School of Health and Social Services

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    Successful ageing : a critical analysis : a dissertation submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy in the School of Sociology, Social Policy, and Social Work at Massey University, Palmerston North, New Zealand
    (Massey University, 2006) Holmes, Jeanne
    The demographics and implications of the growth of the world's population of older people have been well publicised. Frequently, this is linked to concerns about growing demands for social services. In liberal western nations, this rise in the proportion of elderly people is occurring at a period in history when governments are attempting to contain state spending on health care and welfare. Within this context, the gerontological concept of 'successful ageing', which encourages productivity and self-reliance among older people, has emerged. The term 'successful ageing' was coined by R. J. Havighurst in 196l and developed by Rowe and Kahn into a gerontological concept in 1998. Rowe and Kahn's search to identify the factors "that conspire to put one octogenarian on cross-country skis and another in a wheelchair" led them to put forward the view that 'successfully aged' old people are those who remain healthy and socially engaged. The concept of successful aging is widely regarded as promoting well-being in old age. As a result, it has become highly influential in the fields of nursing, social work, and social care. However, the concept has also attracted criticism, mainly for praising the fortunate and privileged elders who have managed to prolong healthy middle age; whilst labelling unwell, disabled, and lonely old people as unsuccessful. In this thesis, my central criticism of the concept of successful ageing is that its definition of 'success' in old age is not based on the views and real life experiences of older people, but instead, on the expertise of scientists and researchers, many of whom have yet to experience the decline and losses normally associated with old age. Consequently, there is a significant difference between the concept of successful ageing and a proportion of elderly people regarding the requirements for the best possible old age. The purpose of this study is to discover the factors which a diverse group of old people regard as essential to optimal old age. It compares and contrasts their self-assessed components of well-being with the externally assessed components of 'successful aging'. The process involved in-depth research with thirty elderly people in New Zealand and the United States. The majority were women. Several ethnic groups were represented. Participants included First Nations people, first generation immigrants, and the descendants of European settlers. Although it was not intentional, my entire sample consisted of people who would have been defined as unsuccessfully aged by the 'successful ageing' paradigm. Yet these people showed resilience, resourcefulness, and often, great satisfaction with their lives. This research demonstrates that there is an incomplete fit between the factors, which older people say produce the best possible old age, and those promoted by the concept of successful ageing. It concludes that in order to promote optimum well-being among older people, it is necessary to take note of the experiences, views, and values of elders themselves.
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    The elderly primigravida : contest and complexity : a Foucauldian analysis of maternal age in relation to pregnancy and birth : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand
    (Massey University, 2001) Payne, Deborah
    This study identifies and analyses the discourses deployed by women recalling their experiences of pregnancy and birth at the age of 35 or over, and by maternity service practitioners describing their practice in relation to women pregnant or giving birth for the first time aged 35 and over. The philosophical approach underpinning the study was derived from the works of Michel Foucault, particularly his concept of discourse and its inextricable relationship with power and subjectivity. The data for the study included texts of published medical, midwifery and women's health literature and relevant government policies. The primary source of data was the transcripts from 32 interviews with women, midwives, general practitioners and obstetricians. The analysis reveals the diversity, contest and complexity that exists amongst women and the practitioners in their ways of thinking about prenatal genetic diagnosis, birth, and maternal age in relation to pregnancy and birth. Textual analysis identified two contesting discourses regarding pregnancy and birth: the scientific medical discourse and the natural birth discourse. The scientific medical discourse demarcates the age of 35 as the time when pregnancy and birth become problematic for such women and assigns to them the label of "elderly" primigravida/primipara to signify their different status. Thus defined, "elderly primigravida/primipara" are recommended to be under the care of an obstetrician and to give birth in an obstetric hospital. The natural birth discourse opposes the construction of maternal age as an independent risk factor. Instead speakers reproducing this discourse argue that other factors are the cause of complications experienced by "elderly" primigravida/primipara, in particular the beliefs and fears perpetuated regarding these women and the interventions that occur as a consequence. Each discourse offers competing subject positions for the first time pregnant woman aged 35 or over. She is positioned in the scientific medical discourse as potentially pathological