Praxis July 2015 e-journal

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE...

Health professional and family perceptions of post-stroke information Children living with serious complex illness: Health professionals’ perspectives of an integrated model of care Cultural responsiveness and the family partnership model

Volume 31. No. 2

JULY 2015

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) ASSOCIATE EDITOR: Jean Gilmour RN, PhD, MCNA (NZ) EDITORS: Norma Chick RN, Willem Fourie RN, Thomas Harding RN, Stephen Neville RN, Michelle Honey RN, Jill Wilkinson RN,

RM, PhD PhD, FCNA (NZ) PhD PhD, FCNA (NZ) PhD, FCNA (NZ) PhD, MCNA (NZ)

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

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

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

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 2423-012X HANNAH & YOUNG PRINTERS

CO NTE NTS EDITORIAL: ‘These women’, critical reflection and cultural safety

Beverley Parton ........................................................................................................................... 4

ARTICLES: Health professional and family perceptions of post-stroke information

Dianne Roy, Susan Gasquoine, Shirrin Caldwell, Derek Nash......................................................... 7

Children living with serious complex illness: Health professionals’ perspectives of an integrated model of care

Cynthia Ward, Alicia Evans, Rosemary Ford, Nel Glass................................................................ 25

Cultural responsiveness and the family partnership model

Zoe Tipa, Denise Wilson, Stephen Neville, Jeffery Adams............................................................ 35

NOTES FOR CONTRIBUTORS.............................................................................................................. 48

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand EDITORIAL Three telephone calls over several weeks a few years

two dimensionally what one thinks one sees. In

back were the catalysts for what became a nursing

critical reflection, a taken-for-granted image, like the

reflection. As an Aotearoa New Zealand nursing journal,

stereotypical ‘these women’, is viewed from different

Nursing Praxis exists as both repository and conduit

angles in various lights and over time. At each point,

of scholarly articles by nurses to influence nursing

the viewer undertaking critical reflection notes their

practice, including nursing practice with Indigenous

own location, illuminated effects on their viewpoints

Peoples. It is here then, with some temerity, I introduce

now, and on their own inherited perspectives from

Māori women, health care and contemporary realities:

epochs past. The result is that the viewer no longer

A critical reflection (Parton, 2015). I also feel some

sees a trivialised image. Rather it is a complex reflection

confidence. I learnt so much from being employed for

of mobile processes that are historical, social, cultural,

over a decade as a registered nurse by Kokiri Marae

economic, and gendered in nature encompassing

Health and Social Services, Lower Hutt. I am Pākehā

‘these women’ AND the viewer. ‘These women’ can

and I initiated those three calls to secondary health

then become heterogeneous and unique with much

care nurses.

to offer the viewer. The viewer changes, recognising themselves as always being part of the scene.

Advocacy is a nursing role and I was advocate for

Emancipatory action becomes a possibility. The now

three Māori women with whom our service had

participating viewer in close relationship� with ‘these

newly

advocacy

women’ is able to work with the women for change.

included reconnecting each of the three women back

Their health care has the potential to become uniquely

into different secondary health services. With each

and heterogeneously women-centred that enables the

telephone call I received unsolicited advice, the essence

women to recognise the health care as culturally safe.

established

relationships.

The

of which was what to do with ‘these women’. I could not verbally respond. The ‘advice’ contained neither

Critical reflection is a foundational tenet of cultural

knowledge nor understanding of the women’s context.

safety

I vividly recall the third time instantly feeling a physical

Whakaruruhau, is the Aotearoa New Zealand

upheaval within, and an inner voice saying, ‘Right!’

nursing theory birthed by Māori nurses as relevant

That feeling never left me. Māori women’s stories of

for all recipients of nursing care. The nurse through

health and health care engagement encountered in

critical reflection acknowledges a spectrum of the

my practice varied widely; exploring Māori women’s

difference/s between his/her self and the recipient

stories within the context of their contemporary

of their care, and the reality and the effects of her/

realities, and with my employer’s support, became a

his power as a nurse and as a service, which is never

doctoral thesis.

neutral. The recipient of care determines whether

(Ramsden,

2002).

Cultural

safety/Kawa

they have experienced the care as culturally safe. incorporates

Difference, power and subjective assessment are

Freire’s (1972) definition of praxis as “the action and

the kawa, the protocols, that respectfully protect

reflection of people upon their world in order to

and shield (whakaruruhau) in the nurse/ recipient of

transform it” (p.36). To reflect critically is much more

care encounter. The Nursing Council of New Zealand

than a description of a mirrored image, of writing

(2011) now applies Kawa Whakaruruhau in nursing

Nursing

Page 4

Praxis’

vision

statement

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand exclusively to Māori health, in the context of Te Tiriti

If you think about your own favourite physical

o Waitangi. Kawa Whakaruruhau as metaphor, and in

landscape, you will see in your landscape stories of

critical reflection with emancipatory action, has the

the past, ways that what has been, impacts on what

potential to change individual nurse practice, service,

is now. You will see present spaces and places, which

programme or structure.

network and connect, or not. You will consider the future, remembering what has been and hoping for

I was unable to respond to the stated and implied

how it will be for yourself and those who come after

characterisations of “these women” in those telephone

you. The women’s stories inform a critical reflection on

conversations some years ago. I am responding now

their past, present and future landscapes, as related to

– well, I think I can at least begin. I recognise, with

their own health and health care engagement and that

reflection, the insidiousness of the white societal

of their whānau.

power and privilege held by those of us who are white, which includes those not-so white but benefiting from

Culturally safe practice at all levels of health care

the racial hierarchy (Fine, 2004). Whiteness theory

provision is not achieved once and for all time and

informs culturally safe nursing practice, service,

situations. Difference and power in relationships are

programme, and structure in recognising power and

dynamic not static. It is also the reality that culturally

privilege. Kawa Whakaruruhau is an equal partnership

safe practice is not necessarily the same for all

between all others and Māori for the benefit of Māori

Māori women across age and stage of life, sexuality,

health. Nurses’ partnership with Māori promotes

urban/rural,

culturally informed and guided nursing knowledge and

education levels, knowledge of te reo and tikanga,

skills at all levels of health care provision to achieve

and connections to whānau, hapū and iwi. There are

equity (fairness) for Māori, their Indigenous and

without doubt commonalities. Like all relationships,

human right.

our nursing commitment to the recipients of our

employed/work-seekers,

varying

care needs ongoing critical reflection. It requires Fifteen urban Māori women’s stories of their own

our sensitivity to our Te Tiriti o Waitangi partnership

health and health care engagement and that of their

relationship with Māori, whether that is our individual

whānau informed my reflection. Other contributing

nursing practice or within the structures of nursing

layers came from the women reflecting on their

services and programmes. Such is the social justice

individual gift of stories in follow-up interviews,

mandate of nursing.

