2014 Nursing Praxis 30.1 March

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE...

Social marketing campaigns that promote condom use among MSM: A literature review

The informed consent process in randomised controlled trial: A nurse-led process

History of the Plunket book: Part 1 1920-1945

RESEARCH BRIEF: Using a Wiki to support student nurses learning discipline specific health terminology

Volume 30. No. 1

MARCH 2014

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

(FREIRE, 1972)

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

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

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

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

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

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

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

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

CO NTE NTS EDITORIAL .......................................................................................................................................... 2

ARTICLES: Social marketing campaigns that promote condom use among MSM: A literature review Stephen Neville, Jeffery Adams, Judith Holdershaw ...................................................................... 5 The informed consent process in randomised controlled trial: A nurse-led process Pip Cresswell, Jean Gilmour ...................................................................................................... 17 History of the Plunket book: Part 1 1920-1945 Jill Clendon, Karen McBride Henry .............................................................................................. 29 RESEARCH BRIEF: Using a Wiki to support student nurses learning discipline specific health terminology Michelle Honey, Iain Doherty, Lisa Stewart, Danting Wei ........................................................... 42

NOTES FOR CONTRIBUTORS............................................................................................................. 45

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Page 1

Nursing Praxis in New Zealand EDITORIAL Indigenous and minority peoples and cultural safety: The role of Nursing Praxis

in Cork, Ireland, about our journal and what we were doing. With the update of our website, we have been able to take advantage of the analytic tools to see that

Undeniably, Nursing Praxis has played an important role

approximately half of those visiting the Nursing Praxis

in promoting nursing research addressing the nexus

website are international visitors, predominately from

between nurses’ practice and the people with whom

North America.

they work. The journal began as a place for nurses to exchange ideas, and to contemplate what nursing

The nexus between people’s culture and health is

is about, and envision its future directions (Perry,

complex, yet its importance for nurses and health

1985). The current strategic focus for Nursing Praxis

providers will undeniably grow with the increasing

is cultural safety, indigenous health, and vulnerable

multiplicity, diversity, and complexity of ethnic and

populations. Since the first publication of Nursing Praxis

cultural groups within many communities. In addition

in November 1985, 31% of all the articles pertain to

to Indigenous peoples and those with settler ancestry,

cultural safety (25%), indigenous (15%), and vulnerable

increasing and diverse migratory patterns, particularly

(60%) populations. Dissemination and translation of

the mix of new migrants, those who have lived in a

research is essential to assist practitioners, funders,

country for two or more generations, intermarriage,

planners, and policy makers in their roles. It is the “so

and the recognition of the cultural needs of non-

what?” question that we should ask when reviewing

ethnic groups such as those with disabilities makes this

research outcomes. Moreover, this crystallises the

an important area in which to share ideas, research

need for interpretations of research findings with

findings, and to debate their various aspects in relation

Indigenous, minority and vulnerable groups to also be

to health and wellbeing. The tenet that culture is an

critically informed by concepts such as social justice,

important factor in the health and wellbeing of people,

human rights, equity, and intersectionality.

their whānau/families, and communities has been long established within health and nursing (Leininger, 1970). and

Nonetheless, people belonging to Indigenous, minority,

internationally as a place where authors can pubish

and vulnerable groups encounter cultural dissonance

research or discursive papers related to cultural

on a daily basis. This is so even with a backdrop where

safety, indigenous health, and vulnerable populations.

cultural safety and cultural competence feature as

For me, the need and importance for nurses and

part of the New Zealand regulated health workforce

other health professionals to disseminate research

practice requirements, and there are ongoing global

and ignite debate was highlighted at conferences I

and societal calls to address existing inequalities and

attended last year (that is, the International Academy

inequities. Cultural responsiveness is an area that we

of Nurse Editors Conference (held in Cork, Ireland)

constantly grapple with as a profession, generally with

and the Critical Perspectives in Nursing and Health

universal approaches to nursing and health service

Care Conference (held in Vancouver, Canada)). That

delivery being the default position.

Nursing

Praxis

is

recognised

nationally

Nursing Praxis has a place in the world was confirmed by the responses to a presentation at last year’s

Culture does count, and its inclusion in health service

International Academy of Nurse Editors conference

delivery and nursing practice makes a difference in the

Page 2

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

lives of indigenous, minority, and vulnerable peoples

health professionals report research findings and

with whom providers connect. It is through the sharing

outcomes, and critically reflect upon topical issues.

of ideas, both nationally and internationally, that we

A recent contributor to Nursing Praxis noted that it

become aware of innovative and different possibilities.

was a leading source for cultural safety publications.

This awareness can provide the impetus to reflect on

Not only do we strategically publish articles that

how to weave the cultural needs of those we ‘care’

focus on broader population groups, we also see the

about with our knowledge of health and wellbeing.

importance of including research that considers the

Only when we are culturally responsive to our

needs of people who intersect with the health system,

Indigenous, minority and vulnerable populations can

but are continually marginalised and their needs

we begin to deliver health services that the recipients

not met. While many of the studies that the journal

will judge to be culturally safe.

publishes are small, they offer valuable insights into people’s health experiences, contexts, and lives that

In the meantime we need to progress the works of

are vital for improving health outcomes. Nursing Praxis

Irihapeti Ramsden and others on cultural safety within

is a forum where nurses can offer solutions, based

contemporary contexts and the challenges that face

on evidence, to the many challenges they face. We

society. It is useful to note, or for some remember, that

welcome international and local perspectives, and

the concept of cultural safety emerged in 1989 out of

promote evidence, insights, and ideas about how to

the concerns of Māori, our Indigenous people in New

better translate cultural safety knowledge into practice

Zealand, about the retention and recruitment of Māori

– something that must benefit indigenous, minority

into nursing – a problem that still persists today. An

and vulnerable peoples.

additional concern expressed was the discourse within nursing practice that focused narrowly on physical,

Associate Professor Denise Wilson

legal and ethical safety. Excluded was the notion

Editor-in-Chief

that Māori often felt culturally unsafe – that is, the experiences left them feeling diminished, demeaned, and disempowered (again a situation that continues to exist today). Cultural safety began its journey as kawa whakaruruhau, a Māori concept for cloak of protection – and became a standard for nursing practice in 1990, although kawa whakaruruhau has morphed into the broader concept it is today and for some vanished

References Freire, P. (1972). Cultural action for freedom. Harmondsworth, UK: Penguin.

Leininger, M. M. (1970). Nursing and anthropology; two worlds to blend. New York: Wiley.

(Ramsden, 2002).

Perry, J. (1985). Editorial. Nursing Praxis in New Zealand, 1(1), 2.

Nursing Praxis utilises Friere’s (1972) definition of

Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu. Victoria University of Wellington, Wellington, New Zealand.

praxis, stating that it is, “The action and reflection of people upon their world in order to transform it.” It provides a legitimate and internationally recognised forum for publications whereby nurses and other Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 3

Nursing Praxis in New Zealand

Reviewers - We need you!

Nursing Praxis is calling for new reviewers in 2014 to join our existing panel. If you have experience reviewing manuscripts or expertise in any areas of nursing and research, please apply now.

Nursing Praxis needs an extensive database of reviewers from many different expertise areas for manuscripts that are submitted across a wide range of subjects related to nursing.

Nursing Praxis manuscripts all go through a blind peer review process before the reviews are considered by the Editorial Board for final recommendations, the authors and Editorial Board do not know who is reviewing the manuscripts.

As a reviewer you may be sent a few requests each year to review papers. You have aprox 3 weeks to complete the review questionaire. If you are requested to complete a review and you are not able to complete the review in the time frame available, just let us know and we will send it to another reviewer.

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

We have an online link for Reviewers to register for our reviewers database go to the Reviewers page under ‘About us’ on our website -

www.nursingpraxis.org

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand SOCIAL MARKETING CAMPAIGNS THAT PROMOTE CONDOM USE AMONG MSM: A LITERATURE REVIEW. Dr Stephen Neville, RN, PhD, FCNA (NZ), Senior Lecturer, Director Postgraduate Programmes, School of Nursing, Massey University, Auckland, NZ Jeffery Adams, PhD, Researcher, Massey University, Auckland, NZ Judith Holdershaw, PhD, Senior Lecturer, Massey University, Palmerston North, NZ

Abstract The turn of the century has seen an increase in reported cases of sexually transmitted infections including the human immunodeficiency virus, particularly in groups of men who have sex with men. Both internationally and in New Zealand the implementation of social marketing human immunodeficiency virus prevention programmes are identified as appropriate mechanisms to promote condom use in men who have sex with men. This paper presents a review of the literature on research-based social marketing initiatives designed to decrease sexually transmitted infections, including the human immunodeficiency virus, through an increase in condom use by men who have sex with men. Eleven quality assured articles met the inclusion criteria and were consequently included in the review. The review presented here strongly supports the utilisation of behaviourally based social marketing campaigns to increase condom use in men who have sex with men. Nurses are frequently first point of contact for consumers of health services. As such they need to have a sound understanding of not only Get it On!, a New Zealand social marketing campaign designed to promote condom use, but also about existing international campaigns. Nurses should also know about social marketing principles if they are to effect positive changes in condom use and address the complex challenges inherent in tackling increased rates of sexually transmitted infections, including the human immunodeficiency virus.

Key words Gay men’s health, men who have sex with men, condom use, sexual risk behaviour, health promotion, social marketing

Introduction Sexually transmitted infections (STI) and human

condoms for anal sex (McCann et al.).

immunodeficiency virus (HIV) are important public health issues. Following several years of decreasing

The term men who have sex with men (MSM) is

reported cases of both STI and HIV in New Zealand,

now widely accepted and used in the literature to

evidence now suggests increased cases of both being

describe men identifying as gay or bisexual, as well

reported (Saxton, Dickson & Hughes, 2010). This

as heterosexual men who engage in sexual activities

phenomenon is consistent with international literature

with other men (Neville & Adams, 2009). MSM are

identifying increases in STI, particularly syphilis

a heterogeneous group, and as such, a variety and

(McCann et al., 2011) and HIV (Saxton, Dickson,

number of sexual and partnering combinations exist.

Griffiths, Hughes & Rowden, 2012). Most significant increases for both STI and HIV have been reported in westernised countries in men who have sex with men (MSM) groups, largely due to a decrease in the use of Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Neville, S., Adams, J & Holdershaw, J. (2014). Social marketing campaigns that promote condom use among MSM: A literature review. Nursing Praxis in New Zealand, 30(1), 5-16.

Page 5

Nursing Praxis in New Zealand For example, MSM may be in an exclusive sexual

movement in the 19th century to improve people’s

relationship with another man, a relationship with

living conditions as a way of reducing the spread of

another man that is not exclusive, in no relationship

infectious diseases such as cholera (Kirsch, 2010).

at all, have no sexual relationships, have sexual

The concept of health promotion has evolved and

relationships with both men and women, or be

gathered momentum from the latter half of the 20th

married to a woman but have sexual relationships with

century and is embodied in the Ottawa Charter for

other men.

Health Promotion (WHO, 1986). The Ottawa Charter identifies three fundamental strategies for health

The literature reviewed in this article provided the

promotion: advocacy for health to create the essential

background to a process and outcome evaluation of

conditions for health, enabling people to achieve

the New Zealand AIDS Foundation’s (NZAF) Get it On!

their full health potential, and mediating between the

social marketing HIV prevention programme (Adams

different interests in society in the pursuit of health.

& Neville, 2013). Get it On! uses social marketing concepts and health promotion activities to influence

The terms health promotion and health education have

the behaviour of MSM through encouraging the uptake

often been used interchangeably leading to confusion

or maintenance of condom use for anal sex, with the

in relation to what the terms mean. Laverack (2007)

aim of reducing HIV transmission. An additional public

asserts that the concepts have a symbiotic relationship

health benefit of increased condom use is also a

with health promotion focussing on influencing

decrease in STIs.

political agendas that will positively influence health, while health education uses education strategies to

A comprehensive overview of current findings in the

facilitate changes to health behaviours. Consequently,

area under investigation is integral to the success of

health education is integral to many health promoting

any project as it determines future research directions

activities. Social marketing, on the other hand, is not

(Schneider, Whitehead, & Elliot, 2007). It influences

intrinsically linked to health promotion and health

the research process by illuminating any gaps in the

education, although it is used by health promoters

literature and guides the development of the research

as a means to delivering health focussed messages to

question/s. Before the overview of the literature is

individuals and communities (Eagle et al., 2013).

presented, this article contextualises social marketing in relation to condom use campaigns by discussing

Kotler was among the first to define ‘social marketing’

the concepts of public health, health promotion and

as a distinct field of marketing, and to include the

health education, as well as presenting the search

traditional ‘4Ps link’; having a Product strategy,

strategy utilised to access the literature for this review.

Price

This literature review focuses on research, including

strategy (Cheng, Kotler & Lee, 2011). However, most

evaluations, of social marketing initiatives designed to

contemporary definitions do not always insist on

increase the use of condoms for anal sex in MSM as a

including all of the 4Ps, especially in health related

way to decrease the incidence of STI and HIV.

social marketing programmes, but tend to utilise

strategy,

Place

strategy

and

Promotion

the principles of commercial marketing, for example

Background

identifying, knowing about and engaging with the target market (Lee & Kotler, 2011). Social marketing

Health promotion has its origins in the public health

involves the design, implementation and control of

movement. Public health began as a social reform

marketing programmes with the aim to increase the

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand acceptability of a social idea or successfully influence

include knowing the target audience (in this case

the behaviour of one or more target groups (Cheng

MSM), identifying subgroups (for example those

et al.; Lee & Kotler). Thus, health related social

identifying as gay versus bisexual), using messages

marketing campaigns are based on techniques utilised

that are appropriate to the target audience, employing

in commercial marketing, with the aim to influence

effective channels to deliver the message (for example

people’s behaviour to achieve a social goal.

online platforms, physical presence at key MSM events or marketing merchandise) and having a clear process

Most social marketing health related campaigns,

and outcome evaluation plan (Noar et al.).

therefore, are underpinned by and use one of the many theories of behaviour change. It is beyond the scope

In relation to reducing the spread of HIV and STIs in

of this article to provide an overview of all of these

MSM, social marketing is predominantly focused on

but the key theories used in social marketing are the

promoting the utilisation of condoms for anal sex.

