IN NEW ZEALAND Journal of Professional Nursing
INSIDE THIS ISSUE... Non-prescribing diabetes nurse specialist views of nurse prescribing in diabetes health Institutional ethnography: An emerging approach for health and nursing research Oncology nurses’ perception of cancer pain: A qualitative exploratory study
Volume 31. No. 1
MARCH 2015
Praxis: “The action and reflection of people upon their world in order to transform it.” (FREIRE, 1972)
E D ITO RIAL BOARD EDITOR-IN-CHIEF: Denise Wilson RN, PhD, FCNA (NZ) ASSOCIATE EDITOR: Jean Gilmour RN, PhD, MCNA (NZ) EDITORS: Norma Chick RN, Willem Fourie RN, Thomas Harding RN, Stephen Neville RN, Michelle Honey RN, Jill Wilkinson RN,
RM, PhD PhD, FCNA (NZ) PhD PhD, FCNA (NZ) PhD, FCNA (NZ) PhD, MCNA (NZ)
COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation. KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection. Transformation is shown by the change of the initial plain Koru design to a more elaborate one.
PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 0112-7438 HANNAH & YOUNG PRINTERS
CO NTE NTS EDITORIAL: Thomas Harding, Stephen Neville ................................................................................................ 2
ARTICLES: Non-prescribing diabetes nurse specialist views of nurse prescribing in diabetes health
Hazel Philips, Jill Wilkinson.......................................................................................................... 5
Institutional ethnography: An emerging approach for health and nursing research
Sue Adams, Jenny Carryer, Jill Wilkinson .................................................................................... 18
Oncology nurses’ perception of cancer pain: A qualitative exploratory study
Alicia Garcia, Dean Whitehead, Helen S. Winter ........................................................................ 27
NOTES FOR CONTRIBUTORS.............................................................................................................. 34
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand EDITORIAL Nursing Praxis in New Zealand is a vehicle for the
with Nursing Praxis in New Zealand and what might
dissemination of nursing research and in particular
interest its readership. They are also required to be
the findings from New Zealand based studies. Over
skilled in providing constructive feedback which assists
the years the journal has worked with many nurses
authors in improving their papers while at the same
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time not being so critical as to crush the aspirations
discursive pieces on a vast array of topics. There is
of the fledgling author. Over two decades ago Maeve
a ‘behind the scenes’ process that occurs before
(1994) in her article “The carrier bag theory of nursing
any article is published and this includes input from
practice” wrote “I want a nurse who brings the passion
administration staff, the Editorial Board and reviewers.
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listed the names of those people who have reviewed
and often on top of already busy workloads. They do
the articles submitted for consideration in the past year.
so because they have a passion for scholarship and
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only have wide-ranging knowledge of the subject area
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and the chosen research method but to also be familiar Page 2
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Nursing Praxis in New Zealand
•
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on the scientific merit of the manuscript including addressing the contribution the
Associate Professor Thomas Harding
work makes to the substantive body of existing
Dr Stephen Neville
knowledge written about; the appropriateness of the methods used to collect, manage and make sense of the data sources; and if using human participants acknowledging any ethical issues that may be present.
References Maeve, M.K. (1994). The carrier bag theory of nursing practice. Advances in Nursing Science, 16(4), 9-22.
At Nursing Praxis in New Zealand a manuscript is sent to two reviewers whom we provide with a reviewer template containing a list of prompt questions designed to help with the review process. Once a review is completed and returned to the Editorial Office it is assigned to two members of the Editorial Board. Our role is to summarise all reviews, and in cases, where there are dichotomous recommendations, for example one reviewer recommending accept and the other reject, we will undertake an independent review and make a recommendation to the Editorial Board.
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand
IMPORTANT NOTICE! Nursing Praxis is becoming an E-Journal Nursing Praxis of New Zealand has been a print journal since November 1985. Beginning in July 2015, Nursing Praxis of New Zealand will be moving to being a fully electronic journal. This will mean we will not be producing Nursing Praxis as a print journal. Nursing Praxis subscribers will continue to have free access to the journal and all articles. Non-subscribers can still access articles by subscribing for one month. www.nursingpraxis.org admin@nursingpraxis.org
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Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand NON-PRESCRIBING DIABETES NURSE SPECIALIST VIEWS OF NURSE PRESCRIBING IN DIABETES HEALTH Hazel Philips, RN, MN, Diabetes Nurse Specialist, Hutt Valley DHB, Wellington, NZ Jill Wilkinson, RN, PhD, Senior Lecturer, School of Nursing, Massey University, Wellington, NZ
Abstract In 2011 a project to trial diabetes nurse specialist prescribing was implemented. Twelve diabetes nurse specialists took part in the project located in four sites throughout New Zealand. Evaluation of the project found diabetes nurse specialist prescribing to be safe, of high quality and appropriate. Consequently, a staged roll-out of prescribing to and approval for another 15 diabetes nurse specialists has taken place. Against that background, and with the aim of informing future workforce planning, this paper presents the results of a survey of non-prescribing diabetes nurse specialists views of nurse prescribing. Members of the diabetes nurse specialist section of the New Zealand Nurses Organisation completed an online survey between May and June 2012 (n=92). All data were analysed descriptively. The results indicate that standing orders are not always adequate and that prescribing is recognised as a natural progression for nurses; 72.8% indicated interest in becoming a prescriber; 57.6% met the postgraduate study requirements and 35.9% had altered study plans to meet the requirements. A statistically significant relationship exists between being accredited as ‘specialist’ with the New Zealand Nurses Organisation (n=39) and the intention to become a prescriber (p=.029). Diabetes nurse specialists agree that prescribing improves access to diabetes services, diabetes management, continuity and quality of care, the use of diabetes nurse specialist time and skills, team dynamics, and reduces delays for patients. Concerns include ongoing access to the required medical supervision. The study implications are that diabetes nurse specialists are ready to become prescribers and more are needed to meet the needs of an increasing number of people with diabetes. Resources for the necessary medical supervision need to be included in future workforce planning if diabetes nurse specialist prescribing is to remain viable and continue to make a positive impact on the health of people with diabetes.
Keywords
that there will be 366 million people with diabetes by
Diabetes nurse specialist; diabetes nurse prescriber;
2030 (Kara et al., 2006). Price-Waterhouse-Coopers
designated prescriber; registered nurse; workforce
estimate the financial implications of diabetes will
planning
reach NZ$1000 million by 2021 (Joshy & Simmons, 2006). There will be a profound impact on the New
Introduction
Zealand health service as the number of people with
Diabetes mellitus (DM) is one of the most common
diabetes increases along with life expectancy. Diabetes
chronic diseases throughout the world. Its management
nurse specialist (DNS) prescribing has the potential
is complex and requires a lifetime of behaviour modification (Courtenay & Carey, 2008; Kara, van der Bijl, Shortridge-Baggett, Asti, & Erguney, 2006). The World Health Organisation (WHO) has predicted
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Philips, H., & Wilkinson, J. (2015). Non-prescribing diabetes nurse specialist views of nurse prescribing in diabetes health. Nursing Praxis in New Zealand, 31(1), 5-17.
Page 5
Nursing Praxis in New Zealand to increase accessibility and services to people with
Act enables prescribing for two classes of prescriber:
diabetes, help alleviate some of the pressure on the
authorised prescribers (medical practitioners, nurse
health service, and provide a more holistic model of
practitioners, dentists, optometrists and midwives);
care (Latter, Maben, Myall, Young, & Baileff, 2012;
and designated prescribers (nurses working in diabetes
Wilkinson, Carryer, & Adams, 2013).
health, pharmacists and dietitians). Designated prescribers are able to prescribe from a limited formulary
Nursing practice has evolved considerably over the
within their area of practice. Specific regulations were
last 20 years with nurses extending their roles, taking
passed in 2011 allowing DNS’s to prescribe from a
on new roles, and specialising in particular areas
schedule of 26 diabetes-related medicines (Medicines
(Bodington, 2011). Nurses who specialise in diabetes
(Designated Prescriber—Registered Nurses Practising
can be professionally recognised by means of a
in Diabetes Health) Regulations, 2011). The schedule
voluntary accredition process available through the
of medicines includes lipid-lowering agents and anti-
New Zealand Nurses Organisation (NZNO) (Aotearoa
hypertensive medications.
College of Diabetes Nurses, 2014).
Accreditation is
defined by the National Diabetes Nurses Knowledge
A project to trial DNS prescribing took place in 2011
and Skills Framework (KSF) (New Zealand Society for
with twelve DNS located in four demonstration sites
the Study of Diabetes, 2009) and is aligned with the
around New Zealand authorised to prescribe under the
Nursing Council of New Zealand (NCNZ) requirements
new regulations. The evaluation of the trial found DNS
for
recognition
prescribing to be safe, of high quality and appropriate
programmes. There are four levels in the KSF, with
(Wilkinson et al., 2013). A staged roll-out to other DNS
the most advanced being ‘specialist diabetes nurse’
has since taken place (Budge & Snell, 2013). The 2011
(level 4). These nurses have developed expert diabetes
project evaluation included the views of various groups
practice and provide care for people with diabetes
of professionals who were affected by DNS prescribing,
who have complex health needs. Specialist nurses
including the non-prescribing nurses who worked with
have undertaken post graduate study towards or
the DNS who were participating in the trial.
professional
development
and
completion of a Masters degree. As a new initiative that would extend beyond the In addition to supporting people with diabetes to
demonstration sites it was important to gauge the level
make lifestyle changes, many nurses who specialise
of interest amongst the nurses most likely to become
in diabetes make changes to the dose or frequency
the next prescribers. Using an online cross sectional
of insulin or oral hypoglycaemic medications using
survey design, this study explored non-prescribing
standing
DNS views about prescribing in diabetes health with
orders
(Medicines
(Standing
orders)
Amendment Regulations, 2011). Any prescriptions
the aim of informing future workforce planning.
for new or repeat medicines however must be provided by an authorised prescriber. Until recently,
Background
nurse practitioners have been the only nurses able to
A literature search using Scopus and PubMed
prescribe medicines in New Zealand.
databases was conducted for articles, letters and editorials. The search terms were: “diabetes”, “primary
The primary legislation governing the supply,
care”, “prescribing”, “diabetes management”, “nurse
manufacture and prescription of medicines in New
prescrib*”, “standing orders”, “prescriptive authority”,
Zealand is the Medicines Amendment Act 2013. This
“non-medical prescrib*”, “specialist nurse prescrib*”,
Page 6
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand nurse
aforementioned research that has established nurse
prescrib*”. Articles were selected for their relevance
prescribers to be safe, effective, efficient, helpful to
to specialist nurse prescribing and/or DNS prescribing.
patients and reduces medical practitioner work load
Limits of English language and the years 2000 to 2012
(Hawkes, 2009; Latter et al., 2011; Latter et al., 2012). A
were applied, and articles were discarded if they
systematic review about the effects of nurse prescribing
were medically focused. Seventy articles in total were
failed to discover reasons why nurses should not
included for consideration.
prescribe medicines, or to substantiate doubts about
“non-prescribing
nurses”,
and
“diabetes
overall safety (Van Ruth, Mistiaen, & Francke, 2008). Most of the literature about RN prescribing is from
Traditionally the roles and responsibilities of doctors
the United Kingdom (UK) where there are more
have been clear; but RN prescribing is seen as blurring
than 19,000 nurse independent and supplementary
the unspoken rules that define these responsibilities
prescribers. A recent survey of 2,454 nurses, 98% of
(Sibbald, Laurant, & Reeves, 2006). Good professional
whom prescribe, reported that 61.3% prescribe on
relationships between nurses and medical practitioners
a daily basis and over 80% prescribe two to three
prior to changes in prescribing seems to lead to less
times a week (RCN Publishing, 2013). Reporting
resistance about RN prescribing (Stenner, Carey, &
similar findings, an observational study by Latter et al.
Courtenay, 2010; Stenner & Courtenay, 2008).