Māori colleagues and on-going marae-based nursing practice, Māori academics and other critical theorists, reflection on Māori fiction and poetry, and academic

Beverley Parton, RN, BA (Nsg), PGDip (Dist)

supervision. The written form of the reflection informs

Doctoral Candidate

culturally safe nursing practice and the categories of

Clinical Training Associate,

difference and power and subjective assessment. I

Massey University Wellington

have presented the findings as landscapes that are both physical and metaphorical.

� Freire (1972) frequently uses the word “communion”, for example, “Communion in turn elicits cooperation...” ( p.171, authors italics).

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand References Fine, M. (2004). Witnessing whiteness/Gathering intelligence. In M. Fine, L. Weis, L. Powell Pruit & A. Burns (Eds.), Off white: Readings of power, privilege, and resistance (2nd ed., pp. 245-256). New York: Routledge.

Freire, P. (1972). Pedagogy of the oppressed (M. Bergman Ramos, Trans.). New York: Herder and Herder.

Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing education and practice. Wellington, NZ: Author. Retrieved from http://www.nursingcouncil.org.nz/Publications/Standards-and-guidelinesfor-nurses Parton, B. M. (Under examination). Māori women, health care and contemporary realities: A critical reflection (Unpublished doctoral thesis). Massey University, Wellington, New Zealand.

Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu (Doctoral thesis), Victoria University, Wellington, New Zealand). Retrieved from http://www.nzno.org.nz/Portals/0/Files/Documents/Services/Library/2002%2 RAMSDEN%20I%20Cultural%20Safety_Full.pdf

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Dianne Roy, RN, PhD, FCNA(NZ), Associate Professor, Unitec Institute of Technology, Auckland, NZ Susan Gasquoine, RN, MPhil (Dist), Head of Department of Nursing, Unitec Institute of Technology, Auckland, NZ Shirrin Caldwell, RN, BA, M Ed, Lecturer, Unitec Institute of Technology, Auckland, NZ Derek Nash, MSc(Hons), Dip Ed, Senior Lecturer, Unitec Institute of Technology, Auckland, NZ

Abstract The global burden of stroke is increasing. Many stroke survivors live with significant impairment; the care and support they and their families require is complex. Literature indicates some evidence to support the routine provision of information to stroke survivors and their families, but the best way to provide information is unclear. We undertook a mixed methods descriptive survey to ascertain information needs of stroke families through identifying current practice and resources, the appropriateness, accessibility, timeliness and information gaps. The survey, which is embedded in a longitudinal research programme titled ‘Stroke Families Whānau Programme’, was used to gain an understanding of family members’ (n=19) and practitioners’ (n=23) opinions on information provision post-stroke. Qualitative and quantitative data were collected via face-to-face interviews. Descriptive statistics were used to analyse quantitative data; content analysis was used for qualitative data. We found that for families, access to information was variable, both in quality and timeliness.

Most described being overwhelmed initially with information they could not absorb; then later floundering as they had to find their own way through the maze. Few could recall information that focused specifically on them as family members. Health professionals described a range of resources and practices used to provide information. They identified barriers to effective provision of information, including language and other communication barriers, time constraints and workload issues. Most did not assess health literacy levels or consider family needs to be separate to or different from the stroke survivor’s. We concluded that access to appropriate information post-stroke was problematic for most families and was compounded by the nature of the experience; shock following the sudden onset and adjusting to changed family dynamics. Health professionals recognised the limitations of resources, time, and funding alongside the need for timely, quality education for families post-stroke, however, a gap was identified between health professionals’ theoretical understanding of best practice in information provision and their actual practice.

Keywords Stroke; patient education; health professionals; families

Introduction and Background

of New Zealand, 2015). Stroke can have negative

The global burden of stroke is increasing. Despite a

consequences on the health, wellbeing and quality

decrease over the past twenty years in stroke mortality

of life of both the stroke survivor and their extended

rates there is an increase in terms of the absolute

family (Ellis, Grubaugh, & Egede, 2013; Yu, Hu, Efird,

number of people affected every year (Feigin et al.,

& McCoy, 2013). Care and support needs are variable,

2014). There are an estimated 60,000 stroke survivors in New Zealand, many of whom live with impairment and need significant daily support (Stroke Foundation Page 7

Roy, D., Gasquoine, S., Caldwell, S., & Nash, D. (2015).

Health professional and family perceptions of post-stroke information. Nursing Praxis in New Zealand, 31(2), 7-24.

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand can be complex and are dependent on the severity,

survivors and families improved their knowledge of

origin and location of the cerebral trauma, the time-

stroke and aspects of patient satisfaction. A reduction

period post-stroke, socioeconomic variables and

in depression scores was also noted. Three Cochrane

ethnicity (Cecil, Thompson, Parahoo, & McCaughan,

reviews (Forster et al., 2012; Forster et al., 2001; Smith,

2013; Harwood et al., 2012a, 2012b; Moloczij,

Forster, & Young, 2009) have concluded that while

2009). Nurses play a pivotal role in stroke care and

there is evidence that the provision of information is

management across all phases of the stroke trajectory

beneficial “the best way to provide information is still

and, along with other health professionals, can help

not clear” (Forster et al., 2012, p. 16).

alleviate the stresses experienced by families caring for their whānau member who is a stroke survivor

Despite what is known about information provision

(Cecil et al., 2013). There is strong evidence for the

post-stroke, stroke survivors and their families

efficacy of a co-ordinated multidisciplinary team (MDT)

continue to report a lack of knowledge and difficulty

approach to stroke care (Clarke, 2013). Core members

in accessing it (Perry & Middleton, 2011) and feel

of a MDT in stroke care include nurses (often stroke

unprepared for the scope and scale of life changes and

nurse specialists), stroke physicians, physiotherapists

life after discharge from hospital (Forster et al., 2012;