and incapable of giving birth without intervention. In contrast, the natural birth discourse positions her as not different from younger women and capable of giving birth naturally. Maternal age has the potential to further complicate pregnancy in that women aged 35 and over are compelled to consider the possibility of being mothers of a child with chromosomal abnormalities, particularly Down syndrome. Analysis of the texts showed that the participants brought numerous discursive identities into being in relation to prenatal genetic diagnosis. While most of the women and practitioners identified themselves as subjects of the medical genetic discourse, the discursive identities brought into play by the women were quite different to those deployed by the practitioners. Although the choice to undergo prenatal genetic diagnosis is a binary yes/no, the women revealed fragmentary and complex subjectivities. The study found that women assessed their capabilities to mother a disabled child drawing on multiple and contradictory discursive meanings of risk, motherhood and disability. In comparison, the practitioners positioned themselves as enforcers of informed choice, information experts and as vulnerable to discipline. I suggest that the legal discourse's subject position of vulnerable practitioner may complicate the practitioners' positioning and interests in informing women. Women's right to informed choice may compete in priority with the practitioners' desire to avoid being disciplined for the wrongful birth of a child. A further finding of the study is the strategies deployed by women, midwives and general practitioners to resist power techniques such as surveillance. Women's tactic of elusion avoids the normalising gaze of prenatal genetic diagnosis. Similarly, a strategy of opposition is used by midwives and some general practitioners to create an opportunity for "older" primigravida/primipara to keep open the possibility of giving birth without intervention.
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    The nature and role of the extended family in New Zealand, and its relationship with the State : based on a study of a provincial city : a thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at School of Social Policy and Social Work, Massey University
    (Massey University, 2000) McPherson, Mervyl J.
    In New Zealand there is a widespread perception that European/Pakeha do not have extended families in the way that Maori and Pacific Islands' cultures do. Yet in recent years social policy has been moving away from reliance on the state towards increasing reliance on one's self and one's family. This study uses survey research, a focus group, demographic analysis and policy analysis to investigate the nature of the extended family in predominantly European/Pakeha New Zealand, and perceptions of the respective roles of the family and the state. Discrepancies are identified between what families are doing, what people think they should be doing, and what policy assumes they will do. The key factors affecting the supply of and demand for extended family support are identified and the trends in these analysed. These issues are then integrated in order to assess the implications for policy and the impact of policies on families and the intergenerational social contract. This thesis found that the predominantly European/Pakeha society of New Zealand does have extended families, in the modified sense rather than the classical sense, as categorised by Litwak (1965). That is, extended families which are based on egalitarianism and choice rather than power and control, and are characterised by a loose, informal set of kin relationships involving an interlocking set of nuclear families which may be geographically dispersed and economically independent, but are bound by a sense of obligation based on affective relationships and the exchange of mutual aid services. These family networks are not large, and little support extends to the wider family beyond parents, adult children and siblings. Also of concern for policymakers is that approximately a quarter to a third of participants in this study did not have extended family living close enough to provide any kind of practical support. This study also found that while people generally believe in helping family members, they believe this help should be given by choice, not obligation, and that nuclear family and labour force commitments take priority over commitments to the extended family. A further finding is that in the future we will face increasing demand for support from both family and the state, and a declining supply of family support, especially if policies make it necessary for the young elderly to stay in the labour force. Families are unable and unlikely to do more than they are already doing, which is already the bulk of social support. Theorists such as Thomson (1981) have proposed that there will be breakdown in the intergenerational social contract at the macro-level of the state as a result of neo-liberal policies of self-reliance, particularly for younger generations, and policies which have favoured the older generation at the expense of the young. It is concluded from this study that the balance of support towards the young rather than the old at the micro-level of the family is preventing this macro-level breakdown. But if more responsibility is put onto families, this will cause breakdown in the micro-level intergenerational contract and upset the balance. Thus there is a need for increased rather than decreased state support to complement what families are able to do and prevent breakdown in the intergenerational contract at both the micro-level of the family and the macro-level of society.