‘Health Belief Model’ (Janz & Becker, 1984), ‘Diffusion

Condom social marketing campaigns were one of the

Theory’ (Green, Ottoson, Garcia, & Hiatt, 2009), ‘The

first mass marketing programmes to be successfully

Theory of Reasoned Action’ (Ajzen & Fishbein, 1980),

used internationally to prevent the spread of HIV

‘The Theory of Planned Behaviour’ (Ajzen, 1991);

in all population groups (Lombardo & Leger, 2007).

‘Protection Motivation Theory’ (Rogers, 1975), ‘Social

Social marketing campaigns promoting condom use

Cognitive Theory’ (Bandura, 2004), ‘The Integrative

have increased the accessibility, affordability and

Model of Behaviour Change’ (Fishbein & Capella,

acceptability of using condoms to prevent the spread

2006), ‘The Stages of Change Model’ (also known as

of HIV and STIs (UNAIDS, 2006).

‘The Transtheoretical Model of Change’) (Bunton, Baldwin, Flynn & Whitelaw, 2000), ‘The Extended

Search strategy

Parallel Process Model’ (Gore & Bracken, 2005). While the use of individual-focused behavioural theories to

The search strategy utilised to access literature for

guide social marketing initiatives has been common

this review was based on processes successfully

in social marketing (Hastings, 2007; Lee & Kotler,

employed by the authors in previous research and

2011), increasing account is given to the importance

occurred in two parts (Neville & Adams, 2009). Firstly,

of deploying the concepts of social influences within

electronic databases were broadly scanned. These

social marketing (Lefebvre, 2011). Including social

included CINAHL, Medline, PubMed, Scopus and Web

approaches to social marketing is particularly relevant

of Science. The following search terms and key words

in HIV prevention where the role of social networks

were used alone or in combination: social marketing,

in disease transmission is increasingly recognised as

evaluation,

important (Keogh, Henderson, Dodds, & Hammond,

prevention, behavioural interventions, men who

2006).

have sex with men, gay, bisexual. We included peer

mass

communication,

HIV/AIDS/STI

reviewed research, systematic reviews, best practice The use of a theoretical framework to assist with the

guidelines, government and non-government reports

conceptualisation of a social marketing campaign

as well as grey literature. This was supplemented with

is identified as a central component to the success

further literature identified and recommended during

of MSM related HIV prevention campaigns (Noar,

the stakeholder consultation process. Inclusion criteria

Palmgreen, Chabot, Dobransky & Zimmerman, 2009).

encompassed studies published in English, those

Other components integral to successful campaigns

related to programmes targeting the incidence of HIV

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand and STI and involving MSM. Studies published from

has historically been, and remains, the modis operandi

2006 onwards were included due to the significant

for sexual health campaigns aimed at reducing HIV

advances in prevention, diagnosis and treatment

and STIs in MSM. However, many of these campaigns

strategies for HIV and STIs. This is supported by

have utilised single intervention strategies, which

Lorimer et al. (2013) who identify that the intervention

in many instances have not resulted in a decrease in

landscape has radically changed in recent times,

infection rates (Higa et al., 2013). In their systematic

for example the utilisation of social media as an

review, Lorimer et al. (2012) advocate for multiple

intervention platform. A comprehensive manual search

theory-driven group and community-level behavioural

was also undertaken which included the scanning of

interventions as a means to increase condom use for

reference lists for additional publications. A decision

anal intercourse in MSM.

was made to exclude conference abstracts as they provided insufficient information to be useful. Phase

Three of the four systematic review articles focussed

two involved the research team critically appraising

specifically on HIV campaigns, while Wei et al. (2011)

all of the literature for suitability and inclusion. Eleven

took a broader approach to look at social marketing

quality-assured published articles were identified for

interventions that increased both HIV and STI testing.

inclusion in the review.

Understandably, each of these systematic reviews urged future researchers to employ more rigorous

Literature review

study designs when developing and evaluating the success of social marketing campaigns. Higa

This section provides a synopsis of the content of the

et al.’s (2013) systematic review found there was

11 articles selected to be included in this literature

little evidence based social marketing behavioural

review. Table 1 provides a summary of these articles,

intervention campaigns specifically designed to

each of which has focussed on the utilisation of

influence sexual behaviour in MSM. This systematic

social marketing concepts to develop and deliver

review sought to identify the reasons for the small

behaviourally based programmes designed to underpin

number of evidence based interventions aimed at MSM

HIV and/or STI prevention initiatives targeting MSM.

and found that those developing, operationalising and evaluating HIV prevention campaigns viewed those

Of the 11 articles, four were systematic reviews, one

at risk of contracting HIV as a homogenous group.

was a pilot intervention study, five were evaluations of

Consequently, recommendations included targeting

existing programmes and one was a social marketing

specific MSM groups, particularly those at the greatest

case study based on the findings of a formal evaluation.

risk of contracting HIV, focus interventions that will

Five articles focussed solely on HIV, two specifically on

influence sexual behaviour that are relevant to MSM,

syphilis as a STI, and four on sexual health messages

and include MSM when designing, implementing and

that incorporated both HIV and STI prevention. All

evaluating social marketing prevention campaigns

of the articles appropriately begin by outlining the

(Higa et al.).

central issues associated with the spread of HIV and/ or STIs. Through the presentation of epidemiological

Seventy per cent of studies included in Noar et al.’s

data, all studies highlighted the increase in rates of

(2009) review utilised research designs that were not

new infections regardless of geographical location.

capable of producing strong causal claims related to the effects of the campaign, even though these studies

The utilisation of behaviourally focussed interventions Page 8

continued to make assertions about the effectiveness Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand of these social marketing campaigns. These authors

A pilot intervention study using a pre- and post-test

identify cost, having to operationalise campaigns

design was used in China on a group of MSM to see if

quickly where there are increased HIV infection rates

exposure to educational materials and the provision

and in geographic areas that do not lend themselves

of free condoms and lubricant improved knowledge

to undertaking randomised controlled trials as barriers

about HIV, increased condom use and access to HIV-

to undertaking a successful programme evaluation.

related services (Tan et al., 2013). The principle of

This is certainly the case in New Zealand where social

joint marketing was the theory underpinning this

marketing campaigns, such as Get it On!, have a

intervention. Joint marketing is founded on commercial

national reach. Also New Zealand is a geographically

marketing concepts and is similar to social marketing

small country, consequently prevention campaigns

in motivating key stakeholders and the target audience

need

innovative

to work together to ensure the adoption of ideas and

methodological designs that are theory based as well

behaviours in specific audiences (Storey, Saffitz &

as persuasive (Noar et al.). The use of multi-media

Rimon, 2008, Wei et al., 2011). While only a pilot study,

avenues and diverse ways of delivering the campaign

this research demonstrated that health promotion

message are examples of this approach.

messages based on social marketing principles increase

to

utilise

contemporary

and

knowledge about HIV, as well as condom use and A Cochrane review of social marketing interventions to

testing in MSM. In addition, the findings of this research

increase HIV/STI testing in MSM also found a limited

engaged and included owners of venues where MSM

number of pre-intervention post-intervention study

frequented. Owners of venues had previously been

designs, and as identified above suggested more robust

identified as central to the success of any behavioural

study designs be employed to evaluate future social

intervention to increase condom use in MSM because

marketing campaigns (Wei et al., 2011). This review

they were needed to grant HIV prevention workers

found limited evidence to suggest that social marketing

access to their businesses (Tan et al.).

campaigns using multi-media channels positively influence HIV/STI testing in MSM living in developed

Lombardo and Leger (2007) utilised a case study type

countries. They also recommend longitudinal impact

approach to identify the strengths and weaknesses of

evaluations to identify whether the social marketing

the “Think Again� Canadian social marketing HIV/AIDS

interventions employed create behaviour change in

prevention campaign designed to increase condom

the identified target population.

use for anal sex in MSM. This research supported the findings of the other studies included in this review.

The remaining seven articles comprising this review

These authors identified that the success of any HIV/

report the findings of evaluations of social marketing

AIDS prevention is contingent on the utilisation of

campaigns designed to reduce rates of HIV and/or

formative research through the engagement of advisory

STI. Two focus exclusively on HIV prevention, three

groups that closely represent the target population,

on both HIV and STI, and two exclusively on STI.

ensuring materials utilised in campaigns are culturally

These evaluations span broad geographical locations

and linguistically appropriate, that key messages can be

including China (Tan et al., 2013), Canada (Lombardo &

accessed and easily interpreted by the target audience,

Leger, 2007), the United States of American (Darrow &

the utilisation of the Internet as a mode of delivery

Biersteker, 2008, Martinez-Donate et al., 2010, Plant et

and finally the utilisation of a sound and appropriate

al., 2010) and Australia (Pedrana et al., 2013, Pedrana

theoretical foundation (Lombardo & Leger).

et al., 2012).

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand The “Drama Downunder” social marketing campaign

to the success of this social marketing campaign which

was launched in Victoria Australia in 2008 (Pedrana

facilitated knowledge translation about HIV/STI in

et al., 2012). Its planning and implementation was

MSM. ‘Edutainment’ has increased in popularity, and

informed by robust formative research. This campaign

has been used elsewhere as a mechanism to increase

was underpinned by adaption of the ‘4Ps of marketing’

learning through innovative ways of delivering content

(namely product strategy, price strategy, place strategy

that entertains and educates (Do & Kincaid, 2006).

and promotion strategy) to a social marketing context.

This approach is endorsed by Lee and Kotler (2012)

Formative research also guided the development

who attribute successful manipulation of the 4Ps of

of a social marketing campaign designed to increase

marketing approach to social marketing campaign

condom use and HIV/STI testing in heterosexually

success. Certainly, this campaign met each of the

identified men who have sex with both men and women

indicators Lombardo and Leger (2007) identified as

(Matinez-Donte et al., 2010). Data were collected via a

being integral to the success of a social marketing HIV/

cross-sectional survey before the commencement of

AIDS prevention campaign. Pedrana et al. surveyed

the programme, at a mid-point during the campaign

a convenience sample of 295 MSM as the basis for

and when the campaign ended. The campaign ran

an impact evaluation of the “Drama Downunder”

over a seven month period. Results showed that the

campaign, which aimed to increase health seeking

intervention was effective with increased condom use

behaviour, HIV/STI testing and knowledge. While the

reported by MSM when having sex with both men and

cross-sectional research design is a limitation, the

women, increased knowledge about HIV/STI, as well as

authors claim the evaluation suggests this “… social

increases in testing (Matinez-Donte et al.). However,

marketing campaign engaged the target audience,

the findings from this study should be interpreted

increased their awareness and knowledge of HIV/STIs,

with caution. Firstly, the duration of the campaign was

and led to increased health seeking behaviors including

limited to a seven month period. As identified above,

seeking testing …” (Pedrana et al., p.657).

Wei et al. (2011) recommend that longitudinal studies are more reliable in determining changes in HIV/

The Internet is recommended as a vehicle for the

STI testing rates. Secondly, weak evaluation designs,

delivery of HIV prevention campaigns (Lombardo &

including the utilisation of a single data source and

Leger, 2007). Pedrana et al. (2013) evaluated the reach,

data collection method (in this case survey only),

interactivity and engagement of a social marketing

have been criticised for not providing robust results

campaign hosted on a social networking site to explore

(Betrand, O’Reilly, Denison, Anhang & Sweat, 2006,

the extent to which the campaign improved knowledge

Mertens & Wilson, 2012).

and attitudes toward HIV/STI. The evaluation utilised a mixed method process evaluation design comparing

The ‘Stop the Sores’ social marketing campaign

product reach and engagement with the target audience

implemented in the County of Los Angeles resulted

over a one year period. Product reach was attained

from a significant increase in the number of MSM

through the number of ‘hit’s on the social networking

presenting with early stage syphilis. Plant et al. (2010)

site, which by the end of the one year period totalled

undertook an evaluation of the programme to assess

2929. Results showed participant engagement was

the impact of ‘Stop the Sores’, particularly knowledge

consistent, ongoing and increased over the period of

about syphilis and to determine whether the campaign

the evaluation. Pedrana et al. highlight the importance

resulted in an increase in testing rates. As with Matinez-

of what they refer to as ‘Edutainment’ as being central

Donte et al.’s (2010) study presented above, a single

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand methodology was used to collect data that informed

for anal sex. These include having an awareness and

the evaluation; 297 face to face surveys with MSM

understanding of health promotion campaigns based

were undertaken by trained interviewers. Findings

on social marketing principles, such as Get it On!, as

showed that exposure to the ‘Stop the Sores’ campaign

well as knowing what is the ‘best’ evidence that can be

resulted in an increase in knowledge about syphilis

translated into practice.

and testing rates in the target population (Plant et al.).

In addition to the limitations already identified in the

As mentioned earlier, the use of condoms as a physical

previous paragraph, this social marketing campaign

barrier is widely recognised as being central to

only ran for three years suggesting that the findings

reducing the spread of sexually transmitted infections

of the evaluation were not robust enough to have

including HIV. If condoms are consistently used for

convinced policy makers and/or funders to support the

anal sex in MSM then the incidence of HIV and STIs

continuation of the programme.

would be dramatically reduced or eliminated (McCann et al., 2011). Governments and non-government

As with Matinez-Donte et al.’s (2010) evaluation,

organisations utilise mass health promotion campaigns

Darrow and Biersteker (2008) undertook an evaluation

to encourage the use of condoms by MSM. In New

of a social marketing campaign designed to reduce

Zealand, the New Zealand AIDS Foundation is the main

syphilis rates in MSM, but this time in Florida. The

promoter of safe sex campaigns including Get it On!,

campaign comprised the distribution of posters

a campaign designed to promote condom use in this

and palm cards to MSM venues, advertisements in

group of people.

local media including radio, television, billboards and newspapers, as well as banner displays on

The literature reviewed has identified behaviourally

websites. Data for this evaluation were collected at

based social marketing campaigns are effective in

the beginning of the social marketing campaign and

promoting condom use in MSM, and RCTs are the

then again at 6 months via survey at selected venues

methodology of choice to determine effectiveness

in South Florida (Darrow & Biersteker). Four hundred

of these programmes (Bertrand, O’Reilly, Denison,

and six MSM comprised the baseline sample and 445

Anhang & Sweat, 2006). However, in a New Zealand

unrelated MSM at follow up. Overall findings from this

context RCT designs are often not appropriate

evaluation found that the campaign objectives were

due to our small geographical size and population.

largely not met and the interventions utilised did not

Consequently,

decrease syphilis rates in MSM.

appropriate methods so that results from any social

researchers

need

to

implement

marketing evaluation will still provide useful and

Implications for nursing

robust outcomes. That being so, nurses should be cognisant of the international literature as well as

Nurses, particularly those working in primary health

findings from local studies as a means to determine

care and/or sexual health, are frequently at the

success or otherwise of behaviourally based social

forefront of delivering health promotion messages at

marketing condom use campaigns.

both individual and community levels. Consequently, the literature reviewed and presented in this article

A longitudinal research design utilising a variety of

has highlighted several issues that could be of

data collection methods would usefully underpin

benefit to nursing practice to assist in influencing

any behaviourally based social marketing campaign

MSM to maintain and improve the use of condoms

promoting condom use in MSM in New Zealand. Study

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 11

Page 12

2013

Pedrana et al.