(PTs), occupational therapist (OTs), speech language

Perry & Middleton, 2011).

therapists (SLTs) and therapy assistants (trained to support PTs and OTs). Multidisciplinary teams may

Research Design

also include social workers, needs assessors, and

Aim

community-based support workers such as the

The mixed methods descriptive survey was to ascertain

Community Stroke Advisors (CSAs) from the Stroke

information and education needs of families of those

Foundation of New Zealand. Trained CSAs assist stroke

who experience a stroke (stroke survivors) through

survivors and their families with any stroke-related

identifying current practice and resources, and the

problems. They make hospital and home visits, support

appropriateness, accessibility, method of delivery,

families and can advise on accessing carer-relief

timeliness and gaps in education and information

services and funding. Some MDTs include stroke co-

giving. Specifically, we wanted to know:

coordinators (usually a nurse, PT or OT) within the team whose role is to co-ordinate in-patient rehabilitation

What information and resources were provided

and services for patients and their families post-stroke.

to/received by families across the care

At the participating DHB for this study these stroke co-

continuum?

ordinators are known as key workers.

How information was delivered?

The importance of information and education provision, alongside the right support, for stroke survivors and

What preferences did families have for the way

their families is well documented (Cameron & Gignac,

information was provided?

2008; Cameron, Naglie, Silver, & Gignac, 2013; Draper & Brocklehurst, 2007; Eames, Hoffmann, Worrall,

What, if any, were the barriers and gaps in

& Read, 2010; Larson et al., 2005; Temize & Gozum,

information provision?

2012; Wallengren, Segesten, & Friberg, 2010; Wright et al., 2012). A recent Cochrane review (Forster et al.,

We used a broad definition of ‘information’ to include

2012) showed that information provision for stroke

any information and education provided to families

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand post-stroke; formal or informal. This study is the

participants and consent obtained prior to data

first phase of a longitudinal programme to improve

collection.

support and care outcomes for stroke families. We were particularly interested in what, if any, of the

Participants

information was specifically family-focused and

Family members: Nineteen people from thirteen

inclusive of family members beyond the primary carer

families volunteered to participate. Demographic data

and stroke survivor.

are presented in Table 1.

Methods

Health professional-participants: Twenty three health

A mixed methods descriptive survey design was used

professionals completed questionnaires either by face-

to gain an understanding of family members’ and

to-face interviews (n=21) or electronically (n=2). Their

practitioners’ opinions on information provision post-

work roles were either for the Stroke Foundation as

stroke.

community stroke advisors (n=5) or administrators (n=2) or for the stroke services, both acute and

Recruitment

rehabilitation, of a large district health board (DHB).

Following ethical approval from the Northern X

DHB employees included registered nurses (n=5)

Regional Ethics Committee (NTX/10/EXP/071) 19 family

and an enrolled nurse, occupational therapists (n=3),

members and 23 health professionals were recruited

a stroke physician, physiotherapists (n=2), speech

using purposive sampling strategies. Inclusion criteria

language therapists (n=2) and therapy assistants (n=2).

for family members were: (1) being a family member

Demographics for participant health professionals are

of someone who had experienced a stroke in the

presented in Tables 2 and 3.

previous two years; and (2) adequate spoken English to complete consent and the questionnaire. We invited

Data collection and analysis

multiple members from the same family to participate.

The development of the survey questionnaires was

Family members were invited through flyers posted in

guided by a literature review and stakeholder advisory

clinical areas at the local hospital (which provides post-

group. Two questionnaires were developed; one

stroke assessment and rehabilitation services) and the

for families of people who had experienced a stroke

local Stroke Foundation support groups or directly

in the preceding two years (stroke families) and

through intermediaries (community stroke advisors

one for health professionals, who work with stroke

and outpatient clinic staff).

families. Questionnaires included open and closed questions that enabled collection of quantitative and

Health professionals were invited to participate

qualitative data. Both questionnaires were piloted

if they currently worked with people post-stroke,

and minor changes made to some questions for

either within the hospital and/or the community.

clarity. Electronic/postal versions were available;

Information flyers were posted in clinical areas. Staff

two of the health professionals (both OTs) chose

were also invited to a presentation about the study;

this option. Questionnaires were administered by

there was no active recruitment, but contact details

research assistants in face-to-face interviews with the

were available. Any direct approach to individuals was

remaining participants (n=40). Data were collected

made via intermediaries.

between September and October 2010. Research assistants received prior training in administering the

Information sheets were provided to all potential Page 9

questionnaires and to avoid introducing bias during the Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 1 Table 1.

Participant Demographics: Family Members

Participant Demographics: Family Members

Mean age Age range Gender Male Female Ethnicity NZ European/Pakeha Other Average time since stroke Time since stroke range Employment status (paid employment) Yes No Change since stroke (total) Increased hours Decreased hours Other change Living with stroke survivor All of the time Most of the time Some of the time Do not live with SS Caregiving responsibilities All of the time Most of the time Some of the time Do not live with SS Previous experience in stroke care Relationship to stroke survivor

Family member (n = 19)

Stroke survivor (n = 13)

53 years 14-77 years

63.7 years 42-84 years

4 15

2 11

18 1 1.6 years 0.4-4.111 years

12 1 1.6 years 0.4-4.111 years N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

8 11 11 0 9 2 11 0 4 4 8 4 6 1 4 Wife (n=7) Husband (n=2) Partner (n=1) Son or Daughter (n=7) Brother (n=1) Mother-in-law (n=1)

SS = stroke survivor; N/A = not applicable One stroke survivor whose family participated had a first stroke 4.11 years prior, with a second stroke in the previous two years, therefore meeting inclusion criteria.

1

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

26

Nursing Praxis in New Zealand

HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION

Table 2

Table 2.