(2012) found that the rate of nurse prescribers was a prescription for every 2.82 consultations.
A review of evidence about the safety and quality of independent prescribing stresses the importance
Research into nurses’ views of prescribing is often
of nurses’ experience in history taking, physical
about nurses who are already authorised to prescribe,
assessment and diagnostic skills, and the need to ask
but who may not be prescribing often or at all (for
about over the counter medicines (Latter, 2008). The
example Carey, Stenner, & Courtney, 2009; Lockwood &
safety of RN prescribing has since been established
Fealy, 2008; Ross & Kettles, 2012). In studies evaluating
in the UK through comprehensive evaluations (Latter
the expansion of independent nurse prescribing, the
et al., 2011; Watterson et al., 2009), and observation
views of nurses, pharmacists, doctors and patients
of consultations (Latter et al., 2012). Surveys in the
have been positive and supportive (Latter et al., 2011;
UK about the adequacy of the initial prescribing
Watterson, Turner, Coull, Murray, & Boreham, 2009).
education report it to be adequate and that ongoing
The views of nurses, nurse specialists and physicians
development, supervision and support maintains safe
surveyed in the Netherlands are reported overall as
practice of RN prescribers (Courtenay, Carey, & Burke,
“neutral to moderately positive” (Kroezen et al., 2014,
2007; Latter, Maben, Myall, & Young, 2007; Smith,
p. 539).
Latter, & Blenkinsopp, 2014).
Despite the above evidence of nurse support,
Nurses
the resistance of doctors to RN prescribing is well
practitioners
documented in New Zealand (Chaston & Seccombe,
administration in areas such as diabetes (Bodington,
2009; Moller & Begg, 2005; Wilkinson, 2011), Australia
2011) and epilepsy (Goodwin, Higgins, & Lewis, 2011;
(Elsom, Happell, & Manias, 2008; McDonald, 2005),
Hosking, 2003). Advice includes adjusting doses,
and England (Hawkes, 2009; Stenner, Carey, &
timing, administration, referrals, or documenting dose
Courtenay, 2009), the resistance remains despite the
adjustment in a patient’s record. These activities are
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
regularly on
advise
patients
medication
and
medical
adjustment
and
Page 7
Nursing Praxis in New Zealand done by specialist nurses on a regular basis (Bodington,
Study Design and Method
2011; Learner, 2006) and for nurses without
A cross-sectional survey design was employed using
prescriptive authority, are generally undertaken
a non-probability purposive sample (Creswell, 2009;
using standing orders or protocols (Tucker & Rhudy,
Polit & Beck, 2008). Members of the DNS section
2003). When nurses prescribe for them typical
(now Aotearoa College of Diabetes Nurses) of the
benefits reported by patients who have diabetes are
NZNO were emailed an invitation to participate in the
improvements in patient access to medications, faster
survey. Inclusion criteria were nurses located as a DNS
service, and a more holistic model of care (Courtenay,
in a secondary care setting. Data were collected via
Stenner, & Carey, 2010; Stenner, Courtenay, & Carey,
the internet using ‘Survey Monkey’, an online survey
2011; Wilkinson et al., 2013).
site, over a four week period during May and June 2012. The membership of the DNS section numbered
Team support is an important factor in the success or
approximately 360, some of whom may work in
failure of nurse prescribing. This has been identified
settings other than secondary care. Based on the 92
by many RN prescribers as a major influence in
responses received the response rate is 25.5%. Eleven
their ability and confidence to prescribe. Whether
of these responses were from nurses who worked as
this support comes from medical practitioners,
a non-prescribing DNS in one of the demonstration
pharmacists or team members, this influence is
sites that participated in the DNS prescribing project
significant (Fisher, 2009; Stenner et al., 2009). When
in 2011.
RN prescribers describe themselves as being part of a cohesive and supportive team, success is almost
A questionnaire was developed for the study and
guaranteed (Courtenay & Carey, 2008). For teams to
consisted of 16 open and closed questions about the
work well together it is essential to consider the views
length of time as a nurse, as a DNS, and as an accredited
of non-prescribing nurses and recognise that their
specialist nurse with the NZNO; postgraduate study;
support has an important influence on overall success.
views with respect to standing orders, views about
It should also be recognised that not all DNS will want
RN prescribing in diabetes; and perception of support
to prescribe, and this stance should be accepted and
from their employer to become a prescriber. As
respected (Bradley, Hynam, & Nolan, 2007).
well, four questions from the ‘team survey’ used in the evaluation of the DNS prescribing project were
The main themes identified in the literature are that
included. Two of these questions about the effect,
RN prescribing is well established, particularly in the
if any, of DNS prescribing on team dynamics where
UK, as a safe, effective and efficient way to provide
asked only of the non-prescribing nurses from the four
medicines to patients who typically benefit from the
DNS prescribing project demonstrations (n=11). The
arrangements. Educational preparation is adequate
responses from all four questions provided data that
and attitudes of other health professionals towards RN
could be compared to the original project evaluation
prescribing is generally supportive. A supportive team
data. The survey was piloted by two DNS with feedback
environment is key to nurses using their prescribing
indicating the questions were easy to interpret and
skills. As the prescribing initiative is new in New
took about 7-10 minutes to complete. Approval for the
Zealand the views of the non-prescribing DNS about
study was granted by the Central Health and Disability
prescribing in diabetes health, and their aspirations
Ethics Committee (MEC/12/EXP058).
towards becoming a prescriber or otherwise, are entirely unknown. Page 8
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Data analysis
Findings
Data were exported from Survey Monkey and analysed
Experience of participants
descriptively using Microsoft Excel and Statistical
The findings identified the DNS respondents to be a
Package for the Social Sciences (SPSS) version 18 (IBM
highly experienced and skilled group. Table 1 shows
SPSS Inc. 2010). Responses from the open questions
the number of years as a RN ranged from 7 to 46 years
were first examined for recurring patterns and then
(Median = 30), with number of years specialising in
organised manually into themes that were relevant to
diabetes ranging from six months to twenty-six years
the aim of the study (Braun & Clarke, 2006); excerpts
(Median = 8). Thirty-nine (42.9%) were accredited as a
have been reported here in italics.
specialist nurse (level 4) withINthe NZNO. NON-PRESCRIBING DIABETES NURSE SPECIALIST VIEWS diabetes OF NURSE PRESCRIBING DIABETES HEALTH
Table 1.
Table 1.
Years as aYears Registered Nurse and asNurse a Diabetes Nurse SpecialistNurse Specialist as a Registered and as a Diabetes
Years as a registered nurse
Years as a diabetes nurse specialist
(n= 90)
(n=86)
27.8
8.4
Median
30
8
Mode
40
3
Range
7 - 46
<1 - 26
Mean
Standing orders
for a prescription from a doctor to adjust treatment
Standing orders were thought to be adequate for
beyond the parameters of the standing order; or to
practice by 44.6% (n=41), whereas 51.1% (n=47)
commence treatment when such was clearly indicated
thought that they were not adequate. Eleven nurses
(n=9, 9.7%). These quantitative findings are supported
(11.9%) stated there were no standing orders in their
by the following short answer response:
area of practice, and 10 (10.9%) commented about their limitations. Most participants (n=77, 83.7%)
The current standing orders are satisfactory in
adjusted medication through standing orders. Three
as far as they go. However, my practice is such
nurses reported that although standing orders were in
that I frequently need to make changes of a
place they were neither well developed nor up to date.
greater magnitude than the standing orders
Frustration was also expressed about having to wait
will allow. I am also at a stage in my practice
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 9
Nursing Praxis in New Zealand that I have skill and knowledge levels similar
and prescribe not the nurseâ&#x20AC;&#x2122;s; another stated that if
to a senior house officer or junior registrar.
standing orders were adequate for practice, nurses
Being able to prescribe within my scope of
would not need to prescribe. Another made the point
practice would enhance my ability to practice
that secondary care services already have access to
and deliver patient focussed care that would
endocrinologists and clinicians who can prescribe.
better meet their needs, as opposed to going to a doctor and asking them to prescribe for
Figures 2 and 3 show that DNS overall agree there are
me.
important or extremely important benefits that DNS prescribing brings for improving access to diabetes
Eleven participants expressed concern about the
services, diabetes management, continuity and
medico-legal aspect of standing orders and the amount
quality of care, fewer delays for patients needing a
of protection for the nurse, if any, they provide.
prescription, more effective use of DNS time, and better use of nursing skills. These questions were asked in the
Support for DNS prescribing
DNS prescribing evaluation and the results are similar
Non-prescribing DNS clearly support independent
to those reported here. The majority of DNS recognise
DNS prescribing as shown in figure 1. One nurse,
prescribing to be a natural progression for nurses, and
however, stated that it is the doctorâ&#x20AC;&#x2122;s job to diagnose
does not divert attention from nursing care.
I support diabetes nurse prescribing Standing orders are adequate for diabetes nurse specialists to adjust medications/insulins I think doctors should prescribe medicines/insulns It's best if the nurse checks with the doctor first before prescribing any medication/insulins Not sure 0
10
20
30
40
50
60
70
80
90
Count Figure 1: Nurses views on patients receiving prescriptions from diabetes nurse specialists Figure 1. Nurses views on patients receiving prescriptions from diabetes nurse specialists
Page 10
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
I support diabetes nurse prescribing Standing orders are adequate for diabetes nurse specialists to adjust medications/insulins I think doctors should prescribe medicines/insulns It's best if the nurse checks with the doctor first before prescribing any medication/insulins Not sure 0
10
20
30
40
50
60
70
80
90
60
70
80
90
Count Figure 1: Nurses views on patients receiving prescriptions from diabetes nurse specialists
Figure 2. Benefits of diabetes nurse prescribing
I support diabetes nurse prescribing Standing orders are adequate for diabetes nurse specialists to adjust medications/insulins I think doctors should prescribe medicines/insulns It's best if the nurse checks with the doctor first before prescribing any medication/insulins Not sure 0
10
20
30
40
50
Count Figure 3. Views on diabetes nurse prescribing Figure 1: Nurses views on patients receiving prescriptions from diabetes nurse specialists
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 11
Nursing Praxis in New Zealand Concerns about DNS prescribing
Other reservations were expressed about the
Diabetes nurse specialists were asked if they have
range of drugs listed in the Schedule (particularly
concerns about DNS prescribing and 48 (52.1%) had
antihypertensive
none. Overall forty comments were received; of these,
agents), and the increased risk for prescribing errors
eight noted concerns regarding support from GPs for
with multiple prescribers, annual competency checks,
prescribing, and five expressed concern regarding
remuneration, and loss of emphasis on the needed
the supervision of future prescribers as the demand
lifestyle changes for diabetics.
medicines
and
lipid-lowering
for supervising consultants increases. Others noted they would have no concerns about DNS prescribing if
Teams
nurses were experienced, have on-going competency
Views regarding changes to team dynamics were asked
assessments, appropriate academic preparation,
of the non-prescribing DNS who worked at the four
and adequate support. The following summarises a
DNS prescribing demonstration sites. That change has
number of responses:
occurred was acknowledged and those changes were bringing benefits to the DNS team. One nurse stated
I think comprehensive academic preparation and
strict
authorisation
criteria
the following:
are
essential to maintain safety for both patient
They [the prescribing DNS] are helping
and practitioner. Also good clinical and
supervise [sic] non-prescribers and highlight
professional support is necessary when the
issues amongst the team. Their knowledge and
nurse begins to prescribe in a clinical setting.
skills have helped improve the dynamics of the
I feel it is of paramount importance to ensure
nursing team. Their clinics take longer now as
nurses are not made vulnerable to failure
they now have more added responsibility, and
to prescribe safely by taking shortcuts or
I have noted that they are not given more time
hurrying the process.
to see patients.
