Praxis July 2014

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE...

Editorial by Grace Wong History of the child health and development book part 2: 1945-2000 Nurse Prescribing: The New Zealand Context The influence of the Cartwright report on gynaecological examinations and communication

Volume 30. No. 2

JULY 2014

Praxis: “The action and reflection of people upon their world in order to transform it.”

(FREIRE, 1972)

EDIT O RIAL BO ARD EDITOR-IN-CHIEF: Denise Wilson RN, PhD, FCNA (NZ) Norma Chick Willem Fourie Thomas Harding Dean Whitehead Stephen Neville Michelle Honey Jean Gilmour Jill Wilkinson

RN, RN, RN, RN, RN, RN, RN, RN,

RM, PhD PhD, FCNA PhD PhD, FCNA PhD, FCNA PhD, FCNA PhD PhD

(NZ) (NZ) (NZ) (NZ)

COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation.

KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection.

Transformation is shown by the change of the initial plain Koru design to a more elaborate one.

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 0112-7438 HANNAH & YOUNG PRINTERS

CO NTE NTS EDITORIAL: Expanding practice and extinguishing risk factors: Nurses and smoking cessation.

Dr Grace Wong............................................................................................................................ 2

ARTICLES: History of the child health and development book part 2: 1945-2000

Jill Clendon, Karen McBride-Henry .............................................................................................. 5

Nurse prescribing: The New Zealand context

Anecita Gigi Lim, Nicola North, John Shaw ................................................................................ 18

The influence of the Cartwright report on gynaecological examinations and communication

Catherine Cook, Margaret Brunton ........................................................................................... 28

NOTES FOR CONTRIBUTORS............................................................................................................. 39

ERRATUM In the March issue of Nursing Praxis, the reference for the following article omitted some of the coauthors. We apologise for this oversight and have corrected the reference on the online version of Nursing Praxis. The correct citation should be: Honey, M., Doherty, I., Stewart, L., & Wei, D. (2014). Research brief: Using a Wiki to support student nurses learning discipline specific health terminology, Nursing Praxis in New Zealand 30(1), 42-44.

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand EDITORIAL Expanding practice and extinguishing risk factors: Nurses and smoking cessation

roles as nurses and in their capacity as smokefree coordinators and health promotion activists. However, it is in the area of smoking cessation that many nurses

It is a happy day when we share successful stories

make personal contributions to a population level

about our profession. When Smokefree Nurses

problem.

Aotearoa/New Zealand started running conference stands in 2009 we were fundamentally lonely people.

Nurses’ role in smoking cessation illustrates, yet

Times have changed. Nowadays nurses approach us

again, the ability of nurses to be flexible and to take a

eagerly, and en masse. Like immunisation and cervical

leadership role. The action was led by “early initiators”,

screening, smoking cessation seems to be becoming

pioneers like Putiputi O’Brien, Pauline Allan-Downes,

something for which nurses are proud to have

Heather Muir, Kaaren Beverly, Loma Tasi and Kate

ownership.

Dallas who believed in the ability and responsibility of nurses in this field. Many were smokefree coordinators

In the past nurses did not commonly deliver smoking

who never forgot their roots in nursing. They were not

cessation help in their everyday practice. Yet now they

concerned about lack of quick results or frightened

do. What has caused this change? I do not believe it

of offending patients. These nurse leaders, assisted

is just because brief stop smoking interventions are

by readily available evidence-based training, showed

required to meet the government health target “Better

us that we can change our practice to bring about the

Help for Smokers to Quit”. It is only partly because

long term behaviour changes needed to address risk

of system requirements such as staff accountability

factors for non-communicable diseases.

through DHB and PHO patient records; on-line and face-to-face education for RNs and students; and the

More nurses now lead brief smoking cessation

ability to write Quit Cards for nicotine replacement

interventions for clients in their everyday practice.

and make Quitline referrals directly through patient

Examples include prisons and general practice settings.

management systems such as MedTech.

Prison nurses were integral in the drive to make prisons smokefree. At primary health care conferences these

Nurses may be responding to a social environment in

days, members of Smokefree Nurses Aotearoa/New

which smoking is becoming denormalised in the drive

Zealand are commonly approached by nurses, doctors

to achieve the government goal of a smoke-free New

and practice managers who explain how brief stop

Zealand by 2025. Strategies to achieve that goal can be

smoking nursing interventions are expanding rapidly.

divided into those dealing with the supply, and demand,

They describe nurses who are primarily responsible for

sides of tobacco use. Decreasing demand for tobacco

both brief interventions and follow ups. Some describe

includes measures such as tax increases to make

practice support for “smoking cessation resource

cigarettes more expensive; establishing smokefree

nurses” who have more education and responsibility

environments (most recently the smokefree parks

to help patients quit over time.

movement); social marketing; and mandatory health warnings on packs. Nurses and their professional

Nurses are full of stories. Nowadays we are hearing

organisations advocated for these strategies in their

more and more positive ones. Two days ago a nurse

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

told me how one encounter can make a world of

cessation interventions because “they have more

difference – “[a difference] that a nurse might not even

time”. Yet I would argue that it is not just a matter of

know about!” She explained that a lady had run up to

time. Nurses learn to work in partnership with patients,

her in the street and told her that she had been smoke-

to listen to them, to respect them as experts in their

free for six months, saying “It was when you talked to

own worlds. Most patients want to quit. Recent focus

me in the hospital. I always remembered”. Although

groups with patients who smoke said they expect

the nurse did not actually remember the particular

their doctors and nurses to ask them about their

incident she commented on not being able to keep

smoking. They need their doctors and nurses to listen

from smiling when it was reported to her. Another

to them, to give them options, and to help them to be

practice nurse had a joyful story about a new patient

“the sort of quitter they want to be”. Nurses respect

who quit smoking, saying he hadn’t quit previously

patients’ wishes and autonomy. They understand that

because he hadn’t been asked about it. Both nurses

healing occurs through their approach to care and

were very happy. When I meet nurses who work in

communication. For some this is scary, but almost all

smoking cessation I sometimes wonder if helping

are willing to learn.

patients quit smoking isn’t a kind of addiction in itself.

Everyone seems so happy and proud.

To conclude, the depth and breadth of nurse activity in the population health space that is tobacco control

Not only are more nurses helping people quit, they are

augur well for the future in terms of nurses tackling

also doing more research about smoking and tobacco

other risk factors for the most common cause of death

control. This illustrates perfectly the capacity that

internationally, namely non-communicable diseases.

nurses have to create the nexus between research

The “late adopters” will change as they observe their

and practice. Recently topical theses have come from

colleagues. Nursing will be at the forefront of both

prison and mental health nurses, hospital nurses,

prevention and treatment as modelled long ago by

nurses who work as smokefree coordinators and nurse

Florence Nightingale. The case of nurses with respect

academics who have explored topics such as practice

to smoking cessation and tobacco control shows that

nurses, diabetes and smoking cessation practice and

we are identifying and claiming this space together.

smoking among Asian youth and families.

Nurses will improve global public health.

And consider this – our work in smoking cessation and

Dr Grace Wong

tobacco control is testimony to our concern and care for

BA, MPH (Hons), RN

one another as well as our values and role in reducing

Senior Lecturer, Auckland University of Technology

inequities. Recently two studies instigated and led by

Director – Smokefree Nurses Aotearoa/New Zealand

Maori nurses, about Maori nurses and smoking, were published. A study led by another Maori nurse leader, addressing smoking among Maori nursing students, is underway.

It is commonly said that nurses can provide smoking Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand

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If you have experience or a specific area of expertise and could spare the time to review one or two papers a year we would appreciate you registering your interest to join the reviewers database.

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand HISTORY OF THE CHILD HEALTH AND DEVELOPMENT BOOK PART 2: 1945-2000 Jill Clendon, RN, PhD, MPhil (Hons), BA, Nursing Policy Adviser/Researcher, New Zealand Nurses Organisation, Nelson, NZ, Adjunct Professor, Victoria University, Wellington, NZ Karen McBride-Henry, RN, PhD, Associate Research Fellow, Victoria University, Wellington, NZ

Abstract This is the second part of a historical review of the New Zealand child health and development record book (also known as the Well Child/Tamariki Ora Health book or Plunket book). It focuses on the years between 1945 and 2000. The first article highlighted how the book documented the development of “scientific mothering”, which marginalized womengenerated mothering knowledge. The present article highlights how during the reviewed time period women began to challenge notions of “scientific mothering”, these changes are signaled in the content of the Well Child/Tamariki Ora Health book over time. In addition, women’s movements, such as LaLeche league and Parent Centre, reflected significant societal changes during this era in relation to mothering and child-rearing practices, the influence of which had a significant impact on the Plunket book’s development. However, tensions between health professionals and women in relation to the value placed on types of knowledge continued to exist as evidenced by the language employed in the Plunket books throughout the time period reviewed. Being mindful of the tensions that exist between competing discourses and knowledge sources is important as they call us to engage with how we value and develop our relationships with women and mothers as health care professionals.

Key words Maternal and child health, history of nursing, New Zealand, Plunket, child health and development record book.

Introduction/Background In part one of this two part article on the history of

and argue that women’s increasing agency in caring

New Zealand’s child health and development record

for their children brought about largely through the

book (currently named the Well Child/Tamariki

influence of the women’s movement, also resulted in

Ora Health Book but commonly referred to as the

profound changes in the content and use of the Plunket

Plunket book), we argued that a persisting medically

book. Whereas in the early part of the 20th century

dominated discourse present in society, had the effect

women were influenced in their child rearing activities

of encouraging mothers to rely on methods of scientific

by the medically dominated discourse in society, by

motherhood as a means of raising their infants, which

the latter half of the 20th century, the situation was

essentially silenced mother-generated knowledge.

reversed and women began to reclaim their position

This in turn had a profound impact on women’s ability to breastfeed leading to a reliance on outside sources to support them to mother. In this second part, we examine the Plunket book from the years 1945 to 2000, Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Clendon, J., & McBride-Henry, K. (2014). History of the child health and development book, Part 2: 1945-2000. Nursing Praxis in New Zealand, 30(2), 5-17.

Page 5

Nursing Praxis in New Zealand as the expert in the care of their children with this clearly reflected in the content and use of the book.

The method with which the study was undertaken is outlined in part one of this article.

1946 – 1970 During the post war years and into the 1950s and 60s the family was seen as the backbone of New Zealand society. The family was widely viewed as a closeknit grouping of mother, father and children living together in harmony. Images such as those of the royal family (New Zealand is a commonwealth country and recognises the British Queen as the head of state)

Figure 1: Plunket book 1950s

were seen as the ideal to live up to. Women who 1

may have been intensively involved in the war effort

in the text by the publishers. A 1950 book included

were expected to return to looking after their children

instructions to ‘FEED baby regularly every four hours,

and husbands at home and motherhood was still the

five feeds a day, and no night feeds’ followed by ‘GIVE

prevailing role of women in society. The ideology of

baby one to two ounces of cool, boiled water some

perfect motherhood was played out in the suburban

time during the day’.3 After space to write the head

streets and back roads of most towns and cities

and chest measurements these notes to the mother

throughout the country with mothers expected to

are printed in the book:

spend their time at home with their children, adhering to what was now seen as the normal ‘scientific’

It is most important that you keep your baby

approach to child rearing and child birth advocated by

under regular supervision; therefore see your

the Royal New Zealand Plunket Society.

Plunket Nurse at regular intervals and follow

2

her advice.

By the late 1940s the Plunket book had increased from

a quarter A4 size to a half A4 size. The Plunket nurse

Always have this book ready when nurse visits

continued to write instructions to the mother on how

you in your home, and bring it with you when

best to raise her children with half a page per day for

visiting the Plunket Rooms. To save Nurse’s

the nurse to write instructions – the same space as in

time enter the date of visit and baby’s age in

the earliest books. The book was a tan colour but with

weeks.4

red and black writing on it, including a request on the front cover for parents to become members of the

Printed instructions entitled ‘First Advice and

Plunket Society by taking out an annual subscription

Instructions’ and a ‘Suggested Routine for Baby’ were

of five shillings. The logo remained a breastfeeding

also included along with handwritten instructions from

mother, now on a red background (see Figure 1).

the nurse on how to prepare humanised milk. For example:

Many of the instructions that in earlier books the nurses had written by hand were now printed directly Page 6

Mix dried milk Karilac to a smooth paste with Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand a little cool boiled water. Add boiling water to

own mothers. Playcentre had been advocating this

make the amount up to 28oz.

approach since its inception in 1941.11 In addition, La

5

Leche League’s philosophies encouraging women to The weight charts in the book underwent change

actively participate in breastfeeding, allowing infants

during this period as well. By 1947 the charts went

unlimited access to the breast, and advocating infant

from a single page ¼ A4 size to taking up two pages of

led weaning were also instrumental in changing

the larger sized book. In addition to the average line

prevailing ideas around childbirth and childcare at

that was still present, there were two further lines –

the time.12 The Plunket Society, however, was slow

one on each side of the average line with the area in

to pick up on these ideas, continuing to advocate

between these two shaded. This section represented

adherence to relatively strict methods of childrearing:

where an average baby should fit in terms of weight.

four hourly feeds, limited time on the breast, and

The new chart went up to 52 weeks and was located

strict routines for sleeping, eating, bathing, and

in the middle of the Plunket book, emphasising the

holding out.13 Encouraging babies to spend time out

growing importance of weight as a measure of health

of doors was a further requirement. In a book from

during this period.

