Praxis March 2015

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

Page 1

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

to publish research findings, literature reviews and

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.

of scholarship to the bedside” (p. 9). These words have resonance today and perhaps encapsulate why

In this edition of Nursing Praxis in New Zealand we have

our reviewers give of their time and expertise freely,

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

The Editorial Board is extremely grateful for the work

a desire to see this contribute to improved patient

undertaken by all reviewers on our database. They

outcomes, and ultimately nursing’s advancement.

have been vital to ensuring Praxis continues to publish high quality manuscripts. Many of the manuscripts we

Once a manuscript is submitted to Nursing Praxis in

have published have been cited by other researchers

New Zealand it is assigned to a reviewer whose details

both within New Zealand and internationally, as well

are logged in our database. Here are some tips that

as utilised by clinicians to change practice and improve

the Editorial Board think are important for reviewers

health outcomes for individuals and communities.

to be aware of and consider when undertaking this important role.

In recent times there has been an exponential increase in the number of journals available for authors to

•

If you are contacted to review for us and are

choose from when publishing, particularly in the online

unable to, let the Editorial Office know as soon

open access market. Consequently, the demand for

as possible.

and demands placed on reviewers is also increasing.

For example, in order for a journal to be attractive to

•

design is outside your area of expertise then

readers it needs to publish top quality manuscripts and

also let the Editorial Office know. You are quite

be highly respected. Consequently, the quality of the

within your rights to decline an invitation to

review process is integral to positively influencing a

review.

journal’s reputation. Reviewers are a vitally important part of the quality assurance and publication processes,

If you think that the topic area or research

•

If you are able then complete the review and submit your feedback to Nursing Praxis in New

a role that often goes unrecognised.

Zealand within four weeks. Remember the The ‘art’ of peer review requires the reviewers to not

timely publication of manuscripts is a quality

only have wide-ranging knowledge of the subject area

indicator of a journal.

and the chosen research method but to also be familiar Page 2

•

Ensure your feedback is presented in a clear,

Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

•

concise and constructive way. Consequently,

For those of us working in research-led academic

if the manuscript is sent back to the author/s

institutions supporting and contributing to the

for further work before publication then they

development of nursing knowledge is expected by our

clearly know the changes they need to make.

employers. Equally, the contribution nurses working in

Nursing Praxis in New Zealand de-identify all manuscripts before sending them out for review.

It is important to maintain confidentiality in relation to the manuscript being reviewed at all times. Authors expect that when they submit their work for review it will not be discussed outside of the review and editorial team.

•

We ask reviewers to make one of the following recommendations; accept and publish in its current form, publish with minor changes, extensive revision and resubmission, and reject.

•

Reviewers’ recommendations should be based

clinical practice make as members of Editorial Boards and reviewers, while not expected by employers, is highly valued by the wider nursing community. Being on Editorial Boards and undertaking roles such as reviewing supports the development of nursing, as well as positively impacting on the health and wellbeing of New Zealanders. If on reading this editorial you think you would like to be a reviewer, then please do contact us. Finally, once again on behalf of the Editorial Board of Nursing Praxis in New Zealand we thank all reviewers both past and present for the work undertaken and the contribution to the wider profession.

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

Page 3

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

Page 4

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

Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand

Page 17

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,

Page 20

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

Page 26

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

Page 29

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

Page 30

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

Page 33

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

Page 34

Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

Thank you to our volunteer reviewers for 2013-2014 Tēnā koutou, tēnā koutou, tēnā koutou katoa.

Ngā mihinui mahana tēnā koutou.

On behalf of the Nursing Praxis in New Zealand Editorial Board and the administration staff I would like to thank the authors of the manuscripts submitted for publication, the reviewers for the reviews and important feedback they provide that improves the quality and standard of published articles, and the readers.

We value and appreciate the roles you all play in keeping Nursing Praxis alive and well.

Me te mihi nui mō ā koutou manaakitanga.

Dr Denise Wilson Editor-in-Chief

Michelle Adams

Peter Donohue

Stephen Neville

Sue Adams

Willem Fourie

Nick Nicole

Margaret Adamson-Lobb

Jean Gilmour

Anthony O’Brien

Kerri Arcus

Rachel Hale

Elaine Papps

Julie Betts

Thomas Harding

Rachel Parmee

Colette Blockley

Julia Hennessey

Trish Rasmussen

Julie Boddy

Kathryn Holloway

Sandra Richardson

Judy Brown

Michelle Honey

Wendy Scott

Liz Buckley

Judith Honeyfield

Lisa Stewart

Karyn Bycroft

Isabel Jamieson

Carmen Timu-Parata

Norma Chick

Jackie Kidd

Dean Whitehead

Helen Childs

Anecita Gigi Lim

Jill Wilkinson

Jill Clendon

Michelle Lorimer

Denise Wilson

Catherine Cook

Marianne Mackenzie

Stacey Wilson

Anna Dawson

Sylvia Meijer

Pamela Wood

Annette Dickenson

Annette Milligan

Judy Yarwood

Liz Ditzel

Please visit our website www.nursingpraxis.org if you would like to become a reviewer or update your details.

Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand

Page 35

Nursing Praxis in New Zealand NOTES

Page 36

Vol. 31 No. 1 2015 - Nursing Praxis in New Zealand

O UR WE BSITE OFFERS • Easy search of our database for past abstracts and articles online • Subscribers may view complete articles and read full issues online • Sign up for email or RSS updates from Nursing Praxis • Subscribe to print copies and/or online • View all information for contributors and reviewers • Purchase back copies of issues online • View advertising rates

w w w.nursingpraxis.org

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org