5(2), 137-143.
Gravitas Research and Strategy Limited. (2005). Quality of life in New Zealand's
largest cities: Resident's survey. Retrieved May 26, 2005, from
http://www.bigcities.govt.nz/pdf2004/Survey_Quality_Of_Life_2004Exec_summary.pdf
277
Green, L. W., & Raeburn, J. (1988). Health promotion. What is it? What will it
become? Health Promotion, 3(2), 151-159.
Grone, O., & Garcia-Barbero, M. (2001, April-June). Integrated care: A position
paper of the WHO European office for integrated health care services.
International Journal of Integrated Care, 1, 1-15. Retrieved October 15, 2004,
from http://www.ijic.org/publish/articles/000036/article_print.html
Groves, R. M. (1989). Survey errors and survey costs. New York: Wiley.
Grundy, E. (1997). Demography and gerontology: Mortality trends among the oldest
old. Ageing & Society, 17(6), 713-725.
Guidotti, T. L. (1989). Health promotion in perspective. Canadian Journal of Public
Health, Revue Canadienne de Sante Publique. 80(6), 400-405.
Gwatkin, D. R., & Guillot, M. (2000). The burden of disease among the world's poor:
Current situation, future trends, and implications for policy. Washington, DC:
Human Development Network of The World Bank.
Halmos, P. (1965). The faith of the counsellors. London: Constable.
Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model
of population health and health promotion. Ottawa, Ontario, Canada: Health
Promotion Development Division.
Hardy, J. (1981). Values in social policy: Nine contradictions. London: Routledge &
Kegan Paul.
Health Benefits Review. (1986). Choices for health care: Report of the health benefits
review. Wellington, New Zealand: Author.
Health Funding Authority. (1998). Service integration: Guidelines for the
development of integration demonstration projects. Wellington, New Zealand:
Author.
278
Health News. (2004). Health of a nation: 29/01/2004: A year in the health of New
Zealand. Retrieved June 6, 2005, from
http://www.healthpages.co.nz/index.php?page=422033+152215552
Health Services Research Centre, & Te Ropu Rangahau Hauora a Eru Pomare.
(2001). National demonstration integrated care pilot projects: Overview
report: Final evaluation report. Wellington, New Zealand: Victoria
University, Health Services Research Centre.
Heffler, S., Levit, K., Smith, S., Smith, C., Cowan, C., Lazenby, H., et al. (2001).
Health spending growth up in 1999: Faster growth expected in the future.
Health Affairs, 20(2), 193-203.
Hennekens, C. H., & Buring, J. E. (1987). Epidemiology in medicine. Boston: Little,
Brown and Company.
Herrin, J., Cangialose, C. B., Boccuzzi, S. J., Weintraub, W. S., & Ballard, D. J.
(2000). Household income losses associated with ischaemic heart disease for
US employees. Pharmacoeconomics, 17(3), 305-314.
Hetzel, B. S. (1976). Health and Australian society. Ringwood, Victoria, Australia:
Penguin.
Hickman, M., Drummond, N., & Grimshaw, J. (1994). A taxonomy of shared care for
chronic disease. Journal of Public Health Medicine, 16(4), 447-454.
Hill, H. W. (1916). The new public health. New York: Macmillan.
Hiss, R. G. (1996). Barriers to care in non-insulin-dependent diabetes mellitus. The
Michigan experience. Annals of Internal Medicine, 124(1 Pt 2), 146-148.
Holt, S., & Beasley, R. (2001). The burden of asthma in New Zealand. Wellington,
New Zealand: Asthma and Respiratory Foundation of New Zealand.
279
Hopkins, C. D. (1980). Understanding educational research: An inquiry approach.
Columbus, OH: Merrill.
Howden-Chapman, P., & Tobias, M. (Eds.). (2000). Social inequalities in health: New
Zealand 1999: A summary. Wellington, New Zealand: Ministry of Health.
Hughes, F. (2003). Nursing sector update. Wellington, New Zealand: Ministry of
Health.
Hunn, J. K. (1961). Report on Department of Mäori Affairs: With statistical
supplement, 24 August 1960. Wellington, New Zealand: Government Printer.
Institute of Medicine (U.S.) Committee on Quality of Health Care in America. (2001).
Crossing the quality chasm: A new health system for the 21st century.
Washington, DC: National Academy Press.
Jansen, P. (1998). The relationships of integrated care organisations and other health
care providers with Maori. Wellington, New Zealand: Transitional Health
Authority.
Jensen, G. A., & G, K. J. (1999). Longitudinal profiling: A differentiated community
nursing model. In E. L. Cohen & V. De Back (Eds.), The outcomes mandate:
Case management in health care today (pp. 152-161). St Louis, MO: Mosby.
Kanter, J. (1989). Clinical case management: Definition, principles, components.
Hospital & Community Psychiatry, 40(4), 361-368.
Kaplan, R., & Norton, D. (1997). Translating strategy into action: The balanced
scorecard. Boston: HBA Press.
Keating, G. (1998). A view from the Ministry of Health. Health Care & Informatics
Review Online, 2(8). Retrieved February 8, 2005, from
http://216.239.57.104/search?q=cache:3TCjtypFKu4J:www.enigma.co.nz/hcro
/website/index.cfm%3Ffuseaction%3Darticledisplay%26FeatureID%3D39+ke
ating+view+from+ministry+health+offers+services&hl=en
280
Keller, L. O., Schaffer, M. A., Lia-Hoagberg, B., & Strohschein, S. (2002).
Assessment, program planning, and evaluation in population-based public
health practice. Journal of Public Health Management and Practice, 8(5), 3043.
Keller, L. O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. (1998). Populationbased public health nursing interventions: A model from practice. Public
Health Nursing, 15(3), 207-215.
Keller, L. O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. A. (2004).
Population-based public health interventions: Practice-based and evidencesupported. Part I. Public Health Nursing, 21(5), 453-468.
Keller, L. O., Strohschein, S., Schaffer, M. A., & Lia-Hoagberg, B. (2004).
Population-based public health interventions: Innovations in practice,
teaching, and management. Part II. Public Health Nursing, 21(5), 469-487.
Kelly, M. P., & Charlton, B. (1995). The modern and the postmodern in health
promotion. In R. Bunton, S. Nettleton & R. Burrows (Eds.), The sociology of
health promotion: Critical analyses of consumption, lifestyle and risk (pp. 7890). London: Routledge.