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    The interrelationship between social support, risk-level and safety interventions following acute assessment of suicidal adolescents : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Social Policy and Social Work at Massey University, Palmerston North, New Zealand
    (Massey University, 2001) Smith, Deborah Anne
    This project was undertaken largely to address (a) the concern that New Zealand has one of the highest rates of youth suicide in the world, and (b) the limited empirical research available on crisis assessment and intervention for suicidal adolescents in New Zealand. Research on youth suicide has primarily focused upon examining factors which place youth at-risk for suicidal behaviour. Social support was chosen as a variable of interest in this study due to (a) its importance in fostering healthy adolescent development, and (b) its identification as an important factor in increasing risk of suicide, particularly if it is lacking or of a negative nature. The present investigation tested a model comprising three constructs: social support (i.e., negative and positive), assessed risk-level of suicide, and safety interventions (e.g., hospitalisation, respite care). Two studies were conducted: an archival study and a vignette study. For the archival study, a record review was conducted using acute assessment reports from the Child, Adolescent and Family Service (CAFS). Data from 50 attempter files and 50 ideator files were collected in order to establish reliable measures for the vignette study. The vignette study involved administering a vignette-style questionnaire to 23 CAFS clinicians. With the exception of the Children's Global Assessment Scale (CGAS) scores in the attempter group, the interrater reliability was good on all indices for the archival study. The vignette study indicated adequate reliability for risk-level ratings based on the multi-rater kappa. The archival study demonstrated that there were significant interactions between group and risk-level (recoded), group and negative support severity (recoded), group and positive support, and negative support severity and total safety interventions (recoded). The vignette study revealed significant interactions between negative support severity (without or with positive support) and assessed risk-level, negative support severity (without or with positive support) and total safety interventions (recoded), and assessed risk-level and total safety interventions (recoded). Overall, results from this study indicated that: (a) the greater the level of negative support severity, the higher the risk-level; (b) the greater the risk-level, the greater the number of safety interventions implemented; (c) the presence of positive support, in addition to negative support, appeared to result in lower risk-level assessments, and (d) certain risk-levels were indicative of particular safety interventions. Revisions to the social support model were necessary based on the results obtained. For the vignette study, clinicians' responses with respect to the decision-making process for risk-level and safety interventions were also explored using the principles from a grounded theory approach and inductive content analysis. The results indicated that clinicians use a methodical process when assessing risk-level and making safety intervention recommendations. Process models for assessing risk-level and recommending safety interventions are presented in relation to these findings. This study makes several important contributions to the research on youth suicide by: (a) providing evidence for reliable social support concepts - namely, that of negative support, positive support and negative support severity, (b) assessing the relationship that both negative and positive support have with suicide risk-level, (c) examining the relationship between risk-level assessment and specific individual safety recommendations (other than hospitalisation), and (d) providing evidence of a relationship between negative support severity and recommended safety interventions, not previously tested. The implications of these results are discussed in terms of their application to (a) youth suicide treatment and prevention, (b) current or proposed services and procedures for at-risk youth, and (c) future research.
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    Breaking the silence : restorative justice and child sexual abuse : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Social Policy at Massey University, Albany, New Zealand
    (Massey University, 2001) Jülich, Shirley Jean
    This research investigated the relationship between justice and child sexual abuse from the perspective of adult survivors. Utilising participant observation, unstructured interviews and focus groups within a feminist framework, 21 adult survivors of child sexual abuse (18 women and 3 men) were consulted to identify issues that were problematic for them. In addition, 2 jurors, 1 judge and 2 counsellors were interviewed. The findings indicated that child sexual abuse has been shrouded by a conspiracy of silence, caused partly by deeply entrenched structures within society. These forces combined with the complexity of recovery, including the possible impacts of Stockholm Syndrome, and the perceived inability of the criminal justice system to meet their needs, have appeared to silence many survivors of child sexual abuse. A review of the economic consequences and an analysis of the subsequent costs of child sexual abuse have indicated the need to implement programmes that would lessen the burden for victims, offenders, their families and the broader society. Survivors cautiously suggested that restorative justice might be sufficiently flexible to encourage victims of child sexual abuse to criminally report, thereby breaking the silence. A cost benefit analysis of a restorative justice programme indicated that significant savings could be made and highlighted that the prevention of child sexual abuse should be a priority. The findings of this research would have implications for policy makers and all those who provide services to victims and offenders of child sexual abuse. Stockholm Syndrome has highlighted the complexity of the recovery process for victims of child sexual abuse. This syndrome combined with the concerns of adult survivors of child sexual abuse would have implications for practitioners within the traditional criminal justice system and the restorative justice movement. Finally, the costs of child sexual abuse in New Zealand would have implications for justice agencies, health agencies, social welfare organisations and the Accident Compensation Corporation of New Zealand.