1954, however, minor changes can start to be seen,

6

reflecting the first changes in Plunket’s approach to Despite the Plunket Society’s persistence in advocating

child-rearing. There are a number of small, printed

strict routines and directions on child-rearing, there

sheets pasted into the book under “Nurse’s Comments

was growing interest internationally in more permissive

and Advice”. These small sheets have sections for

methods of childbirth and childrearing. Views such as

the nurse to complete including length, head, chest,

Dr Spock’s more relaxed approach to motherhood

7

fontanelle and milestones.14 Where previously some

and John Bowlby’s ideas that separation of mother

nurses had written comments regarding milestones,15

and child at birth or in hospital was damaging to the

now there was starting to be formal recognition that

psychological development of the child were starting

milestones were equally as important in measuring

to have an influence on New Zealand mothers who

baby’s development as weight and height. Comments

began to look at alternate means of childbirth and

included in the book include ‘Holds head up well’ and

childrearing.

‘Bright and happy’.16

8

In 1953 the Parents Centre was formed by a group of

By 1961, the Plunket book was tan coloured with

women interested in natural childbirth. The Parents

pale blue highlights and a logo of a mother holding

Centre advocated for women to listen to their own

a baby up to her cheek (see Figure 2). Although the

instincts when caring for their children and challenged

“Suggested Daily Routine” for baby remains largely

the prevailing ideology around strict routines.

The

the same as in the 1950s books, the “First Advice and

Playcentre movement also reflected many of the

Instructions” to the mother have changed and there is

more relaxed ideas around child care, and offered

the addition of a section entitled “Advice to Fathers”:

9

10

women further opportunities to socialise outside the home and become experts in early childhood without

Help your wife to adhere to her daily plan. Be

being separated from their children. Playcentre

punctual for meals. Get to know your baby

believed strongly in allowing children to utilise free

and enjoy him. Changing napkins, tucking

play as a means to explore the environment and

him down, bathing him at the weekends,

learn while being encouraged and taught by their

and bringing him to his mother to be fed

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 7

Nursing Praxis in New Zealand in the evening or early morning provide

Rest during the day continued to be encouraged and

opportunities for you to lend a helping hand

the food recommendations continued unchanged. By

and learn about your baby.

1961 there were three further suggestions for mother.

These included the following:

Your co-operation with the family shopping, the washing up and other household tasks

Visitors:

Discourage

visitors

until

you

will encourage your wife and lighten her

have readjusted yourself to your extra

work.

responsibilities and baby is settled.

An

occasional call from an understanding friend When baby is settled and his mother has

or neighbour makes a welcome break which

regained her strength, try to arrange for

is refreshing and beneficial.

a baby sitter occasionally so that you can take your wife out for an evening’s

The Ex-Baby: Bring him into the family picture as much as possible to help him adjust happily to a new situation.

Post-Natal Examination: Arrange for your medical check when baby is six weeks old.19 When compared with the previous directives for Baby’s Needs, although remaining dictatorial, the tone of these later instructions is more relaxed than previously, recognising that the family unit was now considered important in the raising of children, not just the mother. Some of the ideas around love and

Figure 2: Plunket book 1960s entertainment.17

nurturance advocated by Bowlby, the Parents Centre and Playcentre were clearly starting to be taken notice of by the Plunket Society, but in a similar vein to Spock, medical advice was still considered by the Society as a

The advice to mothers includes the addition of a

key element in the relationship between a mother and

section titled ‘Planning the Day’:

her child.20

Planning the Day: Ask the Plunket Nurse to help you to work out a plan for the day

The weight chart was now also found in the back of the

which will enable you to care for your baby

book and had changed substantially from the 1950s.

and manage the household chores. Feed

It covered two full pages for the period from birth

baby three or four hourly during the day but

to 12 months. There were also weight charts on the

arrange the last feed at night and the first

following pages for 12 to 18 months and 18 months

in the morning to suit all concerned. Sit in a

to five years. A shaded area represented the ‘average’

comfortable chair for nursing: relax and enjoy

baby and spaces were provided for the baby’s length

the feeding time.18

to be added at 3 monthly intervals. Underneath the chart was the following statement:

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand increased throughout the 1960s quite possibly due to Normal babies grow at different rates. The red

the work of the medical director of Plunket at the time

zone on either side of the black line represents

Neil Begg. Begg was firmly committed to preventative

the gains in weight of a large number of babies

medicine

who had progressed satisfactorily during

involving the reduction of tuberculosis in cows, the

their first year. The Plunket Nurse will explain

use of fluoridation tablets, control of hydatids, and

normal variations to individual mothers.

immunisation.25

21

and

oversaw

successful

campaigns

Much significance has been placed on weight gain in

At about the same time, Ryan argues that the

infants over the years, with the weight chart becoming

promotion and marketing of infant formula in New

the symbolic representation of society’s expectations

Zealand, under the pretence of a scientifically proven

around being healthy, both as an adult and as a

means of feeding infants, saw infant formula and

child. Weight gain as a measure of child health was

feeding commodified.26 According to Ryan, the market

emphasised by child health experts for much of the

for artificial milk undermined women’s attempts to

first part of the twentieth century and steady weight

breastfeed – the market controlled by industry and

gain is still seen as important. The weight charts were

health professionals resulted in an overall change in

a prominent feature of early Plunket books and remain

health behaviour.27 Growing options in the artificial

so. This early emphasis on the weight charts has led

milk market also arose with the arrival of new

mothers to focus on this particular measure of child

companies determined to sell their products to an

health that has extended beyond the focus of well

increasingly autonomous group of women.

child nurses who had started to shift the importance of weight to milestones as early as the 1950s and

By the late 1960s, the Department of Health was

60s. This is demonstrated in Plunket books from the

considering its options with regard to services provided

time.

In one book for example the nurse has written:

by Plunket and public health nurses that at times

‘firm muscle tone and tissue, rolling, sits with support,

appeared to overlap. This resulted in the development

playing with toys’.

Over time a growing emphasis on

of a steering committee in 1968 to oversee a study to

health promotion material such as the following from

review the health needs of New Zealand preschool

a 1961 book can be seen:

children.28

22

23

AT EIGHTEEN MONTHS

Times of change: 1970 – 2000

The out-of-doors beckons. He must be protected from traffic and water hazards.

With two exceptions the 1972 Plunket book remained

As he is not old enough to understand about

the same as in 1961. The first was the note on the

these dangers, only his parents can save

inside cover of the book which was written in the style

him.

of a letter rather than being just a list of directions.

24

Some of the content was similar but the tone has While the early books focused very much on weight,

changed to one that finally appeared to mirror

recipes, and remedies, from the mid 1950s, nurses

Bowlby’s line advocating love and care for a child as

began providing anticipatory guidance. That is,

opposed to solely meeting his or her physical needs.

providing information to mothers on what would

The emphasis on encouraging a relationship with the

be likely to happen next as baby grew. This trend

doctor and Plunket nurse remained, but unlike Spock,

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 9

Nursing Praxis in New Zealand there was still no written recognition that the mother’s

to assist a wife who usually does not have any

knowledge was valued. However, Begg’s influence

other home help.30

was clearly visible with notes on fluoridation and immunisations included in the notes to parents found

The weight chart in the book had been revised to

in books at around this time.

include six charts; one each for boys and girls ages

29

0-2years, 2-10 years and 10-16 years. The notice at The Plunket book through the 1970s remained the

the bottom of the chart suggesting that all children

same until around 1978. Perhaps in anticipation of

grow at different rates was gone, and instead it was

looming changes (namely moves by the Department of

suggested the mother should talk to the nurse if the

Health to take over publication of the book as outlined

child fell outside the recommended limits.

below), the 1978 book was twice the size of the old one (see Figure 3). The information it contained was

The tone of the book suggests two possibilities. First,

not substantially different to that of previous books.

although there is no clear evidence of this, the Plunket

As in previous books, the baby was still always a ‘he’

Society may have been aware that the Department

when referred to in the book, but for the first time, the

of Health was about to review the Plunket book and

suggestion to ‘hold out’ baby after feeding was gone.

wanted to maintain control by releasing a newly revised

Advice to fathers was no longer included; instead there

and updated book. The revamped weight charts also

were some ‘helpful suggestions for mother and father’.

suggest that weight continued to be emphasised by

The content of this section was the same as the advice

the Plunket Society as all important in the growth

to fathers had been, it had simply been reworded to

and development of the child. Although the nurses

include both parents. There was, however, a small

may have been emphasising milestones, clearly the

paragraph directed toward fathers:

Society still considered weight an important tool in the surveillance of children – the influence of the medical

In the mornings and evenings there is much

fraternity on Plunket was obvious. Second, although

that the father can do to help his wife and to

the book is conciliatory toward fathers, the implication

get to know his child. New Zealand fathers

is present that although fathers could still be helpful,

play an important part in home and family life

the mother was still the key person in the home. The

and find innumerable little tasks to do in order

new book clearly emphasised the mother’s role in the home as most important. Publications pertaining to motherhood released by the Plunket Society around this time similarly continued to emphasise the role of the mother in the home ‘…the mother is better in her home’; along with the importance of medical surveillance of children ‘…any individual problems should be discussed with an experienced and understanding person like your Plunket nurse or your family doctor’.31

However, feminist views

on motherhood were now starting to influence New Zealand women and Plunket’s perspective flew in the face of up-to-date thinking on the role of women in Figure 3: Plunket book 1978 Page 10

society.

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Motherhood throughout the 1970s in New Zealand

was lead by the Plunket Society and was strongly

saw women seek to regain their place as experts in the

supported by the Homemakers Union and the National

care of their children. Although still acknowledging

Organisation of Women.37 This recommendation

and utilising the advice of medical experts in the care

never came to fruition, policy makers believing the

32

of their children, the growth in breastfeeding rates

introduction of the Domestic Purposes Benefit in

and interest in home births

during this period for

1973 having already addressed some of the lobbyists’

example, demonstrated the success of organisations

concerns. Plunket’s support for the mothers’ wage

such as Parents Centre and La Leche League in

further emphasised their belief that women’s place

encouraging women to follow their own instincts. As

was in the home; however, change was slowly starting

these organisations had slowly encouraged women

to take place in the Plunket Society, partly due to the

to begin to express their own views in relation to

Women’s Movement and partly due to the findings

childbirth and childcare during the 1950s and 1960s,

from the 1968 survey into child health.

33

by the 1970s the scene was set for New Zealand women to actively speak out about their experiences

The report of the findings of the 1968 survey into child

of motherhood.

Conflicting perspectives existed,

health was published in 1974 and became known

however, with some women actively promoting that

as the Salmond Report, named after the Director of

women should stay at home, with others taking the

the Management and Research Services Unit of the

opposite perspective.

Department of Health, George Salmond. The Report

34

was based on the findings of a survey of 520 mothers Despite opposing conflicting views, the women’s

in the Wellington region. Salmond argued that Tudor

movement achieved various outcomes for women,

Hart’s Inverse Care Law was clearly in operation in

one of which was the establishment in 1974 of

the Wellington region and that those mothers who

the Select Committee on Women’s Rights.

The

needed services most were the ones most likely

Select Committee recommended the introduction

to miss out.38 Plunket, and in particular Neil Begg,

of legislation to prohibit sex discrimination, that

Director of Medical Services at Plunket at the time,

further child care centres be established and that

was furious and pointed out that they had been trying

quality standards were revised, that a committee be

to obtain funding from government to provide more

established to examine the implications of paying a

services in new housing areas since 1962.39 Despite

monetary allowance to persons with full time family

the resulting friction between the Health Department

responsibilities, that manual training in schools not

and Plunket, the importance of the Salmond Report

be segregated by sex, and that funding for preschool

was that it highlighted the disparities in health

education be increased.

Progress on implementing

between Māori and Pacific mothers and infants and

these recommendations took time, in particular those

other New Zealanders.40 This, combined with findings

recommendations specific to motherhood, and had

from a study in South Auckland that advocated for

not been implemented at all by 1978 (for example, paid

more Plunket nursing services,41 eventually saw an

maternity leave), or poorly implemented. In addition,

expansion of Plunket services to provide for Māori and

the paucity of statistics on child care and child rearing

Pacific families.

