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
Page 1
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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
Page 2
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
Page 3
Nursing Praxis in New Zealand
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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:
Page 8
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,
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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. Pearson, M. (2003). Training prescribers: Past, present and future. British Journal of Clinical Pharmacology, 55, 480-482. doi:10.1046/ j.1365-2125.2003.01846.x Renouf, P. (2005). Nurse Practitioner (NP) prescribing in New Zealand: An NPs response to the editorial by Drs. Moller and Begg. New Zealand Medical Journal, 118(1226), 1-4. Retrieved from http://journal.nzma.org.nz/journal/ Schmidt, H. G., Norman, G. R., & Boshuizen, H. P. (1990). A cognitive perspective on expertise. Academic Medicine, 65(10), 611-621. Schwertz, D., Piano, M., Kleinpell, R., & Johnson, J. (1997). Teaching pharmacology to advanced practice nursing students: Issues and strategies. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 8(1), 132-136. St. John, P. (2001, 21 November). Up to 20% cost rise with nurse prescribers. New Zealand Doctor. van Soeren, M. H., Andrusyszyn, M.-A., Spence Laschinger, H. K., Goldenberg, D., & DiCenso, A. (2000). Consortium approach for nurse practitioner education. Journal of Advanced Nursing, 32(4), 825-833. doi:10.1046/j.1365-2648.2000.t01-1-01546.x
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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
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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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Nursing Praxis in New Zealand Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: The importance of clinician-patient relationships. Journal of General Internal Medicine, 25, 741-745. doi:10.1007/s11606-010-1292-2 Epstein, R. M. (2013). Whole mind and shared mind in clinical decision-making. Patient Education and Counseling, 90, 200-206. doi:10.1016/j.pec.2012.06.035 Epstein, R. M., & Street, R. L. (2011). Shared mind: Communication, decision making, and autonomy in serious illness. Annals of Family Medicine, 9, 454-461. doi:10.1370/afm.1301. Galaal, K., Deane, K., Sangal, S., & Lopes, A. (2009). Interventions for reducing anxiety in women undergoing colposcopy. The Cochrane Collaboration: Wiley. Gao, W., De Souza, R., Paterson, J., & Lu, T. (2008). Factors affecting uptake of cervical screening among Chinese women in New Zealand. International Journal of Gynecology and Obstetrics, 103, 76-82. doi:10.1016/j.ijgo.2008.04.025 Gillett, G. (2012). Ethics committees in New Zealand. Journal of Law and Medicine, 20(2), 266-272. 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.
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Use a plain font (Arial, Calibri, or Times New Roman).
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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.
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Include a maximum of six (6) keywords.
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Generally manuscripts will not exceed 3,500 words, however longer articles will be considered as long as they are focused and concise.
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If the article is a research report then details of ethical processes followed must be included in the body of the manuscript.
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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
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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.
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All tables and figures must be included at the end of the document each on a seperate page.
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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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