IN NEW ZEALAND Journal of Professional Nursing
INSIDE THIS ISSUE... A new model: The family and child centered care model Duty of care following stroke: Family experiences in the first six months Diffusion of the primary health care strategy in a small district health board in New Zealand Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study
Volume 31. No. 3
NOVEMBER 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, Mandie Foster RN, Tineke Water RN,
RM, PhD PhD, FCNA (NZ) PhD PhD, FCNA (NZ) PhD, FCNA (NZ) PhD, MCNA (NZ) PhD PhD
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: A new model: The family and child centered care model
Mandie Foster.............................................................................................................................. 4
ARTICLES: Duty of care following stroke: Family experiences in the first six months
Andrew Duthie, Dianne Roy, Elizabeth Niven ............................................................................... 7
Diffusion of the primary health care strategy in a small district health board in New Zealand
Heather Robertson, Jenny Carryer, Stephen Neville .................................................................... 17
Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study
Anecita Gigi Lim, Michelle Honey, Nicola North, John Shaw ....................................................... 27
NOTES FOR CONTRIBUTORS.............................................................................................................. 37
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand EDITORIAL A NEW MODEL: THE FAMILY AND CHILD CENTERED CARE MODEL In this editorial, I would like to propose a new paediatric
(Foster, Whitehead, & Maybee, 2010). Theorists
model of care that could be developed and utilised
and clinicians suggest developing paediatric nursing
in practice. I recently presented about the history,
frameworks, practice models, interventions and
development and relevance of family centered care
strategies to support the key principles of FCC
(FCC) and child centered care (CCC) to the paediatric
(Coyne, Murphy, Costello, O’Neill, & Donnellan, 2013).
staff at Christchurch Hospital. The following is a
International institutes, institutional endorsements,
summary of my presentation.
governmental policies and directives are further vehicles used to support FCC practice (Shields, 2010).
Family centered care is a model where care delivery is
Nursing experts propose that through increased self-
centered on the whole family, not just the ill child and
awareness, cultural sensitivity, safety and knowledge
includes a partnership approach through negotiation,
of the power differences and symmetries/asymmetries
trust, respect and building therapeutic relationships
of care provision between staff, parents and children
between staff, parents and children (Shields, Pratt,
a more realistic approach to FCC practice is attainable
Davis, & Hunter, 2007). Despite fifty years of ongoing
(Foster, Whitehead, Maybee, & Cullens, 2013).
research, education and theory into the development, translation and impact of FCC there continues to be
Questions on how children’s rights and CCC can be
difficulties in effectively operationalising this model of
operationalised effectively within a FCC model are
care within paediatrics for staff, parents and children.
a recent development (Corlett & Watson, 2014). It appears from the literature that CCC is embedded
Educational facilities, healthcare institutions and
within a FCC model (Foster, 2013). Clinicians propose
clinicians appear to use a mix of theoretical perspectives
that by integrating the socio-political cultural and
to inform family nursing that are contextually or
ethical contexts of children’s nursing into a FCC practice,
personally driven (Bell 2013). Wright and Leahey
a more child centered approach is achievable (Coyne
(1990) refer to family nursing as the ‘family as context’
& Cowley, 2007). Theorists also suggest that by using
approach where the individual is forefront and the
cultural safety and ethical symmetry as adjuncts to FCC
family is situated in the background. Shields (2010)
the social and cultural contexts of children’s lives will
refers to FCC within paediatrics as care provision that
guide practice and support a child focused approach
includes the whole family. Carter, Bray, Dickinson,
(Randall, Munns, & Shield, 2013).
Edwards and Ford (2014) refers to CCC as the child being forefront and visible within a FCC model where
To re-define FCC or CCC when both models
children’s needs and interests are at the centre of one’s
place the family and child as the central focus of
thinking and practice.
healthcare provision seems flawed especially when recommendations for alternatives are limited. Corlett
Debates over rethinking and questioning the concepts that underpin FCC and whether FCC is an appropriate attainable model of care within paediatrics continues
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Foster, M. (2015). Editorial: The family and child centered care model. Nursing Praxis in New Zealand, 31(3), 4-6.
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand and Watson (2014) suggest FCC needs to be re-defined
providers profess to be culturally, ethically, sensitive
to ‘child and family centered care’ as a way to integrate
and safe when the model of care used fails to address
children’s rights, parents’ rights and contemporary
the client/child within it? There are many tools available
child care policies. I suggest FCC and CCC should be re-
to measure adult perceptions of FCC with no tool
named to ‘family and child centered care’ (FCCC) with
available to measure children’s perception of CCC.
the child coming after family. This would appear a more
The ‘needs of children’s questionnaire’ has just been
realistic title as it is the parents’ legal responsibility and
developed and pilot tested and measures the school
right to safeguard, protect and promote their child’s
aged child’s hospital experience as a means to measure
health, development and welfare and offer guidance
CCC. The tool will set a benchmark for CCC and ways to
to their child in a manner appropriate to that child’s
enact children as active research and care recipients.
developmental level. The parents and family are the child’s main source of strength and support, and are
My presentation to the paediatric staff at Christchurch
the one constant in the child’s care. Staff need to act
Hospital highlighted the absence of a paediatric model
as facilitators for parents to best meet the child’s
of care that includes the family and child as visible and
psychosocial, physical and emotional needs. This then
forefront to healthcare provision. Family nursing and
respects and honors the parents’ and child’s rights and
FCC centers on the family whereas patient centered
is proportionally placed with the child visible yet under
care and CCC centers on the patient/child. In essence
the safe guidance of the family. Family here means
an institution’s vision and mission statement need
whoever has the legal guardianship rights for the child
to include the positive health outcomes for the child
(Carter et al., 2014).
and family. An amalgamation of FCC and CCC needs to occur to create a FCCC model that includes both
I also suggest rewording the Institute of Patient and
the characteristics of FCC and CCC where the family
Family centered Care (2015) FCC definition to: Family
and child are visible, forefront and equal in healthcare
and child centered care is an approach to the planning,
provision. This model then needs to be used by the
delivery and evaluation of healthcare that is grounded
government, organisations and institutions to plan,
in mutually beneficial partnerships among families/
deliver and evaluate child healthcare provision.
parents, children and healthcare providers. Mandie Foster, RN, PhD, Professional Practice Fellow, To date no framework or tool exists that guides or
Centre for Postgraduate Nursing Studies, University
measures a FCCC approach. How can healthcare
of Otago, Christchurch; Registered Nurse, Paediatric Department, Christchurch Hospital, Christchurch, NZ. Email: mandie.foster@xtra.co.nz
References Bell, J. (2013). Family nursing is more than family centered care. Journal of Family Nursing, 19(4), 411-417. Carter, B., Bray, L., Dickinson, A., Edwards, M., & Ford, K. (2014). Child-centred nursing: Promoting critical thinking. Thousand Oaks, California: Sage Publications Inc. Corlett, J.,& Watson, G. (2014). Family-centred care. In G. Watson & S. Rodwell (Eds.), Safeguarding and protecting children, young people and families: A guide for nurses and midwives (pp. 117-138). Thousand Oaks, California: Sage Publications Inc.
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Coyne, I., & Cowley, S. (2007). Challenging the philosophy of partnership with parents: A grounded theory study. International Journal of Nursing Studies, 44(6), 893-904. doi:10.1016/j.ijnurstu.2006.03.002 Coyne, I., Murphy, M., Costello, T., O’Neill, C., & Donnellan, C. (2013). A survey of nurses’ practices and perceptions of family centered care in Ireland. Journal of Family Nursing, 19(4), 469-488. doi:10.1177/1074840713508224 Foster, M. (2013). Family centered care, in the paediatric critical care setting: Child, parent and staff perspectives (Unpublished doctoral thesis). University of Otago Centre for Postgraduate Nursing Studies, Christchurch, New Zealand. Foster, M., Whitehead, L., & Maybee, P. (2010). Parents’ and health professionals’ perceptions of family centered care for children in hospital, in developed and developing countries: A review of the literature. International Journal of Nursing Studies, 47(9), 1184-1193. doi:10.1016/j.ijnurstu.2010.05.005. Foster, M., Whitehead,L,. Maybee, P., & Cullens, V. (2013). The staff’s, parents’ and hospitalized child’s perception and experiences of family centered care within a paediatric critical care setting: A meta-synthesis of qualitative research. Journal of Family Nursing, 19(4), 431-468. doi:10.1177/1074840713496317. Institute for Patient and Family centered Care. (2015). Institute for Patient and Family centered Care. Retrieved from http://www.ipfcc.org/ Randall, D., Munns, A., & Shields, L. (2013). Next steps:Towards child-focused nursing. Neonatal Paediatric and Child Health Nursing, 16(2), 15-20. Shields, L. (2010). Questioning family-centred care. Journal of Clinical Nursing, 19(17-18), 2629-2638. doi:10.1111/ j.1365-2702.2010.03214.x. Shields, L., Pratt, J., Davis, L., &Hunter, J. (2007). Family-centred care for children in hospital. Cochrane Data Base Systematic Review, 1, CD004811. Wright, L., & Leahey, M. (1990). Trends in nursing of families. Journal of Family Nursing, 15(2), 148-154. doi:10.1111/j.1365-2648.1990.tb01795.x
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand DUTY OF CARE FOLLOWING STROKE: FAMILY EXPERIENCES IN THE FIRST SIX MONTHS Andrew Duthie, BAppSc(HB), MOst, Private Practice, Auckland, NZ Dianne E Roy, RN, PhD, FCNA(NZ), Associate Professor, Unitec Institute of Technology, Auckland, NZ Elizabeth Niven, RN, PhD, Senior Lecturer, Unitec Institute of Technology, Auckland, NZ
Abstract Stroke is the third largest cause of death in New Zealand and is a major cause of disability. While a lot is known about the stroke survivor and the primary family caregiver, little is known about how stroke affects the survivor’s wider family. Hermeneutic phenomenology, guided by the work of Max van Manen, was used in this study to investigate the experience of becoming and being a family member of someone who has had a stroke, over the first six months from the initial stroke. It is part of a larger longitudinal four year project exploring the stroke family lifeworld. Three participants from the same extended family were interviewed in 2011-2012 at six weeks, three months and six months following the stroke of a family member. Thematic interpretive analysis showed that the stroke survivor is not the only person who needs care. The overarching theme was duty of care within and for the whole family. There were three sub-themes: care is different for different people, there are care expectations of self and expectations of others; and care brings strain. The family experience revolved around expectations and obligations of their own duty of care and care needs for themselves and that of the stroke survivor, which were also influenced by issues outside the family. In addition there were considerations of fairness regarding the sometimes competing needs of the survivor and the caregiver. Strains on the family changed over time. Competing values of mercy and fairness within this family took up time and risked shifting the focus away from the stroke survivor.
