IN NEW ZEALAND Journal of Professional Nursing
INSIDE THIS ISSUE... Health professional and family perceptions of post-stroke information Children living with serious complex illness: Health professionals’ perspectives of an integrated model of care Cultural responsiveness and the family partnership model
Volume 31. No. 2
JULY 2015
Praxis: “The action and reflection of people upon their world in order to transform it.” (FREIRE, 1972)
E D IT O RIAL BO ARD EDITOR-IN-CHIEF: Denise Wilson RN, PhD, FCNA (NZ) ASSOCIATE EDITOR: Jean Gilmour RN, PhD, MCNA (NZ) EDITORS: Norma Chick RN, Willem Fourie RN, Thomas Harding RN, Stephen Neville RN, Michelle Honey RN, Jill Wilkinson RN,
RM, PhD PhD, FCNA (NZ) PhD PhD, FCNA (NZ) PhD, FCNA (NZ) PhD, MCNA (NZ)
COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation. KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection. Transformation is shown by the change of the initial plain Koru design to a more elaborate one.
PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 2423-012X HANNAH & YOUNG PRINTERS
CO NTE NTS EDITORIAL: ‘These women’, critical reflection and cultural safety
Beverley Parton ........................................................................................................................... 4
ARTICLES: Health professional and family perceptions of post-stroke information
Dianne Roy, Susan Gasquoine, Shirrin Caldwell, Derek Nash......................................................... 7
Children living with serious complex illness: Health professionals’ perspectives of an integrated model of care
Cynthia Ward, Alicia Evans, Rosemary Ford, Nel Glass................................................................ 25
Cultural responsiveness and the family partnership model
Zoe Tipa, Denise Wilson, Stephen Neville, Jeffery Adams............................................................ 35
NOTES FOR CONTRIBUTORS.............................................................................................................. 48
Page 3
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand EDITORIAL Three telephone calls over several weeks a few years
two dimensionally what one thinks one sees. In
back were the catalysts for what became a nursing
critical reflection, a taken-for-granted image, like the
reflection. As an Aotearoa New Zealand nursing journal,
stereotypical ‘these women’, is viewed from different
Nursing Praxis exists as both repository and conduit
angles in various lights and over time. At each point,
of scholarly articles by nurses to influence nursing
the viewer undertaking critical reflection notes their
practice, including nursing practice with Indigenous
own location, illuminated effects on their viewpoints
Peoples. It is here then, with some temerity, I introduce
now, and on their own inherited perspectives from
Māori women, health care and contemporary realities:
epochs past. The result is that the viewer no longer
A critical reflection (Parton, 2015). I also feel some
sees a trivialised image. Rather it is a complex reflection
confidence. I learnt so much from being employed for
of mobile processes that are historical, social, cultural,
over a decade as a registered nurse by Kokiri Marae
economic, and gendered in nature encompassing
Health and Social Services, Lower Hutt. I am Pākehā
‘these women’ AND the viewer. ‘These women’ can
and I initiated those three calls to secondary health
then become heterogeneous and unique with much
care nurses.
to offer the viewer. The viewer changes, recognising themselves as always being part of the scene.
Advocacy is a nursing role and I was advocate for
Emancipatory action becomes a possibility. The now
three Māori women with whom our service had
participating viewer in close relationship� with ‘these
newly
advocacy
women’ is able to work with the women for change.
included reconnecting each of the three women back
Their health care has the potential to become uniquely
into different secondary health services. With each
and heterogeneously women-centred that enables the
telephone call I received unsolicited advice, the essence
women to recognise the health care as culturally safe.
established
relationships.
The
of which was what to do with ‘these women’. I could not verbally respond. The ‘advice’ contained neither
Critical reflection is a foundational tenet of cultural
knowledge nor understanding of the women’s context.
safety
I vividly recall the third time instantly feeling a physical
Whakaruruhau, is the Aotearoa New Zealand
upheaval within, and an inner voice saying, ‘Right!’
nursing theory birthed by Māori nurses as relevant
That feeling never left me. Māori women’s stories of
for all recipients of nursing care. The nurse through
health and health care engagement encountered in
critical reflection acknowledges a spectrum of the
my practice varied widely; exploring Māori women’s
difference/s between his/her self and the recipient
stories within the context of their contemporary
of their care, and the reality and the effects of her/
realities, and with my employer’s support, became a
his power as a nurse and as a service, which is never
doctoral thesis.
neutral. The recipient of care determines whether
(Ramsden,
2002).
Cultural
safety/Kawa
they have experienced the care as culturally safe. incorporates
Difference, power and subjective assessment are
Freire’s (1972) definition of praxis as “the action and
the kawa, the protocols, that respectfully protect
reflection of people upon their world in order to
and shield (whakaruruhau) in the nurse/ recipient of
transform it” (p.36). To reflect critically is much more
care encounter. The Nursing Council of New Zealand
than a description of a mirrored image, of writing
(2011) now applies Kawa Whakaruruhau in nursing
Nursing
Page 4
Praxis’
vision
statement
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand exclusively to Māori health, in the context of Te Tiriti
If you think about your own favourite physical
o Waitangi. Kawa Whakaruruhau as metaphor, and in
landscape, you will see in your landscape stories of
critical reflection with emancipatory action, has the
the past, ways that what has been, impacts on what
potential to change individual nurse practice, service,
is now. You will see present spaces and places, which
programme or structure.
network and connect, or not. You will consider the future, remembering what has been and hoping for
I was unable to respond to the stated and implied
how it will be for yourself and those who come after
characterisations of “these women” in those telephone
you. The women’s stories inform a critical reflection on
conversations some years ago. I am responding now
their past, present and future landscapes, as related to
– well, I think I can at least begin. I recognise, with
their own health and health care engagement and that
reflection, the insidiousness of the white societal
of their whānau.
power and privilege held by those of us who are white, which includes those not-so white but benefiting from
Culturally safe practice at all levels of health care
the racial hierarchy (Fine, 2004). Whiteness theory
provision is not achieved once and for all time and
informs culturally safe nursing practice, service,
situations. Difference and power in relationships are
programme, and structure in recognising power and
dynamic not static. It is also the reality that culturally
privilege. Kawa Whakaruruhau is an equal partnership
safe practice is not necessarily the same for all
between all others and Māori for the benefit of Māori
Māori women across age and stage of life, sexuality,
health. Nurses’ partnership with Māori promotes
urban/rural,
culturally informed and guided nursing knowledge and
education levels, knowledge of te reo and tikanga,
skills at all levels of health care provision to achieve
and connections to whānau, hapū and iwi. There are
equity (fairness) for Māori, their Indigenous and
without doubt commonalities. Like all relationships,
human right.
our nursing commitment to the recipients of our
employed/work-seekers,
varying
care needs ongoing critical reflection. It requires Fifteen urban Māori women’s stories of their own
our sensitivity to our Te Tiriti o Waitangi partnership
health and health care engagement and that of their
relationship with Māori, whether that is our individual
whānau informed my reflection. Other contributing
nursing practice or within the structures of nursing
layers came from the women reflecting on their
services and programmes. Such is the social justice
individual gift of stories in follow-up interviews,
mandate of nursing.
Māori colleagues and on-going marae-based nursing practice, Māori academics and other critical theorists, reflection on Māori fiction and poetry, and academic
Beverley Parton, RN, BA (Nsg), PGDip (Dist)
supervision. The written form of the reflection informs
Doctoral Candidate
culturally safe nursing practice and the categories of
Clinical Training Associate,
difference and power and subjective assessment. I
Massey University Wellington
have presented the findings as landscapes that are both physical and metaphorical.
� Freire (1972) frequently uses the word “communion”, for example, “Communion in turn elicits cooperation...” ( p.171, authors italics). Page 5
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand References Fine, M. (2004). Witnessing whiteness/Gathering intelligence. In M. Fine, L. Weis, L. Powell Pruit & A. Burns (Eds.), Off white: Readings of power, privilege, and resistance (2nd ed., pp. 245-256). New York: Routledge. Freire, P. (1972). Pedagogy of the oppressed (M. Bergman Ramos, Trans.). New York: Herder and Herder. Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing education and practice. Wellington, NZ: Author. Retrieved from http://www.nursingcouncil.org.nz/Publications/Standards-and-guidelinesfor-nurses Parton, B. M. (Under examination). Māori women, health care and contemporary realities: A critical reflection (Unpublished doctoral thesis). Massey University, Wellington, New Zealand. Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu (Doctoral thesis), Victoria University, Wellington, New Zealand). Retrieved from http://www.nzno.org.nz/Portals/0/Files/Documents/Services/Library/2002%2 RAMSDEN%20I%20Cultural%20Safety_Full.pdf
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Dianne Roy, RN, PhD, FCNA(NZ), Associate Professor, Unitec Institute of Technology, Auckland, NZ Susan Gasquoine, RN, MPhil (Dist), Head of Department of Nursing, Unitec Institute of Technology, Auckland, NZ Shirrin Caldwell, RN, BA, M Ed, Lecturer, Unitec Institute of Technology, Auckland, NZ Derek Nash, MSc(Hons), Dip Ed, Senior Lecturer, Unitec Institute of Technology, Auckland, NZ
Abstract The global burden of stroke is increasing. Many stroke survivors live with significant impairment; the care and support they and their families require is complex. Literature indicates some evidence to support the routine provision of information to stroke survivors and their families, but the best way to provide information is unclear. We undertook a mixed methods descriptive survey to ascertain information needs of stroke families through identifying current practice and resources, the appropriateness, accessibility, timeliness and information gaps. The survey, which is embedded in a longitudinal research programme titled ‘Stroke Families Whānau Programme’, was used to gain an understanding of family members’ (n=19) and practitioners’ (n=23) opinions on information provision post-stroke. Qualitative and quantitative data were collected via face-to-face interviews. Descriptive statistics were used to analyse quantitative data; content analysis was used for qualitative data. We found that for families, access to information was variable, both in quality and timeliness. Most described being overwhelmed initially with information they could not absorb; then later floundering as they had to find their own way through the maze. Few could recall information that focused specifically on them as family members. Health professionals described a range of resources and practices used to provide information. They identified barriers to effective provision of information, including language and other communication barriers, time constraints and workload issues. Most did not assess health literacy levels or consider family needs to be separate to or different from the stroke survivor’s. We concluded that access to appropriate information post-stroke was problematic for most families and was compounded by the nature of the experience; shock following the sudden onset and adjusting to changed family dynamics. Health professionals recognised the limitations of resources, time, and funding alongside the need for timely, quality education for families post-stroke, however, a gap was identified between health professionals’ theoretical understanding of best practice in information provision and their actual practice.
Keywords Stroke; patient education; health professionals; families
Introduction and Background
of New Zealand, 2015). Stroke can have negative
The global burden of stroke is increasing. Despite a
consequences on the health, wellbeing and quality
decrease over the past twenty years in stroke mortality
of life of both the stroke survivor and their extended
rates there is an increase in terms of the absolute
family (Ellis, Grubaugh, & Egede, 2013; Yu, Hu, Efird,
number of people affected every year (Feigin et al.,
& McCoy, 2013). Care and support needs are variable,
2014). There are an estimated 60,000 stroke survivors in New Zealand, many of whom live with impairment and need significant daily support (Stroke Foundation Page 7
Roy, D., Gasquoine, S., Caldwell, S., & Nash, D. (2015). Health professional and family perceptions of post-stroke information. Nursing Praxis in New Zealand, 31(2), 7-24. Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand can be complex and are dependent on the severity,
survivors and families improved their knowledge of
origin and location of the cerebral trauma, the time-
stroke and aspects of patient satisfaction. A reduction
period post-stroke, socioeconomic variables and
in depression scores was also noted. Three Cochrane
ethnicity (Cecil, Thompson, Parahoo, & McCaughan,
reviews (Forster et al., 2012; Forster et al., 2001; Smith,
2013; Harwood et al., 2012a, 2012b; Moloczij,
Forster, & Young, 2009) have concluded that while
2009). Nurses play a pivotal role in stroke care and
there is evidence that the provision of information is
management across all phases of the stroke trajectory
beneficial “the best way to provide information is still
and, along with other health professionals, can help
not clear” (Forster et al., 2012, p. 16).
alleviate the stresses experienced by families caring for their whānau member who is a stroke survivor
Despite what is known about information provision
(Cecil et al., 2013). There is strong evidence for the
post-stroke, stroke survivors and their families
efficacy of a co-ordinated multidisciplinary team (MDT)
continue to report a lack of knowledge and difficulty
approach to stroke care (Clarke, 2013). Core members
in accessing it (Perry & Middleton, 2011) and feel
of a MDT in stroke care include nurses (often stroke
unprepared for the scope and scale of life changes and
nurse specialists), stroke physicians, physiotherapists
life after discharge from hospital (Forster et al., 2012;
(PTs), occupational therapist (OTs), speech language
Perry & Middleton, 2011).
therapists (SLTs) and therapy assistants (trained to support PTs and OTs). Multidisciplinary teams may
Research Design
also include social workers, needs assessors, and
Aim
community-based support workers such as the
The mixed methods descriptive survey was to ascertain
Community Stroke Advisors (CSAs) from the Stroke
information and education needs of families of those
Foundation of New Zealand. Trained CSAs assist stroke
who experience a stroke (stroke survivors) through
survivors and their families with any stroke-related
identifying current practice and resources, and the
problems. They make hospital and home visits, support
appropriateness, accessibility, method of delivery,
families and can advise on accessing carer-relief
timeliness and gaps in education and information
services and funding. Some MDTs include stroke co-
giving. Specifically, we wanted to know:
coordinators (usually a nurse, PT or OT) within the team whose role is to co-ordinate in-patient rehabilitation
What information and resources were provided
and services for patients and their families post-stroke.
to/received by families across the care
At the participating DHB for this study these stroke co-
continuum?
ordinators are known as key workers. How information was delivered? The importance of information and education provision, alongside the right support, for stroke survivors and
What preferences did families have for the way
their families is well documented (Cameron & Gignac,
information was provided?
2008; Cameron, Naglie, Silver, & Gignac, 2013; Draper & Brocklehurst, 2007; Eames, Hoffmann, Worrall,
What, if any, were the barriers and gaps in
& Read, 2010; Larson et al., 2005; Temize & Gozum,
information provision?
2012; Wallengren, Segesten, & Friberg, 2010; Wright et al., 2012). A recent Cochrane review (Forster et al.,
We used a broad definition of ‘information’ to include
2012) showed that information provision for stroke
any information and education provided to families
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand post-stroke; formal or informal. This study is the
participants and consent obtained prior to data
first phase of a longitudinal programme to improve
collection.
support and care outcomes for stroke families. We were particularly interested in what, if any, of the
Participants
information was specifically family-focused and
Family members: Nineteen people from thirteen
inclusive of family members beyond the primary carer
families volunteered to participate. Demographic data
and stroke survivor.
are presented in Table 1.
Methods
Health professional-participants: Twenty three health
A mixed methods descriptive survey design was used
professionals completed questionnaires either by face-
to gain an understanding of family members’ and
to-face interviews (n=21) or electronically (n=2). Their
practitioners’ opinions on information provision post-
work roles were either for the Stroke Foundation as
stroke.
community stroke advisors (n=5) or administrators (n=2) or for the stroke services, both acute and
Recruitment
rehabilitation, of a large district health board (DHB).
Following ethical approval from the Northern X
DHB employees included registered nurses (n=5)
Regional Ethics Committee (NTX/10/EXP/071) 19 family
and an enrolled nurse, occupational therapists (n=3),
members and 23 health professionals were recruited
a stroke physician, physiotherapists (n=2), speech
using purposive sampling strategies. Inclusion criteria
language therapists (n=2) and therapy assistants (n=2).
for family members were: (1) being a family member
Demographics for participant health professionals are
of someone who had experienced a stroke in the
presented in Tables 2 and 3.
previous two years; and (2) adequate spoken English to complete consent and the questionnaire. We invited
Data collection and analysis
multiple members from the same family to participate.
