Participatory and deliberative democracy have attracted global attention, both as a field of research and practice. This interest reflects ongoing experimentation with ideas and practices of stakeholder governance, collaborative policy-making and citizen participation. The institutionalisation of such practices in Scotland is taking place through local partnership arrangements and public engagement processes. In particular, the Scottish Government’s Community Planning policy mandates local authorities to develop partnerships where various sectors and organisations are summoned to engage in collaborative policy-making. Central to this agenda is the involvement of citizens and communities through an increasing number of official local forums. In this sense, Scotland resembles other countries where public authorities seek working combinations of strategic partnership governance and local citizen participation. Despite burgeoning interest and developments, however, scarce attention has been paid to the role of public engagement officials tasked with turning participatory and deliberative ideals into everyday practices. Indeed, we still know little about the policy work of official ‘public engagers’ who organise participatory processes by negotiating a contested milieu of actors and agendas, while being constrained and enabled by an evolving ecology of participation. Consequently, this thesis presents findings from two years of ethnographic fieldwork shadowing public engagers in a Scottish Local Authority Area. The uniqueness of these policy workers is that their expertise is not on a particular policy area, but on stakeholder and citizen engagement across policy domains. That is, their expertise is on process, and their job is to facilitate deliberative forums to inform local policy-making. The fundamental question addressed here is not whether participatory policy-making works, but rather how does it work, what kind of work does it take, and what kind of work does it do. By foregrounding the ‘how’ question, this thesis provides a new practice-based analytical framework to both understand and inform participation processes. The findings highlight the importance of the engagers’ political work, thus illustrating the disciplinary force of engagement practice and the contested nature of participatory policy-making. Understanding these dimensions offers insight into new political spaces for the renegotiation of the relationship between authorities and citizens. Accordingly, the research shows how public engagers work to open and develop such spaces in order to foster new relationships through a new ‘politics of process’. In addition, it explores the impact that this work has on the engagers’ community of practice, as well as the challenges they face as engagement work gets institutionalised. Therefore, the thesis offers a distinct ethnographic account of the role of agency in developing official local spaces for participatory and deliberative democracy in Scotland.

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Class of 2009 Abstract / OBJECTIVES: The purpose of this study is to describe clinical pharmacist services in a nurse practitioner (NP) run clinic and how clinical pharmacists might influence prescribing. METHODS: The description of the clinical pharmacist services is based on a 12-week experience of a clinical pharmacist and senior student pharmacist working with the nurse practitioner and nurse practitioner students. A questionaire was developed and consisted of items relating to the nurse practitioners ability to identify possible interactions of OTC medications, herbals and prescription medications. In addition, the questionnare assessed the comfort level of NP’s taking a prescription medication history, checking a patient’s prescription formulary, and selecting appropriate medication therapies. The questionaire uses a retrospective pretest format and was tested as a method of collecting data on how a pharmacist influenced NP prescribing. The site selected for this study was the Arizona State University Center for Healthcare Innovation (ASU Center) located in the heart of Downtown Phoenix (3rd Ave and Van Buren). RESULTS: Only one nurse practitioner worked at the ASU Center. The facility is new to the neighborhood and does not see many patients. The nurse practitioner partner in this project responded that working with a clinical pharmacist on a regular basis, with more patients would definitely help her hone skills necessary to identify interactions and prescribe according to a patients formulary. CONCLUSIONS: Pharmacists provide value-added services in an ambulatory care clinic run by nurse practitioners and provide valuable education and consultation on drug interactions. Pharmacist influence can be measured successfully to using a questionnaire in a retrospective pretest-posttest study design.

This thesis is based on an eighteen-month period of fieldwork with a group of general practitioners in the North East of England. Changing patterns in the practice of primary health care are examined alongside a detailed discussion of the role of the practice nurse in order to set general practice in its cultural and historical context. The thesis takes issue with the positioning of primary health care practitioners squarely within Kleinman's 'professional' sector. Within this context, three major themes relating to the primary health care setting are identified as being of major relevance to the enquiry 1. the use of narratives by patients and practitioners, both clinical and therapeutic 2. The role of the general practitioner and practice nurse in mediation between the patient and the secondary health care sector and the role of the practice nurse in mediation between the general practitioner and the patient3. the similarities in practice between healers in primary health care settings and ethnomedicine in traditional and developed societies These themes are illustrated by the use of fieldwork material and are discussed with reference to current anthropological theory concerning narrative, mediation, dialogics, the placebo effect and the practice of shamanism, as an example of ethnomedicine. On the basis of an examination of the similarities between primary care practitioners and ethnomedical practitioners, namely: quality of practitioner-patient relationship based on narrative understanding, shared cultural explanatory models, and shared mediatory role, this thesis concludes that a shared philosophy underlines the two, and that general practice is in itself a system of ethnomedicine practised within the Western context.