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    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.
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    The everyday always-thereness of living with rheumatoid arthritis : 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) Roy, Dianne
    This study explores the phenomenon of 'living with rheumatoid arthritis'. Utilising a hermeneutic phenomenological methodology informed by the writings of Martin Heidegger and Hans-Georg Gadamer, the study provides an understanding of the meaning the phenomenon has for the participants and illustrates the impact it has had on their lives. The participants in the study were twenty-five people who have varying experiences of the phenomenon. Eleven participants were people who have the disease, six were partners of people who have rheumatoid arthritis, and eight were adult-aged children whose mother or father has the disease. Drawing primarily on the stories shared by the participants, the study uncovers the everyday realities of living with rheumatoid arthritis and it reveals the taken-for-granted nature of the experience. The interpretation offered in the thesis raises new understandings of the complex phenomenon of 'living with rheumatoid arthritis'. The findings of this thesis show that rheumatoid arthritis is always there in the lives of those who experience the phenomenon, whether as partners, adult children, or the person with the disease. In its always-thereness rheumatoid arthritis becomes part of the background familiarity of their lives. Those who live with rheumatoid arthritis take the experience with them into all other worlds. It permeates, to varying degrees, all aspects of their lives. In the presence of rheumatoid arthritis different things matter and things matter differently. Living with rheumatoid arthritis means finding a new way of being-in-the-world. It means developing and maintaining strategies for being-in-the-world with rheumatoid arthritis. As the strategies are developed, these people come to live in the world in an everyday way that in itself becomes taken-for-granted. They, as I suggest, come to live resolutely with the disease. However, living resolutely with rheumatoid arthritis is always tenuous and at the beck and call of the disease and a myriad of other influences. Resoluteness in the everydayness of living with rheumatoid arthritis can be lost at any time, in any way. Living with rheumatoid arthritis becomes a cycle of always working towards and maintaining the everydayness of resolute coping, while knowing it may be lost at any moment, which will necessitate coming again to pick up the strategies that bring one back to a taken-for-granted everydayness.
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    On the margins: nurses and the intermittent care of people with dementia : a discourse analysis : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand
    (Massey University, 2001) Gilmour, Jean Alison
    The purpose of this research has been to explore the representations and practices of nurses in the context of intermittent care for people with dementia, and to situate their accounts within the wider discourses of dementia care. Discourse, as explicated by Michel Foucault, is the body of knowledge, and the related disciplinary practices, that can be considered to be the truth at a particular time, shaping what is possible to be said, and with the associated power to exclude what cannot be said. In the first section of the thesis it is argued that the concept of dementia is not the description of some pre-determined biological phenomenon but a powerful disciplinary construction informed by a specific historical and cultural perspective, a construction that has major policy implications and ramifications for the representations of dementing illnesses in disciplines such as nursing. Section two of the thesis shifts from the disciplinary representations of dementia produced in published texts, to the representations and everyday practices of the nurses and families who participated in this study. While all the nurses' texts represented the care of the person with dementia as problematic, at times, in the institutional setting, there was considerable diversity apparent in nurses' discursive positionings, and in the associated practices and inscriptions of the person with dementia. The organisational context emerged as a major factor influencing those discursive choices and practices. One research site provided particularly successful respite care as judged by family caregivers' expressions of confidence in the service. The dominant nursing discourse in this site framed the hospital as home-like and the relationship with patients as being family-like. The permeability of social and geographic boundaries at this research site signaled inclusion for family and patients in contrast to the more traditional boundaries demarcating social and physical spaces evident in the other sites. This study highlights the institutional bases of powerful discourses such as biomedicine as well as the existence of alternative discourses. The marginal discourse of care as being family and home-like may lack the authority of biomedical and formal nursing discourses, situated as it were outside the academy, but space is provided in this representation to produce a social environment, and nursing practices, that encourage a sense of relationship and social inclusion for people with dementia and their family caregivers. Dementia has proved to be a fruitful area of study in that the current dominance of biomedical knowledge in nursing literature can be challenged as being marginal to nursing concerns. The subsequence discussion of how nurses have suppressed the knowledge and interests of people with dementia and, indeed, the knowledge of nurses themselves, provides a productive starting point for wider discussion about issues of power/knowledge in nursing representations generally.