The development of the survey questionnaires was
Family members were invited through flyers posted in
guided by a literature review and stakeholder advisory
clinical areas at the local hospital (which provides post-
group. Two questionnaires were developed; one
stroke assessment and rehabilitation services) and the
for families of people who had experienced a stroke
local Stroke Foundation support groups or directly
in the preceding two years (stroke families) and
through intermediaries (community stroke advisors
one for health professionals, who work with stroke
and outpatient clinic staff).
families. Questionnaires included open and closed questions that enabled collection of quantitative and
Health professionals were invited to participate
qualitative data. Both questionnaires were piloted
if they currently worked with people post-stroke,
and minor changes made to some questions for
either within the hospital and/or the community.
clarity. Electronic/postal versions were available;
Information flyers were posted in clinical areas. Staff
two of the health professionals (both OTs) chose
were also invited to a presentation about the study;
this option. Questionnaires were administered by
there was no active recruitment, but contact details
research assistants in face-to-face interviews with the
were available. Any direct approach to individuals was
remaining participants (n=40). Data were collected
made via intermediaries.
between September and October 2010. Research assistants received prior training in administering the
Information sheets were provided to all potential Page 9
questionnaires and to avoid introducing bias during the Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 1 Table 1.
Participant Demographics: Family Members
Participant Demographics: Family Members
Mean age Age range Gender Male Female Ethnicity NZ European/Pakeha Other Average time since stroke Time since stroke range Employment status (paid employment) Yes No Change since stroke (total) Increased hours Decreased hours Other change Living with stroke survivor All of the time Most of the time Some of the time Do not live with SS Caregiving responsibilities All of the time Most of the time Some of the time Do not live with SS Previous experience in stroke care Relationship to stroke survivor
Family member (n = 19)
Stroke survivor (n = 13)
53 years 14-77 years
63.7 years 42-84 years
4 15
2 11
18 1 1.6 years 0.4-4.111 years
12 1 1.6 years 0.4-4.111 years N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
8 11 11 0 9 2 11 0 4 4 8 4 6 1 4 Wife (n=7) Husband (n=2) Partner (n=1) Son or Daughter (n=7) Brother (n=1) Mother-in-law (n=1)
SS = stroke survivor; N/A = not applicable One stroke survivor whose family participated had a first stroke 4.11 years prior, with a second stroke in the previous two years, therefore meeting inclusion criteria.
1
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
26
Nursing Praxis in New Zealand
HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION
Table 2
Table 2.
Participant Demographics: Health Professionals
Participant Demographics: Health Professionals Profession Registered Nurse Enrolled Nurse Occupational Therapist Stroke Physician Physiotherapist Speech Language Therapist Therapy Assistant Community Stroke Advisor Other Total
Number 5 1 3 1 2 2 2 5 2 23
Workplace Hospital - Rehabilitation Ward Hospital - Rehabilitation Ward Hospital - Rehabilitation Clinic Hospital - Older Adult Service Hospital - Rehabilitation Clinic Hospital - Rehabilitation Clinic Hospital - Rehabilitation Clinic Stroke Foundation - Community Stroke Foundation - Office
HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 3
Table 3.
Participant Demographics: Health Professionals (cont.)
Participant Demographics: Health Professionals (cont.) Health Professionals (n=23) Work experience in stroke services (no. of years) Mean Range Stroke specific skills/education Yes No Clients with stroke (% of workload) Mean Range Time point on stroke continuum where working with stroke families (multiple responses possible) Acute Rehabilitation Life after stroke/Community
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Number 11.25 1.5-35 19 4 52 5-100 11 11 11
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
27
Nursing Praxis in New Zealand interviews they discussed specific items if necessary,
specifically about the information and education
but did not provide further explanation. Interviews
needs of families. Many responses given suggest
lasted approximately 45 minutes and were held at a
that participants did not consider family needs to
mutually convenient time and place.
be separate to or different from those of the stroke survivor (Table 4).
A range of demographic data was collected from all participants. Health professionals were asked about
Information
development
and
preparation:
their role in development and provision of information
Participants were asked about their role in the
for stroke families, details of what and how they
development and/or preparation of information
provide information and their opinions on if or how
for families. Examples provided included: policy
this might be improved. Family members were asked
development and sign-off (n=3, including two RNs),
about information provision at the time of the stroke
development and facilitation of carer-specific support
as well as information provision since the stroke
groups (n=2), being consulted on readability and
survivor’s discharge.
aphasia friendliness (n=1), and developing education packages (n=1).
All data, including transcribed responses to open questions, were entered into Excel® (Excel 2010,
Information
delivery
and
content:
All
health
Microsoft Corporation, USA) spread sheets to facilitate
professional participants (n=23) provided written
analysis. Descriptive statistics were used to analyse
information, with most (n=12) specifically naming
quantitative data providing a description of the
material produced by the Stroke Foundation. Eleven
characteristics of the sample and the participants’
participants (including all RNs/EN) provided verbal
responses. Content analysis was used to identify and
explanations, including answering questions during
catalogue patterns of response (Burnard, 1991) in
consultations and/or caring moments. The RNs in
the qualitative data. Key topic areas from the survey
particular highlighted the importance of assessing
questionnaires informed the ‘template’ approach
family needs to identify at what level they are at
to thematic content analysis (Newell & Burnard,
before providing information. Other modes of delivery
2011) where the researchers asked questions of the
reported were follow-up contact (phone or in person),
data set. For example, what teaching strategies did
providing hands-on demonstrations (n=3) to stroke
health professionals use? What did families say about
survivors and families, and community follow-up (n=4).
information they received on living with a person
Five participants indicated they provided audio-visual
who has had a stroke? Following this, categories were
material while one (RN) advised on suitable websites.
developed and data organised within these. One
A small range of content examples were provided,
researcher (DR) took overall responsibility, but a whole-
most of which pertained to the stroke survivor rather
team approach was used in the process. Category
than being family-specific.
codes are used to present the findings with qualitative and quantitative findings reported simultaneously.
Teaching strategies: Health professionals reported a
Excerpts of qualitative responses are given in italics.
number of strategies used when providing information. Three participants (including two RNs) completed
Findings
ongoing assessment of family needs and personalised
Health professionals
information for specific families. One RN noted the
The participating health professionals were asked
importance of talking, building trust and relationships
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 4 Table 4 Table 4 Table 4 Findings Summary: Health Professionals (multiple responses possible) Table 4. Findings Summary: Health Professionals (multiple responses possible) Findings Summary: Health Professionals (multiple responses possible) Findings Summary: HealthHealth Professionals (multiple(multiple responsesresponses possible) possible) Findings Summary: Professionals
Nursing Praxis in New Zealand
Category: Category: Information Category: development Information development Category: and preparation Information development and preparation Information development and preparation and preparation Information delivery Information delivery Information delivery Information delivery
Information format and Information format and content Information format and content Information format and content content Teaching strategies Teaching strategies Teaching strategies Teaching strategies
Timing of information Timing of information giving Timing of information giving of information Timing giving giving Effective methods of Effective methods of information delivery Effective methods of information delivery Effective methods of information delivery information delivery
Effectiveness of available Effectiveness of available information Effectiveness of available information Effectiveness information of available information Web-based information Web-based information Web-based information Web-based information
Gaps/omissions/lack in Gaps/omissions/lack in information provisionin Gaps/omissions/lack information provision Gaps/omissions/lack information provisionin information provision Page 13
Examples given: n=23 Examples given: n=23 Policy development 3 Examples given: n=23 Policy development 3 Examples given: n=23 Development and facilitation of support groups 2 Policy development 3 Development and facilitation of support groups 2 Policy development 3 Assessment ofand readability 1 Development facilitation of support groups 2 Assessment of readability 1 Development and facilitation of support groups 2 Education package development 1 Assessment of readability Education package development 1 Assessment of readability 1 Provided information from Stroke Foundation (SF) Educationwritten package development 1 12 Provided written information from Stroke Foundation (SF) Education package development 1 Answered questions during caring 12 Provided written information frommoments Stroke Foundation (SF) 11 Answered questions during caring moments 12 Provided information frommoments Stroke Foundation (SF) Follow-up post discharge – in person and phone 11 Answeredwritten questions during caring 12 4 Follow-up post discharge – in person and phone 11 Answered questions during caring moments Hands-on 4 Follow-up demonstration post discharge – in person and phone 11 3 Hands-on demonstration 4 Follow-up post discharge – in person and phone Assessed readiness for and understanding of information 3 Hands-on demonstration 4 6 Assessed readiness for and understanding of information 3 Hands-on demonstration provided 6 Assessed readiness for and understanding of information 3 provided readiness for and understanding of information 6 Assessed Verbal information 6 provided 6 Verbal information 6 provided Written information 20 Verbal information 6 Written information 20 Verbal 6 Audio-visual material 5 Writteninformation information 20 Audio-visual material 5 Written information 20 Advice on suitable websites 1 Audio-visual material 5 Advice on suitable websites 1 Audio-visual material 5 Importance of goodwebsites communication skills ‘listening so as to 12 Advice on suitable 1 Importance of goodwebsites communication skills ‘listening so as to 12 Advice on suitable 1 understand thecommunication family needs’ skills ‘listening so as to Importance what of good 12 understand what the family needs’ Importance of good ‘listening so as to 12 Ongoing assessment of family needs skills and personalising 3 understand what thecommunication family needs’ Ongoing assessment of family needs and personalising 3 understand what the family needs’ information for specific members Ongoing assessment of family needs and personalising 3 information for specific family needs members Ongoing assessment of family and personalising 3 Demonstration techniques equipment 3 information for of specific familyand members Demonstration techniques equipment 3 information for of specific familyand members Individual, group and community based presentations 3 Demonstration of techniques and equipment Individual, group and community based presentations 3 Demonstration techniques and equipment 3 Role plays, group goal of setting and use ofbased visual presentations aids 4 Individual, and community 3 Role plays, goal setting and use of visual aids 4 Individual, group and community 3 Timing according to individual 5 Role plays, goal setting and usefamilies ofbased visual presentations aids 4 Timing according to individual 5 Role plays, goal setting and usefamilies of visual aids 4 Acute phase information need 22 Timing according to individual families 5 Acute phase information need families 22 Timing according to individual 5 On-going information need in rehabilitation phase 7 Acute phase information need 22 On-going information need in rehabilitation phase 7 Acute phase information need 22 Combination of verbalneed and written 11 On-going information in rehabilitation phase 7 Combination of verbal and written 11 On-going information in rehabilitation phase 7 Delivered face-to-face 8 Combination of verbalneed and written 11 Delivered face-to-face 8 Combination of verbal 11 Phone calls, home visitsand andwritten community group classes 7 Delivered face-to-face 8 Phone calls, home visits and community group classes 7 Delivered face-to-face 8 Family meeting with multidisciplinary team 6 Phone calls, home visits and community group classes 7 Family meeting with multidisciplinary team 6 Phone calls, home visits and community group classes 7 DVDs, and other visual aids team 4 Familydiagrams meeting with multidisciplinary 6 DVDs, diagrams and other visual aids 4 Family meeting with multidisciplinary team 6 Key worker to deliver consistent information 1 DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 DVDs, diagrams and other visual aids 4 Information from Stroke Foundation (SF) is superior especially Key worker to deliver consistent information 1 Information from Stroke Foundation (SF) is superior especially Key worker to deliver consistent information 1 “Life After Stroke” 8 Information from Stroke Foundation (SF) is superior especially “Life After Stroke” 8 Information from Stroke Foundation (SF) is superior especially SF DVD/video effective 12 “Life After Stroke” 8 SF DVD/video effective 12 “Life After Stroke” 8 Least familiar/comfortable 4 SF DVD/video effective 12 Least familiar/comfortable 4 SF DVD/video effective 12 Useful for ‘young ones’ 4 Least familiar/comfortable Useful for ‘young ones’ 4 Least familiar/comfortable 4 Never internetones’ for information 5 Useful use for ‘young 4 Never use internetones’ for information 5 Useful for ‘young 4 Concern ‘unreliable’ information 8 Never useabout internet for information 5 Concern about ‘unreliable’ information 8 Never use internet for information 5 Need to ensure ‘credibility, dependability and appropriateness’ 2 Concern about ‘unreliable’ information 8 Need to ensure ‘credibility, dependability and appropriateness’ 2 Concern about ‘unreliable’ information 8 Recommendation of specificdependability site Need to ensure ‘credibility, and appropriateness’ 2 Recommendation of specificdependability site Need to ensure ‘credibility, and appropriateness’ 2 1 Recommendation of specific site 1 Recommendation of specific site Gaps identified - ‘we don’t prepare families enough to be 22 1 Gaps identified - ‘we don’t prepare families enough to be 22 1 caregivers’ Gaps identified - ‘we don’t prepare families enough to be 22 caregivers’ Gaps identified ‘we don’t prepare families enough to be 22 Information in a- range of languages 3 caregivers’ Information in a range of languages 3 caregivers’ Requirements hands-on care, service access, funding 7 Information in of a range of languages 3 Requirements hands-on care, service access, funding 7 Information in of a range languages 3 Information tailored toof specific needs 5 Requirements of hands-on care,family service access, funding 7 Information tailored to specific family needs 5 Vol. 31 No. 2 2015 Nursing Praxis in New Zealand Requirements of hands-on care, service access, funding 7 Information tailored to specific family needs 5 Information tailored to specific family needs 529 29 29 29
information delivery
Delivered face-to-face 8 Phone calls, home visits and community group classes 7 Family meeting with multidisciplinary team 6 DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 Effectiveness of available Information from Stroke Foundation (SF) is superior especially HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION information “Life After Stroke” 8 SF DVD/video effective 12 Web-based information Least familiar/comfortable 4 Table 4 Useful for ‘young ones’ 4 Table 4. (cont.) Never use internet for information 5 Findings Summary: Health Professionals (multiple responses possible) Concern about ‘unreliable’ information 8 Findings Summary: Health Professionals (multiple responses possible) Need to ensure ‘credibility, dependability and appropriateness’ 2 Recommendation of specific site Category: Examples given: n=23 1 Information development Policy development 3 Gaps/omissions/lack in Gaps identified - ‘we don’t prepare families enough to be 22 and preparation Development and facilitation of support groups 2 information provision caregivers’ Assessment of 1 Information in areadability rangeOF of POST-STROKE languages 3 HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS INFORMATION Education package development 1 Requirements of hands-on care, service access, funding 7 Information delivery Provided written information Stroke Foundation (SF) Information tailored to specificfrom family needs 5 12 co-ordination of information givingmoments 3 Answered questions during caring 11 post discharge in person andusing phone Health literacy assessment Follow-up Yes – informally ‘I simplify–things by not medical jargon’ 10 29 4 Hands-on demonstration No (‘not my role’) 13(2) 3 Assessed for and understanding of information Barriers in information Language readiness including ‘jargon’ 4 6 provided provision Difficulty arranging family meetings 5 Information format and Verbal information Poor quality & limitations of the written information available 26 content Written information Time constraints and workload issues (including follow-up to 6 20 Audio-visual material and the right information at the right 5 assess understanding Advice 1 time) on suitable websites Teaching strategies Importance of good communication skills ‘listening so as to Knowledge gaps None 4 12 understand what the family‘we needs’ Accessing support services need to do more from inside 5 Ongoing assessment family needs and us’ personalising 3 rather than expectingoffamilies to contact ‘post-discharge is information for specific family members scary’ Demonstration of techniques and equipment 3 Changes to make a ‘Changing the culture around educating families. Clinicians do Individual, group community presentations 3 difference not prioritise this.and Recognising thisbased is important so staff are Role plays, goal setting and use of visual aids allowed time to deliver information and develop skills to do so’ 184 Timing of information Timing according to individual families Early family involvement 145 giving Acute phaseof information need Assessment family needs 9 22 On-going information needfor in staff rehabilitation Professional development on strokephase management 77 Stroke specialists/advanced nursing practice 1111 Effective methods of Combination of verbal and written Improve resources including multiple languages and modalities 4 8 information delivery Delivered face-to-face Recognising family visits needsand as different from stroke survivor 27 Phone calls, home community group classes 16 Family meeting with multidisciplinary team DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 Effectiveness of available Information from Stroke Foundation (SF) is superior especially information “Life After Stroke” 8 to encourage patient and family participation. [patient SF DVD/video effective was not the first language. One RN said, it 12 Demonstrating and equipment; showing education] is a challenge with non-English speaking Web-basedtechniques information Least familiar/comfortable 4 Useful for ‘young ones’ families. Using a mixture of visual aids is helpful4as well them how to do things was considered important internet for information 5 as when teaching practical aspects ofNever care use provision. as pamphlets translated into other languages such Concern about ‘unreliable’ information 8 Participants used a mixture of individual and group Mandarin. Need to ensure ‘credibility, dependability and appropriateness’ 2 approaches including community-based group of specific site Recommendation presentations. Participants used role-plays, goal setting Timing of information-giving: There was general 1 in The latter Gaps identified prepare families enough to betiming to individual 22 andGaps/omissions/lack a variety of visual aids. was noted as- ‘we don’trecognition of the need to tailor information caregivers’ being particularlyprovision helpful for families where English family needs and, as one RN reported, the state of the Information in a range of languages 3 Requirements of hands-on care, service access, funding 7 Page 14 Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand Information tailored to specific family needs 5
Nursing Praxis in New Zealand
29
Nursing Praxis in New Zealand family; it’s not one-size-fits-all, everyone is different.