Keywords Stroke; family; duty; care; experience; New Zealand
Introduction and Background Stroke is the third largest cause of death in New Zealand
primary caregivers’ experience (Bulley, Shiels, Wilkie,
and is a major cause of disability. An estimated 45,000
& Salisbury, 2010; Greenwood, Mackenzie, Cloud, &
people live with a stroke in New Zealand and around
Wilson, 2009; Lutz, Young, Cox, Martz, & Creasy, 2011).
70% are dependent on others to help with their daily
The importance of family in stroke recovery was noted
activities (Stroke Foundation of New Zealand, 2014;
by Vincent et al. (2007) and Brunborg and Ytrehus
Stroke Foundation of New Zealand and New Zealand
(2014) who described how important family, friends
Guidelines Group, 2010). While a lot is known about
and other social networks were to the stroke survivor’s
the impact of stroke on the survivor and the primary
rehabilitation and well-being.
caregiver little is known about how stroke affects the wider family. Impacts such as financial difficulties, strain and isolation have been seen as significant factors on the
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Duthie, A., Roy, D. E., & Niven, E. (2015). Duty of care following stroke: Family experiences in the first six months. Nursing Praxis in New Zealand, 31(3), 7-16. Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand In the New Zealand context Dyall, Feigin, and Brown
stroke where at least two family members agreed to
(2008) and Corbett, Francis, and Chapman (2006)
participate; (2) adequate spoken English to complete
focused their studies on Māori stroke survivors and
consent and the interview. Informed consent was
their caregivers. Dyall et al. (2008), using statistics
obtained in writing at the beginning of the project
from Feigin et al. (2006), argued there is greater health
and on-going verbal consent obtained before each
disparity and financial impact for Māori whānau than
subsequent data collection phase. Consistent with the
non-Māori families, as Māori have strokes at younger
longitudinal project, ‘family’ was defined broadly to
ages; 62 years for Māori compared to 75 years for
include people who live in close relationship with the
Europeans.
stroke survivor. Five families who met inclusion criteria were recruited by intermediaries for the longitudinal
This study is part of a larger longitudinal hermeneutic
project (total participants = 14), with one of these
project
researchers
families consenting to participate in this study. This
from the Department of Nursing, Unitec Institute of
family were recruited as the stroke event coincided
Technology and the Waitemata District Health Board,
with the first author’s availability to complete the
Auckland, New Zealand.
study. The family included the spouse of a stroke
(2011-2015)
undertaken
by
survivor (Ivy) and two other family members (Deb and
Research Design
Jane). All of the participants were health professionals. To maintain anonymity their specific disciplines are not
Aim
disclosed and other identifying data excluded. All data
The aim of this study was to investigate the phenomenon
were anonymised and stored in password protected
of becoming and being a family member of a stroke
digital format only accessible to the research team.
survivor over the period of six months after the initial
Pseudonyms were chosen by the researcher and are
stroke.
used throughout.
Methodology
Data collection
This was an exploratory study using hermeneutic
Face-to-face,
phenomenological research methodology.Hermeneutic
undertaken at six weeks, three and six months post-
phenomenology aims to understand the significance of
stroke (December 2011 – May 2012). The interviews
practical activities and experiences in everyday lives and
were between one to two hours in length and were
is well suited to studying human issues and concerns
held at a mutually agreed location. Interview questions
(Plager, 1994) such as family experiences post-stroke.
focused on participants’ experiences at the time of the
The processes used in the study were guided by those
stroke and in the weeks and months that followed.
described by van Manen (1997).
Preliminary interpretive analysis of interviews at
semi-structured
interviews
were
each time-point informed questions for subsequent Methods
interviews.
Participants for the study were recruited from the larger longitudinal project (Northern X Regional Ethics
Data analysis
Committee: NTX/11/EXP/062/AM02) using purposive
All
sampling strategies. Inclusion criteria were: (1) family
anonymised prior to analysis. Data were analysed
of a person admitted to the Assessment, Treatment
thematically. Theme consolidation was developed
and Rehabilitation (ATR) ward following a first-ever
over time through writing, reflecting and rewriting
Page 8
interviews
were
transcribed
verbatim
and
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand (van Manen, 1997). Mind maps were also used to
reflexive account provides the information necessary
explore relationships between themes, with analytical
for evaluation of the plausibility (rigour) of the findings
processes and decisions recorded in a reflexive journal.
(Koch & Harrington, 1998).
The researcher had regular meetings with the research
Findings
team to discuss analysis and theme development, which opened the interpretation to critique. The overarching theme evolved from words such as care,
Duty of Care
cope, and expectations, which were derived from key
The overarching theme was duty of care. Societal,
phrases used in the participants’ interviews. These
personal and perceived pressures from health
phrases became the building blocks to the overall
professionals over issues surrounding duty of care were
theme of duty of care. The participants explained their
identified as the principal concern of the family’s stroke
caring actions differently, including such factors as who
experience. Duty of care was expressed through three
provides care and who has particular care obligations,
sub-themes: Different for different people; Expectations
which was reflected in the sub-themes. The overarching
of self and expectations of others; and Strain. These
theme of duty of care was reflective of all participants’
themes interacted and contributed to the primary
experiences, albeit not necessarily mirrored by each
author’s interpretation of the stroke experience
at every time point. The analytical processes used
(Figure 1).
support the credibility of the interpretation and the
DUTY OF CARE FOLLOWING STROKE: FAMILY EXPERIENCES IN THE FIRST SIX MONTHS
Duty of Care
Health system
E DOC Ivy
D
S
Family E = They have a DOC to Ivy & Dave
Key E = Expectations S = Strain D = Differently DOC = Duty of Care
S = Balancing other
E = Mercy? Ivy
obligations
S
Government E DOC Ivy Just to society
D = DOC Dave
Conflict Mercy for Ivy vs Fairness Dave
Figure 1: Duty of Care - Interaction of themes Page 9
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand According to the Oxford dictionary, duty of care is “a
person, the moral judgement becomes impartial and
moral and legal obligation to ensure safety or well-being
therefore fits in a justice ethic. Therefore the skill and
of others” (“Duty of Care,” 2014). In considering the
maturity of the health professional’s moral perception,
moral basis for caring, Noddings (1986) describes how
and their ability to balance the wider needs and the
caring for someone is not just about a person’s actions.
individual’s needs, have great bearing on a successful
Noddings suggests that caring is about connection,
outcome. In this study, the family’s moral perception
how fully a person considers and has empathy for the
and their view of the health system were challenged
care recipient’s reality. Caring is also a choice which is
by questions of fairness, justice and mercy. Over time
sometimes natural and effortless, but at other times
these perceptions affected how the family care for one
and in other situations requires effort and is a response
another, contributed to family strain and their care
to moral obligation or duty.
capacity.
Nortvedt (1996) discusses the moral aspects of the
Different for different people
ethic of care, contending that moral perception (ability
The research data revealed caring as complex and
to perceive a recipient’s reality) is a crucial skill to fully
multi-layered. Different people show their care in
care for a recipient’s needs. Nortvedt argues that, in
different ways and for different reasons. This relates
caring, principles of mercy, fairness and justice are used
to each participant’s expectations of themselves and
to help all parties achieve an effective care relationship.
others within the family as well as society’s wider
He explains that fairness and justice are used to guide
expectations.
care decisions for large populations, but that in faceto-face relationships, the principle of mercy is more
The consequences of stroke are different for different
appropriate. In this article mercy refers to care actions
people. Ivy and Dave were almost expecting the stroke
that are given to an individual beyond standard care in
to happen. Before the stroke they were forewarned by
recognition of high needs.
their doctor that Dave’s lifestyle and co-morbidities would likely lead to a stroke. The event was quite
When a health professional is engaged in direct care
different for Jane, who was shocked and upset when
of a patient the allocation of a needed resource will
she found out. Deb had expected the stroke and felt
be influenced by the close face-to-face relationship,
much more immediate concern for Ivy than for Dave
as the person-to-person nature of the relationship
when she heard the news.
demands that special consideration should be given. This may go beyond an equal distribution that is
I mean the stroke was kind of like inevitable really
ethical in a larger, anonymous group, resulting in extra
because of all his health problems. So it wasn’t a
resources being made available for the individual. Thus
surprise … I wouldn’t like to see [Ivy] struggling caring
fairness characterises caring for a large population,
for [Dave] either. I don’t think that’s really fair ‘cause
leading to care decisions that are just and fair for
she’s like worked hard all her life and I don’t think
all patients, whereas the principle of mercy guides
she should have to do that, I don’t, and I’ve already
decisions on an individual basis. An example of the
told her that she shouldn’t become his caregiver and
ethical challenge is where one patient’s care involves
I really wouldn’t want, I wouldn’t let that happen to
a potential use of other patients’ resources. Nortvedt
Ivy. (1, Deb)
(1996) argues that if moral perception is concerned with the patient’s condition, and not the patient as a Page 10
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Deb had personal experience of her own parent’s strain
the sadness was for a life changed. She felt ambivalence
as caregivers and knew what Dave’s stroke could mean
around her duty of care for Dave as, although she would
for Ivy. Deb felt a duty and responsibility for Ivy’s care
have liked to have him home, she acknowledged that
and moved from caring about (she shouldn’t become his
the care in the rest home was better than she could
caregiver) to caring for (I wouldn’t let that happen).
have achieved at home.
Caring is also dependent on location, knowledge,
The participants showed care for different reasons and
experience and family relationship. Early on Ivy
in different ways. They also had different expectations
explained how she met an old neighbour in the hospital
around care. They had expectations on who should be
after Dave’s stroke. The neighbour’s husband had
doing it, how it should be done and the location. These
recently had a stroke and her way of showing her duty
expectations are explored in the next theme.
of care for him was to stay by his bedside constantly. Ivy on the other hand made sure she took time to look
Expectations of self and expectations of others
after herself.
Stroke requires a response from family. The responses of family members in this study depended on expectations
I said [to the neighbour], “You’ve got to take care of
around their role in caring within the family. Different
number one … if and when he comes home, you’re
expectations were expressed by different family
going to have to have your health like I am”. And she
members, and were reflected in experiences reported
[Ivy’s old neighbour] said, “Well how many girlie days
by the participants in their interactions with employees
have you had?” I said, “Well I have about two a week,
in government departments and health professionals
I know he’s in good hands”. I just say to [Dave], “that’s
working in a range of healthcare settings. These
it, I’ve got to go to this or do that” and he understands.
expectations of care had to be weighed against the
(1, Ivy)
participants’ capacity to respond, considering their other duties, obligations and their own health.
Perhaps because of her health professional background Ivy could see the need to stay healthy and prepared
Deb and Jane felt they had a role in caring for Ivy and
for the burden of caring. There was already knowledge
Dave immediately after the stroke. This expectation
that caring for the stroke survivor at home would be a
had to be measured against other duties and their
burden.
emotional safety. Caring as part of the stroke family was only one duty among many.