On line settings.

A variety of settings.

Gay men who accessed the “Queer as F**k” Facebook page.

A total of 33 MSM specific studies met the inclusion criteria – 9 evidence based and 24 non evidence based.

Comparison of evidence based interventions versus non evidence based interventions to determine effectiveness.

Evaluate reach, interactivity and engagement of “Queer as F**k” to inform future sexual health interventions and evaluations using social networking sites.

Purpose

2013

2013

Tan et al.

Lorimer et al.

A variety of settings.

167 papers were selected for appraisal and were independently reviewed by 2 reviewers with 4 studies being included in the systematic review.

To consolidate and update available evidence, to identify consistent and inconsistent trends in the effectiveness of behavioural interventions for HIV prevention and assess the relevancy of available

Intervention All MSM, 18 years and over, who visited To assess the strength of a group = 8 MSM the social venues. joint marketing approach to social venues – increase HIV knowledge, the gay bars (3), rate of condom use and saunas (2), access to HIV-related gymnasiums (3) services.

Control group = 6 MSM social venues – gay 13-11 Social bars marking campaigns that promote condom use among MSM: A literature review (2), saunas (2), gymnasiums (2) in Shenzhen, China.

2013

Table 1: Summary of reviewed articles Year Setting Participants/Study Material

Higa et al.

Author/s

13-11 Social marking campaigns that promote condom use among MSM: A literature review

Table 1: Summary of reviewed articles

Evaluation methodology incorporating a mixed method longitudinal design.

Methods used included online survey, a scrap book exercise, as well as individual and focus group face to face interviews.

Pilot intervention study.

Intervention included the distribution of educational materials, condoms and lubricant by trained peer educators.

Participants completed a baseline survey and then again at 1 year.

Systematic review.

Systematic review.

Research Design

- Strong and consistent evidence supporting group and community level interventions associated with decreases in unprotected anal intercourse, but inconsistent evidence supporting interventions at an individual level.

- Skills building at a group level effective at reducing unprotected anal intercourse.

- Behavioural interventions delivered by trained

- Joint marketing approaches for reducing high-risk sexual behaviour and increasing HIV-related knowledge is an effective HIV prevention strategy.

- Working with both owners of MSM venues and MSM who frequent these social spaces is important to ensure the success of HIV prevention strategies.

- Behavioural interventions play an important role HIV prevention.

- High risk MSM need to be specifically targeted.

- Using evidence based interventions important to ensure success of behavioural interventions.

- The use of engaging YouTube video clips related to sexual health increased the number of members.

- The use of YouTube video clips on Facebook pages like “Queer as F**k” is a useful mechanism for the “viral” spread of key sexual health messages for gay men.

- Ongoing participant engagement with the content is heavily reliant on the quality and credibility of the information provided.

- In order for social networking sites to to successfully deliver sexual health messages they must provide the impetus and space for interactions with others, as well as “Edutainment”.

Conclusions

Nursing Praxis in New Zealand

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

2010

2012

2011

Plant et al.

Pedrana et al.

Wei et al.

A variety of settings.

Victoria, Australia.

Los Angeles County.

A variety of settings.

Convenience sample of 295 gay men aged 18-66 years. Participants were recruited at gay community venues and events, as well as snowballing.

297 MSM and male-to-female transgendered people were recruited from the street, bars, cafes, a community centre, bathhouses and sex clubs.

167 papers were selected for appraisal and were independently reviewed by 2 reviewers with 4 studies being included in the systematic review.

To evaluate the impact of a social marketing campaign aimed to increase healthseeking behaviour and HIV/STI testing and enhance HIV/STI knowledge in gay men.

Evaluate a social marketing campaign “Stop the Sores” to increase syphilis testing, knowledge and awareness among MSM.

To consolidate and update available evidence, to identify consistent and inconsistent trends in the effectiveness of behavioural interventions for HIV prevention and assess the relevancy of available evidence.

No RCTs, CCTs or ITS design studies were To assess the impact of identified. Of the 3 studies included, 2 social marketing were serial cross-sectional pre-test-post- interventions on HIV/STI test design studies without a control, testing uptake among MSM 13-11 Social marking campaignsand that promote condom use among MSM: Aand literature review 1 was a serial cross-sectional pretransgender women test-post-test design study with a compared to precontrol. intervention testing uptake in the same population.

Martinez2010 Northern San 3 waves of approximately 260 Evaluate the effectiveness Donate et al.

Diego County, independent samples recruited every of Hombres Sanos [Healthy California, USA. other month of heterosexually identified Men] a social marketing Latino MSM and gay-identified Latino campaign to increase MSM over the age of 18 years. Data condom use and HIV collection sites included low-risk (men’s testing. shelter, shopping centre) and high-risk (clubs, bars) venues.

Noar et al.

2009 A variety of 38 HIV/AIDS campaign evaluation Conduct a 10 year settings articles published in peer reviewed systematic review of journals.

HIV/AIDS mass communication campaigns focussed on sexual behaviour, HIV testing, or both (1998-2007) and to compare the results with earlier campaigns.

2013

Lorimer et al.

in Shenzhen, China.

13-11 Social marking campaigns that promote condom use among MSM: A literature review

- The campaign was effective in reaching both heterosexually identified and gay-identified Latino MSM. - Engaging key informants contributed to the success of the programme.

- Only small changes in increased condom use and HIV testing.

Campaigns have changed and improved over time by - targeting defined audiences through audience segmentation procedures - designing campaign themes around behaviour change - using behavioural theories to inform campaign design - using stronger research designs to measure

Systematic review.

- Strong and consistent evidence supporting group and community level interventions associated with decreases in unprotected anal intercourse, but inconsistent evidence supporting interventions at an individual level.

- Skills building at a group level effective at reducing unprotected anal intercourse.

- Behavioural interventions delivered by trained professionals most effective across individual and groups.

- Exposure to the “Stop the Sores” campaign associated with an increase in syphilis testing, knowledge and awareness.

- The use of unprompted questions to assess sexual health related campaigns and knowledge should be standard in all evaluations.

- Exposure to this social marketing campaign increased knowledge, prompted MSM to seek sexual health information and increased HIV/STI testing.

- High levels of recognition and recall of the campaign’s key messages.

- Strong acceptance of the campaign within the MSM community.

- Limited evidence suggesting multi-media social marketing campaigns promote HIV testing in MSM in developed countries.

Cross-sectional survey design on a handheld computer.

Systematic review.

On-line Survey.

Paper based survey.

Participants completed a baseline survey and then again at 1 year.

Systematic review.

Nursing Praxis in New Zealand

Page 13

Page 14

Lombardo, A., & Leger, Y.

2008

Darrow, W., & Biersteker, S.

Fort Lauderdale and Miami, South Florida, USA.

A variety of settings

623 MSM over the age of 18 years who had at least 1 sexual experience from community venues – bars, night clubs, gay pride events and public beaches.

other month of heterosexually identified Latino MSM and gay-identified Latino MSM over the age of 18 years. Data collection sites included low-risk (men’s shelter, shopping centre) and high-risk (clubs, bars) venues.

38 HIV/AIDS campaign evaluation articles published in peer reviewed journals.

Evaluate the impact of a social marketing campaign designed to reduce syphilis infections.

Conduct a 10 year systematic review of HIV/AIDS mass communication campaigns focussed on sexual behaviour, HIV testing, or both (1998-2007) and to compare the results with earlier campaigns.

Men] a social marketing campaign to increase condom use and HIV testing.

2007

Canada

Materials from the national “Think Again” and AIDS Committee of Toronto websites, Canadian based print material and interviewed key stakeholders involved in the campaign.

To identify strengths and weaknesses of the Canadian “Think Again” social marketing campaign as a learning tool for other campaigns.

13-11 Social marking campaigns that promote condom use among MSM: A literature review

2009

Noar et al.

California, USA.

Venue based surveys at baseline and then again at 6 months to assess changes in exposure to campaign materials, awareness, knowledge about syphilis, perceptions of risk, sexual behaviour, clinic visits, testing and treatment for syphilis.

Social marketing case study using interviews, documentation regarding the planning and implementation of the campaign, including funding proposals, timelines and evaluation plans, as well as recent evaluation reports.

Systematic review.

on a handheld computer.

- Formative research is an important component of any social marketing campaign.

- Campaign materials need to be culturally and linguistically appropriate.

- Campaign messages should be unambiguous - Pre test messages before using to test for unintentional consequences of health messages.

- Campaign material need to be accessible to the target audience.

- Theoretical concepts should be used when designing campaigns to help focus messages to encourage behaviour change through established principles.

Campaigns have changed and improved over time by - targeting defined audiences through audience segmentation procedures - designing campaign themes around behaviour change - using behavioural theories to inform campaign design - using stronger research designs to measure effectiveness.

- Awareness of syphilis and perceptions of risk increased among those living in Fort Lauderdale but not among those living in Miami.

- Risky sexual practices and patterns of recreational drug use did not change.

- No significant increases in knowledge, clinic visits, or testing or treatment for syphilis detected over the 6 month period.

MSM. - Engaging key informants contributed to the success of the programme.

- Only small changes in increased condom use and HIV testing.

Nursing Praxis in New Zealand

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand samples should also be varied and include the various

Zealand MSM have highlighted the importance of

MSM subgroups within the target audience, as well

having sound social marketing campaigns to promote

as key stakeholders drawn from urban, provincial and

the use of condoms for anal sex in this group. This article

rural environments. However, nurses should be aware

reviewed 11 studies that evaluated the utilisation of

that research by Hughes and Saxton (2006) identify

behaviourally based programmes, underpinned by

a micro-clustering of MSM within central Auckland

social marketing concepts, to increase condom use in

suburbs. Consequently, when undertaking research

MSM. The literature strongly supported the utilisation

with this group the utilisation of specific sampling

of well-designed behaviourally based social marketing

strategies to address this phenomenon is important.

campaigns as a means to increase condom use in MSM. While condom use and MSM has been the focus of this

Conclusion

article, the social marketing concepts presented in the literature reviewed have been successfully utilised in

Recent increases in HIV and STI infection rates in New

other population based campaigns.

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Nursing Praxis in New Zealand THE INFORMED CONSENT PROCESS IN RANDOMISED CONTROLLED TRIALS: A NURSE-LED PROCESS Pip Cresswell, RN, MN, Clinical Research Nurse, Wellington Hospital, Wellington, NZ Jean Gilmour, RN, PhD, Senior Lecturer, College of Health, Massey University, Wellington, NZ

Abstract Clinical trials are carried out with human participants to answer questions about the best way to diagnose, treat and prevent illness. Participants must give informed consent to take part in clinical trials that requires understanding of how clinical trials work and their purpose. Randomised controlled trials provide strong evidence but their complex design is difficult for both clinicians and participants to understand. Increasingly, ensuring informed consent in randomised controlled trials has become part of the clinical research nurse role. The aim of this study was to explore in depth the clinical research nurse role in the informed consent process using a qualitative descriptive approach. Three clinical research nurses were interviewed and data analysed using a thematic analysis approach. Three themes were identified to describe the process of ensuring informed consent. The first theme, Preparatory partnerships, canvassed the relationships required prior to initiation of the informed consent process. The second theme, Partnering the participant, emphasises the need for ensuring voluntariness and understanding, along with patient advocacy. The third theme, Partnership with the project, highlights the clinical research nurse contribution to the capacity of the trial to answer the research question through appropriate recruiting and follow up of participants. Gaining informed consent in randomised controlled trials was complex and required multiple partnerships. A wide variety of skills was used to protect the safety of trial participants and promote quality research. The information from this study contributes to a greater understanding of the clinical research nurse role, and suggests the informed consent process in trials can be a nurse-led one. In order to gain collegial, employer and industry recognition it is important this aspect of the nursing role is acknowledged.

Key words: nurse-led process, informed consent, randomised controlled trials, clinical research nurse Introduction Clinical trials involve direct observation of people

Researchers must ensure patients give well informed

to answer questions about how illness can be safely

voluntary consent to participate in RCTs (Beardsley,

prevented,

Randomised

Jefford & Milshkin, 2007), and increasingly this

controlled trials (RCTs) are the only type of clinical trial

important and challenging role has become part of

that can show cause and effect relationships between

clinical research nurses’ responsibilities (Cantini &

variables. Patients in RCTs are randomly allocated

Ells, 2007; Tomlin, deSalis, Toerien, & Donovan, 2012).

to either the intervention being investigated or the

Clinical research nurses usually manage RCTs with

diagnosed

or

treated.

current standard treatment. The random allocation means any difference between the two groups at the end of the RCT is likely to be caused by the investigational intervention (Jadad & Enkin, 2007).

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Cresswell, P., & Gilmour, J. (2014). The informed consent process in randomised controlled trial: A nurse-led process.

Nursing Praxis in New Zealand, 30(1), 17-28.

