Patient-doctor relationships between same-sex attracted women and general practitioners (GPs) have been presented as problematic in the literature. The problems arise from women’s concerns about the potential for negative attitudes amongst GPs. They also relate to GPs’ concerns about offending patients if they ask about sexual orientation due to the stigmatised nature of minority sexual orientation. As a result, disclosure of sexual orientation can be difficult and the patient-doctor relationship can be compromised. The aim of this study was to explore the nature of patient-doctor relationships in this context and how optimal relationships can be achieved. / Using a critical hermeneutic approach, I conducted in-depth interviews with 33 same-sex attracted women and 28 doctors. This included 24 pairs of people in a current patient-doctor relationship. I found that women commonly experienced silencing of their minority sexual orientation within general practice settings, but that this was occasionally desired and not problematic for some women and most GPs. For other women and for many GPs, the silence resulting from a lack of disclosure was a response to perceived risks to women’s personal identity and GPs’ professional identity. Few GPs asked directly about sexual orientation, placing the burden of responsibility for disclosure on same-sex attracted women. Building reciprocal trust could overcome the perceived risks inherent in revealing minority sexual orientation. I initially defined optimal patient-doctor relationships in terms of existing models of cultural competence and patient-centredness; however I found that such relationships were built on cultural sensitivity rather than cultural competence, and relationship-centredness rather than patient-centredness. / I developed a new model of sexual identity disclosure that demonstrated the key influences on disclosure of sexual orientation to GPs for same-sex attracted women. These influences were women’s sexual identity experience, risk perceptions, and the level of knowing within the patient-doctor relationship. The model depicts women’s range and fluidity of sexual identity experiences and challenges current assumptions that disclosure is essential for effective health care. The model has transformative potential for general practice education and research. It could assist GPs to understand that not all women desire disclosure, but that the majority of women are happy to disclose if asked. GPs would be encouraged to take note of the socio-political environment in which women live and its influence on women’s fears and actual experiences of discrimination. Finally, understanding the role of trust and reciprocal knowing in mitigating perceived risks would encourage GPs to focus more on relationship building. This could also assist GPs to overcome their own perceptions of risk and encourage them to broach the subject of sexual orientation, ultimately enhancing the patient-doctor relationship.

Globally the population is ageing and as a consequence people are living longer with multiple chronic conditions. A range of factors, including decreased lengths of hospital stay and a greater focus on community based care, has lead to an increasing acuity of patients admitted to acute care settings, many with complex care needs. To date, models of nursing care in acute settings have been configured to focus on acute, procedural care and do not meet the unique needs of the older person. In order to ensure optimal health outcomes of older hospitalised people, nursing care needs to be responsive to the priorities and needs of patients and their families. This study sought to collaboratively develop a model of nursing care with nurse clinicians to improve the care of older people in the acute care setting. Model development was driven by an action research framework, using evidence-based principles and a comprehensive needs assessment. A three phased, mixed method design was embedded within the overarching conceptual and philosophical framework of action research. The first phase of the study comprised a needs assessment and allowed appraisal of the needs of patients as perceived by patients, carer’s and nurses, this was performed using the Caring Activity Scale [CAS](1). Qualitative data and semi-structured interviews added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. Managing the discharge process and carer burden arose mainly from the carer semi-structured interviews only. Data revealed significant differences between patients, carer’s and nurses in relation to priority and satisfaction with care. Patients did not place a large importance on discharge care which contrasted with the focus of nursing initiatives. During the subsequent phases of the study a collaborative approach, using action research principles, was used to develop and implement a model of nursing care. A key feature of this model was the introduction of a team structure with a focus on patient centred care. Significant differences were identified in the pre model and post model patient groups in relation to satisfaction with care, with the post model group more satisfied than the pre group model group. Further, improvements in functional status and medication knowledge were demonstrated among patients cared for under the new model. This study has demonstrated that developing a model of care appropriate to the needs of patients, carer’s and nurses can be achieved through the use of action research principles. Study data illustrates the importance of collaboration, empowerment and change management principles in driving clinical improvement and patient satisfaction with care. The findings also underscore the importance of promoting and educating patients and carers as well as nurses about the importance of discharge planning to optimise post-discharge health outcomes. / Doctor of Philosophy (PhD)

Thesis (M.S.)--Rochester Institute of Technology, 2007. / Typescript. Includes bibliographical references (p. 67-68).

Thesis (Ph.D.)--McMaster University, 2000. / Includes bibliographical references. Also available via World Wide Web.

Thesis PlanB (M.S.)--University of Wisconsin--Stout, 2007. / Includes bibliographical references.

Universiẗat, Diss., 2006--Frankfurt (Main).

Thesis (Ph.D.)--University of Adelaide, Dept. of Public Health, 2000. / Bibliography: leaves 203-219.

Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003. / Includes bibliographical references. Also available in a print form.

Thesis (Ph.D.) -- University of Western Sydney, Hawkesbury, 1997. / Bibliography : leaves 361-375.

Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003. / "March 2003." Includes bibliographical references (leaves 340-350). Also available electronically.