Nursing and Midwifery

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Making sense of the Director of Nursing structural positioning in New Zealand public hospitals (2006-2012) : a thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, Massey University
(Massey University, 2013) Hughes, Kerri-ann
This dissertation reports on research examining and analyzing nursing leadership structures in New Zealand public hospitals, and in particular, the Director of Nursing (DoN) structural positioning. Leadership in hospital nursing is critical if the profession is to meet the challenges facing health services in the 21st century. The research has been undertaken using case study methodology and focuses on how organizational decision-making structures have impacted on nursing leadership in public hospitals. ‘Sense-making’ has been used as a theoretical construct to understand both the formal and informal structures that influence organizational decision-making. Phase one of the research involved examining twenty District Health Board (DHB) organizational and nursing charts. In phase two and three, the Directors of Nursing (DoNs) and the Chief Executive Officers (CEOs) were surveyed using a series of demographic and qualitative questions to draw out understanding of the Director of Nursing (DoN) role. The research has found that the constructs of power and authority influence the decision making processes at the executive level of the DHB. An analysis of the data indicates that the current structural positioning of the DoN is hindered by the existing dual accountability line reporting structures in DHBs and this is a barrier to alignment with Magnet hospital principles which provide evidence of effective patient outcomes. The focus primarily adopted by District Health Boards on professional line reporting only for nursing is not conducive to achieving effective and safe patient outcomes as it removes authority from the DoN and yet places unrealisticexpectations on accountability of how the DoN can achieve effective and safe patient outcomes within the public hospital setting.
BSMC : is there room for me? : an exploration of nursing leadership in primary health care : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Auckland, New Zealand
(Massey University, 2012) Calverley, Rachael
The unpredictability of health in a dynamic climate can result in a multiplicity of challenges. Indeed unpredictability has been referred to as the essence of creativity. Strong leadership in healthcare and importantly nursing is crucial to seeking solutions to organizational change especially when decision making will impact on the population’s health. By influencing policy objectives through leadership, nurses have the opportunity to develop strategies that make a difference to future complex problems. With the implementation of the Governments Better Sooner More Convenient (BSMC) policy agenda and principles underway from 2008 onwards, to reframe primary health care services, a series of key principles emerged including: a more personalized primary health care system with services moved closer to home; reduction in demand on hospitals and a package of services centred on integrated family health centres, with nurses taking a key role in shifting services from the secondary to primary care needs of patient support. From seventy health collective submissions positioning themselves to address these principles, nine were selected to move through to the next stage of development. The applications from all of the successful organizations referred to the need for improved multi-professional working and/or the importance of the nursing workforce to the BSMC agenda. Importantly, it would appear that a high quality nursing leadership function within the BSMC health collectives developing BSMC service configurations would be required to meet their goals. The purpose of this study was to explore with nurse leaders how they were able to contribute to these evolving primary health care collectives and changes that influenced the development of new or reviewed services, in addition to gaining insight into their challenges and opportunities as nurse leaders. The literature suggests a move away from the post heroic model of leadership and refers more frequently to coalitions of experts or leaders as a collective intelligence. These emerging characteristics represent a distributed leadership model that is leadership shared across varying people, professions and roles. It is this distributed model of leadership that provided a conceptual framework and a clear point of reference for this study. A qualitative approach derived from an interpretive perspective was the methodology chosen for this research. Eight out of nine potential nurse leaders involved in each of the regional health collectives participated in telephone interviews and communicated with the researcher via email networks. Theme identification was the essential task for the analysis process. Four key themes were identified with subthemes: politicization (power to influence), infrastructure (teams and education/training), coalitions of leaders (communication and relationships) and resilience (battling and visibility). The findings suggest on-going challenges to nurses leading in primary health care which include fragmentation among nurses, variable investment in regional nursing infrastructure, interdisciplinary relationship issues and limited training to develop future nurse leaders. Addressing these results requires clinical, strategic and professional nursing leaders to work within fora that are unified, cohesive and collectively agreed on their purpose.