35

persisted, making it difficult to measure changes.

36

Regardless of the tension between the Health The idea of paying a monetary allowance to full time

Department and the Plunket Society, Plunket and public

mothers until their children reached the age of six

health nurses continued to provide nursing support to

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 11

Nursing Praxis in New Zealand mothers in much the same way as previously. Although

behaviour. The book was published by the Division

the Plunket Society advocated mothers remaining in

of Health Promotion at the Department of Health

the home, caring for their children under the medical

in Wellington. In an attempt to make the book less

guidance of a Plunket nurse and family doctor, the care

medically focused and more user-friendly, the art work

offered by the nurses themselves began to reflect the

was reproduced from the popular book on bringing up

needs of mothers.

children titled Pyjamas Don’t Matter, written by New

42

Zealand author Trish Gribben in collaboration with However, mothers’ perceptions of Plunket nurses as

then Medical Director of Plunket David Geddis. Gone

being focused solely on issues such as weight, along

at last were the strict four hourly routines advocated

with the continuing dictatorial publications

43

to come

out of the Society, contributed to the reputation Plunket gained at the time as dogmatic and authoritarian.44 Concern over a continuing crossover of health care services between Plunket and public health nurses also continued and in late 1977 a further committee was established to identify child health problems of significance, to formulate recommendations to deal with these problems and to advise on the co-ordination and further development of child health services.45 Of the numerous recommendations to come from this later study, one indicated that public health nurses would slowly decrease their services to preschool

Figure 4: Plunket book 1980s

children with Plunket nurses taking over most of these.

A second recommended the introduction of a standard

for many years by the Plunket Society. But the value of

health and development record book for use by both

the parent was yet to be recognised; advice remained

Plunket and public health nurses. The study reported

medically focused with guidance for care of the child

that a prototype book developed by the Department

by a medical professional required.

of Health had been trialled in 1980 and subsequently modified and prepared for national use.46 The Plunket

A second book accompanied the new Plunket book and

Society would no longer be responsible for publication

had an identical cover but in orange. This second book

of the health and development record book.

was entitled “Recording child health and development: A handbook for professionals using the ‘Health and

The new book was introduced nationally in 1982 (see

Development Record’ book”.47 This book included a

Figure 4). Only slightly different from the prototype

range of clinical guidelines for the health professional

that had been trialled throughout 1980 and 1981,

as he or she examined the infant or child. It also had

the new book was the same size as the revamped

a section on encouraging the parent to bring the book

Plunket book had been but twice as thick. It contained

to all appointments as well as a reminder to the health

nearly 100 pages of health information, space for the

professional to remember to ask the parent to view the

nurse to write, tick boxes for the mother to check

book each time the child was seen and to ‘exploit’48 it

progress, weight charts, immunisation records, safety

for parent education, standardised record keeping and

information, and numerous suggestions for controlling

health services research. As the Department of Health

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand took over publication of the Plunket book, it also sought

Plunket nurse services.55 During the late 1980s and

to take control of Plunket nursing practice by offering

into the 1990s, the Plunket Society sought to further

such clinical guidelines. How well the handbook was

improve its services to Māori. By 1990 over two thirds

actually used by Plunket nurses is unknown. What

of Plunket branches had child health programmes

was clear from reading Plunket books from the time

that worked in partnership with local Māori groups

was that some Plunket nurses resisted efforts to make

and all new Plunket nurses undertook training in

them use the new forms.

49

The new Health Department record books recognised the presence of Māori and Pacific families, offering a bilingual introduction to the book along with culturally diverse pictures and graphics. Despite these efforts, there is little information available in the literature on the actual experiences of Māori or Pacific mothers in caring for their infants and young children during this period. That lack remains today. What research there is shows a mixed response to services provided by Plunket, with some appreciating the service provided but others indicating it did not meet their needs.50

Figure 5: Plunket book 1990-2000s

There is also a lack of research on the experiences of mothers from other minority groups including those

biculturalism.56 There were also an increasing number

of Asian ethnicity, gay or lesbian parents, and even

of Māori Plunket nurses.57

fathers who take on a primary caregiving role with infants (one exception being work by David Mitchell

By the 1990s the Plunket book had 128 pages of

and Philip Chapman into fatherhood and Plunket).

51

information and checklists for the nurse and mother to

This lack of information makes it difficult to assess the

refer to as needed (see Figure 5). These new Plunket

potential impact or even the role of the Plunket book

books were now named the Well Child/Tamariki Ora

in these families over time.

Health Book, recognising the bicultural nature of health care that was starting to be provided in New Zealand.

For Māori and Pacific mothers, culturally specific

An immunisation certificate included at the back of

Plunket nursing services had traditionally been

the book was required to be completed and shown

limited. Following publication of Hardy’s report into

when a child was enrolled at pre-school or school.

52

malnutrition in South Auckland children in 1972

There was also a record of all immunisations received,

and the Salmond Report in 1975, Plunket obtained

and four weight charts to track height and weight. In

a contract to increase services to children in South

later books, many mothers have written notes about

Auckland where the majority of families were Māori

their children in the margins and on pages set aside

or Pacific.

specifically for this purpose. Writing in Plunket books

53

Up to 71 nurses were working in the

area by 1988.

Evaluation of the contract showed

had not always been encouraged. In the early days of

that, despite the increased number of nurses due to

the Plunket book it was considered the property of the

perceived cultural and access barriers some Māori

nurse and mothers did not write in it.58 More recently,

and Pacific mothers still felt uncomfortable using

nurses have encouraged writing in the books as they

54

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 13

Nursing Praxis in New Zealand have sought to encourage mothers to take ownership

such as Parent Centre, health care professionals were

of the books and use them as a memoir. A book called

compelled to respond and hesitantly incorporate

‘Thriving Under Five’ also accompanied the Plunket

mother and family-centred knowledge, as evidenced in

book providing further information on child raising

the narratives contained in the Plunket book. This trend

for parents. A wide variety of sources of information

emphasises that sources of knowledge are dynamic

began to be available to mothers including child care

and that overtime those involved in the care of infants

books by Christopher Green, Penelope Leach, and

can change and influence hegemonic discourses. In

Miriam Stoppard.

Along with these practical guides,

part one of the review we noted Erik Olssen’s argument

magazines such as Little Treasures parenting magazine

that the Plunket Society’s ‘prescriptive ideology’

(published by a disposable diaper company), and

forced mothers to follow a rigid course of child-

the World Wide Web became increasingly accessed

rearing, and Linda Bryder and Philippa Mein-Smith’s

sources of parenting information.

counter-argument that women had greater agency

59

60

62

61

in the relationship with their nurse and could choose Despite Plunket nurses offering considerable individual

whether to adhere to the strict routines advocated

support and care to mothers over time, the Plunket

by the Plunket Society.64 Our review of the Plunket

book itself still did not at any point specifically recognize

book suggests that in the years 1900 to 1945, Olssen’s

the knowledge or experience of mothers as they care

prescriptive ideology was the dominant discourse in

for their children. The 1990s books encourage the

child rearing and the Plunket book contributed to this

mother to ‘be patient’, to ‘seek help’, to ‘eat and sleep

discourse. However, societal changes, combined with

well’, and to ‘share feelings’.

Nowhere does the book

the growing self-determination of women through the

provide written affirmation that the mother herself

women’s movement as reflected in the development

holds any knowledge of value.

of the Plunket book and the narratives of mothers and

63

nurses within these, suggests that Bryder and Mein-

Conclusion

Smiths’ perspectives gain increasing credence in the post 1945 period.

This paper reviewed the development of the child health and development record book, known as the

The Plunket book is a New Zealand icon and this

Plunket book, during the years of 1945 to 2000. The

historical review demonstrates how the development,

historical review illustrates how over time other types

content and use of the book both reflected and

of knowledge can challenge and shape thinking about

contributed to the dominant discourses over the

issues of infant and child well-being, drawing attention

period reviewed. Nurses through their practice with

to the impact of valuing certain types of knowledge to

the book contribute to these discourses. We suggest it

the exclusion of other sources. The first section of this

is important to note the impact this element of nursing

two part article, which reviewed the years from 1900-

practice can have on mothers and their mothering

1945, demonstrated how medical knowledge governed

experience over time, and to use this knowledge to

infant care practices to the exclusion of mother-

continually improve practice.

generated knowledge. However, as women challenged this hegemonic discourse through societal initiatives,

Page 14

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Endnotes 1 Helen May, ‘Postwar Women 1945-1960 and Their Daughters 1970-1985: An Analysis of Continuity, Contradiction, and Change in Two Generations of Pakeha Women as Mothers, Wives, and Workers’, PhD Thesis, 1988 2 Jill Clendon, ‘Motherhood and the ‘Plunket Book’: A Social History’, PhD thesis, Massey University, 2009. See also part 1 of this two part review for a brief history of the Plunket Society.

3 Plunket book PBFJ1, 1950, Authors private collection.

4 Ibid.

5 Ibid.

6 See Plunket books PBCO1, 1947 and PBSC2, 1952 for examples, Author’s private collection.

7 Benjamin Spock, The Common Sense Book of Baby and Child Care, New York, 1945.

8 John Bowlby, Child Care and the Growth of Love, London, 1953.

9 Marie Bell, ‘The Pioneers of Parent’s Centre: Movers and Shakers for Change in the Philosophies and Practices of Childbirth and Parent Education in New Zealand’, PhD thesis, Victoria University of Wellington, 2004.

10 Ibid.; Sue Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand, Auckland, 1996.

11 Diti Hill, Robyn Reid and Sue Stover, ‘More Than Educating Children: The Evolutionary Nature of Playcentre’s Philosophy of Education’, in Sue Stover, ed, Good Clean Fun: New Zealand’s Playcentre Movement, Auckland, 1998, pp30-38.

12 R. Gordon, ‘The Role of La Leche League in the Promotion and Support of Breastfeeding’, in Annette Beasley and Andrew Trlin, eds, Breastfeeding in New Zealand: Practice, Problems and Policy, eds, Palmerston North, 1998; Karen McBride-Henry, ‘Responding to the Call to Care: Women’s Experience of Breastfeeding in New Zealand, PhD Thesis, Massey University, 2004; Kathleen Ryan and Vivian Grace, ‘Medicalization and Women’s Knowledge: The Construction of Understandings of Infant Feedng Experiences in PostWWII New Zealand’, Health Care for Women International, 22, 5, 2001, 483-500.

13 ‘Holding out’ was recommended during this time as a means of encouraging infants to move the bowels soon after feeding. In practice, a sheet of newspaper or some form of catching device was placed on the floor and immediately after baby was fed he or she was held in a sitting position over the newspaper in order to catch a bowel motion. If successful, this usually meant less dirty laundry for the mother so was a practice that although had little impact on toilet training, was considered to lessen the mother’s workload somewhat.

14 Plunket book PBPW3, 1954, Author’s private collection.

15 See for examples Plunket books PBCL1, 1937; PBVL1, 1939; PBSC1, 1942, Author’s private collection.

16 Plunket book PBPW3, 1954, Author’s private collection.

17 Plunket book PBLD1, 1961, Author’s private collection.

18 Ibid.

19 Ibid.

20 The early editions of Spock clearly emphasised the importance of following the directions of a physician as part of raising a healthy child (Spock, The Common Sense Book of Baby and Child Care; Apple, ‘Constructing Mothers: Scientific Motherhood in the 19th and 20th Centuries’). The interesting difference is that Spock acknowledged the wisdom the mother brought to caring for her children whereas this was never acknowledged by the Plunket Society.

21 Plunket book PBLD1, 1961, Author’s private collection.

22 Plunket books PBFJ1, 1950; PBLD1, 1961; PBPW3, 1954, Author’s private collection.

23 Plunket book PBLD1, 1961, Author’s private collection.

24 Ibid.

25 Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000, Auckland, 2003.

26 Kathleen Ryan, ‘Women’s Narratives of Infant Feeding: The Politics of Knowledges and Practices in Post WWII New Zealand’, PhD thesis, University of Otago, 1998 27 Ryan, ‘Women’s Narratives of Infant Feeding: The Politics of Knowledges and Practices in Post WWII New Zealand’.

28 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 15

Nursing Praxis in New Zealand 29 Plunket book PBKP2, 1972, Author’s private collection.

30 Plunket book PBJC1, 1978, Author’s private collection.

31 Neil Begg, The New Zealand Child and His Family, Christchurch,1970, pp20 and 73.

32 Ryan, ‘Women’s Narratives of Infant Feeding: The Politics of Knowledges and Practices in Post WWII New Zealand’; McBride-Henry, ‘Responding to the Call to Care: Women’s Experience of Breastfeeding in New Zealand’.

33 Sue Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand, Auckland, 1996.

34 Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand.

35 Women’s Rights Committee, The Role of Women in New Zealand Society: Report of the Select Committee on Women’s Rights, Wellington, 1975.