Stroke changes lives. These changes may be different depending on the background of the people affected by
I think, there is a danger [that] certain people [could]
stroke. Three months after the stroke Ivy was coming to
become too dependent on you and that’s not possible
terms with the changes the stroke had made in her life.
because you’ve got another side to your life. So, I’ve always found when I have offered assistance that I
I get the feeling of relief rather than sadness. I mean
need to be just a wee bit careful that I don’t get eaten
there’s sadness there but not that I can’t cope with it
alive, but in this case I’m sure it won’t be so. (1, Jane)
and the fact that he is probably in a better position where he is than here. (2, Ivy)
Jane was concerned that the recipient of her care could become dependent and that she, as a carer, could
The relief Ivy felt was the relief of a burden lifted and Page 11
become overwhelmed. Although both Jane and Deb Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand worried that the care they provided might become all-
At the six month point, Ivy felt threatened by the
consuming, there was an implicit expectation that they
possibility of Dave coming home and her expectation
had a duty of care, especially toward Ivy.
that she would be shown understanding and given mercy by health professionals was not met. Care
There were also expectations wider than the family.
actions were not given in recognition of her needs.
Rest homes have a duty to be fair to all their patients
Her hope that the duty of care would be maintained
and to use their resources wisely. The government
by the rest home staff was not being fulfilled. Instead
also has a duty to be just, with responsibility to the
she felt forced to say: I’m not ready to have him home.
wider society and the taxpayer. The family perceived
Ivy knew the limits of her ability to care for Dave. She
that both health service providers and government
was concerned about what it would mean for her role
departments had expectations that the family should
as Dave’s wife if she relinquished her resolve and took
take on various aspects of the stroke survivor’s care. As
on Dave’s care.
a consequence, at three months Ivy felt pressured to take on the additional caregiving activities.
The stroke burden changed over time for this family. The family appeared to be challenged by expectations
I get the certain feeling that because they know I’m
and decisions around if, when and how to care for
a [health professional] that I’m actually going to be
one another. As time progressed, questions of moral
in there doing his exercises and doing 110 things, I’m
judgement around care including the values of mercy,
being very careful to withdraw from that because
fairness and justice were raised and became tiring and
I’m his wife and his friend but I’m not his nurse… I
time consuming for the family.
know that some of the wives do do some of the minor exercises etc. (2, Ivy)
Strain The burden of fitting in care around life’s other on-
Ivy consciously chose not to take on the caregiving
going responsibilities and priorities proved draining.
role; she was Dave’s wife and friend. Yet she still felt
By six months the stroke experience became the new
societal pressure and expectations from other wives,
norm for the wider family. The prolonged concern and
rehabilitation staff and employees from government
duty of care became tiring.
departments to take on the duty of care. The other family members also had the strong impression that
For Jane the immediate nature and extra energy
Dave and the health professionals involved in his care
devoted for caring for Ivy and to a lesser extent Dave
expected he would go home following a period of
caused conflict with other now more immediate duties.
rehabilitation. Ivy and Deb reported that the rest home staff asked Ivy to think about selling their family home
I am concerned [about Ivy’s health] and sometimes
and purchase one that better suited Dave’s needs.
I feel I almost need time out. That sounds a bit mean but I just backed off just a couple of weeks
Over time, shifts in needs and capacity to care
ago because I had a few problems with a grown up
influenced care responses, both expected and given.
daughter and I just really needed to have just one
These care responses in turn shaped other family
thing to concentrate on at the time. My work’s lovely
members’ perceptions of what care they deserve and
and very involved and very busy and I just recognise
ought to receive.
that there’s a limit to what I can cope with. (3, Jane)
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand While Jane remained concerned for Ivy’s health, by six
within the family to take on such a responsibility. As
months she felt a need for time out from caring. Other
time changed so did the family duties as they were
more immediate duties of care, such as to her daughter
continually reassessed. Over time strain built and
and to her work took precedence. Sometimes the wider
irritation increased.
family may feel the need to pull away, to re-prioritise and recognise self-limits in order to fulfil the duty to self
Like with this whole thing about getting Dave a power
of self-care.
wheelchair, Ivy has been trying to use every avenue that she can [including Deb’s work] to get him a
Financial strain was a consistent theme throughout
power wheelchair and Dave is actually able [to use] a
the interviews. The perception was that dealing
manual wheelchair … I do feel that Ivy has pushed the
with government departments, instead of providing
boundaries. (3, Deb)
assistance to reduce the financial burden, increased the strain on the stroke family.
By the end of the six months Deb was experiencing a number of conflicts. Deb perceived Ivy as blurring her
About three or four days after his stroke I learned,
professional and personal boundaries by using Deb’s
to my horror, that WINZ [Work and Income New
connections to access an electric wheelchair for Dave.
Zealand] will take away his pension … Being on the
Deb’s opinion was that Dave would benefit in the
other side [of the health system] is just no joke …
exercise involved in using a manual wheelchair, and her
The WINZ experience was probably the worst thing
professional view was that other patients had a greater
that Dave and I experienced. You’re just simply not a
need. There were conflicts between the principles of
human being. (1, Ivy)
mercy and fairness.
The financial strain was immense. Ivy and Dave were
Deb became concerned with the amount of energy
faced with potentially losing their home through the
her duty of care towards Ivy and Dave was consuming
inability to pay the mortgage because of the loss of
at the expense of her own immediate family. This
Dave’s pension. This caused significant strain. For Ivy
caused some resentment around the caring role she
it was as if the government was not fulfilling its duty
had assumed. It seemed Deb was disturbed that Ivy
to care for them. The strain was not helped by Ivy’s
demanded mercy for herself in getting Dave an electric
perception of being treated like a case number and not
wheelchair to lessen her burden, but at the expense of
a human being in her interactions with WINZ staff.
Dave’s rehabilitation. Deb appeared to be conflicted between Ivy’s need for mercy and Dave’s right to
The family’s moral perception and their view of the
fairness.
health system were challenged by questions of fairness, justice and mercy. These perceptions affected how the
Discussion
family cared for one another and contributed to family
The overarching theme in this study was duty of care
strain and their care capacity. Early on, out of a sense of
within and for the whole family, which was reflected in
duty Deb took on power of attorney for Ivy and Dave.
the sub-themes: care is different for different people;
While she knew it would only be effective if both Ivy
there are care expectations of self and expectations of
and Dave became incapacitated, Deb still felt a lot of
others; and care brings strain. While caring is a choice
conflicting emotions about whether it was her place
which is sometimes natural and effortless, at other
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand times and in other situations it requires effort and
Duty of care encapsulated this family’s experience of
is a response to moral obligation or duty (Noddings,
becoming and being a stroke family. Moral judgements
1986). Both such aspects of care were revealed in the
were made around who should provide the care and
experiences of participants in this study.
where Dave should reside. Balancing family expectations and the different care needs increased family strain
The participants were all female family members with
especially when the family’s expectations appeared
no blood relationship but with strong family-like bonds.
to differ from those of the health professionals. This
They were all health professionals which made this
is consistent with research by Lutz et al. (2011) which
sample unusual in that they had professional as well as
found that the expectations of family members in
personal experience of becoming and being a stroke
regard to stroke rehabilitation and discharge planning
family. Their professional backgrounds meant they had
was not always congruent with those of rehabilitation
more knowledge and resources available and were more
providers.
confident in their ability to navigate the health system than other families may have been. Concomitantly,
Ivy knew her limits and what role she was able to play
being a health professional gave them increased
but did not feel that the health professionals showed
awareness of the realities of caring for a stroke survivor,
her any mercy. Instead she felt a sense of enforced
including their own limitations of providing that care to
duty that threatened her health and potentially her
an adequate and safe level. This awareness brought
relationship with Dave. While Ivy was able to recognise
greater stress when the health professionals appeared
her limitations and was able to resist the pressures to
to ignore those limitations and gave the impression that
bring her husband home, other caregivers may not be
the family, especially Ivy, should take on that duty of
able to do so. Similarly, Lutz et al. (2011) described the
care anyway. Also, as a family of health professionals,
importance of caregivers recognising personal limits
they focused on caring for the carer. Both Jane and
to providing care and having a strong sense of self-
Deb discussed caring for Ivy and themselves, alongside
advocacy if they are to avoid the “crisis of discharge”
Dave, and expressed their views and obligations of the
where the stroke survivor’s level of need outweighs the
health system.
caregiver’s capacity to provide care.
The participants’ professional backgrounds shaped
Financial, physical and emotional strains were
their perceptions regarding mercy and fairness in the
significant aspects of the post-stroke experience for the
care of stroke survivors and their families, which was
family in this study. This is consistent with the findings
reflected in their experiences. As family they initially
of Greenwood et al. (2009) and Bulley et al. (2010) who
had a strong sense of mercy for Ivy as Dave’s wife rather
found that financial concerns around entitlements was
than as his caregiver. Ivy was a reluctant caregiver,
a common challenge. Bulley et al. (2010) also described
preferring the role of wife and advocate for Dave,
how emotional burdens of post-stroke care impacted
which was supported by the other family members.
primary caregivers’ self-identity and hope for the
This was tempered as Dave’s rehabilitation progressed.
future. However these emotional burdens were often
Dave’s right to fairness around his rehabilitation and his
prioritised behind physical care by health professionals.
preference to return home conflicted with Ivy’s request
These emotional burdens were reflected in the findings
for mercy. She is a small woman who was concerned
of this study as participants grappled with questions
about being the primary caregiver for Dave who is a big
around the moral and practical aspects of their duty of
man. This value conflict placed strain on the family.
care. The family became preoccupied with what can be
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand considered as moral and ethical judgments regarding
for stroke survivors in an environment when over
who was most in need of care, the stroke survivor or the
time some challenges diminish and new ones emerge
spouse. Trying to balance their duty of care to the stroke
(Greenwood et al., 2009).
survivor and spouse with other responsibilities brought strain to the extended family. Moral questions around
Conclusion
care distracted family members from the possibility
Becoming and being a stroke family may call forth a duty
of the stroke survivor coming home. Processing these
of care, which is different between family members
moral judgments appeared to separate the family from
depending on what other responsibilities they have.
the stroke survivor’s progress. Considerations of family
Balancing these responsibilities as they continually
dynamics may be useful areas of further research.
change and are reassessed can be a strain on the family. Competing values of mercy and fairness within
Strengths and Limitations
the family in this study took up time and risked shifting
The richness of the data gained from the series of in-
the focus away from the stroke survivor’s progress.