Kelsey, J. (1993). Rolling back the State: Privatisation of power in Aotearoa/New
Zealand. Wellington, New Zealand: Bridget Williams Books.
Kennedy, I. (1983). The unmasking of medicine (Rev. ed.). London: Granada.
Keppel, G. (1991). Design and analysis: A researcher's handbook (3rd ed.).
Englewood Cliffs, NJ: Prentice-Hall.
Khawaja, M., & Dunstan, K. (2000, September). Changing face of New Zealand's
population. Key Statistics, 7-10.
Khawaja, M., & Thomson, N. (2000, January/February). Population ageing in New
Zealand. Key Statistics, 7-10.
281
King, A. (2003). Childhood obesity symposium. Retrieved May 8, 2005, from
http://www.beehive.govt.nz/ViewDocument.aspx?DocumentID=17723
King, A. (2005). King announces more primary nursing scholarships. In
beehive.govt.nz. Retrieved April 25, 2005, from
http://www.beehive.govt.nz/ViewDocument.aspx?DocumentID=22414
King, M. (2004). The Penguin history of New Zealand (Rev. ed.). Auckland, New
Zealand: Penguin Books.
Kiro, C. A. (1997). Tackling inequality in health. Social Work Review, 8(4), 15-17.
Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as
cultural systems. Social Science & Medicine, 12(2B), 85-95.
Kodner, D. L., & Spreeuwenberg, C. (2002, October-December). Integrated care:
Meaning, logic, applications, and implications: A discussion paper.
International Journal of Integrated Care, 2, 1-8. Retrieved January 19, 2005,
from http://www.ijic.org/publish/articles/000089/article.pdf
KPMG Consulting. (2001). Strategic review of undergradutate nursing education:
Final report to the Nursing Council. New Zealand: Nursing Council of New
Zealand.
Labonte, R. N. (1996). Community development in the public health sector: The
possibilities of an empowering relationship between the state and civil society.
Unpublished PhD Thesis, York University, Toronto, Canada.
Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa, Canada:
National Health and Welfare.
Lamm, R. D. (1994). The ethics of excess. Hastings Center Report, 24(6), 14.
282
Lassey, M. L., Lassey, W. R., & Jinks, M. J. (1997). Health care systems around the
world: Characteristics, issues, reforms. Upper Saddle River, NJ: Prentice
Hall.
Last, J. M. (1998). Public health and human ecology (2nd ed.). Stamford, CT:
Appleton & Lange.
Laverack, G. (2005). Public health: Power, empowerment, and professional practice.
New York: Palgrave Macmillan.
Laverack, G., & Labonte, R. (2000). A planning framework for community
empowerment goals within health promotion. Health Policy & Planning,
15(3), 255-262.
Law, C. M., de Swiet, M., Osmond, C., Fayers, P. M., Barker, D. J., Cruddas, A. M.,
et al. (1993). Initiation of hypertension in utero and its amplification
throughout life. BMJ, 306(6869), 24-27.
Law, C. M., Egger, P., Dada, O., Delgado, H., Kylberg, E., Lavin, P., et al. (2001).
Body size at birth and blood pressure among children in developing countries.
International Journal of Epidemiology, 30(1), 52-57.
Lewis, S. (1997). Regionalization and devolution: Transforming health, reshaping
politics? (Occasional Paper No. 2). Saskatoon, Saskatchewan, Canada:
HEALNet Regional Health Planning, Health Services Utilization and Research
Commission.
Leyva-Flores, R., Kageyama, M. L., & Erviti-Erice, J. (2001). How people respond to
illness in Mexico: Self-care or medical care? Health Policy, 57(1), 15-26.
Lincoln, Y. S., & Guba, E. G. (2000). Paradigmatic controversies, contradictions, and
emerging confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of
qualitative research (2nd ed., pp. 163-188). Thousand Oaks, CA: Sage.
283
Litchfield, M. (2001, July 28-29). The role of rural nursing: Conservative and
progressive models. Paper presented at the National Conference of Rural
Nurses in New Zealand, University of Otago, Dunedin, New Zealand.
Litwin, M. S. (1995). How to measure survey reliability and validity. Thousand Oaks,
CA: Sage.
Lomas, J. (1997). Devolving authority for health care in Canada's provinces: 4.
Emerging issues and prospects. CMAJ Canadian Medical Association Journal,
156(6), 817-823.
Lomas, J., & Rachlis, M. (1996). Moving rocks: Block funding in PEI as an incentive
for cross-sectoral reallocations among human services. Canadian Public
Administration, 39(2), 581-600.
Lomas, J., Woods, J., & Veenstra, G. (1997). Devolving authority for health care in
Canada's provinces: 1. An introduction to the issues. CMAJ Canadian Medical
Association Journal, 156(3), 371-377.
Ludermir, A. B., & Lewis, G. (2001). Links between social class and common mental
disorders in Northeast Brazil. Social Psychiatry & Psychiatric Epidemiology,
36(3), 101-107.
Lynch, J. W., Kaplan, G. A., & Shema, S. J. (1997). Cumulative impact of sustained
economic hardship on physical, cognitive, psychological, and social
functioning. New England Journal of Medicine, 337(26), 1889-1895.
MacLean, F. S. (1964). Challenge for health: A history of public health in New
Zealand. Wellington, New Zealand: Government Printer.
MacLean, F. S. (1966). Medical services. In A. H. McLintock (Ed.), An
encyclopaedia of New Zealand (Vol. 2, pp. 521-542). Wellington, New
Zealand: Government Printer.
284
Mahler, H. (1988, April 5-9). Opening address. Paper presented at the Healthy Public
Policy, 2nd International Conference on Health Promotion, Adelaide,
Australia.
Malcolm, L. (1997). GP budget holding in New Zealand: Lessons for Britain and
elsewhere? BMJ, 314(7098), 1890-1892.
Malcolm, L., & Shalowitz, M. (1997). Managed/integrated care in New Zealand:
Contrasts with the USA. Unpublished paper.
Marmor, T., & Mashaw, J. (2001). Canada's health insurance and ours: The real
lessons, the big choices. In P. Conrad & R. Kern (Eds.), The Sociology of
health and illness: Critical perspectives (6th ed., pp. 479-489). New York:
Worth Publishers.
Marmot, M., & Bobak, M. (2000). International comparators and poverty and health
in Europe. BMJ, 321(7269), 1124-1128.
Marsden, M. (1975). God, man and the universe: A Maori view. In M. King (Ed.), Te
Ao Hurihuri: The world moves on: Aspects of Maoritanga (pp. 191-219).