36 Committee on Women, ‘The Role of Women in Society’ Reviewed: What’s Been Done? A Report on Progress Towards Implementation of the Report by the Parliamentary Select Committee on Women’s Rights, 1975, Wellington, 1978.

37 Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand.

38 George Salmond, Maternal and Infant Care in Wellington: A Health Care Consumer Study, Wellington, 1975.

39 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

40 Salmond, Maternal and Infant Care in Wellington: A Health Care Consumer Study.

41 Morag Hardy, ‘Malnutrition in Young Children at Auckland’, New Zealand Medical Journal, 75, 480, 1972, 291-96.

42 Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand.

43 The infant care manuals published by Plunket during the 1970s continued to be Neil Begg’s New Zealand Child and his Family with the final edition published in 1974 (Neil Begg, The Child and His Family, Dunedin, 1974. From 1979, Trish Gribben, Roy Muir and David Geddis (who had taken over as Medical Director of Plunket in 1977) co-authored a newer book entitled Pyjamas Don’t Matter (Trish Gribben, David Geddis and Roy Muir, Pyjamas Don’t Matter (or What Your Baby Really Needs), Auckland, 1979.

The new book was less dictative and acknowledged the parent as the expert in decision making but did not come with Plunket’s branding.

44 Salmond, Maternal and Infant Care in Wellington: A Health Care Consumer Study.

45 Committee on Child Health, Child Health and Child Health Services in New Zealand, Department of Health, Wellington, 1982.

46 Ibid.

47 Department of Health, Recording Child Health and Development: A Handbook for Professionals Using the ‘Health and Development Record’ Book, Wellington, 1984.

48 Ibid.

49 Clendon, ‘A Social History of the Plunket Book; Plunket book PBPW5, 1984, Author’s private collection.

50 Sally Abel, Sitaleki Finau, David Tipene-Leach, Michelle Lennan and Julie Park, Infant Care Practices Amongst Māori, Pacificans and Pakeha; Implications for Maternity and Well Child Services in New Zealand, Suva, Fiji, 2003; Sally Abel, Eseta Finau, Filipo Motulalo, Lavili Ahokovi and Sitaleki Finau, Tongan Infant Care Practices: A Qualititative Study of the Practices of Auckland Tongan Caregivers of under 12 Month Old Infants, Auckland, 1999.

51 David Mitchell, ‘Involving Dads in Plunket Services’, Plunket at Work, 2002; David Mitchell and Phillip Chapman, Involving Dads in Our Service: A Collaborative Project, Nelson, 2001.

52 Hardy, ‘Malnutrition in Young Children at Auckland’.

53 Salmond, Maternal and Infant Care in Wellington: A Health Care Consumer Study.

54 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

55 Michael Clinton, Child Health Services in South Auckland Project: Report to the Hon. Mr David Caygill, Minister of Health, Wellington, 1988.

56 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

57 Ibid.

58 Clendon, ‘Motherhood and the ‘Plunket Book’: A Social History’.

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 59 Ibid.

60 Christopher Green, Babies! A Parent’s Guide to Surviving (and Enjoying) Baby’s First Year, East Roseville: NSW, 1999.

61 Penelope Leach, Baby and Child, London, 1988.

62 Miriam Stoppard, Complete Baby and Child Care, London, 1995.

63 Plunket book PB JC1, 1998, Author’s private collection.

64 Olssen, Erik. ‘Truby King and the Plunket Society: An Analysis of a Prescriptive Ideology’. The New Zealand Journal of History, 15, 1, 1981, 3-23; Linda Bryder, ‘The Plunket Nurse as a New Zealand Icon’, 2002, online, available: http://www.nursing.manchester. ac.uk/ukchnm/publications/seminarpapers/ 30 October 2013; Philippa Mein-Smith, ‘Mothers, Babies, and the Mothers and Babies Movement: Australia through Depression and War’, Social History of Medicine, 6, 1, 1993, 51-83; Linda Bryder, ‘Perceptions of Plunket: Time to review historians’ interpretations’, New Countries and Old Medicine: An international conference on the history of medicine and health, Auckland, 1994.

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 17

Nursing Praxis in New Zealand NURSE PRESCRIBING: THE NEW ZEALAND CONTEXT Anecita Gigi Lim, PhD, MHSc, GradDipSciPharm, (FCNZ), RN, Senior Lecturer, School of Nursing, University of Auckland, Auckland, NZ Nicola North, PhD, MA (SocSci), RN, RM, Associate Professor – Health Systems, School of Population Health, University of Auckland, Auckland, NZ John Shaw, PhD, PGDipClinPharm, BSc, FPS, Professor of Pharmacy, School of Pharmacy, University of Auckland, Auckland, NZ

Abstract The purpose of this study was to examine the introduction of nurse prescribing in New Zealand, especially with respect to the basis of concerns related to level of knowledge and skills required of practitioners for safe prescribing; and further to compare experiences in New Zealand with those in other countries where nurses are authorised to prescribe. It is argued that prescribing rights previously extended to Nurse Practitioners and now being extended to other groups of nurses, and also to other health professions, is a matter provoking concern with respect to patient safety and adequacy of educational preparation. Unlike in the UK where extending prescribing rights to nurses did not involve rigorous educational preparation, Nurse Practitioners in New Zealand now undergo a stringent process involving Masters degree preparation in biological sciences and pharmacology (similar to USA). However, despite differences between policy environments, in New Zealand, criticisms grouped into concern about knowledge, patient safety and the impacts on team work and the health system echoed that voiced in the UK. The view that the educational model to prepare medical practitioners to prescribe is the ‘gold standard’ is critiqued and alternative models supported for extending prescribing rights to nurses and other professions. The expectation now is that extended prescribing rights are unlikely to be reversed. As the first two professions to be granted prescriptive authority in New Zealand, experiences in preparing both midwives and nurses educationally are expected to influence the models of educational preparation for other professions. The focus of the debate needs to shift from arguing against extending prescribing authority (especially to nurses), to consideration of how practitioners can be best prepared for and supported in the role.

Key words Nurse prescribing, authorised prescribing, Nurse Practitioner, patient safety, prescribing education

Introduction

but was limited to normal perinatal care. Later in 2002, Nurse Practitioners were also given the right

In New Zealand as in other countries, extension of

to prescribe, subject to meeting rigorous conditions

prescribing rights to nurses triggered strong and vocal

of approval (“Medicines (Designated Prescriber:

opposition, particularly from the medical profession.

For decades, only medical doctors, dentists and veterinarians had prescriptive authority. In 1989 in New Zealand this authority was extended to midwives Page 18

Lim, A. G., North, N., & Shaw, J. (2014). Nurse prescribing: The New Zealand context. Nursing Praxis in New Zealand, 30(2), 18-27

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Nurse Practitioners) Regulations,” 2005). Prescriptive

nurses (Ministry of Health, 2013b). Educational

authority for nurses was intended to be far wider

preparation for a delegated and designated prescribing

than for midwives. This provoked concern for patient

role (defined below) requires that the health

safety based on whether nurses were educationally

practitioners are “...sufficiently knowledgeable to

prepared for a prescribing role (Moller & Begg, 2005).

safely prescribe prescription medicines or prescription

This caution was in spite of the prescriptive authority

medicines of a specified class or description”.

being restricted to nurses individually approved by the Nursing Council of New Zealand as Nurse Practitioners.

In view of the recent extension of limited prescribing

The latter title referred to a newly gazetted advanced

rights to groups of nurses (and other health professions)

scope of practice available only to registered nurses

in addition to Nurse Practitioners, this paper examines

with at least 5 years’ experience in their specified

the introduction of nurse prescribing in New Zealand,

clinical area, and who had completed a 2-year Master’s

outlining the basis of concerns related to the level

degree in an approved clinical nursing programme that

of knowledge and skills required of practitioners for

included a suite of prescribing papers (Lamond, Crow,

safe prescribing, and compares experiences in New

& Chase, 1996; Lim, Honey, & Kilpatrick, 2007; Renouf,

Zealand with those in other countries where nurses

2005).

are authorised to prescribe.

This development entailed the setting up of mechanisms to oversee the extension of prescribing rights to other health professions. In 2001 a New

Extending prescribing rights to nurses in New Zealand: Experiences and criticisms

Prescribers Advisory Committee was established to assess applications for extending limited independent

Prescriptive authority: Explaining the terminology

prescribing authority to new groups of health

used in New Zealand

practitioners, and to advise the Minister of Health.

Prescriptive authority refers to a practitioner’s right

This committee was disestablished in July 2006, after

to issue a medical prescription, an order (often in

which applications for extension of prescribing rights

written form) by a qualified health care professional

were made directly to the Ministry of Health which,

to a pharmacist or other therapist for a treatment

upon receipt of an application, sets up a process to

to be provided for the patient. A prescription is,

assess the appropriateness of the extension (“Health

therefore, a legal written document that not only

Practitioners Competence Assurance Act,” 2003).

instructs in the preparation and provision of a medicine or device, but more importantly, includes

Further changes to legislation to extend prescriptive

the prescriber’s responsibility for the clinical care of

authority to other groups of nurses and health

the patient and the outcomes to be achieved (Maxwell

professions have recently been introduced in New

& Walley, 2003). Prescribing involves the application of

Zealand. Amendments to the Medicines Act 1984 in

biomedical knowledge, including pharmacology and

2011 gave diabetes nurses (Ministry of Health, 2011)

therapeutics, and critical thinking to establish a safe,

and pharmacists (Ministry of Health, 2013a) designated

effective and appropriate outcome of treatment and

prescriptive authorities. Additional amendments to

deliberations regarding risk/benefit considerations

the Medicines Act 1984 in December 2013 extended

(Naylor, 2004; Schwertz, Piano, Kleinpell, & Johnson,

prescriptive authority to other health practitioners, for

1997).

example delegated prescriptive authority to specialist

agencies being responsible for ensuring that the

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Approving prescriptive authority involves

Page 19

Nursing Praxis in New Zealand prescriber understands and has the knowledge and

and diabetes nurse specialists after undergoing

skills to undergo a process of deliberation, and has a

the required educational preparation and training

sound grounding in the biomedical sciences. The latter

(Ministry of Health, 2011). In

requirement has strongly influenced the philosophy

to the Medicines Regulation 2011 required medical

and practice of health service provision and delivery,

practitioners, dentists and midwives (who were

and is widely agreed as the necessary knowledge

Authorised Prescribers) to prescribe within their scope

base for prescriptive authority (Aronson, Henderson,

of practice for patients under their care, as defined by

Webb, & Rawlins, 2006; Boshuizen & Schmidt, 2008;

their responsible authorities established under the

Bradbury-Jones, Irvine, & Sambrook, 2010; Brar,

Health Practitioners Competence Assurance Act 2003.

2011, amendments

Boschma, & McCuaig, 2010; Bullock & Manias, 2002; Carr, 2004; Christensen, Jones, Higgs, & Edwards,

In 2013, prompted by nursing leadership, amendments

2008; Clarkson, 2001; Grindle & Dallat, 2000; Gwee,

to the Medicines Act 1984 in 2013 further extended

2009).

nurse prescribing rights. Following the successful implementation of prescribing roles to Nurse

In New Zealand prescriptive authority is outlined in

Practitioners in the previous decade and to diabetes

the Medicines Act (“Medicines Act 1981,” 1984) and

nurses in 2011 (Ministry of Health, 2011), the Nursing

in the Medicines Regulation of 1984 (“Medicines

Council of New Zealand launched a discussion

Regulation,” 1984). Under this Act Authorised

document to determine the feasibility of extending

Prescribers can prescribe all medicines from Part 1A or

prescriptive authority to other clinical nurse specialist

Part 1 B of Schedule 1 of the Medicines Regulations.

and community nurse groups (Nursing Council of New

Only three health practitioners were Authorised

Zealand, 2013). Strong support from many sectors and

Prescribers (doctors, dentists and midwives) until 1999

nursing organisations was evident in the submission

when the New Zealand government agreed to extend

that led to lobbying by the Nursing Council and other

prescriptive authority to include Nurse Practitioners.

organisations to the government (Nursing Council

However,

considered

of New Zealand, 2013). In December 2013, the New

differently to other practitioners. Then authority to

Zealand government agreed to extend prescriptive

prescribe came by virtue of training and preparation

authority to other health practitioners as Delegated

in prescribing which was acquired after, not as part of,

Prescribers under a limited and more specified formulary

undergraduate education. A new term was, therefore,

(Ministry of Health, 2013b). Delegated Prescribers are

introduced in the amendments to the Medicine Act

health practitioners to whom a delegated prescribing

1984 for Nurse Practitioners. The term Designated

order has been issued by an Authorised Prescriber from

Prescriber was coined, defined as: “...a person who,

their specified class or group. A Delegated Prescribing

immediately before 1 November 2005, was authorised

Order is a written instruction, issued in accordance with

by the former regulations to prescribe within their

regulations by an Authorised Prescriber, authorising a

scope of practice and a specified prescription medicine

health practitioner to prescribe specified prescription

in Part 1A or Part 1B of Schedule 1 of the Medicines

medicines. Specified prescription medicines means

Regulations 1984 (“Medicines (Designated Prescriber:

prescription medicines specified by the Director-

Nurse Practitioners) Regulations,” 2005). In 2011,

General by notice in the Gazette.