Stroke book was specifically mentioned by many
Participant nurses reported that it was important
participants (n=8). The Stroke Foundation DVD/
to get information to the family straight away in the
video was noted by many participants (n=12) as
acute phase and for on-going information-giving that
being “useful”, “effective” or “very effective”. Three
reinforced this. They also said it was important to work
participants (RN, OT, PT) were not aware of any such
with individual family needs and avoid bombarding
resource being available, while two others (one a RN)
them with information before they were ready or at a
thought they were only available for staff training days,
time of acute distress.
but not for families. Participants who saw these as effective noted that they should only be used as part
Effective methods of information delivery: The
of an overall package of information and only at the
importance of good communication skills was
right time and if appropriate.
reported by many participants, including all the RNs (n=5). This included listening so as to understand what
Participants were asked their opinion of the
the family needs, engaging in on-going conversation,
effectiveness of web-based information. Overall this
and following up discussion with family after written
was a form of information with which participants
information has been provided. Verbal communication
were least familiar and comfortable: it’s a bit scary.
was considered most effective when supported
Four participants (two OTs, two PTs) thought it would
by written information. Face-to-face was the most
be useful for young ones and likely to become more
often reported means for verbal communication, but
appropriate as the population becomes more computer
telephone calls, home visits and community groups/
literate. Five participants, including two nurses, never
classes were also considered effective by community
use the internet for information or had no idea of
stroke advisors. Family meetings with the MDT were
effectiveness of this method of delivery and eight
mentioned specifically by six participants. Diagrams,
identified the potential for unreliable information and
DVDs and other visual forms of information were
the need to ensure any material/websites are credible,
reported (n=4) as being effective. Six participants
dependable, and appropriate. Only one participant, a
reported assessing patient and/or family needs prior
RN, recommended specific sites to families; advising
to giving information, including assessing readiness for
them not to just ‘Google’ it. Another RN noted that
information (n=2) and understanding of information
while she did not provide information about websites,
given (n=3). One participant (an RN) suggested the use
families will find things and educate themselves.
of a key worker� was an effective method of delivering consistent information to all families.
Gaps/omissions in information provision: Twenty two participants identified gaps. There was general
Effectiveness
of
available
information:
Most
recognition that more effort [is needed] in supporting
participating health professionals noted that the
families: emotional support as well as imparting
Stroke Foundation resources were superior to the
knowledge about stroke. As one RN noted, we don’t
DHB material: The DHB information is boring, too
prepare the family enough to be carers at home.
many words, and no pictures. The Stroke Foundation
When the patient goes home the family expect all
information is better. The Stroke Foundation Life after
will be normal; they aren’t prepared because they’ve
�Key-worker: a designated health professional (nurse, physiotherapist, occupational therapist or speech language therapist) within the stroke care team at the participating DHB whose role is to co-ordinate in-patient rehabilitation services for some patients post-stroke. Page 15
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand gone from a setting where nurses do things to no
strategies implemented, or what to improve on, but
professional care being provided at home.
family health literacy is not assessed at all because the main focus is the patient.
Some (n=3) identified the lack of information available in a range of languages, while others (n=7) identified
Barriers
in
information
provision:
Participants
gaps in provision of information about hands-on care
identified a range of barriers from language (n=4)
requirements, access to services and equipment and
and other communication barriers such as health
funding options for any such equipment. Others (n=5)
professionals using jargon, family meetings being
identified a lack of information tailored for each family,
difficult to arrange especially if including a number of
be this related to cultural norms, family dynamics, or
family members. One participant, a stroke physician
readiness to learn.
stated, we need more resources in different languages. I find it frustrating that I don’t have time to give
Three nurses identified lack of co-ordinated approach to
families what they would benefit from. Trying to get
information-giving in the acute (hospital) phase where
families all together at once is hard. Family whānau
wrong or outdated information is given, information is
meetings are needed to talk through issues. The quality
not co-ordinated in the patient’s folder or information
and limitations of the written information available
is missed due to frequent nursing changes. Finding the
was mentioned by two participants, in particular lack
right balance between giving too much or not enough
of information that focuses specifically on family.
information was also identified as a challenge.
Time constraints and workload issues were identified by some (n=6). A senior RN said, nurses are under-
Health literacy assessment: Participants were asked
resourced. I used to have the time to talk to every
if they or anyone in the MDT assessed health literacy
stroke patient and their family, but then some of my
levels. Nine answered “yes” and 13 “no”; one participant
clinical roles were taken away and I was given financial
did not respond. One senior RN responded, some may
roles, so now there’s no time to do that anymore.
say they do, but they don’t. Those who answered “yes” were asked how this is done. Fifteen participants
There was also recognition that sometimes information
answered in a way that suggested the question was
was given at the wrong time in the post-stroke
not clearly understood. Another explanation is that
trajectory: we give an overload of information at the
participants did not understand what was meant
start and then nothing afterwards.
by ‘health literacy’ or how it might be assessed. Responses that appeared to relate specifically to
Knowledge gaps: Participants who see families
assessment of health literacy (n=10) identified limited
post discharge (n=13, only 1 RN) were asked what
assessment, most often through asking questions of
(if any) information need or gaps in knowledge they
the families to check understanding; informally (RN),
identified? Five of the 13 said no gaps or described
I’m generally aware if patient and family understand
gaps specifically related to the stroke survivor, not the
(RN), I simplify things by not using medical jargon and
family. Gaps identified specific to families included
I assess through questions asked to the family (OT).
knowing what, where, and how to access support
Two participants (both therapy assistants) indicated
services and resources in the community, the need for
that assessing health literacy was the role of others in
support and education about long-term implications
the MDT. One participant (SLT) stated: there are family
of stroke and the need for health professionals to
meetings to ask questions and assess effectiveness of
be proactive in the community in providing care and
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand support for family: we need to do more from inside
Family members
rather than expecting families to contact us. Post
Family members (n=19) were asked their opinions
discharge is scary … we don’t support people as well
on information provision at the time of the stroke
as we should.
(when the stroke survivor was in hospital) and then about information they had sought or received since
What changes would make a difference? One
discharge. We were particularly interested in knowing
response encapsulated key points raised by many
about family-specific information; such as taking care
participants (n=14): Changing the culture around
of themselves and learning to live with a person who
educating families. Clinicians do not prioritise this.
has had a stroke.
Recognising this is important so staff are allowed time to deliver information and develop skills to do so. Nine
Information provision at time of stroke – living with
participants suggested getting the family involved
a stroke survivor: Participants were asked if they had
early and providing on-going information and support.
received any information about living with a stroke
A co-ordinated approach and improved continuity of
survivor (as opposed to information about stroke),
care was also noted as being important to improving
most (n=14) had not. One participant who stated she
processes. Changing the format and venue of family
had not received information commented: During
meetings (away from the bedside) was also noted.
my husband’s stay in hospital not much information
Seven participants (including four nurses) identified
was given. I felt I didn’t actually want the information
that having more time (having time to assess family
then because my brain felt scrambled, I wouldn’t have
needs) and funding (including for interpreters) would
coped with lots of information.
enable them to be more effective, while 11 (including four nurses) indicated more professional development
The
was required. Four participants (2 RNs, physician, SLT)
information specifically focused on their needs were
suggested a co-ordinated proactive team approach
asked how the information prepared them to support
utilising health professionals with specialised/specific
and care for the stroke survivor. Three reported
expertise: A proactive team approach is needed with
the information as being useful and that they felt
more stroke specialists and advanced practice nurses;
prepared. Two participants (sisters whose father had
only these people can educate effectively.
a stroke) reported that rather than preparing them
five
participants
who
reported
receiving
for their role, the information given was frightening Improving resources, including availability in multiple
and offered no hope, which was devastating. The
languages and a range of modalities such as online and
prognosis for the stroke survivor was initially very poor
DVDs, and taking a multi-cultural approach were also
and this was communicated to the family; preparing
recommended. One nurse noted: They [family] should
us for the worst.
get the level of assessment and caring like the actual patient. Stroke is a family crisis. … Give information
Information provision at time of stroke – information
in the early weeks and build trust. Others said: we
about stroke: Family participants were asked to identify
don’t currently engage family as well as possible.
sources of information (Figure 1). These included
Acknowledge that they [family] have complex needs,
nurse (n=5), CSA (n=4), doctor (n=3), PT (n=3), social
that they need a different type of communication than
worker (n=3), OT (n=2), other health professional
the patient.
(n=3), family/whānau (n=3), other family (n=1).
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION 6
Count
5 4 3 2 1
At time of stroke
0
Post discharge
Source of information
Figure Source of information to (multiple families (multiple responses possible) Figure 1. Source of 1. information provision provision to families responses possible)
The type of information received varied with booklets
a VHS video but had no capacity to play it: I was given a
or written material (n=5) and verbally (n=4) the
video but we had no video player. We only have a DVD
most reported forms (Figure 2). AND The participant who player at home. INFORMATION HEALTH PROFESSIONAL FAMILY PERCEPTIONS OF POST-STROKE responded ‘DVD/video’ noted that she had been given
7 6
Count
5 4 3
At time of stroke
2
Post discharge
1 0 Book
DVD
Verbal
Web
Other
Information type
Figure 2. received by families fromfrom healthhealth professionals (multiple responses possible) Figure 2. Type Typeofofinformation information received by families professionals (multiple responses possible) Page 18
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Participants generally agreed that the information was
answers. Another commented: If we hadn’t made a
easy to understand. Free text comments included:
point of asking and asking again, I don’t think we would
well presented with pictures and easy to understand;
have received any information. ... Communication was
the brochure information was good. Talking with staff
difficult. There were a couple of people who did help
was also good. One participant who did not find the
but majority seemed too rushed, stressed or lazy.
information easy to understand commented: words [terminology] and the process [pathophysiology] of
Participants were asked if they got information from
stroke were hard to understand. There were too many
anywhere or anyone else they had not already told us
medical terms.
about (e.g. health professionals, immediate family) (Figure 3). Of the 14 participants who provided details,
Participants
described
being
overwhelmed
by
seven accessed information via the internet. Friends
paperwork initially. The need to be assertive in
and extended family were also additional sources
information-seeking was also noted: The hospital
of information, often providing books or sharing
staff were marvellous. They gave us information and
their personal experiences of living with stroke. One
pamphlets... I asked all the questions; the staff helped.
participant said: my brother-in-law is a doctor and my
But information was not given voluntarily. Whenever
sister-in-law a nurse so I got info from them.
I saw an improvement I asked questions and got the
HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION 12
Count
10 8 6 4 2
At time of stroke
0
Post discharge
Source of information
Figure 3. Sources of information additional to thatadditional received from health professionals (multiple responses possible) Figure 3. Sources of information to that received from health professionals (multiple
responses possible) All family participants (n=19) were asked the question:
pathophysiological effects of the stroke, including
Remembering back to when your family member was
knowing the early warning signs of stroke, signs of
first discharged, what do you wish you knew then
deterioration, the possibility of seizures, and the impact
that you know now? Seventeen responded. Eight
of personality changes. Many (n=10) wished they had
participants wished they had known more about the
been given more information about the demands of
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand caring for the stroke survivor; the constant care with
ways, but not really. People told me to set boundaries,
every day being full-on, and the stroke survivor not
but I’m not able to do this with my partner. Sometimes
being able to be left alone. While family members
I get frustrated and have to walk away.
knew it would be tough they did not realise how time consuming it would be. Two participants indicated that
Six of the nine thought they had been given the right
nothing could have prepared them for their caring role;
information at the right time. The three who did not
one stating had she known she wouldn’t be sitting here
agree, commented on not getting enough or only
now, while the other might have run a mile had she
getting it at the time of the stroke when they were
known in advance what the demands would be. One
in shock and not able to take it in. One commented:
said: I wish I knew how hard it would be for both sides
The doctors were really busy. I received confusing
[and] how important to get a break when you can.
information, and I really needed someone to explain
Participants reported not being told about support
the information.
groups and other services available post-discharge (n=4). They thought health professionals should have
The final question asked: If you were asked to talk to
given them this information rather than us trying to
someone who had a family member who had just had
find out or hearing it from friends. Participants wanted
a stroke, what is the one piece of information you think
the whole family, not only the primary carer, included
they most need? An extensive range of responses was
in family meetings with health professionals.
given. The responses that pertained specifically to information needs included: There are places out there
Information provision post-discharge: Ten participants
to get help, when dad first had the stroke mum had no
reported receiving no additional information post
one, but found support groups helpful, make contact
discharge (Figure 3). Nine participants received
with others for support; Get as much information as
information post discharge from a range of sources
you can. Get support and have breaks away when
(Figure 1). Written (n=6) and verbal (n=5) forms of
possible; Demand information! Or get someone to
information were the most frequently reported (Figure
ask for you; Doctors give horrific details, but nurses
2) with most (n=8) indicating the material was easy
give more hope and provide comfort; Seek advice
to understand. One commented: it was easier than
from a professional rather than hearsay; The Stroke
the first time when stroke occurred, suggesting that
Foundation and GP have the best advice; The Stroke
there may have been some repetition in information
Foundation are fantastic; Talk to other people who
provision that was useful. Six of the nine indicated that
have been through it, because it’s hard to know unless
their information needs were met at this time.
you’ve been there.
When asked if the information provided prepared
Two representative general comments were: Nothing
them for their on-going role in supporting and caring
can prepare you for it, it’s very sudden and takes time
for the stroke survivor four responded ‘yes’, one
to get through; Family support in those times is very
adding: I wouldn’t have been able to cope without it.
important, be ready for the long haul.