Participant Demographics: Health Professionals

Participant Demographics: Health Professionals Profession Registered Nurse Enrolled Nurse Occupational Therapist Stroke Physician Physiotherapist Speech Language Therapist Therapy Assistant Community Stroke Advisor Other Total

Number 5 1 3 1 2 2 2 5 2 23

Workplace Hospital - Rehabilitation Ward Hospital - Rehabilitation Ward Hospital - Rehabilitation Clinic Hospital - Older Adult Service Hospital - Rehabilitation Clinic Hospital - Rehabilitation Clinic Hospital - Rehabilitation Clinic Stroke Foundation - Community Stroke Foundation - Office

HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 3

Table 3.

Participant Demographics: Health Professionals (cont.)

Participant Demographics: Health Professionals (cont.)

Health Professionals (n=23) Work experience in stroke services (no. of years) Mean Range Stroke specific skills/education Yes No Clients with stroke (% of workload) Mean Range Time point on stroke continuum where working with stroke families (multiple responses possible) Acute Rehabilitation Life after stroke/Community

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Number 11.25 1.5-35 19 4 52 5-100 11 11 11

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

27

Nursing Praxis in New Zealand interviews they discussed specific items if necessary,

specifically about the information and education

but did not provide further explanation. Interviews

needs of families. Many responses given suggest

lasted approximately 45 minutes and were held at a

that participants did not consider family needs to

mutually convenient time and place.

be separate to or different from those of the stroke survivor (Table 4).

A range of demographic data was collected from all participants. Health professionals were asked about

Information

development

and

preparation:

their role in development and provision of information

Participants were asked about their role in the

for stroke families, details of what and how they

development and/or preparation of information

provide information and their opinions on if or how

for families. Examples provided included: policy

this might be improved. Family members were asked

development and sign-off (n=3, including two RNs),

about information provision at the time of the stroke

development and facilitation of carer-specific support

as well as information provision since the stroke

groups (n=2), being consulted on readability and

survivor’s discharge.

aphasia friendliness (n=1), and developing education packages (n=1).

All data, including transcribed responses to open questions, were entered into Excel® (Excel 2010,

Information

delivery

and

content:

All

health

Microsoft Corporation, USA) spread sheets to facilitate

professional participants (n=23) provided written

analysis. Descriptive statistics were used to analyse

information, with most (n=12) specifically naming

quantitative data providing a description of the

material produced by the Stroke Foundation. Eleven

characteristics of the sample and the participants’

participants (including all RNs/EN) provided verbal

responses. Content analysis was used to identify and

explanations, including answering questions during

catalogue patterns of response (Burnard, 1991) in

consultations and/or caring moments. The RNs in

the qualitative data. Key topic areas from the survey

particular highlighted the importance of assessing

questionnaires informed the ‘template’ approach

family needs to identify at what level they are at

to thematic content analysis (Newell & Burnard,

before providing information. Other modes of delivery

2011) where the researchers asked questions of the

reported were follow-up contact (phone or in person),

data set. For example, what teaching strategies did

providing hands-on demonstrations (n=3) to stroke

health professionals use? What did families say about

survivors and families, and community follow-up (n=4).

information they received on living with a person

Five participants indicated they provided audio-visual

who has had a stroke? Following this, categories were

material while one (RN) advised on suitable websites.

developed and data organised within these. One

A small range of content examples were provided,

researcher (DR) took overall responsibility, but a whole-

most of which pertained to the stroke survivor rather

team approach was used in the process. Category

than being family-specific.

codes are used to present the findings with qualitative and quantitative findings reported simultaneously.

Teaching strategies: Health professionals reported a

Excerpts of qualitative responses are given in italics.

number of strategies used when providing information.

Three participants (including two RNs) completed

Findings

ongoing assessment of family needs and personalised

Health professionals

information for specific families. One RN noted the

The participating health professionals were asked

importance of talking, building trust and relationships

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION Table 4 Table 4 Table 4 Table 4 Findings Summary: Health Professionals (multiple responses possible) Table 4.

Findings Summary: Health Professionals (multiple responses possible) Findings Summary: Health Professionals (multiple responses possible) Findings Summary: HealthHealth Professionals (multiple(multiple responsesresponses possible) possible) Findings Summary: Professionals

Nursing Praxis in New Zealand

Category: Category: Information Category: development Information development Category: and preparation Information development and preparation Information development and preparation and preparation Information delivery Information delivery Information delivery Information delivery

Information format and Information format and content Information format and content Information format and content content Teaching strategies Teaching strategies Teaching strategies Teaching strategies

Timing of information Timing of information giving Timing of information giving of information Timing giving giving Effective methods of Effective methods of information delivery Effective methods of information delivery Effective methods of information delivery information delivery

Effectiveness of available Effectiveness of available information Effectiveness of available information Effectiveness information of available information Web-based information Web-based information Web-based information Web-based information

Gaps/omissions/lack in Gaps/omissions/lack in information provisionin Gaps/omissions/lack information provision Gaps/omissions/lack information provisionin information provision Page 13