Nurse

Practitioners

were

further amendments to the Medicines Act 1984 extended prescriptive authority (Designated) to other

To summarise the developments that have extended

health professionals including some pharmacists

prescribing rights to increasing groups of nurses,

Page 20

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand enabling legislation in 1999 gave prescribing rights

clinical knowledge are two distinct, yet influential,

to Nurse Practitioners, although at least another five

aspects of the prescriber’s prescribing decisions are

years passed before the law was implemented and the

influential considerations on how medical students are

first nurses applied for approval. Nurse Practitioners

prepared to prescribe (Pearson, 2003).

could prescribe as Designated, not Authorised, prescribers. For nursing the most important changes

The major criticisms relating to nurse prescribing reflect

to the legislation in 2013 were first, the legal

concerns that in training and education, nurses do not

endorsement of Nurse Practitioners as Authorised

gain the biomedical knowledge required to diagnose

Prescribers, some groups of nurses such as Diabetes

illness and treat disease: but such criticisms ignore

Nurses being Designated Prescribers, and adding a

the clinical knowledge of experienced nurses being

new category of Delegated Prescribers that extended

educationally prepared to prescribe. Deficiencies in

limited prescribing rights to additional groups of

clinical reasoning capabilities are also ascribed to a lack

nurses (Ministry of Health, 2013b).

of biological knowledge and medication-related issues in undergraduate nursing education (Hemingway &

Educational preparation for prescribing

Davies, 2006; Latter, Rycroft-Malone, Yerrell, & Shaw,

Physicians are educated and trained in the diagnosis

2000). Critics warn that without attention to scientific

and treatment of disease. Historically prescribing is

education and biomedical knowledge in nurse training

an important skill required of a doctor in any speciality

and education, nurses will lack the knowledge and

(Maxwell & Walley, 2003). Education for prescribing

skills necessary to make differential diagnoses and

and prescribing practices, behaviours and decisions

prescribe drugs (Jordan & Griffiths, 2004), potentially

of doctors and their biomedical knowledge base,

putting patients at risk.

have been extensively studied (Naylor, 2004). Medical prescribing and its biomedical knowledge base are,

The introduction of nurse prescribing in New Zealand

therefore, frequently used as the point of reference

As for midwives, an expanded Nurse Practitioner role

in arguments against extending prescribing rights to

was introduced to improve access to health services

other professions such as to nurses and pharmacists.

and affordability for patients, and so justified as benefitting health consumers (Ministry of Health,

However, critics argue that the application of biomedical

2000a). Following several years of debate and

knowledge is a particular characteristic of non-expert

development on the role (Ministry of Health, 2001a,

reasoning, with medical experts predominantly using

2002; Nursing Council of New Zealand, 2001), the

clinical (not biomedical) knowledge to represent

impetus to implement the prescriber role came from

and diagnose a patient problem (Patel, Evans, &

the New Zealand Health Strategy and associated

Groen, 1989; Schmidt, Norman, & Boshuizen, 1990).

Primary Health Care Strategy (Ministry of Health,

While biomedical knowledge concerns itself with the

2000b, 2001b). This set out to shift the orientation

pathological principles, mechanisms, or processes

of the health system from hospital and acute services

underlying the manifestations of disease, clinical

to a population health focus, with an associated shift

knowledge refers to knowledge of how a disease

of care from hospitals to ambulatory and community-

may manifest itself in patients, and the expected

based settings.

complaints, the nature and variability of the signs

profession for the achievement of the strategies and

and symptoms and the ways in which the disease can

associated focus on services aimed at keeping people

be managed. Views that biomedical knowledge and

well, ranging from promotion of health and screening

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nurses were identified as a key

Page 21

Nursing Praxis in New Zealand for disease to assessment, diagnosis, treatment and

Similarly in Canada, nurse practitioner education

rehabilitation, so emphasising the increasing need for

was first introduced in 1975, and regulation of

a highly skilled workforce (Ministry of Health, 2001b).

advanced nursing practice is seen to be “…within the current scope of nursing practice” (Canadian Nurses

The granting of Nurse Practitioner status and

Association, 1999).

prescribing authority to registered nurses was planned to be stringent. At least four years of clinical

In the UK rationale for extending prescribing rights

experience in a specific clinical area was a pre-requisite

to nurses and other health professions was similar

with completion of a 2-year clinical Masters degree

to that of the US and Canada, but the introduction is

designed to address the perceived deficiencies in

both relatively recent and widespread. Enabling policy

nurses’ knowledge (Ministry of Health, 2002) and to

was made, it appears, for pragmatic reasons of cost

support a nursing preference for advanced education

reduction and improving access. The Cumberledge

to provide the necessary knowledge base (Gardner,

Report in 1986 first recommended extending

Dunn, Carryer, & Gardner, 2006). Before they may

prescriptive authority to other health professionals

apply for prescriptive authority nurses must complete

to improve access, reduce cost and allow greater

an educational and practical programme specific

flexibility of health care services and delivery. The

to pharmacology and therapeutics. The suite of

necessary legislation was passed in 2001 (Department

prescribing courses has a strong focus on pharmacology,

of Health & Social Security, 1986) with district nurses

therapeutics and clinical decision-making (Nursing

and health visitors being the first professions outside of

Council of New Zealand, 2005). Five schools of nursing

medicine to be granted prescriptive authority (Otway,

have developed Masters programmes to prepare

2002). The move in the UK in 2002 to give legislative

Nurse Practitioners for prescribing, each approved

authority for nurses to prescribe was probably the

and regularly accredited by the Nursing Council. The

greatest extension of prescribing rights anywhere in

Nursing Council also sets the competencies required

the world. The UK is also exceptional in that extending

for safe and effective prescribing, and monitors and

prescriptive authority to nurses was included in a

audits each programme. Nonetheless, wide variation

broader initiative that involved other professions,

exists between institutions with regard to content

including pharmacists and midwives (Latter, Maben,

delivery and assessments (Lim et al., 2007).

Myall, & Young, 2007).

A global perspective on nurse prescribing

By contrast with New Zealand, USA and Canada, in the

Nurses in the US have had prescriptive authority since

UK a post-registration educational requirement is not

at least the 1960s, when physician shortages and

required for district nurse and health visitor prescribing

distribution threatened service delivery and nurses

under patient group directives or formulary. However,

addressed the gap. Along with clinical nurse specialists,

for nurses who are prescribing from an extended

nurse midwives and nurse anaesthetists, nurse

formulary through a supplementary prescribing

practitioners are but one of a number of advanced

model, a 26 day course (completed over three to six

nursing roles considered under the umbrella title

months) in higher education is mandatory, and course

Advanced Practice Nurse (APN). Nurses in all 50 states

outcomes and content are based on the 25 stated

now have prescriptive authority. Both pharmacology

competencies stipulated by the Nursing and Midwifery

and science education for nurses is strongly supported

Council of the UK (Jordan & Griffiths, 2004).

at the undergraduate level (Hales & Dignam, 2002).

Page 22

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Initial responses to nurse prescribing in New Zealand

Zealand echoed similar concerns in the UK, where a

In spite of advanced educational preparation in

lack of specialist training and competence were the

pharmacology being stipulated, extending prescribing

predominant issues raised (Chaston & Seccombe,

rights to nurses did not go unchallenged. While in

2009).

New Zealand introduction of the Nurse Practitioner role was not of itself opposed, extending prescribing

Other arguments sidestepped the issue of competence

rights to Nurse Practitioners was contested. A survey

to prescribe, with one such concerning the effect of

of media commentary at the time is one indicator of

the changes on team work (Mackay, 2003). Some

professional and public opinion. An initial burst of

suggested that a blurring of roles could arise where

comment circa 2000-2001 greeted the proposal for

two different prescribers may differ in prescribing

and subsequent implementation of nurse prescribing;

decisions, potentially impacting on the team’s

and there was a second burst some five years later

dynamics (Moller & Begg, 2005). This view echoed

over slow progress in implementation. Excluding

concerns in the UK about balance of power (Baird,

official media releases, comments by doctors were

2001). General practitioners felt they were still liable

typically critical (Fallow, 2005), and were countered

for the actions of the practice nurses, and were left to

by nurses (Bickley, 2005). For their part, doctors raised

manage complex medical cases (Banning, 2004).

concerns about patient safety and whether nurses had the necessary knowledge to examine, diagnose and

Criticisms about nurse prescribing need to be

prescribe (Clarkson, 2001; Johnston, 2005). Concerns

interpreted in the policy contexts of the country

about increased costs to the health system were also

in which concerns are voiced, as those that have

raised (St. John, 2001). Some medical critics suggested

introduced nurse prescribing have developed different

that if nurses wanted to prescribe they should

educational models to prepare practitioners for the

complete medical training; others drew attention

role. Research findings regarding the adequacy of

to the importance of teamwork and potential threat

educational preparation and competence of nurse

from confusion of roles, with fears expressed that

prescribers undertaken in one country, for example

patients would be both confused and (when fees were

UK (Courtenay, 2008), do not necessarily apply to

involved), likely to choose the cheaper option, nurses.

nurse prescribers in other countries. In contrast to the introduction of nurse prescribing in the USA and UK,

Relative silence in the media on the topic since about

in New Zealand implementation was accompanied

2006 suggests that despite there being prescribing

by both rigorous educational preparation to remedy

Nurse Practitioners “unleashed directly on an

the agreed deficiencies in pharmaco-therapeutic

unsuspecting public� (Boswell, 2005), to date there

knowledge, and a robust process of approving

had been no dire consequences. The criticisms, many

individual nurses to prescribe (Gardner et al., 2006;

of which echo those voiced in other countries, can be

Ministry of Health, 2002). In spite of these differences,

grouped into: concerns about knowledge; concerns

the introduction of prescriptive authority for nurses

about patients; and concerns about team work and

in New Zealand attracted similar criticisms to those

the health system. For example, it was argued that,

expressed in other countries.

as nurses lack the educational and clinical preparation undertaken by doctors at undergraduate level and

Discussion

through clinical training, safety may be compromised (Moller & Begg, 2005). These concerns voiced in New Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Advocates of nurse prescribing (Hales & Dignam, Page 23

Nursing Praxis in New Zealand 2002) claim that nurses have always attended to a

As the first two health professions (other than

crisis when doctors have been unavailable, including

the medical profession) to be granted prescriptive

at times advising doctors on what to prescribe for the

authority in New Zealand, it is to be expected that

patient. Some studies have raised concerns related to

experiences in preparing both midwives and nurses

lack of pharmacology knowledge and education in the

educationally will influence the development of

undergraduate nursing curriculum (King, 2004; Latter &

models of prescribing and approaches to educational

Courtenay, 2004). However, this is addressed through

preparation for other professions. While there is

the requirements of Masters-level postgraduate clinical

extensive literature on medical prescribing, to date

education covering pharmacology and pharmaco-

research on prescribing by other professions, including

therapeutics, diagnostic reasoning and evidence-based

nurses, is limited. Furthermore, views differ on the

practice and research, partly assessed, monitored,

best way to prepare medical prescribers (Lamond

evaluated and designed by doctors (Renouf, 2005).

et al., 1996; Maxwell & Walley, 2003; Naylor, 2004; Patel et al., 1989). To date the only two professions

Support for preparation of Nurse Practitioners

in New Zealand that are authorised to prescribe

at Masters degree level, where the principles of

are midwives who (like doctors) are prepared at

pharmacology and therapeutics are taught, is growing

undergraduate level (though preparation is limited

internationally as in New Zealand (American Academy

and focused on perinatal prescribing), and nurses

of Nurse Practitioners, 1993; van Soeren, Andrusyszyn,

whose preparation is at postgraduate level and more

Spence Laschinger, Goldenberg, & DiCenso, 2000).

comprehensive. To date research is lacking to support

Evidence is needed regarding the relationship between

the relative merits of each educational framework,

curricula and approaches in postgraduate education

and more importantly, the impact this may have on

and competent prescribing. Furthermore, in support

the dynamics of the interdisciplinary team. It may

of formal, higher education of nurses in preparation

be that there is an argument, for example, for inter-

for prescribing, some educationalists are pointing

professional education in prescribing for all health

to a need for ongoing post-registration support

professionals. The question then arises should this

and continual clinical development in prescribing

be at undergraduate or postgraduate level or both? A

(Hemingway & Davies, 2006; Latter et al., 2007). New

further consideration is how continuing education and

Zealand’s response to concerns about nurse prescribing

support for prescribing for prescribers in both medical

has been to address the preparation of nurses

and other health professions can be addressed. These

through focusing on pharmacology and therapeutics

are important questions facing New Zealand, as in

knowledge in a broader context of clinical reasoning.