depth interviews with the three participants over a six
Assessing expectations of family members from the
month period helped to give strength to this study’s
beginning of the stroke journey and monitoring moral
findings. Inclusion of family members additional to
questions of fairness, mercy and priorities between
the primary carer was another strength, given the
the stroke survivor and the family as the recovery
“concept of the secondary carer is seldom addressed
progresses is important. Health professionals should
in stroke research” (Greenwood et al., 2009, p. 350).
work with families to identify options for ongoing care
The age range of the participants (40-70 years) allowed
that balance the needs and expectations of not only the
experience between generations to be available for
stroke survivor but also family members.
analysis. The homogeneity of the study participants was a weakness. Participants were all female, Caucasian, and middle class, which limited the study’s perspective and may reduce transferability of findings. The data and findings of this study contribute to the larger longitudinal hermeneutic project (2011-2015), which will address the need for longitudinal qualitative studies to identify that articulate experiences of caring
References: Brunborg, B., & Ytrehus, S. (2014). Sense of well-being 10 years after stroke. Journal of Clinical Nursing, 23(7-8), 1055-1063. doi:10.1111/jocn.12324 Bulley, C., Shiels, J., Wilkie, K., & Salisbury, L. (2010). Carer experiences of life after stroke: A qualitative analysis. Disability and Rehabilitation, 32(17), 1406-1413. doi:10.3109/09638280903531238 Corbett, A., Francis, K., & Chapman, Y. (2006). The experience of whānau caring for members disabled from the effects of a cerebro-vascular accident. Contemporary Nurse: A Journal for the Australian Nursing Profession, 22(2), 255-263. doi:10.5172/conu.2006.22.2.255 Duty of Care. (2014). In Oxford Dictionaries. Retrieved from http://www.oxforddictionaries.com/definition/english/duty-of-care
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Nursing Praxis in New Zealand Dyall, L., Feigin, V., & Brown, P. (2008). Stroke: A picture of health disparities in New Zealand. Social Policy Journal of New Zealand, 33, 178-191. Feigin, V., Carter, K., Hackett, M., Barber, P. A., McNaughton, H., Dyall, Dyall, L...Anderson, C. (2006). Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003. Lancet Neurology, 5(2), 130-139. doi:10.1016/S1474-4422(05)70325-2 Greenwood, N., Mackenzie, A., Cloud, G. C., & Wilson, N. (2009). Informal primary carers of stroke survivors living at home: Challenges, satisfactions and coping: A systematic review of qualitative studies. Disability and Rehabilitation, 31(5), 337- 351. doi:10.1080/09638280802051721 Koch, T., & Harrington, A. (1998). Reconceptualizing rigour: The case for reflexivity. Journal of Advanced Nursing, 28(4), 882-890. doi:10.1046/j.1365-2648.1998.00725.x Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., & Creasy, K. R. (2011). The crisis of stroke: Experiences of patients and their family caregivers. Topics in Stroke Rehabilitation, 18(6), 786-797. doi:10.1310/tsr1806-786 Noddings, N. (1986). Caring: A feminine approach to ethics and moral education. Berkley, Ca.: University of California Press. Nortvedt, P. (1996). Sensitive judgment nursing, moral philosophy and an ethics of care. Oslo, Norway: Tano Aschehougs Fonteneserie. Plager, K. A. (1994). Hermeneutic phenomenology. In P. Benner (Ed.), Interpretive phenomenology (pp. 65-83). Thousand Oaks, CA: Sage. Stroke Foundation of New Zealand. (2014). Facts about stroke in New Zealand. Retrieved from http://www.stroke.org.nz/stroke- facts-and-fallacies Stroke Foundation of New Zealand and New Zealand Guidelines Group. (2010). Clinical guidelines for stroke management 2010. Wellington, New Zealand: Stroke Foundation of New Zealand. van Manen, M. (1997). Researching lived experience: Human science for an action sensitive pedagogy (2nd ed.). London, Ontario:The Althouse Press. Vincent, C., Deaudelin, I., Robichaud, L., Rousseau, J., Viscogliosi, C., Talbot, L., & Desrosiers, J. (2007). Rehabilitation needs for older adults with stroke living at home: Perceptions of four populations. BMC Geriatrics, 7, 20. doi: 10.1186/1471-2318-7-20
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand DIFFUSION OF THE PRIMARY HEALTH CARE STRATEGY IN A SMALL DISTRICT HEALTH BOARD IN NEW ZEALAND Heather Robertson, RN, PhD, Nurse Leader – Primary and Community, Tairawhiti District Health, Gisborne, NZ Jenny Carryer, RN, PhD, FCNA(NZ), MNZM, Professor, School of Nursing, Massey University, Palmerston North, NZ Stephen Neville, RN, Ph.D, FCNA(NZ), Associate Professor, Head of Department – Nursing, Auckland University of Technology, Auckland, NZ
Abstract The Primary Health Care Strategy (2001) was launched in New Zealand by a Labour-led coalition. This paper reports the findings of a study examining aspects of the implementation of the Strategy on primary health care nursing in a small district health board in New Zealand and contributes new understanding on the depth of issues in the diffusion of the Strategy itself. The research approach was an instrumental case study informed by constructionism and underpinned by a qualitative interpretive design. Data were collected from multiple sources including relevant policy documents and strategic plans as available on organisational websites at the local district health board and primary health organisation level. Qualitative data were obtained using in-depth individual interviews with managers at middle and senior levels at the local district health board and two primary health organisations. Focus groups were held with primary health care nurses. Findings demonstrated that poor diffusion processes negatively influenced the deployment of primary health care nursing in this district; nurses did not understand the intent and potential of the Primary Health Care Strategy. We suggest that policy implementation must include robust diffusion processes in the design and be purposefully inclusive of nursing where relevant.
Keywords Diffusion; innovation; primary health care (PHC); primary health care nursing
Introduction and Background The Primary Health Care Strategy (PHCS) declared
people with chronic conditions (Halcomb, Patterson,
that a strong primary health care (PHC) system was
& Davidson, 2006; Temmnink, Francke, Hutten,
considered fundamental to improving the health of
van der Zee, & Abu Saad, 2000). Changes to service
New Zealanders and for tackling inequalities (Ministry
delivery, shorter hospital stays and an increased focus
of Health (MoH), 2001). The launch heralded a
on population health and health promotion, meant
radical policy change to strengthen service delivery
that the responsibilities for nurses working in primary
in PHC (Workforce Taskforce, 2008) and provided
health care (PHC) had increased (MoH, 2005).
an opportunity for PHC nurses to engage fully with government and their employers in developing
It was imagined that the extensive contribution nursing
new nursing roles and responsibilities (MoH, 2005).
could make to reducing health inequalities, achieving
It coincided with an international call for nursing innovation to produce a new form of health service delivery given an increase in health care demand from
Page 17
Robertson, H., Carryer, J., & Neville, S. (2015). Diffusion of the Primary Health Care Strategy in a small district health board in New Zealand. Nursing Praxis in New Zealand, 31(3), 17-26. Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand population health gains and preventing disease,
that supported nurses adoption of an integrated
would be fully realised as a result of the PHCS (Expert
approach to practice incorporating both population
Advisory Group on Primary Health Care Nursing, 2003).
and personal health (Kent, Horsburgh, Lay-Yee, Davis,
The expert advisory group reported that there was no
& Pearson, 2005; MoH, 2005).
nursing voice in decision-making, a noticeable lack of nursing leadership infrastructure in PHC settings and
There is emerging evidence that primary health care
an absence of clinical career pathways. They also noted
nurses do improve health outcomes and should be
that PHC nurses lacked adequate resources to support
utilised accordingly (Cumming et al., 2005; Laughlin &
their education, autonomy and skill development. This
Beisel, 2010; Finlayson, Sheridan, & Cumming, 2009;
study thus explored and examined the situational and
International Council of Nurses, 2008; McMurray,
structural factors contributing to the implementation
2007; Nelson, Connor, & Alcorn, 2009; Sheridan,
of the PHCS in a district health board (DHB) with a
2005). There is also evidence of the nursing potential
particular focus on the utilisation of nurses.
to reduce inequalities in health between the social groups (Hoare, Mills, & Francis, 2012; International
Background
Council of Nurses, 2008; Marshall, Floyd, & Forrest,
There is an abundance of international literature that
2011). The conceptualisation of primary health care is
concentrates on the positive characteristics of PHC
also in harmony with the philosophy of nursing.
(Arford, 2005; International Council of Nurses, 2008; McMurray, 2007; Sloand & Groves, 2005; Starfield
Nonetheless, a WHO (2008) report on PHC identified
& Shi, 2007; Walker & Collins, 2009; World Health
impatience with the inability of health services
Organisation (WHO), 2008). A PHC paradigm privileges
internationally to deliver levels of national coverage
a broader remit than the provision of episodic care for
to meet changing health and societal need. In New
ill health. It works toward the development of health
Zealand, while there may have been small pockets
by putting the emphasis on prevention, community
of change, overall primary health care development
involvement and working with sectors outside of
has been disappointing and many of the features of
health (Keleher, 2000; Sweet, 2010). The International
health services have remained unchanged (Ashton &
Council of Nurses (2008) has said that it is through the
Tenbensel, 2010; Gauld, 2009). Despite the PHCS now
principles of PHC that nursing can make an important
having nearly a 15 year history, the opportunity for real
contribution toward progress in the goal of “health
change for nursing has been obstructed by misaligned
for all” noting that nursing is considered the “very
policy levers and also by custom and practice issues
essence of primary health care” (p.7).
(Carryer & Yarwood, 2015). Greenhalgh, Robert, Bate, Macfarlane and Kyriakidou (2005) argue the
Much of the relevant published New Zealand literature
process of planned change in health is complex. Some
focuses on the introduction of primary health
innovations are readily accepted, whereas others are
organisations (PHOs) and funding models associated
poorly supported.
with the implementation of the PHCS but makes little mention about the impact on PHC nursing. The PHCS promised the effective deployment of nurses to make the best use of nursing knowledge and skills. It was about aligning nursing practice with community need and developing funding streams for service delivery Page 18
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Research Design
was known by research participants. Integrity of the research was strengthened through individual
Aim
interview participant checks and audio taping of
To enhance understanding of the impact of the
the interviews and focus groups. All processes were
implementation of the PHCS on PHC nurses in a small
described in full, personal biases were acknowledged
DHB in New Zealand.
and enhanced by self-critical reflection on author preconceptions that had potential to affect the
Methodology
research.