It has given me strength. The on-going support keeps me going. Two said ‘no’, one saying: No information
Discussion
can prepare you for that. The remaining three were
Our study showed that health professionals and
positive in regard to the information provided but were
families value and recognise the importance of
more tentative in their response. One said: In some
information sharing in improving outcomes post-
Page 20
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand stroke. Health professionals were asked specifically
2010). Health literacy has been defined as “the degree
about the information needs of families. Their
to which individuals have the capacity to obtain,
responses, however, suggest that most did not
process and understand basic health information and
consider information needs of the family to be
services needed to make appropriate health decisions”
separate to or different from those of the stroke
(Kickbusch, Wait, & Maag, 2005, p. 8). The 2006 Adult
survivor. The structure of the questions or the way the
Literacy and Life Skills Survey (Ministry of Health, 2010)
research assistants asked them may have contributed
showed that the majority (56.2%) of New Zealanders
to this finding, although similar trends were noted
have poor health literacy skills. Health literacy
in responses of participants (n=2) who completed
demands increase at times of a new diagnosis (Reid &
the questionnaire online. Access to information for
White, 2012), such as stroke. Health professionals can
families was variable, both in quality and timeliness.
help reduce these demands by incorporating health
Many described being initially overwhelmed with
literacy awareness and best practice strategies when
information they could not absorb. Few could recall
working with stroke families.
information that focused specifically on them as family members, yet they identified unmet needs
Digital literacy is an important component of health
such as understanding the demands of caring and the
literacy. Our findings showed few health professionals
importance of attending to their own health and well-
(and only one nurse) referred families to suitable
being. These aspects are consistent with findings of
websites and were reluctant to or never used
a narrative review of 35 studies exploring information
web-based resources. This is in contrast to family
needs of families of people with chronic obstructive
participants, many of whom used the internet to
pulmonary disease (Caress, Luker, Chalmers, & Salmon,
source information. A recent study of NZ consumers
2009) that identified few studies which addressed,
health information needs found two thirds of the 1783
even peripherally, family needs for information.
participants had used the internet to access health information (Honey, Roy, Bycroft, Boyd, & Raphael,
Health professionals, especially nurses, recognised the
2014), which suggests health professionals need to
limitations of resources, time and funding alongside
overcome their discomfort and enhance their digital
the need for timely, quality education for families
literacy skills and expertise to work with families to
post-stroke. For example, they identified the paucity
identify reliable web-based resources to help meet
of information and education material in languages
their information needs.
other than English. Consistent with practice guidelines (Stroke Foundation of New Zealand and New Zealand
Despite the theoretical position espoused by many
Guidelines Group, 2010) and research evidence
of the health professionals, including nurses, about
(Cameron & Gignac, 2008; Cameron et al., 2013),
the importance of identifying the ‘right time’ for
many spoke of the importance of delivering jargon-
information provision, the practice reality that was
free information at the right time and specific to family
evident in both health professional and family data
needs. They identified using ‘teach-back’ techniques
was that of ‘dumping’ information on families in
to assess understanding, yet there was little evidence
case they ‘missed out’, irrespective of family needs.
of any formal consideration of health literacy levels of
Numerous studies have shown that information needs
either the stroke survivor or family members. This is
for stroke survivors and families change across the
consistent with previous research (Eames et al., 2010;
care continuum (Hanger, Walker, Paterson, McBride, &
Gustafsson, Hodge, Robinson, McKenna, & Bower,
Sainsbury, 1998; Mak, Mackenzie, & Lui, 2007; Wiles,
Page 21
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Pain, Buckland, & McLellan, 1998) and, consistent with
web-based resources as well as advanced nursing
our findings, many families are overwhelmed by the
scopes of practice, as suggested by a RN participant,
information provided in the acute period only to report
have the potential to address unmet needs in this
unmet information needs post-discharge (Cameron et
population. Changes in practice and service delivery
al., 2013; Eames et al., 2010; Perry & Middleton, 2011).
models may be warranted to enable a proactive co-
Ameliorating the gap between actual practice and best
ordinated approach based on assessed needs for each
practice may require reflection on and evaluation of
family across the care continuum.
current education provision and a re-assessment of how best to deliver quality education that meets the
Strengths and Limitations
needs of both stroke survivors and their families. To
A major strength of this study is that we included a
provide best practice for stroke survivors and their
range of family members, not only the primary carer,
family, post-stroke education should be based on
and that we sought the opinions of a range of health
assessment of health literacy and changing needs
professionals who work with stroke families. The
across the post-stroke continuum.
non-inclusion of stroke survivors may be seen as a limitation, however this was a deliberate strategy as
Recommendations for practice
we wanted to focus specifically on family information
Family centred approaches in stroke care are
needs and stroke survivors’ opinions are more widely
advocated to enhance support and improve outcomes
known. Questionnaires were designed specifically
for stroke families (Cameron, 2013; Clarke, 2014;
for this study. Our sampling strategy, sample size
Fischer, Roy, & Niven, 2014). Such approaches must
and limited ethnic diversity within the sample limits
include recognition that family needs are inter-linked
transferability of findings.
with but different from the stroke survivor and that needs change over time, often alongside the stages
Conclusions
of the stroke trajectory. Nurses and other health
Access to appropriate information post-stroke was
professionals need to work in partnership with families,
problematic for most families, in both quality and
assessing individual and family needs for information
timeliness, and was compounded by the nature of
not only about strokes but also in maintaining their
the experience; shock following the sudden onset
own health and well-being. Family education in the
and adjusting to changed family dynamics. Nurses
acute setting tends to be focused on information about
and other health professionals recognised the
stroke and providing care to the stroke survivor on
limitations of resources, time and funding alongside
discharge. Equally important is the inclusion of social
the need for timely, quality information provision
and emotional support resources (Larson et al., 2005).
post-stroke, however, a gap was identified between
Effective provision of information can be complex
health professionals’ theoretical understanding of best
and time-consuming. It cannot be assumed that
practice and their actual practice. Information needs
family members have the same health literacy skills
specific to stroke families are often overlooked. It is
and information needs (Honey, Roy, Bycroft, & Boyd,
important to communicate effectively with families
2014). It is important to raise staff awareness around
and acknowledge that they may have complex needs
the centrality of health literacy as a pre-requisite
that are different to the stroke survivor’s needs.
for health teaching. Nurse-led initiatives that assess health literacy and the credibility of stroke specific
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Nursing Praxis in New Zealand References Burnard, P. (1991). A method of analysing interview transcripts in qualitative research. Nurse Education Today, 11(6), 461-466. doi:10.1016/0260-6917(91)90009-Y Cameron, J. I., & Gignac, M. A. M. (2008). “Timing it Right”: A conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home. Patient Education & Counseling, 70(3), 305-314. doi:10.1016/j. pec.2007.10.020 Cameron, J. I., Naglie, G., Silver, F. L., & Gignac, M. A. M. (2013). Stroke family caregivers’ support needs change across the care continuum: A qualitative study using the timing it right framework. Disability & Rehabilitation, 35(4), 315-324. doi:10.3109/0 9638288.2012.691937 Cameron, V. (2013). Best practices for stroke patient and family education in the acute care setting: A literature review. MEDSURG Nursing, 22(1), 51-55. Caress, A. L., Luker, K. A., Chalmers, K. I., & Salmon, M. P. (2009). A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 18(4), 479-491. doi:10.1111/j.13652702.2008.02556.x Cecil, R., Thompson, K., Parahoo, K., & McCaughan, E. (2013). Towards an understanding of the lives of families affected by stroke: A qualitative study of home carers. Journal of Advanced Nursing, 69(8), 1761-1770. doi:10.1111/jan.12037 Clarke, D. J. (2013). The role of multidisciplinary team care in stroke rehabilitation. Progress in Neurology and Psychiatry, 17(4), 5-8. doi:10.1002/pnp.288 Clarke, D. J. (2014). Nursing practice in stroke rehabilitation: Systematic review and meta-ethnography. Journal of Clinical Nursing, 23(9-10), 1201-1226. doi:10.1111/jocn.12334 Draper, P., & Brocklehurst, H. (2007). The impact of stroke on the well-being of the patient’s spouse: An exploratory study. Journal of Clinical Nursing, 16(2), 264-271. doi:10.1111/j.1365-2702.2006.01575.x Eames, S., Hoffmann, T., Worrall, L., & Read, S. (2010). Stroke patients’ and carers’ perception of barriers to accessing stroke information. Topics in Stroke Rehabilitation, 17(2), 69-78. doi:10.1013/tsr1702-69 Ellis, C., Grubaugh, A. L., & Egede, L. E. (2013). Factors associated with SF-12 physical and mental health quality of life scores in adults with stroke. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of the National Stroke Association, 22(4), 309317. doi:10.1016/j.jstrokecerebrovasdis.2011.09.007 Feigin, V. L., Forouzanfar, M. H., Krishnamurthi, R., Mensah, G. A., Connor, M., Bennett, D. A., . . . Murray, C. (2014). Global and regional burden of stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet, 383(9913), 245-254. doi:10.1016/S0140-6736(13)61953-4 Fischer, R., Roy, D. E., & Niven, E. N. (2014). Different folks, different strokes: Becoming and being a stroke family. Kai Tiaki Nursing Research, 5(5), 5-11. Forster, A., Brown, L., Smith, J., House, A., Knapp, P., Wright, J. J., & Young, J. (2012). Information provision for stroke patients and their caregivers. Cochrane Database of Systematic Reviews (11), CD001919. doi:10.1002/14651858.CD001919.pub3 Forster, A., Smith, J., Young, J., Knapp, P., House, A., & Wright, J. (2001). Information provision for stroke patients and their caregivers. Cochrane Database of Systematic Reviews(3), Cd001919. doi:10.1002/14651858.cd001919 Gustafsson, L., Hodge, A., Robinson, M., McKenna, K., & Bower, K. (2010). Information provision to clients with stroke and their carers: Self-reported practices of occupational therapists. Australian Occupational Therapy Journal, 57(3), 190-196. doi:10.1111/ j.1440-1630.2008.00765.x Hanger, H. C., Walker, G., Paterson, L. A., McBride, S., & Sainsbury, R. (1998). What do patients and their carers want to know about stroke? A two-year follow-up study. Clinical Rehabilitation, 12(1), 45-52. doi:10.1191/026921598668677675 Harwood, M., Weatherall, M., Talemaitoga, A., Barber, P. A., Gommans, J., Taylor, W., . . . McNaughton, H. (2012a). An assessment of the Hua Oranga outcome instrument and comparison to other outcome measures in an intervention study with Maori and Pacific people following stroke. The New Zealand Medical Journal, 125(1364), 57-67. Harwood, M., Weatherall, M., Talemaitoga, A., Barber, P. A., Gommans, J., Taylor, W., . . . McNaughton, H. (2012b). Taking charge after stroke: Promoting self-directed rehabilitation to improve quality of life: A randomized controlled trial. Clinical Rehabilitation, 26(6), 493-501. doi:10.1177/0269215511426017 Honey, M. L. L., Roy, D. E., Bycroft, J., & Boyd, M. (2014). New Zealand consumers’ health information needs: Results of an interpretive descriptive study. Journal of Primary Health Care, 6(3), 203-211. Page 23
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Nursing Praxis in New Zealand Honey, M. L. L., Roy, D. E., Bycroft, J., Boyd, M., & Raphael, D. (2014). Promoting the meaningful use of health information for New Zealand consumers. Studies in Health Technology and Informatics, 201, 11-17. doi:10.3233/978-1-61499-415-2-11 Kickbusch, L., Wait, S., & Maag, D. (2005). Navigating health: The role of health literacy. Bad Gastein. Retrieved from http://www. ilonakickbusch.com/kickbusch-wAssets/docs/NavigatingHealth.pdf Larson, J., Franzén-Dahlin, A., Billing, E., Arbin, M., Murray, V., & Wredling, R. (2005). The impact of a nurse-led support and education programme for spouses of stroke patients: A randomized controlled trial. Journal of Clinical Nursing, 14(8), 995-1003. doi:10.1111/j.1365-2702.2005.01206.x Mak, A. K. M., Mackenzie, A., & Lui, M. H. L. (2007). Changing needs of Chinese family caregivers of stroke survivors. Journal of Clinical Nursing, 16(5), 971-979. Ministry of Health. (2010). Korero Mārama: Health literacy and Māori: Results from the 2006 Adult Literacy and Life Skills Survey. Wellington: Ministry of Health. Retrieved from http://www.moh.govt.nz.Need link to page - remove the fullstop after the URL Moloczij, N. (2009). Sustaining one’s own health and wellness while supporting a stroke survivor: Spouses’ and partners’ perspectives (Master of Health Science thesis, Auckland University of Technology, Auckland, New Zealand). Retrieved from http://hdl. handle.net/10292/654 Newell, R., & Burnard, P. (2011). Research for evidence-based practice in healthcare (2nd ed.). Oxford, UK: Wiley-Blackwell. Perry, L., & Middleton, S. (2011). An investigation of family carers’ needs following stroke survivors’ discharge from acute hospital care in Australia. Disability And Rehabilitation, 33(19-20), 1890-1900. doi:10.3109/09638288.2011.553702 Reid, S., & White, C. (2012). Understanding health literacy. Best Practice Journal, 45, 4-9. Smith, J., Forster, A., & Young, J. (2009). Cochrane review: Information provision for stroke patients and their caregivers. Clinical Rehabilitation, 23(3), 195-206. doi:10.1177/0269215508092820 Stroke Foundation of New Zealand. (2015). Facts about stroke in New Zealand. Retrieved from http://www.stroke.org.nz/stroke-factsand-fallacies Stroke Foundation of New Zealand and New Zealand Guidelines Group. (2010). Clinical guidelines for stroke management 2010. Wellington: Stroke Foundation of New Zealand. Temize, H., & Gozum, S. (2012). Impact of nursing care initiatives on the knowledge level and perception of caregiving difficulties of family members providing home care to stroke patients. HealthMed, 6(8), 2681-2688. Wallengren, C., Segesten, K., & Friberg, F. (2010). Relatives’ information needs and the characteristics of their search for information - in the words of relatives of stroke survivors. Journal of Clinical Nursing, 19(19/20), 2888-2896. doi:10.1111/j.13652702.2010.03259.x Wiles, R., Pain, H., Buckland, S., & McLellan, L. (1998). Providing appropriate information to patients and carers following a stroke. Journal of Advanced Nursing, 28(4), 794-801. doi:10.1046/j.1365-2648.1998.00709.x Wright, L., Hill, K. M., Bernhardt, J., Lindley, R., Ada, L., Bajorek, B. V., . . . Nelson, M. R. (2012). Stroke management: Updated recommendations for treatment along the care continuum. Internal Medicine Journal, 42(5), 562-569. doi:10.1111/j.14455994.2012.02774.x Yu, Y., Hu, J., Efird, J. T., & McCoy, T. P. (2013). Social support, coping strategies and health-related quality of life among primary caregivers of stroke survivors in China. Journal of Clinical Nursing, 22(15-16), 2160-2171. doi:10.1111/jocn.12251
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Nursing Praxis in New Zealand HEALTH PROFESSIONALS PERSPECTIVES OF CARE FOR SERIOUSLY ILL CHILDREN LIVING AT HOME Cynthia Ward, MA (Applied), BN, Chief Executive Officer, True Colours Children’s Health Trust, Hamilton, NZ Alicia Evans, PhD, MBA, BN, Senior Lecturer, Australian Catholic University, Melbourne, Australia Rosemary Ford, PhD, MN, B Hth Mgt., Deputy Head of School, Australian Catholic University, Ballarat, Australia Nel Glass, RN; Dip Neuro Nurs, BA, MHPEd, PhD, FACN, Honorary Professor, Australian Catholic University, Melbourne, Australia
Abstract The aim of this article is to report the findings on health professional’s perceptions of beneficial care for seriously ill children and their families. This paper represents one component of a PhD qualitative evaluation study investigating care provided by a child health Trust in New Zealand. The Trust provides an integrated care model of nursing and psychological support to children with complex health needs and their families who live at home. The research methodology was informed by critical realism. The research method chosen was a focus group. There were twelve health professional participants who worked in collaboration with the Trust team to provide care to seriously ill children. Data were analysed using a realist analysis to identify initial key aspects and subsequent themes. Five themes were identified: collaboration between health providers; effective communication; expert skills; support for colleagues and, after-hours care availability. Participants perceived the Trust model of care to be integral for children with serious illness, and their families in the community. This study extends our current understanding of models of care for children with complex health needs. It has relevance to health providers who are first ‘on call’ for children with serious illness and their families as well as those involved with continuity of care.
Keywords
2013; McCann, Bull, & Winzenburg, 2012). Parents/
Seriously ill children; health professionals; model of
families are now required to learn how to safely and
care; complex health needs
effectively deliver technical interventions, following instruction from community nurses. Some examples
Introduction
of these interventions are: oxygen and ventilation
Global advances in medical knowledge and technology
therapy, tracheotomy care, suctioning, feeding-tube
have resulted in increased survival of neonates with
care, intravenous nutrition and intravenous drug
complex illnesses. Many of these neonates now live
regimens (Eilas & Murphy, 2012; Maddox & Pontin,
into childhood, however their care requirements
2013; Shuster et al., 2011; Whiting, 2013).
have become more complex (Elias & Murphy, 2012; Maddox & Pontin, 2013; Schuster, Chung, & Vestal,
Shuster and colleagues (2011) described care provided
2011). Previously these children remained in a hospital
by parents/families as a ‘shadow health care’ (p. 91)
setting, however the contemporary care setting is the
system upon which health care services rely. Publically
family home with parents the primary carers and
funded child health care systems would be unable
providers of their child’s technical and personal cares (Dybwik, Tollali, Nielson, & Brinchmann, 2011; Elias & Murphy, 2012; Hewitt-Taylor, 2012; Maddox & Pontin, Page 25
Ward, C., Evans, A., Ford, R., & Glass, N. (2015). Health professionals perspectives of care for seriously ill children living at home. Nursing Praxis in New Zealand, 31(2), 25-34. Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand to function without this level of parental support
Background
(Shuster et al., 2011). Buhler-Wilkerson (2007) argued
It has been well established that families benefit
home care could be the cornerstone of a system to
from health care that is provided in an integrated
meet the needs of the chronically ill. However, the
and co-ordinated way, particularly when the child
management of technical, physical and emotional
is being treated in their home (American Academy
care for children at home has a direct impact on the
of Pediatrics: Council on Children with Disabilities
parent/family in terms of physical, mental health and
and Medical Home Implementation Project Advisory
emotional resilience. Parents often have been found
Committee, 2014; Association for Children with Life-
to experience altered roles, financial burden, marital
Threatening or Terminal Conditions and their Families,
strain, psychological distress (Carnevale, Alexander,
& Royal College of Paediatrics and Child Health, 2003;
Davis, Rennick, & Troini, 2006; Ling, 2012; Santacroce,
Ministry of Health, 2010). Many of these children
2003; Schuster et al., 2011; Whiting, 2013) and low
have complex and disabling health needs, sometimes
quality of life (Al-Gamal, 2013). There continues to
requiring palliation. In response to this, in New Zealand,
be the question of how to deliver funded care that
District Health Boards recommended care models
has the potential to reduce the physical, emotional
for this group of children (Craig, McDonald, Adams,
and financial burden for parent/family carers (Buhler-
Reddington, & Wicken, 2010; Paediatric Society of
Wilkerson, 2007; Shuster et al., 2011).
