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Abstract. Developed nations are implementing initiatives to transform the delivery of primary care. New models have been built around multidisciplinary teams, information technology and systematic approaches for chronic disease management (CDM). In Australia, the General Practice Super Clinic (GPSC) model was introduced in 2010. A case study approach was used to illustrate the development of inter-disciplinary CDM over 12 months in two new, outer urban GPSCs. A social scientist visited each practice for two 3-4-day periods. Data, including practice documents, observations and in-depth interviews (n = 31) with patients, clinicians and staff, were analysed using the concept of organisational routines. Findings revealed slow, incremental evolution of inter-disciplinary care in both sites. Clinic managers found the facilitation of inter-disciplinary routines for CDM difficult in light of competing priorities within program objectives and the demands of clinic construction. Constraints inherent within the GPSC program, a lack of meaningful support for transformation of the model of care and the lack of effective incentives for collaborative care in fee-for-service billing arrangements, meant that program objectives for integrated multidisciplinary care were largely unattainable. Findings suggest that the GPSC initiative should be considered a program for infrastructure support rather than one of primary care transformation.

The current study used grounded theory methods to analyze trans men's positive emotions. The sample included 11 participants who were assigned a female sex at birth and currently identify with a binary male identity. Results yielded eight positive emotion themes emerging for trans men, which included the following: confidence, comfort, connection, feeling alive, amazement, pride, happiness, and interpersonal reactionary emotions. Participants reported specific gender experiences within these themes, including a sense of brotherhood, excitement related to taking testosterone, authentic pride in identifying as a man, and happiness connected to others using correct gender language (e.g., pronouns, family labels, greetings). A theoretical model from the eight themes and 39 higher order categories emerged, indicating the importance of initial internal emotions, confidence related to trans men's identity processes, and the ways in which positive interpersonal interactions affect positive emotions. Implications include using emotion-focused therapy and including more positivity into trans individuals' experiences and emotions.

ObjectiveOrganizational responses that support healthcare workers (HCWs) and mitigate health risks are necessary to offset the impact of the COVID-19 pandemic. We aimed to understand how HCWs and key personnel working in healthcare settings in Melbourne, Australia perceived their employing organizations' responses to the COVID-19 pandemic.MethodIn this qualitative study, conducted May-July 2021 as part of the longitudinal Coronavirus in Victorian Healthcare and Aged Care Workers (COVIC-HA) study, we purposively sampled and interviewed HCWs and key personnel from healthcare organizations across hospital, ambulance, aged care and primary care (general practice) settings. We also examined HCWs' free-text responses to a question about organizational resources and/or supports from the COVIC-HA Study's baseline survey. We thematically analyzed data using an iterative process.ResultsWe analyzed data from interviews with 28 HCWs and 21 key personnel and free-text responses from 365 HCWs, yielding three major themes: navigating a changing and uncertain environment, maintaining service delivery during a pandemic, and meeting the safety and psychological needs of staff . HCWs valued organizational efforts to engage openly and honesty with staff, and proactive responses such as strategies to enhance workplace safety (e.g., personal protective equipment spotters). Suggestions for improvement identified in the themes included streamlined information processes, greater involvement of HCWs in decision-making, increased investment in staff wellbeing initiatives and sustainable approaches to strengthen the healthcare workforce.ConclusionsThis study provides in-depth insights into the challenges and successes of organizational responses across four healthcare settings in the uncertain environment of a pandemic. Future efforts to mitigate the impact of acute stressors on HCWs should include a strong focus on bidirectional communication, effective and realistic strategies to strengthen and sustain the healthcare workforce, and greater investment in flexible and meaningful psychological support and wellbeing initiatives for HCWs.

BackgroundImplementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care.MethodsPEP Intervention practices received education, clinical audit and feedback and practice facilitation.Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires.Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar’s test and multilevel analysis was used to determine the effect of the intervention on follow-up scores.ResultsFive hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes.ConclusionsThe lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures.Trial registrationAustralian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Objectives Given increased numbers and enhanced responsibilities of Australian general practice nurses, we aimed to delineate appropriate roles for primary health care organisations (PHCOs) to support this workforce. Methods A two-round online Delphi consensus process was undertaken between January and June 2012, informed by literature review and key informant interviews. Participants were purposively selected and included decision makers from government and professional organisations, educators, researchers and clinicians from five Australian states and territories Results Of 56 invited respondents, 35 (62%) and 31 (55%) responded to the first and second invitation respectively. Participants reached consensus on five key roles for PHCOs in optimising nursing in general practice: (1) matching workforce size and skills to population needs; (2) facilitating leadership opportunities; (3) providing education and educational access; (4) facilitating integration of general practice with other primary care services to support interdisciplinary care; and (5) promoting advanced nursing roles. National concerns, such as limited opportunities for postgraduate education and career progression, were deemed best addressed by national nursing organisations, universities and peak bodies. Conclusions Advancement of nursing in general practice requires system-level support from a range of organisations. PHCOs play a significant role in education and leadership development for nurses and linking national nursing organisations with general practices. What is known about the topic? The role of nurses in Australian general practice has grown in the last decade, yet they face limited career pathways and opportunities for career advancement. Some nations have forged interprofessional primary care teams that use nurses' skills to the full extent of their scope of practice. PHCOs have played important roles in the development of general practice nursing in Australia and internationally. What does this paper add? This study delineates organisational support roles for PHCOs in strengthening nurses' roles and career development in Australian general practice. What are the implications for practitioners? Effective implementation of appropriate responsibilities by PHCOs can assist development of the primary care nursing workforce.

W orldwide, meeting the health needs of trans, genderdiverse and nonbinary (TGDNB) people is shifting toward primary care. Presentations to health care providers regarding gender transition are also increasing rapidly. Therefore, all primary care providers need familiarity with TGDNB treatment guidelines and inclusive practice, and more primary care clinicians are gaining the experience and confidence to manage gender assessments and transitions.Four articles collected in this issue of CMAJ raise a number of issues that health care providers should be aware of when working with this population. A large survey by Pinto and colleagues 1 considers the acceptability to clients of including options beyond male and female in clinical records systems; Bonifacio and colleagues 2 discuss the management of gender dysphoria in adolescents by primary care practitioners, providing extensive background and guidance on affirmative care; Beswick and colleagues' case report 3 offers succinct advice on improving processes for cervical cancer screening in trans men; and Lam and Abramovich 4 concisely outline key points for achieving inclusive practice for TGDNB people.Terminology is challenging in this fast-moving field; "umbrella" terms vary across time and nations, including transgender, trans, trans*, trans and gender-diverse, trans and gender-nonconforming. I use "TGDNB," as advised by our consumer advisory panel at the Monash Health Gender Clinic in Australia. In the Canadian context, Pinto and colleagues 1 include "2-spirit" for Indigenous TGDNB people in their broader term: lesbian, gay, bisexual, transgender, transsexual, queer, questioning and 2-spirit (LGBTQ2S).A key shift is from a binary notion of gender as only male or female, with some people moving from one to the other, to seeing gender identity as a spectrum or galaxy. Readers can see some of these shifts in language between the survey questions used in Pinto and colleagues' study, conducted from 2013 to 2016, 1 to the terminology used in Bonifacio and colleagues' more recent review of the care of adolescents who identify as TGDNB. 2 The use of "female to male" ("FTM") by Beswick and colleagues, 3 while still used as an identifier by some trans men, has recently fallen from favour, especially with increasing nonbinary gender identifications, such as bigender (alternating between female and male) or neither male nor female. "Female to male" now usually describes 1 binary process of transition among a range of possibilities, rather than describing people.Trans, gender-diverse and nonbinary people often face difficulties in having their gender identity recognized in clinical records systems. Pinto and colleagues' mixed-methods study 1 provides useful guidance. The survey portion included TGDNB people at higher rates than usual in clinical samples: 1.02% had a diagnosis for gender dysphoria, and 1.22% had no diagnosis, but their gender identity differed from clinical records. However, interpreting the interview portion of the study is somewhat difficult, given a skewed...

Background and objectiveGeneral practice is the most common source of healthcare for people who use methamphetamine. The aim of this study was to explore primary care providers' understandings of access to and service utilisation by this group. MethodsSemi-structured interviews were conducted with general practitioners, practice nurses and alcohol and other drug service providers from two large towns in rural Victoria.