I support diabetes nurse prescribing Standing orders are adequate for diabetes nurse specialists to adjust medications/insulins I think doctors should prescribe medicines/insulns It's best if the nurse checks with the doctor first before prescribing any medication/insulins Not sure 0
10
20
30
40
50
60
70
80
Count
Diabetes nursereceiving specialists considering becoming a prescriber Figure 1:Figure Nurses4.views on patients prescriptions from diabetes nurse specialists Page 12
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
90
Nursing Praxis in New Zealand Another nurse commented that the rest of the nursing
already studying towards this goal, or have finished a
team were now keen to take on the extra responsibility,
clinical master’s degree. Three had become motivated
whilst another acknowledged a more streamlined
to enrol in study because they intended to become a
service for patients who were seen by these nurses.
prescriber. Six aimed to attain DNS accreditation first, and two reported no change as they were already on
Intention to become a prescriber
the NP pathway. Three nurses pointed out that prior to
Forty-eight (52.2%) nurses indicated ‘yes’, they had
the DNS prescribing project, being a NP was the only
considered becoming a DNS prescriber themselves,
way that nurses could prescribe and they expressed
and a further 19 (20.6%) thought ‘maybe’. Figure
interest in the opportunity to prescribe without
4 also shows the responses to this question from
registering as a NP.
the non-prescribing nurses in the DNS prescribing project
demonstration
sites.
Increased
stress,
Participants were asked to list the names of any
added responsibility with no extra time allocated
postgraduate papers they had already completed
for appointments, increased workload with no extra
at university. Seventy-six (82.6%) responses were
remuneration, and the study requirements were cited
obtained. Of the responses that listed a completed
as reasons for not wanting to become a prescriber.
postgraduate qualification, 12 nurses (15.8%) had
Fifty-nine (64.1%) DNS thought their employer would
a clinical masters degree, and 8 (10.5%) had a post
support their plans to become a prescriber.
graduate diploma. The list of papers completed included those required by the Nursing Council for
A chi square analysis was used to determine if there
DNS to be authorised to prescribe: pathophysiology
is a relationship between accreditation as a specialist
(n=11, 14.5%), clinical assessment and diagnosis
diabetes nurse with the NZNO and the intention to
(n=25, 32.9%), pharmacology (n=19, 25%), and a
become a prescriber. The results indicate a statistically
prescribing practicum (n=7, 9.2%). The list of other
significant relationship exists (X2 [2, N=85]=7.068,
papers completed was extensive and most nurses
p=.029). Specialist nurse accreditation requirements
(n=76) had completed more than one paper. Twenty-
are similar to the current experience and education
four DNS were engaged in post graduate study in 2012.
requirements of the Nursing Council to be authorised to prescribe in diabetes health as specified in the
Prescribing for other groups of specialist nurses
New Zealand Gazette notice (Nursing Council of New
The possibility of prescribing being made available to
Zealand, 2011, March 31).
other groups of specialist nurses was answered by 87 nurses, of whom 54 (62.1%) thought other specialist
Professional development
nurses should be able to prescribe in their area of
The connection between the intention to prescribe
practice.
and specialist nurse accreditation with the NZNO is reinforced if nurses had already completed some
Discussion
or all of the required post-graduate papers for
The experience and knowledge of the nurses in this
prescribing. Thirty-three (35.9%) DNS had altered
study are high, and the findings are similar to those
their professional development plans since the DNS
reported in the UK workforce survey of diabetes
prescribing project began to include papers that were
specialist nurses (Gosden, James, Anderson, & Morrish,
necessary to become a prescriber. Fifty-three (57.6%)
2010). In the current study 72.8 percent indicated
reported no change to their plans because they are
some interest in becoming a prescriber. Almost 43
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 13
Nursing Praxis in New Zealand percent are accredited as diabetes nurse specialists
& Nolan, 2007; Otway, 2002; Stenner et al., 2009). In
with the NZNO, and these nurses are significantly
this study, non-prescribing DNS clearly support their
(p=.029) more likely to have intentions to seek
prescribing colleagues, acknowledging the benefit of
prescribing authorisation from the Nursing Council of
a more streamlined service for patients. Support from
New Zealand. Accreditation requires completion of
non-prescribing nurses for DNS prescribing has been
post graduate papers with a focus on diabetes and 27
reported in the evaluation of the DNS prescribing
percent had a completed postgraduate qualification;
project (Wilkinson et al., 2013) and 11 of these nurses
most had engaged in more than one postgraduate
responded to this survey also. Their support almost
paper. Interest in prescribing was sufficient for DNS
a year later is apparent which suggests they have
to make adjustments to their post-graduate study
confidence in the nurses who prescribe and believe
plans to include the core papers required to become
them to be competent.
a prescriber in diabetes health. The possibility of being a prescriber without having to be a nurse practitioner
Bradley and Nolan (2007) also reported ‘ruffled
was noted with interest.
feathers’ amongst some non-prescribing nurses, and Hosking (2003) reports the view that prescribing
Currently a majority of DNS services utilise standing
should remain the domain of the doctor. A small
orders for titration of insulin and oral diabetes
number of nurses expressed similar views in this study.
medications. The limitations of standing orders
Certainly prescribing may not be for every nurse, but
are frustrating and often nurses have to wait for a
the literature is clear that support from colleagues
prescription from a doctor in order to commence
will influence the prescribing nurse’s confidence
treatment for their patients. Bodington (2011) suggests
and competence, and ultimately the success of DNS
that diabetes nurse specialists have expertise that is
prescribing.
often called on by doctors who have less experience of diabetes management. The option to become a DNS
The DNS prescribing project evaluation noted improved
prescriber could help relieve this frustration and lead
team dynamics in each demonstration site, and
to a greater sense of job satisfaction.
increased motivation to take on extra responsibility. Comments from nurses in both the evaluation and
McHale (2010) has explored concerns about the
this study point out the prescribing nurses’ willingness
medico-legal aspect of the UK-equivalent to standing
to share knowledge and support junior staff. Good
orders, Patient Group Directives, and notes that
working relationships within teams is dependent on an
orders should not be automatically followed if it
understanding of changes in roles and addressing any
would be clinically inappropriate to do so. Nurses
concerns (Stenner et al., 2009).
are accountable for their actions and must be able to defend those actions whether a standing order is
Concerns identified about DNS prescribing are similar
involved or not (Carryer & Boyd, 2003). Competence
to those reported in the UK. That is, access to medical
in the use of a standing order is a requirement of its
mentors (Latter et al., 2007), the experience and
use as well as annual competence assessment by the
educational preparation of potential prescribers,
issuer of the order (Ministry of Health, 2012).
the authorisation criteria, robust organisational infrastructure and support, and on-going competency
Peer support has been identified as a major influence
assessments (Courtenay & Carey, 2008). Certainly
in the success or failure of any new initiative (Bradley
the current Regulations specify ongoing medical
Page 14
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand supervision of DNS prescribers. However, the Nursing
acknowledge the limitations of the study are inclusive
Council has recently consulted on a specialist level of RN
of those usually associated with survey designs, but
prescribing, and their decisions regarding education,
particular limitations are the non-probability sample
experience and collaborative team environments are
employed and the potentially incomplete email list
expected to encompass DNS prescribers (Nursing
of the DNS section of the NZNO. The low response
Council of New Zealand, 2013, February). At present,
rate to the survey (25.5%) is another limitation but is
DNS must provide evidence of on-going support and
likely to reflect the inclusion criterion of DNS located
professional development annually.
in secondary care settings. Statistical generalisation of the findings is not possible, although there are some
The implications of these findings as the managed roll-
similarities between these findings and that reported
out of DNS prescribing continues is that nurses are
elsewhere. Further research that includes more
interested in becoming prescribers in diabetes health
detailed demographic information of nurses would
and many already meet the experience and education
identify where nurses who are interested in prescribing
requirements to become a prescriber. There are now
are located geographically which could be matched to
a total of 27 nurses prescribing in diabetes health and
areas of high diabetes need.
many more are needed if the needs of an increasing number of people with diabetes are going to be met
Conclusion
(Budge & Snell, 2013). The areas of need are often
Registered nurse prescribing in New Zealand is in
remote geographical regions where the initial and
its infancy and any new initiative requires care and
ongoing medical supervision of nurses prescribing in
support for it to develop and progress. This study
diabetes health stipulated in the Medicines (Designated
highlights that interest in prescribing in diabetes
Prescriber â&#x20AC;&#x201C; Registered Nurses Practising in Diabetes
health is high amongst currently non-prescribing DNS
Health) Regulations 2011 can lead to added pressure
and there is evidence that team dynamics are good
on medical staff. Resources for the necessary medical
in this environment. Professional aspirations aside,
supervision need to be included in future workforce
DNS prescribing can make an important difference
planning.
for people with diabetes and for this reason must be actively supported at all levels of the health sector.
Other than the evaluation of the DNS prescribing
If DNS prescribing is to remain viable and continue
project, this is the first study in New Zealand to
to medical supervision need to be included in future
explore the views of non-prescribing DNS regarding
workforce planning.
nurse prescribing in diabetes health. The authors
References Aotearoa College of Diabetes Nurses. (2014). Accreditation handbook for nurses in the specialty of diabetes. Wellington, New Zealand: NZNO Bodington, M. (2011). Enhancing the DSN role: Independent and supplementary prescribing. Journal of Diabetes Nursing, 15(2), 5360. Bradley, E., Hynam, B., & Nolan, P. (2007). Nurse prescribing: Reflections on safety in practice. Social Science and Medicine, 65(3), 599609. doi:10.1016/j.socscimed.2007.03.051
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 15
Nursing Praxis in New Zealand Bradley, E., & Nolan, P. (2007). Impact of nurse prescribing: A qualitative study. Journal of Advanced Nursing, 59(2), 120-128. doi:10.1111/j.1365-2648.2007.04295.x Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa Budge, C., & Snell, H. (2013). Registered nurse prescribing in diabetes care: 2012 Managed national roll out. New Zealand: New Zealand Society for the Study of Diabetes. Retrieved from http://www.health.govt.nz/publication/registered-nurse-prescribingdiabetes-care-2012-managed-national-roll-out Carey, N., Stenner, K., & Courtney, M. (2009). Adopting the prescribing role in practice: Exploring nurses’ views in a specialist children’s hospital. Paediatric Nursing, 21(9), 25-31. Carryer, J., & Boyd, M. (2003). The myth of medical liability for nursing practice. Nursing Praxis in New Zealand, 19(3), 4 -12. Chaston, D., & Seccombe, J. (2009). Mental health nurse prescribing in New Zealand and the United Kingdom: Comparing the pathways. Perspectives in Psychiatric Care, 45(1), 17-23. doi:10.1111/j.1744-6163.2009.00196.x Courtenay, M., & Carey, N. (2008). Preparing nurses to prescribe medicines for patients with diabetes: A national questionnaire survey. Journal of Advanced Nursing, 61(4), 403-412. doi:10.1111/j.1365-2648.2007.04534.x Courtenay, M., Carey, N., & Burke, J. (2007). Independent extended and supplementary nurse prescribing practice in the UK: A national questionnaire survey. International Journal of Nursing Studies, 44(7), 1093-1101. doi:10.1016/j.ijnurstu.2006.04.005 Courtenay, M., Stenner, K., & Carey, N. (2010). The views of patients with diabetes about nurse prescribing. Diabetic Medicine, 27(9), 1049-1054. doi:10.1111/j.1464-5491.2010.03051.x Creswell, J. W. (2009). Research design: Qualitative, quantitative and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage. Elsom, S., Happell, B., & Manias, E. (2008). Expanded practice roles for community mental health nurses in Australia: Confidence, critical factors for preparedness, and perceived barriers. Issues in Mental Health Nursing, 29(7), 767-780. doi:10.1080/01612840802129269 Fisher, R. (2009). Relationships in nurse prescribing: Revealing the processes. British Journal of Community Nursing 14(12), 518 - 524. Goodwin, M., Higgins, S., & Lewis, S. (2011). Epilepsy specialist nurse prescribing practice in the United Kingdom: A national questionnaire survey. Seizure, 20(10), 754-757. doi:10.1016/j.seizure.2011.07.004 Gosden, C., James, J., Anderson, U., & Morrish, N. (2010). UK workforce survey of DSNs and nurse consultants: update. Journal of Diabetes Nursing, 14(7), 250-257. Hawkes, N. (2009). Handing over the prescription pad. BMJ, 339, b4835. doi:10.1136/bmj.b4835 Hosking, P. (2003). Prescribing and the epilepsy specialist nurse. Seizure, 12, 74-76. doi:10.1016/j.seizure.2011.07.004 Joshy, G., & Simmons, D. (2006). Epidemiology of diabetes in New Zealand: Revisit to a changing landscape. New Zealand Medical Journal, 119(1235); Retrieved from https://www.nzma.org.nz Kara, M., van der Bijl, J. J., Shortridge-Baggett, L. M., Asti, T., & Erguney, S. (2006). Cross-cultural adaptation of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus: Scale development. International Journal of Nursing Studies, 43(5), 611-621. doi:10.1016/j.ijnurstu.2005.07.008 Kroezen, M., van Dijk, L., Groenewegen, P. P., de Rond, M., de Veer, A. J. E., & Francke, A. L. (2014). Neutral to positive views on the consequences of nurse prescribing: Results of a national survey among registered nurses, nurse specialists and physicians. International Journal of Nursing Studies, 51(4), 539-548. doi:10.1016/j.ijnurstu.2013.08.002 Latter, S. (2008). Safety and quality in independent prescribing: An evidence review. Nurse Prescribing, 6(2), 59-66. Latter, S., Blenkinsopp, A., Smith, A., Chapman, S., Tinelli, M., Gerard, K., . . . Dorer, G. (2011). Evaluation of nurse and pharmacist independent prescribing. Southampton: Department of Health. Retrieved from http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126429 Latter, S., Maben, J., Myall, M., & Young, A. (2007). Evaluating nurse prescribers’ education and continuing professional development for independent prescribing practice: Findings from a national survey in England. Nurse Education Today, 27, 685-696. doi:10.1016/j.nedt.2006.10.002 Latter, S., Maben, J., Myall, M., Young, A., & Baileff, A. (2012). Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations. Journal of Research in Nursing, 12(1), 7-25. doi: 10.1177/1744987106073949 Learner, S. (2006). Prescription for change. Nursing Standard, 20(32), 20-21.