Wellington, New Zealand: Hicks Smith.
Marshall, M., Gray, A., Lockwood, A., & Green, R. (1998, Update September 22,
2003). Case management for people with severe mental disorders. In May 25,
2005, from The Cochrane Library, Wiley Interscience
Martin, J. (2002). The implications of the 2001 primary health care strategy for
providers and consumers. Unpublished master's thesis, Massery University,
Palmerston North, New Zealand.
Marwick, J. (1996, May 2-4). What do we mean by managed care? Paper presented at
the Ministry of Health Managed Care Conference: Options for New Zealand,
Wellington, New Zealand.
285
Maurin, J. T. (1990). Case management: Caring for psychiatric clients. Journal of
Psychosocial Nursing and Mental Health Services, 28(7), 6-12, 32-13.
McCormick, R. (1997). Integrated care. Auckland: Northern Regional Health
Authority.
McCormick, R., & Ranger, W. (1997). Integrated care: Draft North Health strategy
and implementation plan: Prepared for the Integration Group. Auckland, New
Zealand: Northern Regional Health Authority.
McKegg, A. (1991). 'Ministering angels': The government backblock nursing service
and the Maori health nurses, 1909-1939. Unpublished master's thesis,
University of Auckland, Auckland, New Zealand.
McKegg, A. (1992). The Maori Health Nursing Scheme: An experiment in
autonomous health care. New Zealand Journal of History, 26(2), 145-160.
McKenzie, L. (1997). Discussion paper on integrated care. Wellington, New
Zealand: Transitional Health Authority.
McKenzie, L., & Webster, J. (1997). Investigation into the ownership and purchase
issues for the Crown in relation to integrated care developments in New
Zealand: Report for Treasury. Wellington, New Zealand: Unpublished.
McKeown, T. (1979). The role of medicine: Dream, mirage, or nemesis? Princeton,
NJ: Princeton University Press.
McKillop, A. M. (1998). Native health nursing in New Zealand 1911-1930: A new
work and a new profession for women. Unpublished master's thesis, Massey
University, Palmerston North, New Zealand.
McMurray, A. (2003). Community health and wellness: A socioecological approach.
Sydney, Australia: Mosby.
286
Mengesha, Y. A., & Bekele, A. (1998). Relative chronic effects of different
occupational dusts on respiratory indices and health of workers in three
Ethiopian factories. American Journal of Industrial Medicine, 34(4), 373-380.
Mertens, D. M. (1998). Research methods in education and psychology: Integrating
diversity with quantitative & qualitative approaches. Thousand Oaks, CA:
Sage Publications.
Michel, J. (1997). Review of practice nurse services in the northern region:
Unpublished report. Auckland, New Zealand: Northern Regional Health
Authority.
Ministry of Health. (1996). Well child - Tamariki ora national schedule. Wellington,
New Zealand: Author.
Ministry of Health. (1997). The health and wellbeing of older people and kaumatua:
The public health issues. Wellington, New Zealand: Author.
Ministry of Health. (1998). Report of the ministerial taskforce on nursing: Releasing
the potential of nursing. Wellington, New Zealand: Author.
Ministry of Health. (1999). NZ food: NZ people: Key results of the 1997 national
nutrition survey. Wellington, New Zealand: Author.
Ministry of Health. (2000). The New Zealand Health Strategy: Discussion Document.
Wellington, New Zealand: Author.
Ministry of Health. (2001a). The New Zealand disability strategy: Making a world of
difference: Whakanui oranga. Wellington, New Zealand: Author.
Ministry of Health. (2001b). The New Zealand health strategy. Wellington, New
Zealand: Author.
Ministry of Health. (2001c). The Primary Health Care Strategy. Wellington, New
Zealand: Author.
287
Ministry of Health. (2002a). Call for registration of interest - Primary health care
nursing innovations funding. Wellington, New Zealand: Author.
Ministry of Health. (2002b). A guide for establishing primary health organisations.
Wellington, New Zealand: Author.
Ministry of Health. (2002c). He korowai oranga: Maori health strategy. Wellington,
New Zealand: Author.
Ministry of Health. (2002d). Health of older people in New Zealand: A statistical
reference. Wellington, New Zealand: Author.
Ministry of Health. (2002e). The New Zealand health workforce: Framing future
directions: Discussion document. Wellington, New Zealand: Health
Workforce Advisory Committee.
Ministry of Health. (2002f). Nurse Practitioners in New Zealand. Wellington, New
Zealand: Author.
Ministry of Health. (2003a). Funding for primary health care nursing scholarships. In
Primary health care strategy. Retrieved April 29, 2005, from
http://www.moh.govt.nz/moh.nsf/wpg_index/Primary+Health+Care+Publications+by+Title
Ministry of Health. (2003b). Investing in health: Whakatohutia te oranga tangata: A
framework for activating primary health care nursing in New Zealand.
Wellington, New Zealand: Author.
Ministry of Health. (2003c). Nutrition and the burden of disease: New Zealand 19972011. Wellington, New Zealand: Author.
Ministry of Health. (2003d). NZ food NZ children: Key results of the 2002 national
children's nutrition survey. Wellington, New Zealand: Author.
288
Ministry of Health. (2003e). Primary health care and community nursing workforce
survey – 2001. Wellington, New Zealand: Author.
Ministry of Health. (2003f). Tobacco facts 2003: Public Health Intelligence
Occasional Report (No. 20). Wellington, New Zealand: Author.
Ministry of Health. (2004a). Care plus: An overview. In Primary health care strategy.
Retrieved April 29, 2005, from http://www.moh.govt.nz/moh.nsf/wpg_index/Primary+Health+Care+Care+Plus#overview
Ministry of Health. (2004b). Guideline for specialist health services for older people.
Wellington, New Zealand: Author.
Ministry of Health. (2004c). Health expenditure trends in New Zealand 1990-2002.
Wellington, New Zealand: Author.
Ministry of Health. (2004d). A portrait of health: Key results of the 2002/03 New
Zealand health survey. Wellington, New Zealand: Author.
Ministry of Health. (2004e). Primary health care strategy implementation - Q&As. In
Primary health care strategy. Retrieved April 29, 2005, from
http://www.moh.govt.nz/moh.nsf/wpg_Index/AboutPrimary+Health+Care+Strategy+Implementation
Ministry of Health. (2005). Primary health care nursing scholarships. Retrieved May
25, 2005, from
http://www.moh.govt.nz/moh.nsf/0/8a26a197747fd6decc256fb8007ee02a?Op
enDocument
Ministry of Health, & Coopers & Lybrand. (1995). Co-ordinated care for Maori:
Issues for development. Wellington, New Zealand: The Ministry.