Faculty of Health Sciences School of Pharmacy 0107750d VANNIEKERKD@mweb.co.za / The prescription habits of general practitioners are continually under the scrutiny of ethical critics. There are numerous factors that influence a practitioner’s decision as to which antihypertensive agents to prescribe for the treatment of hypertension. As outlined in various international and national guidelines for the management of hypertension, the recommended treatment depends on ethnicity, current life-style, diet, smoking, age, gender, family history and possible underlying or secondary conditions such as diabetes mellitus, heart failure, isolated systolic hypertension, myocardial infarction, pregnancy, and evidence of coronary artery disease (CAD), stroke or peripheral vascular disease. Currently the control of blood pressure in patients with hypertension is far from optimal with over 70% of hypertensive patients being reported as having imperfect control. A number of factors related to the patient, the practitioner or the medication may explain the high incidence of inadequate blood pressure control. One possible explanation for the poor control of blood pressure may be that practitioners fail to comply with the guidelines. Hence the aim of my study was firstly to determine whether a practitioner’s decision as to which medication to prescribe in the treatment of hypertension is influenced by the Southern African Hypertension Society Guidelines. Secondly, in an attempt to assess the validity of the results of the primary analysis, the actual prescription habits (MediCross® database) were assessed and compared to the general practitioner’s recall of their prescription habits. Questionnaires were distributed to 320 MediCross® practitioners and prescription habits were identified and substantiated by the screening of an existing MediCross® database. I chose as my sample MediCross® general practitioners, as they are demographically representative of all major urban areas in South Africa; likely to be open-minded to supporting research and answering questionnaires (as MediCross® is part of a Clinical Research Site Management Organisation); and I had access to the database of the prescriptions made by MediCross® practitioners hence enabling me to fulfil my second objective. However, it must be kept in mind that these practitioners are representative of general practitioners in urban areas only (as the title of my research report indicates). My results show that 33.1% adhere to the guidelines (when a non-conservative definition of diuretics is used); 27% have heard of the guidelines and have a copy of them. When asked to give their own opinion however, 39% thought they adhered to the guidelines. The results also show that ACE inhibitors are the most commonly prescribed drug class for uncomplicated hypertension but a comparison to a MediCross® database, of which the quality is questionable, does not support this. As the response rate to the questionnaires was only 24.7%, these results are only a pilot study; however they suggest that few general practitioners use the guidelines or even have a copy of the guidelines. This pilot study suggests that the guidelines need to be distributed more widely. Furthermore the general practitioners that responded to the questionnaire indicated that the management of hypertension is difficult in that there is no single treatment regimen appropriate for all populations and each different patient. It was also their view that clinical guidelines for the management of hypertension should more accurately reflect the uncertainty of when to initiate treatment and individual variation if they are going to take these guidelines seriously and comply with them.

In light of the increasing prevalence of obesity in the UK, health professionals working within general practice are urged to initiate discussion about weight with overweight and obese patients. Despite such appeals, evidence suggests that only a minority of health professionals routinely talk to patients about weight loss. To understand more about the barriers to raising the topic of weight in general practice, three empirical studies guided by qualitative research design were carried out. The first two studies draw on psychological theory to identify barriers to raising the topic of weight. Semi-structured interviews were conducted with 17 GPs and 17 primary care nurses. The third study conducted with 20 GPs is underpinned by discourse analysis and uses trigger film interviews to capture and critically analyse the discursive production of, and macro-discourses shaping, barriers. In study 1 and 2, three main themes summarise barriers identified from GP and primary care nurse perspectives: limited understanding about obesity care, concern about negative consequences and limited time to raise a sensitive topic. In study 3, four discursive frameworks were identified as underpinning constructions about the barriers to broaching discussion about obesity: medical-reductionist, medical-holistic, moral and ethical. Findings extend understanding about the ways in which obesity is constructed as both a medical and non-medical issue. The findings have implications for health professional education, policy and research including the need to expose and challenge dominant understandings of obesity as a behavioural problem, to address barriers operating at the socio-cultural as well as the individual-level, and to enhance understanding about the socially embedded and pernicious effects of obesity stigma in the consultation and beyond.