Page 16
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Lockwood, E. B., & Fealy, G. M. (2008). Nurse prescribing as an aspect of future role expansion: The views of Irish clinical nurse specialists. Journal of Nursing Management, 16(7), 813-820. doi:10.1111/j.1365-2934.2008.00853.x McDonald, K. (2005, Sept). AMA cops a blast over role reversal, Australian Nursing Review, p. 1. McHale, J. V. (2010). Nurse prescribing: Does more responsibility mean more litigation? British Journal of Nursing, 19(5), 315-317. Medicines (Designated Prescriber—Registered Nurses Practising in Diabetes Health) Regulations. (2011). Wellington, New Zealand: New Zealand Government. Medicines (Standing orders) Amendment Regulations. (2011). Wellington, New Zealand: New Zealand Government. Medicines Amendment Act. (2013). Wellington, New Zealand: New Zealand Government. Ministry of Health. (2012). Standing order guidelines. Wellington: Author. Moller, P., & Begg, E. (2005). Independent nurse prescribing in New Zealand. New Zealand Medical Journal, 118(1225), 10-13. Retrieved from https://www.nzma.org.nz New Zealand Society for the Study of Diabetes. (2009). National diabetes nursing knowledge and skills framework. Retrieved from http://www.nzssd.org.nz/dnss/framework.html Nursing Council of New Zealand. (2011, March 31). Medicines (Designated Prescriber—Registered Nurses Practising in Diabetes Health) Notice 2011. New Zealand Gazette, 41, 1006 -1007. Nursing Council of New Zealand. (2013). Consultation on two proposals for registered nurse prescribing: Community nurse prescribing and specialist nurse prescribing [Consultation document]. Wellington, New Zealand: Author. Otway, C. (2002). The development needs of nurse prescribers. Nursing Standard, 16(18), 33-38. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). London: Lippincott Williams & Wilkins. RCN Publishing. (2013). Nurse prescribing - Update 2013. London: RCN Publishing. Ross, J. D., & Kettles, A. M. (2012). Mental health nurse independent prescribing: what are nurse prescribers’ views of the barriers to implementation? Journal of Psychiatric And Mental Health Nursing, 19(10), 916-932. doi:10.1111/j.1365-2850.2011.01872.x Sibbald, B., Laurant, M. G., & Reeves, D. (2006). Advanced nurse roles in UK primary care. Medical Journal of Australia, 185(1), 10-12. Smith, A., Latter, S., & Blenkinsopp, A. (2014). Safety and quality of nurse independent prescribing: A national study of experiences of education, continuing professional development clinical governance. Journal of Advanced Nursing 70, 2506-2517. doi:10.1111/jan.12392 Stenner, K., Carey, N., & Courtenay, M. (2009). Nurse prescribing in dermatology: Doctors’ and non-prescribing nurses’ views. Journal of Advanced Nursing, 65(4), 851-859. doi:10.1111/j.1365-2648.2008.04944.x Stenner, K., Carey, N., & Courtenay, M. (2010). Implementing nurse prescribing: A case study in diabetes. Journal of Advanced Nursing, 66(3), 522-531. doi:10.1111/j.1365-2648.2009.05212.x Stenner, K., & Courtenay, M. (2008). The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain. Journal of Advanced Nursing, 63(3), 276-283. doi:10.1111/j.1365-2648.2008.04707.x Stenner, K., Courtenay, M., & Carey, N. (2011). Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views. International Journal of Nursing Studies, 48(1), 37-46. doi:10.1016/j.ijnurstu.2010.06.006 Tucker, S., & Rhudy, L. (2003). Preparing CNSs for prescriptive authority. Clinical Nurse Specialist, 17(4), 194-199. doi:10.1111/j.13652648.2008.04944.x Van Ruth, L. M., Mistiaen, P., & Francke, A. L. (2008). Effects of nurse prescribing of medication: A systematic review. Internet Journal of Healthcare Administration, 5(2), 1-31. Watterson, A., Turner, F., Coull, A., Murray, I., & Boreham, N. (2009). An evaluation of the expansion of nurse prescribing in Scotland. Stirling: Scottish Government Social Research. Retrieved from http://www.scotland.govt.uk/publications/2009/09/24131739/0 Wilkinson, J. A. (2011). Extending the prescribing framework to nurses: Lessons from the past. Collegian, 18(4), 157-163. doi:10.1016/j. colegn.2011.07.001 Wilkinson, J. A., Carryer, J., & Adams, J. (2013). Evaluation of a diabetes nurse specialist prescribing project. Journal of Clinical Nursing, 23, 2355-2366. doi:10.1111/jocn.12517
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Nursing Praxis in New Zealand INSTITUTIONAL ETHNOGRAPHY: AN EMERGING APPROACH FOR HEALTH AND NURSING RESEARCH Sue Adams, RN, MSc, Senior Lecturer, School of Nursing, Massey University, Albany, NZ Jenny Carryer, RN, PhD, Professor, School of Nursing, Massey University, Palmerston North, NZ Jill Wilkinson, RN, PhD, Senior Lecturer, School of Nursing, Massey University, Wellington, NZ
Abstract This article introduces institutional ethnography as a valuable approach to sociological inquiry for health and nursing research in New Zealand. Institutional ethnography has gained increasing prominence across the world because of the potential transformative nature of the research. Institutional ethnography explores how everyday activities and experiences are coordinated by the ruling relations and their institutional processes and discourses. By mapping how our everyday lives are textually organised, the ruling relations are made explicit. This article provides an overview of institutional ethnography, introducing key concepts. Research particularly relevant to health and nursing will be referred to as a way of showing the value of institutional ethnography to nurse researchers. The paper concludes by describing how institutional ethnography is being used in research on establishing nurse practitioners and their services in rural primary health care.
Keywords Institutional ethnography; ruling relations; nurse practitioners; health research; sociological inquiry
Introduction Institutional ethnography (IE) is a critical form of
the everyday activities and experiences of people, and
social inquiry founded by Dorothy Smith. Institutional
the institutional construction of the social world. The
ethnography can be described as a “Marxist-feminist,
term institutional ethnography explicitly connects an
reflexive-materialist, qualitative method of inquiry”
emphasis on the structures of power – institutions –
(Hussey, 2012, p. 2). Since Smith’s early writings
with the everyday practices and experiences of people
during the 1970s, IE has continued to be shaped and
at the local level – ethnography (Appelrouth & Edles,
developed by Smith along with a growing group of
2011).
well-respected researchers and theorists from North America and, increasingly, other parts of the world.
This paper introduces IE as a valuable research
Institutional ethnography publications listed on Scopus
approach for health and nursing in New Zealand and
have more than doubled for each five year period from
adds to previous articles on methodology published
1990, to a total of 184 in August, 2014. Institutional
in this journal. The theoretical underpinnings of IE as
ethnography is now being used across a wide diversity of disciplines, including health, social work, law and justice, and education, because of its relevance to exploring and making visible the relationship between Page 18
Adams, S., Carryer, J., & Wilkinson, J. (2015). Institutional ethnography: An emerging approach for health and nursing research. Nursing Praxis in New Zealand, 31(1), 18-26.
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
ruling relations and experiential knowledge in the
Institutional ethnography: An alternative sociology
everyday world are described. Finally, a brief overview
Institutional ethnography is an alternative sociology.
is provided of how IE is being used for research on
It describes how the social world is (ontology), the
nurse practitioners in rural primary health care.
knowledge required to understand our social world
an alternative sociology, and the key concepts of the
(epistemology), and how we go about collecting that Dorothy Smith (b. 1926), a Canadian sociologist
knowledge (methodology). The key premise of IE
and feminist activist, began her work developing
is that our social world, and our everyday activities
an alternative sociology during the second-wave of
in it, are controlled and coordinated textually and
the contemporary women’s movement in the 1960s
discursively by the institutional or ruling relations of
and 1970s. She has been described as “a world-
our society. The web of ruling relations is produced
renowned Marxist feminist scholar and activist and a
by the ruling apparatuses that are “those institutions
formidable intellect” (Carroll, 2010, p. 9). Her work in
of administration, management, and professional
founding IE stemmed from what Smith described as
authority, and of intellectual and cultural discourses,
the disjuncture she experienced early in her career
which organise, regulate, lead and direct contemporary
between being a sociologist in a male dominated and
capitalist societies” (Smith, 1990b, p. 2). Organisation
gendered institution, and a single mother of two young
and coordination of society, or of our social world, is
children (Smith, 2005). She objected to the ways that
achieved textually. Texts may be written, oral or visual,
traditional positivist sociology categorised people into
and are replicated across time and place, appearing in
designated groups, including housewives and single
many different places and locations simultaneously.
mothers, and then sought to explain their activities,
People are connected through texts from their local
behaviours, or their culture. She believed that this
setting to others in similar local settings but outside of
generated ideology not knowledge, and served
their interactional world (Bisaillon, 2012). For example,
further to perpetuate oppression and discrimination,
how a person with diabetes navigates the health
particularly for women (Smith, 1974, 1990a). She
system, how a nurse prepares a patient for surgery, and
identified that her own experience and knowledge of
how a victim of domestic violence accesses services. It
her everyday life was disconnected from the official or
is the texts actively entering into our everyday activities
authoritative representations of her world and work
that result in such similar experiences. Mostly, these
as a sociologist (Bisaillon, 2012). However, as her work
texts are unknown to us and taken-for-granted.