In search of nursing : the long-term impact of the New Zealand health reforms on ward nursing : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Manawatu, New Zealand
(Massey University, 2012) Teekman, Englebert Cornelis
This thesis began with my curiosity about why, despite repeated attention to nurses’ health assessment skills (at undergraduate and professional development level), it has remained an under-utilised skill. A focused ethnography was conducted in six acute wards of a provincial New Zealand hospital. Twelve registered nurses were observed and interviewed in the first phase of the research and multiple additional primary data sources were utilised. Early findings indicated that nurses did not undertake health assessment and raised much broader questions about the nature of ward nursing practice and the amount of control ward nurses have over their work environment and their own nursing practice. The research was extended to include seven stakeholders, senior nurses who had good insight and knowledge of ward nursing practice. A structuration theory lens was applied to assist in the analytic process. The findings of this research reveal the long-term impact of the NZ health reforms on ward nursing practice. The introduction of generic management principles and the continuous restructuring of the health care environment have impacted on nursing practice and reduced nurses’ autonomy. Nurses have come to rely on standardised documented processes to provide essential care, relying significantly less on knowledge of a patient’s actual health status. Much recent local and international quantitative research has revealed a number of concerning findings about the reduced time nurses spend at the bedside, the complexity of nursing work flow, the increase in interruptions, missed nursing care, and the vital role nurses have in preventing many adverse events and unexpected deaths. This thesis provides a rich qualitative understanding of the circumstances behind these quantitative findings and reveals that nurses are now struggling to provide care consistent with the ethos of nursing. I argue that challenging the nature of nurse education will not improve nurses’ ability to deliver nursing care. Instead I argue that the current acute ward environment does not support registered nurses to provide the nature of care for which their education has prepared them.
A qualitative exploration of environmental and relational factors affecting service user involvement from the perspective of community mental health nurses : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Palmerston North Campus, New Zealand
(Massey University, 2012) Brown, Vicky Keryn
Mental health policy and clinical guidelines require service user involvement principles within clinical practice and service provision, yet few national studies exist to examine Mental Health Nurse’s (MHNs) viewpoints about its implementation. This qualitative research project asks the question ‘What are the environmental and relational factors which affect service user involvement in community mental health team settings from the perspectives of community MHNs?’ The research aims were: (1) Explore how the practice environment supports service user involvement; (2) Explore how they include, or not, service users in the provision of care; and, (3) To discuss how the group of community MHNs recognise and describe service user involvement. Central ethics approval was gained and eight community MHNs in two District Health Board’s (DHBs) with over 5 years experience were interviewed. Participant’s discussion was audio taped, transcribed and then analysed utilising a thematic analysis approach. From this analysis, two predominant themes arose. Theme one highlights the ‘relationship dynamics of practice’ through exploration of concepts of historical changes; conflicting relationships, influential attitudes and powerlessness. Theme two explores ‘strength based approaches’ from the participants perspectives and includes recovery; inclusive practices; challenging stigma and beliefs towards service user involvement. Mutual agreement about the benefits of service user involvement was identified. However, changes to funding, hierarchical mental health organisations, nurses’ education, stigmatising attitudes and lack of nursing identity have impacted on the implementation and support of service user involvement. Recommendations for further research and suggestions for nursing practice are offered through building nursing capacity, capability, quality and strengthening the profession.
Living large : the experiences of large-bodied women when accessing general practice services : a thesis presented in partial fulfillment of the requirements for the degree of Master of Philosophy (Nursing) at Massey University, Palmerston North, New Zealand
(Massey University, 2011) Russell, Nicola
The ‘obesity epidemic’ of the past two decades has resulted in numerous studies reporting higher levels of stigma and discrimination experienced by obese/overweight women, both within the health care system and society in the main. Despite general practice being the most utilised point of access for health care services, there has been very little international or national exploration of the experiences of large-bodied women accessing these services. Utilising a qualitative, descriptive research design, this post-structuralist feminist study has enabled a group of large-bodied women to express their stories of accessing general practice services. Eight self identified large-bodied women volunteered to participate in semi-structured face-to-face interviews. Thematic analysis identified seven themes: Early experiences of body perception, Confronting social stereotypes, Contending with feminine beauty ideals, Perceptions of health, Pursuing health, Respecting the whole person and Feeling safe to access care. The women in this study articulated broader interpretations of health and well-being than those teachings reproduced within dominant bio-medical and social discourses of obesity. When these women’s personal context, beliefs and values are silenced by the health care provider, the rhetoric of health care professional claims of patient-centred care has given way to these women experiencing stigmatisation and a sense of ambiguity about general practice services. However, when space is given for multiple interpretations of obesity to exist within the patient-health care provider relationship, these women feel respected, their health needs are satisfied and they are more comfortable to engage in health screening services. Resisting the powerful socio-cultural milieu which supports the superiority of a slim female body as a signifier of both health and beauty presents a challenge for health care professionals to negotiate. I contend however, that giving consideration to the perspectives of large-bodied women and critically reflecting upon one’s own personal beliefs and attitudes about the overweight/obese, presents an opportunity to ensure clinical practice for this population is truly patient-centred.
