Knowledge construction

In Tairawhiti there were notable failings in the communication channel about the purpose, function and impact of the Primary Health Care Strategy’s intent. A communication channel is the means for which the message of a new idea gets from one person to another (Rogers, 2003). Communication involves a sender, a message and a recipient. Early signs of misunderstanding were evident regarding the purpose of PHOs:

There are also some perception issues about PHOs that they will be set up only for Māori or for Māori at the expense of other people in this district with poor health statistics (TDH, District Annual Plan, 2002/03, p.49).

Finlayson et al. (2009) agree that nationally, a significant number of people including nurses were unaware of the role of PHOs let alone the broader remit of the Primary Health Care Strategy. The differences in meaning and

understanding of primary health care/primary care implications of the Strategy between those who participated in the study confirmed this locally. Knowledge of the Strategy by the managers ranged from basic understanding through to in-depth comprehension:

I read through one of the documents some time ago but in some ways for me it’s more the concept of trying to have a greater focus around primary health care as opposed to me being familiar with some dot points contained within the Strategy. (I.2, p.1) I like its focus in terms of population health. That wasn’t there before the Primary Health Care Strategy it was very much focussed on the individual. I like its attempt to try and integrate services and health professionals in a way that it hasn’t before. I mean there is still a long way to go. I like its emerging focus in self-management and self-responsibility and its emerging attempt to share ownership of the information and probably clinical decision-making not only amongst the health professionals but also with the person as well. (I.10, p.1)

Conversely, only four of the 32 primary health care nurse participants demonstrated any awareness of the Primary Health Care Strategy as the following excerpt illustrates:

May I ask what is the Primary Health Care Strategy, can we get that right in my head. (FG.1, p.1)

This finding was similar to previous research undertaken in Tairawhiti which demonstrated that primary health care nurses did not understand the implications of the Primary Health Care Strategy (Adamson et al., 2005). This is concerning given that the Strategy as previously noted, explicitly recognised the significance of nursing’s contribution to primary health care (Expert Advisory Group on Primary Health Care Nursing, 2003). I found this mismatch perplexing initially, especially as one of the managers firmly believed that information regarding the Strategy had been widely distributed across the district:

I think you would have had to have had to have had your eyes shut if you were around at that time. (I.8, p.2)

Despite the certainty of this manager, I found no evidence of the information on the Strategy being provided to the broad range of primary health care nurses in Tairawhiti around the time of its release. Condensed information was provided seven years after the Strategy’s release in a local primary health care nurse newsletter emailed and sent to primary health care nurses.

Communication is always challenging in complex organisations, across communities and between different practitioner groups. Even when the information is disseminated, it may not be actively received. One of the nurses cites that high clinical workloads and time pressures interfered with the uptake of any information sent electronically:

I don’t even have time sometimes, to be on my emails because you know like my clinical work is so high. (FG.1, p.4)

The time factor also suggests a reason why hard copy information might not be read. It does however highlight the importance of active engagement with stakeholders following the roll out of the Primary Health Care Strategy. Face to face discussion may have been more effective in persuading individuals to accept a new idea. In saying that, there was evidence in the TDH Board minutes that a primary nursing meeting was facilitated for groups of nurses that:

...brainstormed solutions to health scenarios. This was particularly useful in demonstrating the variety of expertise, the potential for overlap of services and the necessity for a coordinated approach (TDH Board minutes, 28 November, 2003, p.7).

Nelson Connor et al., (2009) state key people who are responsible for communicating from within and to the nursing sector must be identified. There was evidence that one cohort of nurses had greater appreciation of the Primary Health Care Strategy than others. From the focus groups it became apparent that the public health nurses employed at TDH had opportunity to discuss the Strategy, both at the time the Strategy was launched, and in the years that followed:

When I was at public health, I was more aware of it because we talked about it and a lot of the programmes were based around initiatives to show that we were meeting the some of the topics talk about but like the outreach immunisations and those sorts of things. (FG.4, p.1)

Public health nurses are employed by TDH’s provider arm rather than being in general practice or private community based settings. As one of the public health nurses at the time of the release of the Primary Health Care Strategy, I can confirm public health nurses were not only provided with information, but actively discussed the Strategy to look at opportunities to contribute to achieving its goals. This is somewhat ironic given that public health nursing was largely excluded by the singular focus on the general practice environment.

Despite this focus, nurses in a general practice in the newly formed PHOs, or NGO sector, showed minimal awareness of the Strategy. One primary health care nurse, acutely aware of her limited knowledge, used her initiative and read the Strategy in preparation for a focus group. For this nurse, reading the Strategy clarified her understanding of the changes that had taken place in her working environment and the impetus behind those changes.

So the more that I read and I had never seen the document before, which was a bit sad ....and so when I was reading it I was thinking it was like all lights were switched on all over the place thinking well that is because that’s when that happened and that’s why that is and yeah, so it all made sense but I hadn’t read the document. (FG.4, p.1)

What this suggests is that understanding of the Primary Health Care Strategy was dependent on the nurse’s place of employment and was generally limited. Rogers (200) and Greenhalgh et al. (2005) both confirm that intra- organisational networks and inter-professional team work facilitate the development of shared meanings and values in relation to the innovation. But if such networks are not operating effectively then dissemination is limited through widespread lack of awareness.

The diffusion process is comparative to societal norms, value systems and accepted behaviour within organisations (Greenhalgh et al., 2005). Further, the capacity to influence others is associated with an individual’s social standing, personal characteristics, self-esteem and intelligence. Rogers (2003) argues most people depend upon the subjective evaluation of information conveyed from individuals like themselves, especially when there is a high degree of professional resemblance between the person/people attempting to introduce the innovation. In analysing the data against the importance of professional relationships one of the managers confirmed its significance:

….and yeah there is something to be said that doctors talk to doctors and nurses talk to nurses. We have completely different language sets and that makes sense. (I.6, p.8)

People with similar education, social standing and beliefs share homophilous communication. Homophilous innovation communication is more effective than heterophilous or that between people with different attributes. Individuals also tend to expose themselves more readily to ideas that comply with their existing values (Rogers, 2003). There is a close association between knowledge of innovations and an area of interest. Peers with similar dispositions in life are more inclined to accept one another’s messages than if the same peers were receiving the information from individuals outside the group (Diaz, 2007). The author extends this acceptance to individuals with more education or more money.

6.6 Concluding statement

The success of implementing any innovation depends on the knowledge of the nature of that innovation, as well as the adopters within their socio- organisational context (Greenhalgh et al., 2004, 2005; Rogers, 2003). This chapter provided evidence of the numerous contributing factors that prohibited the effective diffusion of the Primary Health Care Strategy in Tairawhiti. This was made worse by the lack of a local strategic plan for primary health care development. Overall, there was little evidence in Tairawhiti of steps taken in moving toward a state of readiness, in adopting the broader intent of the Strategy and towards having all the key players supported and on board.

Initially the propensity to act was high as evidenced by activity around PHO development, the mainstay of the changes that took place. However, limited participant understanding of the Strategy negatively influenced the implementation processes.

As a direct consequence of the poor diffusion process, shared understanding was not reached in Tairawhiti and not all parts of the health system were disposed to adopting the Primary Health Care Strategy. The chance of successful implementation diminished further with limited and ineffective engagement following the Strategy’s release. Incomplete understanding then reduced the chance of effective deployment of the primary health care nursing workforce to contribute toward achievement of the Strategy’s intent. In the next chapter multiple layers of resistance in Tairawhiti are examined.

Chapter Seven: Multiple layers