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ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 4. Barrierssince 2007. Many of these nurses will not yethave reached a confident level of practice, with298 nurses undertaking their training in conjunctionwith a postgraduate academic programmebetween 2007 and 2009. An advantage of anapproach which embeds training in an academicprogramme is achieving a high completion ratefor the Certificate of Competence and thereforecompletion of three client assessments and careplans. Becoming confident, efficient and gainingcompetence in the use of the Flinders toolsrequires, however, experience beyond the threeclient assessments and care plans needed to fulfilthe requirements for the Certificate. Anecdotallya minimum of six client assessments maybe required before a health professional is fullyconfident in the use of the tools.While there were limitations in the survey reported(43% response rate), with only 100 respondentsachieving a Certificate of Competence, togetherBarrier Number PercentageTime 126 85Lack of funding 39 26No electronic version 37 25Resistance from clients to pay 36 24Client reluctance for long visit 31 21No space or spare room 25 17Resistance from GPs 21 14Resistance from nurses 18 12Resistance from management 18 12Lack of mentoring 12 8Language—not a Maori framework; clientsdo not have English as first languageTable 5. Enablers5 3Repeats questions; not user-friendly 3 2Lack of confidence 2 1Other 8 5Enabler Number PercentageStrong leadership in practice 29 35Ongoing contact with trainer 27 33Funding for programme 20 24Support from nurses 18 22Support from GPs 17 21Newsletters/conferences 3 4with the short time frame since the Flinders ProgramTM has been implemented in NZ, the findingsare of interest. Although 82 (55%) of the healthprofessionals surveyed were using some or all ofthe Flinders tools and processes, the low surveyresponse rate may indicate that a greater numberof health professionals who have trained in theFlinders Program TM are not using the Flinderstools and therefore may have ignored the survey.The majority of respondents in the survey were alsostill relatively inexperienced (77% had completedsix or fewer assessments) suggesting there may be alarge gap between training and implementation inclinical client care. The resources required to trainnurses are considerable and ongoing educationand support for the nurses completing self-managementtraining is essential if they are to developconfidence and maintain their competence. 14Comments from the nurses who responded to thesurvey indicate value gained in learning to developa collaborative approach to client care planningwith active participation of clients. The FlindersProgram TM specifically ensures that a collaborativeapproach to decision-making occurs betweenthe client and health professional. While thetool most frequently used is that related to goalsetting, there is the possibility that goals may notbe client-centred or client-determined withoutuse of the Flinders problem identification process.Identifying which clients will benefit most fromself-management support 15 may enable prioritisingand tailoring of support to client needs. 16The evidence for the effectiveness of variousmodels of self-management on long-term healthoutcomes is variable. 17–19 Nevertheless, there islikely to be an ongoing and increasing focus onself-management programmes in NZ primarycare, particularly with a nurse role. The FlindersProgram TM is one approach to structured longtermcondition management that has been availablein NZ since 2005. The survey findings suggestthat while training has been predominatelywith primary care nurses, the uptake and implementationof the full Flinders Program TM is limited.Barriers to implementation are reported asincluding time for one-hour structured appointments,resistance from colleagues, lack of spaceand insufficient ongoing support. Consideration292 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
ORIGINAL SCIENTIFIC PAPErSquantitative researchshould be given to implementation of complexinterventions before extensive training resourcesare committed. Without structured support forquality improvement initiatives and long-termcondition programmes such as the Flinders ProgramTM , the ability to implement learned skills isdifficult. The identification of ongoing supportfrom the trainer cannot be considered a sustainableoption other than in the short term. Furtherresearch is needed to both provide evidencefor the value of the Flinders Program TM in NZprimary care and also to determine how complexinterventions and new models of care can best beintroduced into primary care.NZ general practice has access to fundingstreams such as Care Plus which can provide forlong-term condition management programmes.There is however great variability in how PrimaryHealth Organisations (PHOs) and generalpractices utilise funding streams, highlightinga need for support for overall change in generalpractice. Some PHOs have utilised the FlindersProgram TM as a structured assessment for CarePlus enrolment. 