Needs assessment and decision making in the Plunket nurse setting : what's the story? : a thesis presented in partial fulfilment of the requirements of the degree of Master of Philosophy (Nursing), Massey University, Wellington, New Zealand
(Massey University, 2011) Hussey, Alison Louise
Programmes delivered to populations of young children have had a high profile in recent years, as the relationship between childhood health and long term wellbeing is emphasised and funders and policy makers seek effective interventions to reduce health outcome disparity between some groups of children. Plunket nurses are employed by the Royal New Zealand Plunket Society (Inc) (Plunket) to deliver a programme of contacts to families with children aged from birth to five years, under a primary health care programme known as the Well Child Framework (Ministry of Health, 2010c). Seven universal or ‘core’ visits result in an assessment of family health need which informs decisions about the additional support offered to reduce risk to child health outcomes and improve health equity. This study was undertaken to clarify how Plunket nurses think about needs assessment, describe how Plunket nurses make decisions when planning care, and explore the influences on Plunket nurse needs assessment and decision making. A constructivist paradigm provided the framework for qualitative interviews with seven Plunket nurses. Data were analysed using narrative and thematic methods to construct three group narratives. The findings add to knowledge of New Zealand well child practice established through the limited previous studies in the Plunket nurse setting. Plunket nurses’ relationships with families emerged as the foundation for needs assessment, a process study participants described as complex, where a range of social, economic and community determinants are considered to establish family resilience and identify risks to child health outcomes. Decisions about planned care are contingent on family participation and agreement, and are influenced by peer and Clinical Leader supervision, the nurse’s knowledge and experience, and the available referral options. The study findings emphasise the importance of facilitative funding models to accommodate the unpredictable nature of work with families in the community, and consistent leadership to translate the underpinnings of service specifications to the reality of practice. Support for the Clinical Leader role, and further research to establish Plunket nurse professional development needs and to improve understanding of the dynamics in relationships between Plunket nurses and families are recommended.
Implementing a Critical Care Outreach Team : what difference has it made for nurses? : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Albany, New Zealand
(Massey University, 2011) Davies, Kathryn Erin
The aim of this study is to describe the implementation of Critical Care Outreach (CCO) and to understand what difference implementing a Critical Care Outreach Team (CCOT) has made to ward nurses in a secondary level general hospital in New Zealand. A CCOT was established at the study hospital in 2006. The aim was to implement an early warning score, to provide education and to share appropriate intensive care skills from CCOT nurses on the wards. Additionally, patients discharged from the Intensive Care Unit were to be followed up. The difference this made to ward nurses in this hospital was unclear. International studies had reported suboptimal patient care on acute wards and the emergence of CCOTs. Research was warranted to gain an understanding of the impact of the service on ward nurses. The methodology chosen for the study was case study, and was underpinned by Change Management Theory and elements of whole system reform (Fullan, 2010). Fullan’s (2007) Change Management Theory of a three phased approach to change management, initiation, implementation and institutionalisation was selected for the study. Data was collected from a nursing focus group, three interviews, and District Health Board documents related to the CCOT. Interviews and nursing focus group data were analysed by thematic analysis and documents analysed by subject. Implementing the CCOT facilitated the shift of late recognition/late intervention of patients to early recognition/early intervention. An area of whole hospital reform occurred. The use of an early warning score promoted more timely patient review, communication between nurses and doctors, improved observation frequency and an environment of objectivity developed. Nurses benefited from education, were empowered to escalate patient concerns, improved their assessment and specific clinical skills, and reported that they were supported by the CCOT. The CCOT has had a positive effect on the early recognition and early intervention of the physiologically unstable patient. The challenge to New Zealand nursing now is to continue to build on the evidence from this study that CCOT has a beneficial impact on ward nurses. The challenge to the District Health Board is to preserve CCOT to ensure that nurses are supported and late recognition/late intervention is truly a phenomenon of the past.
Dancing around the families : a grounded theory of the role of neonatal nurses in child protection : a thesis presented in partial fulfillment of the requirements for the degree of Master of Philosophy in Nursing at Massey University (Albany), New Zealand
(Massey University, 2011) Saltmarsh, Tina Anne
The Ministry of Health objectives aim to protect the health and safety of children by reducing death rates, injury and disability from abuse. Family Violence is a significant health issue that impacts on children. Health professionals are key in the screening for Family Violence and assessment for child abuse. The philosophies of Family Centered Care and Developmental Care underpinning neonatal nursing practice are especially relevant for child protection. Nurses are in an ideal position to intervene before abuse perpetration. Increased awareness of child maltreatment and requirements for screening and reporting led to my research question, “What is happening for Neonatal Nurses in Child Protection?” Glaserian Grounded theory guided this study and the analysis of data. A total of ten semi-structured interviews was undertaken with nurses working in the participating neonatal units. Data were analysed and constructed into a substantive grounded theory, Dancing Around the Families and a Basic Social Psychological Process of Knowing at Risk Families. Dancing Around the Families explains nurses’ coping and acting upon child protection issues. It is about the creative conversations and work required to help support or enhance the infant’s safety. Difficulty with communication and transparency of information sharing between services, and differing perspectives creates this dance. Knowing at Risk Families captures how neonatal nurses construct child protection by acting on their personal and professional levels of knowledge. Nurses act on gut instincts, intuition or Red Flags to put supports in place for the protection of the infant. Child protection presents a state of conflict for nurses, where a sense of social justice prevails in their care, and their ideals and reality are often not congruent. Implications for practice require nurses to consider the way we look at families, as well as family capacities, capabilities and health literacy, and the importance of facilitating attachment.