other countries where prescribing rights are being

Educational preparation for a Nurse Practitioner role

extended to other health professions.

that includes prescribing is essential if nurses are to succeed in the extended and designated roles. In a social context where concerns about the adequacy of

Conclusions

nurses’ knowledge and skills persist, a burden is placed upon regulatory authorities and educational providers

The extension of prescribing rights to nurses (and

to ensure that the public is not exposed to risk from

other health professions) in New Zealand, and other

incompetent nurse prescribers, including authorised

countries, is unlikely to be reversed. We argue that

prescribers (e.g. nurse practitioners) and designated

extending prescriptive authority to nurses, and to other

prescribers (e.g. diabetes nurse specialists).

professions, who are educationally prepared for the

Page 24

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand role, need not bring with it the negative consequences

respect to supporting prescriber competence. In this

feared by its critics. In New Zealand the absence to

respect, an examination of how concerns have been

date of feared consequences most likely reflects policy

addressed in extending prescriptive authority to

requiring robust educational preparation of nurses for

nurses is equally relevant for other professions (e.g.

the new role. Our contention is that the focus of the

pharmacists, podiatrists and physiotherapists) to

debate needs to shift from arguing against extending

inform their considerations on how best to meet the

prescribing rights, to how practitioners can be best

educational needs in prescribing when prescriptive

prepared for the role, and more broadly to the health

authority is extended to these professions.

system, educational and regulatory contexts with

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Nursing Praxis in New Zealand Nursing Council of New Zealand. (2005). Implementing Nurse Practitoner prescribing: Consultation document. Wellington, New Zealand: Author. Retrieved from http://old.nurse.org.nz/nurse_practitioner/consultation.pdf Nursing Council of New Zealand. (2013). Executive summary: Analysis of submissions consultation: Two proposals for registered nurse prescribing. Retrieved from http://nursingcouncil.org.nz/Publications/Consultation-documents/Analysis-of-submissionsconcerning-registered-nurse-prescribing Otway, C. (2002). The development needs of nurse prescribers. Nursing Standard, 18(18), 33-38. doi:10.7748/ns2002.01.16.18.33. c3140 Patel, V., Evans, A. E., & Groen, G. J. (1989). Biomedical knowledge and clinical reasoning. In D. A. Evans, & V. L. Patel (Eds.), Cognitive science in medicine: Biomedical modeling (pp.53-112). Cambridge, MA: MIT Press.

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Nursing Praxis in New Zealand THE INFLUENCE OF THE CARTWRIGHT REPORT ON GYNAECOLOGICAL EXAMINATIONS AND NURSES’ COMMUNICATION Catherine Cook, PhD, RN, Lecturer, School of Nursing, Massey University, Auckland, NZ Margaret Brunton, PhD, RN, Associate Professor , School of Communication, Journalism and Marketing, Massey University, Auckland, NZ

Abstract The Cartwright Report of the Cervical Cancer Inquiry of 1987/8 made detailed recommendations about the primacy of communication with respect to informed consent, specifically for women undergoing gynaecological examinations. This paper reports findings from a wider study into women’s experiences of what makes examinations go well. The data are specific to nurses and a subset of women participants. Data are from semi-structured interviews with six nurses, and seven women who had attended a sexual health clinic and had a speculum examination. These data are a portion of a larger study about women and gynaecological examinations, in which a total of 16 women patients and 16 clinicians (including 10 doctors) were interviewed. Clinicians were recruited through self-selection in response to a request for participants who believed that for the most part, women were satisfied with the clinical care they received, and reattended. Subsequently, women who had been examined by these nurses and doctors were recruited. The recently developed concept of ‘shared mind’ was employed to analyse the data, using an iterative content analysis to identify which clinical communication strategies were used, and the way in which women responded. The findings demonstrate that nurses, through a shared mind process, can provide an environment to meet both the physical and emotional needs of women and enhance the likelihood of their re-attendance. This paper highlights Cartwright’s legacy as it is enacted by a group of nurses in New Zealand.

Keywords Cartwright Report; communication; sexual health; women’s health; cervical screening; New Zealand

Introduction Twenty-five years on from the publication of Judge

& Lu, 2008; Jameson, Sligo & Comrie, 1999; Lovell,

Sylvia Cartwright’s Report of the Cervical Cancer Inquiry

Kearns & Friesen, 2007; Paterson, 2012; Priest, Sadler,

(1988), literature attests to the enduring influence

Sykes, Marshall, Peters & Crengle, 2010). The report

of the recommendations. Extant literature primarily

findings were also contested (Bryder, 2009) and these

addresses sweeping changes to regulation and policy

claims refuted (Bunkle, 2010; Matheson, 2010). Some

(for example Collins & Brown, 2009; McCredie et al.,

discrepancies and recent alterations to the structure of

2008; Manning, 2009; Townshend, Sellman & Haines, 1998). There is critique of the uneven progression of the National Cervical Screening Programme, established as one of Cartwright’s recommendations (Bethune & Lewis, 2009; Gao, De Souza, Paterson Page 28

Cook, C., & Brunton, M. (2014). The influence of the Cartwright report on gynaecological examinations and nurses’ communication. Nursing Praxis in New Zealand, 30(2), 28-38.

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand ethics committees are also noted (Gillett, 2012; Tolich

examined in total privacy, and under

& Baldwin, 2005).

conditions which enable the woman to respond with trust and to communicate her

There is, however, a paucity of literature about what

views, symptoms and feelings as an equal (p.

the enactment of Cartwright’s recommendations

116).

might ‘look like’ at the level of direct clinical care. The purpose of this paper is to explore whether there is

Cartwright’s

focus

on

clinical

communication

continuing evidence of ways in which clinical care in

highlighted doctors rather than other clinicians as the

a sexual health setting is influenced by Cartwright’s

inquiry investigated the dubious ethicality of medical

legacy. This research builds on an earlier study (Cook,

research by Professor Herbert Green at National

2011) which explored the strategies of nurses and

Women’s Hospital in Auckland. She emphasised that

doctors who appreciate the relational aspects of

women’s consent to examinations and related clinical

examinations, and included women’s assessment of

procedures must be given without coercion. She

these clinicians’ contribution to anxiety reduction, as

pointed out that it was the doctor’s duty to be mindful

consistent with Cartwright’s recommendations.

of the influence of power relations, which might lead a woman to consent through “…natural courtesy or a

The Cartwright Report

wish to please someone who appears to be of greater status than herself” (1988, p.116).

Cartwright’s

Report

(1988)

made

detailed

recommendations related to communication between

Cartwright’s recommendations espoused a respectful

individual doctors and women patients. She argued

understanding of the patient’s human dignity, which

for the centrality of advocacy and collaboration in

included their right to effective communication and

clinician-patient encounters, so enabling women to

informed consent. This paper continues exploration

voice less than unequivocal consent and to express

of how the spirit of Cartwright’s recommendations is

their concerns. The resulting report was highly critical

carried forward in clinical care ‘at the bedside’ during

of the paternalistic authority wielded by doctors;

gynaecological examinations. Data presented here

further noting that nurses shared culpability in their

illustrate relational strategies reported by six nurses

failure to advocate for women.

and seven women, as part of a larger study carried out in two New Zealand sexual health clinics.

Cartwright’s

report

specifically

addressed undergoing

That benefits accrue from sensitive and skilful

gynaecological examinations. She emphasised the

communication during an invasive, non-sedated

requirement for doctors to convey to women their

procedure entailing a private area of a woman’s body

cognisance of, and responsiveness to the privacy

might appear common-sense logic. However, Cook

needs and sacredness women associated with the

(2009, 2011), in an earlier study focussed on women

genital area:

and sexually transmitted infection (STI) diagnoses,

communication

needs

of

women

found that despite examinations being normalised, Any doctor conducting a vaginal examination,

women commonly had negative experiences in

needs a sympathetic understanding that the

relation to nurses and doctors’ communication. Cook

genital tract is a sacred part of a woman’s

(2011) critiqued numerous studies about women’s

body, which should be treated with respect,

examination anxiety in which the clinical role is largely

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 29

Nursing Praxis in New Zealand or completely absent (for example, Barron, Foxall,

clinical communication research. It provides a useful

& Houfek, 2005; Galaal, Deane, Sangal, & Lopes,

tool for assessing which communication strategies

2009; Kocobas & Khorshid, 2011; Sharp et al., 2012;

make a difference in clinical practice (Epstein, 2013).

Tahseen & Reid, 2008). Instead, extant clinical research

Shared mind may occur naturally, but with awareness

explores women’s ‘failure’ to follow-up appointments

can also be promoted.

in relation to cancer-related anxiety and general coping. Interventions such as educational material, use

A shared mind framework in the interface with

of music and environmental aspects are measured,

the patient recognises the clinician is present and

without cognisance of relational contributions in

demonstrates attentiveness in the form of “…sharing

manifesting or easing distress. Although there are

of thoughts, feelings, perceptions, meanings and

some exceptions, in phenomenological and post-

intentions…” (Epstein & Street, 2011, p. 455). The

structuralist critiques (such as Buetow, Janes, Steed,

authors argue that this degree of involvement benefits

Ihimaera, & Elley, 2007; Giuffre & Williams, 2000;

patients through a relationship process that extends

McWilliam & O’Donnell, 1998), and in clinical research

the respect enshrined in patient centred care to

regarding examination of women with a sexual trauma

encompass collaboration. The collaborative process

history (Ackerson, 2012; Du Mont, White, & McGregor,

empowers patients through a mutual progression of

2009; Swahnberg, Wijma, & Siwe, 2011), a prevailing

negotiation that arrives at a shared decision (Edwards

research conclusion is that the endemic problem of

& Elwyn, 2006).

anxiety and poor follow-up ‘belongs’ to women.

Presence is central, and we argue that this approach Cook’s (2011) previous research led to the current

requires more active involvement from nurses and

study. This paper explores the strategies of nurses who

doctors than that typically espoused by the shared

recognise and value relational aspects of examinations,

decision-making models of patient centred care (Elwyn

and includes women’s assessment of these nurses’

et al., 2012; Entwistle, Carter, Cribb, & McCaffery,

contribution to anxiety reduction. We contend that,

2010). In this study, nurses were committed to finding

as women’s health may benefit from gynaecological

out what women wanted to achieve, rather than what

examinations undertaken across the lifespan for

they, the clinician, might desire. Nurses were alert to

numerous clinical reasons, it behoves clinical staff to

the possibility that the women’s wishes were part of

ensure women have optimal experiences. Nurses and

an unstable, evolving process, consequently it was

doctors have the power to foster the likelihood that

only through the relational interaction that women

women will decide to re-attend.

discovered what they did and did not want.

The ‘shared mind’

The shared mind concept involves the clinician first becoming “attuned” to the patient, through

Optimal decision-making can be facilitated through

recognising that many values are socially mediated

relational communication. The latter emphasises

and that communication through the expression of

knowing the patient as a person in order to arrive

emotion, language and actions will move beyond

at consensus, rather than regarding communication

mere information transfer to facilitate decision-

as a transactional process to extract information as

making (Epstein & Street, 2011). Second, developing

a commodity (Epstein & Street, 2011). The concept

trust includes recognising different domains of power

of ‘shared mind’ has developed as a result of recent

and dynamics that constrain communication. Third,

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand egalitarian power sharing presupposes that a form

Clinicians were recruited from both an urban and a

of equality is established in the relationship through

provincial sexual health clinic. These clinics provide

asking explicitly what patients want to know, and

a free service. Clinicians self-selected to join the

checking for understanding while ensuring that

study. They responded to a research advertisement

the patient is not in information overload (Back &

circulated to clinical staff, which asked the following

Arnold, 2006). Finally, establishment of common

questions: ‘Are you a clinician who undertakes cervical

ground is facilitated by a process of negotiation that

smears and other gynaecological examinations? In

promotes autonomy through “respectful resolution of

general, do you perceive that women are satisfied

differences” (Epstein, 2013, p. 203).

with the care they receive from you during these procedures?’ Subsequent to clinicians’ interviews,

In the following examples, we illustrate the ways

women who consulted these clinicians were later

nurses working in two sexual health clinics employed

recruited, following an appointment. Nurses and

finely nuanced communication skills that align with

doctors were recruited from these sexual health

the communicative model of the ‘shared mind’,

clinics as specialist services where women considered

and thus demonstrate how the Cartwright (1988)

‘complex’ or ‘difficult’ are regularly referred by General

recommendations are enacted in contemporary clinical

Practitioners. Women who had been examined by the

practice. Recommendations pertinent to the analysis

clinical participants were interviewed to ascertain

are as follows: Cartwright argued for egalitarianism

whether there was concordance between clinicians’

and respect, reminding practitioners that “the

and women’s accounts.

focus should be centred on the patient and not on the doctor” (p. 136). The centrality of the patient’s

Participants were recruited between August 2012

perspective included Cartwright’s infrangible position

and June 2013. Initial telephone contact was made

in relation to informed consent: “The patient must

with the clinic directors by the first author, and a

freely give consent to all treatment and research. There

snowball sample was achieved as the information was

must be full disclosure” (p. 37). Such requirements

distributed to staff. This was appropriate as a specific

focus on how decisions are negotiated in the clinical

population was required, and the participants were

environment, and the ‘shared mind’ framework will be

likely to know others who share the characteristics

used to explore communication between participants

that make them eligible for inclusion in the study. The

within the clinical setting of two sexual health clinics.

six nurse participants were women aged between 32 and 58 years. Nurses’ ethnicity is problematic to

Methods and participants

report as it may result in loss of anonymity, given the small number of sexual health nurses in New Zealand.