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    "Linking as one" : an intimate breastfeeding moment : a thesis presented in fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand
    (Massey University, 2001) Dignam, Denise Miriam
    Breastfeeding is more than the act of providing nutrition to an infant. It is a dynamic interpersonal process, frequently suggested by both women and authors to be an intimate activity. Health professionals have tended to explore the biophysical aspects of breastfeeding largely ignoring the breastfeeding woman's perspective and the effect social and psychological processes have on breastfeeding success. This grounded theory study drew on a range of data sources to describe breastfeeding womens' experience of intimacy. Data included interviews with twenty women participants, observational field notes, theoretical memos, drawings, literature and pictorial work. The study supported the premise that women experienced moments of intimacy when breastfeeding. Breastfeeding is represented in the basic social psychological process 'linking as one'. Linking as one is the intimate act of gifting, for comfort, pleasure and growth, human milk and human contact to a baby or child. 'Linking as one' is mutually exclusive and mutually satisfying to both participants. It is not all women's experience nor is it associated with every breastfeeding encounter. The findings support a substantive descriptive model of the breastfeeding process that represents and facilitates intimate breastfeeding moments. The model provides a framework for theoretical research, which may lead to further conceptual refinement. The model also provides a framework for education curricula and nursing clinical practice. Clinical application includes the use of concepts as prompts from which to explore interpersonal breastfeeding dynamics with breastfeeding clients. The concepts include breastfeeding comfort, ownership of the breast, mutual gifting and knowing. Exploration of these concepts may enable breastfeeding women to maintain and promote successful breastfeeding experiences.
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    A study of medical, nursing, and institutional not-for-resuscitation (NFR) discourses : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Sociology, Social Policy and Social Work at Massey University, Palmerston North, New Zealand
    (Massey University, 2002) Bickley Asher, Joy Lynley
    This study investigates the way that medical, nursing and institutional discourses construct knowledge in the specific context of Not-for-resuscitation (NFR) in a New Zealand general hospital where NFR guidelines are available in the wards and from the regional ethics committee. The thesis argues that there are ranges of techniques that staff use to construct NFR knowledge, enacted through various forms of speech and silence, which result in orderly and disorderly experiences for patients nearing death. The study was conducted through a critical analysis of the talk of health professionals and the Chairperson of the Regional Ethics Committee. Critical discourse analysis, a methodology that is primarily concerned with a critical analysis of the use of language and the reproduction of dominant ideologies or belief systems in discourse, was employed. The researcher examined the transcribed, audiotaped talk of eleven professional staff members of a large metropolitan general hospital, and the Regional Ethics Committee Chairperson. The results of the analysis indicate that medical discourses do not dominate the construction of NFR knowledge within the institution. Nor do the institutional or ethics committee discourses, written as NFR policy documents, dominate by instilling order into NFR practices with patients. Rather, a range of discourse practices within the disciplines of nursing, medicine, management and policy advice work to determine what happens to patients in the context of NFR and, unexpectedly, cardiopulmonary resuscitation. NFR discourses designed by the institution to influence and standardise practice at the bedside are resisted by professional discourses through the techniques of keeping quiet and keeping secrets, forcing others to keep quiet, delays in speaking up, through to speaking up against opposition. These techniques of speech and silence constitute a divergence between institutional discourses and professional discourses, and divergence within nursing and medical discourses. Both medical and nursing discourses underplay the degree of influence their professional power had over NFR events. This research is potentially significant at two levels; firstly because of what it reveals about the way in which health professionals and policy advisors construct NFR knowledge and secondly, because of the relationship between NFR practices in the health sector and societal ideas about control of death at the beginning of the twenty-first century. These findings will have particular relevance for the shaping of future health care policies. The outcomes of this study also point to the need for further research, both into NFR and into cardio-pulmonary resuscitation events particularly with regard to the implications of the policies for patients and their families.