New Zealand 1997; Paediatric Society of New Zealand, 2008; Smith & Overden, 2007).
It is important that home care for seriously ill children with complex medical needs is provided in the context
In accordance with the District Health Board
of a child health model of care that is family-centred
recommendations and due to identified service gaps
and that a partnership forms between the child, family
(Ward, 2005), a Child Health Trust was established
and health professionals. Fowler et al. (2012) highlight
in 2004 in New Zealand. Its aim was to provide an
that nurse partnership activities are not new to nurses
integrated model of nursing and psychological care for
who work with parents. Fowler and colleagues (2012)
children with serious complex illnesses, being treated
argue that partnership requires nurses to skilfully
at home. There was recognition that parents/families
create the conditions for an effective relationship to
ultimately carried the burden of care for their children
emerge. This then provides opportunity for optimal
at home. This model is based on the Te Whare Tapa
collaboration and coordination to enhance better
Whā health and wellness model developed by Mason
outcomes in care (Barnes & Rowe, 2008; Denboba,
Durie (1996). The model is underpinned by four
McPhearson, Kenney, Strickland, & Newacheck, 2006;
dimensions representing the basic beliefs of life: te
Fowler et al., 2012; Kenny, Denboba, Strickland, &
taha hinengaro (psychological health); te taha wairua
Newacheck, 2011; Price & McNeilly, 2009; Simkiss,
(spiritual health); te taha tinana (physical health); and
2011; Yarwood, 2008).
te taha whānau (family health).
The research reported here aims to contribute to the
At the time the Trust was founded, there was no other
body of knowledge on the topic of health related care
organisation providing continuity of care to children
for seriously ill children living at home and health
with illnesses that were predominantly non-palliative.
service evaluation. This has significance for medical,
Chronicity and complexity of care demanded service
nursing and allied health professionals who care for
delivery that commenced at the time of the child’s
seriously ill children and their families.
diagnosis and to be available throughout the child’s
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand lifespan. While palliative care has significantly
management of health crisis.
developed over the last decade worldwide (Baker, et al., 2008; Ministry of Health, 2012) and hospices
Within the integrated model of care, Trust team
provide holistic care there remains a gap in care and
members and non-Trust health professionals strive to
research for those with chronic complex conditions.
meet the needs of the child and their parents/families.
This population group is increasing as more children
This is delivered through effective communication,
now survive and the complexity of the illnesses is more
collaboration and coordination of care. For instance,
intensive on resources and skill.
collaborative home visits or clinic appointments bring together in partnership the child/family and non-Trust
Carter and Thomas (2011) argue a plethora of
health professionals (nurses, paediatricians and allied
agencies and professionals are required to support
health workers) and Trust team members. The history
this population group. In the United Kingdom,
of the development of the service and its evolution has
challenges for these families have been recognised at
been reported elsewhere (Ward, 2009).
a government level, resulting in the implementation of family and child-centred initiatives such as Every Child
Methodology
Matters, the Early Support Programme and Aiming
The aim of the PhD qualitative evaluation study is to
High for Disabled Children (Carter & Thomas, 2011).
investigate the contribution of the integrated model of care to the welfare of the child with a serious
Bolitho and Huntington (2006) argue that the New
complex illness, the child’s siblings, parents, and their
Zealand government has children’s health as a priority.
professional carers. The methodological framework
These are reflected in strategies and frameworks such
was multi-layered critical realism that incorporated
as the: Child Health Strategy (Ministry of Health, 1998);
the identification of key ‘realist’ themes and emergent
He Korowai Oranga (King & Turia, 2002); The New
critical themes. Bhaskar (1975), recognised as the
Zealand Health Strategy (King, 2000); and The Primary
founder of critical realism, was influenced by Marx’s
Health Care Strategy (King, 2001). However, the reality
work. Bhaskar, (1975) divided critical realism into three
is that caring for seriously ill children in the community
domains: the empirical, the actual and the real. The
has huge impact on families in New Zealand (Barnes
‘empirical’ is described as the observable encounter
& Rowe, 2008), with limited resources available to
that happens and exists according to our immediate
meet the need. There is much more to do to improve
experience. The ‘actual’ refers to what happens
services to this population group.
independent of the observer and the ‘real’ refers to objects, their structures and their causal powers, or
The Trust is situated in a residential house, containing
the domain that includes mechanisms that produce
offices and therapeutic spaces. The Trust employs
different events (Alvesson & Skoldberg, 2009). Bhaskar
four clinicians who provide a variety of clinical nursing
(1975) describes ‘reality’ as complex, structured and
and psychological cares for the child/family on-site at
multi-layered.
the Trust, in the family home and in acute inpatient care services. At any time, Trust team members care
Pawson and Tilley (1997), influenced by Bhaskar’s
for 130 – 150 children/families, in terms of symptom
work, extended the realist belief, going on to create
management,
Realist Evaluation which has its roots in realism. Realist
family
counselling/psychosocial non-Trust
Evaluation is concerned with identifying underlying
health professionals, and 24 hour on-call nursing for
causal mechanisms, how they work and under what
support,
Page 27
collaboration/advocacy
with
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand conditions. This produces a closer understanding of
responsible for recruitment and data collection. There
what causes change (Pawson & Tilley, 1997). For this
were 12 focus group participants from the hospital
study, the realist lens allowed the authors to explore
and community. They comprised of nursing, allied
the distinctive nature of the integrated model of care;
health and medical personnel, thus representing the
how it worked, what was involved and what possible
key disciplines and professional expertise required to
causal relationship contributed to the outcomes of
provide care for children. The Child Health Trust works
care for families (Pawson & Tilley, 1997).
with a vast number of health professionals from other agencies. Excluded from the research were those
Data collection
health professionals who were not direct key referrers
Data were collected through three methods: individual
or who did not work in close collaboration with the
interviews, focus group interviews and researcher
Trust team.
reflective
journaling.
Individual
semi-structured
interviews were conducted with children, who were
Data analysis
patients of the Child Health Trust. Separate focus
Utilising a critical realist approach the de-identified
groups were conducted with the child’s siblings,
transcript was read and searched to find emerging
parents, and the health professionals involved in care
aspects, repeated patterns that resulted in realist
of these children. This article focuses on the focus
themes. Interpretation and theorising from the whole
group data from the health professionals and the
story and its meaning was sought, with the attention
identification of realist themes.
of focusing on the ’what’ in the story, rather than ‘how’ it was told (Braun & Clarke, 2006; Liamputtong,
Health professional focus group
2010). A systematic approach determined the rigour of
The focus group was facilitated with open ended
data analysis that was applied within the framework
questions used to elicit information from participants.
of familiarisation, identifying themes, manual coding,
Examples of these questions were; “what are
mapping and recoding of themes for the purpose of
some of the differences you see for families once
understanding until saturation of these themes had
they have started engaging with the Trust”, “how
been attained. Reflexive journaling by the first author,
is communication conveyed, with you as health
kept an ongoing record of experiences and reactions
professionals, the Trust and the families”, “to what
that helped inform the decisions made regarding
extent do you find the Trust helps you find solutions
assumptions and the subject material.
when working with families”? The focus group was audio-recorded, transcribed verbatim and analysed
Ethical considerations
initially for identification of any key emerging aspects
As the first author is employed by the Trust and close to
and subsequently the development of realist themes.
the work, a research assistant that was not associated with the Trust joined the research team specifically
Participants
for participation recruitment, data collection and de-
Participants for this study were health professionals
identifying the original data. The study was approved
who referred paediatric patients to the Child Health
by the Australian Catholic University Ethics Committee,
Trust. They were recruited from the local hospital and
Melbourne (201327V).
community agencies. Fifty-eight health professionals were sent an information pack which included a letter
Findings
of invitation to contact the research assistant who was
Health professionals willingly shared their perspectives
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand of the integrated model of care used by the Children’s
‘that’ [emotional support] is taken care of…
Care Trust. Participants viewed the integrated model
parents don’t need to talk to me about it. [The
of care as both positive and a vital aspect of care
Trust] is more appropriate, so it complements,
delivery. Participants discussed what they valued as
and they know that they are there for the
attributes of the Children’s Health Trust in providing
emotional support and they are very good with
the integrated model of care to children and their
boundaries on what their role is and what our
families. They also acknowledged the attributes they
role is.
valued in their relationships with the Trust. There were five themes that characterised perspectives of
Another participant stated:
the integrated model: collaboration between health
My job is to go in and work with the child who is
providers, transparent communication, expert skills,
acutely unwell, and a lot of the time I will be in a
support amongst colleagues and access to after-hours
room with a child who is extremely unwell and
care.
in fact the [Trust member] will often come and sometimes take the parents from the room, or
Valued Attributes of the Integrated Model of Care
sit with the parent in the room, and it actually
Collaboration between health providers
allows me to focus on just the child, which is,
Participants in this study perceived the integrated
as far as I am concerned really my main job,…
model of care to complement their ability to provide
knowing that the family have that support.
care. Under the auspices of the integrated model
[They] are there at the same time as me, as I am
of care the Trust team members worked with the
providing more of the medical care for the child.
parents and families to provide emotional support. Participants reported this as a very important aspect
Effective Communication
of care. Non-Trust health professionals reflected that
Communication with the Trust team members was
previous to the integrated model of care, they had
strongly valued by study participants. They reported
endeavoured to appropriately respond to emotional
that effective communication was essential when
disclosures. They now believed their responses did not
multi-agencies were involved with a child’s care. This
necessarily result in the best family outcomes. Clear
transparent communication facilitated the attainment
role definitions and boundaries between non-Trust
of child/family carers’ goals. Participants were highly
health professionals and Trust team members have
appreciative of the role of Trust team members as a
resulted in greater efficacy of care provision. Non-Trust
mouthpiece for the child/family. They thus received
health professionals are now free to use their own
important information about responses to care, and
scope of skill, knowledge and expertise to best effect.
were able to appropriately vary the care. Participants reported
One participant stated:
that
this
transparent
communication
supported their professional relationships with
The integrated model of care kind of
families. This then enabled further very useful
complements our service. Prior to [the
conversations regarding the care of the child.
integrated model of care]…families would disclose something to you and so we would try
One participant said:
and deal with it possibly not in the best way. I
I often talk [with the Trust team member after
find now that I go in and do my job which is to
she has had] a meeting with a family… and she
check medical interventions and knowing that
will say, I have spoken with mother and gained
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand her permission, and there is always that, mum is
what is being said, and what is being reflected.
aware that this is what I am going to tell you….
There is always a plan at the end of it, I think
if she feels that there is something that I need
they are very skilled at that….and they have the
to know to help me give better care, and better
knowledge and the skill to bring people back
support, then she has no hesitation in asking
and settle them down… communication wise
their permission, and seeking me out and telling
they have got it.
me and that has worked really well you know, time and time again. So it’s a very transparent
Expert Skills
process.
Participants
acknowledged
that
medical/nursing
knowledge and medical technology have enabled Study participants noted the important communication
children to survive what were previously fatal
role provided by Trust team members in the event that
conditions. They were also very aware of their need
a sick child was hospitalised. Parent-carers were often
to continually learn and adapt their clinical practice
unsure how to relinquish their care role and allow
in a rapidly changing care environment. Participants
health professionals to take the lead. An admission
acknowledged that Trust team members demonstrated
to acute care provides the parent-carer with a period
advanced skills in symptom management, end-of-
of respite. During this time they were encouraged
life care, and family communication strategies. This
by Trust team members to be fully in their role as
sharing of expertise, guidance and mentoring was an
parent. Participants described the Trust team as being
aspect of the integrated model of care that was highly
committed to finding workable solutions for families,
valued by participants and contributed to their own
and working hard to ensure the voices/needs of the
knowledge and skill base.
child, parent and family were heard. One participant stated: It was stated that:
[The Trust team members] have the ability to
…it links back to patient advocacy, so when
talk things through, raise issues, sometimes
you have got a family who have a long-term
about my treatment, perhaps with the child…
hospitalisation and there are difficulties for
the nursing background…part of what [they] do
parents to know what their role is and when
is advising health professionals particularly at
they don’t agree with the consultant or some
end of life.
of the medical decisions [the Trust team members] have worked alongside us really well,
In relation to one of the Trust team members, the
and alongside the family really well in order
participant further reflected:
to provide the best care for the baby and the
Because of [her] level of knowledge in terms of
family.
symptom management and pain management, and all that stuff she gives a lot of advice to
Another participant shared:
nursing and medical staff about medications
In patient meetings, [inclusive of parents,
and the right path to take…. [this has resulted
the Trust team members] are very skilled at
in] up skilling all of us in our end of life care.
saying… ‘Now what I am hearing is’… there is a lot of validation so that everybody that is sitting around that table is very clear about Page 30
It was further stated: I think they have skill and sensitivity [in] Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand listening to families and also siblings, who can
is going on and advise them what to do… when
be very young children [about end-of-life care
it is happening, at the time.
and issues]. They really engage in a positive way with them as well, and can normalise it in a good way for some of those families.
Another participant shared: ….when they [the parents] take their baby home from us, they are really scared about what is
Support amongst colleagues
out there, and to know that they have the home
Study participants reported that Trust team members
care nurses and they have [Trust team members]
provided emotional and practical support to children
who have that ‘in the middle of the night stuff’,
and
that phone call to ask that question,… it’s just so
their
families.
In
addition,
much-needed
support was extended to themselves as health
important and brings their anxiety down.
professionals. Participants reported the heavy burden they experienced at times within the emotionally
Considering the strong approval for the 24 hour on-
confronting nature of their care role with children with
call service provided by Trust team members, it was
serious complex illnesses. The collegial support from
not surprising to see health professionals’ anxiety
the Trust team members was very welcome at such
over the vulnerability of the service. Participants were
times; it enhanced their care delivery and made them
concerned for the welfare of Trust team members in
feel less isolated and lonely in their clinical work.
terms of the heavy load that could occur during the overnight call service. They were also concerned about
For example: I first began in NICU [the Neonatal Intensive
the sustainability of the Child Health Trust and the need for ongoing funding.
Care Unit] my second week and we had a crisis in the ward, I just freaked you know…. The Trust
One participant reported:
team invited me back to talk, and really it was a
That is a weakness that I know they are aware
complete debrief… They seem to know when we
of. I have spoken to the [Trust team members]
need them… they just seem to know when you
many times and it is potentially a big issue, that
are going through rough times.
they provide 24 hour service… probably to the detriment of the [Trust team members’] mental
After-hours care availability
health… I worry a lot about that after-hours
After-hours support provided by Trust members was
service.
recognised by participants as an important component of care for the parent/family. This is particularly in
Another participant said:
relation to minimising anxiety when their child’s
I have tried really hard to get [District Health
condition deteriorated. The participants highlighted
Board] funding… it is a problem because they
the benefit and assurance this provides to families.
have a huge proportion of the clients. I just definitely worry about that after hours stuff, it
One participant stated: And the after-hours stuff is huge; I think whether
is a big problem and I know that the [Trust team members] are aware of it.
it’s for a health crisis or an emotional crisis. The family knows that they can call and get [a Trust
Discussion
team member] to talk them through whatever
There is an abundance of literature regarding children
Page 31
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand who live with serious complex illness and rely on
them to increase their own skills, along with improving
technology for their survival (Dybwik et al., 2011; Elias
care to children and their parents/families. There is
& Murphy, 2012; Maddox & Pontin, 2013; Schuster et
a clear need for health professionals who work with
al., 2011). These children are predominately cared for
children to strengthen their knowledge of paediatric
by their parents in the family home, a role that is seen
and family health. A shared understanding between
as the ‘norm’ by health service providers and society in
all those providing health services and a high level
general. Parents provide a ‘shadow health care’ service
expertise ensures better care for children and their
on which health professionals have become reliant
families (Law, McCann, & O’May, 2011). Health
(Shuster et al., 2011, p.91).
professionals in this study found this shared knowledge and competency to be supportive of their care role
This study supports Shuster and colleagues (2011)
with seriously ill children and their families.
previous finding that parents provide high levels of care in the home, care that in previous years was
While after hours care was deemed to be an important
provided in a hospital setting. Participants in this study
benefit to families, study participants also noted
acknowledged the heavy demand faced by parent-
that limited resources might eventually reduce this
carers as they manage the long term care of chronic
aspect of the IMC provided by the Child Health Trust.
complex illnesses in their child.