The study was approved by the relevant District Health

All nurses conducted between 5 to 30 speculum

Boards and university research ethics committee.

examinations each week.

Data are from interviews with six nurses, and seven women who had attended a sexual health clinic and

The semi-structured questions in the interview tool

had a speculum examination. These data are a portion

were devised from previous research (Cook, 2011)

of a larger study about women and gynaecological

focussing on the perceived contribution of nurses and

examinations, in which a total of 16 women patients

doctors. For example, nurses and doctors were asked

and 16 clinicians (including 10 doctors) were

about the development of their skill, any significant

interviewed.

influences on the development of their practice,

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 31

Nursing Praxis in New Zealand strategies used, and what they perceived was involved

concept are used in the data analysis: attunement,

in managing both technical and relational aspects of

developing trust, egalitarian power sharing and

an examination.

achieving common ground.

To protect women from the perception that study

Attunement

(non)participation might influence care, patients were provided with a research advertisement by nurses and

If a patient is unable to speak freely with her doctor

doctors at the completion of the consultation. Clinical

out of embarrassment or a feeling of inferiority,

staff told women about the study and the importance

then important symptoms might pass unnoticed

of women’s perceptions. The seven women (patient)

(Cartwright, 1988, p. 116)

participants whose data appear below were aged between 23 and 47 years. Four identified as Māori and

Nurses described a gentle inquiry, sensitive to signs of

three as New Zealand European. Women were asked

distress from patients. One young woman described,

about their experience of examination in the context of

“[t]hey make you feel comfortable… you feel like you

their historical experiences and perceptions of aspects

can open up to them about anything… about your

of the procedure and communication interface.

life and your children” (PR3).

Women recounted

that nurses sometimes shared their stories in return; Interviews lasted approximately one hour, were

“…maybe she talks about her life as well”, (PR14) to

digitally

attune with women.

recorded

with

permission,

and

fully

transcribed. A content analysis was carried out by both authors in order to identify repeated patterns in

The complexity of attunement was recognised by

the data. An initial line-by-line manual coding of the

nurses. In the following quote, in which the nurse

transcripts, focussed on consistencies with Cartwright’s

described following women’s lead if their preference

recommendations (which guided analysis, though not

is for distraction, negotiating the meaning of bodily

the data collection) was carried out by each author.

tension, and attending to the technical aspects of the

Results were compared, and a high level of inter-rater

examination:

reliability found.

So we talk about other things going on in their The authors then sought an appropriate model which

lives as I’m doing the exam, that’s from the

would help explicate the data.

A comprehensive

start to the finish… I guess it’s just following

literature review revealed the relatively new addition

the woman’s lead, just following her lead.

of the ‘shared mind’ model (Epstein, 2013). The model

Stopping if you see she’s tensing up – or

provided a continuing fit with the data, and aided in

something – just continually talking, relaxing,

organising data into coherent categories consistent

trying to take her mind off it. It’s a gradual

with the model.

process actually… (CR2).

Results

Psychological perspectives were also acknowledged by one nurse, who explained, “[T]here’s so much

The concept of ‘shared mind’ provides a framework

shame attached to STIs, I tell women you haven’t done

to convey the subtle communication strategies that

anything wrong. You’ve just experienced illness in the

enhance examinations. Four sub-themes from the

genital region” (CR12). Women were in agreement that

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Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand even before they meet a clinician, the examination is an

the client where they feel they can say, ‘stop’, and

encounter ‘loaded’ with meaning different from many

explaining what’s happening at each step and checking

other clinical appointments: As one woman noted, “…

in at each step… ‘this is what I’m doing now, are you

There’s still lots of stigma around people who have…

okay with that?’” (CR13). Every woman respondent

STIs and lots of stigma around going to get checked”

noted how nurses communicated. As one explained,

(PR4). Another explained “you feel like you’ve done

“It was a combination of – because it was the fact

something wrong… Like, you feel dirty…” (PR3).

that she was talking with me throughout the process, giving me information but also asking me, so using

Sometimes the sense of sharing was intensely

her receptive language to listen to how I was feeling

personal, as practitioners found ways to be inclusive

through the process as well…” (PR15).

and empowering. For example, a nurse explained that during an examination, “a young woman stated,

Numerous incidents illustrated that, despite different

‘I wonder what it’s like being down there and seeing

levels of knowledge between nurses and patients,

what you’re seeing’. And I said, ‘well, would you like to

trust developed as the parties created common ground

see?’” She went on to explain, “I got the mirror and we

through a focus on equality. One nurse explained the

were really joined together in this experience of her

exploratory process with women as individuals. She

exploring her body and I was getting as much pleasure

had been dealing with a woman, in her fifties, who

out of it as she was… so I thought the learning goes on

had not had an examination since a negative clinical

… I thought, gosh, we’ve come a long way in a short

experience in her teens:

fifteen minutes or so” (CR3).

Just the ability to say well, you’re here because

Developing trust

you’ve got problems that you’ve had for years and years and years and you’ve actually plucked

Gynaecologists, administrators and health professionals

up the courage to come in and I need to make

need to listen to their patients, communicate with

today okay. I need to make today okay but I

them, protect them, offer them the best health care

haven’t quite got the grasp of what I’m meant

within their resources (Cartwright, 1988, p. 172).

to do and how I’m meant to help you and what words would help (CR6).

Nurses detailed rituals of preparation and procedures that were consistently respectful and appeared

It was a reflexive process of seeking input and

sacrosanct. Attention was given to respect for each

developing trust with women. One woman said she

woman “giving permission” through “trying to be a

found reassurance, because “different nurses have

bit organic with time in terms of how they [women]

different presence, but this one was particularly

prepare in their own private way” thus, “maintaining

fantastic that she could ‘read’ me… and help me value

privacy and dignity” throughout (CR12). As another

myself more” (PR8). The process of both the clinician

nurse described; “…it is so personal and private…

and the woman becoming known to each other, even

this is a shared experience… we are going to put all

in small ways for a brief time, was evident in the data.

those things in place, draping the person properly, asking permission, all those things” (CR3).

This

Egalitarian power sharing

empowerment of women continued throughout, as a nurse depicted, “…establishing a relationship with Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

It is critically important that the health professional Page 33

Nursing Praxis in New Zealand is certain that consent is freely given and that she

but her body was saying no. She was closing

[patient] has not acquiesced from natural courtesy or a

her eyes, I could see she wanted to dissociate.

wish to please someone who appears to be of greater

She clenched up. I really picked up that there

status than herself (Cartwright, 1988, p. 116).

had been some trauma that she wasn’t telling me about. I found that examination very

The clinical focus on empowering women was

difficult because I wanted to stop it. I didn’t

recounted as consistent throughout the examination,

think she was ready and she insisted that I

for example, “saying things like ‘you’re the boss’, or

carry on, just get the damn thing over and

‘you’re in control’, ‘tell me to stop if anything’s painful

done with… I felt upset afterwards (CR3).

or whatever other reason’” (CR12).

One clinician

explained that “the woman is in the most vulnerable

The clinician continued to describe what it was like for

position and the clinician in the most powerful

her to be caught up in the embodied complexity of a

position, and trying to somehow even up the balance,

woman’s decision-making: “that’s the kind of dance of

really giving the client the power in the examination”

it all… the privilege and the horror of it all” (CR3). As

(CR3), or recognising how difficult the process can

one woman with a history of sexual trauma described,

be for women. One woman explained how helpful it

“I need more than one tissue because I’m now sobbing.

was to have a clinician who was aware of her need for

And then I insisted on having it done… I suppose we

reassurance: “I think she sensed I needed that, and she

call that being vulnerable” (PR16). Another explained,

was right there” (PR15).

“I just had to grin and bear it, literally, and just go ‘aw’” (PR8). The distress was shared by both parties.

Nurses consistently voiced their alertness to the instability of women’s consent; as the examination

Achieving common ground

unfolded, continuous permission was not assumed. In the words of one, “I just spend a bit of time talking to

Nurses who most appropriately should be the advocates

them and reassuring them that if it’s going to be too

for the patient, feel sufficiently intimidated by medical

uncomfortable, if they’re really dead set against this

staff (who do not hire or fire them) that even today

examination, then it won’t happen” (CR2). Checking-

they fail or refuse to confront openly the issues arising

in involved a visual connection to ensure enduring

from the 1966 trial (Cartwright, 1988, p. 172)

consent, negotiated as an on-going process. This may involve “positioning of the bed so that the patient’s

Nurses saw their role as advocates for women. As one

actually got eye contact with you” (CR6). As another

explained, “I’ve watched somebody ram a speculum

argued, the ability to see the woman’s face was

into somebody”. She continued that, although “it’s

crucial, because if a woman with a trauma history

really hard, when there’s that power differential

disassociates, “if the person’s no longer ‘there’, so I

with doctors”, she didn’t hesitate to take action. She

feel where’s the consent?” (CR13).

explained, it was a case of her taking a stand: ‘“not for my patients, you’re not doing that’ and ‘“no way

One clinician recalled a haunting incident where she

are you doing that to me [imagining receiving this

was torn between wanting to stop, and respecting the

treatment herself] and I don’t want you to do it to

woman’s wish to persist. She depicted how she asked:

anybody else again’” (CR6). There were also times when nurses spoke of a deeper emotional connection

Is it okay if I lift the gown? She was saying yes, Page 34

that recognised their shared experience as women: Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand I will just sort of sit there for a bit afterwards…

practice. Doctors interviewed who had been at medical

and we’ll just have a quiet minute... giving

school in New Zealand or were already practising

them that minute… she’ll just lie there for

during or after the Cartwright Inquiry detailed the

a bit and I’ll just sit there for a bit and we

consciousness-raising impact of the report, which

won’t say anything. This is where they feel it,

reinforced feminist values and desire to advocate for

in here, so this is where I put my hand. I put

women. This politicised view shaped their teaching. We

my hand on their tummy… so that just gives

noted that nurses identified these interviewed doctors,

them a bit of time to breathe or relax or let

and others with similar politics, as key clinicians whose

everything go or whatever (CR2).

clinical teaching had shaped their practice.

Humour at times contributed to rapport. For example, a

Employing the ‘shared mind’ framework illustrates

nurse explained how she joked with women who were

how clinical practice moves beyond patient centred

sex-working to show she appreciated the challenges

care. Throughout the data, there was evidence of

of their work; that she was not just seeing them as a

nurses being mindfully ‘present’ during examinations,

woman who might have an infection risk:

thereby attuning themselves to the woman’s physical and psychological experience of a gynaecological

I’ve learnt a few things that I can talk to them

examination.

about like trick sex and stuff… so that they know I have some knowledge, I’m not just a

Attunement was evident in clinician’s recognition

clinician who’s said right, I’m here to do your

that eliciting women’s stories helped their patients

sexual health check (CR6).

to explore their beliefs and expectations. Stories are important, as they can be used as cues to decision-

Common ground was also achieved through assurances

making processes (Epstein, 2013).

Furthermore,

of the ‘everyday’ nature of sexual health concerns.

as Politi and Street (2010) argue, this degree of

A young woman told of sharing an embarrassing

attending required a level of sensitivity beyond factual

problem with a nurse: “…she told me that it was good

information giving. The data also attest to nurses’

for me to tell her and that I didn’t have to hide it or

attunement to women’s vulnerability to feeling

be ashamed or be scared or embarrassed or anything”

stigmatised, understanding the socially mediated

(PR13). There was a depth to the narratives about the

meanings attached to STIs. As Entwistle et al. (2010)

interaction described throughout the data, expressed

argue, developing sensitivity to the context in which

in one instance by a nurse: “You can play with words,

information is offered enables a more cohesive and

but there is something, another whole leap in

mutual sharing, evident in this research.

vulnerability when it comes to the body” (CR3). These data attested not only to the vulnerability of women

In order to facilitate trust between nurses and patients,

being examined, but also that of nurses.

the former described their ‘presence’ throughout examinations. While acknowledging their familiarity

Discussion

and ease with examining women, nurses indicated openness and acceptance of their own deliberations

The impact of the Cartwright Report became evident

about what exactly might be best for an individual

as nurses and doctors in the larger study answered

woman. The emphasis on developing trust appeared

questions about people and events shaping their

to ease the perception of the invasiveness of the

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Page 35

Nursing Praxis in New Zealand examination.