Page 17

Nursing Praxis in New Zealand doctor or researcher supervision (Pick, Liu, Drew, &

responsibilities. The Nursing Council of New Zealand

McCaul, 2010). Gaining informed consent in RCTs

(2007) competencies for safety to practice situate

involves good communication as participants must

responsibility for ensuring informed consent in RCTs

understand the purpose, risks and benefits of the

with the clinical research nurse. The competencies

research and that taking part is voluntary (National

include establishing that, in order to protect their

Ethics Advisory Committee, 2012). Information

rights clients have adequate explanation of the

sheets and consent forms are the main tools used to

effects, consequences and alternatives of proposed

explain the research and to record the participant’s

treatment options. The competencies also require

signature, indicating consent to take part in the trial.

nurses to discuss ethical issues and make appropriate

Increasing trial complexity and regulation mean

professional judgements about clients’ decision-

information sheets are lengthening and becoming

making abilities.

more complicated (Antoniou et al., 2011). Therefore, informed consent should be seen as an ongoing

As a consequence of researchers ignoring participants’

process and not simply the act of signing a consent

human rights New Zealand guidelines on informed

form (Allmark & Mason, 2006).

consent have been developed. An investigation into a failure to inform women with cervical cancer that they

Clinical research nurses need a comprehensive

were in a clinical trial and withholding of treatment

understanding of their nursing specialty, and of the

without their knowledge, known as The Unfortunate

research process along with legislative and ethical

Experiment (Coney, 1988), highlighted this issue. This

requirements. The clinical research nurse may write

negation of the women’s rights led to the creation of

RCT protocols, proposals and submissions to ethics

new protections for research participants including

committees, manage budgets, and recruit patients to

The Office of the Health and Disability Commissioner,

take part in a trial (Poston & Buescher, 2010). Their

the Code of Health Consumers Rights (1996) and

nursing role includes ethical trial management and

independent ethics committees to review all research

patient protection through patient advocacy (Davis,

on

Hull, Grady, Wilfond, & Henderson, 2002). The clinical

Commissioner, 2012). The independent National

research nurse role, in the informed consent process,

Ethics Advisory Committee publishes guidelines on the

has been described in international literature as being

ethical standards that health and disability researchers

facilitative or collaborative in nature but further in-

must meet when conducting RCTs (National Ethics

depth exploration has been recommended (Cantini

Advisory Committee, 2012).

human

participants

(Health

and

Disability

& Ells, 2007). The study reported in this paper aimed to explore the experience of New Zealand clinical

The complexity of ensuring informed consent is

research nurses with respect to the informed consent

highlighted, by the evidence that RCT participants do

process in RCTs.

not understand at least some aspects of RCTs despite signing informed consent forms and the availability of ethical guidelines internationally (Brown, Butow, Butt,

Literature Review

Moore, & Tattersall, 2004; Flory & Emmanuel, 2004; Joffe, Cook, Clearly, Clark, & Weeks, 2001). Joffe et al.

Bell (2009) reports there is minimal nursing literature

(2001) reported 70% of 207 oncology RCT participants

and workforce data related to New Zealand research

did not know their treatment was not the best proven

nurses, and little recognition of their expertise or

treatment for their cancer. Random allocation is

Page 18

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand difficult for participants to understand. For example,

benefits and risks of RCTs to potential participants and

a retired man in an RCT reported knowing about

assess their understanding but they do not explain

random allocation but still thought he would get the

how clinical research nurses do this. These authors

intensive treatment because he had more free time

noted that clinical research nurses reported being

than employed participants (Featherstone & Donovan,

involved in a collaborative informed consent process

2002).

and recommended an in-depth exploration of this concept.

Part of the reason for lack of understanding may be poor communication. The analysis of 82 recorded informed consent discussions between doctors and patients found random allocation was mentioned less than two-thirds of the time and only 17% of the doctors checked their patient’s comprehension (Jenkins, Fallowfield, Souhami, & Sawtell, 1999). These communication gaps may be related to clinicians’ knowledge as a research study found less than half of 61 clinicians, who had recorded RCT consent from 197 patients, understood the trials were being done to benefit future patients rather than the trial patients (Joffe et al., 2001).

Internationally, many strategies have been suggested to improve informed consent processes. Allowing sufficient time to absorb information and decide on participation is vital (Brown et al., 2004). One to one discussions with trial personnel, oral synopses and “teach-back”, where the patient explains what they have understood from the information provided, have been shown to increase comprehension (Baer, Good, & Schapira, 2011; Flory & Emmanuel, 2004; Kripalani,

Research Method Aims The study aim was to explore the experience of clinical research nurses with respect to the informed consent process in RCTs, and to ascertain their strategies for ensuring patient voluntariness and understanding.

Methodology An in-depth exploration of the clinical research nurses’ role in informed consent has been recommended (Cantini & Ells, 2007).

For the present study a

qualitative

approach

descriptive

was

chosen.

Qualitative description describes events in terms that most people would agree accurately describes these events. This approach stays close to the data and is less interpretive than other qualitative methods (Sandelowski, 2000).

Bengtzen, Henderson, & Jacobson, 2008).

Method

Because the RCT informed consent process is complex,

In April 2012, following ethics committee approval of

it is important to understand the experiences of clinical research nurses involved in the process. The informed consent process is often fully or partially delegated to the clinical research nurse (Cantini & Ells, 2007; Tomlin et al., 2012). Ehrenberger and Lillington (2004) have described the nursing role as facilitating the informed consent process. Cantini and Ells (2007) report clinical research nurses explain the purpose, Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

the research (HEC: Southern A Application 12/17), 30 attendees at a clinical research nurse study day were emailed an invitation to participate, together with an information sheet. Three clinical research nurses volunteered. They had worked as clinical research nurses for universities and hospitals in acute and community settings in palliative care, general practice,

Page 19

Nursing Praxis in New Zealand mental health, and critical care, and had taken part in

description method. In terms of analytic rigour the

postgraduate research education. The semi-structured

first author developed the initial analysis while the

recorded interviews averaged 45 minutes in length

second author, who was the research supervisor, had

and took place in April and May 2012. Interview

an overview of the transcripts and the analysis and

question topics included who had the responsibility for

confirmed that the analysis connected to the original

obtaining informed consent, how voluntary consent

data.

and understanding of the trial were ensured, issues with the informed consent process and how those

Other strategies for ensuring validity in qualitative

issues are addressed. The questions were included

research include triangulation of data and clarifying

in the research information sheet. The interview

the view the researcher brings to the research

transcripts were sent to the clinical research nurses

(Creswell, 2009). Triangulation of data means verifying

for review to ensure confidentiality and privacy and to

it with other sources where possible. Much of the

increase research rigour. They all requested that parts

information reported by the interviewees for this

be removed from the transcripts. Pseudonyms were

research corresponded with information provided by

used from the outset of transcribing. Transcription was

the other interviewees and also with the first author’s

carried out by the first author, so the researcher could

experience as a clinical research nurse. When data

stay close to the data as recommended for qualitative

corresponds with information in the literature, this

description (Sandelowski, 2000).

also provides triangulation. Much of the data provided by the interviewees indicated that recommendations

Qualitative research uses inductive analysis, that is,

found in the literature for increasing participant

the researcher breaks down data and then builds it

understanding and ensuring voluntariness were being

up again into patterns and groups and then further

followed.

into more conceptual information by going back and forward between the data and the resulting concepts.

Findings

The researcher looks for the meaning the participants see in an issue (Creswell, 2009). Thematic analysis, as

This trial aimed to understand the informed consent

described by Braun and Clarke (2006), was used to

process experiences of some clinical research nurses.

identify themes in the data. The researcher’s thoughts

Three themes identified from the interviews show

about the main interview ideas were recorded directly

the multiple partnerships clinical research nurses

after the interview. The transcripts were read through

engage in as part of the informed consent process.

twice then words or phrases which captured the

The preparatory partnership theme encompasses

essence of what the interviewee was saying were

all the relationships required before a potential trial

highlighted. Similar codes were grouped together,

participant can be approached to see if they wish to

and then categories identified which reflected the

take part in a clinical trial. This theme has subthemes

grouped codes. Some categories such as voluntariness

of protection and access. The theme of partnering

and understanding were informed by the literature

the participant has several subthemes - ensuring

review, while others were data driven. The categories

voluntariness, ensuring understanding and providing

were then linked into themes and subthemes. Braun

participant advocacy. The third theme of partnering

and Clarke (2006) noted that themes do not emerge

the project has subthemes of project promotion and

from data; rather the researcher actively identifies

ensuring quality (see Figure 1).

them, which is the interpretive part of the qualitative Page 20

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

Preparatory Partnerships Protection Access

A

Participant Partnerships Ensuring voluntariness Ensuring understanding

INFORMED CONSENT – A NURSELED PROCESS

Project Partnerships Promotion Quality

Advocacy

Q Quality

Figure 1: Clinical research nurse role in the informed consent process

Preparatory Partnerships So instead of accessing the list of clients Preparatory partnerships encompasses the wide range

the case manager had that day, which

of relationships the clinical research nurses formed

would have been easy ... we had to go with

before potential trial participants were invited to

this process which was a bit slower, and

take part. It has two subthemes of protection of and

develop rapport with these people (the case

access to potential participants. The first partnership

workers). (CRN C)

focused on protection of trial participants, and was

Figure 1: Committee Clinical which research nurse role with an Ethics helped ensure patient safety, and potentially determined how particular populations can be approached. One clinical research nurse needed to forge partnerships with mental health case workers to encourage them to approach their clients about RCT participation. The Ethics Committee had stipulated that the clinical research nurse could not make the initial approach to ensure patient privacy and prevent pressure to participate:

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

critical informed care trials, theconsent Ethics Committee may agree in Inthe process to proxy consent being obtained from family, when potential participants are too ill to provide consent: In the first instance we might, if the patient was unconscious, speak to family and would get their assent to participate in the study, or we would ask them if they thought the patient would want to participate. (CRN A)

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Nursing Praxis in New Zealand In these cases the nurses need to form partnerships

Partnering the Participant

with participants’ families to enable consent to be given.

The second theme, partnering the participant, is

The second subtheme, access to potential participant populations, involved forming other partnerships with health professionals, such as general practitioners who have existing relationships with that population.

The clinical research nurses reported that part of

a partnership with the trial participant and has three subthemes – ensuring voluntariness, ensuring understanding and providing participant advocacy.

Ensuring

voluntariness

started

with

providing

information prior to recording written consent:

their preparatory partnership role is to reduce health

The sending of the information sheet was

professionals’ concerns about the workload impact

always separated from the actual consenting

and practice scrutiny:

process and so people voluntarily get back to you once the information sheet is sent out to

The research nurses used Medtech, the

them. (CRN B)

practice management system, but they had to find times to go in and not be in anyone’s way

The clinical research nurses reported using their

and all that and try and be invisible and not

nursing experience, and assessment and interview

trip over anyone. (CRN B)

skills to ensure patients’ voluntary participation,

When an RCT involves a higher level of risk to the participant, such as using an experimental treatment

starting with reviewing the information sheets with them:

or a medication off-label (that is, when a medication

Maybe their level of concentration wasn’t very

is used for a purpose it has not so far been licensed

good in terms of responding to non-apparent

for), then an additional partnership is needed with a

stimuli, you know, talking to themselves,

doctor or an investigator that is involved in the trial.

distracted, high on something – yes, and so

The clinical research nurse would also judge whether

then you’d say maybe we should reschedule.

participants or their family would prefer a doctor to

(CRN C)

obtain their written consent: Nurses develop skills in promoting patient motivation It’s more of a holistic judgment really based

to change behaviour such as smoking cessation.

on the patient’s condition, and the family and

However, it is important that clinical research nurses

what’s gone on already … so even if there’s a

reflect on their influence and take care not to persuade

[low risk] study you could consent for, maybe

trial participants to take part in RCTs. One nurse

you wouldn’t. (CRN A)

commented:

Once a potential trial participant has been identified,

You do have to be careful to strike a balance

the doctor may be enlisted to explain the trial, answer

between being welcoming but not persuasive.

questions and ask the participant or family for written

(CRN B)

consent while the clinical research nurse provides detailed explanations and answers.

To ensure understanding, the clinical research nurses reported having one to one discussions and correcting any misconceptions patients had after reading

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand information sheets. They reinforced content in various

as if she was having difficulty understanding the trial.

ways, such as summarising the information sheet and

At the meeting, the clinical research nurse confirmed

reinforcing the need to go through its content carefully:

she understood the trial even, though she had a physiological problem affecting her speech, and was

I put it in my own words and make sure that

able to give informed consent.

I’m really confident that they do understand.

(CRN B) Occasionally we get patients who say, “Oh I’ll just sign it anyway.” And so, we always make sure that we go through it, [asking] “Do you understand, and can you tell me?” You know it’s a serious business. (CRN A)

Partnership with the Project The third theme, partnership with the project, has the subthemes of promotion and quality. To answer the research question, a trial must be promoted so that sufficient and appropriate patients take part. Clinical research nurses need to promote trials to preparatory

Two clinical research nurses described asking their

partners and potential participants. Recruitment can

patients to explain back the information they had

be very time consuming as a clinical research nurse

received by asking, “Can you tell me what the steps

found when she had to sit in waiting rooms throughout

are going to be?”(CRN B). They also invited family

the region, waiting for mental health case workers to

members to attend consent discussions to increase

approach potential participants on her behalf. Clinical

patient understanding.

research nurses have patient recruitment targets and deadlines, but they also need to remain aware of

Providing advocacy was not limited to trial procedures.

avoiding pressuring people to take part:

Because the informed consent process is ongoing, clinical research nurses can find themselves supporting

I know people who’ve said they’ve felt under

participants through life events and requests for other

pressure to consent people.

advice. This additional support was given because the

haven’t found that but I can imagine that

consent was:

you might if you were part of a study where

I personally

recruiting was really difficult. There would Commitment... to provide them with adequate

be a temptation to consent people not as

support and assessment throughout the

rigorously as you might because you might

research so even though you might think,

feel you know desperate to have this person

“Oh this patient is ringing me about their

as part of your study. (CRN B)

cold or something”. You still have to be their advocate or support them through whatever

The other aspect of partnering the project described

that [phone] call is because that is part of the

by the clinical research nurses is maintaining quality.

research. (CRN B)

One aspect of maintaining quality involves research associates (known as monitors) overseeing the

The clinical research nurses also described advocating

conduct of the trial on behalf of the pharmaceutical

for potential participants by trying not to exclude

companies. The monitors review all written informed

willing participants, where possible. An example was

consent forms and check that appropriate participants

provided by a clinical research nurse, about talking on

are taking part in the trial. In critical care, a clinical

the phone to a person with dysphasia who sounded

research nurse talked about going beyond the

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 23

Nursing Praxis in New Zealand guideline requirements:

described in the literature review, the clinical research nurses in this study appeared to be involved in a nurse-

We keep being told by our monitors ... that we

led informed consent process.

didn’t need a witness [to an informed consent signature]. I always try and get a witness just

An important research finding was the emphasis on

because it makes me feel better (CRN A).

the need not to pressure people into RCT participation.

Ensuring quality also means clinical research nurses must collect the maximum data possible, so they tried to maintain some sort of partnership with the patients even when they no longer wished to continue RCT procedures.