Examples given: n=23 Examples given: n=23 Policy development 3 Examples given: n=23 Policy development 3 Examples given: n=23 Development and facilitation of support groups 2 Policy development 3 Development and facilitation of support groups 2 Policy development 3 Assessment ofand readability 1 Development facilitation of support groups 2 Assessment of readability 1 Development and facilitation of support groups 2 Education package development 1 Assessment of readability Education package development 1 Assessment of readability 1 Provided information from Stroke Foundation (SF) Educationwritten package development 1 12 Provided written information from Stroke Foundation (SF) Education package development 1 Answered questions during caring 12 Provided written information frommoments Stroke Foundation (SF) 11 Answered questions during caring moments 12 Provided information frommoments Stroke Foundation (SF) Follow-up post discharge – in person and phone 11 Answeredwritten questions during caring 12 4 Follow-up post discharge – in person and phone 11 Answered questions during caring moments Hands-on 4 Follow-up demonstration post discharge – in person and phone 11 3 Hands-on demonstration 4 Follow-up post discharge – in person and phone Assessed readiness for and understanding of information 3 Hands-on demonstration 4 6 Assessed readiness for and understanding of information 3 Hands-on demonstration provided 6 Assessed readiness for and understanding of information 3 provided readiness for and understanding of information 6 Assessed Verbal information 6 provided 6 Verbal information 6 provided Written information 20 Verbal information 6 Written information 20 Verbal 6 Audio-visual material 5 Writteninformation information 20 Audio-visual material 5 Written information 20 Advice on suitable websites 1 Audio-visual material 5 Advice on suitable websites 1 Audio-visual material 5 Importance of goodwebsites communication skills ‘listening so as to 12 Advice on suitable 1 Importance of goodwebsites communication skills ‘listening so as to 12 Advice on suitable 1 understand thecommunication family needs’ skills ‘listening so as to Importance what of good 12 understand what the family needs’ Importance of good ‘listening so as to 12 Ongoing assessment of family needs skills and personalising 3 understand what thecommunication family needs’ Ongoing assessment of family needs and personalising 3 understand what the family needs’ information for specific members Ongoing assessment of family needs and personalising 3 information for specific family needs members Ongoing assessment of family and personalising 3 Demonstration techniques equipment 3 information for of specific familyand members Demonstration techniques equipment 3 information for of specific familyand members Individual, group and community based presentations 3 Demonstration of techniques and equipment Individual, group and community based presentations 3 Demonstration techniques and equipment 3 Role plays, group goal of setting and use ofbased visual presentations aids 4 Individual, and community 3 Role plays, goal setting and use of visual aids 4 Individual, group and community 3 Timing according to individual 5 Role plays, goal setting and usefamilies ofbased visual presentations aids 4 Timing according to individual 5 Role plays, goal setting and usefamilies of visual aids 4 Acute phase information need 22 Timing according to individual families 5 Acute phase information need families 22 Timing according to individual 5 On-going information need in rehabilitation phase 7 Acute phase information need 22 On-going information need in rehabilitation phase 7 Acute phase information need 22 Combination of verbalneed and written 11 On-going information in rehabilitation phase 7 Combination of verbal and written 11 On-going information in rehabilitation phase 7 Delivered face-to-face 8 Combination of verbalneed and written 11 Delivered face-to-face 8 Combination of verbal 11 Phone calls, home visitsand andwritten community group classes 7 Delivered face-to-face 8 Phone calls, home visits and community group classes 7 Delivered face-to-face 8 Family meeting with multidisciplinary team 6 Phone calls, home visits and community group classes 7 Family meeting with multidisciplinary team 6 Phone calls, home visits and community group classes 7 DVDs, and other visual aids team 4 Familydiagrams meeting with multidisciplinary 6 DVDs, diagrams and other visual aids 4 Family meeting with multidisciplinary team 6 Key worker to deliver consistent information 1 DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 DVDs, diagrams and other visual aids 4 Information from Stroke Foundation (SF) is superior especially Key worker to deliver consistent information 1 Information from Stroke Foundation (SF) is superior especially Key worker to deliver consistent information 1 “Life After Stroke” 8 Information from Stroke Foundation (SF) is superior especially “Life After Stroke” 8 Information from Stroke Foundation (SF) is superior especially SF DVD/video effective 12 “Life After Stroke” 8 SF DVD/video effective 12 “Life After Stroke” 8 Least familiar/comfortable 4 SF DVD/video effective 12 Least familiar/comfortable 4 SF DVD/video effective 12 Useful for ‘young ones’ 4 Least familiar/comfortable Useful for ‘young ones’ 4 Least familiar/comfortable 4 Never internetones’ for information 5 Useful use for ‘young 4 Never use internetones’ for information 5 Useful for ‘young 4 Concern ‘unreliable’ information 8 Never useabout internet for information 5 Concern about ‘unreliable’ information 8 Never use internet for information 5 Need to ensure ‘credibility, dependability and appropriateness’ 2 Concern about ‘unreliable’ information 8 Need to ensure ‘credibility, dependability and appropriateness’ 2 Concern about ‘unreliable’ information 8 Recommendation of specificdependability site Need to ensure ‘credibility, and appropriateness’ 2 Recommendation of specificdependability site Need to ensure ‘credibility, and appropriateness’ 2 1 Recommendation of specific site 1 Recommendation of specific site Gaps identified - ‘we don’t prepare families enough to be 22 1 Gaps identified - ‘we don’t prepare families enough to be 22 1 caregivers’ Gaps identified - ‘we don’t prepare families enough to be 22 caregivers’ Gaps identified ‘we don’t prepare families enough to be 22 Information in a- range of languages 3 caregivers’ Information in a range of languages 3 caregivers’ Requirements hands-on care, service access, funding 7 Information in of a range of languages 3 Requirements hands-on care, service access, funding 7 Information in of a range languages 3 Information tailored toof specific needs 5 Requirements of hands-on care,family service access, funding 7 Information tailored to specific family needs 5 Vol. 31 No. 2 2015 Nursing Praxis in New Zealand Requirements of hands-on care, service access, funding 7 Information tailored to specific family needs 5 Information tailored to specific family needs 529 29 29 29

information delivery

Delivered face-to-face 8 Phone calls, home visits and community group classes 7 Family meeting with multidisciplinary team 6 DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 Effectiveness of available Information from Stroke Foundation (SF) is superior especially HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION information “Life After Stroke” 8 SF DVD/video effective 12 Web-based information Least familiar/comfortable 4 Table 4 Useful for ‘young ones’ 4 Table 4. (cont.)

