General Practice and Primary Care - Theses
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ItemWe understand our gender best: gender diverse young people and their experiences with general practitioners( 2017)Gender diverse young people are a marginalised population with specific health care needs. Studies suggest that these needs are not being met by their general practitioners (GPs), but existing research focuses on gender diverse adults or non-Australian populations. The experiences of Australian gender diverse young people with GPs have not been studied in depth. Thirty-seven young gender diverse people shared their experiences with GPs. Many had negative experiences with GPs, with a majority of non-binary people having had mostly negative experiences. Participants’ experiences were positively impacted by GPs showing respect for gender diverse people, GPs being knowledgeable about gender diversity, a positive and friendly attitude from GPs, a welcoming clinic environment in which gender diverse patients were called by their chosen names, and GPs treating gender diverse patients like autonomous individuals. Negative experiences were characterised by GPs being uninformed or misinformed about gender diversity, GPs being insulting or demeaning, clinics requiring that patients be known by their birth names and assigned genders, GPs and staff misgendering gender diverse patients, and GPs attributing gender diversity to mental illness or vice versa. This study was conducted through an online survey, asking open-ended questions which provided answers suitable for qualitative analysis. Answers were analysed through thematic analysis, using a framework based on that of phenomenology. The recommendations put forth are that GPs must be educated on gender diversity; paperwork and computer systems should be able to accept input of genders other than male and female; GPs should respect gender diverse patients as individuals who know themselves; clinic waiting rooms should be welcoming and staff educated about gender diversity; GPs should not assume that gender diversity causes or is caused by mental illness; and GPs should believe, listen to, and respect the input of gender diverse patients. Further study on this topic could focus on the experiences of gender diverse Indigenous people, people born outside of Australia, or people living in regional areas; or on the experience of gender diverse people with other healthcare practitioners.
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ItemAn exploration of monitoring people with depression in the general practice setting( 2015)This study is about how general practitioners monitor the effectiveness of the care they provide for people experiencing depression. It seeks to better understand how the monitoring of people with depression should occur in the general practice setting, from the perspective of general practitioners, patients and carers. It does this with the intention of contributing to the debate about how to improve the quality of general practice care for people experiencing depression. The study comprises three main parts, beginning with a literature review in two sections. The first chapter discusses key concepts including depression, primary care’s role in depression care and what defines effective depression care. The second chapter is a scoping review of the primary care depression literature outlining what is known about monitoring practice in this context. The second part of the thesis presents the findings of a survey of 576 people with depressive symptoms who attend general practice, regarding how they recognise recovery from depression. The third part of the thesis reports on findings from eight in-depth case studies, which explore the views and experiences of GPs, patients and carers involved in the giving and receiving of depression care in the general practice setting. The findings of the case studies confirm that monitoring practice is a highly complex, iterative process. Broadly speaking, there are three key phases of monitoring that must be addressed as care proceeds, beginning with engagement in care (including ‘watchful waiting’), moving through a phase of ‘paying attention’ (to the individual patient’s experience) and the ultimate phase of ‘getting better’, where monitoring practice may help or hinder the attainment of recovery from depression. The case study data also show that from the very earliest phases of monitoring (commonly beginning before a diagnostic label has actually been applied), work must be done to achieve a shared understanding of the problem, to set priorities for care amidst competing demands, and to revisit issues regarding who and what can help in dealing with the problem. The thesis concludes by presenting four propositions for depression monitoring practice, which are intended to provide a framework to assist GPs in pragmatically addressing both technical and relational aspects of depression care.
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ItemExploring social constructions of, and the use of power to deal with, patient aggression in general practice( 2015)This thesis investigates the meaning of patient aggression in general practice and the use of power to deal with it, through a multi-case comparison of four general practices sampled on the basis of different business models. Much debate on the topic has focused on encapsulating the concept so that prevalence and associated factors could be determined. Current accounts highlight aggression directed towards general practitioners, but pay less attention to the experiences of other workers. Previous research has overlooked the contested nature of the concept along with contextual and interactional circumstances surrounding patient aggression. This thesis addresses these gaps by exploring how general practice workers from different occupational backgrounds understand patient aggression and how various types of general practice organisations use power to deal with the phenomenon. I adopt a social constructionist approach to argue that the meaning of patient aggression arises from the type of interaction. Qualitative methodologies underpin this multiple case study, which involved semi-structured interviews, observation, and document analysis. To explore the use of power, I draw on an analytical framework based on Steven Lukes’ (2005) critical conceptualisation of power. I discovered two interactional prototypes in general practice: front-line interactions between practice gatekeepers and patients, and rapport-building interactions between health professionals and patients. Gatekeepers tend to normalise patient aggression, whilst health professionals lean towards trivialisation. Normalisation renders the frequent exposure to aggression at the front line an acceptable and normal ‘part of the job’. In contrast, trivialisation enables health professionals to suppress perceptions of heightened vulnerability and avoid victimisation. Both interactional prototypes employ medicalisation and stigmatisation. To understand the use of power to deal with patient aggression, I compare a small partnership practice, a community health service, a large group practice, and a corporate-owned practice. I discuss how these practices manage the meaning of their interactions with patients differently. I interpret this management of meaning as an exercise of power in the third dimension, which is the most sophisticated way to deal with patient aggression. The current understanding of how to deal with patient aggression aligns with the use of power in the first dimension and, therefore, overlooks less manifest types of power. This thesis makes three contributions to the literature on patient aggression. First, it offers insights into different constructions of meaning based on the nature of the interaction. Second, it clarifies how business models shape ways general practices interact with their patients. In departing from a mere behavioural focus, data analysis focuses on processes behind the social construction of ‘patient aggression’ and examines organisational characteristics that determine the use of power to deal with aggression. Third, this thesis contributes to the literature that applies Lukes’ (2005) framework to the examination of organisational phenomena. The findings help in identifying organisational features that influence interactions with patients. Implications for further research include the application of a similar design to a rural-urban comparison, specialist care settings, and a cross-national study. It is also of interest to further explore the impact of the organisational context on other phenomena.