Ministry of Maori Development. (1999). Evaluation for Maori: Guidelines for
government agencies. Wellington, New Zealand: Te Puni Kokiri.
289
Ministry of Social Development. (2002). The social report: Te purongo oranga
tangata 2002. Wellington, New Zealand: Author.
Ministry of Social Development. (2004). The social report: Te purongo oranga
tangata 2004. Wellington, New Zealand: Author.
Minnesota Department of Health. (2001). Public Health Interventions Applications
for Public Health Nursing Practice. St. Paul, MN: Author.
Minto, R. (2004). Nursing participation and governance in primary health
organisation or talking primary health care, thinking primary care:
Commentary 3. Vision EIT, 12(1), 12-13.
Modrcin, M., Rapp, C. A., & Poertner, J. (1988). The evaluation of case management
services with the chronically mentally ill. Evaluation and Program Planning,
11(4), 307-314.
Naidoo, J., & Wills, J. (1994). Health promotion: Foundations for practice. London:
Bailliere Tindall.
National Health Committee. (1998). Social, economic and cultural determinants of
health: Action to improve health. Wellington, New Zealand: National
Advisory Committee on Health and Disability.
National Health Committee. (2005). People with chronic conditions: A discussion
paper. Wellington, New Zealand: National Advisory Committee on Health
and Disability.
Neuman, S., & McCormick, S. (Eds.). (1995). Single-subject experimental research:
Applications for literacy. Newark, DE: International Reading Association.
Neuman, W. (2000). Social research methods: Qualitative and quantitative
approaches (4th ed.). Boston: Allyn and Bacon.
290
New Zealand Health Information Service. (2004). Nurses and midwives. In New
Zealand workforce statistics 2004. Retrieved January 19, 2005, from
http://www.nzhis.govt.nz/stats/nursestats-p.html
New Zealand Steering Group to Oversee Health and Disability Changes. (1997).
Implementing the coalition agreement on health: The report of the steering
group to oversee health and disability changes. Wellington, New Zealand:
Ministry of Health.
Newell, K. W. (1975). Health by the people. Geneva, Switzerland: World Health
Organization.
Niessen, L. W. (2002). Roads to health: Multi-state modelling of population health
and resource use. Amsterdam: Rozenberg Publishers/Dutch University Press.
Nursing Council of New Zealand. (2001a). Framework for post-registration nursing
practice education. Wellington: Author.
Nursing Council of New Zealand. (2001b). The Nurse Practitioner. Wellington, New
Zealand: Author.
Nursing Council of New Zealand. (2002). Guidelines for cultural safety, the Treaty of
Waitangi, and Maori health in nursing and midwifery education and practice.
Wellington, New Zealand: Nursing Council of New Zealand.
Nursing Council of New Zealand. (2004). Health Practitioners Competence
Assurance Act 2003. Retrieved March 5, 2005, from
http://www.nursingcouncil.org.nz/hpca.html
Oakley, A. (1981). Interviewing women: A contradiction in terms. In H. Roberts
(Ed.), Doing feminist research (pp. 30-61). London: Routledge & Kegan Paul.
Oksenberg, L., Cannell, C., & Kalton, G. (1991). New strategies for pretesting survey
questions. Journal of Official Statistics, 7(3), 349-366.
291
Ovretveit, J. (1998, March 1). Integrated care: Models and issues. Health Care &
Informatics Review Online, 2(5). Retrieved May 2, 2004, from
http://www.enigma.co.nz/hcro/website/index.cfm?fuseaction=articledisplay&
FeatureID=29
Papenhausen, J. L. (1990). Case management: A model of advanced practice? Clinical
Nurse Specialist, 4(4), 169-170.
Parry, G. (1982). A fence at the top: The first 75 years of the Plunket Society.
Dunedin, New Zealand: Royal New Zealand Plunket Society.
Parsons, M., Anderson, C., Senior, H., & Jacobs, S. (2004, Autumn). Ageing in place:
Is this a viable alternative to residential homes in New Zealand? Agendas.
Pattison, S. (2000). A critique of pastoral care (3rd ed.). London: SCM Press.
Pearson, G. (1973). Social work as the privatized solution of public ills. British
Journal of Social Work, 3(2), 209-227.
Pert, H. (1998). Experience with integration initiatives in New Zealand – A GP
perspective. Healthcare Review Online, 2(10). Retrieved November 7, 2004,
from
http://hcro.enigma.co.nz/website/index.cfm?fuseaction=articledisplay&Featur
eID=45
Petersen, S., Peto, V., Scarborough, P., & Rayner, M. (2005). Economic costs. In
Coronary heart disease statistics (13th ed., pp. 197-200). London: British
Heart Foundation.
Peto, R., Lopez, A. D., Boreham, J., Thun, M., & Heath, C. (1994). Mortality from
smoking in developed countries, 1950-2000: Indirect estimates from national
vital statistics. Oxford, United Kingdom: Oxford University Press.
Petrou, S. (1998). Health needs assessment is not required for priority setting. BMJ,
317(7166), 1154.
292
Phillips, D. C., & Burbules, N. C. (2000). Postpositivism and educational research.
Lanham, MD: Rowman & Littlefield Publishers.
Pomare, E. W., Keefe-Ormsby, V., Ormsby, C., Pearce, N., Reid, P., Robson, B., et
al. (1995). Hauora, Maori standards of health. III: A study of the years, 19701991. Wellington, New Zealand: Te Ropu Rangahau Hauora a Eru
Pomare/Eru Pomare Maori Health Research Centre.
Porter-O'Grady, T. (1999). Sustainable partnerships: The journey toward health care
integration. In E. L. Cohen & V. De Back (Eds.), The outcomes mandate:
Case management in health care today (pp. 2-11). St Loius, MO: Mosby.
Powles, J. (1973). On the limitations of modern medicine. Science, Medicine, & Man,
1(1), 1-30.
Powles, J. (1988). Professional hygienists and the health of the nation. In R. MacLeod
(Ed.), The Commonwealth of science: ANZAAS and the scientific enterprise in
Australasia 1888-1988 (pp. 292-307). Auckland, New Zealand: Oxford
University Press.