Safeguarding the practices of nursing : the lived experience of being-as preceptor to undergraduate student nurses in acute care settings : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Albany, New Zealand
(Massey University, 2001) Rummel, Louise G.
An Heideggerian Hermeneutic approach has been adopted to explore the experience of being-as preceptor to undergraduate student nurses in the acute care setting. This thesis addresses the question: What is the experience of being a preceptor to undergraduate student nurses in an acute care setting? Fifteen preceptor-participants were interviewed twice, with each interview being approximately one hour. Heideggerian Hermeneutical Analysis was used to reveal the experience of preceptors as they precept undergraduate student nurses. The thesis begins by placing nursing education in an historical, socio-political and professional context that provides the background to current New Zealand nursing practice. Student nurses undergoing their nursing education learn the meaning of being a nurse in many different contexts. This research is situated in the acute care context where both preceptors and student nurses engage in the practice of nursing. The methodological background shapes the way the research is presented to explicate the meaning of being-as preceptor. The four data chapters reveal the preceptors' experience and open with dialogue showing how nurses become preceptors. This is followed by exploration of how preceptors assessed where the student was at, moves to preceptors promoting learning and closes with discussion of how preceptors keep students and patients safe. Many practices were uncovered during the revelations of the preceptors as they disclosed to the researcher narratives of their everyday practice world. Common themes that emerge from the data include: Becoming attuned- the call, The Emerging Identity of 'being-as' Preceptor: Keeping the student in mind, Assessing where the student is at: The Preceptor and Preceptee Working and Growing Together, and The Preceptor as Builder of Nursing Practice: Teaching Reality Nursing. A number of common themes support the relational themes which are of greater complexity. A constitutive pattern, the highest form of interpretation that emerges from the data, was Safeguarding the Practices of Nursing. This constitutive pattern lies within every text either directly or is inferred from each participant's dialogue. It contains the central meaning of the thesis. It is constituted from common and relational themes as they present themselves in the analytical process. In this thesis the experience of being-as preceptor is unveiled through the participants' own words as the researcher takes the reader back to the 'things themselves' as is espoused by hermeneutic phenomenology.
Responding to the call to care : women's experience of breastfeeding in New Zealand : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Wellington, New Zealand
(Massey University, 2004) McBride-Henry, Karen Sharee
New Zealand breastfeeding experts have long contended that New Zealand does not have a breastfeeding culture, as demonstrated by anecdotal evidence suggesting that women find breastfeeding difficult to initiate and sustain. A review of the literature indicates that, in New Zealand, breastfeeding knowledge falls within the domain of health care professionals, which marginalises women's own experiential knowledge about breastfeeding. Therefore, this study explores the experience of breastfeeding for women in New Zealand. A reflective lifeworld research methodology underpins this study, allowing the participants' narratives to be explored without the use of pre-existing theoretical frameworks that may close down on aspects of the interpretive analysis. Nineteen women were interviewed for this study, all of whom were New Zealanders who were either breastfeeding at the time of the interviews, or had breastfed within the last two years. Many of the participants had breastfed more than one child. What emerges as the central thesis of this study is that breastfeeding is a priori to unique embodied experiences. A number of sub-themes, which further explicate this central thesis, include: the silencing of the reality of breastfeeding within the public domain, the pervasive influence of society, or 'the they', through the accepted frameworks by which breastfeeding women interpret their individual breastfeeding experiences, and breastfeeding as a means of facilitating close relationships between women and their infants. The findings of this study will assist health care professionals working alongside breastfeeding women, as it offers fresh understandings of what it is to be a breastfeeding woman. It is important that health care professionals lay aside their previously-held perceptions about breastfeeding, and pay careful attention to individual women's experiences prior to planning interventions. If health care professionals value women's embodied breastfeeding narratives, women will be supported to articulate their breastfeeding experiences, thereby increasing women's confidence in their embodied breastfeeding knowledge and capabilities

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