The demands for high quality primary care have become strained by a deficit in the primary care physician supply and the complexity of delivering care to aging populations that are often living with complex co-morbidities. Provider co-management has emerged in practice to help alleviate some of the care delivery demands by having more than primary care provider (PCP) complete care management tasks for the same patient. There is extensive literature investigating two physicians co-managing patient care, and physician-physician assistant co-management, yet limited studies have investigated nurse practitioner (NP)-physician co-management. NPs currently are the fastest growing health care workforce in the United States. Several organizations support the expanded utilization of NPs in primary care. As more U.S. states are granting NPs independent scope of practice, which is free of physician oversight, the potential for NPs to co-manage patients with physicians, and alleviate some of the primary care strain, has increased. However, there are limited to no studies that have investigated NP-physician co-management in primary care. Further, there is a lack of evidence of PCP perspectives about co-managing care, its impact on patient and practice outcomes, or a tool to measure NP-physician co-management in practice or research. More evidence about NP-physician co-management is warranted and will be investigated in this dissertation. The purpose of this dissertation is to investigate NP-physician co-management in primary care by synthesizing the existing evidence, gathering data from PCPs about NP-physician co-management and to develop a valid and reliable tool to measure it. In Chapter 1, background of the current demands on primary care is presented and accompanied by a discussion about the need to expand the NP workforce in primary care to help meet the demand. Evidence about the history of provider co-management is presented and gaps in the literature are identified. Specific aims of the dissertation are introduced and tied to existing theoretical underpinnings. In Chapter 2, aim one of the dissertation is addressed by qualitatively obtaining data on the PCP perspective of NP-physician co-management. In Chapter 3, aim two of the dissertation is addressed. A systematic review of the literature was conducted to determine the effects of NP-physician co-management compared to a single physician delivering care. In Chapter 4, aim three is addressed. Based on the collective findings of Aim 1 and Aim 2, a new tool is developed and psychometrically tested to measure NP-physician co-management. Content validity and reliability testing of the tool is conducted. In Chapter 5, the results of the dissertation are synthesized. Practice, policy, and research implications are discussed, and strengths and limitations of the dissertation are presented.

Australian policy contexts are promoting school transformation through teacher learning and the development of schools as professional learning communities. However, Australian practitioners have very limited contextualised research to guide their efforts in response to these policies. The researcher’s involvement in a school revitalisation process provided the impetus for this research study that investigates the practitioner experience of a developing professional learning community at RI College (pseudonym for a large independent girls’ school in Brisbane). This study endeavours to gain a more informed and sophisticated understanding of developing a professional learning community with the intention of ‘living’ this vision of RI College as a professional learning community. Praxis-oriented research questions focus on the practitioner conceptualisation of their school as a developing professional community and their experience of supporting/hindering strategies and structures. The study gives voice to this practitioner experience through the emerging participatory/co-operative research paradigm, an epistemology of participative inquiry, a research methodology of co-operative inquiry and mixed methods data collection strategies. Incorporating ten practitioner inquiries over two years, recursive cycles of action/reflection engaged practitioners as co-researchers in the collaborative reflective processes of a professional learning community while generating knowledge about the conceptualisation and supporting/hindering influences on its development. The outcomes of these first-person and second-person inquiries, together with a researcher devised online survey of teachers, were both informative and transformative in nature and led to the development of the researcher’s theoretical perspectives in response to the study’s research questions. As outcomes of co-operative inquiry, these theoretical perspectives inform the researcher’s future actions and offer insights into existing propositional knowledge in the field. Engagement in this practitioner inquiry research has had significant transformative outcomes for the co-researchers and has demonstrated the power of collaborative inquiry in promoting collective and individual professional learning and personal growth.

As a practitioner involved in the planning and development of educational activities in the field of public health, I have worked within many pedagogical traditions and program parameters. Through this work, I have experienced both subtle and radical shifts in the range of skills, knowledge and relationships required to collaboratively plan and evaluate educational work. In this professional and community-based landscape, competing and often overlapping models of education and evaluation have led to much conceptual confusion and ambiguity around narrowly defined notions of best practice, evidence and knowledge legitimacy. Drawing from Dorothy Smith’s (1999) standpoint theory from which my inquiry was developed as a result of my participation with colleagues in the field, I explore how three professional practice networks of learning and development practitioners speak of the skills, knowledge, relationships and worker identities in a changing field. This research seeks to explicate the kinds of informal and largely unarticulated knowledge that is produced through the changing contexts of work. This research maps the changing conditions of educational work through my own case stories of educational practice and uses these as a springboard for discussion among three diverse professional practice networks. The Story/Dialogue Method (S/D-M) developed by Labonte and Feather (1996), is a constructivist methodological approach that, in this application, structures group dialogue into reflective insights and theories about how educational work occurs in varied settings among different professional and community-based groups. A strong reliance on interpersonal skills was articulated by all three networks to build trust, assess individual and organisational learning needs, to build partnerships and to motivate learners. Skills were often described vaguely and summarised as a series of situational specific attributes. A valuing of reflexive, working knowledge as opposed to professional or discipline-based expertise was raised as an important aspect of partnership building and in negotiating program parameters. The need to build individual and organisational relationships through formal and informal encounters was cited as a series of legitimate yet often ‘behind the scenes’ professional practices. Aligning with the notion of worker identity described by Chappell, Rhodes, Solomon, Tennant and Yates (2003) as process, practitioners spoke of their identities as constructed and temporary, negotiated through newly emerging roles and changing relationships with peers and learners. This study suggests that evidence-based practice is a contested term drawing its meanings from multiple theoretical and pedagogical traditions including that of intuition. Perhaps unsurprisingly then, evidence guiding educational approaches is viewed as a pragmatic and eclectic mix of tools stored to be adapted for use in new ways. Additionally, this study concludes that all participants (including myself) regard educational practice as a collaborative and continually negotiated endeavour.