Nursing and Midwifery

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End date: 1997

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    An ethnography of caring and control in an acute psychiatric unit : a dissertation presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing Studies at Massey University
    (Massey University, 1992) Boddy, Julienne Mary
    The setting for this study was a 19 bed general hospital psychiatric ward serving a heterogeneous population. The objective of the study was to generate thick description of the cultural knowledge patients and nurses used to organise their behaviour and interpret their experience in an acute psychiatric unit. Further aims were to describe the nature of the service provided, and more specifically to identify relationships between caring and controlling in this social context, and the outcomes for patients of caring and controlling interventions by nurses. Over a 10 month period primary data were obtained through participant observation and ethnographic interviews, with analysis of documentation providing secondary data. Thirty patients and 20 nursing staff acted as informants. They were selected on the basis that they had experienced the event being studied, and that they were both willing and able to share the experience. A cyclic research process was adopted, in which initial data analysis followed early data collection resulting in more focussed questions for subsequent data collection. Content analysis was undertaken to inductively derive patterns or themes from the data. Validity of data was achieved through triangulation of multiple data sources. Interpretations of the findings were verified and clarified in collegial dialogue with other psychiatric nurses, and with academic colleagues. The central thesis which emerged from the data is that the nature of caring and controlling acts by nurses is shaped by the social organisation of care, and by the dominant belief system of that setting. A view of mental illness as a life long event for the majority of inpatients, coupled with beliefs about the "outside world" as tough, contributed to nurses' feelings of powerlessness to change situations for, or with patients, and so diminished expectations for change. Caring as a moral obligation was often interpreted by nurses as a moral obligation to provide a safe haven, with nurturance and acceptance of patients viewed as chronically psychiatrically disabled. Additionally, features of the organisational context including nurses' lack of autonomy in their practice, the absence of both appropriate environmental controls and a clearly articulated rule structure, and the competing demands on nurses arising from the provision of the after hours crisis service from the ward, contributed to an organisational context which was not supportive of sustained therapeutic interaction between nurses and patients. There was a culture of chronicity in the ward. Implications of these findings for psychiatric nursing education and practice, and for service development are discussed.
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    The nursed passage : a theoretical framework for the nurse-patient partnership : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1988) Christensen, Judith C.
    This study focused on nursing in action. The research goal was to identify nursing-relevant dimensions within a person's experience of being a hospital patient undergoing elective surgery. In order to discover and conceptualise the underlying processes which are present as patients are nursed through this experience, an open question was posed - What is happening here? A qualitative research method was the most appropriate means of discovering an answer to this question. The particular method chosen was the grounded theory approach developed by Glaser and Strauss. Data were collected in five surgical wards of a large city hospital over a period of five months. The research participants were twenty-one patients and the nurses involved in their care. Primary sources of data were interviews and the nursing records. These were augmented by field notes and accounts of observed incidents relating to the care of each patient. Using the inductive strategies of the grounded theory method, numerous descriptive concepts were generated during data analysis. These were ordered within an integrating social process derived from anthropology. By this means a grounded theory in the form of a theoretical framework - the Nursed Passage - was developed. Within this passage the patient is the passagee and nursing is translated into action through the agency of the nurse. The Nursed Passage is a patterned partnership with three key elements. Firstly, the temporal element, characterised by ongoing movement and constant change, is conveyed in the sequence of phases or stages. Secondly, the participative element is portrayed as a patterned relationship in which both nurse and patient are actively involved in progressing the patient through the passage. Finally, the contextual element recognises complex factors within the nursing environment which have an impact on the shape of the relationship between patient and nurse. This theoretical framework, generated from the reality of nursing as it occurs in one setting, assigns a specific shape to the encounter between nurse and patient. It identifies the contribution nursing alone can make to optimise each patient's hospital experience. In this way it both complements and facilitates the work of medical and other colleagues with whom nurses work. Thus, it serves to revalue nursing in terms that can maximally utilise the registered nurse's knowledge and skill for the benefit of all concerned, but particularly the patient and the nurse. Consequently, it has potential value for nursing practice, education and research.