The clinical research nurses provided information before scheduling informed consent meetings, used assessment skills to discern voluntariness, and were aware of and managed their own skills so patients were not persuaded to take part in RCTs. They were all experienced clinical research nurses who

We do ask … if they don’t want to carry on

had undertaken postgraduate research education.

in the study would they mind us finding out

Therefore, they may have recruited in a more ethical

how they’re doing for the follow-up, like not

and informed manner than clinical research nurses

ringing them but looking on the computer to

in Tomlin et al.’s (2012) study where, in 23 informed

see what’s happened so that we still have the

consent interviews, some ignored what participants

outcome data. (CRN A)

said or misled them, thereby breaching their rights.

These authors did not comment on the clinical research

Quality RCT data analysis, known as an “intention-to-

nurses’ level of experience or education, or on the

treat” analysis, must include every participant who

difference between the clinical research nurses who

was randomised to one of the groups in the trial (Jadad

behaved ethically and those who did not. Those who

& Enkin, 2007), although participants may choose not

did not may have been less experienced or less well

to be followed-up.

educated. However, Tomlin et al.’s research highlights a need for clinical research nurses working autonomously

Discussion

to have ongoing support and supervision.

The small number of participants in this research

Many clinical research nurse roles have developed in

is a limitation, which means the findings cannot be

an ad hoc fashion, which can create issues of isolation

generalised to other clinical research nurses. However,

and lack of support (Hill & MacArthur, 2006). Clinical

the clinical research nurse interviews highlighted

research nurses are generally recruited for expertise

the nursing contribution to RCTs. Ensuring informed

in their nursing field, and research education can

consent in RCTs is a complex process managed by

be experiential rather than formally taught. Clinical

the clinical research nurses that involves numerous

research is a specialty, and education on topics such as

partnerships to ensure patient safety and access.

research ethics, trial management and understanding

Clinical research nurses worked closely with patients

the competing demands of participant and trial

to ensure their participation is voluntary, they

advocacy is important (Cantini & Ells, 2007; Tomlin et

understand, and that they provide advocacy and

al., 2012). Clinical supervision is used widely overseas

support. They also partnered with the projects to

to enable clinicians to develop their practice. It involves

promote the research and maintain quality. Rather

professionals meeting regularly to reflect on their work,

than facilitating or collaborating in informed consent as

enhances practical and theoretical understanding

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand and increases clinician resilience. Supervision can be

et al., 2008). The clinical research nurses also involved

particularly valuable when people work autonomously

family members, where possible.

(Winstanley & White, 2003), and therefore, may be useful for clinical research nurses.

Teach-back is the most effective way of ensuring participants

understands

their

clinical

trial

Another important finding was the clinical research

involvement (Baer et al., 2011; Kripalani et al., 2008).

nurses’ efforts to ensure that potential trial participants

Teach-back means asking participants to explain their

understood the ramifications of trial involvement. Like

understanding of an informed consent discussion

nurses in other areas of health care, clinical research

in their own words to the information provider. This

nurses see themselves as interpreters attempting

enables misinformation to be clarified straight away.

and

Two of the clinical research nurses interviewed for this

investigators’ aims and understandings. They also try

study described using “can you tell me” as a method

to bridge gaps between written documentation and

of checking whether participants understood trial

potential participants’ understanding (Davis et al.,

information, which is teach-back in action.

to bridge the gap between trial participants’

2002). There is a lot of information to understand, which may be completely new to potential participants.

The research findings also suggest there is a link

between the conceptualisation of nurse-led practice Each clinical research nurse described using a mixture and the clinical research nurseprocess role in the RCT informed Theverbal informed consent process in randomised controlled trials: A nurse-led of13-09 both written and methods of communication with participants, having one to one interactions,

consent process. Nurse-led practice has evolved as the

oral synopses and allowing time for decision-making

increasing demand for health care has led to nurses

as recommended in the literature (Baer et al., 2011;

taking on work previously carried out by doctors

Brown et al., 2004; Flory & Emmanuel, 2004; Kripalani

(Ndosi, Vinall, Hale, Bird, & Hill, 2011). The nurse may

Table 1:

Table 1 Classification of Nurse-led Practice Classification of Nurse-led Practice

Activity

Level 1

Level 2

Level 3

Assessment

Site/type specific

Specialty-specific

Broad and first line

Referral method

Internal medical

Internal medical or other discipline

External/internal sources any type

Diagnostic tests

Medically initiated

Joint with discussion

Independent decision/order

Prescription

Not undertaken

Within clear protocols

Independent interpretation of tests/drug prescription

Decision making

With permission

In discussion

Autonomous

Discharge

Refers back to medical staff

Discharges from nurse led service

Discharge from service, hospital and/or into community

Note:Source Source - Richardson and(2003, Cunliffe p. 82) with permission John Wiley and Son (publisher) Note: - Richardson and Cunliffe p. 82)(2003, with permission of John Wiley and Sonof(publisher)

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 25

Nursing Praxis in New Zealand work in partnership with doctors but has significant

nurses lead it by maintaining preparatory, participant

scope for independent practice and autonomous

and project partnerships throughout the RCT.

decision-making. According to Richardson and Cunliffe (2003), nurse-led practice has six common activities

Recommendations

and three levels of practice, with differing levels of autonomy and independence. The level may vary

Research specific education may increase clinical

according to the expertise of the nurse or the trust of

research

the doctor. The six common activities are assessment,

requirements of the informed consent process and the

referral, diagnostic tests/consultations, prescription,

skills required, and should be encouraged in clinical

decision-making and discharge (see Table 1).

research nurse role descriptions and professional

nurse

understanding

of

the

ethical

development plans. As clinical research nurses Applying Richardson and Cunliffe’s (2003) classification

often work autonomously, they need access to peer

to the clinical research nurses’ role in informed

support and clinical supervision to encourage practice

consent shows it can be a nurse-led process. The

development and competence. Clinical research

interviewed clinical research nurses carried out the

nurses should explore how such support can be

informed consent process in multiple partnerships

accessed with managers, employers and colleagues.

with other health professionals while at all times

Experienced clinical research nurses could consider

managing the process. They substituted for the doctor

gaining supervision skills so that they can support

or researcher and maintained partnerships with their

practice development. Useful further research would

patients throughout the RCT. This fits the classification

include repeating this study with larger groups of

of working in partnership, but with a high level of

clinical research nurses to confirm if they are carrying

independence and autonomy. They carried out four

out similar nurse-led informed consent processes.

of Richardson and Cunliffe’s (2003) common activities across the three levels of practice. Assessment of the

Conclusion

participant’s voluntary involvement, understanding and eligibility to take part was carried out by the

Gaining informed consent in RCTs is a complex process

clinical research nurses. Referral into the RCT was by

managed by clinical research nurses and requires

self-referral or other health professionals. Decision-

multiple partnerships. Clinical research nurses use

making to take part was made by the patient during

a wide variety of skills and strategies to ensure

interaction with the clinical research nurses, even if a

participant safety, access and support, to be confident

doctor collected the signature on the consent form.

of voluntary participation; ensure understanding of

Discharge occurred at the end of the trial to either self-

the RCT; and to promote quality research. The findings

management or other health professionals. Diagnostic

of this research indicate the informed consent process

testing and prescription activities are not part of the

in RCTs across several different settings is nurse-led.

informed consent process, but these can easily be

Clinical research nurses should not hesitate to frame

substituted with some of the many other activities

their role in the informed consent process as nurse-

undertaken independently by the clinical research

led in order to achieve collegial, employer and industry

nurse, such as establishing voluntary participation

recognition. Recognition would strengthen requests

and understanding, or forming partnerships with

for a clinical research nurse career pathway, ongoing

gatekeeper health professionals. Informed consent is

research specific education and support mechanisms,

an ongoing process and it is clear that clinical research

such as effective systems of peer support and clinical

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand supervision to encourage ongoing competence and

by continuing research, and clinical research nurse

practice development. Clinical research nurses need to

presence and presentations at nursing and industry

make and take opportunities to gain such recognition

conferences.

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European Journal of Cancer, 35, 1187-1193. doi:10.1016/S0959-8049(99)00116-1 Joffe, S., Cook, E. F., Cleary, P. D., Clark, J. W., & Weeks, J. C. (2001). Quality of informed consent in cancer clinical trials: A crosssectional survey. Lancet, 358, 1772-1777. doi:10.1016/S0140-6736(01)06805-2 Kripalani, S., Bengtzen, R., Henderson, L. E., & Jacobson, T. A. (2008). Clinical research in low-literacy populations: Using teach-back to assess comprehension of informed consent and privacy information. IRB: Ethics & Human Research, 30(2), 13-19.

National Ethics Advisory Committee. (2012). Ethical guidelines for intervention studies: Revised edition. Wellington, New Zealand: Ministry of Health. Retrieved from http://neac.health.govt.nz/system/files/documents/publications/ethical-guidelines-forintervention-studies-2012v2_0.pdf Ndosi, M., Vinall, K., Hale, C., Bird, H., & Hill, J. (2011). The effectiveness of nurse-led care in people with rheumatoid arthritis: A systematic review. International Journal of Nursing Studies, 48, 642-654. doi:10.1016/j.ijnurstu.2011.02.007 Nursing Council of New Zealand. (2007). Competencies for registered nurses. Wellington, New Zealand: Author. Retrieved from http:// nursingcouncil.org.nz/Nurses Pick, A., Liu, A., Drew, V. L., & McCaul, J. (2010). Getting started in clinical research: The role of the research nurse. Nursing Times, 107(Online), 1-2. www.nursingtimes.net/ Poston, R. D., & Buescher, C. R. (2010). The essential role of the clinical research nurse (CRN). Urologic Nursing, 30(1), 55-63, 77.

Richardson, A., & Cunliffe, L. (2003). New horizons: The motives, diversity and future of ‘nurse led’ care. Journal of Nursing Management, 11(12), 80-84. doi:10.1046/j.1365-2834.2002.00364.x Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. doi:10.1002/1098240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G Tomlin, Z., deSalis, I., Toerien, M., & Donovan, J. L. (2012). Patient advocacy and patient centredness in participant recruitment to randomized-controlled trials: Implications for informed consent. Health Expectation,. 1-13. doi: 10.1111/ j.13697625.2012.00792.x Winstanley, J., & White, E. (2003). Clinical supervision: Models, measures and best practice. Nurse Researcher, 10(4), 7-38. doi:10.7748/ nr2003.07.10.4.7.c5904

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand HISTORY OF THE CHILD HEALTH AND DEVELOPMENT BOOK PART 1: 1920 TO 1945 Jill Clendon, RN, PhD, MPhil (Hons), BA, Nursing Policy Advisor/Researcher, New Zealand Nurses Organisation, Nelson, NZ, Adjunct Professor, Victoria University, Wellington, NZ Karen McBride-Henry, RN, PhD, Associate Research Fellow, Victoria University, Wellington, NZ

Abstract The New Zealand child health and development record book (also known as the Well Child/Tamariki Ora Health Book or Plunket book) has recorded the history of infant-rearing practices in New Zealand for almost 100 years. Since its initial publication it has been used by mothers and health professionals to track the health and development of children under the age of five years. The book also provides insight on the development of mothering practices and provides commentary on the medicalisation of mothering and the emergence of mothering as a science from the time of its inception. This article, part one of two, explores the history of the Plunket book during the years of 1920 to 1945.

Information for this article stems from both primary and secondary sources, including an extensive collection of Plunket books from across New Zealand. The findings chronicle the development of a medicalised relationship between mothers and health professionals. The exploration reveals that the rise of scientific mothering coincided with the devaluing of women-centred mothering knowledge, and as a result the language that described women’s mothering experiences was silenced.

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

Introduction/Background

deal with change intergenerationally, and in a manner that contributes to their self-identity as women and

The New Zealand child health and development

mothers.1 As part of a larger study exploring the role

record book (also known as the Well Child/Tamariki

and impact of the Well Child/Tamariki Ora Health book

Ora Health book or Plunket book) is a small booklet

in New Zealand society, the first section of this two

given to New Zealand mothers on the birth of a child.

part article outlines the history of the book from its

Since the 1920s it has been used as a tool by mothers,

inception in 1920 to 1945. We argue that a persisting

nurses and other health professionals to record growth

medically dominated discourse in the book had the

and development of a child from birth to five years.

effect of encouraging mothers to rely on methods of

Despite weathering numerous social changes across

“scientific motherhood” as a means of raising their

the past five generations, including transformations

infants, resulting in a profound impact on women’s

in child-rearing practices, modifications in nursing

ability to breastfeed and a reliance on outside sources

practice and changes in society as a whole, the Well

to support their mothering. In addition, this exploration

Child/Tamariki Ora Health book remains an expected element of motherhood in New Zealand today.

Mothers have used the book as a tool to link past with present, to maintain kinship ties across generations, to Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Clendon, J & McBride-Henry, K. (2014). History of the child health and development book Part 1: 1920 to 1945. Nursing Praxis in New Zealand, 30(1), 29-41.

Page 29

Nursing Praxis in New Zealand highlights how women’s own mothering knowledge

both primary and secondary historical sources and in

becomes subservient to the hegemonic discourse of

particular a collection of 54 Well Child/Tamariki Ora

medicine.