‘ordinariness’ of sexual health and sexuality concerns, as nurses invited women to consider that such events

The ideal of empowerment could be fraught,

might be more commonplace and manageable than

particularly in instances where women had trauma

women imagined. In so doing, nurses were actively

histories. Nurses struggled to clearly assess whether

shifting a negative, socially mediated understanding of

women’s voiced determination to persist with

sexual health.

difficult examinations qualified as consent, given bodily and dissociative responses indicating the

Limitations

contrary. Recollections of uncertainty about whether collaboration had occurred were distressing for

This study offers insights into women’s experience in

practitioners. Epstein (2013) highlights research

the context of two sexual health clinics in New Zealand.

indicating that decision-making is complex, and

The limitations of a self-selected sample include the

whereas clinicians may believe they make decisions

possibility that cogent participants will be overlooked.

independently, this is not the case. Working with past

Also, it is possible that retrospective recall may not

trauma is an example of the argument that there

fully represent the dialogue or activity at the time of

is not necessarily clear ownership of “the resulting

the recounted events.

perspective, preference or choice” (p.202). Nurses aimed for Cartwright’s aspiration of consent certainty

Conclusion

and yet their intentions were confounded when women had reasons for both wanting and not wanting

Sandra Coney, more than twenty years on from

to proceed with examinations. This ambivalence is

publication of her ‘whistleblowing’ collaboration

highlighted by Du Mont et al. (2009) is their study of

(Coney & Bunkle, 1987) reflects, “Silvia Cartwright’s

women’s perceptions of post-assault examinations.

greatest contribution to health care in New Zealand

Women reported that with the help of supportive

was to make the woman’s experience central and

nurses’ they experienced feelings of distress, but also

to shape her recommendations so that they would

empowerment through taking action for their health

protect and empower patients in the future” (2009, p.

and possible identification of the assailant. Epstein

70). This paper is a small contribution to highlighting

and Street (2011) contend that paternalism must not

Cartwright’s legacy as it is enacted by a group of

overpower patient decision-making. Shared mind

nurses in New Zealand. The authors share the desire

may entail clinicians and women sharing complicated

to centralise women’s experience, and to challenge

ambivalence. The latter warrants further empirical

medical research to investigate the relational

research.

communication practices that foster or dissuade willingness in women to attend gynaecological

Achieving common ground was fostered by the

appointments. The concept of ‘shared mind’ is a useful

nurses’ orientation towards advocacy for women.

tool for exploring communication nuances that are

Nurses strove for a clear understanding of women’s

human factors with the potential to enhance patient

perspectives.

care in increasingly technically-focussed healthcare.

This

included

endeavouring

to

minimise discomfort within a safe, non-judgemental environment, while delivering the best of physical care.

Implications for practice

Importantly, communication was centred around the

Page 36

Vol. 30 No. 2 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand The authors believe that the findings attest that

evidence of nurses being mindfully ‘present’ during

through a shared mind process, the role of nurses

examinations, thereby attuning themselves to the

can contribute to a morally defensible practice of

woman’s physical and psychological experience of a

respectfully communicating with women to provide an

gynaecological examination. We believe the findings

acceptable procedure of gynaecological examination,

clearly demonstrate that the model has the potential

consistent

the

to benefit patients through a relationship process that

Cartwright Report. The model can make a difference

extends the respect enshrined in patient centred care

in clinical practice as suggested by Epstein (2013).

to encompass collaboration, and therefore deserves

Although ‘shared mind’ processes in some instances

consideration as a valuable adjunct to practice.

with

the

recommendations

of

may ensue intrinsically, with awareness, practice can also be advanced. Throughout the data, there was

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Giuffre, P., & Williams, C. (2000). Not just bodies: Strategies for desexualizing the physical examination of patients. Gender & Society, 14(3), 457-482.

Jameson, A., Sligo, F., & Comrie, M. (1999). Barriers to Pacific women’s use of cervical screening services. Australian and New Zealand Journal of Public Health, 23(1), 89-92. doi:10.1111/j.1467-842X.1999.tb01211.x Kocobas, P., & Khorshid, L. (2011). A comparison of the effects of a special gynaecological garment and music in reducing the anxiety related to gynaecological examination. Journal of Clinical Nursing, 21, 791-780. doi:10.1111/j.1365-2702.2011.03958.x.

Lovell, S., Kearns, R., & Friesen, W. (2007). Sociocultural barriers to cervical screening in South Auckland, New Zealand. Social Science & Medicine, 65, 138-150. doi:10.1016/socscimed.2007.02.042 McCredie, M., Sharples, K., Paul, C., Baranyai, J., Medley, G., Jones, R., & Skegg, D. (2008). Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: A retrospective cohort study. Lancet Oncology, 9(5), 425-434. doi:10.1016./S1470-2045(08)70103-7 McWilliam, E., & O’Donnell, S. (1998). Probing protocols: The genital examination as a pedagogical event. Body & Society, 4(3), 85-101. doi:10.1177/1357034X98004003005 Manning, J. (Ed.). (2009). The Cartwright papers: Essays on the cervical cancer inquiry 1987-88. Wellington, New Zealand: Bridget Williams Books.

Matheson, C. (2010). A patient’s response to recent criticisms of the findings in the report of the cervical cancer inquiry 1988. New Zealand Medical Journal, 123(1321), 95-101.

Paterson, R. (2012). The good doctor: What patients want. Auckland, New Zealand: Auckland University Press.

Priest, P., Sadler, L., Sykes, P., Marshall, R., Peters, J., & & Crengle, S. (2010). Determinants of inequalities in cervical cancer stage at diagnosis and survival in New Zealand. Cancer Causes Control, 21, 209-214. doi:10.1007/s10552-009-9451-7.

Politi, M. C., & Street, R. L. (2010). The importance of communication in collaborative decision making: Facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17, 579-584. doi:10.1111/j.1365-2753.2010.01549.x.

Sharp, L., Cotton, S., Thornton, A., Gray, N., Cruickshank., Whynes, D., …Little, J. (2012). Who defaults from colposcopy? A multi-centre, population-based, prospective cohort study of predictors of non-attendance for follow-up among women with low-grade abnormal cervical cytology. European Journal of Obstetrics & Gynecology, 165, 318-325. Doi:10.1016/j.ejogrb.2012.08.001 Swahnberg, K., Wijma, B., & Siwe, K. (2011). Strong discomfort during vaginal examination: Why consider a history of abuse? European Journal of Obstetrics & Gynecology and Reproductive Biology, 157, 200-205. doi:10.1016/j.ejogrb.2011.02.025 Tahseen, S., & Reid, P. (2008). Psychological distress associated with colposcopy: Patients’ perception. European Journal of Obstetrics & Gynecology and Reproductive Biology, 139(1), 90-94. doi:10.1016/j.ejogrb.2007.09.001 Tolich, M., & Baldwin, K. M. (2005). Unequal protection for patient rights: The divide between university and health ethics committees.

Bioethical Inquiry, 2(1), 34-40. doi:10.1007/BF02448813 Townshend, P. L., Sellman, J. D., & Haines, R. (1998). The Cartwright report ten years on: The obligations and rights of health consumers and providers. New Zealand Medical Journal, 111(1075), 390-393.

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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 on publication. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board.

Nursing Praxis in New Zealand original research, discursive (including conceptual, position papers and critical reviews that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession

Guidelines for Manuscripts While we encourage authors to be creative in the way they present their information, the following requirements must be met: •

Manuscripts should be word processed, formatted for A4 size paper, with double line spacing, page numbers on the bottom right side of the page and the manuscript title in the header of each page.

•

Use a plain font (Arial, Calibri, or Times New Roman).

•

Include an abstract of no more than 300 words, summarising the article. For research articles the abstract must include information about the research design, participants, and data collection and analysis methods.

•

Include a maximum of six (6) keywords.

•

Generally manuscripts will not exceed 3,500 words, however longer articles will be considered as long as they are focused and concise.

•

If the article is a research report then details of ethical processes followed must be included in the body of the manuscript.

•

Tables and figures each need to be presented on a separate page at the end of the manuscript. Insert into Manuscript <INSERT TABLE NO. / FIGURE NO. ABOUT HERE> where the table or figure should be inserted. Generally these should be inserted AFTER the pece of text where they are first referred to.

Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org The Editorial Board reserves the right to modify the style and length of any article submitted, so that it conforms to the Journal format. Major changes to an article will be referred to the nominated author for approval prior to publication.

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Nursing Praxis in New Zealand Manuscript Submissions •

Please supply manuscripts as a Word Document by e-mail to admin@nursingpraxisnz.org

•

Manuscripts must be word processed, with double spacing, the title in the header and page numbers in the lower right of the footer. on each page.

•

All tables and figures must be included at the end of the document each on a seperate page.

•

Check you have used a plain font (Calibri, Arial or Times Roman).

• •

No details of the author are to be displayed on the manuscript, please include this as a separate document (see below).

An authors submission form must accompany your submission, this can be downloaded from the Nursing Praxis website www.nursingpraxis.org This form details each author (and the contribution they have made to the manuscript), a corresponding address and each author must sign the form.

Referencing It is the author’s responsibility to ensure that all references and citations are accurate and that all referencing follows 2010 APA (6th edition) conventions (see the Nursing Praxis website for examples). This includes all electronic references, which must include doi number for journal articles. References in the text should cite the author’s name(s), followed by the date of publication. Where direct quotations are used, page numbers must be given. References at the end of a manuscript should be listed alphabetically on a separate sheet formatted with a hanging indent and italicised, not underlined. E.g: American Psychological Association (APA). (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Smythe, L., & Giddings, L. S. (2007). From experience to definition: Addressing the question ‘What is qualitative research?’ Nursing Praxis in New Zealand, 23(1), 37-57.

Review Process All manuscripts will be blind critiqued by at least two reviewers prior to a decision being made by the Editorial Board.

Subsequently the author will be notified of acceptance (along with any recommended changes) or rejection of the manuscript. Regular features are not peer reviewed. The review process takes, on average, three months.

Copyright Authors are responsible for the accuracy of their articles. After publication the article and its illustrations become the property of the Nursing Praxis in New Zealand journal.

Letters to the Editor Should not exceed 200 words. A nom de plume is acceptable provided full name and address are supplied. Please e-mail as a Word document.

Commentaries Nursing Praxis welcomes commentaries on papers published in its pages. These should be approximately 1000 words in length and should offer a critical but constructive perspective on the published paper. Original authors will be given the opportunity to respond to published commentaries.

Research Briefs Generally should not exceed 1500 words. Content must include a statement of the topic and purpose of the research; participants and the mode of recruitment; what was done (method and procedure for data collection and analysis); and

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Nursing Praxis in New Zealand a brief indication of the findings and their implications for nursing. As the material will be read by a broad cross-section of nurses, abstracts from theses are often not suitable in their original form and so require reworking.

Our Stories Nursing Praxis in New Zealand welcomes submissions to ‘Our Stories’. We are interested in publishing short articles that focus on nursing experiences over time. Our Stories will profile historical and contemporary stories, which reveal the contributions of individual nurses to our profession. Short articles, not exceeding 1500 words, are welcomed which provide insight to the contribution that a New Zealand nurse has made to the profession either locally, nationally, internationally. Such articles could include the stories behind the research, interviews with key nurses or the stories of those who have inspired and influenced their colleagues through their passion and commitment to the profession.

Book Reviews Book reviews should not exceed 500 words. Content must include a statement about the book’s topic and purpose, key points of interest in the book, a critique of the contents, and an indication of the implications or relevance for nursing or health practice.

Practice Issues and Innovations Articles are welcomed which highlight practice issues and innovations. Such articles might constructively discuss current nursing policy, practice or describe new approaches to nursing practice. This should be prepared as outlined for manuscripts above.

Send all Submissions via: E-mail – as a Word document together with scanned original copy of signed author information to: admin@nursingpraxis.org OR Post – One hardcopy of all documents together with a copy on a disk as a Word document to: Nursing Praxis in New Zealand

P O Box 1984

Palmerston North 4440

New Zealand

Indexes Nursing Praxis in New Zealand is indexed in: • CINAHL (Cumulative Index of Nursing and Allied Health Literature), and • ProQuest.

The entire list of articles previously published in Nursing Praxis are available on the Nursing Praxis website www.nursingpraxis.org

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