progressed Smith updated her terminology from a sociology for women to that of a sociology for people
Informants or participants in the research are
clearly signalling that we must begin our understanding
knowledgeable subjects, and it is from this starting
of the social world from the experiences or standpoint
point that researchers in IE begin to discover how
of people as they go about their everyday lives (Smith,
people’s everyday activities and experiences are
2005).
textually coordinated by the ruling relations. Power imbalances, tensions, and contradictions are the entry
Today, Dorothy Smith still holds a position as professor
points to exploring how their social world has been
emerita at the University of Toronto, as well as adjunct
organised by society’s structures, which is of particular
professor at the University of Victoria, British Columbia,
value for nursing. Nurses working in clinical settings, are
where she continues to develop IE with scholars and
subjected to organisational and institutional processes
students from across the world.
created from dominant ideologies, such as biomedicine,
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 19
Nursing Praxis in New Zealand health care management, and the regulation of
and reflexive. While endeavouring to introduce the
professions. The nurses’ work is controlled by these
reader to the key concepts of IE, it is imperative that
systems, and yet they often experience tensions and
these concepts themselves should not become a
contradictions between what they are required to do,
part of the ruling relations that coordinate the work
and what they believe is the right thing to do for that
of researchers and could defeat the purpose of IE.
particular patient in that particular context (McGibbon
Bisaillon (2012) explains that “[t]hrough proximity and
& Peter, 2008; McGibbon, Peter, & Gallop, 2010).
personal investment, we might … neglect to interrogate and challenge the very language, concepts, notions,
Using data collection methods, such as interviews
and ideas that we are accustomed to using” (p. 614).
and observations, the researcher opens the door
Hence as the key concepts are described, the reader’s
to exploring how the institutional processes, or
attention will be drawn to publications on IE, and
ruling relations, shape those experiences (Deveau,
reveal a little of how these concepts are used to inform
2008). The analytic focus and key endpoint of IE is
the IE researcher, particularly in the field of health and
on understanding how society’s institutions govern
nursing research. The key concepts of IE are explored
people’s lives, explicating how their lives are socially
further under two broader theoretical concepts the
coordinated (Walby, 2007). The exposure of the ruling
ruling relations, and experiential knowledge in the
or institutional relations brings into consciousness
everyday world.
possibilities for change and transformation, showing the people, informants and researchers ways of
The ruling relations
achieving change. Political activist ethnography has
Social relations are located in people’s interactional
emerged from IE as a more radical approach where
activities, the activities that we do in our everyday
ruling regimes are that individuals and researchers
lives, and, Smith (2006b) says, we participate in those
explicitly and actively want to change identified
social relations without knowing what we are doing.
(Hussey, 2012). Such researchers are often engaged in
The ruling relations or institutional relations are a
political and human rights movements.
part of the social relations. They are the “complex of objectified social relations that organise and regulate
Key concepts in institutional ethnography
our lives in contemporary society” (Smith, 1999, p. 74).
Marie Campbell, an eminent institutional ethnographer
McCoy (2006) explains: “You get out of bed, turn on the
and nurse, discusses how to “think” as an institutional
tap, make coffee, read the newspaper you collected
ethnographer, identifying the importance attached
from your front step – and you are participating in
to “understanding the social world that is enacted in
institutional relations (municipal water systems,
institutions” (Campbell, 2010, p. 497). She says that
international trade, the mass media)” (p. 111). Here,
meanings are never fixed, which relates both to the
your social world is being coordinated and organised
definitions of terms in IE, and the social world itself
by those ruling relations. These ruling relations are
as we are exploring it. In many ways this premise has
textually mediated through print, film, TV, internet,
led to the ongoing evolution of IE, as researchers work
mass media, and so on. In other words, the ruling
with, and make sense of, the key concepts in their
relations enter into the local social setting by texts,
world of research.
which may be written, oral or visual. These texts are produced from governments, agencies, corporations,
The caveat for this section of the article is that IE is
organisations, industry, educational and research
a way of exploring the social world that is dynamic
establishments, professional bodies, the media,
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Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand cultural and religious groups, and have the ability to
policy, strategy, practice guidelines, contracts and so
reach many people. Such texts are both standardising
on. The researchers are not arguing that authoritative
and replicable. A “web of relations” is created through
knowledge is a bad thing, what they are primarily
which ruling is achieved (Bisaillon, 2012, p. 618) and
concerned about is that nurses’ knowledge from their
results in people from across different areas but in
experience is not acknowledged, often invisible, and
similar local settings experiencing the social world in
not utilised in the creation of new knowledge.
similar ways. Research by Hamilton and Campbell (2011) investigated As we go about our everyday activities, we activate
nursing productivity, workload and staffing in three
the texts that coordinate our social world, and we
Texas hospitals, in the context of recent hospital
are ‘hooked up’ into the relations of ruling, usually
reform. The hospitals used sophisticated software
subconsciously in a way that we take-for-granted
packages to collect data and calculate staffing levels
our activities and experiences (Smith, 1999). In
for optimum productivity. The texts, in this case the
turn the ruling relations are perpetuated and may
software packages, are the way that the authoritative
be strengthened further. Chubin (2014) wrote an
knowledge is used in the local situation to control the
autoethnography as a woman in Iran experiencing
activities and actions of the nurses. The researchers
sexual harassment, and using IE described the
found the assumed dominance of institutional and
institutional processes that create and sustain the
managerial knowledge, applied through software,
silence of women. She stated “[w]omen’s silence
subordinated what nurses know. The day to day
… both originates from and sustains patriarchal
experiential knowledge of the nurses was not taken into
institutional processes” (p. 184). By continuing to
account nor used to inform the processes. The power
participate in the web of ruling relations, through their
that plays out between texts is known as intertexual
silence in this instance, the women are seemingly
hierarchy (Smith, 2005). Certain texts more powerfully
affirming the ideologies and work of the institutional
organise what happens in the locality than others.
powers.
For example, in a residential care setting for women with mental illness, the regulatory texts about patient
The knowledge that is held by the ruling relations
safety took precedence over diabetes guidelines with
is objectified knowledge – it is the official or
the recommended exercise requirements (Lowndes,
authoritative knowledge of our social world. There
Angus, & Peter, 2013). In other words, people generally
is an emerging body of nursing research from North
activate the more powerful texts. These regulatory,
America using IE to explore how the authoritative
or boss texts, are created and authorised through
knowledge is incorporated into institutional processes
institutional processes, instructing people on what to
to strongly control and organise the work of nurses
do, how to act, or how to carry out specific practices
in the clinical setting (Folkmann & Rankin, 2010;
(Bisaillon, 2012).
Hamilton & Campbell, 2011; McGibbon & Peter, 2008; tension, contradiction or disjuncture, which the nurses
Experiential knowledge in the everyday world
experience as their nursing knowledge and everyday
People’s lived experiences and ways of knowing the
experience is in contrast to regulation and control
world are often in contrast to ideological or conceptual
applied to their work. Authoritative knowledge may be
ways of knowing about something (Smith, 2005). The
incorporated into legislation, professional regulation,
experiential knowledge of people in their social world
Rankin, 2009). The researchers identify points of
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 21
Nursing Praxis in New Zealand is central to IE - the actualities of everyday activities
consciousness (Smith, 2005). For nurses, they often
and experiences – what people do, and sometimes
experience the disjuncture between their professional
don’t do, and how they go about doing things. Smith
experiential knowledge, and that of the authoritative
talks about ‘doings’ and ‘happenings’ and distinguishes
or official knowledge imposed on them through
experience in IE from the phenomenological idea of
the ruling relations. However, nurses have been so
experience (Smith, 1999). In IE, experience is used
strongly conditioned to perceive the world from the
as a way to explore how one person’s local world, or
perspective of the institution or ruling relations that
locality, is connected to others working and living in
they continue to engage with and perpetuate the
similar situations but in different places. So experience
institutional processes (Rankin & Campbell, 2009).
from the standpoint of people in that locality is used to provide clues and information about how people’s
Disjuncture is often experienced as a tension or
lives are coordinated and organised within society
frustration, or even stress and distress. However, how
(Bisaillon, 2012).
a person’s experience has been textually mediated through institutional processes is often beyond
Experiential knowledge is embodied knowledge. It is
awareness. Rankin and Campbell (2009) explored how
the taken-for-granted tacit knowledge of the people
health information technology and health services
in a particular setting. Folkmann and Rankin (2010)
research has generated objectified, authoritative
explored the medication work of nurses in hospitals
knowledge that is being used to reform the health care
and identified that the embodied knowledge of the
system with the promise of ongoing improvements.
nurses was at odds with the objectified or authoritative
From observing and talking with nurses they found
knowledge that created the institutional processes
“[a]t each turn of nursing activity the nurses relied
for medication procedures in hospitals. Starting their
on knowledge from a care pathway – as opposed
research from the standpoint of the nurses, Folkmann
to relying on what they know as knowledgeable
and Rankin found that nurses’ medication work did
actors, embodied and embedded in a professional
not progress in a linear and standardised way as was
domain” (Rankin & Campbell, 2009, p. 15). The nurses
expected by the regulatory controls and institutional
talked about how their nursing work ‘chafed’. They
processes that were in place, but was characterised
experienced the tension of living in two worlds – one,
by “complexity, interruption and ambiguity” (p. 3224).
their embodied world of knowing about nursing and
The intent of the technologies and procedures was to
how to do it, and two, the other world of research-
improve patient safety, but their coordinating power
based and standardised knowledge applied to a whole
did not acknowledge nurses’ knowledge around the
patient group through care pathways. Similarly, IE
complexity of the situation. The lack of inclusion of
research in paediatric intensive care units identified
the nurses’ knowledge was a significantly missed
the often extraordinary distress that the nurses
opportunity in reforming processes and procedures
experienced as they endeavoured to make sense of
for the ordering, dispensing and administering of
their lived experiences of caring for extremely sick,
medications. Inadvertently, patient safety is at risk.
and often dying children, while their work was being controlled by biotechnologically driven institutional
A tension or contradiction that exists between the
processes (McGibbon & Peter, 2008; McGibbon et al.,
authoritative knowledge and embodied knowledge is
2010).
called a disjuncture. People experience this as living in two worlds, which Smith called the bifurcation of Page 22
The lived experience of people’s actions in their Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand everyday lives in IE is often termed work. Work may be
perhaps satisfy media, public, and governmental
activities that are a part of paid work, but equally may
concerns. But these texts – both the forms, documents,
be our work as parents, carers, service users, members
and management discourse - had an adverse effect on
of a community group, voluntary workers, members
quality where the reduced wait time did not equate
of clubs and societies, and so on. Work is what takes
to better care. These researchers identified that so-
time, effort and intent in people’s everyday lives and
called quality emergency care was a powerful ruling
is in some way connected by the work of others, using
discourse, which inserted into the nurses’ work the
similar resources, and organised by similar information
interests of politics and economics.
and texts (Smith, 2005). In this sense work is not elsewhere will be doing similar things and activities.
Applying institutional ethnography in New Zealand: Nurse practitioners and the ruling relations
The concept of work is used in IE to really focus the
The research being undertaken by the first author
researcher on what people do and how their activities
explores the problem of why in New Zealand (NZ) we
and experiences are being structured within society
have so few nurse practitioners (NPs) in rural primary
by the ruling relations through texts. As examples,
health care. Internationally, NPs have provided essential
Eric Mykhalovskiy (2008) explored the everyday
primary health care services to indigenous, deprived,
‘healthwork’ of poor, socially marginalised people
rural and mainstream populations. Significant health
living with HIV. He identified the disjunctures these
disparity continues to exist in underserved populations
people experienced between their lived experiences
in NZ. Health services in rural areas of NZ are facing
and the conceptual and rational biomedical decision.
serious challenges with an ageing population, reducing
Mykhalovskiy explored the healthwork of people with
medical workforce, and more complex health need.