Powney, J., & Watts, M. (1987). Interviewing in educational research. London:
Routledge & Kegan Paul.
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach:
Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin.
Protemix. (2003). Media Release - 16 November 2003. Retrieved February 21, 2005,
from http://www.protemix.co.nz/corporate/Article.asp?id=8
Puetz, B. E., & Shinn, L. J. (1997). The nurse consultant's handbook. New York:
Springer Pub. Co.
Radical Therapist-Rough Times Collective. (1974). The Radical therapist.
Harmondsworth, United Kingdom: Penguin.
293
Raeburn, J. (1996, June 17-19). How effective is strengthening community action as a
strategy for health promotion. Paper presented at the First International
Symposium on Health Promotion Effectiveness, University of Toronto,
Ontario, Canada.
Raeburn, J., & Rootman, I. (1997). People-centred health promotion. Chichester,
United Kingdom: John Wiley.
Rea, H., McAuley, S., Stewart, A., Lamont, C., Roseman, P., & Didsbury, P. (2004).
A chronic disease management programme can reduce days in hospital for
patients with chronic obstructive pulmonary disease. Internal Medicine
Journal, 34(11), 608-614.
Reamy, J. (1995). Health service regionalization in New Brunswick, Canada: A bold
move. International Journal of Health Services, 25(2), 271-282.
Rice, D. P., Kelman, S., & Miller, L. S. (1992). The economic burden of mental
illness. Hospital & Community Psychiatry, 43(12), 1227-1232.
Rifkin, S. B., & Walt, G. (1986). Why health improves: Defining the issues
concerning 'comprehensive primary health care' and 'selective primary health
care'. Social Science & Medicine, 23(6), 559-566.
Robson, C. (1993). Real world research: A resource for social scientists and
practitioner-researchers. Oxford, UK: Blackwell.
Rodmell, S., & Watt, A. (1986). The Politics of health education: Raising the issues.
London: Routledge & Kegan Paul.
Rogers, C. (1969). Freedom to learn: A view of what education might become.
Columbus, OH: C. E. Merrill Pub. Co.
Rogers, W. (1991). Explaining health and illness: An exploration of diversity. New
York: Harvester Wheatsheaf.
294
Room, G. (1979). The sociology of welfare: Social policy, stratification and political
order. Oxford: Blackwell/Martin Robertson.
Rosen, G. (1958). A history of public health. New York: MD Publications.
Rothman, A. A., & Wagner, E. H. (2003). Chronic illness management: What is the
role of primary care? Annals of Internal Medicine, 138(3), 256-261.
Rotter, J. B. (1966). Generalized expectancies for internal versus external control of
reinforcement. Psychological Monographs: General & Applied, 80(1), 1-28.
Russell, M., Cumming, J., Slack, A., Paterson, D., & Gilbert, A. (2003). Integrated
care: Reflections from research. In R. Gauld (Ed.), Continuity amid chaos:
Health care management and delivery in New Zealand (pp. 201-213).
Dunedin, New Zealand: University of Otago Press.
Saggers, S., & Gray, D. (1991). Aboriginal health and society: The traditional and
contemporary Aboriginal struggle for better health. North Sydney, Australia:
Allen & Unwin.
Scarrow, H. A. (1972). The impact of British domestic air pollution legislation.
British Journal of Political Science, 2(3), 261-282.
Schon, D. A. (1983). The reflective practitioner: How professionals think in action.
New York: Basic Books.
Schrijvers, G. (2001, November). In pursuit of evidence based integrated care.
International Journal of Integrated Care, 1. Retrieved September 16, 2003,
from http://www.ijic.org/publish/articles/000060/article_toc.html
Schuman, H., & Presser, S. (1981). Questions and answers in attitude surveys:
Experiments on question form, wording, and context. New York: Academic
Press.
295
Scott, G. (1997, August 1). Integrating purchasing and integrating care. Health Care
& Informatics Review Online, 2(1). Retrieved May 4, 2004, from
http://www.enigma.co.nz/hcro/website/results/200501121402444100982.pdf
Shibuya, K., Mathers, C. D., Boschi-Pinto, C., Lopez, A. D., & Murray, C. J. (2002).
Global and regional estimates of cancer mortality and incidence by site: II.
Results for the global burden of disease 2000. BMC Cancer, 2(1), 37.
Shipley, J. (1995). Advancing health in New Zealand. Wellington, New Zealand: New
Zealand Government.
Shobhana, R., Rama Rao, P., Lavanya, A., Williams, R., Vijay, V., & Ramachandran,
A. (2000). Expenditure on health care incurred by diabetic subjects in a
developing country--a study from southern India. Diabetes Research &
Clinical Practice, 48(1), 37-42.
Shortell, S. M., Gillies, R. R., Anderson, D. A., Erickson, K. M., & Mitchell, J. B.
(1996). Remaking health care in America: Building organized delivery
systems. San Francisco: Jossey-Bass Publishers.
Slovic, P., & Gregory, R. (1999). Risk analysis, decision analysis, and the social
context for risk decision making. In J. Shanteau, B. A. Mellers & D. A. Schum
(Eds.), Decision science and technology: Reflections on the contributions of
Ward Edwards (pp. 353-365). Boston, MA: Klumer Academic.
Somerville, G. (1984). Community development in health: Addressing the confusions.
London: King's Fund Centre.
Statistics New Zealand. (2004). National Population Projections (2004(base) – 2051)
- Hot Off The Press. Retrieved January 26, 2005, from
http://www2.stats.govt.nz/domino/external/pasfull/pasfull.nsf/web/Hot+Off+T
he+Press+National+Population+Projections+2004(base)+–+2051?open
296
Statistics New Zealand. (2005a). Births and Deaths (March 2005 quarter) - Media
Release: Birth rates for older women continue to rise. Retrieved May 26,
2005, from
http://www2.stats.govt.nz/domino/external/pasfull/pasfull.nsf/web/Media+Rel
ease+Births+and+Deaths+March+2005+quarter?open
Statistics New Zealand. (2005b). Future Pacific population - Summary of latest
trends. In Population monitor. Retrieved May 27, 2005, from
http://www.stats.govt.nz/popn-monitor/future-pacific-popn/future-pacific-popsummary-latest-trends.htm
Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I.
Conceptual model, treatment program, and clinical evaluation. Archives of
General Psychiatry, 37(4), 392-397.
Stewart, J., & Thomas, S. (2004). Health promotion in context. Environmental Health
Journal: EHJ, 112(12), 382-384.