A qualitative interpretive design informed by constructionism was employed. The diffusion of
Ethical approval was granted after submitting a
innovation theory offered by Rogers (2003) and
detailed ethical application to the Massey University,
Greenhalgh et al. (2005) provided the theoretical
Northern Campus Human Ethics Committee. Advice
lens to collect the data and analyse the findings. This
from the National Coordinator, Health and Disability
theory offered conceptual clarity in designing and
Ethics Committee identified application to a regional
measuring the impact of change in a health setting.
ethics committee was not required as this piece of
It facilitated locating the meaningful components to
research did not involve patients and the risk of harm to
expose the reasoning that underpinned the complex
participants was considered minimal. As an employee
adoption process.
of the DHB of study, the principal researcher (HR) sought approval from the chief executive and clinical
Method
board. The researcher also obtained permission from
Using a single instrumental case study, documentation
the chief executives of other organisations involved.
data were collected from multiple sources including
All ethical requirements were met.
relevant policy and strategic plans as available on the local DHB and PHO websites. A total of 42 people
The diversity of different groups as part of the
participated in the qualitative data collection that took
investigation was considered as central. Cultural
place over a 20 week time period in 2010. In-depth
considerations were of high importance and MÄ ori
individual interviews were held with ten managers at
input was actively sought in each step of the research
middle and senior levels at the DHB and two PHOs.
process.
Five focus groups were held with 32 PHC nurses that included practice nurses, public health nurses, tamariki
Findings
ora nurses, rural nurses, sexual health nurses and Iwi
The organisational and individual diffusion of the
based nurses. While representation was sought from
Strategy in this local DHB negatively impacted on the
all primary health care nursing groups, no district
intended development of the PHC nursing role. Key
nurses or occupational health nurses participated in
themes included: local strategy, local knowledge and
the focus groups.
impacts on understanding.
Thematic analysis was used as the process for
Local strategy
identifying, analysing and describing themes or
There were notable failings in the communication
patterns within the qualitative data. This enabled
channel around the purpose, function and impact
the communication of findings and interpretation
of the whole of Strategy intent. The DHB 2002/2003
of meaning and provided crucial insight into what
District Annual Plan (Tairawhiti District Health,
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand 2002a) clearly identified that planners and funders
from basic understanding through to in-depth
understood that there was a MoH requirement to
comprehension:
implement the PHCS. The MoH directed each DHB to develop a local strategic plan to provide direction in
I like its focus in terms of population health…I like
working toward the Strategy objectives. This plan was
its attempt to try and integrate services and health
to have local meaning, local buy in and local support.
professionals in a way that it hasn’t before. (I.10, p.1)
A local PHC discussion document was developed and identified the why, who, and the what, of the PHC plan
Conversely, only four of the thirty-two PHC nurse
although there was little mention of nursing in this
participants had any awareness of the PHCS as the
document. In November 2002, the draft document
following excerpt illustrates:
was presented to the community and public health advisory committee for endorsement (Tairawhiti
May I ask what is the Primary Health Care Strategy?
District Health, 2002b). At this meeting it was
Can we get that right in my head. (FG.1, p.1)
confirmed that once agreement around the discussion document was reached, it would then become the
We found this knowledge gap puzzling initially,
local strategy and guide recommendations for funding
especially as one of the managers firmly believed that
decisions going to the Board. The document was never
information regarding the Strategy had been widely
finalised into a local strategy. This notable absence of
distributed across the district:
a local strategy was confirmed by one manager: I think you would have had to have had your eyes I understood that there was going to be a [DHB]
shut if you were around at that time. (I.8, p.2)
primary health care strategy … and seven years on there still hasn’t been a strategy. (I.5, p.5)
There was evidence that one cohort of nurses had greater appreciation of the PHCS than others. From
We found no evidence of a planned local
the focus groups it became apparent that public health
communication approach. No district annual plans
nurses employed at the local DHB had opportunity to
articulated how information of the Strategy was to be
engage in conversations around the PHCS, both at the
communicated, or how all the stakeholders, including
time the Strategy was launched, and in the years that
nurses, were to be engaged. As a result, nurses and
followed:
other health professionals were alienated from the local development process and unable to gain
When I was at public health, I was more aware
certainty about the cause and effect of the Strategy.
of it because we talked about it and a lot of the
Consequently there were differences in meaning
programmes were based around initiatives … (FG.4,
and understanding of PHC/primary care implications
p.1)
of the Strategy between the managers interviewed and the nurses who participated in the focus groups
Public health nurses were not only provided
confirmed this locally.
information, but actively discussed the Strategy and looked at opportunities for public health nursing to
Local knowledge
contribute to its principles. The irony is that public
Knowledge of the Strategy by the managers ranged
health nurses were largely excluded by the singular
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand national focus on the general practice environment.
Poor engagement suggests there was very little
Whereas nurses in general practice under the auspices
likelihood of shared understanding across the
of newly formed PHOs, or in the non-government
district. Inactivity of Strategy communication and
organisation sector, showed minimal awareness of
implementation caused several participants to
the Strategy.
suggest it was an academic document or a document that sat on the shelf rather than a genuine blueprint
Impacts on understanding
for change:
Disseminating information on the PHCS to PHC nurses was significantly compromised by the lack of
I don’t think the Strategy, like many of the strategies
PHC nursing leadership across the study DHB. Two
that we’ve seen enlighten the life of the health
managers confirmed this was the case:
sector, have become really live working documents. It is become another nice to have that I go and find
What we need is to have nurse leaders but we do
in the library and refer to if I’m doing academic
not have the funding to do that. (I.1, p.5)
papers. (I.6, p.2)
… advancing primary care nursing from a leadership
In order to reach a point of effectiveness there
perspective and a collective perspective from the
first needed to be a shared understanding of the
ground up is not equitable and quite variable. (I.5,
terminology. Both the MoH and DHB in this research
p.13)
continually struggled with this. The term primary care was frequently used interchangeably with PHC in the
Further, no key person or cluster of people stood out
district annual plans and other strategic documents.
as driving the PHCS forward across the study region.
The Strategy was frequently referred to as the primary
This is supported by the following comment by one of
care strategy (Tairawhiti District Health, 2002a, p.7 &
the managers who was a leading player in PHC at the
52). Further, the MoH website directs readers to their
time the Strategy was released:
PHC publications which are predominantly primary care related documents.
They have relied on the structures to circulate that information. Without having the one message
In a similar vein, the definition of PHC nursing was not
deliverer you have got multiple deliverers all having
well understood across the sector. It could be argued
a take on health. (I.9, p.3)
that there was a shared degree of ignorance about the place, role and contribution of PHC nurses. This was
Multiple
messengers
allowed
for
multiple
confirmed by the significant number of participants
interpretations of the PHCS with personal values
who struggled to articulate the fundamental ideology
and biases added to information. Another manager
of PHC nursing. The limited appreciation of the role and
suggested that communication regarding the Strategy
the difficulty in articulating the depth was illustrated
was less than meaningful engagement:
by managers and nurses alike. The implications of the wrong use of the terminology continued to shape
I suspect that it was more lip service than
communication processes and the decision-making
engagement. (I.2, p.2)
and propensity to act at all levels of the health system in the study area.
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Discussion
implementation activity away from the innovation
The Strategy was a directive from the MoH, the
toward organisations second guessing what they were
principal agency responsible for health policy.
required to do rather than concentrating on local
However,
priorities.
the
operational
decision-making
for
implementation of the Strategy rested locally with newly formed DHBs and resulted in variability in each
Successful dissemination and assimilation of an
DHB’s response across New Zealand (Cumming et al.,
innovation depends on the ability of an organisation to
2005; Finlayson, Sheridan, Cumming, & Fowler, 2011;
be able to manipulate structures and activities in place,
Gauld, 2008; Primary Health Care Advisory Council,
as well as the ability of the stakeholders to understand
2009). This suggests a failure to successfully engage all
the new conceptualisation that accompanies the
potential significant stakeholders, including nurses, at
diffusion process (Greenhalgh et al., 2005). The
both a national and local level in articulating a shared
authors concur that the complexity of organisations
vision or common purpose to support the roll out of
especially those with fragmented internal and external
the Strategy.
structures constrains innovativeness and making it happen requires an orderly, planned and regulated
Diffusion
approach, with all systems ‘properly managed’ in order
The poor diffusion process of the PHCS reduced
to mainstream the innovation within the organisation.
the chance for successful adoption in this local
As this research identified, the PHCS required a
DHB. Greenhalgh et al. (2005) argue adopters of
formulated approach, that involved nursing, to drive
innovations must first ascribe meaning to it and it is
the expected changes forward.
their understanding and belief about an innovation that predisposes their reaction and subsequently
Understanding the role communication plays in
directs actions in response. Numerous innovations
innovation should not be underrated (Leeuwis, 2011).
require a lengthy period of years from the time the
Leeuwis also argues the everyday communication
innovation becomes available to the time it becomes
among stakeholders is critical for the re-ordering
widely adopted (Rogers, 2003). Even so called
of social relationships and the emergence of space
“evidence based innovations undergo a lengthy period
for change in networks. In this study the place of
of negotiation among potential adopters, in which
employment impacted on access to information and
their meaning is discussed, contested, and reframed”
meant that different people knew different things at
(Greenhalgh Robert, Bate, Macfarlane, & Kyriakidou,
different times.
2004, p.594). The magnitude of organisations having the capacity organisation’s
to absorb new knowledge and be receptive and
predisposition to implementing an innovation. Rogers
ready to change cannot be underestimated (Smith,
(2003) concurs that mandated change or authoritative
McDonald, & Cumming 2008). The change process
decisions are usually associated with a higher rate
deserves greater attention in health care settings
of diffusion and the adoption of an innovation.
(Chreim, Williams, Janz, & Dastmalchian, 2010).
Greenhalgh et al. (2005) also assert that dictating the
Having a dedicated PHC project manager in each DHB
adoption of the innovation is not necessarily conducive
to lead implementation would have been beneficial
to acceptance and implementation. The authors
at the outset. This may have led to the identification
argue the impact of political directives can divert
of common values required, engagement and
Political
Page 22
drive
can
increase
an
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand constructive
conversations
to
increase
mutual
usually within general practice, whereas PHC has a
understanding, respect and commitment to shared
broader more comprehensive remit (Adamson et
gains in personal and population care (Buetow, 2008).
al., 2005; Carryer, 2004; Docherty, 2004; Holdaway, 2002; Keleher, 2001). If the terminology is not well
Impacts on understanding
understood then invariably barriers are created that
Strong leadership and good strategic vision enables
impede the implementation of the Strategy’s intent
systems to respond more easily and quickly to
(Carryer, 2004).
innovation and secure the necessary influence (Greenhalgh et al., 2005; Hamer, 2010; Martin, Weaver,
This particular perception has been at the heart of
Currie, Finn, & McDonald, 2012). Numerous authors
the challenges experienced, aggravated the perceived
argued for a director of PHC nursing to be based within
complexity of the Strategy and contributed to the
each DHB (Carryer, 2004; Expert Advisory Group on
difficulty in articulating a shared vision with common
Primary Health Care Nursing, 2003; Finlayson et al.,
purpose across a range of stakeholders, including
2009). The paucity of nursing leadership was validated
nurses. Previous research undertaken in the DHB of
by the majority of nurses who remain unaware of the
this study, identified PHC nurses did not understand
PHCS nationally with regional diversity and varied
PHC terminology (Adamson et al., 2005) and we found
investment in PHC nurse leadership roles (Sheridan,
that this had not changed in the 5 years following.