Never use internet for information 5 Findings Summary: Health Professionals (multiple responses possible) Concern about ‘unreliable’ information 8 Findings Summary: Health Professionals (multiple responses possible) Need to ensure ‘credibility, dependability and appropriateness’ 2 Recommendation of specific site Category: Examples given: n=23 1 Information development Policy development 3 Gaps/omissions/lack in Gaps identified - ‘we don’t prepare families enough to be 22 and preparation Development and facilitation of support groups 2 information provision caregivers’ Assessment of 1 Information in areadability rangeOF of POST-STROKE languages 3 HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS INFORMATION Education package development 1 Requirements of hands-on care, service access, funding 7 Information delivery Provided written information Stroke Foundation (SF) Information tailored to specificfrom family needs 5 12 co-ordination of information givingmoments 3 Answered questions during caring 11 post discharge in person andusing phone Health literacy assessment Follow-up Yes – informally ‘I simplify–things by not medical jargon’ 10 29 4 Hands-on demonstration No (‘not my role’) 13(2) 3 Assessed for and understanding of information Barriers in information Language readiness including ‘jargon’ 4 6 provided provision Difficulty arranging family meetings 5 Information format and Verbal information Poor quality & limitations of the written information available 26 content Written information Time constraints and workload issues (including follow-up to 6 20 Audio-visual material and the right information at the right 5 assess understanding Advice 1 time) on suitable websites Teaching strategies Importance of good communication skills ‘listening so as to Knowledge gaps None 4 12 understand what the family‘we needs’ Accessing support services need to do more from inside 5 Ongoing assessment family needs and us’ personalising 3 rather than expectingoffamilies to contact ‘post-discharge is information for specific family members scary’ Demonstration of techniques and equipment 3 Changes to make a ‘Changing the culture around educating families. Clinicians do Individual, group community presentations 3 difference not prioritise this.and Recognising thisbased is important so staff are Role plays, goal setting and use of visual aids allowed time to deliver information and develop skills to do so’ 184 Timing of information Timing according to individual families Early family involvement 145 giving Acute phaseof information need Assessment family needs 9 22 On-going information needfor in staff rehabilitation Professional development on strokephase management 77 Stroke specialists/advanced nursing practice 1111 Effective methods of Combination of verbal and written Improve resources including multiple languages and modalities 4 8 information delivery Delivered face-to-face Recognising family visits needsand as different from stroke survivor 27 Phone calls, home community group classes 16 Family meeting with multidisciplinary team DVDs, diagrams and other visual aids 4 Key worker to deliver consistent information 1 Effectiveness of available Information from Stroke Foundation (SF) is superior especially information “Life After Stroke” 8 to encourage patient and family participation. [patient SF DVD/video effective was not the first language. One RN said, it 12 Demonstrating and equipment; showing education] is a challenge with non-English speaking Web-basedtechniques information Least familiar/comfortable 4 Useful for ‘young ones’ families. Using a mixture of visual aids is helpful4as well them how to do things was considered important internet for information 5 as when teaching practical aspects ofNever care use provision. as pamphlets translated into other languages such Concern about ‘unreliable’ information 8 Participants used a mixture of individual and group Mandarin.

Need to ensure ‘credibility, dependability and appropriateness’ 2 approaches including community-based group of specific site Recommendation presentations. Participants used role-plays, goal setting Timing of information-giving: There was general 1 in The latter Gaps identified prepare families enough to betiming to individual 22 andGaps/omissions/lack a variety of visual aids. was noted as- ‘we don’trecognition of the need to tailor information caregivers’ being particularlyprovision helpful for families where English family needs and, as one RN reported, the state of the Information in a range of languages 3 Requirements of hands-on care, service access, funding 7 Page 14 Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand Information tailored to specific family needs 5

Nursing Praxis in New Zealand

29

Nursing Praxis in New Zealand family; it’s not one-size-fits-all, everyone is different.

Stroke book was specifically mentioned by many

Participant nurses reported that it was important

participants (n=8). The Stroke Foundation DVD/

to get information to the family straight away in the

video was noted by many participants (n=12) as

acute phase and for on-going information-giving that

being “useful”, “effective” or “very effective”. Three

reinforced this. They also said it was important to work

participants (RN, OT, PT) were not aware of any such

with individual family needs and avoid bombarding

resource being available, while two others (one a RN)

them with information before they were ready or at a

thought they were only available for staff training days,

time of acute distress.

but not for families. Participants who saw these as effective noted that they should only be used as part

Effective methods of information delivery: The

of an overall package of information and only at the

importance of good communication skills was

right time and if appropriate.

reported by many participants, including all the RNs (n=5). This included listening so as to understand what

Participants were asked their opinion of the

the family needs, engaging in on-going conversation,

effectiveness of web-based information. Overall this

and following up discussion with family after written

was a form of information with which participants

information has been provided. Verbal communication

were least familiar and comfortable: it’s a bit scary.

was considered most effective when supported

Four participants (two OTs, two PTs) thought it would

by written information. Face-to-face was the most

be useful for young ones and likely to become more

often reported means for verbal communication, but

appropriate as the population becomes more computer

telephone calls, home visits and community groups/

literate. Five participants, including two nurses, never

classes were also considered effective by community

use the internet for information or had no idea of

stroke advisors. Family meetings with the MDT were

effectiveness of this method of delivery and eight

mentioned specifically by six participants. Diagrams,

identified the potential for unreliable information and

DVDs and other visual forms of information were

the need to ensure any material/websites are credible,

reported (n=4) as being effective. Six participants

dependable, and appropriate. Only one participant, a

reported assessing patient and/or family needs prior

RN, recommended specific sites to families; advising

to giving information, including assessing readiness for

them not to just ‘Google’ it. Another RN noted that

information (n=2) and understanding of information

while she did not provide information about websites,

given (n=3). One participant (an RN) suggested the use

families will find things and educate themselves.

of a key worker� was an effective method of delivering consistent information to all families.

Gaps/omissions in information provision: Twenty two participants identified gaps. There was general

Effectiveness

of

available

information:

Most

recognition that more effort [is needed] in supporting

participating health professionals noted that the

families: emotional support as well as imparting

Stroke Foundation resources were superior to the

knowledge about stroke. As one RN noted, we don’t

DHB material: The DHB information is boring, too

prepare the family enough to be carers at home.

many words, and no pictures. The Stroke Foundation

When the patient goes home the family expect all

information is better. The Stroke Foundation Life after

will be normal; they aren’t prepared because they’ve

�Key-worker: a designated health professional (nurse, physiotherapist, occupational therapist or speech language therapist) within the stroke care team at the participating DHB whose role is to co-ordinate in-patient rehabilitation services for some patients post-stroke.

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand gone from a setting where nurses do things to no

strategies implemented, or what to improve on, but

professional care being provided at home.

family health literacy is not assessed at all because the main focus is the patient.

Some (n=3) identified the lack of information available in a range of languages, while others (n=7) identified

Barriers

in

information

provision:

Participants

gaps in provision of information about hands-on care

identified a range of barriers from language (n=4)

requirements, access to services and equipment and

and other communication barriers such as health

funding options for any such equipment. Others (n=5)

professionals using jargon, family meetings being

identified a lack of information tailored for each family,

difficult to arrange especially if including a number of

be this related to cultural norms, family dynamics, or

family members. One participant, a stroke physician

readiness to learn.

stated, we need more resources in different languages.