20 If self-management support isto work, there is a need to better understand theinfrastructure, systems and training needed forclients, health professionals, policy makers andhealth care organisations. 19 Several authors 21,22consider that new models of practice are needed,with policy makers appreciating that supportis needed not only at a client level, but also apractice level. Harris et al. 3 argue that while implementingself-management support in generalpractice is challenging, there are difficulties notonly in the context of work pressures, but alsoin the traditional, more directive, approach ofgeneral practice.Practices most successful with long-term conditionprogrammes in general are recognised aspractices that have systematically assessed theirchronic care systems and apply client-centredgoal setting and action planning, have establishedlong-term condition clinics and provide dedicatednursing time. 6,23 Without addressing barrierssuch as infrastructure, adherence to fundingstreams, delivery systems and resistance frommanagers and some health professionals, the introductionof new and complex patient interventionsin primary care remains difficult.References1. National Health Committee. Meeting the needs of peoplewith chronic conditions. Wellington: National Health Committee;2007.2. Ministry of Health. The 2006/2007 New Zealand HealthSurvey. Wellington: Ministry of Health; 2008.3. Harris MF, Williams AM, Dennis SM, Zwar NA, Davies GP.Chronic disease self-management: implementation with andwithin Australian general practice. MJA. 2008;189(10):17–20.4. Adams K, Griener A, Corrigan J. The 1st annual crossing thequality chasm summit—a focus on communities. WashingtonDC: National Academic Press; 2004.5. Coster S, Norman I. Cochrane reviews of educational and selfmanagementinterventions to guide nursing practice: a review.Int J Nurs Stud. 2009;46:508–528.6. Bycroft J, Tracey J. Self-management support: a win-win solutionfor the 21 st century. N Z Fam Physician. 2006;33(4):243–248.7. Collins S. Explanations in consultations: the combined effectivenessof doctors’ and nurses’ communication with patients.Med Educ. 2005;39:785–796.8. Astin F, Closs JS. Guest editorial: chronic disease managementand self-care support for people with long-termconditions: is the nursing workforce prepared. J Clin Nurs.2007;16(7b):105–106.9. Macdonald W, Rogers A, Blakeman T, Bower P. Practicenurses and the facilitation of self-management in primary care.J Adv Nurs. 2008;62(2):191–199.10. Battersby M. Health reform through coordinated care: SAHealth Plus. BMJ. 2005;330:662–665.11. FHBHRU 2009 [cited The ‘Flinders Model’ of Chronic ConditionSelf-Management. Available from: http://som.flinders.edu.au/FUSCA/CCTU/self_management.htm12. Hordacre A, Howard S, Moretti C, Kalucy E. Report of the2005–2006 Annual Survey of Divisions of General Practice.Adelaide: Primary Health Care Research and InformationService, Department of General Practice, Flinders Universityand Australian Government, Department of Health and Ageing;2007.13. Shortus T, McKenzie S, Kemp L, Proudfoot J, Harris MF. Multidisciplinarycare plans for diabetes—how are they used? MJA.2007;187(2):78–81.14. Jordan JE, Osborne RH. Chronic disease self-management educationprograms: Challenges ahead. MJA. 2007;186(2):84–87.15. Newman SP, Steed L, Mulligan K. Self-management interventionsfor chronic illness. Lancet. 2004;364:1523–1537.16. Osborne R. Optimising care for people with chronic disease.MJA. 2008;189(10):5.17. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patientself-management of chronic disease in primary care. JAMA.2002;288(19):2469–75.18. Glasgow NJ, Jeon Y-H, Kraus SG, Pearce-Brown CL. Chronicdisease self-management support: the way forward for Australia.MJA. 2008;189(10):s14–s16.19. Jordan JE, Briggs AM, Brand CA, Osborne RH. Enhancing patientengagement in chronic disease self-management supportinitiatives in Australia: the need for an intergrated approach.MJA. 2008;189(10):9–13.20. Hill J. Care Plus enrolment Manaia PHO. Personal communication.Nov 2008.21. Newman SP. Chronic disease self-management approacheswithin the complex organisational structure of a health caresystem. MJA. 2008;189(10):7–8.22. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart E,Stange KC. Initial lessons from the first national demonstrationproject on practice transformation to a patient-centred medicalhome. Ann Fam Med. 2009;7(3):254–260.23. Zwar N, Harris M, Griffiths R, Roland M, Dennis S, PowellDavies G, et al. A systematic review of chronic disease management:Australian Primary Health Care Research Institute;September 2006.ACKNOWLEDGMENTSProfessor MalcolmBattersby and Dr SharonLawn provided advicefor the project and thesurvey participantsare acknowledged fortheir contribution.FUNDINGThe project receivedfunding from the STARResearch fund.COMPETING INTERESTSDr Janine Bycroft is aFlinders accredited trainer.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 293
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ETHICSObesity, autonomy and the har
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ethicsCritiqueIf this account of th
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RESEARCH GEMSCommunication skills a
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