2005).
This was concerning given the Strategy explicitly recognised the significance of nursing’s contribution
Many nurses in this study attempted to contribute
to PHC (Expert Advisory Group on Primary Health Care
meaningfully to PHC development but at the same
Nursing, 2003).
time there were and are those who remain content to accept delegated nursing tasks (Docherty, Sheridan,
Limitations
& Kenealy, 2008). Without shared governance and
This was a single case study and is thus viewed by some
collective leadership the ability to impact on planning
as a less desirable form of inquiry (Flyvbjerg, 2004;
and funding decisions or influence their own practice,
Griffiths, 2004; Yin, 2003). Perceived limitations are
allocate resource, or bring about significant change
overridden by the fact that this methodology allowed
was unlikely (Adamson et al., 2005; Attree, 2005;
the capturing of multiple realities to provide evidence
Calverley, 2012; Carryer, 2004; Chreim et al., 2010;
transferable to other PHC nursing settings. Opinions
Expert Advisory Group on Primary Health Care
were confirmed, where ever possible, from supporting
Nursing, 2003; Nelson, Wright, Connor, Buckley, &
literature which was important in mitigating this risk.
Cumming 2009; Robertson-Malt & Chapman, 2008). Recommendations Terminology confusion
One of the least studied aspects of policy change is
The defective diffusion process was aggravated by a
knowledge on how and why social structures, internal
lack of common understanding of the terminology.
and external influences, and diffusion processes affect
PHC in New Zealand continues to be regarded as
the adoption of policy driven innovations in health.
largely synonymous with general practice (National
These factors are powerful predictors of whether an
Health Committee, 2000). Primary care is defined
innovation will be adopted or not. Policy development
as the first point of entry into a health system,
must include in its design, programmes that are
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand congruent with the values and goals of all major
and other stakeholders as intended adopters of the
stakeholder groups including nurses. If this is not
Strategy. This had a negative effect on the adoption
achieved, then effort must be made towards reaching
decision-making process across the district and the
a common understanding.
substantial lack of nursing engagement.
Conclusion
Implementing the Strategy required engagement,
It was very clear that the PHCS promised so much, but
discussion and debate until a common understanding
delivered so little. Despite the directive to implement
was reached. Instead ineffective diffusion and
the Strategy in a region with high levels of deprivation,
dissemination
very little had changed for service delivery and PHC
understanding. As a consequence there was no
nursing during the study period (2010-2014 years).
shared vision across the health sector. Therefore,
There was little evidence of actions taken in moving
this research reinforces the importance of a planned
toward a state of readiness. The flawed diffusion
approach to change, early attention to detail and the
process was one of the most significant factors in the
necessity for purposeful and meaningful engagement
poor implementation results. This was evidenced by
of all stakeholders, including nurses, following policy
the gap in understanding by various DHB staff, nurses
change or when strategic documents are released.
resulted
in
limited
stakeholder
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Nursing Praxis in New Zealand Ministry of Health (MoH). (2005). Evolving models of primary health care nursing practice. Wellington, New Zealand: Ministry of Health. National Health Committee. (2000). Improving health of New Zealanders by investing in primary health care. Wellington, New Zealand: National Health Committee. Nelson, K., Connor, M., & Alcorn, G. (2009). Innovative nursing leadership in youth health. Nursing Praxis in New Zealand, 25(1), 27-37. Nelson, K., Wright, T., Connor, M., Buckley, S., & Cumming, J. (2009). Lessons from eleven primary health care nursing innovations in New Zealand. International Nursing Review, 56(3), 292-298. doi:10.1111/j.1466-7657.2008.00702.x Primary Health Care Advisory Council (PHCAC). (2009). Service models to meet the aims of the Primary Health Care Strategy and deliver better, sooner, more convenient primary health care: Discussion paper. Retrieved from http://www.nzdoctor.co.nz/ media/26221/phcac%20service%20models%20document.pdf Robertson-Malt, S., & Chapman (2008). Finding the right direction: The importance of open communication in a governance model of nurse management. Contemporary Nurse, 29(1), 60-66. doi:10.5172/conu.673.29.1.60 Rogers, E.M. (2003). Diffusion of innovations (5th ed.). New York, NY: The Free Press. Sheridan, N.F. (2005). Mapping a new future: Primary health care nursing in New Zealand (Unpublished doctoral dissertation). The University of Auckland, Auckland, New Zealand. Sloand, E., & Groves, S. (2005). A community-orientated primary care nursing model in an international setting that emphasizes partnerships. Journal of the American Academy of Nurse Practitioners, 17(2), 47-50. doi:10.1111/j.1041-2972.2005.00010.x Smith, J., McDonald, J., & Cumming, J. (2008). Developing and implementing high impact changes in primary health care in New Zealand. Discussion document prepared for District Health Boards New Zealand. Wellington, New Zealand: Health Research centre. Starfield, B., & Shi, L. (2007). Commentary: Primary care and health outcomes: A health services research challenge. Health Ser vices Research, 42(6), 2252-2256. doi:10.1111/j.1475-6773.2007.00739.x Sweet, M. (2010). Revolution road: The challenging journey to primary health care. Australian Nursing Journal, 18(5), 26-29. Tairawhiti District Health (2002a). Tairawhiti District Health Board District Annual Plan 2002-2003. Gisborne, New Zealand: Tairawhiti District Health. Tairawhiti District Health. (2002b, 28th November). Tairawhiti District Health Community and Public Health Advisory Committee (CPHAC) minutes. Gisborne, New Zealand: Tairawhiti District Health. Temmink, D., Francke, A.L., Hutten, J.B.F., Van Der Zee, J., & Abu-Saad, H.H. (2000). Innovations in the nursing care of the chronically ill: A literature review from an international perspective. Journal of Advanced Nursing, 31(6), 1449-1458. doi:10.1046/j.1365-2648.2000.01420.x Walker, B.B., & Collins, C.A. (2009). Developing and integrated primary care practice: Strategies, techniques, and a case definition. Journal of Clinical Psychology, 65(3), 268-280. doi:10.1002/jclp.20552 Workforce Taskforce. (2008). Working together for better primary health care: Overcoming barriers to workforce change and innovation. Wellington: Ministry of Health. World Health Organisation (WHO). (2008). Primary health care. Now more than ever. Geneva: World Health Organisation. Retrieved from http://www.who.int/whr/2008/whr08_en.pdf Yin, R.K. (2003). Case study research: Design and methods (3rd ed.). Thousand Oaks, CA: Sage Publications.
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Nursing Praxis in New Zealand LEARNING TO BECOME A NURSE PRESCRIBER IN NEW ZEALAND USING A CONSTRUCTIVIST APPROACH: A NARRATIVE CASE STUDY Anecita Gigi Lim, RN, PhD, Senior Lecturer, University of Auckland, Auckland, NZ Michelle Honey, RN, PhD, Senior Lecturer, University of Auckland, Auckland, NZ Nicola North, RN, PhD, Associate Professor, School of Population Health, Auckland, NZ John Shaw, BSc (Hons), PGDipClinPharm, PhD, Professor of Pharmacy, University of Auckland, Auckland, NZ.
Abstract: Prescribing is no longer the sole purview of the medical profession as a wider group of health practitioners in New Zealand, including nurses, may now prescribe. Research on the educational preparation of nurses for a prescribing role is so far limited. This study aims to understand the experiences of postgraduate nurses learning to become nurse practitioner prescribers when undertaking courses that employed a constructivist pedagogical approach. Narrative inquiry, using multiple case analyses, was used to explore the perceptions, views and experiences of ten experienced prospective nurse prescribers. Thematic analysis revealed two main themes: improved clinical practice, and enhanced professional relationships. This study found a constructivist approach to learning facilitated prospective nurse prescribers to confidently draw on their clinical knowledge and experience while developing the knowledge and skills for prescribing. Limitations of this study include the small sample size, and further research into the development of authorised and designated nurse prescribers in New Zealand is recommended.
Key words Nurse prescribing; constructivism; narrative case study; narrative inquiry; prescribing education
Introduction Medical prescribing, in terms of both education and
This article describes the pedagogical underpinnings of
practice, has been extensively researched but this has
one of the first postgraduate programmes developed
not been the case with nurse prescribing (Coombes,
for nurse practitioners to gain prescriptive authority.
Mitchell, & Stowasser, 2008; Franson, Dubois, de Kam,
Nurses intending to become nurse practitioner pre-
Burggraaf, & Cohen, 2009; Garbutt et al., 2006; Gwee,
scribers were interviewed to gain an understanding of
2009). One reason for this is that internationally, pre-
their experiences of undertaking these postgraduate
scriptive authority differs between countries, and
prescribing programmes.
hence the educational preparation for nurses to prescribe also varies. This has detracted from consistent
Background
research into the educational preparation and practice
Nurse prescribing in New Zealand: A brief history
of nurse prescribing despite the fact that registered
In New Zealand, the nurse practitioner role was intro-
nurse prescribing is well established in some countries, notably the United Kingdom and is generally regarded positively (Latter et al., 2010). Page 27
Lim, A.G., Honey, M., North, N., & Shaw, J. (2015). Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study. Nursing Praxis in New Zealand, 31(3), 27-36. Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand duced to improve patient access to health care services
prescribers gained the same prescriptive authority as
(National Health Committee, 2000). The introduction
doctors, dentists and midwives as authorised prescrib-
of the nurse practitioner role also represented a sig-
ers, and a new category of prescribers called delegated
nificant advance for professional nursing and posi-
prescribers was added to the Act. There are now three
tioned nurses to practice autonomously. Autonomous
levels of prescriptive authority in New Zealand: au-
practice for nurse practitioners includes performing
thorised, designated and delegated. These legislative
comprehensive health assessments, clinical diagnosis
changes bring challenges and potential for confusion to
and prescribing treatments. The introduction of nurse
nurse prescribing roles.
prescribing in New Zealand has developed concurrently with the role of the nurse practitioner (Nursing Council
Educational preparation of nurses for prescribing has
of New Zealand, 2005). Since 1999, nurse practition-
always been considered in the changes to the legisla-
ers in New Zealand can prescribe as long as they have
tion. Educational preparation includes knowledge of
completed the necessary educational preparation (Lim,
applied biological sciences, advanced assessment and
Honey, & Kilpatrick, 2007).