I find it frustrating that I don’t have time to give

Three nurses identified lack of co-ordinated approach to

families what they would benefit from. Trying to get

information-giving in the acute (hospital) phase where

families all together at once is hard. Family whānau

wrong or outdated information is given, information is

meetings are needed to talk through issues. The quality

not co-ordinated in the patient’s folder or information

and limitations of the written information available

is missed due to frequent nursing changes. Finding the

was mentioned by two participants, in particular lack

right balance between giving too much or not enough

of information that focuses specifically on family.

information was also identified as a challenge.

Time constraints and workload issues were identified by some (n=6). A senior RN said, nurses are under-

Health literacy assessment: Participants were asked

resourced. I used to have the time to talk to every

if they or anyone in the MDT assessed health literacy

stroke patient and their family, but then some of my

levels. Nine answered “yes” and 13 “no”; one participant

clinical roles were taken away and I was given financial

did not respond. One senior RN responded, some may

roles, so now there’s no time to do that anymore.

say they do, but they don’t. Those who answered “yes” were asked how this is done. Fifteen participants

There was also recognition that sometimes information

answered in a way that suggested the question was

was given at the wrong time in the post-stroke

not clearly understood. Another explanation is that

trajectory: we give an overload of information at the

participants did not understand what was meant

start and then nothing afterwards.

by ‘health literacy’ or how it might be assessed.

Responses that appeared to relate specifically to

Knowledge gaps: Participants who see families

assessment of health literacy (n=10) identified limited

post discharge (n=13, only 1 RN) were asked what

assessment, most often through asking questions of

(if any) information need or gaps in knowledge they

the families to check understanding; informally (RN),

identified? Five of the 13 said no gaps or described

I’m generally aware if patient and family understand

gaps specifically related to the stroke survivor, not the

(RN), I simplify things by not using medical jargon and

family. Gaps identified specific to families included

I assess through questions asked to the family (OT).

knowing what, where, and how to access support

Two participants (both therapy assistants) indicated

services and resources in the community, the need for

that assessing health literacy was the role of others in

support and education about long-term implications

the MDT. One participant (SLT) stated: there are family

of stroke and the need for health professionals to

meetings to ask questions and assess effectiveness of

be proactive in the community in providing care and

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand support for family: we need to do more from inside

Family members

rather than expecting families to contact us. Post

Family members (n=19) were asked their opinions

discharge is scary … we don’t support people as well

on information provision at the time of the stroke

as we should.

(when the stroke survivor was in hospital) and then about information they had sought or received since

What changes would make a difference? One

discharge. We were particularly interested in knowing

response encapsulated key points raised by many

about family-specific information; such as taking care

participants (n=14): Changing the culture around

of themselves and learning to live with a person who

educating families. Clinicians do not prioritise this.

has had a stroke.

Recognising this is important so staff are allowed time to deliver information and develop skills to do so. Nine

Information provision at time of stroke – living with

participants suggested getting the family involved

a stroke survivor: Participants were asked if they had

early and providing on-going information and support.

received any information about living with a stroke

A co-ordinated approach and improved continuity of

survivor (as opposed to information about stroke),

care was also noted as being important to improving

most (n=14) had not. One participant who stated she

processes. Changing the format and venue of family

had not received information commented: During

meetings (away from the bedside) was also noted.

my husband’s stay in hospital not much information

Seven participants (including four nurses) identified

was given. I felt I didn’t actually want the information

that having more time (having time to assess family

then because my brain felt scrambled, I wouldn’t have

needs) and funding (including for interpreters) would

coped with lots of information.

enable them to be more effective, while 11 (including four nurses) indicated more professional development

The

was required. Four participants (2 RNs, physician, SLT)

information specifically focused on their needs were

suggested a co-ordinated proactive team approach

asked how the information prepared them to support

utilising health professionals with specialised/specific

and care for the stroke survivor. Three reported

expertise: A proactive team approach is needed with

the information as being useful and that they felt

more stroke specialists and advanced practice nurses;

prepared. Two participants (sisters whose father had

only these people can educate effectively.

a stroke) reported that rather than preparing them

five

participants

who

reported

receiving

for their role, the information given was frightening Improving resources, including availability in multiple

and offered no hope, which was devastating. The

languages and a range of modalities such as online and

prognosis for the stroke survivor was initially very poor

DVDs, and taking a multi-cultural approach were also

and this was communicated to the family; preparing

recommended. One nurse noted: They [family] should

us for the worst.

get the level of assessment and caring like the actual patient. Stroke is a family crisis. … Give information

Information provision at time of stroke – information

in the early weeks and build trust. Others said: we

about stroke: Family participants were asked to identify

don’t currently engage family as well as possible.

sources of information (Figure 1). These included

Acknowledge that they [family] have complex needs,

nurse (n=5), CSA (n=4), doctor (n=3), PT (n=3), social

that they need a different type of communication than

worker (n=3), OT (n=2), other health professional

the patient.

(n=3), family/whānau (n=3), other family (n=1).

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION 6

Count

5 4 3 2 1

At time of stroke

0

Post discharge

Source of information

Figure Source of information to (multiple families (multiple responses possible) Figure 1. Source of 1. information provision provision to families responses possible)

The type of information received varied with booklets

a VHS video but had no capacity to play it: I was given a

or written material (n=5) and verbally (n=4) the

video but we had no video player. We only have a DVD

most reported forms (Figure 2). AND The participant who player at home. INFORMATION HEALTH PROFESSIONAL FAMILY PERCEPTIONS OF POST-STROKE responded ‘DVD/video’ noted that she had been given

7 6

Count

5 4 3

At time of stroke

2

Post discharge

1 0 Book

DVD

Verbal

Web

Other

Information type

Figure 2. received by families fromfrom healthhealth professionals (multiple responses possible) Figure 2. Type Typeofofinformation information received by families professionals (multiple responses possible) Page 18