Participants stressed the need for further funding and resources for this part of the service to strengthen
Study participants reported the integrated model of
capacity and ensure sustainability.
care provided by the Child Health Trust to be a vital service for parents and families through its provision
Limitations
of clinical and psychosocial support. The integrated
The
model of care had positive benefits for children, their
therefore, bias may have been introduced during
families and health professionals, one of which was
data interpretation and analysis, when perceiving
collaboration and communication. The importance
participants words in a particular way. An external
of collaboration between service providers should
research assistant was invited to join the research team
not be underestimated given its role in supporting
specifically for participation selection, data collection
good outcomes (Yarwood, 2008). Hewitt-Taylor (2012)
and de-identification of the data to minimise this risk
stresses the need for collaboration and communication
and strengthen the rigour of the research.
first
author
was
an
insider
researcher,
to achieve a common understanding between all concerned and to ensure service provision directly
Conclusion
meets the needs of parents/families.
There has been a paradigm shift in health care over the last decade due to babies now surviving into
Another benefit of the integrated model of care was
childhood. They also now live at home with complex
the expertise provided by the Trust team members to
illnesses. This brings a greater demand of care from
the non-Trust health professionals. This is a significant
both
finding because it is known that clinical expertise leads
involved. Currently parents provide care that was once
to positive results for both families and other health
provided by clinicians, regardless of the complexity of
professionals providing the care (Carter & Thomas,
care and the technical skill required. In New Zealand,
2011). Health professionals in this study believed the
a Child Health Trust was established in order to assist
expertise provided by Trust team members assisted
families in these difficult circumstances. The findings
Page 32
parents/families
and
health
professionals
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand presented here are one part of an evaluation of this
children and their parents/families. The findings of
service. The findings highlight the importance that
this study are important in providing evidence that the
health professionals place on the contribution that
service is valued by health professionals. That parents
a service such as the Child Health Trust’s integrated
carry a high burden in their caring role is confirmed
model of care brings to children with serious complex
in this study. The integrated model of care provides
illnesses, and their families. Health professionals
a service that is vital in supporting those providing
identified benefits to both the children and their
the care; whether that is parents/families or health
families and to themselves as health professionals.
professionals overseeing this care.
These benefits included; transparent communication, support and collaboration between all parties, expertise in skills and reduced anxiety and fear for
“Thank you to Rodmor Charitable Trust for funding this research project”
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Zoe Tipa, Doctoral Candidate, MPhil, BHS(Nursing), National Advisor Māori Health, Plunket, Auckland, NZ Denise Wilson, MA(Hons), PhD, RN, Professor Māori Health, Auckland University of Technology, Auckland, NZ Stephen Neville, MA(Hons), PhD, RN, Associate Professor, Auckland University of Technology, Auckland, NZ Jeffery Adams, BA, MA (Applied), PhD, Senior Research Officer, The SHORE and Whāriki Research Centre, Massey University, Auckland, NZ
Abstract: A major New Zealand well child care service requires its nurses to establish functional relationships with clients, their family/whānau, and children. The Family Partnership Model is used to develop nurses’ knowledge, skills and techniques to establish partnership relationships and effective communication with vulunerable clients. The cultural responsiveness of the Family Partnership Model for working with Māori (indigenous people of New Zealand) whānau was investigated within the well child context. We asked, does the Family Partnership Model support culturally responsive nursing practice within the well child context? This mixed methods study involved two phases: Phase 1 – an online survey with 23 nurses who had completed the Family Partnership Model training, and 23 who had not; Phase 2 – observation of nurses’ practice and interviews with 10-matched nurse-Māori client pairs. Quantitative data were analysed using descriptive statistics, while qualitative data were thematically analysed. Some differences were found for those who had completed Family Partnership Model training in qualities that are necessary precursors for culturally responsive practice, and in areas indicative of culturally responsive practice. Three themes identified were: having respectful relationships, being client-led, and lacking the skills. The Family Partnership Model appears to support some development of areas necessary for culturally responsive practice with vulnerable clients. However, we recommend further work and research is required to support nurses to develop their cultural responsiveness and translate this into their practice.
Key words Well child care; family partnership model; child and family nursing; Māori; nurse-patient relationship
Introduction
Partnership Model, developed in the United Kingdom the
(Davis, Day, & Bidmead, 2002). The Family Partnership
relationships developed between nurses and clients,
Model is based on establishing relationships and
and is necessary for the clients’ and whānau (extended
communication for working with others, and informs
family) cultural needs to be incorporated into care
a programme to develop knowledge, skills and
delivery. The health and wellbeing of Māori children
techniques for those working with children and their
and their whānau is an ongoing concern for the
families. Plunket nurses undertake a 10-session Family
delivery of health and social services in New Zealand.
Partnership Model training that aims to enhance their
The Royal New Zealand Plunket Society (known as
communication and ability to establish partnerships
Cultural
responsiveness
is
contingent
on
Plunket) provides well child services to 90% of children and their families nationwide, and to 65% of Māori children born in 2010 (Royal New Zealand Plunket Society, 2012). Plunket is committed to the Family Page 35
Tipa, Z., Wilson, D., Neville, S., & Adams, J. (2015). Cultural responsiveness and the family partnership model. Nursing Praxis in New Zealand, 31(2), 35-47. Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand with families. However, it is not clear if the Family
of children (Tipene-Leach, 2012). Yet, despite Māori
Partnership Model supports culturally responsive
reporting good health in the 2012/13 New Zealand
nursing practice. In this article we report the findings
Health Survey, ongoing health inequities for parents
of a study investigating whether the Family Partnership
and their children are evident, such as unmet health
Model influenced culturally responsive practice for
needs (Ministry of Health, 2012b).
nurses working with Māori whānau. Providing culturally safe and responsive care is crucial
Background
for reducing health disparities and inequities for Māori
Māori, indigenous peoples of New Zealand, experience
(Robson & Harris, 2007; Wilson & Barton, 2012).
persistent inequities in health status and outcomes,
Cultural responsiveness is grounded in worldviews,
similar to other Indigenous peoples who have histories
relationships, cultural contexts, and connecting in
of colonisation. They comprise 14.9% of the New
‘culturally-normed’ ways of functioning (Werkmeister-
Zealand population (Statistics New Zealand, 2013).
Rozas & Klein, 2009). Werkmeister-Rozas and Klein go
Ninety percent of Māori live in households with other
further, stating cultural responsiveness is a “cocreated
family members, and of these, 42.9% are couples
reality between worker and client” (p.6). This concept
with children, 26.5% are single adults with children
defies the adoption of universal or one-size-fits-all
and 11.5% in multi-family households (Te Puni Kōkiri,
approaches. In addition to practitioners’ awareness of
2011). Many Māori women have children at a younger
their own cultural positions, cultural responsiveness
age than other women living in New Zealand, are
is informed by a critical analysis of Māori whānau
disconnected from their iwi and lack wider whānau
realities in terms of equity, social justice, rights,
support (Ritchie, 2007). Consequently, Māori whānau
intersectionality, and complex interactions that impact
and children are often deemed at risk and vulnerable.
their daily lives (Anderson et al., 2009; Bellon-Harn
For example, Māori children suffer health disparities
& Garrett, 2008; Kelly, 2009; Pauly, MacKinnon, &
and inequities at higher rates than other children living
Varcoe, 2009). In this article, cultural responsiveness
in New Zealand (Ministry of Health, 2012a, 2012b).
refers to nurses working alongside clients to provide culturally supportive care, which incorporates the
Health inequities occur within a complex context
differences and needs that exist between themselves
that
and clients to optimise safe and responsive well-child
includes
being
indigenous;
experiencing
discrimination, poverty and unemployment; and
care delivery that meets their cultural needs.
having low levels of education. Many Māori children live in areas of high deprivation, with 41% of
Walker (2004) identified that in order to be responsive
Māori whānau living in neighbourhoods with high
to individual Maori needs, issues need to be explored
deprivation (NZDep 2006 deciles 9 and 10) compared
within the context of their wider whānau. For Māori,
with 15% of non-Māori, while 73% of Māori live in
the obligation and orientation of the collective whānau
deciles 6 to 10 neighbourhoods compared with 44% of
and community surpasses the general focus of health
non-Māori (Ministry of Health, 2010). There is a high
services on individuals (Metge, 1995). Therefore,
likelihood that Māori children will live in poverty, an
the nature of the partnership between nurses and
adverse experience that impacts lifelong health and
Māori whānau is fundamental to a culturally safe
social outcomes (Marie, Fergusson, & Boden, 2008;
and responsive well child service delivery. In New
Poulton et al., 2002). The health system has a role
Zealand every registered nurse is required annually to
to manage improvement in the poor health status
demonstrate cultural competence, of which cultural
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand safety is a core component. It is clients who determine
agreement of aims and processes; mutual trust and
whether the quality of their care is culturally safe or
respect; openness and honesty; clear communication
not (Nursing Council of New Zealand, 2011; Ramsden,
and negotiation” (p. 1). They suggested the term
2002). However, a criticism of cultural competence is
‘partnership’ is often not examined or defined within
the lack of client and whānau input into the process
health policy and services, thus professionals and
of determining whether nurses are ‘culturally safe’
consumers have difficulty in determining its success.
practitioners (Wilson, 2008).
While Braun et al. mention the role of personal constructs, an absence of research about the cultural
The Family Partnership Model provides a framework
responsiveness of the Family Partnership Model also
for health professionals to support families considered
exists. We aimed to establish whether this model could
to be vulnerable. Rossiter, Fowler, Hopwood, Lee and
promote culturally responsive practice for Plunket
Dunston (2011) defined vulnerable families as those
nurses working with Māori.
with, “... circumstances characterised by relationship breakdowns, ineffective parenting and disruptions
Research Design
in secure attachment between young children and
A two-phased mixed methods design was used to
parents” (p. 378). They maintained that families’
evaluate the effectiveness of the Family Partnership
vulnerability can be generational, and is often situated
Model training. Due to the word limit, the research
within contexts of inequities and disadvantage that
reported in this paper focuses on the cultural
negatively impacts children’s health and development.
responsiveness component of a larger outcome
The Family Partnership Model is a supportive parent-
evaluation research design – therefore, we report the
centred approach underpinned by the helping process,
findings related to whether the Family Partnership
whereby health professional-parent partnerships aim
Model
to achieve beneficial changes in children’s health,
practice within the well child context (see Table 1).
development, and outcomes (Rossiter et al., 2011).
The evaluation research methodology enabled the
The helping process focuses on parent identified
exploration of complex outcomes for clients and those
problems, and involves health professionals working
undertaking the Family Partnership Model training
with them to clarify the problem(s) and plan actions to
programme.
supports
culturally
responsive
nursing
achieve desired outcomes that are evaluated together. Helping involves sharing power, working with parents,
Aim
and using the dual expertise of both parents and
The research aimed to evaluate the extent to which
health professionals. Importantly, it requires health
Plunket nurses implement the Family Partnership
professionals to display respect, humility, and effective
Model when working with Māori, and whether it could
communication (Fowler et al., 2012).
be considered culturally responsive. The question driving the research was, “does the Family Partnership
There is an absence of conceptual models to guide
Model support culturally responsive nursing practice
those working in partnership with children and their
within the well child context?”
families (Braun, Davis, & Mansfield, 2006). Central to the Family Partnership Model is the notion that
Method
partnerships promote effective relationships. Braun
The project was approved by Massey University
et al. described partnership as “... active involvement;
Human Ethics Committee Northern and the Royal New
shared decision-making; complementary expertise;
Zealand Plunket Society Ethics Committee. Information
Page 37
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 1. 1. Table Overview of Research DesignDesign Overview of Research Phase
1 Does the Family Partnership Model suport culturally responsive nursing practice within the well child context? 2
Method
Online survey
Participants Nurses with: FPM training (n=23) No FPM training (n=23)
Observations
Matched Nurses (n=10)
Interviews
and
Analysis
Descriptive statistics
Thematic analysis
Interpretation Questions
1. What effect does the family partnership training have on nursing practice? 2. To what extent do well child nurses meet the needs of Māori clients?
Clients (n=10)
sheets were provided to potential participants for both
were then statistically analysed using EXCEL version 14
phases of the study. In Phase 1, consent was implied
to generate median scores for each group.
on submission of the survey, while in Phase 2 written consent was obtained. Participation in Phase 2 was
Phase 2: Observation and interview. Nurses who had
voluntary and all participants had a right to withdraw
undertaken the Family Partnership Model training
from the study at any point. Confidentiality was
were invited to participate in Phase 2. Participation
maintained by assigning participants pseudomyns, and
depended on nurses securing a Māori client’s consent
storing data in a secure cabinet or password protected
for the researcher (first author) to observe their
computer files.
practise while assessing an infant, and to take part in a semi-structured interview – 10 nurses and their
Phase 1: Survey. Phase 1 involved an anonymous
clients agreed to participate. Permission was obtained
online survey, using Survey Monkey. Purposive
from The Centre for Child and Parent Support and
sampling involved sending an invitation to participate
developers of the Family Partnership Model to utilise
in the study to 25 nurses who had completed the
the Interpersonal and Communication Skills Rating
Family Partnership Model training, and 25 nurses yet to
Scale to observe the nurses clinical assessment of
complete the training. The invitation was distributed to
the infants (Maras, Faulkner, & Wills, 2006). The
nurses by Plunket Clinical Leaders nationally, because
observation scale was used to assess nurses against
they were aware of who had completed and not
13 communication qualities and skills considered
completed the training. A 30-item questionnaire plus
essential to working in partnership, using a 5-point
three free response questions explored areas such
Likert scale, where 1 represented minimal evidence of
as communication, decision making, service delivery,
the qualities and skills and 5 represented considerable
qualities and skills, confidence, the Treaty of Waitangi
evidence of the qualities and skills.
and cultural safety. Quantitative data were checked for invalid responses and one respondent was removed
Māori clients were invited to include wider whānau
from each group because each person had only
members in the interview/observation process.
registered and neither answered any questions. Data
However, whānau members present during interviews
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
21
Nursing Praxis in New Zealand chose not to participate. Therefore, digitally recorded
involved familiarisation with the data, the generation
and transcribed interviews were undertaken with each
of initial codes, searching for themes, defining,
Māori client with their whānau present directly after
reviewing and reporting the themes. Interpretation
the nurses’ visits, and then with the nurse later that
of the findings involved bringing together the data
day. Separate questions were asked of the nurse and
analysis from Phases 1 and 2, and then presenting
the Māori client (see Table 2). Qualitative data from
these using the two focused questions (see Table 1).
the interviews and surveys were thematically analysed
Our approach to the analysis was inductive and data
CULTURAL RESPONSIVENESS THE FAMILY using Braun and Clarke’s (2006) AND framework. This PARTNERSHIP driven,MODEL focusing initially on the semantic content of the data.
Table Table 2. 2. Semi-Structured Interview Questions
Semi-Structured Interview Questions Clients’ Questions
Plunket Nurses’ Questions
How do you feel the visit went today?
Can you tell me about your experience with Plunket as a whole?
Do you have any comments about the assessment today?
What do you think are the most important things for a Plunket nurses to offer your family?
Do you think you approach Māori clients and whānau differently to other clients?
How do you think [Plunket Nurse’s name] works in partnership with you?