Health Books that a wide number of people across New Zealand shared with the first author by for her

Historiography (the method of historical investigation)

PhD research. The earliest book in the collection is

includes both uncovering historical occurrences and

from 1921, with the most recent 1998. There are at

understanding why these may have taken place.2 It is

least two books from each intervening decade. Photos

particularly useful to nurses investigating the social,

characterising the books are included where relevant

political, economic and historical contexts associated

and where the books are referred to in the text they

with societal change and the impact of these on the

are referenced by descriptor and date. Originals of

practice of nursing.3 Data collection revolves around

these books have not been retained as many families

the identification and sourcing of primary and

consider them family heirlooms to be passed from

secondary data and the verification and evaluation

mother to child, however the first author retains copies

of this material. Primary data is text, photos and

of all of the books with the permission of contributors.8

other sources that were created at the time under investigation and secondary data is that written

The origins of the book

at a later date about the time in question. Wood describes the dimensions of primary historical data

In 1907 Frederick Truby King, superintendent of the

evaluation as provenance, purpose, context, veracity,

Seacliff Mental Hospital near Dunedin, New Zealand,

and usefulness.4 Such critical evaluation of historical

staunch advocate of breastfeeding and later Director

data is essential to ensure reliability and validity of

of the Division of Child Welfare in the Department of

the research – one source should not be considered

Health founded the Society for Promoting the Health

a factual representation of a situation, but two or

of Women and Children.9 Later known as the Royal

more that report the same occurrence may enable

New Zealand Plunket Society, or simply the Plunket

stronger conclusions to be drawn. Although historical

Society, the aim of this organisation was to build on

research is not traditionally aligned with any particular

work initiated by Truby King, his wife and the ‘nurse’10

epistemological approach,5 we bring a critical

he had trained.11 This work involved advocating for

perspective to this work, based on an assumption that

breastfeeding, the preparation of ‘humanised milk’

knowledge is shaped by historical, social, political,

in cases where breastfeeding was unsuccessful, the

gender and economic conditions that for some people,

distribution of humanised milk, and the education of

particularly women, can be oppressive.6 By taking

women in the correct way to feed and care for their

a critical perspective, we seek to understand why a

infants known as the ‘Truby King method’.12 Although

phenomenon has occurred and how we can use that

Truby King was instrumental in the establishment of

knowledge as a basis for change.7 Understanding how

the Plunket Society and was involved in it in a variety of

and why such a small element of nursing practice can

capacities up until his death in 1938, the organisation

have such a profound impact on mothers and their

and administration of it was by women. It was largely

mothering experience over time enables nurses today

a women led organisation. In a similar fashion to

to consider the implications of contemporary practice

movements in the USA and the UK, New Zealand

on the potential future outcomes of healthcare.

maternalists used the Plunket Society as a means of promoting the interests of women and mothers and

The sources of information for this article include Page 30

the health of their children.13 Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand One of the early ways in which the Plunket Society

Record Book’ until publication was taken over by

sought to spread its message of healthy infant care was

the Department of Health in the early 1980s and it

through the employment of nurses. The employment

became the ‘Health and Development Record’. Today

of nurses and development of the nursing arm of

it is known as the Tamariki Ora/WellChild book but it

the Plunket Society occurred as a precursor to the

has been commonly referred to by the New Zealand

publication of the first child health and development

public since the 1920s as the ‘Plunket book’ and will be

record books. A brief overview of the development of

referred to as such in this article.

nursing in the Plunket Society provides some context for the development of the book.

Once Central Council approval to print the Plunket book had been gained, it was not until late 1922 that formal

Plunket nursing developed as a distinct specialty

confirmation is noted in the Central Council minutes

of nursing practice from around 1914 when it was

that the books were now being used by the branches.19

decided that only nurses who had a minimum of three

The cost of developing and printing the Plunket books

years hospital training and were on a government

was also noted when the Dunedin Branch mentioned

register (registered nurses) would be accepted for

a large outlay for printing of Case Sheets for the new

Plunket nurse training.

Prior to this there was no

case-recording system and printing of the Baby Record

requirement that Plunket nurses be registered nurses.

Books in the same report.20 (The book came into use at

By 1920 the Plunket Society employed 55 registered

the same time as ‘A uniform system of book-keeping

nurses.

There was a large concentration of nurses

and case-recording’ was implemented for nurses.21)

around the Dunedin and Southland regions, with the

However, the books were in use as early as June of

remaining nurses spread the breadth and depth of the

1921 in Christchurch and possibly earlier in Dunedin.22

15

14

country.16 In an attempt to address the professional development needs of Plunket nurses, on the 16th

While it is possible to believe that the development of

July 1919 Plunket nurse Anne Pattrick was offered the

the Plunket book arose as a result of improvements in

position of ‘Travelling Plunket nurse’. In appointing

nursing practice and the desire to provide good care

Anne Pattrick, Plunket formally recognised the need

to mothers and their infants, the book also ensured

for Plunket nurses as a whole to have some type of

Plunket nurses could maintain vigilant supervision

practice guidance and support for their work. Parallel

over the actions of the mother. Where the book was

with the development of Anne Pattrick’s position,

created as a tool of practice, this cannot be seen as

changes were also occurring in nursing practice.

separate from the idea that the nurse and nursing

17

practice at the time were products of hegemonic In November 1920, the Society’s Central Council,

biomedical practices. For example, by 1928, Plunket

made a decision to proceed with the printing of small

nurses appointed to permanent positions had a

booklets to be held by the mother and brought with

minimum of four years training23 – all of it based in

her when taking her baby to the Plunket rooms.18

hospitals under the guidance of doctors. Notions of

These booklets were for the Plunket nurse to record

pathology and the idea that bodies could be screened,

instructions for such things as feeding regimes and

surveilled and controlled to identify potential risk

care of the baby. The booklets were to be known as

rather than actual illnesses underpinned part of the

the ‘Baby Record’. This name remained until the late

development of the book.24 Hence the book itself

1950s when it became the ‘Baby Record Book’. In

became a tool of surveillance. Plunket nurses, and

the early 1970s it was known briefly as the ‘Plunket

their use of the Plunket book, therefore, contributed

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 31

Nursing Praxis in New Zealand to the construction of a motherhood that was

1880s and in New Zealand until the 1900s.32 Although

heavily influenced by the biomedical model. Erik

advertisements in New Zealand newspapers offered

Olssen argued that the Plunket Society’s persistent

infant feeding bottles for sale from around the 1860s,33

messaging perpetuated a ‘prescriptive ideology’ and

it was not until around the time the Plunket Society was

that structure and routine came to define the New

established in 1908 that ideas of scientific motherhood

Zealand ‘character’ during this time period.

Linda

were perpetuated through the media in similar ways to

Bryder, however, contends that women were given

those in America. The newspaper column Our Babies

insufficient credit for being able to choose whether

(written by Hygeia who is believed to have been Truby

or not to use Plunkets’ services or follow the advice

King’s wife Bella34) appeared in numerous newspapers

given.26 Philippa Mein-Smith agrees, suggesting that

throughout New Zealand from 1907, along with the

Olssen’s ‘prescriptive ideology’ was tempered by the

booklets Feeding and Care of Baby from 1908 and

actual practice of mothers. Bryder also argues that

What Baby Needs from 1912 – both written by Truby

the autonomy and practice of Plunket nurses served

King.35 Numerous other publications by Truby King

mothers well over the course of the 20th century

during the period 1910 to 1920 similarly exhorted

28

describing the Plunket nurse as a ‘New Zealand icon’.

strict feeding regimes and medically directed care of

Olssens’, Bryders’ and Mein-Smiths’ perspectives

infants and children.36 These publications were similar

likely have some merit in this early time period. The

to the publications that came out of the Children’s

Plunket book undoubtedly contributed to the manner

Bureau in the United States at about the same time

in which the New Zealand mother raised her children,

advocating similar techniques of scientifically directed

and analysis of the book enables us to consider both

child care.37 The Plunket book was a further means of

perspectives in light of what mothers and nurses wrote

ensuring adherence to these techniques of scientific

in the books over time. This will be revisited in part

motherhood.

25

27

two of this review.

The Plunket book was one of many publications that contributed to the biomedical model of scientific care of infants and children, also known as ‘scientific motherhood’.29 Scientific motherhood saw women become increasingly reliant on the direction of medical experts for advice on how to raise their children. As early as the 1840s publications started to appear in America that encouraged women to seek scientific sources of information on child care.30 By the turn

Figure 1: Plunket book from 1921

Figure 2: Plunket book from the 1930s

Note: Printed with permission of the Royal New Zealand Plunket Society (2014, 12 February).

of the century, advertisements exhorting mothers to select products according to their scientific merits

The early books: 1921 to 1945

along with various articles and advice in women’s magazines were abundant.31 This early movement

Books during the period 1921 to 1945 were a tan

toward scientific motherhood, however, was not

colour with black writing and were approximately

reflected in New Zealand. Artificial infant formula, for

10cm x 13cm in size. There was a logo on the front and

example, although available in America and Britain

rear covers that depicted a woman holding an infant in

from the 1840s, was not available in Australia until the

her arms swathed in a blanket (see Figure 1).

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand By 1932 the logo had changed to that of a breastfeeding

reducing New Zealand’s high (although declining)

mother (see Figure 2). There was an old French proverb

infant mortality rate.43 The book outlined a set of

at the start of the Plunket books from this era:

‘baby’s needs’ including ‘...ensuring an abundance of

pure, cool, outside air’ and ‘No night feeding’.44 The

The most loving act a mother can do is to

instructions were underpinned by the following: ‘To

nurse her baby. Nothing can ever replace the

prevent risk of mistakes by the mother, the Plunket

milk and heart of a mother.

Nurse will enter clearly in this book any recipe for

38

food she may order.’45 As noted earlier, one of the key The quotation reflected one of the aims of the Plunket

reasons for the introduction of the book was that the

Society and Truby King: to promote breastfeeding

Plunket Society clearly thought the book would assist

as the optimal way to feed baby. It remained in all

the mother to follow the directions of the nurse more

Plunket books up until 1952. By 1954 the proverb was

accurately, thus ensuring adherence to the Truby King

gone from the Plunket Society’s books but remained

method. These instructions included not only the

in Health Department issued books (used by public

directives printed in the book but also those that were

health nurses ) up until 1962. The intention of the

added by the nurse.

39

Plunket Society was to support breastfeeding and offer an appropriate alternative if breastfeeding were not

The weight chart took up an entire page of the book

possible. The formation of the Karitane Products Society

with a graph on one side depicting pounds up the X

in 1927 to market the humanised milk products Karilac

axis and age in weeks along the Y axis. On the opposite

and Kariol developed by Truby King as appropriate

side of the page was a chart where the weight has

alternatives to breast milk supported the Plunket

been written in numbers with the date. Weight was

Society in its work, however, raises questions over the

a key measure of infant health and phrases such as

priorities of the Society and its intentions to support

‘bonny baby’ and ‘Plunket baby’ reflected a chubby,

breastfeeding. Karilac was a sugar mixture added to

apparently healthy looking infant. An infant gaining

whole cow’s milk that was designed to resemble the

weight was a healthy infant and inclusion of charts

sweetness of human milk. Its ingredients were lactose,

to measure an infant’s weight was a simple means of

glucose and gelatine.

Kariol (a fat emulsion – also

gauging the health of the infant. Measuring weight

known as NZ emulsion) was designed to supply the fat

was also a further example of the influence of scientific

content of human milk and consisted of vegetable oil,

methods of child rearing, and enabled additional

cod liver oil and dextrose. Advertising by the Karitane

surveillance and monitoring of a mothers’ actions.

40

41

Products Society and another infant formula company Glaxo helped to normalize the process of artificial

Throughout the 1920s and into the 1930s, the content

feeding and further encouraged women to accept

written by the nurse in Plunket books was both

scientific methods of infant care.

descriptive and prescriptive. The nurse would describe

42

the current state of the baby such as ‘baby well’ or The simple text printed in these early books reflected

‘quite normal’.46 The nurse would then offer advice

the dogma of the time with regard to the strict

to the mother – often on feeding and occasionally

parenting routines advocated as the most effective

on the treatment of minor conditions such as skin

way to maintain the health of baby – health that,

rashes. The advice offered by Plunket nurses in the

according to Truby King, was paramount to maintaining

Plunket book was, however, seen as problematic by

and strengthening New Zealand’s population and

some. By 1930, doctors were embroiled in a number

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 33

Nursing Praxis in New Zealand of arguments with Plunket nurses over who should be

of doors all day. Have windows wide open at night

providing what type of care to whom. Doctors did not

keeping baby out of draughts’.53 The emphasis on fresh

believe nurses should be undertaking diagnoses and

air and sunshine was designed to prevent rickets. The

by 1934 nurses were ordered to remove references to

addition of cod liver oil to the diet was for the same

baby illnesses in their annual reports. Examination

reason.54 Baby was also required to be woken for feeds

of the early Plunket books provided examples of why

and to be fed at the same time each day with the times

doctors may have been concerned that nurses were

stringently listed by the nurse in the book.55 Advice was

undertaking diagnosis and prescription of care:

also provided for the mother and in the same book the

47

nurse has written the following: In 1929: “Give 1 table sp of cooled boiled water before feeds until rash is better”.48 In

For Mother. Take three good plain nourishing

1931: “Breast fed 4 hourly. Slightly jaundiced,

meals a day. No between meals, no rich foods.

skin soft. To have magnesia each day till

Drink a cup of water every time baby is fed.

trouble cleared up”.

Have plenty of fresh fruit and vegetables –

49

whole meal bread. Have a good walk out of

By Plunket nurses actively undertaking prescribing

doors every day. Rest for an hour in afternoon

(defined as ‘to direct to be used as a remedy’ ),

with feet up. Sponge nipples before and after

doctors were concerned that their increasing mandate

each feed with boiled water and fresh piece of

in this area would be undermined. By 1941, doctors

cotton wool. Dry nipples well afterwards.56

50

had secured for themselves the sole right to be funded to prescribe medications to the general public.51

Another area of emphasis in these early books was bowel motions. Most of the books have an entry at

Despite doctors successfully lobbying government for

the bottom of each visit describing the current state

the sole right to be funded to prescribe and to force

of the bowels. This would usually be along the lines

nurses to remove any references to diagnosis, Plunket

of ‘motions normal’ or ‘motions hard’ although some

nurses clearly continued to work with families in much

were more descriptive including ‘motions curdley

the same way as previously, in particular with regard

[sic]’57 and ‘motions a little sluggish’.58 More often than

to the writing of prescriptions or directives within

not, a simple N was written at the bottom of the page

the books which continued well into and beyond the

indicating that bowel functioning was “normal”. The

1940s. The need to prescribe care to mothers again

emphasis on monitoring of bowel motions was for two

reflects the biomedical paradigm of the time; the

reasons. First, in the late nineteenth century and into

nurses clearly believed that the best way for mothers

the early twentieth century many infant deaths were

to raise their children was under the direction of a

attributable to diarrhoeal disease.59 Monitoring of

scientifically trained professional.

bowel motions enabled the mother or nurse to pick up

52

early signs of illness and treat accordingly – hopefully One of the key pieces of advice offered by Plunket

preventing avoidable death. The second reason

nurses in the Plunket book was to ‘keep the baby

behind the emphasis on monitoring bowel motions

outdoors’. This was not only printed in the books

was to ensure regularity of habits. Truby King believed

but also reiterated by the nurse. For example, in one

that mothers who reared their children following his

book from 1933 under ‘Helpful Remarks, Advice and

methods emphasising such regularity would raise

Instructions’, the nurse has written ‘Keep baby out

children who were ‘…of sound character and pure in

Page 34

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand thought’.60

Completely weaned.

5 feeds 7oz.

Although most of the writings in the early Plunket

Emulsion ¼ teaspoon a day.

books were inclined toward clinical advice, some

Orange Juice.

nurses commented on things specific to baby. For example, from a 1939 Plunket book, when ‘Vera’ is

40oz recipe

33 weeks old, the nurse has written ‘diet slip given’.