diagnoses, pharmacology and therapeutics, alongside a prescribing practicum where the knowledge is ap-
Prescriptive authority in New Zealand is outlined in the
plied within a clinical context. The educational prepa-
Medicines Act of 1981 and in the Medicines Regula-
ration for all nurse prescribers requires attainment of
tion of 1984. Under the Act, health professionals with
prescribing competencies and these are examined by
prescriptive authority (authorised prescribers) can
the Nursing Council of New Zealand (2007). Research
prescribe all medicines from Part 1A or Part 1B of the
into the effectiveness of the educational preparation of
Schedule 1 of the Medicines Regulations. Three health
New Zealand nurse prescribers has been lacking.
professional groups were authorised prescribers (doctors, dentists and midwives) until 1999 (Medicines
International education for nurse prescribers
Amendment Act 1999) when prescriptive authority for
Internationally, support for master’s degree prepara-
nurses was considered by the New Zealand government
tion of nurse practitioner prescribers, where theory of
and the legislation was amended.
pharmacology and therapeutics is included, has grown (Brar, Boschma, & McCuaig, 2010; Latter et al., 2010;
Educational preparation for prescribing was included
Van Ruth, Mistiaen, & Francke, 2008). In addition, on-
in the undergraduate programme for doctors, den-
going post-registration support and continuing clinical
tists and midwives, which was not the case for nurses.
development in the area of prescribing is also advo-
Therefore the term, designated prescribers, was added
cated (Hemingway & Davies, 2006). Strickland-Hodge
in the amendments to the Act. Unlike authorised pre-
(2008) argue that prescribing is more than the physical
scribers, designated prescribers are required to un-
act of ordering medicines and requires skills in clinical
dergo additional education in pharmacology and ther-
reasoning, decision-making, and medication manage-
apeutics to become prescribers. Since 1999, further
ment. Ross and Loke (2009) noted that the range of skills
amendments to the Act (in 2011) extended prescriptive
required for safe and appropriate prescribing creates a
authority to pharmacists and diabetes nurse special-
major challenge for those involved in designing educa-
ists, so that pharmacists, diabetes nurse specialists and
tional programmes. They observed that while prescrib-
nurse practitioners could become designated prescrib-
ing a ‘one-off’ drug for the younger healthy patient may
ers. The extension was further refined in 2013 (Medi-
be relatively straightforward, rational prescribing in
cines Amendment Act 2013), when nurse practitioner
the case of an elderly patient with co-morbidities and
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand multiple drugs can be difficult and challenging. Writing
supervision and mentoring in prescribing activities. At
a prescription therefore requires more than just text-
the time of this study, the senior colleague was a doctor
book knowledge of pharmacology and therapeutics; it
as there were no senior nurse practitioner prescribers.
requires deliberate judgment and an ability to carry out
This will change over time with the availability of more
practical and complex tasks (Braunwald, 2005).
senior nurse practitioner prescribers.
The prescribing curriculum in New Zealand
A constructivist pedagogical approach
New Zealand educational programmes for nurses in-
The development of a programme for nurse prescribers
tending to become prescribers aim to produce compe-
at one university recognised the characteristics of their
tent professionals with expert skills, able to think criti-
students: the students were experienced clinical nurs-
cally and autonomously, and who are accountable for
es, who were close to completing their master’s degree.
their own practice (Gardner, Gardner, & Proctor, 2004).
Constructivism as a learning theory views learning as
The Nursing Council of New Zealand regulates the edu-
building on the individual’s current understanding
cational requirements and identifies the competencies
and skills by incorporating new information and skills.
required for nurse prescribers. When nurse prescribing
Learning occurs where information and experiences
was introduced into New Zealand a clinically focused
are meaningful and specific to the individual (Powell
master’s degree, or its equivalent, was required for
& Kalina, 2009). Constructivism operates under the as-
entry into practice as a nurse practitioner along with
sumption that learning takes place at multiple levels
additional approved pharmacology courses relevant to
of intelligence, each of which relates to certain modes
the nurse practitioner’s scope of practice (Ministry of
of communication, and is seen to be a natural process
Health, 2002; Nursing Council of New Zealand, 2002).
for learners. A constructivist approach puts the focus
This study uses one New Zealand university programme
on the learner and his/her experiences, on which new
to illustrate how the Nursing Council competencies for
knowledge can be built (Powell & Kalina, 2009; Young &
prescribing are met.
Maxwell, 2007).
Context for the study
Bruner (1996), a seminal constructivist theorist, sug-
In order to prepare nurses for prescribing, the univer-
gests that learning is an active process, stimulated
sity where this study was based provides mandatory
by curiosity. In the university programme described
courses in applied science and assessment and diagnos-
above, utilising a constructivist learning approach sup-
tic reasoning as the foundation for subsequent courses
ports the notion that experienced nurses can build
(Lim et al., 2007). Other specific prescribing courses
their knowledge and skills in interaction with their work
cover the topics of pharmacology and therapeutics,
environments, drawing on prior learning. Thus learning
including practical considerations for prescribing and
is cumulative (Bruner, 1996), and past knowledge and
the principles of medicines evaluation, pharmaco-
experiences can shape future learning for the nurse.
economics and therapeutics. The capstone course is a
According to Biggs (2003) a constructivist approach as-
prescribing practicum that provides the opportunity to
sists learners in their journey of discovery by bridging
apply knowledge and skills in pharmacotherapeutics to
new learning with existing knowledge.
prescribing practice, specific to the nurses’ clinical practice area. In the prescribing practicum the nurse works
There are several reasons for employing a constructivist
closely with, and under the supervision of, a senior col-
learning approach to prescribing education for nurses.
league in the same clinical area, who provides direct
First, the students were nurses with considerable clini-
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand cal experience. Years of clinical experience have been
tal type of case study. Unlike the intrinsic case study
related to clinical expertise (Benner, Tanner, & Chesla,
where interest in individual narrative is the goal, in
2009). Second, a clinical background benefits nurses by
the instrumental case study, case studies are related
providing a context wherein the learning of new skills
to a need for a general understanding and insight into
and knowledge can occur. The expert nurse acquiring
the question by studying particular case narratives
the new skill of prescribing is a practitioner “who per-
(Shkedi, 2005). Ethical approval to conduct the study
ceives situations as a whole, uses past concrete situa-
was obtained from the university’s Human Research
tions as paradigms, and moves to the core of the prob-
Ethics Committee (Ref. 2007/249). Using a purposive
lem without wasteful consideration of a large number
sampling process, ten nurses who had completed the
of irrelevant options” (Dreyfus & Dreyfus, 1996, p. 125).
required programme of study to become nurse prac-
The notion of expertise, as defined by Benner (1984),
titioner prescribers at the university which is the con-
develops through experience as preconceived notions
text for this study were recruited; this is a subset of a
and expectations are challenged, refined, or discon-
larger study. Purposive sampling in qualitative research
firmed by an actual situation.
allows the selection of participants that will best help the researcher understand the phenomena and the
Methods
research question (Creswell, 2009). Data was collected
The qualitative approach employed in this study ena-
in 2008 from nurses intending to be nurse practitioner
bled access to context-specific knowledge embedded
prescribers, who at that time would have been desig-
in learning the practice of prescribing. As prescribing
nated prescribers. The participants were postgraduate
is a complex phenomenon, qualitative research, spe-
students in prescribing, and participant characteristics
cifically multiple case narratives, offer a useful way
are summarised in Table 1.
to describe and explain phenomena narrated by the participants, and to develop theory regarding these
Semi-structured interviews were conducted in which
constructed phenomena (Shkedi, 2005). Multiple case
participants were asked to describe their roles and
narratives are concerned mainly with the instrumen-
their experiences in the process of developing to be-
Table 1: Description of Participants (n=10)
Page 30
Participants
Clinical practice area
Years of experience in practice area
P1
Ophthalmology
10 years
P2
Child Health
10 years
P3
Mental Health
8 years
P4
Primary Care
10 years
P5
Child Health
12 years
P6
Sexual Health
15 years
P7
Emergency Care
10 years
P8
Primary Care
15 years
P9
Gerontology
15 years
P10
Primary Care
10 years
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand come prescribers. The interviews took place at the
That pharmacology preparation was really useful
participants’ convenience and lasted 45 to 60 minutes.
for me…but I looked at what she [patient] was pre-
Recorded interviews were transcribed verbatim. After a
senting with, like headaches, and I looked at what
thorough reading of transcripts, units of data selected
she was on [drugs] I could see there were interac-
from each case were entered in the Narralizer® soft-
tions. (P2)
ware. Narralizer is user-friendly, qualitative research software, which allows the researcher to conduct tex-
Learning for participants occurred in an environment
tual data analysis, develop a comprehensive narrative
that was described as conducive to consolidation, ap-
description, store bibliographic items and build theo-
plication, and integration of concepts applied to patient
ries grounded in data.
situations.
Analysis proceeded using a multiple case narratives
So that’s my background, from a young nurse to 20
approach, based on continual stages. Each level is con-
years later, 30 years later. But for me, I don’t find
structed based on the level “below” and cannot be con-
medications as scary now. But what it does tend to
structed without this previous level of analysis (Shkedi,
do to you, I think, is realize how much I don’t know. So
2005). Four levels of analysis were undertaken result-
even if I didn’t become a prescriber what this paper
ing in two main themes. The resultant narrative based
[pharmacology and therapeutic course] has done for
report is the translation of the participants’ narratives
me is... to be able to critique medication quite care-
into theoretical academic language, within a concep-
fully now. (P10)
tual framework, and includes authentic pieces of narratives from many of the cases.
Extensive prior clinical experience enabled participants to recall previous clinical situations. Better understand-
Findings
ing of the underlying mechanisms of side-effects and
Two main themes that illustrated a constructivist ap-
adverse effects were identified by the majority of par-
proach in postgraduate study for prescribing emerged
ticipants as the most important aspect of their learning.
from the analysis. These were: improved clinical practice, and enhanced professional relationships, de-
...knowledge of the medications and things and just
scribed below in detail using illustrative quotes.
the side effects of those medications, and their systemic effects are important to understanding how
Improved clinical practice
patients are managing. (P1)
As the participants learned more about pharmacology to improve their understanding of drugs, they could
Knowledge of pharmacology enhanced the nurses’ abil-
immediately apply this new knowledge to their clini-
ity to identify potential drug(s) to use in specific situa-
cal work, and draw on that experience to make sense
tions, and increased their confidence and involvement
of new knowledge. Thus, although the participants
as a healthcare team member in managing patients’
were not yet authorised to prescribe, their narratives
regimens.
revealed how application of improved pharmacological knowledge immediately benefitted their day-to-day
…the course, gave me a real overview of what other
practice.
medications were out there and what they did and how they worked. Now that is very important when I
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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand come to take a history in a patient, because patients
Enhanced professional relationships
don’t always come knowing their medications. (P1)
The prescribing practicum was viewed by all participants as the most useful of the prescribing education
Participants observed that the new knowledge im-
courses. Participants felt that the mentoring process
proved the way they educated patients about medica-
not only enhanced their relationship with the doctors,
tions. They also considered that the learnt knowledge
as prescribing mentors, but also provided an avenue to
and skills enabled them to improve their critical think-
allow doctors to understand what they (nurses) did.
ing skills in terms of their understanding of patient assessment and clinical management.