What aspects of family partnership do you find useful in your practice?
What do you think Plunket nurses need to do to work more effectively with Māori clients and communities?
What do partnership, protection, participation and equality mean for you in practice?
Do you have any comments you would like to add about today?
Are you given the chance to direct the way a visit is going?
Is there anything else you wanted to add?
Survey. Generally, there were some notable differences
Findings
in the precursors and indicators for culturally responsive
The survey response rate was 92% (n=23) for those who
practice between those who had undertaken the
had completed the Family Partnership Model training,
training and those who had not (see Table 4 and 5).
and 92% (n=23) for those who had not completed the
With regard to the precursors to culturally responsive
training (see Table 3). The Family Partnership Model
practice, those who had completed the Family
training group worked for a marginally less length of
Partnership Model training rated higher technical
time at Plunket. Ten matched nurse-Māori client pairs
knowledge as an essential quality than those who
participated in the observations and interviews. The
had not completed the training. However, there was
findings are presented under the following headings:
no appreciable difference between those who had
The effect of the Family Partnership Model training on
and those who had not completed the training in how
nursing practice, and Meeting Māori clients’ needs.
they rated the qualities of humility, respect, quiet enthusiasm, and personal integrity. Furthermore,
The effect of the Family Partnership Model training
those who had completed the training rated
on nursing practice
interpersonal and emotional attunement and empathy
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 4
Table 4.
Survey Responses: Precursors for Culturally Responsive Survey Responses: Precursors for Culturally Responsive PracticePractice No Family Partnership Model Training (N=23) Frequency Distribution (%(n))
Survey Questions General Communication
Family Partnership Model Training (N=23) Frequency Distribution (%(n))
Not good
Could be better
Quite good
Very good
Median
Not good
Could be better
Quite good
Very good
Median
0
0
43.5 (10)
56.5 (13)
4
0
0
72.7% (16)
22.7 (5)
3
Not important
Quite important
Very important
Essential
Median
Not important
Quite important
Very important
Essential
Median
Humility
4.5 (1)
4.5 (1)
18.2 (4)
72.7 (16)
4
0
4.5 (1)
18.2 (4)
77.3 (17)
4
Respect
0
0
13.6 (3)
86.4 (19)
4
0
0
9.1 (2)
90.9 (20)
4
Communication (verbal, non-verbal and written) Importance of qualities when working with Māori clients and whānau1
4.5 (1)
0
50.0 (11)
45.5 (10)
3
0
0
50.0 (11)
50.0 (11)
3
Technical knowledge
0
22.7 (5)
54.2 (12)
22.7 (5)
3
0
13.6 (3)
54.5 (12)
31.8 (7)
3
Interpersonal and emotional attunement
0
4.5 (1)
18.2 (4)
77.3 (17)
4
0
4.5 (1)
27.3 (6)
68.2 (15)
4
Empathy
0
4.5 (1)
13.6 (3)
81.8 (18)
4
0
9.1 (2)
22.7 (5)
68.2 (15)
4
Personal integrity
0
0
13.6 (3)
86.4 (19)
4
0
0
13.6 (3)
86.4 (19)
4
Not good
OK
Good
Excellent
Median
Not good
OK
Good
Excellent
Median
Attention/active listening
0
0
63.6 (14)
36.4 (8)
3
0
4.5 (1)
45.5 (10)
50.0 (11)
3
Prompting and exploration
0
22.7 (5)
54.5 (12)
22.7 (5)
3
0
0
81.8 (18)
18.2 (4)
3
Empathetic responding
0
4.5 (1)
68.2 (15)
27.3 (5)
3
0
4.5 (1)
63.6 (14)
31.8 (7)
3
Enthusing and encouraging
0
4.5 (1)
63.6 (14)
31.8 (7)
3
0
9.1 (2)
50.0 (11)
40.9 (9)
3
Enabling changes in ideas
0
40.9 (9)
59.1 (13)
0
3
0
40.9 (9)
54.5 (12)
4.5 (1)
3
Negotiating
0
27.3 (6)
59.1 (13)
13.6 (3)
3
0
27.3 (6)
59.1 (13)
13.6 (3)
3
Problem management
0
18.2 (4)
72.7 (16)
9.1 (2)
3
0
22.7 (5)
68.2 (15)
9.1 (2)
3
Quiet enthusiasm
Communication Skills with Māori clients and whānau
Confidence in:2
Not very confident
Moderately confident
Very confident
Median
Not very confident
Moderately confident
Very confident
Median
4.5 (1)
68.2 (15)
27.3 (6)
2
4.5 (1)
54.5 (12)
40.9 (9)
2
Participating in Māori health community initiatives
50.0 (11)
45.5 (10)
4.5 (1)
1
22.7 (5)
59.1 (13)
18.2 (4)
1
Responding to the needs of Māori whānau and communities
27.3 (6)
63.6 (14)
9.1 (2)
2
9.1 (2)
68.2 (15)
22.7 (5)
2
Working with Māori clients/whānau
Note: 1 1 = Not important/Not good
4 = Essential/Excellent; 2 1 = Not very confident
3 = Very confident
Nursing Praxis in New Zealand CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 5
Table 5.
Survey Responses: Indicators of Cultural Responsiveness
Survey Responses: Indicators of Cultural Responsiveness
No Family Partnership Model Training (N=23) Frequency Distribution (%(n))
Survey Questions
Family Partnership Model Training (N=23) Frequency Distribution (%(n))
Not well
Could be better
Quite well
Very well
Median
Not well
Could be better
Quite well
Very well
Median
0
21.7 (5)
60.9 (14)
17.4 (4)
3
0
4.5 (1)
72.7 (16)
22.7 (5)
3
Not well
Could be better
Quite well
Very well
Not well
Could be better
Quite well
Very well
0
0
43.5 (10)
56.5 (13)
4
0
4.5 (1)
54.5 (12)
40.9 (9)
3
Rarely
Sometimes
Often
Always
Median
Rarely
Sometimes
Often
Always
Median
0
4.3 (1)
26.1 (6)
56.5 (13)
4
0
4.5 (1)
72.7 (16)
22.7 (5)
3
Not easily
Could be better
Quite easily
Very easily
Median
Not easily
Could be better
Quite easily
Very easily
Median
0
22.7 (5)
68.2 (15)
13.6 (3)
3
0
9.1 (2)
68.2 (15)
22.7 (5)
3
Not well
Could be better
Quite well
Very well
Median
Not well
Could be better
Quite well
Very well
0
50.0 (11)
45.5 (10)
9.1 (2)
3
0
36.4 (8)
45.5 (10)
18.2 (4)
3
Not well
Moderately well
Above average
Very well
Median
Not well
Moderately well
Above average
Very well
Median
Partnership
0
31.8 (7)
27.3 (6)
40.9 (9)
3
0
13.6 (3)
40.9 (9)
45.5 (10)
3
Participation
0
31.8 (7)
36.4 (8)
31.8 (7)
2
0
18.2 (4)
54.5 (12)
27.3 (6)
3
Protection
0
50.0 (11)
18.2 (4)
31.8 (7)
3
0
36.4 (8)
31.8 (7)
31.8 (7)
3
Equality
0
27.3 (6)
36.4 (8)
36.4 (8)
3
0
18.2 (4)
50.0 (11)
31.8 (7)
3
Communication How well do you communicate with Māori Plunket clients? Decision Making How well do you think you involve Māori parents/caregivers and/or whānau in decisions relating to their care? How often do you make clinical decisions mostly upon the client’s needs and preferences (when working with Māori specifically)? Service How easily do you make contact/engage with Māori Plunket clients?
How well do you think your service/practice meets the needs of Māori Plunket clients? Delivery of Treaty of Waitangi principles
Note:
1 = Not well/Rarely/Not easily
4 = Very well/Always/Very easily
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand
CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 3 Table 3.
Treaty of Waitangi Training and of Years of Practice Treaty of Waitangi Training and Years Practice No Family Partnership Model Training (N=23)
Family Partnership Model Training (N=23)
Overall
91.3% (n=21)
100% (n=23)
95.6% (n=44)
1-2 years
21.7% (n=5)
9% (n=2)
15.2% (n=2)
3-5 years
26.1% (n=6)
48% (n=11)
34.8% (n=16)
6-10 years
34.8% (n=8)
22% (n=5)
28.3% (n=13)
≥11 years
17.4% (n=4)
22% (n=5)
19.6% (n=9)
No response
4.3% (n=1)
0 (n=0)
2.2% (n=1)
Completed Treaty of Waitangi Training
(N=46)
Years worked for Plunket
as less essential than those who had not completed
to improving health outcomes, there was little
the training. With regard to communication skills,
evidence that nurses evaluated their practice about
those who had completed the training rated higher
what worked or did not work and whether they were
attention/active listening (as excellent), and prompting
making a difference. Two themes were generated from
and exploration (as good or excellent) than those had
the interviews with regard to the effect of the Family
not undertaken the training. The Family Partnership
Partnership Model training on the nurses’ practice:
Model training appeared to improve nurses’ confidence
Having respectful relationships and Being client-led,
in working with Maori clients/whanau, participating
which were consistent with the survey findings.
in Maori community activities, and responding to whanau and community needs (see Table 4). With
Having respectful relationships. Having respectful
regard to indicators of cultural responsiveness, overall
relationships
little difference existed between the two groups except
partnerships with Māori clients. Respect was conveyed
those who had not completed the training were more
in the nurses’ body language and actions (such as being
likely to make clinical decisions based on clients’ needs
courteous and showing an interest in Māori clients
and preferences (see Table 5).
and their extended whānau), and was considered
were
essential
for
establishing
necessary for widening the scope of discussions with Observations. Overall, nurses’ practice demonstrated moderate
evidence
of
interpersonal
and
communication skills (see Table 6). While there was moderate evidence of eye contact (3.9), being non-threatening (3.9), and appropriate sensitivity (3.8), there was less evidence of assertiveness (3.1)
Māori clients. I think sometimes we’re a bit wary when we shouldn’t be and if we just treat everybody with the same amount of respect... Hopefully you build up that relationship where you know what
and sense of humour (2.6). Nurses’ were reluctant
your client wants from you. (Nurse)
to discuss cultural issues and challenge parenting
It’s just like when she greets you and stuff like
practises not congruent with current evidence, and
that. Then they greet the kids. It makes you feel
avoided being disrespectful to or offending Māori
good about having that person in your house.
clients. Despite generally demonstrating commitment
(Client)
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
23
Nursing Praxis in New Zealand
CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 6
Table 6. Observation of Interpersonal and Communication Skills
Observation of Interpersonal and Communication Skills
Interpersonal and Communication Skills
Median Score (1-5)
Warmth
3.5
Listening skills
3.5
Humility
3.6
Appropriate confidence
3.4
Positive, open body language
3.6
Eye contact
3.9
Assertiveness
3.1
Enthusiasm
3.5
Genuineness
3.5
Non-judgemental
3.6
Non-threatening
3.9
Sense of humour
2.6
Appropriate sensitivity
3.8
Note: Maras et al. (2006); 1 = Very little evidence, 5= Considerable evidence
Establishing respectful relationships was driven
with family that’s working with them all the
by a fear of damaging the relationship with clients
time, and supporting … they want that support
and whānau by a range of complex variables. Thus,
and you don’t want to upset that relationship.
nurses actively avoided discussing cultural issues
It’s quite tricky. (Nurse)
or challenging parenting practices that were not ‘evidence based’, for example, which were considered
Humility, being non-judgemental, empathy, listening,
disrespectful or would cause offence. Nurses were also
understanding clients’ experiences, and being inclusive
sensitive to damaging clients’ relationships with their
and willing to change practice were other qualities
whānau by offering conflicting advice or interventions
nurses believed to be essential in order to establish
that were different to what whānau provided or
trust with Māori clients and their whānau.
suggested. …acknowledging his Mum there, she was like, It’s all very well for us to be in there 20 minutes
“Oh hi, how are you?” That was really good.
every couple of months, but they’re dealing
Because our family is really family oriented,
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand including everyone else was really good. (Client)
are coming from a place that we’re working for them. It’s not just coming down on them. It’s
Being client-led. Being client-led involved providing an
saying, “You love your baby and you want to
approach that created an ‘environment’ that enabled
keep it safe.” (Nurse)
clients to participate freely and willingly. It also required nurses to resist urges to provide solutions.
Nurses indicated health literacy influenced their ability
The nature of the client-nurse relationship influenced
to respond to client-centred needs, priorities, and
clients’ determination as to whether a service was
confounding influences. Those clients with higher
appropriate and met their needs.
levels of health literacy were more able to articulate their needs. A fine line exists between challenging
We are not going to be effective just by telling
parenting
practices
and
everybody what to do, that they actually have to
confidence and capability.
undermining
clients’
find out themselves.…If you don’t have a good relationship, it’s not going to be a happening
If she asks more complex questions, she’s
thing. (Nurse)
probably getting a more complex answer from me, whereas a mother with a low level of
Homes were clients’ preferred environment because it
education may not even ask that question. With
reduced anxiety and increased their control within the
the lower health literacy, I’m trying to ask the
partnership. In addition, it eliminated the logistically
questions and fathom out where the thinking is
difficult task of getting to a clinic with small children.
at. (Nurse)
Successful client-led practice involved not only professional and technical expertise, but an ability to
Meeting Māori clients’ needs.
include the client and their whānau, inviting them to
Family Partnership Model training appeared to
ask questions and direct the conversation to identify
improve nurses’ perceptions about how well they
their needs.
communicated with Maori Plunket clients, although they were less likely, than those who received no
The Family Partnership Model Training increased
training, to rate including Maori parents/caregivers
nurses’ focus on engagement and the establishment of
and whanau in care-related decisions as quite well or
meaningful relationships with Māori clients, indicating
very well. However, a difference was noted for those
that they were better positioned to meet their needs.
who had not completed the training indicating that
The following nurse’s comment typifies a shift in
they more often or always made decisions based on
practice:
Maori client needs and preferences. Nevertheless, Family Partnership Model training signified nurses’
The parents make the decisions… we can jump
greater ease when making contact and engaging with
up and down and say this is by far the safest and
Maori Plunket clients, and that their service or practice
these awful things can happen if you continue
met their needs. In terms of delivering the Treaty of
to do this, but I’m not going to go in there each
Waitangi principles of partnership, participation,
night and tuck the baby into bed. They’ve got to
protection, and equality, nurses who had completed
be responsible to make the decision. They need
their training rated they did so as above average or
to trust us so that so that they know that we
very well – higher than those who had not completed
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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand the training (see Table 5). The theme emerging from
has different backgrounds and stuff. (Client)
the interview data in relation to meeting the clients’ needs was lacking the skills.
While nurses’ ethnicity was not an issue for many clients, there was a desire to see more Māori nurses
Lacking the skills. The Family Partnership training
who possessed knowledge of Māori language and
qualitatively influenced most dimensions of nurses’
culture, and understood concepts such as humility.
practice (Tables 4 and 5), although nurses did report
Some clients indicated a preference for a Māori nurse,
lacking the skills for working with Māori clients and
as they were better able to understand their social and
whānau. Importantly for clients, being Māori was
cultural realities:
about their culture and identity, which contrasts with stereotypical, deficit views that health professionals
I found that the Māori lady [the nurse] was
often adopt. The following Māori client stressed the
more, she knew our struggles, she didn’t know
importance of their Māori identity while exemplifying
us personally but she knew of our struggles. It
the complexity that occurs when health professionals’
was her that asked about if we needed anything
mistakenly offer stereotyped or deficit views for their
… and … said that she knew how we have
culture:
struggled and she was willing to help. (Client)
I think what a lot of Māori are complaining
Māori clients and some nurses indicated that providing
about is that they’re being classed as Māori,
a culturally safe and responsive service and workforce
which is strange because they’re also wanting
required growing the Māori well child nurse and
to be known as Māori. It’s terrible. We want to
kaiawhina workforce because non-Māori nurses may
be proud as being Māori, but we don’t want to
lack the necessary skills to work with this group. For
be categorised as Māori either. (Client)
example, Māori nurses and kaiawhina (qualified health workers who work with Plunket nurses to deliver
Nurses showed a genuine interest in clients ‘being
services and support parents and whānau) offered
Māori’ (that is, their culture and identity), and this was
different views and ways of engaging with Māori
confirmed by clients. While viewing equal treatment
clients to improve engagement with vulnerable Māori
as important, they did recognise clients may have
whānau, and increase the cultural responsiveness of
different perspectives and priorities, and that
nurses and the well-child service.
identification of culture was essential for supporting clients.