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    Food choices and feeding patterns for women and infants in rural northern Thailand : an ethnographic study : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1992) Ratanawadee Boonyaprapa
    The question for this study arose from the situation that malnutrition remains one of the major health problems among Thai children, particularly the under-fives. The purpose of it was to develop better understanding as to what sustains beliefs and practices associated with infant nutrition. An ethnographic approach was chosen as the research method. One rural village in northern Thailand was selected as the site of fieldwork for a period of 10 months. Data were collected through participant observation, interview, and ethnographic records. Key informants were 18 pregnant women and mothers of the under-twos. General informants were elderly kinswomen, fathers of the under-twos, volunteer health workers and community health workers. From the data it can be argued that what each woman does with regard to her own nutrition during pregnancy and following childbirth and the feeding pattern that she adopts for her infant are the outcomes of interplay between a complex network of cultural, social, personal and situational factors. These act and interact as pushes and pulls in a woman's decision making, frequently conflicting. Four main sources of pushes and pulls are: traditional beliefs; personal factors including attitudes, feelings, needs and experiences; sociocultural situations and changes; and government health services. If nursing interventions aimed at promoting a well nourished woman and a well nourished child are to be effective, nurses must be aware of these multiple influences. The conceptual account generated from the findings of this study has potential value for nursing practice, education and research. It identifies the aspects amenable to change by nurses and other health workers in their work to counter malnutrition situation, and so to improve the health of mothers and children.
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    The actualized caring moment : a grounded theory of caring in nursing practice : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1991) Euswas, Payom Wiriya
    The purpose of this study was to provide a partial theoretical description of the phenomenon of caring in nursing practice. Three practice settings involving cancer patients were selected: hospital, hospice, and community with thirty patients and thirty-two nurses participating in the study. A research design combining a phenomenological perspective and grounded theory strategies was implemented. Data were collected by indepth interview, participant observation, and records. The data were analysed by the method of constant comparative analysis. A number of concepts were developed from the data and the theoretical framework of "The Actualized Caring Moment" was formulated to explain how the actual caring process occurs in nursing practice. This caring moment is the moment at which the nurse and the patient realise their intersubjective connectedness in transforming healing-growing as human beings in a specific-dynamic changing situation. The actualized caring moment is a gestalt configuration of three main caring components: The preconditions, The ongoing interaction, and The situated context. The Preconditions, which consist of the nurse, personally and professionally prepared to care, and the patient, a person with compromised health and wellbeing, are prerequisites for the occurrence of the caring process. The nurse has the qualities of benevolence, commitment, and clinical competency to be ready to care. The patient is a unique person in a vulnerable state and requires assistance from the nurse to meet personal health needs. The Ongoing Interaction, the actual caring process, is the continuity of the nurse-patient interaction moment-by-moment which brings together six caring elements: Being there, Being mindfully present, A relationship of trust, Participation in meeting needs, Empathetic communication, and Balancing knowledge-energy-time. The Situated Context is the situation and environment where the actual caring process is taking place, and this is comprised of circumstances of the nurse-patient meeting and care-facilitating working conditions The conceptual framework of "The Actualized Caring Moment" offers nurses an opportunity to understand their practice more fully in providing effective nursing service. Consequently, its implications are valuable for education, research, and the development of knowledge focused on the discipline of nursing.