Stock, S., Redaelli, M., Luengen, M., Wendland, G., Civello, D., & Lauterbach, K. W.
(2005). Asthma: Prevalence and cost of illness. European Respiratory
Journal, 25(1), 47-53.
Stonehouse, E. A. (1972). In the name of Nurse Maude. Christchurch, New Zealand:
Nurse Maude District Nursing Association.
Talbot, L., & Verrinder, G. (2005). Promoting health: The primary health care
approach (3rd ed.). Marrickville, NSW, Australia: Elsevier Australia.
Tanur, J. M. (Ed.). (1992). Questions about questions: Inquiries into the cognitive
bases of surveys. New York: Russell Sage Foundation.
Tarimo, E., & Webster, E. G. (1994). Primary health care concepts and challenges in
a changing world: Alma-Ata revisited. Geneva, Switzerland: Division of
Strengthening of Health Services, World Health Organization.
297
Taylor-Gooby, P., & Dale, J. (1981). Social theory and social welfare. London:
Edward Arnold.
Tesh, S. N. (1988). Hidden arguments: Political ideology and disease prevention
policy. New Brunswick, NJ: Rutgers University Press.
The Robert Wood Johnson Foundation. (2000). Patient education and consumer
activation in chronic disease. In Meeting Proceedings. Retrieved June 20,
2003, from http://www.rwjf.org/files/publications/other/PatientEducation.pdf
Thomas, B., & Lovell, K. (1999). Mental health nursing and case management in
Great Britain. In E. L. Cohen & V. De Back (Eds.), The outcomes mandate:
Case management in health care today (pp. 112-121). St Louis, MO: Mosby.
Tobacco in New Zealand. (n.d.). In National Drug Policy New Zealand. Retrieved
June 3, 2005, from
http://www.ndp.govt.nz/publications/tobaccofacts2003.html
Tones, B. (1986). Health education and the ideology of health promotion: A review of
alternative approaches. Health Education Research, 1(1), 3-12.
Tones, K., & Tilford, S. (1994). Health education: Effectiveness, efficiency, and
equity (2nd ed.). London: Chapman & Hall.
Tones, K., Tilford, S., & Robinson, Y. (1990). Health education: Effectiveness and
efficiency. London: Chapman and Hall.
Toop, L. J., Nuthall, J. J., & Hodges, I. D. (1996). Primary care teamwork in the
Christchurch area: Part 2: Barriers to greater collaboration. New Zealand
Family Physician, 23(6), 51-59.
Townsend, P., Phillimore, P., & Beattie, A. (1988). Health and deprivation:
Inequality and the North. London: Croom Helm.
298
Transitional Health Authority. (1997). Discussion paper on integrated care.
Wellington, New Zealand: Author.
Tschudin, V. (1995). Models for counselling. In Counselling skills for nurses (4th ed.,
pp. 38-55). London: Baillière Tindall.
Tsouros, A. (1995). The WHO Healthy Cities project: State of the art and future
plans. Health Promotion International, 10:(2), 133–141.
Turnock, B. J. (2001). Public health: What it is and how it works. Gaithersburg, MD:
Aspen Publishers.
Ulschak, F. L., & SnowAntle, S. M. (1990). Consultation skills for health care
professionals: How to be an effective consultant within your organization. San
Francisco: Jossey-Bass Publishers.
Upton, S., & New Zealand Department of Health. (1991). Health policy: Your health
and the public health: Summary: A statement of government health policy.
Wellington, New Zealand: Minister of Health.
Wadsworth, Y. (1997). Do it yourself social research (2nd ed.). St. Leonards, NSW,
Australia: Allen & Unwin.
Walkerdine, V. (1984). Developmental psychology and the child-centred pedagogy.
In J. Henriques, W. Hollway, C. Urwin, C. Venn & V. Walkerdine (Eds.),
Changing the subject: Psychology, social regulation and subjectivity (pp. 153202). London: Methuen.
Walsh, J. A., & Warren, K. S. (1979). Selective primary health care: An interim
strategy for disease control in developing countries. New England Journal of
Medicine, 301(18), 967-974.
299
Wano, H. (2003). Tui Ora Limited: A Taranaki experience in Maori health
development. In R. Gauld (Ed.), Continuity amid chaos: Health care
management and delivery in New Zealand (pp. 151-167). Dunedin, New
Zealand: University of Otago Press.
Warden, J. (1998). Britain's new health policy recognises poverty as major cause of
illness. BMJ, 316(7130), 495.
Weight-control Information Network. (2004). Economic costs related to overweight
and obesity. In Statistics Related to Overweight and Obesity. Retrieved May
25, 2005, from http://win.niddk.nih.gov/statistics/#econ
Weil, M., & Karls, J. M. (1985). Case management in human service practice. San
Francisco: Jossey-Bass Publishers.
Wells, K. P. (1998, September 1). Assessing integrated care as a solution for New
Zealand. Health Care & Informatics Review Online, 2(11). Retrieved May 4,
2004, from
http://www.enigma.co.nz/hcro/website/results/2005011214393051000985.pdf
Werner, D., Sanders, D., Weston, J., Babb, S., & Rodriguez, B. (1997). Questioning
the solution: The politics of primary health care and child survival with an indepth critique of oral rehydration therapy. Palo Alto, CA: HealthWrights.
Wilkinson, R., & Marmot, M. G. (2003). Social determinants of health: The solid
facts. Copenhagen, Denmark: World Health Organization, Regional Office for
Europe.
Wilkinson, W., & Sidel, V. W. (1991). Social applications and interventions in public
health. In W. W. Holland, R. Detels & G. Knox (Eds.), Oxford textbook of
public health (2nd ed., pp. 47-70). Oxford, United Kingdom: Oxford
University Press.
Williams, A. (2000). Nursing, medicine, and primary care. Philadelphia: Open
University Press.
300
Wilson, D. (1996). Where do we go from here? The 72 billion dollar question. In M.
Stingl & D. Wilson (Eds.), Efficiency versus equality: Health reform in
Canada (pp. 165-177). Halifax, Novi Scotia, Canada: Fernwood Publications.
Wilson-Barnett, J. (1988). Patient teaching or patient counselling? Journal of
Advanced Nursing, 13(2), 215-222.
Wilton, P., & Smith, R. D. (1998). Primary care reform: A three country comparison
of 'budget holding'. Health Policy, 44(2), 149-166.