I am often asked if they can have a Māori Plunket nurse. Unfortunately there are none in my area She [nurse] acknowledges the fact that we’re
so I let them know I work in partnership with
Māori, so that’s pretty cool and the fact that
a Kaiawhina and if they want we can co-visit.
when she asks us what books we wanted, what
I don’t think doing a TOW [Treaty of Waitangi]
language - she actually done it for us. (Client)
workshop gives me the skills to work with
I think everyone should be treated equally but at the same time, they should acknowledge everyone’s culture…. I think it would be good in a way because you can relate better. Everyone
Page 45
Māori clients, maybe working with a group of Māori mums and asking what they want from Plunket would be a better way to go and reflect the contract to their needs as well. (Nurse)
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Nevertheless, clients in high need communities
tikanga is built on the foundation of respect for one
reported some nurses’ desensitisation led them to
another and the differences inherent within and
disregard their realities and engage in culturally non-
between groups of people. Family Partnership Model
responsive and disrespectful practice (calling without
training highlights the importance of recognising the
appointments, for example). This contributed to clients
culture of Māori clients and their whānau, encouraging
reporting that they could not plan their days, and led
nurses to take a holistic view in order to be culturally
some to not be at home or keep appointments.
safe and responsive, and make a difference for clients. However, we found that nurses did not routinely
. . . maybe before she comes, just to text and
evaluate the effectiveness of their practice, and client-
say she’s on her way, because sometimes I’ll be
related health literacy could influence the degree of
in the shower and then she’ll come and I don’t
client engagement in the partnership with nurses.
know if she’s been or not. Or like I wait all day and they don’t come at all, which has happened
While significant differences were noted in terms
to me with some services, not Plunket. (Client)
of the development of qualities considered to be the necessary precursors for culturally responsive
Discussion
practice, translation of Family Partnership Model
Plunket’s organisational philosophy is, “The best start
learning into nurses’ everyday practice with Māori
for every child”. Parents and whānau together with
clients and whānau requires ongoing support. Nurses’
well child nurses play crucial roles in providing that
self-report that they communicate, make contact and
‘best start’ for Māori children. Cultural competence
engage with Māori clients, involve parents in care-
and cultural responsiveness are key components
related decisions, make decisions based on clients’
of quality care, contingent on the development of
needs and preferences, and think they meet their
relationships and trust necessary to promote reciprocal
needs. However, the lack of consistent differences
and open interactions (Wiggins, 2008). Health, social
across all indicators between those who had Family
beliefs and practices are shaped by Māori clients’
Partnership Model training and those who had not
cultural orientation, and are complexly impacted and
(supported by the interview findings), highlighted
compounded by the intersectionality of inequities,
areas that nurses need more confidence with in regard
poverty, colonisation, health literacy, and racism (Kelly,
to being culturally responsive. This highlights the need
2009). Undoubtedly, persistent inequities perpetuate
for the Family Partnership Model training to focus
vulnerability and compromise health outcomes
more on translating, engaging and working with Māori
(Barber, 2013).
into nurses’ practice to improve their confidence and competence. While the suggestion to grow the
Family Partnership Model training appears to develop
Māori nurse and kaiawhina workforce by nurses and
some of the necessary qualities that are precursors for
clients is an area for attention, the reality is the Māori
culturally responsive nursing practice. A well known
nursing workforce remains small (Nursing Council of
whakataukī (Māori proverb), kāhore te kūmara e
New Zealand, 2012) – reinforcing the need to also
kōrero mo tāna reka – the kumara does not speak of its
strengthen the existing well child nursing workforce to
own sweetness, highlights the importance of humility
work with Māori.
within Māori culture, especially for connecting with Māori clients (Mead, 2003; Smith, 2012). In addition,
Page 46
Fowler et al. (2012) found adopting the Family
Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Partnership Model was a “complex and dynamic
Zealand, 2011). Such explorations should be ongoing
process” (p.3306) requiring nurses to take on new
and be experientially based. Bellon-Harn and Garrett
practices and approaches, such as becoming “navigators
(2008) recommend using a VISION model to improve
and shapers” (Hopwood, Fowler, Lee, Rossiter, &
cultural responsiveness, as it provides structure to
Bigsby, 2013, p. 207). In addition to committing to
exploring self, forming client relationships, interaction
changing practice styles and approaches, nurses need
styles, and strategies to achieve needs, expectations
to critically examine their practice in order to make
and goals by both the health professional and family,
necessary changes, including challenging negative
aided by the use of vignettes.
thoughts and beliefs they may have (Fowler et al., 2012). Further areas of development include evaluating
The limitations of this study should be noted and
whether their practice was effective, and assessing and
caution used in using the findings beyond the
adapting practice according to clients’ health literacy
participant group. While the observational assessment
levels. Development of culturally responsive practice
ratings using the Interpersonal Skills Rating Scale
requires ongoing support and guidance in the form of
were relatively subjective, triangulating the interview
mentorship (Wiggins, 2008) and clinical supervision
data with the observation data strengthened the
(Keatinge, Fowler, & Briggs, 2008).
researcher’s assessment of nurses’ practice. The noninclusion of whānau in Phase 2 interviews meant
The desensitisation of some nurses resulted in
that limited feedback was obtained regarding the
disrespectful and culturally non-responsive practice,
partnership between the nurse and the wider whānau.
and is noteworthy. There is an increasing body of
Furthermore, the survey collected self-reported
national and international literature that reports
information that could not be verified. Future research
health professionals’ practice that lacks sensitivity to
would benefit from using a pre-post intervention
clients’ life circumstances and realities, and that is
research design.
discriminatory toward those belonging to Indigenous and minority groups, negatively impacts client
Conclusion
outcomes (Bearskin, 2011; Browne & Fiske, 2001;
The Family Partnership Model training that well child
Harris et al., 2012; Human Rights Commission, 2011;
nurses undertake appears to develop some of the
Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe,
necessary qualities for developing partnerships with
2010). In addition to the cultural responsiveness
vulnerable families. However, with regard to translating
indicators providing areas to focus the development
this training into practice with Māori clients, further
and contextual relevance of the Family Partnership
work is required to support and assist nurses to put this
Model training, such training should also focus on
into practice, particularly when it comes to exploring
exploring nurses’ own socialisation, cultural identity,
clients’ cultural backgrounds and challenging their
and values and beliefs that can impact on their
parenting practices. Culturally responsive practice is
practice and development of relationships (Bellon-
contingent on nurses developing partnerships with
Harn & Garrett, 2008; Ibrahim, 2010). These areas
vulnerable families, often from different cultural
are fundamental for the development of culturally
backgrounds, but to benefit the whānau and work with
safe practice, which is a regulated competency all
them to provide infants with the ‘best start’, they need
registered nurses should meet (Nursing Council of New
ongoing support, mentorship and/or supervision.
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Nursing Praxis in New Zealand References Anderson, J., Rodney, P., Reimer-Kirkham, S., Browne, A. J., Khan, K. B., & Lynam, M. J. (2009). Inequities in health and healthcare viewed through the ethical lens of critical social justice: Contextual knowledge for the global priorities ahead. Advances in Nursing Science, 32(4), 282-294. doi:10.1097/ANS.0b013e3181bd6955 Barber, P. (2013). Reducing inequality. In M. Rashbrooke (Ed.), Inequality: A New Zealand crisis (pp. 167-180). Wellington, New Zealand: Bridget Williams Books. Bearskin, R. L. B. (2011). A critical lens on culture in nursing practice. Nursing Ethics, 18(4), 548-559. doi:10.1177/0969733011408048 Bellon-Harn, M. L., & Garrett, M. T. (2008). VISION: A model of cultural responsiveness for speech-language pathologists working in family partnerships. Communication Disorders Quarterly, 29(3), 141-148. doi:10.1177/1525740108315879 Braun, D., Davis, H., & Mansfield, P. (2006). How helping works: Towards a shared model of process. London, UK: Parentline Plus. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77-101. doi: 10.1191/1478088706qp063oa Browne, A. J., & Fiske, J. A. (2001). First Nations women’s encounters with mainstream health care services. Western Journal of Nursing Research, 23(2), 126-147. Davis, H., Day, C., & Bidmead, C. (2002). Working in partnership with parents: The parent adviser model. London, UK: Harcourt Assessment. Fowler, C., Rossiter, C., Bigsby, M., Hopwood, N., Lee, A., & Dunston, R. (2012). Working in partnership with parents: The experience and challenge of practice innovation in child and family health nursing. Journal of Clinical Nursing, 21(21-22), 3306-3314. doi:10.1111/j.1365-2702.2012.04270.x Gifford, H., Wilson, D., Boulton, A., Walker, L., & Shepherd-Sinclair, W. (2013). Māori nurses and smoking: What do we know? New Zealand Medical Journal, 126(1384), 53-63. Harris, R., Cormack, D., Tobias, M., Yeh, L-C., Talamaivao, N., Minster, J., & Timutimu, R. (2012). The pervasive effects of racism: Experiences of racial discrimination in New Zealand over time and associations with multiple health domains. Social Science & Medicine, 74(3), 408-415. doi:10.1016/j.socscimed.2011.11.004 Hopwood, N., Fowler, C., Lee, A., Rossiter, C., & Bigsby, M. (2013). Understanding partnership practice in child and family nursing through the concept of practice architectures. Nursing Inquiry, 20(3), 199-210. doi:10.1111/nin.12019 Human Rights Commission. (2011). Structural discrimination: The need for systemic change to achieve racial equality (A discussion paper by the Human Rights Commission). Wellington, New Zealand: Human Rights Commission. Ibrahim, F. A. (2010). Social justice and cultural responsiveness: Innovative teaching strategies for group work. Journal for Specialists in Group Work, 35(3), 271-280. doi:10.1080/01933922.2010.492900 Isaacs, A. N., Pyett, P., Oakley-Browne, M. A., Gruis, H., & Waples-Crowe, P. (2010). Barriers and facilitators to the utilization of adult mental health services by Australia’s Indigenous people: Seeking a way forward. International Journal of Mental Health Nursing, 19(2), 75-82. doi:10.1111/j.1447-0349.2009.00647.x Keatinge, D., Fowler, C., & Briggs, C. (2008). Evaluating the Family Partnership Model (FPM) program and implementation in practice in New South Wales, Australia. Australian Journal of Advanced Nursing, 25(2), 28-35. Kelly, U. (2009). Integrating intersectionality and biomedicine in health disparities research. Advances in Nursing Science, 32(2), E42-E56. doi:10.1097/ANS.0b013e3181a3b3fc Maras, P., Faulkner, N., & Wills, J. (2006). Working with parents, schools and communities - making a difference: An Evaluation of the Bromley Children Project. London, England: The University of Greenwich. Retrieved from http://www2.gre.ac.uk/__data/ assets/pdf_file/0006/679065/Bromley_Children_Final_Report.pdf Marie, D., Fergusson, D. M., & Boden, J. M. (2008). Ethnic identification, social disadvantage, and mental health in adolescence/young adulthood: Results of a 25 year longitudinal study. Australian and New Zealand Journal of Psychiatry, 42(4), 293-300. Mead, H. M. (2003). Tikanga Māori: Living by Māori values. Wellington, NZ: Huia. Metge, J. (1995). New growth from old: The whānau in the modern world. Wellington, New Zealand: Victoria University Press. Ministry of Health. (2010). Tatau kahukura: Māori health chart book 2010 (2nd ed.). Wellington, NZ: Author. Ministry of Health. (2012a). The health of New Zealand adults 2011/12: Key findings of the New Zealand Health Survey. Wellington, NZ: Author. Retrieved from http://www.health.govt.nz/publication/health-new-zealand-adults-2011-12
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Nursing Praxis in New Zealand Ministry of Health. (2012b). The health of New Zealand children 2011/12: Key findings of the New Zealand health survey. Wellington, NZ: Author. Retrieved from http://www.health.govt.nz/system/files/documents/publications/health-of-new-zealand-child2011-12-v2.pdf Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of Waitangi, and Maori health in nursing education and health. Wellington, NZ: Author. Retrieved from http://www.nursingcouncil.org.nz/download/97/cultural-safety11.pdf Nursing Council of New Zealand. (2012). The New Zealand nursing workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2011. Wellington, NZ: Author. Retrieved from http://nursingcouncil.org.nz/Publications/Reports Pauly, B., MacKinnon, K., & Varcoe, C. (2009). Revisiting “who gets care?”: Health equity as an arena for nursing action. Advances in Nursing Science, 32(2), 118-127. doi:10.1097/ANS.0b013e3181a3afaf Poulton, R., Caspi, A., Milne, B. J., Thomson, W. M., Taylor, A., Sears, M. R., & Moffitt, T. E. (2002). Association between children’s experience of socioeconomic disadvantage and adult health: A life-course study. The Lancet, 360(9346), 1640-1645. Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu (unpublished doctoral dissertation). Victoria University of Wellington, Wellington, New Zealand. Retrieved from http://culturalsafety.massey.ac.nz/thesis.htm Ritchie, J. (2007). Childrearing practices and attitudes. In A. Weatherall, M. Wilson, D. Harper, & J. McDowall (Eds.), Psychology in Aotearoa / New Zealand (pp. 48-58). Auckland, NZ: Pearson. Robson, B., & Harris, R. (Eds.). (2007). Hauora: Māori standards of health IV. A study of the years 2000-2005. Wellington, NZ: Te Rōpū Rangahau Hauora a Eru Pōmare. Retrieved from http://www.hauora.maori.nz Rossiter, C., Fowler, C., Hopwood, N., Lee, A., & Dunston, R. (2011). Working in partnership with vulnerable families: The experience of child and family health practitioners. Australian Journal of Primary Health, 17(4), 378-383. doi:10.1071/PY11056 Royal New Zealand Plunket Society. (2012). Submission on the Inquiry into the determinants of wellbeing for Māori children. Retrieved from http://www.plunket.org.nz/assets/What-we-do/Submissions/Wellbeing-for-Maori-Children.pdf Smith, L. T. (2012). Decolonizing methodologies: Research and indigenous peoples (2nd ed.). London: Zed Books. Statistics New Zealand. (2013). 2013 Census quick statistics about Māori. Retrieved from http://www.stats.govt.nz/Census/2013census/profile-and-summary-reports/quickstats-about-maori-english.aspx Te Puni Kōkiri. (2011). Māori families and households. Retrieved from www.tpk.govt.nz/documents/download/227/tpkmaorifamilies-2011.pdf Tipene-Leach, D. (2012). Viewpoint: Is the ‘safer’ sleeping environment the remaining holy grail of SUDI prevention? In E. Craig, J. Adams, G. Oben, A. Reddington, A. Wicken, & J. Simpson (Eds.), Te Ohonga Ake: The health status of Māori children and young people in New Zealand (pp. 29-31). Dunedin, New Zealand: NZ Child and Youth Epidemiology Service. Retrieved from http:// dnmeds.otago.ac.nz/departments/womens/paediatrics/research/nzcyes/pdf/Health_Status_of_Maori_Children_and_Young_ People_in_New_Zealand.pdf Walker, R. (2004). Ka whawhai tonu mātou: Struggle without end (Rev. ed.). Auckland, New Zealand: Penguin. Werkmeister-Rozas, L., & Klein, W. C. (2009). Cultural responsiveness in long-term-care case management: Moving beyond competence. Care Management Journals, 10(1), 2-7. doi:10.1891/1521-0987.10.1.2 Wiggins, M. S. (2008). The partnership care delivery model: An examination of the core concept and the need for a new model of care . Journal of Nursing Management, 16(5), 629-638. doi:10.1111/j.1365-2834.2008.00900.x Wilson, D. (2008). The significance of a culturally appropriate health service for indigenous Māori women. Contemporary Nurse, 28(12), 173-188. Wilson, D., & Barton, P. (2012). Indigenous hospital experiences: A New Zealand case study. Journal of Clinical Nursing, 21(15-16), 2316-2326. doi:10.1111/j.1365-2702.2011.04042.x
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Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses. • Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession. Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal in PDF format. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board. Nursing Praxis in New Zealand publishes original research, discursive papers (including conceptual, position papers and critical reviews that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession. Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org
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