HIV in their navigation of health services and taking,
Additionally, the ongoing medicalisation of health and
or not taking, treatments, particularly antiretroviral
specialism of services is doing little to reduce health
therapies. In a study in aged care facilities in the United
inequalities. Nurse Practitioners are a highly trained
States, Tim Diamond (1992) as a participant observer,
and economically sound workforce solution (Bauer,
used IE to investigate the work that both residents
2010; Federal Trade Commission, 2014), available in
and health care assistants do to accommodate the
NZ since 2001. Yet progress to establish NPs as part
institutional processes that organise their day to day
of mainstream primary health care services in NZ has
lives.
been extremely slow. Progress has been compounded
peculiar to one individual, but it is likely that others
by policy and legislative issues and a failure to explore A group of nursing researchers investigated the issue
the potential from a range of organisations and
of quality and wait times in emergency departments
institutions. In this section, research, which is currently
(EDs) from the standpoint of nurses and their work
in progress, will be used to overview the research
(Melon, White, & Rankin, 2013). They looked at the
approach and methods.
nurses’ work to reach a triage decision, structured by the Canadian Triage and Acuity Scale (CTAS), and the
The entry point for an IE investigation begins in a
ongoing ‘invisible’ work between the logging of the
particular orientation of the researcher’s interest
numerical score (one to five) and the patient being
and attention (Campbell & Gregor, 2004). It is not
seen by a physician. These texts had specific intention
necessary for the researcher to remain neutral. The
to demonstrate efficiency and quality, in order to
stance for this research is unashamedly in support of
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 23
Nursing Praxis in New Zealand the NP project in NZ and considers how NP services
The unravelling of an IE can be a concern for ethics
can be increased in rural primary health care. The
committees who themselves are part of the ruling
focus of interest, or the puzzle to be solved, is to make
relations that coordinate research (Truman, 2003),
visible how the ruling relations have controlled the NP
and was a disjuncture the researcher (SA) noticed in
project.
the ethics application. The researcher (SA) needed to demonstrate how ethical safety could be ensured
In IE there are three tasks that are paramount to
(and was absolutely committed to doing this) for
inquiry: documenting the work that people do in their
the participants, while undertaking an IE to uncover
locality, identifying textually mediated discourses, and
potentially unknown institutional processes of ruling.
mapping social relations (Lowndes et al., 2013). Data
Ethics for the research was approved by the Massey
collection techniques in IE are largely consistent with
University Human Ethics Committee (North).
those of other qualitative ethnographic approaches, including interview, observation and textual analysis.
The first author (SA) is now reaching the end of what
The research began with the first author interviewing
is often called in IE the phase one of interviews. These
NP candidates, or interns, and NPs about their
are the interviews with participants in the locality, and
experiences of becoming a NP and working in practice.
in addition to NP candidates and NPs, informants have
However, importantly, the researcher’s purpose in
now included general practitioners, practice managers
an IE is not to “generalise about the group of people
and nurse leaders. Most of these interviews have
interviewed but to find and describe social processes
been conducted individually, but some have been as
that have generalised effects” (DeVault & McCoy,
small groups or talk groups. Institutional ethnography
2012, p. 383). The focus in the interviews is not on
considers informants’ stories and descriptions of what
finding recurrent themes, but on identifying the texts
they do and have done. The researcher’s work is to
that are being activated by the NP candidates and
identify some of the institutional texts, processes and
NPs in coordinating their experiences. Each informant
discourses that are shaping the informants’ experiences
provides new information, and each interview builds
(DeVault & McCoy, 2012). The points of tension and
on the knowledge gained from the previous interview.
contradiction that can identify a disjuncture between
Data collection and analysis are iterative and inductive
lived embodied experience and institutional reality are
processes that begin from the first interview and
particularly important and often only identified during
continue to the final write-up (Bisaillon & Rankin,
the data collection process. A particular disjuncture
2013). Rarely can an IE be planned out in advance –
may become the focus of the research, known as the
especially in identifying who is going to be interviewed,
problematic, from which the ruling relations can be
when and about what. DeVault and McCoy (2012)
further explored and exposed.
explain: The next phase of the research is to investigate
Page 24
The process of inquiry is rather like grabbing
the institutional processes and discourses at the
a ball of string, finding a thread, and then
extra-local level, which may include further specific
pulling it out. Institutional ethnographers
interviews with individuals from institutions and
know what they want to explain, but they can
organisations who are producing the organising texts
discover only step by step whom they need to
and discourse. Analysis is ongoing throughout the
interview or what texts and discourses they
research process. However, at this stage mapping is
need to examine. (p. 383)
introduced as a particular analytical tool in IE. Mapping Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand is a geographical metaphor used “to explore particular
because of the ability to expose the ruling relations and
corners or strands within a specific institutional
institutional processes of power that are controlling
complex, in ways that make visible their points of
the development of NP services. By explicating the
connection with other sites and courses of action”
ruling relations NPs and their colleagues in primary
(DeVault & McCoy, 2012, p. 383). Key to analysis in IE
health care settings will see how their world is being
is that there is a course of action that produces a text,
shaped, providing an opportunity for those NPs to
and this in turn leads to further action. This is called
interact and engage differently with the institutional
the “act-text-act sequence” (Smith, 2006a, p. 67).
processes. It is hoped too that this information will be
The researcher’s work is to expose which texts and
used by some of the institutions and organisations to
discourses are coordinating NP candidates, NPs, and
review their texts and discourses.
others, in local practices to establish and implement NP services. Particular interest is paid to the texts
This paper has introduced the reader to IE, and
that enable or impede particular activities, and the
identified ways in which IE as sociological inquiry
power afforded to those texts by the practitioners
could be applied in the NZ health context. IE offers
themselves. The relationship between texts and action
a range of possibilities for the NZ researcher. It is an
can be mapped, ultimately highlighting opportunities
emergent mode of inquiry where researchers will need
for change.
to adapt, revise, and improvise as IE is used in different applications (DeVault & McCoy, 2012), including to the
Conclusion
NZ context. Particularly, IE may have useful applications
Institutional ethnography is an emerging approach
in NZ addressing inequalities in health; health and
to sociological inquiry. The authors have described
service needs of Māori, marginalised and high health
how IE is being applied to research on establishing
needs groups; and the nursing contribution to health
NP services in rural primary health care. Institutional
service delivery.
ethnography was considered particularly relevant
References Appelrouth, S., & Edles, L. D. (2011). Sociological theory in the contemporary era (2nd ed.). Thousand Oaks, CA: Pine Forge Press, SAGE. Bauer, J. C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of costeffectiveness. Journal of the American Academy of Nurse Practitioners, 22(4), 228–231. doi:10.1111/j.1745-7599.2010.00498.x Bisaillon, L. (2012). An analytic glossary to social inquiry using institutional and political activist ethnography. International Journal of Qualitative Methods, 11(5), 607-627. Retrieved from http://ejournals.library.ualberta.ca/index.php/IJQM/article/ view/17779/14579 Bisaillon, L., & Rankin, J. (2013). Navigating the politics of fieldwork using institutional ethnography: Strategies for practice. Forum Qualitative Sozialforschung, 14(1). Retrieved from http://www.qualitative-research.net/index.php/fqs/article/view/1829/ Campbell, M. (2010). Institutional ethnography. In I. Bourgeault, R. Dingwall, & R. DeVries (Eds.), The SAGE handbook of qualitative methods in health research (pp. 497-512). London: Sage. Campbell, M., & Gregor, F. (2004). Mapping social relations: A primer in doing institutional ethnography. Lanham, MD: AltaMira Press. Carroll, W. K. (2010). ‘You are here’: Interview with Dorothy E. Smith. Socialist Studies, 6(2), 9-37. Retrieved from http://socialiststudies. com/index.php/sss/article/view/23708/17592 Chubin, F. (2014). You may smother my voice, but you will hear my silence: An autoethnography on street sexual harassment, the discourse of shame and women’s resistance in Iran. Sexualities, 17(1-2), 176-193. doi:10.1177/1363460713511097 Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 25
Nursing Praxis in New Zealand DeVault, M. L., & McCoy, L. (2012). Investigating ruling relations: Dynamics of interviewing in institutional ethnography. In J. F. Gubrium, J. A. Holstein, A. B. Marvasti, & K. D. McKinney (Eds.), The SAGE handbook of interview research: The complexity of the craft (2nd ed., pp. 381-395). Thousand Oaks, CA: Sage. Deveau, J. L. (2008). Examining the institutional ethnographer’s toolkit. Socialist Studies, 4(2), 1-20. Retrieved from http:// socialiststudies.com/index.php/sss/article/view/23749/17633 Diamond, T. (1992). Making gray gold: Narratives of nursing home care. Chicago, IL: University of Chicago Press. Gilman, D.J., & Koslov, T.I. (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. US: Federal Trade Commission. Retrieved from http://www.nacns.org/docs/FTC140307aprnpolicy.pdf Folkmann, L., & Rankin, J. (2010). Nurses’ medication work: What do nurses know? Journal of Clinical Nursing, 19(21-22), 3218-3226. doi:10.1111/j.1365-2702.2010.03249.x Hamilton, P., & Campbell, M. (2011). Knowledge for re-forming nursing’s future: Standpoint makes a difference. Advances in Nursing Science, 34(4), 280-296. doi:10.1097/ANS.0b013e3182356b6a Hussey, I. (2012). “Political activist as ethnographer” revisited. Canadian Journal of Sociology, 37(1), 1-24. Retrieved from http:// ejournals.library.ualberta.ca/index.php/CJS/article/view/10214/13564 Lowndes, R., Angus, J., & Peter, E. (2013). Diabetes care and mental illness: Constraining elements to physical activity and social participation in a residential care facility. Canadian Journal of Diabetes, 37(4), 220-225. doi:10.1016/j.jcjd.2013.03.361 McCoy, L. (2006). Keeping the institution in view: Working with interview accounts of everyday experience. In D. E. Smith (Ed.), Institutional ethnography as practice. (pp. 109-125). Lanham, MD: Rowman & Littlefield. McGibbon, E., & Peter, E. (2008). An ethnography of everyday caring for the living, the dying, and the dead: Toward a biomedical technography. Qualitative Inquiry, 14(7), 1134-1156. doi:10.1177/1077800408322229 McGibbon, E., Peter, E., & Gallop, R. (2010). An institutional ethnography of nurses’ stress. Qualitative Health Research, 20(10), 13531378. doi:10.1177/1049732310375435 Melon, K., White, D., & Rankin, J. (2013). Beat the clock! Wait times and the production of ‘quality’ in emergency departments. Nursing Philosophy, 14(3), 223-237. doi:10.1111/nup.12022 Mykhalovskiy, E. (2008). Beyond decision making: Class, community organizations, and the healthwork of people living with HIV/AIDS. Contributions from institutional ethnographic research. Medical Anthropology: Cross Cultural Studies in Health and Illness, 27(2), 136-163. doi:10.1080/01459740802017363 Rankin, J. (2009). The nurse project: An analysis for nurses to take back our work. Nursing Inquiry, 16(4), 275-286. doi:10.1111/j.14401800.2009.00458.x Rankin, J., & Campbell, M. (2009). Institutional ethnography (IE), nursing work and hospital reform: IE’s cautionary analysis. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 10(2), 1-20. Retrieved from http://www.qualitative-research. net/index.php/fqs/article/view/1258/2721 Smith, D. E. (1974). Women’s perspective as a radical critique of sociology. Sociological Inquiry, 44(1), 7-13. Retrieved from http:// onlinelibrary.wiley.com/doi/10.1111/j.1475-682X.1974.tb00718.x/pdf Smith, D. E. (1990a). The conceptual practices of power: A feminist sociology of knowledge. Toronto, ON: University of Toronto Press. Smith, D. E. (1990b). Texts, facts and femininity: Exploring the relations of ruling. London: Routledge. Smith, D. E. (1999). Writing the social: Critique, theory, and investigations. Toronto, ON: University of Toronto Press. Smith, D. E. (2005). Institutional ethnography: A sociology for people. Lanham, MD: Altamira Press. Smith, D. E. (2006a). Incorporating texts into ethnographic practice. In D. E. Smith (Ed.), Institutional ethnography as practice pp. 6588. Lanham, MD: Rowman & Littlefield. Smith, D. E. (2006b). Introduction. In D. E. Smith (Ed.), Institutional ethnography as practice (pp. 1-12). Lanham, MD: Rowman & Littlefield. Truman, C. (2003). Ethics and the ruling relations of research production. Sociological Research Online, 8(1). Retrieved from http:// www.socresonline.org.uk/8/1/truman.html Walby, K. (2007). On the social relations of research: A critical assessment of institutional ethnography. Qualitative Inquiry, 13(7), 1008-1030. doi:10.1177/1077800407305809
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Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand ONCOLOGY NURSES’ PERCEPTION OF CANCER PAIN: A QUALITATIVE EXPLORATORY STUDY Alicia Garcia, MN, RN, Clinical Teaching Associate, Massey University, School of Nursing, Palmerston North, NZ Dean Whitehead, PhD, MSc, BEd, RN, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia Helen S. Winter, MSc (oncology), BSc (hons), MBBS, Regional Cancer Treatment Service, MidCentral District Health Board, Palmerston North, NZ
Abstract: Cancer pain and its management are complex and may impact on many aspects of a cancer patient’s journey. Despite advances in understanding the aetiology of cancer pain and pharmacological developments, the limited effectiveness of pain treatment remains a challenge for health professionals. Many patients with cancer continue unnecessarily to experience severe unrelieved pain. The present research was conducted to explore how oncology nurses perceive cancer pain in patients for whom they provide care. Five Registered Nurses working in a New Zealand oncology ward were purposefully sampled. Semi-structured interviews were audio-recorded and transcribed verbatim. Subsequently transcripts were analysed using thematic/content analysis. The findings offer insight into how nurses themselves respond to under-treatment of cancer pain. Responses such as frustration, helplessness and emotional distress were reported. Findings of this study were consistent with existing literature, namely identification of shortfalls in training and education, lack of comprehensive assessment of pain, and deficits in pharmacological and non-pharmacological treatment of pain. The study highlights the need for improvement in these areas and identifies the need to further explore issues of cancer pain management with patients themselves.