Woods, K. J. (2001, April-June). The development of integrated health care models in
Scotland. International Journal of Integrated Care, 1, 1-13. Retrieved August
12, 2004, from http://www.ijic.org/publish/articles/000033/article_print.html
World Bank. (1993). World development report 1993: Investing in health: World
development indicators. Oxford, United Kingdom: Oxford University Press.
World Health Organization. (1978). Declaration of Alma-Ata. Retrieved May 5, 2001,
from http://www.euro.who.int/AboutWHO/Policy/20010827_1
World Health Organization. (1985). Target for health for all. Copenhagen, Denmark:
World Health Organization Regional Office for Europe.
World Health Organization. (1986). Ottawa charter for health promotion. Geneva,
Switzerland: Author.
World Health Organization. (1992). Twenty steps for developing a Healthy Cities
project. Copenhagen, Denmark: WHO Regional Office for Europe.
World Health Organization. (1997). The Jakarta declaration on leading health
promotion into the 21st century. Jakarta, Indonesia: Author.
World Health Organization. (2000). The world health report 2000 - Health systems:
Improving performance. Geneva, Switzerland: Author.
301
World Health Organization. (2001a). Innovative care for chronic conditions. Geneva,
Switzerland: Author.
World Health Organization. (2001b). Report of the commission on macroeconomics
and health: Macroeconomics and health: Investing in health for economic
development. Geneva, Switzerland: Author.
World Health Organization. (2002a). Innovative care for chronic conditions: Building
blocks for action. Geneva, Switzerland: Author.
World Health Organization. (2002b). The World health report 2002: Reducing risks,
promoting healthy life. Geneva, Switzerland: Author.
World Health Organization. (2003). The World Health report 2003: Shaping the
future. Geneva, Switzerland: Author.
Zerwekh, J. V. (1992). Public health nursing legacy: Historical practical wisdom.
Nursing & Health Care, 13(2), 84-91.
302
Appendices
303
Appendix 1
Structure of the New Zealand Health and Disability Support Sector
1999
304
305
Appendix 2
Structure of the New Zealand Health and Disability Support Sector
2005
306
307
Appendix 3
Questionnaire
308
Study Code Number: Today’s Date:
/
/
HEALTH SYSTEMS &
NURSING RESEARCH
Day Month Year
Interview Questionnaire
Thank you for agreeing to take part
If you have any concerns, please do not hesitate to contact: Nicolette Sheridan
Department of Community Health, Telephone: 09 373 7599 extension 87811
The first questions asks about your role in the integrated care project
1.
What is your full name?
______________________________________________________________
2.
Who is your employer?
______________________________________________________________
3.
What is your primary role in the project?
______________________________________________________________
ALL of the following questions ask about the integrated care project
4.
What is the title of the project?
______________________________________________________________
5.
Who are the organisations in partnership in the project?
______________________________________________________________
6.
What is the purpose of the project?
______________________________________________________________
7.
Does the project achieve this purpose?
______________________________________________________________
8.
Does the project plan to deliver a new health service?
Yes No
If you answered yes, how does the project plan to deliver a new health
service?
______________________________________________________________
______________________________________________________________
______________________________________________________________
309
9.
Has the project delivered an existing health service differently?
Yes No
If you answered yes, how does the present health service differ from the
service provided before the project begun?
______________________________________________________________
______________________________________________________________
______________________________________________________________
10.
Does the project provide any of the following health care services?
Screening and prevention
Health promotion
Diagnostic tests and expert advice
Treatment and follow-up
Rehabilitation
11.
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Answer this question only if one or more general practice organisations are
partners in the project.
In your view, are there incentives for general practice to be a partner in the
project?
Yes No
If you answered yes which one of the following, in your view, is the main
incentive for general practice to be a partner in the project?
Generate income
Plan and/or deliver new health services
Improve existing health services
Gain new skills
Another incentive (specify) ______________________________________
12.
Answer this question only if one or more hospital organisations are partners
in the project.
In your view, are there incentives for the hospital to be a partner in the
Yes No
project?
If you answered yes which one of the following, in your view, is the main
incentive for the hospital to be a partner in the project?
Generate income
Plan and/or deliver new health services
Improve existing health services
Reduce hospital admissions
Another incentive (specify) ______________________________________
310
13.
Does the project target a specific ethnic group?
Yes No
If you answered yes which one of the following ethnic groups was targeted?
Maori
Pacific
Maori and Pacific
Another ethnic group (specify) __________________________________
Does the project target this ethnic group only, or this ethnic group and the
wider population.
Ethnic group only
Ethnic group and the wider population
14.
Does the project target a geographic area?
Yes No
If you answered yes what geographic area was targeted?
______________________________________________________________
______________________________________________________________
15.
Does the project target a specific age group?
Yes No
If you answered yes, which one of the following age groups was targeted?
0-20
21-55
Over 55
All ages
16.
In this question, ‘condition’ refers to a state that is not a disease, such as
pregnancy.
Does the project target a disease or condition?
Yes No
If you answered yes what disease or condition was targeted?
______________________________________________________________
What approach was taken to address the disease or condition?
______________________________________________________________
If you answered no what issue was targeted?
______________________________________________________________
What approach was taken to address the issue targeted?
______________________________________________________________
311
17.
Which one of the following levels of approach was adopted by the project?
Individuals and families
Communities
System
Combination of any of the above (specify) __________________________
______________________________________________________________
18.
Which of the following project strategies were used to achieve integration?
Clinical guideline development
Clinical guideline promotion
Case management
Database development
Another strategy
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
If you answered another strategy how was integration achieved?
______________________________________________________________
If you answered clinical guideline development who developed the
guideline? _____________________________________________________
If you answered clinical guideline promotion how were they promoted?
______________________________________________________________
If you answered case management who was the case manager?
______________________________________________________________
19.
Has the project received dedicated funding?
Yes No
If you answered yes who provided the main funding to the project?
______________________________________________________________
______________________________________________________________
20.
In your view, are financial incentives offered to project partners who provide
health services within the project?
Yes No
21.
In you view, are material incentives offered to clients (or patients) who
participate in the project?
Yes No
If you answered yes what material incentives were offered to clients?
______________________________________________________________
______________________________________________________________
22.
Answer this question only if one or more general practice organisations are
partners in the project.
312
In your view, did general practice incur financial costs as a result of
participating in the project?
Yes No
23.
Answer this question only if one or more hospital organisations are partners
in the project.
In your view, did the hospital incur financial costs as a result of participating in
the project?
