PurposeThe purpose of this paper is to reflect on research evidence and practice experience of transforming primary care to a more integrated and holistic model.Design/methodology/approachIt is based on a scoping review which has been guided by primary care stakeholders and synthesises research evidence and practice experience from ten international case studies.FindingsAdopting an inter-professional, community-orientated and population-based primary care model requires a fundamental transformation of thinking about professional roles, relationships and responsibilities. Team-based approaches can replicate existing power dynamics unless medical clinicians are willing to embrace less authoritarian leadership styles. Engagement of patients and communities is often limited due to a lack of capacity and belief that will make an impact. Internal (relationships, cultures, experience of improvement) and external (incentives, policy intentions, community pressure) contexts can encourage or derail transformation efforts.Practical implicationsTransformation requires a co-ordinated programme that incorporates the following elements – external facilitation of change; developing clinical and non-clinical leaders; learning through training and reflection; engaging community and professional stakeholders; transitional funding; and formative and summative evaluation.Originality/valueThis paper combines research evidence and international practice experience to guide future programmes to transform primary care.
Learning of a manipulative response was examined in 6-13-month-old well babies and in risk infants who, in the perinatal period, had experienced a range of respiratory interventions (low- and high-risk). 2 contingency conditions (contingent and yoked) were crossed with 2 locations of feedback (local and remote). Both well-baby and low-risk groups reliably discriminated between contingent and noncontingent feedback when it was presented locally, whereas high-risk babies failed to make this distinction in the conditioning phase. Risk status reliably predicted the learning performance. No response acquisition was obtained in the remote feedback condition. In extinction, the well-baby and low-risk groups decreased their responding, but the high-risk group showed an initial response burst. The findings are discussed in the context of risk-related differences in contingency awareness and frustrative nonreward. Overall, the results confirm that the effects of perinatal compromise involving respiratory complications influence infants' processing of contingency information during the first year of life.
Background Medical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians. Methods The primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process. Results We found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua. Conclusion Given the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well.
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