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    Schizophrenia, a way of being-in-the-world : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1995) Walton, Jo Ann; Walton, Jo Ann
    This phenomenological study describes what it is like to live with a schizophrenic illness and relates the understanding gained from this descripton to implications for nursing practice. The participants in the study were ten adults who have been diagnosed with schizophrenia, who take regular medication and who are living independent lives in the community. Over a period of sixteen months they were interviewed about the effects of the illness on their everyday lives. During this time they explained the challenges and difficulties which have faced them, both during and long after the resolution of acute illness. As they describe it, schizophrenia is a part of who they are. The narrative contained in this thesis presents the participants' stories in aggregated form, setting their experiences alongside ideas from the early work of Martin Heidegger, whose phenomenological writing informed the analysis and interpretation of the data. As the participants explain, schizophrenia has touched every aspect of their lives. Living with schizophrenia is shown to affect their whole Being-in-the-world. It incorporates Being-with-others, living carefully and taking a stand on life. While hoping for a cure, their reality is of living with a chronic illness which has major effects on their lives. At the same time the participants are shown to define themselves not in terms of their illness and treatment, but in respect of their hopes and dreams and the stance each is taking on his or her own life. In this way their existential predicament is highlighted in the study. Participants are on the one hand very much like all other people, while on the other hand they have to contend with very different concerns than do most others. In itself the description of the experience of schizophrenia contained in the thesis is useful for its potential to increase understanding of the illness by nurses and other health professionals. Further than this, however, the study is shown to have implications in terms of nursing practice and the provision of health care. With regard to the seriously mentally ill the data bring into question some of the theoretical positions which have held sway in nursing for many years. The research demonstrates that it is practicable to attend to the subjective experiences of people who suffer from schizophrenia and to understand their needs and desires from the position of fellow human being, without the need for a guiding theory from which to interpret what they are saying or what their words "really mean." It is argued that relationships between nurses and clients which are based on understanding and trust rather than distance hold promise in the care of those with schizophrenia. Heidegger's concept of solicitude as care for others is addressed in this regard, and is shown to be most appropriate as a basis for nursing care in the mental health arena.
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    Cultural perceptions of illness in rural northeastern Thailand : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1994) Nuntaboot, Khanitta; Khanitta Nuntaboot
    In a transitional society like Northeastern Thailand, alternative and often competing therapeutic methods have been widely used by local people. Most illnesses are managed without recourse to the Government health care services. In Thailand there is a paucity of studies which explore and develop an understanding of how rural people regard illness in terms of causes and classification and how this knowledge influences what actions they take to deal with it. The impact of medical pluralism on illness management has rarely been studied in this country. The purpose of this study is to provide an understanding of the cultural meanings of illness for people in rural Northeast Thailand and their behaviour regarding health and illness care. An ethnographic approach, employing participant observation, interviews and ethnographic records, was selected as the research method, with fieldwork carried out in one rural village in Northeast Thailand where the researcher lived for 12 months. The findings suggest that what people do during an illness is guided by their healing knowledge which is experiential in nature. Mutual influences exist between people's beliefs about illness and their experiences of illness and healing methods. The experiential healing knowledge encompasses broad illness categories and beliefs in multiple causes of an illness. Multiple healing methods including both Western medicine and village curing methods are applied in any illness situation. Western medicine is believed to be effective to treat disease which is viewed as one part of illness, while village curing is believed to effectively treat other causes of illness as well as disease. Kin and neighbours actively participate in the articulation of illness situations, being involved in diagnosing the illness and identifying and prioritising multiple therapeutic management options. This description of people's perceptions of illness and its management, generated from the data, is crucial to increasing the knowledge base of members of nursing and other health professions. Such knowledge identifies critical aspects and possibilities for change in the practice of health professionals when working with rural people in Northeast Thailand. The study concludes with a discussion of strategies for practice and education which might be applied by nurses and other health professionals to improve the utilisation of available health care services.