Doctors do not really understand what a nurse practitioner does, let alone, nurses prescribing. So the men-
I guess what it’s done is made me think more, a lot
torship experience provided the opportunity for us to
more, about drug interactions, safety with medica-
discuss the role and [nurse] prescribing. (P6)
tions more so …it has given me more depth of knowledge to allow me to think more about what I am do-
Prescribing decision-making and risk-benefit analysis
ing. (P8)
undertaken during the practicum were elements of learning that participants considered essential for pre-
Some participants were initially ambivalent about pre-
scribing. Not only did it provide them with the essential
scribing. They revealed difficulties in understanding the
experience of making risk and benefit choices, it also
complexities involved in making drug choices and deci-
enhanced their understanding of the dilemmas that
sions related to an individual patient’s situation.
doctors face in making prescribing decisions, providing greater insight into what doctors actually do:
Knowledge of the medications and things, and just the side-effects of those medications, systemic ef-
I would say doing the training certainly has changed
fects are all important to understanding how pa-
my practice up to this point… I’m a lot more aware of
tients are managing. (P1)
what’s happening whenever we use medication and I have a greater insight into where some of the doctors
Learning to prescribe increased their knowledge and
are coming from. (P2)
confidence about choices of treatment versus nontreatment, the need for monitoring and evaluation,
Participants felt that they had increased their abil-
dosing considerations related to efficacy of treatment,
ity to communicate with doctors about the drugs that
and the role of patient adherence to treatment and its
patients were prescribed, and were more confident in
consequences.
their contribution to decision-making in the healthcare team. One example illustrates this:
So if I was looking at the medication this patient was on, for example a beta blocker, I can now ask myself,
…I’m more confident in arguing my point of view
is this patient suitable for a beta blocker or not? Now
when I have disagreements, particularly about the
I look at their age and their medical condition. For
medication regimen… Rather than trying to sub-
example, if they are asthmatic or whether they have
tlety influence the doctor now I’ll be hopefully argu-
any chronic cardiac problems or whether they’ve ever
ing with them on a level footing. You know I mean, I
had it before and so on. These can affect the way the
mean having clinical discussions. (P9)
patient will handle the drug. (P1) Page 32
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand A constructivist approach to the educational prepara-
portant as a foundation for a constructivist approach
tion of those becoming nurse practitioner prescribers
to learning. The participants’ past clinical experiences
illustrates how their previous clinical experience en-
and expertise in many aspects of patient care have
hanced their learning to prescribe.
been shown in this study to provide some advantage to learning the new skill of prescribing, as they were able
Discussion
to identify and describe their learning needs and how
Post-graduate education in pharmacology and pre-
these could be applied to practice.
scribing by experienced nurses is a necessary step to acquiring the knowledge and skills to prescribe safely
In the context of postgraduate education in learning to
and competently. This study shows that as participants’
prescribe, the participants revealed how the education
theoretical knowledge of drugs was extended and
process opened up much wider learning opportuni-
improved they were able to apply new knowledge to
ties. As experienced nurses who were active clinically,
many aspects of prescribing, and their application of
they were able to immediately apply new knowledge to
learning immediately improved their clinical practice,
existing clinical situations, an approach often referred
in particular their medication management skills. The
to as ‘situated learning’ (Herrington, Reeves, & Oliver,
learning process described by the participants can be
2014). Situated learning is a concept advocated in so-
seen as dynamic, starting with their existing practical
cial constructivist approaches where knowledge is con-
knowledge and moving both forwards and backwards
ceived as being embedded or connected to the situation
between theoretical and clinical knowledge in a dynam-
where learning occurs, and where what is learned tends
ic and iterative manner, illustrated in Figure 1.
to be context-bound or tied to the situation in which it is learned (Herrington et al., 2014). Learning to pre-
The nurse participants in this study came to prescrib-
scribe, increased participants’ confidence as members
ing education with prior attitudes and experiences, im-
of the healthcare team and to engage in clinical discus-
LEARNING TO BECOME A NURSE PRESCRIBER IN NEW ZEALAND USING A CONSTRUCTIVIST APPROACH: A NARRATIVE CASE STUDY
Pharmacology and therapeutic principles.
PRACTICAL KNOWLEDGE Previous knowledge and clinical experience. Previous Knowledge of patient context. Previous knowledge of medication. Applied to
THEORETICAL KNOWLEDGE Pharmacodynamics Pharmacokinetics Therapeutics
CLINICAL KNOWLEDGE Enhanced knowledge and clinical practice. Enhanced clinical reasoning skills Prescribing
Figure 1: Nurses’ learning process in developing theoretical, clinical, and practical knowledge in prescribing, reflecting a constructivist approach. Page 33
Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand sions with colleagues. Their professional relationships
research include ongoing research into nurse prescrib-
with doctors, and their experiences with their medical
ing as nurses develop from novice to expert prescrib-
colleagues as prescribing mentors during the prescrib-
ers, and the applicability of a constructivist approach
ing practicum, were described by most participants as
to prescribing education for other health professional.
being very positive. There is growing evidence that certain clinical environments encourage the development
Conclusion
of expertise; such environments are characterised by
In addressing the central question of how experienced
continuity of care, autonomy of practice, a supportive
nurses learn new knowledge related to prescribing,
clinical environment and the opportunity to reflect on
participants revealed how they were advantaged by a
and share clinical experiences; factors which are prac-
constructivist approach where they were able to draw
tised and promoted in the advanced nurses’ current
on their prior experience and to integrate this with new
roles and clinical areas (Benner et al., 2009; Paterson
knowledge, skills and learning experiences. This study
& Higgs, 2008).
found that there are elements already existing in the clinical setting that strengthen and consolidate the skills
Another notable finding related to participants’ in-
and the knowledge learnt in the prescribing courses,
sights into the prescribing roles of doctors. By working
elements fostered by a constructivist approach to pre-
with doctors as prescribing mentors during the practi-
scribing education. It also illustrated that, as postgradu-
cum, participants better understood the complexities
ate students learning to prescribe, nurses have the
involved in the process of prescribing and its applica-
advantage of a rich experiential background on which
tion for specific patients. This experience supported
to draw. As a consequence, their present clinical work
their development of the skills of reasoning and clinical
immediately benefits from new learning being applied
decision-making. Constructivist approaches to learning
and, through a constructivist approach, their learning
make extensive use of cooperative learning, which was
is broader than just understanding pharmacology and
shown as students were exposed to the doctors’ think-
therapeutics. The findings of this study may have impli-
ing processes (Young & Maxwell, 2007).
cations for the educational preparation of nurses who are authorised, designated or delegated prescribers. It
The small sample of only ten nurse participants is a
is also likely that other experienced health profession-
limitation of this study; however, this was negated by
als, for example pharmacists, could similarly benefit
use of a multiple case narrative methodology which
from a constructivist approach to learning to prescribe,
provided an abundance of rich data. Areas for further
and this is an area for further research.
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Nursing Praxis in New Zealand Braunwald, E. (2005). Forward. In D. E. Golan (Ed.), Principles of pharmacology (pp. vii). Philadelphia, PA: Lippincott Williams and Wilkins. Bruner, J. S. (1996). The culture of education. Cambridge, MA: Harvard University Press. Coombes, I. D., Mitchell, C. A., & Stowasser, D. A. (2008). Safe medication practice: Attitudes of medical students about to begin their intern year. Medical Education, 42(4), 427-431. doi:10.1111/j.1365-2923.2008.03029.x
Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage. Dreyfus, H. L., & Dreyfus, S. E. (1996). The relationship of theory and practice in the acquisition of skill. In P. Benner, C. A. Tanner & C. A. Chesla (Eds.), Expertise in nursing practice (pp. 29-48). New York, NY: Springer. Franson, K. L., Dubois, E. A., de Kam, M. L., Burggraaf, J., & Cohen, A. F. (2009). Creating a culture of thoughtful prescribing. Medical Teacher, 31(5), 415-419. doi:10.1080/01421590802520931 Garbutt, J., DeFer, T., Highstein, G., McNaughton, C., Milligan, P., & Fraser, V. (2006). Safe prescribing: An educational intervention for medical students. Teaching and Learning in Medicine, 18(3), 244-250. doi:10.1207/s15328015tlm1803_10 Gardner, G., Gardner, A., & Proctor, M. (2004). Nurse practitioner education: A research-based curriculum structure. Journal of Advanced Nursing, 47(2), 143-152. doi:10.1111/j.1365-2648.2004.03073.x
Gwee, M. (2009). Teaching of medical pharmacology: The need to nurture the early development of desired attitudes for safe and rational drug prescribing. Medical Teacher, 31, 847-864. doi:10.1080/01421590903168119 Hemingway, S., & Davies, J. (2006). Non-medical prescribing education provision: How do we meet the needs of the diverse nursing specialisms? Nurse Prescriber, 2(4), e58. doi:10.1017/S1467115805000581 Herrington, J., Reeves, T. C., & Oliver, R. (2014). Authentic learning environments. In S. J. Michael, M. D. Merrill, J. Elen & M. J. Bishop (Eds.), Handbook of research on educational communications and technology. New York, NY: Springer. Latter, S., Blenkinsopp, A., Smith, A., Chapman, S., Tinelli, M., Gerard, K., . . . Dorer, G. (2010). Evaluation of nurse and pharmacist independent prescribing. United Kingdom: University of Southampton, Keele University. Retrieved from http://eprints.soton.ac.uk/184777/
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Nursing Praxis in New Zealand Ross, S., & Loke, Y. (2009). Training good prescribers: What are the best methods? Clinical Medicine, 9(5), 478-480. doi:10.7861/ clinmedicine.9-5-478 Shkedi, A. (2005). Multiple case narrative: A qualitative approach to studying multiple populations. Philadelphia, PA: John Benjamins Publishing. Strickland-Hodge, B. (2008). Nurse prescribing: The elephant in the room? Quality in Primary Care, 16(2), 103-107. Van Ruth, L., Mistiaen, P., & Francke, A. (2008). Effects of nurse prescribing of medication: A systematic review. The Internet Journal of Health Care Administration, 5(2), 1-31. Young, L. E., & Maxwell, B. (2007). Teaching nursing: Theories and concepts. In L, E. Young & B. L, Paterson (Eds.), Teaching nursing: Developing a student centered learning environment (pp. 8-19). Philadelphia, PA: Lippincott Williams and Wilkins.
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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, critical review and position papers 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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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand
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