Yes No
24.
In this question, ‘non-nursing personnel’ refers to all project personnel,
excluding nurses.
Does the project employ dedicated non-nursing personnel?
Yes No
If you answered yes describe the practice of non-nursing personnel.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
25.
In this question, ‘nurse’ refers only to registered general or comprehensive (or
equivalent) trained nurses.
Does the project employ nurses?
Yes No
If you answered yes continue with the following question, which asks about
seventeen interventions or activities that may have been undertaken by
nurses in the project. A definition of each intervention will be read to you,
before you are asked to decide whether this intervention was undertaken and
give a yes/no response.
Surveillance
Disease and health event investigation
Outreach
Screening
Case finding
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Referrals and follow-up
Case management
Delegated functions
Yes No
Yes No
Yes No
Health teaching
Counselling
Consultation
Yes No
Yes No
Yes No
Collaboration
Coalition building
Community organising
Yes No
Yes No
Yes No
313
Yes No
Yes No
Yes No
Advocacy
Social marketing
Policy development and enforcement
26.
Each of the seventeen interventions listed above can be undertaken at three
levels of population-based practice. These levels are: individual and family,
community, and systems.
Use the following scale to select one option: (1) individual and family; (2)
community; (3) system, and (4) combination of 1 and/or 2 and/or 3. For each
yes response in question 25, where you indicated a particular intervention
was undertaken by nurses in the project, you are now asked to decide the
level of population-based practice of that intervention.
Individual Community System Combination
& family
27.
Intervention
1
2
3
4 (specify)
Surveillance
Disease and health event investigation
Outreach
Screening
Case finding
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4 _______
4 _______
4 _______
4 _______
4 _______
Referrals and follow-up
Case management
Delegated functions
1
1
1
2
2
2
3
3
3
4 _______
4 _______
4 _______
Health teaching
Counselling
Consultation
1
1
1
2
2
2
3
3
3
4 _______
4 _______
4 _______
Collaboration
Coalition building
Community organising
1
1
1
2
2
2
3
3
3
4 _______
4 _______
4 _______
Advocacy
Social marketing
Policy development and enforcement
1
1
1
2
2
2
3
3
3
4 _______
4 _______
4 _______
If you would like to offer any other comment, please indicate below.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Thank you for taking part in this study
314
Appendix 4
Interventions undertaken by nurses in integrated care projects:
Frequency tables
315
Screening intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
23
8
3
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
17 (77.3)
7 (87.5)
2 (66.7)
13 (56.5)
6 (75)
0 (0)
Disease/Condition or Well-health
Chronic (%)
5 (21.7)
3 (37.5)
0 (0)
Well-health (%)
13 (56.5)
3 (37.5)
2 (66.7)
Outreach intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
22
9
1
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
17 (77.3)
8 (88.8)
1 (100)
12 (54.5)
7 (77.8)
0 (0)
Disease/Condition or Well-health
Chronic (%)
Well-health (%)
12 (54.5)
3 (33.3)
0 (0)
7 (31.8)
5 (55.6)
0 (0)
Disease and health event investigation intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
14
1
5
Ethnic Group
Low Income
Disease/Condition or Well-health
Maori (%)
Low decile area (%)
Chronic (%)
Well-health (%)
9 (64.2)
1 (100)
3 (60)
4 (28.6)
0 (0)
0 (0)
6 (42.9)
0 (0)
4 (80)
6 (42.9)
1 (100)
0 (0)
Advocacy intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
29
13
3
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
20 (67)
12 (92.3)
2 (66.7)
15 (51.7)
10 (76.9)
1 (33.3)
Disease/Condition or Well-health
Chronic (%)
Well-health (%)
17 (58.6)
4 (30.8)
0 (0)
6 (20.7)
6 (46.2)
1 (33.3)
Social marketing intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
12
4
0
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
10 (83.3)
3 (75)
0 (0)
10 (83.3)
2 (50)
0 (0)
Disease/Condition or Well-health
Chronic (%)
Well-health (%)
5 (41.7)
3 (75)
0 (0)
6 (50)
1 (25)
0 (0)
Policy development and enforcement intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
24
6
0
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
20 (83.3)
6 (100)
0 (0)
10 (41.7)
4 (66.7)
0 (0)
Disease/Condition or Well-health
Chronic (%)
15 (62.5)
3 (50)
0 (0)
Well-health (%)
6 (25)
2 (33.3)
0 (0)
316
Collaboration intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
30
13
1
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
21 (70)
12 (92.3)
1 (100)
Disease/Condition or Well-health
Chronic (%)
15 (50)
10 (76.9)
0 (0)
18 (60)
4 (30.8)
0 (0)
Well-health (%)
7 (23.3)
6 (46.2)
1 (100)
Consulting intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
31
2
7
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
21 (67.7)
2 (100)
0 (0)
Disease/Condition or Well-health
Chronic (%)
16 (51.6)
0 (0)
2 (28.6)
18 (58.1)
0 (0)
3 (42.9)
Well-health (%)
7 (22.6)
1 (50)
0 (0)
Counselling intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
29
3
0
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
19 (65.5)
2 (66.7)
0 (0)
Disease/Condition or Well-health
Chronic (%)
14 (48.3)
2 (66.7))
0 (0)
18 (62.1)
3 (100)
0 (0)
Well-health (%)
6 (20.7)
0 (0)
0 (0)
Delegated functions intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
29
1
0
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
21 (72.4)
1 (100)
0 (0)
16 (55.2)
0 (0)
0 (0)
Disease/Condition or Well-health
Chronic (%)
17 (58.6)
0 (0)
0 (0)
Well-health (%)
7 (24.1)
0 (0)
0 (0)
Case management intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
30
0
7
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
21 (70)
0 (0)
0 (0)
16 (53.3)
0 (0)
2 (28.6)
Disease/Condition or Well-health
Chronic (%)
17 (56.7)
0 (0)
2 (28.6)
Well-health (%)
7 (23.3)
0 (0)
0 (0)
Referral and follow-up intervention undertaken by nurses in projects
Individual
Community
Systems
Total No.
projects
30
0
0
Ethnic Group
Low Income
Maori (%)
Low decile area (%)
21 (70)
0 (0)
0 (0)
16 (53.3)
0 (0)
0 (0)
Disease/Condition or Well-health
Chronic (%)
17 (56.7)
0 (0)
0 (0)
Well-health (%)
7 (23.3)
0 (0)
0 (0)
317
318