Milk 171/2oz

61

Several weeks later, the nurse has written that Vera

Karilac 3 level tablespoons

‘does not take very kindly to vegetable puree’. Other

Boiling water 221/2 ounces.71

62

examples include the commonly used ‘sturdy boy’63 and ‘fine baby boy’.64 Recipes provided by Plunket nurses during this time were for foods that were simple yet nourishing – oat jelly, barley jelly, apple in muslin, prune pulp and juice, crusts and butter, semolina, spinach puree, knuckle in soup.65 Mothers who were bottle feeding their babies were given careful directives on preparing milk mixtures. Entries into Plunket books show that meticulous adjustments were made according to baby’s weight and tolerance of the previous week’s regime.

Plunket nurses used carefully formulated charts to determine the exact quantities to feed baby.66 Various charts and formulae for calculating milk percentages and caloric values in artificial milk had been developed over time, starting with those by Thomas Morgan Rotch, Charles W. Townsend, and Maynard Ladd in the late 1800s and early 1900s.67 Truby King also developed formulae most likely based on those from overseas.68 In addition to humanised milk, a strong emphasis was placed on vitamin C intake and mothers were encouraged to feed their infants orange juice.69 The recommendation to offer orange juice and cod liver oil to artificially fed babies was to make up for any loss of vitamins in artificial milk through the manufacturing process. Orange juice supplementation was intended to prevent scurvy and as noted above, cod liver oil was added to prevent rickets.70 The entry into this book from 1932 was typical: (Baby is 23 weeks old and weighs 14 pounds 5 ounces.)

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Another common suggestion around this time was to offer baby a bone to chew on - presumably to assist with teething.72 It was also common, if the baby was restless, to give baby cooled boiled water prior to feeds. The underlying rationale was that the boiled water would settle baby and ease wind.

Stringent advice continued to be offered on feeding regimes. As in the book from 1929, in a Plunket book from 1933, the mother is advised to give baby 10 minutes on one breast and 5 minutes on the second.73 Feeding an infant four hourly and not at night resulted in what may well have been an adequate milk supply dwindling and supplementary feeding then being required.

This pattern can be traced throughout

many of the Plunket books. Mothers would initiate four hourly feeding and by the time baby was a few months old, supplementary feeding had been started as mother’s milk supply reduced.74 For those mothers not breastfeeding, the effort required to prepare the humanised milk advocated by the Plunket Society was enough to take up several hours. As an example, a mother in 1941 was given very clear directions on preparing meals for her 2 wk old infant: Feeding 3 hrly, 6 feeds daily 7am, 10am, 1pm, 4pm, 7pm, 10pm 10 ½ milk 10 ½ water – boiling 1 ½ tbsp Karilac

Page 35

Nursing Praxis in New Zealand Kariol: ½ tsp increase by ¼ tsp daily to 4 level

circumstances also impacted on the Plunket Society

tsp in the day divided between the 5 feeds

itself and in 1931, Plunket’s Central Council reduced

At 3 weeks: Orange juice ½ tsp in ½ tsp warm

Plunket nurse salaries.81 The Plunket books from this

boiled water

era, however, do little to reflect any of the economic

Give extra water daily

hardship suffered at this time. Writings in the books

Dissolve Karilac in the boiling water. Add to

in the 1930s consisted of the same instructions found

the milk. Boil 3 minutes. Re-measure and

in the books in the 1920s. This may be because the

make up to 20oz again with boiled water.

majority of women using the services of Plunket

Strain. Cool quickly.

were middle class. Some historians have argued that

Keep cool. Stir before using.

75

From 1920 until 1945 mothers were encouraged to visit the Plunket rooms once a week to have their baby weighed. Plunket books have had age-specific weight charts in them since their inception. There is varying emphasis on feeding or weight in different books from this era indicating no particular aspect was targeted by the Society in the early days of the book. For example, although weight was clearly the emphasis in one book from 1921, a book from 1929 does not have the weight chart filled in at all.76 This is unusual as most books had the weight chart carefully completed. The instructions to the mother in the 1929 book are, however, detailed and include encouraging feeding from both breasts alternating the starting breast at each feed, winding, holding baby out at bathing and encouraging mother to have a rest each day.77 By 1937 there were two weight charts in the book, one for baby up to 9 months and the second from 10 months to 18 months. There continued to be the line representing the average on the second chart but with the addition of a disclaimer at the bottom of the page that stated: ‘Average for Girls, slightly less. Average for Boys, slightly more’.78 The chart was located at the front of the book and was one of the first things to be seen when opening the book.

By the mid 1930s, the economic depression was starting to have a major impact on the lives of working class New Zealand families.79 Wages had been cut and unemployment was at record levels.80 These

Page 36

the hardships suffered throughout the depression were class-based between the employed and the unemployed, indicating that the depression highlighted inequalities between the two that eventually lead to the introduction of a universal social security system.82 The middle (employed) class were affected by the depression differently and the impact was more clearly seen in the changed hopes and aspirations of the generation growing up during this time.83 Motherhood throughout this period was challenging.

During the Depression, May surmises that women were largely powerless yet managed to survive through initiative and hard work.84 The experience of having to make do with what was available shaped women in New Zealand to be resourceful and industrious, setting them up well to cope with what World War Two brought them. However, the experiences of World War Two and the Depression meant that politically New Zealand moved into an era where elections were won based on the economic and social security net respective policies could provide.85 The introduction of the 40 hour working week and the basic male wage by the 1935 Labour government continued to ensure women remained in the home and that their primary role was that of mother and housewife.

By 1938, the impact of the economic depression was clearly continuing to affect the Plunket Society. For the first time, at least in the Auckland region, Plunket published in the Plunket book a note calling for mothers to help maintain the Plunket Society by becoming Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand an annual subscriber.86 Despite the fact that by this

Others found that not only were they required to work

time the country was clearly on its way out of the

in occupations that were previously considered male

Depression due to a range of fiscal policies introduced

but that they were still required to ‘keep the home fires

by J. G. Coates, the incumbent New Zealand Prime

burning’ so that their men would have a home to return

Minister, the Plunket Society continued to ask for a

to.93 Organisations such as the Plunket Society also

donation for services provided and continues to do so

became involved in the war effort. Plunket antenatal

today. The Depression however, ensured the passing

clinics, although curtailed by the introduction of five

of the Social Security Act 1938 into law occurred with

free antenatal check-ups by general practitioners

little protest although doctors offered some opposition

as part of the 1938 Social Security Act, continued to

arguing successfully for the right to charge a top up

flourish in Auckland offering vital support to mothers-

fee for general practitioner services.

The new Act

to-be.94 Plunket also ran a number of lectures on child

introduced a range of welfare reforms that guaranteed

care for volunteers who may be willing to assist with

state support from ‘the cradle to the grave’.

looking after large numbers of children in the event

87

88

89

of an emergency.95 The perpetuation of scientific As women remained within the home during this

motherhood continued.

period, child care and parenting practices continued into the 1940s much as previously. The techniques

Conclusion

of scientific motherhood continued to dictate that the mother must follow the direction of a medical

From the early books of the 1920s to the books

professional – routine and regularity were emphasised

published toward the end of World War II there were

in all the New Zealand publications around child care

few changes. Content throughout the examined

during this time. International experiences were the

period remained much the same, with the rhetoric of

same. Apple argues that by the second quarter of

scientific motherhood perpetuated by the role of the

the twentieth century, letters to women’s magazines

Plunket nurse and the Plunket book having profound

and child care journals from mothers reflected what

influence on mothers. The idea that adhering to the

women were reading and being told by their doctors

strict routines of the ‘Truby King method’ would result

rather than what they were personally experiencing.

91

in a healthy, live infant, meant that women willingly

The Plunket book produced in the 1940s does not

entered into a relationship with their Plunket nurse

differ substantially from earlier books. The cover

and followed the instructions given in their Plunket

still depicts a breastfeeding mother and the book is

books. However, this adherence ultimately silenced

the same size and colour. The advice offered to the

women’s experiential knowledge. The consequence

mother is the same. The 1940s was at the height of

of compliance with strict routines resulted in many

World War Two and as a result, many fathers were

women being unable to continue breastfeeding, as

absent from homes. Older children and grandmothers

milk supply reduced, and also undermined women’s

who may have helped with the younger children were

abilities to trust their own mothering instincts. In the

often sent to work, and mothers were left alone to

next article we will examine how the emergence of

raise their infants. Although, New Zealand women had

a women-centric language over the following years

readily become involved in the war effort, the war had

challenged notions of scientific mothering, resulting

mixed blessings for women. Some found employment

in significant changes in Plunket book content and the

opportunities that they may not have previously had.

practice of Plunket nurses.

90

92

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Page 37

Nursing Praxis in New Zealand Endnotes 1 Jill Clendon and Denise Dignam, ‘Child Health and Development Record Book: Tool for Relationship Building Between Nurse and Mother’, Journal of Advanced Nursing, 66, 5, 2010, pp.968-977.

2 John Sweeney, ‘Historical Research: Examining Documentary Sources’, Nurse Researcher, 12, 3, 2005, pp.61-73.

3 Ibid., p.62.

4 Pamela Wood, ‘Understanding and Evaluating Historical Sources in Nursing History Research’, Nursing Praxis in New Zealand, 27, 1, 2011, pp.25-33.

5 Janet Hargreaves, ‘The Under-Used Resource of Historical Research’, Nurse Researcher, 15, 3, 2008, pp.32-44.

6 Anne McMurray and Jill Clendon, Community Health and Wellness: A Socio-Ecological Approach, Sydney, 2011.

7 Alan Pearson and Karin Hannes, ‘Evidence about Patients’ Experiences and Concerns’, in: Tammy Hoffmann, Sally Bennett and Chris Del Mar, eds., Evidence Based Practice Across the Health Professions, 2nd edn., Sydney, 2013, pp.221-239.

8 Jill Clendon, ‘A Social History of the Plunket Book’, PhD thesis, Massey University, 2009.

9 Gordon Parry, A Fence at the Top: The First 75 Years of the Plunket Society, Dunedin, 1982, p.47.

10 Truby King’s first ‘nurse’ was not registered with the Nursing Council of New Zealand but was working as a nurse at the Seacliffe Mental Hospital with Truby King. She was considered ‘capable and receptive’ (Parry, 1982, p.18) and willing to take part in Truby King’s crusade.

11 Mary King, Truby King - The Man: A Biography by Mary King, London, 1948, p.153.

12 The ‘Truby King Method’ was a specific approach to child rearing that advocated strict techniques of feeding, sleeping and infant behaviour designed to result in a healthy infant and child. Parry, 1982; Stephen Humphries and Pamela Gordon, A Labour of Love: The Experience of Parenthood in Britain 1900-1950, London, 1993.

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

14 Hester Maclean, Nursing in New Zealand, Wellington, 1932, pp.93-94; See also Bryder, p.37. for further discussion on this.

15 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000, p.68.

16 Ibid., p.68.

17 The Royal New Zealand Society for the Health of Women & Children, Hocken Library Archives, Archive number AG7 1-2-1, Literature – Central Council Minute Book 1917-1926.

18 Ibid.

19 The Royal New Zealand Society for the Health of Women & Children, Report of Central Council and Fifteenth Annual Report of the Dunedin Branch, Dunedin, 1922, p.16; Hocken Library archive: Archive Number: AG7 1-3-1. Description: Literature – Annual Reports of Council.

20 The Royal New Zealand Society for the Health of Women & Children, Report of the Central Council and Fifteenth Annual Report of the Dunedin Branch, p.36.

21 Ibid., p.16.

22 Plunket book PBJW1, 1921, Author’s private collection.

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

24 Michel Foucault, ‘The Subject and Power’, in Hubert Dreyfus and Paul Rabinow, eds., Michel Foucault: Beyond Structuralism and Hermeneutics, New York, 1982; Anne Kelly and Anthea Symonds, The Social Construction of Community Nursing, London, 2003, pp.208-228.

25 Olssen, Erik. ‘Truby King and the Plunket Society: An Analysis of a Prescriptive Ideology’. The New Zealand Journal of History, 15, 1, 1981, pp.3-23.

26 Linda Bryder, ‘Perceptions of Plunket: Time to review historians’ interpretations’, Conference Paper presented at New Countries and Old Medicine: An International Conference on the History of Medicine and Health, Auckland, 1994.

27 Philippa Mein-Smith, ‘Mothers, Babies, and the Mothers and Babies Movement: Australia through Depression and War’, Social History of Medicine, 6, 1, 1993, pp.51-83.

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 28 Linda Bryder, ‘The Plunket Nurse as a New Zealand Icon’, 2002, online, available: http://www.nursing.manchester.ac.uk/ukchnm/ publications/seminarpapers/ 30 October 2013.

29 Rima Apple, ‘The Medicalization of Infant Feeding in the United States and New Zealand: Two Countries, One Experience’, Journal of Human Lactation 10, 1, 1994, pp.31-7.

30 Rima Apple, ‘Constructing Mothers: Scientific Motherhood in the 19th and 20th Centuries’, Social History of Medicine, 8, 2, 1995, pp.161-78.

31 Ibid.

32 Apple, ‘The Medicalization of Infant Feeding in the United States and New Zealand: Two Countries, One Experience’ 33 See for example advertisements for infant feeding bottles by ‘Jonas Harrop, chemist and druggist’ in various editions of the Tuapeka Times from1868 and by ‘F. Foster, Pharmaceutical Chemist’ in various editions of the Evening Post from 1870. Both accessed 3 February 2014 from http://paperspast.natlib.govt.nz/cgi-bin/paperspast?a=d&cl=search&d=TT18691016.2.32.1&srp os=1&e+-------100-TT-1----2infant+feeding+bottles-34 King, Truby King - The Man: A Biography by Mary King.

35 Sullivan, Jim, I Was a Plunket Baby: 100 Years of the Royal New Zealand Plunket Society Inc. Auckland, 2007; Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

36 See for example Truby King, Baby’s First Month : Hints to Fathers and Mothers, Wellington, 1913; Truby King, Natural Feeding of Infants, Dunedin, 1917; Truby King, The Story of the Teeth and How to Save Them, Wellington, 1917.