Key words Cancer pain; oncology nurses; pain assessment; pain management; education
Introduction
for chemotherapy drugs (Chapman, 2011). Treatment
Pain is one of the most distressing symptoms
effects such as chemotherapy-induced neuropathy
experienced by patients with cancer undergoing active
may also contribute to reported pain (De Grandis,
treatment (Stark, Tofthagen, Visovsky, & McMillan,
2007; Lavoie Smith, Cohen, Pett, & Beck, 2010).
2012). Despite advances in understanding the aetiology of cancer pain, pharmacological developments, pain
Barriers to effective pain management are commonly
assessment tools and management guidelines, pain
reported throughout health care systems and may
often remains poorly managed. Many patients with
relate to the system, health professionals, and
cancer continue to experience severe and unrelieved
patients themselves (Bennett, Flemming, & Closs,
pain resulting in unnecessary suffering (Dulko, Hertz,
2011). With regard to nursing oncology practice, a
Julien, Beck, & Money, 2010; Fairchild, 2010; Huntoon, 2009). Acute pain can be triggered by surgery and diagnostic procedures such as bone marrow aspirations and repeated intravenous cannulations Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Garcia, A., Whitehead, D., & Winter, H. S. (2015). Oncology nurses’ perception of cancer pain: A qualitative exploratory study. Nursing Praxis in New Zealand, 31(1), 27-33. Page 27
Nursing Praxis in New Zealand lack of knowledge surrounding opioid delivery and its
feelings, and experiences (Garton & Copland, 2010).
effects contribute to pain prevalence (Voshall, Dunn,
Questions were open-ended to allow flexibility and
& Shelestak, 2013). Yildirim, Cicek, and Uyar (2008)
encourage a richer narrative. Examples of the included
found that oncology nurses possessed inaccurate
questions were: What does pain mean to you?, How
knowledge about commonly used analgesics and
do you perceive cancer pain?, Does the pain reported
consequently exaggerated anxiety about the potential
by your patients have any impact on your practice?,
for psychological dependence occurring. Furthermore,
How do you feel when your patient is in pain?, How
patients themselves are often reluctant to report pain
well prepared do you feel to effectively manage a
related to concerns about the impact of subsequent
patients pain?. Further prompts, where needed, were
treatment decisions, personal cost, and their own
used in order to clarify and to extend related concepts
fears of addiction and dependence (Simone, Vapiwala,
of cancer pain management.
Hampshire, & Metz, 2012). The interviews were audio-taped to ensure data Oncology nurses are noted as being at the frontline
accuracy. Once transcribed, inductive thematic analysis
of cancer pain management (Aycock & Boyle, 2009).
was conducted to identify codes, categories and
Nurses perform and evaluate many interventions for
themes relevant to the research question (Fereday &
pain management and have an essential role in deciding
Muir-Cochrane, 2006). A Framework Analysis approach
when changes in plans are required (Bernardi, Catania,
was applied (Richie & Spencer, 1994). Immersion in the
Lambert, Tridello, & Luzzani, 2007; Chapman, 2011).
raw data was achieved by listening to the interview
This study explored how oncology nurses perceive,
tapes and then repeated reading of the transcripts to
experience and assess cancer pain in their patients
ensure familiarity with the data. Index headings were
and, subsequently highlighted factors affecting the
developed by ordering the transcripts with numerical
delivery of effective pain management strategies.
codes around a number of different initial categories. Themes emerged from this process using a ‘mapping
Methods
and interpretation’ strategy (Ritchie & Spencer, 1994).
A qualitative descriptive exploratory study was conducted using semi-structured interviews in order
Study ‘trustworthiness’ was, in part, achieved through
to achieve a detailed exploration of oncology nurses’
bracketing previous theoretical preconceptions (Guba
perceptions of cancer pain in patients were receiving
& Lincoln, 1989). Furthermore, the participants
chemotherapy. A purposive sampling method was
were given access to their original transcripts for
used to include experienced participants who had
confirmation (only one declined). No participant
knowledge of the phenomenon in question (Berg,
presented any issue with their transcript. In addition,
2009; Sandelowski, 2010). The participants were five
member cross-checking of the transcripts was
second-level chemotherapy-certified oncology nurses.
carried out by the primary researcher and two senior
The age of participants ranged from 32 to 55 years, with
researchers; one whose field of medical research is
an average time of ten years working in the oncology
oncology.
field. All the available participants were female. Ethical approval for the research was obtained Data were collected using one-to-one semi-structured
through the Multi-regional Health and Disability
interviews. Interviews are commonly used to gather
Ethics Committee (reference: MEC11/EXP/039). The
in-depth exploration of nurse’s perceptions, views,
participants were informed of the objectives of the
Page 28
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand study and signed informed consent were obtained. Anonymity was maintained during the transcription
My aim is quite idealistic I suppose, but is to
process and pseudonyms were used to report findings.
have everybody’s pain under control so that they’re either pain free or it is so minimal, that
Results
they’re able to do what they want, ...their daily
Inductive analysis of data resulted in six themes:
living uninhibited by pain. (Mara)
Meaning of and interpretation of cancer pain
I mean, ideally you would like to have no pain
All participants were second level chemotherapy
at all, but ... I don’t know how realistic that is
certified nurses. They mainly cared for patients
in all cases, so I think you’ve got to bring their
undergoing
pain down to a level that they can deal with,
chemotherapy
or
having
adjuvant
treatment. Most participants described cancer pain as
they’re comfortable with. (Kelly)
being complex, difficult to treat, and its variability from patient to patient. Some participants viewed cancer as
Despite their desire to see their patients with no pain,
a terminal disease and identified the ‘futility’ of pain
nurses reported that their nursing reality was different;
treatment. In this case,
often expressing frustration and helplessness. One of the most common factors they reported was not
…if the person has a non-curative disease, that
having enough time in their busy schedule.
pain essentially is potentially not going to go away ever, they’re going to live with it… it will
I think it’s hard, ....sometimes when the ward
be there probably until they die because we
is so busy it’s really hard to try to get, ....you
are not going to cure the disease. (Sam)
know like these regular meds in, I guess there are no excuse for not giving things on time,
The participants made efforts to understand patients
but when the ward is really, really busy, is hard
self-reporting of their pain. They nursed patients with
to be exactly on time. (Kelly)
different types of cancer and reported that cancer pain was different among patients, often creating difficulties
It’s just....you know... you feel your pulse go
in managing cancer pain as they encountered different
up, you feel hot, it’s... I find that emotionally....
symptoms across a range of cancers.
emotionally draining because you know you can’t do anything and you could be doing
Not having had cancer... I listen carefully you
better. (Sam)
know, I try sort of ... yeah I try as best I can to understand it from what they tell me.... it
... you can’t get on top of someone’s pain, you
varies from one patient to another and ....
almost feel that you’ve failed them I guess,
different types of cancers. (Lara)
and these days, particularly, when you’ve got sophisticated technology, and we’ve got quite
Expectations, frustration and realities
improved procedures and methods, but we
Most participants expressed the desire to see
still can’t always get on top of someone’s pain,
their patients with little or no pain. They had high
I don’t think...and it doesn’t, as a nurse, at the
expectations of themselves and were committed to
end of an eight hour shift, I don’t think you
achieving the best possible outcomes.
go away, you don’t go home feeling fulfilled,
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand someone’s kind of in just as much pain, or
lot of pain.... they might not telling you, but
worse pain, when you leave, than when you
they may be very obvious to someone else, or
came. (Kate)
another patient says I’m ringing for (such and such), they appear in a lot of pain and you go
Place in managing patient’s pain
up and say: are you in pain and they say no.
Relationships between different health professionals
Because they don’t breathe well.... or they are
were considered important to clarify specific patient
not able to take a deep breath, you go: can you
cancer care issues. For instance, the participants in
take a deep breath for me, no I can’t. (Sam)
this study actively recognised the role of the palliative care team. They identified how the support team
Psychological interventions
influenced the way they managed patient’s pain within
There was an awareness of the role of psychological
the oncology unit.
interventions
on
impacting
pain
management.
However, it was reported that demanding work I mean you’re not doing it all on your own …
environments, usually outside their control, hindered
you’re bringing other members of the team as
this type of activity.
well…like if you’ve got somebody who is a very complex case you are not going to be dealing
Sometimes work does not facilitate....the
with that all on your own, you’re going to get
psychological
people like the palliative care team involved
don’t get enough time to sit down with the
or, the doctors, the physio. (Kelly)
patients.... they’re running....so that stuff is
aspect
patient....
nurses’
often overlooked. (Sam) Luckily we have the hospice team, pain management team that...ramp it up, if there’s
I think yea, I think sometimes nurses maybe,
a person that’s in a lot of pain. (Lara)
kind
of
forget
the
non-pharmaceutical
things that may be helpful even as simple as Unreported pain
changing someone’s position or, um, maybe
The patient’s fear of addiction and treatment side
changing something in their environment,
effects negatively impacted on the pain management
maybe something they can reach more easily,
process. The participants’ knowledge of interpreting
those kind of measures in terms of patients
their patients’ non-verbal communication was a
pain relief as well. (Kate)
reported advantage: Training and education I was asking about his pain.... it was like.... he
Participants openly reported the limitations of the
kept saying his pain was 7 out of 10.... which
education and training they received related to
is obviously very significant pain. If I was in 7
oncology-related pain assessment, pain pharmacology
out of 10 pain, I would be wanting some pain
and pain management. They expressed the desire for
relief.... every time I asked him he refused pain
ongoing study days in pain management as well as in
relief. (Kelly)
topics related to pharmacology.
When they do get out of bed, you know,
I don’t actually, consciously remember having
they’re wincing ... you know, they appear in a
a lot in my training around pain medication
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Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand and pain relief ... I guess, rightly or wrongly, I
is the single most reliable indicator of pain intensity
guess we learned a lot of it through experience.
