Danielle Williams

This article presents an analysis of interviews with Australian women who had smoked or were currently smoking during pregnancy. It explores how they spoke about their experiences of smoking, cessation and harm minimisation during pregnancy. Eighteen women underwent a single in-depth interview, these were analysed using an iterative thematic method. We found that smoking, cessation and harm minimisation by pregnant women are complex social practices. Participants viewed smoking as a potential risk to fetal health and as an actual risk to their own health and described feeling embarrassed and ashamed of smoking when pregnant. Their opinions about the relative seriousness of health risks posed by smoking when pregnant were often informed by their own personal observations and experiences. Participants used this knowledge to engage in lay epidemiological processes as they rationalised and made sense of the relative risks of smoking, quitting or cutting down. They also sought legitimacy for their claims about the safety of quitting or cutting down in two potentially contradictory ways. These were personal experience/observations and medical advice. Our findings contribute to sociological understanding about lay responses to medical advice on smoking in pregnancy and will be of value to healthcare professionals who work with pregnant women.

Despite efforts to achieve conceptual clarity, advanced practice nursing continues to reside in a liminal space, unable to secure ongoing recognition as a viable means of healthcare delivery. This is particularly evident in general practice where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system. This review synthesises published qualitative studies reporting experiences of advanced practice nursing in general practice. The panoramic view provided by patients, nurses and doctors within this novel context, offers a fresh perspective on why advanced practice nurses have struggled to gain acceptance within the healthcare milieu. We conducted a systematic review of qualitative studies that explored the experiences of patients, nurses and doctors who had contact with advanced practice nurses working in general practice. Published work from 1990 to June 2016 was located using CINAHL and PubMed. The full text of relevant studies was retrieved after reading the title and Critical appraisal was undertaken and the findings of included studies were analysed using the constant comparative method. Emergent codes were collapsed into sub-themes and themes. Twenty articles reporting the experiences of 486 participants were included. We identified one major theme: legitimacy; and three sub-themes: (1) establishing and maintaining confidence in the advanced practice nurse, (2) strengthening and weakening boundaries between general practitioners and advanced practice nurses and (3) establishing and maintaining the value of advanced practice nursing. We set out to describe experiences of advanced practice nursing in general practice. We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Additionally, advanced practice nurses struggle to negotiate and clarify scopes of practice while general practitioners have trouble justifying the costs associated with advanced practice nursing roles. Therefore, much work remains to establish and maintain the legitimacy of advanced practice nursing in general practice.

Despite an increasingly pathologised discourse on overweight and obesity, the clinical experiences of large bodied individuals remain relatively unexplored. In addition, interventions targeting overweight and obesity have generally failed to recognise the role that weight related discrimination and stigma play in both the uptake of interventions and the experience of healthcare consumers. This Australian research used a grounded theory approach, informed by constructivism, to further understanding and generate dialogue about the experiences of large bodied female healthcare consumers. Participants included 22 women, who were purposively sampled, all of whom identified as overweight or obese. Data was collected from two major sources: intensive interviews with participants and literature. For the participants in this study, being overweight or obese created a significant barrier to positive clinical interactions with their medical professionals. Women described their interactions with medical professionals, particularly general practitioners (GPs) as the most challenging to manage. Participants believed that when they became patients, they were defined by their body size, which worked to create a one-dimensional identity – that of a fat patient. These findings suggest that weight-related discrimination and stigma has a significant impact on both the clinical interaction, and the health and wellbeing of large bodied, female healthcare consumers.

Objective: To examine Australian patients’ motivations for seeking bariatric surgery. Background: The reasons for seeking bariatric surgery are incompletely understood. This information is needed to inform health-service planning and therapeutic decisions. Methods: Ten focus groups were audio-recorded, transcribed verbatim, and analyzed thematically. Results: Thirty-two women and 17 men (mean age 55 years; range 23–72) who had received or were waitlisted for publicly- or privately funded bariatric surgery engaged in the study. Novel findings highlighted the importance of other bariatric surgery recipients, health professionals’ recommendations (e.g., bariatric surgeons, medical specialists, and general practitioners), the media (e.g., televisions shows on bariatric surgery), and having private health insurance. We also confirmed previous findings that people seek surgery for physiological and psychological health, and because of previous failed weight loss attempts and significant others (e.g., wanting to live longer for children). Conclusion: Many individual, societal and environmental factors influence people to seek bariatric surgery. Exposure to recipients of bariatric surgery and recommendations made by health professionals appear to be common factors prompting a surgical pathway not previously reported. Bariatric surgery uptake may spread in social networks, which has growing implications for health service planning as more people seek this pathway.

Objective: To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery.Methods: Seven semi‐structured focus groups were conducted. A broad interview schedule guided the discussions which were audio‐recorded and transcribed verbatim. Data were analysed thematically.Results: Twenty‐six women and 15 men with a mean age of 54 years (range 24–72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post‐surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery.Conclusion: Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post‐surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

Current general practitioner shortages need to be addressed, especially in areas of need. This study was designed to investigate which registrar characteristics were associated with retention in the field of general practice (and in the region of training). The authors performed a retrospective cohort study of people who entered general practice training in Tasmania from 1995-2005, and included a crosssectional survey conducted between November 2008 and April 2009 that assessed the association between baseline characteristics and current field of practice and practice location. Fifty-four percent of the cohort was working in general practice in Tasmania at the time of the survey. General practice registrars were more likely to be a GP working in Tasmania if they were nonmedically partnered (OR 14.42, p=0.001). They were also more likely to be living in Tasmania if they were older (OR 1.47, p=0.029) or nonmedically partnered (OR 23.4, p=0.014). Regional training providers may best be able to serve their training region by addressing the specific needs of the general practice registrar family unit.

Elevated blood pressure (BP) is a major modifiable risk factor. However hypertension still remains underdiagnosed, untreated or suboptimally treated. This study aimed to identify and explore barriers to initiating medication and treating elevated BP to target levels in the general practice setting. Six focus groups involving 30 clinicians were audio recorded, transcribed in full and analysed for common emerging themes using an iterative thematic analysis. After making the decision to commence treatment, medication initiation was relatively straightforward. Clinical uncertainty about true underlying BP, distrust of measurement technology, and distrust of the evidence underpinning hypertension management were expressed. Patient age, gender and comorbidity influenced treatment strategy. Related themes included perceived patient attitude, clinical inertia, and patient centred care. Systems issues included lack of resources and lack of time. The management of an asymptomatic chronic disease within a patient centred, encounter based primary care context can be challenging.