37 Apple, ‘Constructing Mothers: Scientific Motherhood in the 19th and 20th Centuries’; Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

38 Plunket book PBJW1, 1921, Author’s private collection.

39 In areas that were not served by Plunket nurses, public health nurses provided well child services to mothers. It was often mothers in rural and remote areas, low income mothers and Maori and Pacific mothers who were recipients of public health nursing services. Public health nurses provided well child services from around 1953 and continue to provide some well child services to high need families today. Prior to 1953, Native health nurses provided support to Maori mothers and children until the 1930s when the role was combined with school nurses and the nurse became known as the District nurse. This role was then combined with the occupational health nurse to create the public health nurse in 1953 (Alison Garlick, ‘Determined to Make a Difference: A Study of Public Health Nursing Practice with Vulnerable Families’, MN thesis, Massey University, 2006; A.H. McKegg, ‘”Ministering Angels”: The Government Backblock Nursing Service and the Maori Health Nurses, 1909 - 1939,’ Masters thesis, University of Auckland, 1991; Anne McKillop, ‘Native Health Nursing in New Zealand 1911-1930: A New Work and a New Profession for Women’, Masters thesis, Massey University, 1998).

40 Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000, p.92.

41 Ibid., p.92.

42 Karen McBride-Henry, ‘Responding to the Call to Care: Women’s Experience of Breastfeeding in New Zealand’, PhD thesis, Massey University, 2004; Kathleen Ryan, ‘Women’s Narratives of Infant Feeding: The Politics of Knowledges and Practices in Post WWII New Zealand’, PhD thesis, University of Otago, 1998.

43 Parry, A Fence at the Top: The First 75 Years of the Plunket Society, p.13; Philippa Mein-Smith argues that the infant mortality rate had begun declining well before the ‘Truby King method’ of raising infants became a part of many New Zealand mothers’ daily routine despite claims by infant welfare specialists including Truby King that it was changes made as part of the baby health movement (Philippa Mein-Smith, ‘Truby King in Australia: A Revisionist View of Reduced Infant Mortality’, New Zealand Journal of History, 22, 1, 1988, pp.23-43).

44 Plunket book PBJW1, 1921, Author’s private collection.

45 Ibid.

46 Plunket book PBKAH1, 1931, Author’s private collection.

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

48 Plunket book PBPW4, 1929, Author’s private collection.

49 Plunket book PBKAH1, 1931, Author’s private collection.

50 R.F. Patterson, The University English Dictionary, London, n.d.

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Nursing Praxis in New Zealand 51 A. Baker, ‘Setting the Rules: Pharmaceutical Benefits and the Welfare State,’ in Peter Davis, ed., For Health or Profit? Medicine, the Pharmaceutical Industry, and the State in New Zealand, Auckland, 1992, p.19.

52 For example, books from 1942 (PBSC1), 1956 (PBRD) and 1984 (PBPW5) all contain directives of varying types. From 1939: ‘Has thrush. Clean mouth with glycerine and borax before and after feeds until clear’; from 1942: ‘Give baby plenty of boiled water, cough mixture ½ teaspoon every 4 hours after fluids. Mix well: Glycerine, 1 teaspoon, Olive Oil, 2 teaspoons, Orange juice 3 teaspoons.’; From 1956: ‘Rash on face. Vaseline to eyebrows twice daily’; From 1984: ‘Cord on – treat 4hrly with clear meths’, Author’s private collection.

53 Plunket book PBDH1, 1933, Author’s private collection.

54 Rima Apple, Mothers and Medicine: A Social History of Infant Feeding 1890 - 1950, Madison, 1987.

55 Plunket book PBDH1, 1933, Author’s private collection.

56 Plunket book PBDH1, 1933, Author’s private collection.

57 Varying entries from Plunket books PBHN1, 1937 and PBBH1, 1936, Author’s private collection.

58 Plunket book PBKP1, 1939, Author’s private collection.

59 F. Davidson, ‘Infant Feeding in New Zealand: A Review of Infant Feeding Practices from the 1890s to the Present Day’, Proceedings of the Nutrition Society of New Zealand, 9, 1984; Philippa Mein-Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880-1950, London, 1997.

60 Mein-Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880-1950, p.95.

61 Plunket book PBVL1, 1939, Author’s private collection.

62 Plunket book PBVL1, 1939, Author’s private collection.

63 Plunket book PBCL1, 1937, Author’s private collection.

64 Plunket book PBSC1, 1942, Author’s private collection.

65 Many Plunket books included inserts that outlined various food suggestions for infants and young children. See for example Plunket books PBKP1, 1931 and PBVL1, 1938, Author’s private collection.

66 See for example The Royal New Zealand Society for the Health of Women & Children, ‘Hocken Library Archive Ag007-011/054 Records Notebook Containing Recipes for Humanised Milk’, and ‘Hocken Library Archive: Ag-007-011/062 Helen V Walker’s Notebook Containing Recipes and Notes,’ Dunedin.

67 Apple, Mothers and Medicine: A Social History of Infant Feeding 1890 - 1950.

68 Ryan, ‘Women’s Narratives of Infant Feeding: The Politics of Knowledges and Practices in Post WWII New Zealand’.

69 See for example Plunket books PBCL2, 1941 and PBCL1, 1932, Author’s private collection.

70 Apple, Mothers and Medicine: A Social History of Infant Feeding 1890 - 1950.

71 Plunket book PBKP1, 1932, Author’s private collection.

72 See for example Plunket books PBKP1, 1932 and PBDH1, 1933, Author’s private collection.

73 Plunket book PBDH1, 1933, Author’s private collection.

74 See for example Plunket books PBBH1, 1936 and PBCL1, 1937, Author’s private collection.

75 Plunket book PBCL2, 1941, Author’s private collection.

76 Plunket book PBPW4, 1929, Author’s private collection.

77 Ibid.

78 Plunket book PBHN1, 1937, Author’s private collection.

79 Philippa Mein-Smith, A Concise History of New Zealand, New York, 2005.

80 Mein-Smith, A Concise History of New Zealand; Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000.

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

82 Mein-Smith, A Concise History of New Zealand; Margaret McClure, A Civilised Community: A History of Social Security in New Zealand 1898-1998, Auckland, 1998.

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Nursing Praxis in New Zealand 83 Examples of this can be seen in excerpts from the participants in Helen May’s 1988 study on postwar women and their daughters (Helen May, ‘Postwar Women 1945-1960 and Their Daughters 1970-1985: An Analysis of Continuity, Contradiction, and Change in Two Generations of Pakeha Women as Mothers, Wives, and Workers’, PhD Thesis, 1988 and Sue Kedgley’s 1996 book on motherhood in New Zealand (Sue Kedgley, Mum’s the Word: The Untold Story of Motherhood in New Zealand, Auckland, 1996).

84 May, ‘Postwar Women 1945-1960 and Their Daughters 1970-1985: An Analysis of Continuity, Contradiction, and Change in Two Generations of Pakeha Women as Mothers, Wives, and Workers’.

85 Ibid.

86 Plunket book PBVL1, 1938, Author’s private collection.

87 Mein-Smith, A Concise History of New Zealand; McClure, A Civilised Community: A History of Social Security in New Zealand 18981998; Brian Easton, The Nationbuilders, Auckland, 2001.

88 McClure, A Civilised Community: A History of Social Security in New Zealand 1898-1998; Mein-Smith, A Concise History of New Zealand.

89 Michael King, The Penguin History of New Zealand, Auckland, 2003.

90 Mary King’s book ‘Mothercraft’ was the main Plunket publication during this period and was republished approximately every two years from 1934 to 1944 (Mary King, Mothercraft, Sydney, 1934-1944).

91 Apple, ‘Constructing Mothers: Scientific Motherhood in the 19th and 20th Centuries’.

92 May, ‘Postwar Women 1945-1960 and Their Daughters 1970-1985: An Analysis of Continuity, Contradiction, and Change in Two Generations of Pakeha Women as Mothers, Wives, and Workers’.

93 Ibid.

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

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

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 41

Nursing Praxis in New Zealand RESEARCH BRIEF: USING A WIKI TO SUPPORT STUDENT NURSES LEARNING DISCIPLINE SPECIFIC HEALTH TERMINOLOGY Michelle Honey, RN, PhD, FCNA (NZ), Senior Lecturer, School of Nursing, University of Auckland, Auckland, NZ Iain Doherty, PhD, Director, eLearning Pedagogical Support Unit, University of Hong Kong, Hong Kong Lisa Stewart, BA, PGDipHsc, MNurs(Hons), RN, Professional Teaching Fellow, School of Nursing, University of Auckland, Auckland, NZ Danting Wei, Medical Student, University of Auckland, Auckland, NZ This study aimed to clarify whether a collaborative exercise using a Wiki to teach nursing students health-specific terminology resulted in better learning. In one New Zealand School of Nursing a list of health-related and disciplinespecific terms was created, first-year nursing students were expected to learn these before their initial clinical practice.

However, students found the terms difficult to learn. The use of a collaborative Wiki exercise to create a glossary of health terms was seen as a way to aid student learning, while also providing a learning environment where students would develop collaborative skills.

What is a Wiki?

groups to either an undirected Wiki activity (control, n=4), or an intervention group (n=4) where students

A Wiki is a Web 2.0 tool that consists of one or more

were directed to use a Wiki to collaboratively create a

web pages where those with permission can work

glossary of health-related terms. Gains in knowledge

collaboratively to create and edit content. Wiki pages

were measured by pre and post multiple-choice tests

support the use of text, images, and multimedia such

based on the application of health terminology to

as audio and video files. Users can also post comments

short videos of clinical scenarios. Two percent of the

to explain the changes that they made, and see a

course grade was awarded to students as a motivation

history of changes already made. In this study the free

for completing the on-line tests with the 2% awarded,

software, Wikispaces (http://www.Wikispaces.com)

irrespective of test scores. IBM SPSS Statistics version

was used. The introductory page of each Wiki provided

19 was used for analysis, including using a linear

brief information about the purpose of a Wiki, an

mixed-effects models procedure to generate a p-value.

example of what to do, and where to find Wikispaces

Additionally, patterns of Wiki usage were analysed, and

help pages. The process of inviting students to join their

a focus group interview was undertaken to evaluate

respective tutorialâ&#x20AC;&#x2122;s Wiki group was straightforward. It

the student experience of using a Wiki. In second

consisted of entering studentsâ&#x20AC;&#x2122; email addresses into a

semester 2011 student nurses self-selected into eight

form which sent an invite. Students could then accept

tutorial groups of 12 to14 students. The research was

and join their Wiki.

explained to all students enrolled in the introductory

The Study This study used a randomized control trial, where students were randomly allocated in their tutorial

Page 42

Honey, M., & Doherty, I., Stewart, L., Wei, D. (2014). Using a wiki to support student nurses learning discipline specific health terminology. Nursing Praxis in New Zealand, 30(1), 42-44.

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand nursing course, who were then invited to participate.

Additionally, the control groups used more diagrams

Ethical approval was obtained from the organisation’s

and pictures. Neither the total edits made on a Wiki

ethics committee.

page, nor the structure and quality of posts had a significant effect on students’ test results.

Results Focus Group Students (N=111) were invited to participate in this study; 93% (n=103) completed the pre-test and 88%

The focus group provided an opportunity for students

(n=98) the post-test. The overall class pre-test scores

to share their experience of using a Wiki. Ten students

ranged from 6 to 15 out of 15 (40% to 100%). The

from both the control and intervention groups

post-test scores ranged from 9 to 15 (60% to 100%).

attended. When asked about their engagement with

The results indicate that the intervention group had a

the Wiki, a common comment was about just doing

smaller average percent improvement in pre to post

what was required to get the allocated marks: “I did

testing compared to the control group. Further analysis

only what was necessary to gain the marks.” Some

using mixed models, with the treatment as the fixed

students shared that they made more postings

effect and the group as the random effect, resulted in a

leading up to the exam but did not feel they used it

p-value of 0.674, indicating that there is no “treatment

for revision. When asked why they had not engaged,

effect”. That is, the use of a Wiki to create a glossary of

reasons given included: “having no reminders”, “there

health-related terms did not improve test scores.

wasn’t much interaction” and “it was a waste of time”.

Some students were concerned about correcting,

Wiki Use

or commenting on, someone else’s contribution: “I didn’t have the right” and “I may offend the writer”.

The activity on the Wikis was monitored by counting

However, others disagreed. The focus group interviews

the numbers of edits, and both the control and

clarified that this on-line learning activity did not suit

intervention group Wikis were active having a similar

the learning style of all students.

number of edits. In addition, the content of the Wikis was analysed. A matrix was developed and each Wiki

Limitations

was analysed and rated looking at the use of diagrams, quality of the posting, the structure of overall postings

The use of videos and multiple-choice questions in

and inclusion of additional material, such as web

the pre- and post-test were a limitation because the

links, videos (You-Tube) and references. Whilst the

pre-test average score in both control and intervention

intervention groups’ Wikis had more structure and

groups was over 80%, meaning there was no real

tended to focus on the health terminology terms

possibility of showing significant gains in learning.

provided, the contributors provided little additional

Another limitation was the student self-selection

information and did not engage with one another

of which tutorial group they joined. This may have

about any other parts of the course. In contrast, the

led to similar students joining a particular tutorial

control groups used a more informal structure and

group,

their contributions were more like a social networking

group processes and personality dynamics may have

site where a number of discussions took place.

impacted on Wiki groups; but this was not studied.

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

impacting

randomisation.

Furthermore,

Page 43

Nursing Praxis in New Zealand Implications and conclusion was creative use of a Wiki, or a Wiki structured with This study, on the use of Wikis to support student

a specific learning activity. Conclusions drawn from

nurses in learning health terminology found no

this study were the need for an incentive to encourage

significant difference between the intervention

participation, clear instructions about the possible

and control groups. However, Wiki use did enable

benefits and how to use a Wiki, and recognition that

interaction between students regardless of whether it

not all students enjoy on-line learning.

Page 44

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses.

• Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession.

Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal on publication. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board.

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

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

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

•

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

•

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

•

Include a maximum of six (6) keywords.

•

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

•

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

•

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

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

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Page 45

Nursing Praxis in New Zealand Manuscript Submissions •

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

•

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

•

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

•

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

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

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

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

In the case of historical research, referencing compliant with the New Zealand Journal of History is acceptable.

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

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

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

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

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

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Research Briefs Generally should not exceed 1500 words. Content must include a statement of the topic and purpose of the research; participants and the mode of recruitment; what was done (method and procedure for data collection and analysis); and a brief indication of the findings and their implications for nursing. As the material will be read by a broad cross-section of nurses, abstracts from theses are often not suitable in their original form and so require reworking.

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

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

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

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

P O Box 1984

Palmerston North 4440 New Zealand

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

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

Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand NOTES

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Vol. 30 No. 1 2014 - Nursing Praxis in New Zealand

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www.nursingpraxis.org

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