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    Community participation in health development in Thailand : a thesis presented in fulfillment of the requirement for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1997) Tassniyom, Nit
    This thesis is a chronicle of research into the implementation of community participation in health development in Thailand. Community participation is recognised as the key concept of primary health care. Participation in this study has been conceptualised as power. Therefore, to participate is to achieve power, and participation is a process of empowerment. The research participants were health workers employed at the subdistrict health centre, and village health volunteers. These participant groups were chosen because the researcher perceived that they were groups with relatively little power in the Thai health service. The research involved the participants in a two stage process. The first stage was an examination of the concept of participation in relation to the community's experience with development projects. During this stage it became apparent to the researcher that the original concept of community participation was poorly understood by both participant groups. The second stage involved the use of participatory research to achieve community empowerment by supporting the participants in an analysis-action-reflection process. Dialogue, with equal respect between the researcher and participants, was the key method to encourage analysis of their existing situation in order to raise their awareness, the most important step of empowerment. Simultaneously, action research was also utilised to solve a selected health problem, dengue fever control. A comparison between the results of the implementation of action research processes and that of the participatory research processes utilised in this study revealed that participatory research better ensured community participation in health development. The findings provide an understanding of the theoretical concept of community participation in health development, and its enaction by the use of an empowerment process. The utilisation of a new primary health care approach, whereby the community is empowered to be self reliant and solve its own health problems, would depend on the acceptance and application of the empowerment approach by health workers. The empowerment approach would need to be pivotal in the work of all health personnel, including the implementation of policies and routine practice. Specifically, the empowerment approach has much to offer community health nursing and its adoption would support the World Health Organisation's recommendation that a problem-solving, process-oriented and community-based curriculum is necessary to adequately prepare these practitioners. The adoption of this approach would require expansion of the present curriculum to include not only public health science and nursing science concepts, but also those related to community development. The new curriculum would uniquely equip nurses to work in communities and this in turn would provide specialised knowledge for community health nursing, allowing it to be differentiated from other nursing specialties.
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    Pain as embodied experience : a phenomenological study of clinically inflicted pain in adult patients : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1991) Madjar, Irena
    This phenomenological study describes the lived experience of pain inflicted in the context of medically prescribed treatment, explores the meanings of such pain for patients who endured it and for nurses whose actions contributed to its generation, and presents a thematic description of the phenomenon of clinically inflicted pain. The study is informed by phenomenology, both in terms of its premises and orientation, and its research design and method. The participants in the study were 14 adult patients, admitted to hospital following burn injuries, or receiving intravenous chemotherapy upon diagnosis of cancer, and 20 nurses involved in their care. Data collection took place over a period of five months and included participant observation and compilation of field notes, and a total of 89 tape-recorded interviews (48 with patients and 41 with nurses). Through the process of hermeneutic interpretation a number of themes were identified and used to describe the phenomenon of clinically inflicted pain and the structure of the lived experience of the patients and nurses concerned. The phenomenon of clinically inflicted pain is described in terms of four related themes: 1) the hurt and painfulness of inflicted pain; 2) handing one's body over to others; 3) the expectation and experience of being wounded, and 4) restraining the body and the voice. These themes point to the embodied nature of pain experience and the extent to which the person is involved not only in the enduring of pain but also in its generation. The broader lifeworld of clinically inflicted pain involves patients in the experience of constituting such pain, often as punishment and almost always as something unavoidable, and in turn being constituted by their experiences in terms of losing and seeking to regain a sense of embodied self and of personal situation, and by changed experiences of lived space and lived time. Nurses who themselves helped to generate pain, frequently overlooked the patient's lived exerience and thus the essential nature of inflicted pain as painful, wounding, and demanding cooperation and composure from the patient. Instead, the pain frequently became invisible to nurses involved in its infliction, or when it could not be overlooked or ignored, it was perceived as inevitable, non-harmful, and even as beneficial to patients' recovery. The strategic responses that nurses adopted to pain infliction included detachment from the perceived impact and consequences of their own actions and objectification of the person in pain as a body-object on whom certain tasks had to be performed. An alternative to the strategy of detachment and objectification was involvement in a therapeutic partnership between the nurse and the patient, where shared control over pain infliction and relief helped to sustain trust in the relationship and preserve personal integrity of the patient and the nurse. The study points to dangers for both patients and nurses when clinically inflicted pain is ignored, overlooked, or treated with detachment. It also points a way toward nursing practice that is guided by thoughtfulness and sensitivity to patients' lived experience, and awareness of freedom and responsibility inherent in nursing actions, including those involved in inflicting and relieving pain. The study raises questions about nurses' knowledge, attitudes, and actions in relation to clinically inflicted pain, and highlights the need for nursing education and practice to consider the contribution of a phenomenological perspective to the understanding of human experience of pain, and the nursing role in its generation, prevention, and relief.