(Caraceni et al., 2012). Accordingly, participants in this
(Kate)
study clearly acknowledged the importance of selfreporting of pain. Reassuringly, this is in contrast with
In my training we actually did very little ...
previously reported findings that oncology nurses both
study about pain at all.... In actual nursing
underestimated and did not believe the level of pain
training, the course didn’t actually cover in
reported by patients (Bernardi et al., 2007).
great deal pain or pain management. (Kelly) Rushton, Eggett, and Sutherland (2003) reported that It’s actually a very good idea to have more
oncology nurses have difficulty in understanding the
educational on board, sort of in-services about
pharmacology of analgesics. For example, almost 40%
pain management. I would appreciate that, I
of them did not know that 30 mg of oral morphine
would probably get a lot of out of that. (Lara)
would be equivalent to morphine 10mg intravenous. Participants in this study were not able to clearly
I think it’s good to have regular study days
articulate knowledge of mechanisms of action or
on pain, just because new drugs are coming
dosages of pain management drugs. However, they
out and the combinations that you can use
openly admitted to a deficit of knowledge in relation
with steroids, with anti-inflammatory, and like
to cancer pain and its management, and expressed
Gabapentin and how they work. (Sam)
the desire for further knowledge. Added to the educational limitations, work conditions adversely
Discussion
affected the physical and emotional health of the
These study findings provide a New Zealand perspective
nurses. They viewed oncology nursing as a difficult
on previous studies (Portenoy, 2011; Yildirim et al.,
occupation. High rates of stress in oncology nurses
2008; Xue, Schulman-Green, Czaplinski, Harris, &
are related to suffering, grief, and death exposure on
McCorkle, 2007). Comprehensive pain assessment is
a regular basis (Dougherty et al., 2009). Furthermore,
considered as the cornerstone of pain management
Saltmarsh and De Vries (2008) found that nurses
and, consequently, assessment guidelines have
experienced high levels of emotional distress during
been developed by different organisations. The
cytotoxic administration due to fears relating to
Joint Commission on Accreditation of Health-care
chemotherapy side-effects and cytotoxic spillage.
Organisations (JCAHO) advocates assessment of pain
Although this study did not examine such issues, it
as the ‘fifth vital sign’ - including pain characteristics
highlights further competing demands on nurses to
such as onset, intensity, location, duration, aggravating
adequately monitor and manage cancer pain. Accounts
and relieving factors (Virizuela, Escobar, Cassinello, &
of participants’ work in the oncology unit illustrated
Berrega, 2012; Zhu & Weingart, 2012). In this study, the
the highly technical and skilled nature of cancer care.
participants reported assessing patients’ pain based
Other factors such as rotating shifts added to their
on their pain intensity only. These guidelines were not
stress levels. Organisational factors such as shortages
mentioned by the nurses interviewed in this study;
of staff and lack of resources also hindered nurses’
a finding similar to that reported elsewhere (Cohen
use of non-pharmacological pain alleviation methods
et al., 2003; Mitra & Jones, 2012). Pain experience is
in the management of cancer pain. This fact is well
subjective and personal; hence self-reporting of pain
documented outside New Zealand (Fleming, 2010; Mcilfatrick et al., 2006; Saltmarsh & De Vries, 2008).
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Page 31
Nursing Praxis in New Zealand the pathophysiology of cancer pain management and
Limitations
pharmacological interventions. The study findings
This was a single site study with a small sample size.
highlighted the on-going effects of organisational
Therefore, the ability to make any generalisation from
barriers, such as the business of the ward, heavy
these findings is limited. The sample consisted of five
workload, and the lack of staff and resources – on
oncology nurses working in one oncology centre and
both
these may not be representative of all oncology nurses
pain alleviation methods. Personal barriers such as
in New Zealand. Factors such as where nurses received
emotional distress, frustration and helplessness,
their first or second level chemotherapy certification
especially related to the under-treatment of pain,
were not recorded.
emerged as a further barrier.
In order to extend the findings of this study, further
It is evident that current methods of training and
research into the oncology nurses’ experiences and
education do not always prepare nurses with the
practices related to cancer pain in other oncology units
appropriate knowledge and skills needed for providing
in New Zealand is recommended. The present findings
effective
could be compared and contrasted with patients’
Therefore, on-going informal and formal educational
experiences through undertaking similar studies
programs should be in place to improve nurses’
investigating patients themselves.
knowledge and practices in cancer-related pain.
Conclusion
Concluding statement
The findings of this study are consistent with
The competing demands on nurses in a busy
studies from the wider international literature. This
oncology unit along with knowledge deficits in pain
study highlights issues concerning oncology nurses
management issues may lead to the under-treatment
experiences of cancer pain and the various factors that
or mismanagement of cancer pain. More concerted
facilitate or hinder effective pain management in an
and effective training and education is seen as the most
oncology unit in New Zealand. While nurses’ attitudes
appropriate strategy to overcome this dilemma - as
to managing cancer pain were generally positive, there
well as appropriate resources put in place to facilitate
was a need for further education concerning both
putting extended training into effective practice.
pharmacological
cancer
and
pain
non-pharmacological
management
strategies.
References Aycock, N., & Boyle, D. (2009). Interventions to manage compassion fatigue in oncology nursing. Clinical Journal of Oncology Nursing, 13(2), 183-190. doi:10.1188/09.CJON.183-191. Bennett, M., Flemming, K., & Closs, S. J. (2011). Education in cancer pain management. Supportive and Palliative Care, 5(1), 20-24. doi:10.1097/SPC.0b013e328342c607 Bernardi, M., Catania, G., Lambert, A., Tridello, G., & Luzzani, M. (2007). Knowledge and attitudes about cancer pain management: A national survey of Italian oncology nurses. European Journal of Oncology Nursing, 11(3), 272-279. doi:10.1016/j. ejon.2006.09.003 Berg, B. L. (2009). Qualitative research methods for the social sciences (7th ed.). NY: Pearson. Caraceni, A., Hanks, G., Kaasa, S., Bennett, M. I., Brunelli, C., Cherny, N.,...Zeppetella, G. (2012). Use of opioid analgesics in the treatment of cancer pain: Evidence-based recommendations from the European Association for Palliative Care. The Lancet, 13(2), e58-e68. doi:10.1016/S1470-2045(12)70040-2.
Page 32
Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Chapman, S. (2011). Chronic pain syndromes in cancer survivors. Nursing Standard, 25(21), 35-41. Cohen, M. Z., Easley, M. K., Ellis, C., Hughes, B., Ownby, K., Green Rashad, B.,... Bailey, J. (2003). Cancer pain management and the JCAHO’s pain standards: An institutional challenge. Journal of Pain and Symptom Management, 25(6), 519-527. De Grandis, D. (2007). Acetyl-L-Carnitine for the treatment of chemotherapy-induced peripheral neuropathy. CNS Drugs, 21(1), 39-43. Dougherty, E., Pierce, B., Ma, C., Panzarella, T., Rodin, G., & Zimmermann, C. (2009). Factors associated with work stress and professional satisfaction in oncology staff. American Journal of Hospice & Palliative Medicine, 22(2), 105-111. doi:10.1177/1049909108330027 Dulko, D., Hertz, E., Julien, J., Beck, S., & Mooney, K. (2010). Implementation of cancer pain guidelines by acute care nurse practitioners using an audit and feedback strategy. Journal of the American Academy of Nurse Practitioners, 22(1), 45-55. doi:10.1111/ j.1745-7599.2009.00469.x. Fairchild, A. (2010). Under-treatment of cancer pain. Supportive and Palliative Care, 4(1), 11-15. doi:10.1097/SPC.0b013e328336289c Fereday, J., & Muir-Cochrane. (2006). Demonstrating rigour using thematic analysis: A hybrid approach of inductive coding and theme development. International Journal of Qualitative Methods, 5(1), 1-11. Flemming, K. (2010). The use of morphine to treat cancer-related pain: A synthesis of quantitative and qualitative research. Journal of Pain and Symptom Management, 39(1), 139-154. doi:10.1016/j.jpainsymman.2009.05.014. Garton, S., & Copland, F. (2010). ‘I like this interview; I get cakes and cats’: the effect of prior relationships on interview talk. Qualitative Research, 10(5), 533-551. doi:10.1177/1468794110375231 Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, CA: Sage. Huntoon, M. A. (2009). Intrathecal drug therapy for cancer pain: Time for a boost. Pain Practice, 9(5), 325-326. Lavoie Smith, E. M., Cohen, J. A., Pett, M. A., & Beck, S. L. (2010). The reliability and validity of a modified total neuropathy scorereduced and neuropathic pain severity items when used to measure chemotherapy-induced peripheral neuropathy in patients receiving texanes and platinums. Cancer Nursing, 33(3), 173-183. Mcilfatric, S., Sullivan, K., & McKenna, H. (2006). Nursing the clinic vs. nursing the patient: Nurses’ experience of a day hospital chemotherapy service. Journal of Clinical Nursing, 15(9), 1170-1178. Mitra, R., & Jones, S. (2012). Adjuvant analgesics in cancer pain: A review. American Journal of Hospice & Palliative Medicine, 29(1), 70-79. doi:10.1177/1049909111413256 Portenoy, R. K. (2011). Treatment of cancer pain. The Lancet, 377(9784), 2236-2247. doi.10.1111/j.1533-2500.2009.00306.x Ritchie, J., & Spencer, E. (1994). Qualitative data analysis for applied policy research. In A. Bryman, & R. G. Burgess (Eds.), Analysing qualitative data (pp. 172-194). London: Routledge. Rushton, P., Eggett, D., & Sutherland, C. W. (2003). Knowledge and attitudes about cancer pain management: A comparison of oncology and non-oncology nurses. Oncology Nursing Forum, 30(5), 849-855. Saltmarsh, K., & De Vries, K. (2008). The paradoxical image of chemotherapy: A phenomenological description of nurses’ experiences of administering chemotherapy. European Journal of Cancer Care, 17(5), 500-508. doi:10.1111/j.1365-2354.2007.00909.x. Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing & Health, 33(1), 77-84. doi:10.1002/ nur.20362. Simone, C. B., Vapiwala, N., Hampshire, M. K., & Metz, J. M. (2012). Cancer patient attitudes towards analgesic utilisation and pain intervention. Clinical Journal of Pain, 28(2), 157-162. doi:10.1097/AJP.06013e318223be30. Stark, L., Tofhagen, C., Visovsky, C., & McMillan, S. (2012). The symptom experience of patients with cancer. Journal Hospice Palliative Nursing, 14(1), 61-70. doi:10.1097/NJH.obo13e318236de5c. Virizuela, J. A., Escobar, Y., Cassinello, J., & Borrega, P. (2012). Treatment of cancer pain: Spanish Society of Medical Oncology recommendations for clinical practice. Clinical & Translational Oncology, 14(7), 499-504. doi:10.10007/s12094.012.0831.1 Voshall, B., Dunn, K. S., & Shelestak, D. (2013). Knowledge and attitudes of pain management among nursing faculty. Pain Management Nursing, 14(4), e226-e235. doi:10.1016/j.pmn.2012.02.001 Xue, Y., Schulman-Green, D., Czaplinski, C., Harris, D., & McCorkle, R. (2007). Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service. Clinical Journal of Oncology Nursing, 11(5), 687-695. Yildirim, Y. K., Cicek, F., & Uyar, M. (2008). Knowledge and attitudes of Turkish oncology nurses about cancer pain management. Pain Management Nursing, 9(1), 17-25. doi:10.1016/j.pmn.2007.09.002. Zhu, J., & Weingart, S. N. (2012). Pain intensity in cancer. Annals of Palliative Medicine, 1(2), 177-178. doi:10.3978/j.issn.22245820.2012.07.02 Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand
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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: â&#x20AC;˘ Inform and stimulate New Zealand nurses. â&#x20AC;˘ 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. Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org
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Nursing Praxis in New Zealand
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