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
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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.