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Participants generally agreed that the information was

answers. Another commented: If we hadn’t made a

easy to understand. Free text comments included:

point of asking and asking again, I don’t think we would

well presented with pictures and easy to understand;

have received any information. ... Communication was

the brochure information was good. Talking with staff

difficult. There were a couple of people who did help

was also good. One participant who did not find the

but majority seemed too rushed, stressed or lazy.

information easy to understand commented: words [terminology] and the process [pathophysiology] of

Participants were asked if they got information from

stroke were hard to understand. There were too many

anywhere or anyone else they had not already told us

medical terms.

about (e.g. health professionals, immediate family) (Figure 3). Of the 14 participants who provided details,

Participants

described

being

overwhelmed

by

seven accessed information via the internet. Friends

paperwork initially. The need to be assertive in

and extended family were also additional sources

information-seeking was also noted: The hospital

of information, often providing books or sharing

staff were marvellous. They gave us information and

their personal experiences of living with stroke. One

pamphlets... I asked all the questions; the staff helped.

participant said: my brother-in-law is a doctor and my

But information was not given voluntarily. Whenever

sister-in-law a nurse so I got info from them.

I saw an improvement I asked questions and got the

HEALTH PROFESSIONAL AND FAMILY PERCEPTIONS OF POST-STROKE INFORMATION 12

Count

10 8 6 4 2

At time of stroke

0

Post discharge

Source of information

Figure 3. Sources of information additional to thatadditional received from health professionals (multiple responses possible) Figure 3. Sources of information to that received from health professionals (multiple

responses possible) All family participants (n=19) were asked the question:

pathophysiological effects of the stroke, including

Remembering back to when your family member was

knowing the early warning signs of stroke, signs of

first discharged, what do you wish you knew then

deterioration, the possibility of seizures, and the impact

that you know now? Seventeen responded. Eight

of personality changes. Many (n=10) wished they had

participants wished they had known more about the

been given more information about the demands of

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand caring for the stroke survivor; the constant care with

ways, but not really. People told me to set boundaries,

every day being full-on, and the stroke survivor not

but I’m not able to do this with my partner. Sometimes

being able to be left alone. While family members

I get frustrated and have to walk away.

knew it would be tough they did not realise how time consuming it would be. Two participants indicated that

Six of the nine thought they had been given the right

nothing could have prepared them for their caring role;

information at the right time. The three who did not

one stating had she known she wouldn’t be sitting here

agree, commented on not getting enough or only

now, while the other might have run a mile had she

getting it at the time of the stroke when they were

known in advance what the demands would be. One

in shock and not able to take it in. One commented:

said: I wish I knew how hard it would be for both sides

The doctors were really busy. I received confusing

[and] how important to get a break when you can.

information, and I really needed someone to explain

Participants reported not being told about support

the information.

groups and other services available post-discharge (n=4). They thought health professionals should have

The final question asked: If you were asked to talk to

given them this information rather than us trying to

someone who had a family member who had just had

find out or hearing it from friends. Participants wanted

a stroke, what is the one piece of information you think

the whole family, not only the primary carer, included

they most need? An extensive range of responses was

in family meetings with health professionals.

given. The responses that pertained specifically to information needs included: There are places out there

Information provision post-discharge: Ten participants

to get help, when dad first had the stroke mum had no

reported receiving no additional information post

one, but found support groups helpful, make contact

discharge (Figure 3). Nine participants received

with others for support; Get as much information as

information post discharge from a range of sources

you can. Get support and have breaks away when

(Figure 1). Written (n=6) and verbal (n=5) forms of

possible; Demand information! Or get someone to

information were the most frequently reported (Figure

ask for you; Doctors give horrific details, but nurses

2) with most (n=8) indicating the material was easy

give more hope and provide comfort; Seek advice

to understand. One commented: it was easier than

from a professional rather than hearsay; The Stroke

the first time when stroke occurred, suggesting that

Foundation and GP have the best advice; The Stroke

there may have been some repetition in information

Foundation are fantastic; Talk to other people who

provision that was useful. Six of the nine indicated that

have been through it, because it’s hard to know unless

their information needs were met at this time.

you’ve been there.

When asked if the information provided prepared

Two representative general comments were: Nothing

them for their on-going role in supporting and caring

can prepare you for it, it’s very sudden and takes time

for the stroke survivor four responded ‘yes’, one

to get through; Family support in those times is very

adding: I wouldn’t have been able to cope without it.

important, be ready for the long haul.

It has given me strength. The on-going support keeps me going. Two said ‘no’, one saying: No information

Discussion

can prepare you for that. The remaining three were

Our study showed that health professionals and

positive in regard to the information provided but were

families value and recognise the importance of

more tentative in their response. One said: In some

information sharing in improving outcomes post-

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand stroke. Health professionals were asked specifically

2010). Health literacy has been defined as “the degree

about the information needs of families. Their

to which individuals have the capacity to obtain,

responses, however, suggest that most did not

process and understand basic health information and

consider information needs of the family to be

services needed to make appropriate health decisions”

separate to or different from those of the stroke

(Kickbusch, Wait, & Maag, 2005, p. 8). The 2006 Adult

survivor. The structure of the questions or the way the

Literacy and Life Skills Survey (Ministry of Health, 2010)

research assistants asked them may have contributed

showed that the majority (56.2%) of New Zealanders

to this finding, although similar trends were noted

have poor health literacy skills. Health literacy

in responses of participants (n=2) who completed

demands increase at times of a new diagnosis (Reid &

the questionnaire online. Access to information for

White, 2012), such as stroke. Health professionals can

families was variable, both in quality and timeliness.

help reduce these demands by incorporating health

Many described being initially overwhelmed with

literacy awareness and best practice strategies when

information they could not absorb. Few could recall

working with stroke families.

information that focused specifically on them as family members, yet they identified unmet needs

Digital literacy is an important component of health

such as understanding the demands of caring and the

literacy. Our findings showed few health professionals

importance of attending to their own health and well-

(and only one nurse) referred families to suitable

being. These aspects are consistent with findings of

websites and were reluctant to or never used

a narrative review of 35 studies exploring information

web-based resources. This is in contrast to family

needs of families of people with chronic obstructive

participants, many of whom used the internet to

pulmonary disease (Caress, Luker, Chalmers, & Salmon,

source information. A recent study of NZ consumers

2009) that identified few studies which addressed,

health information needs found two thirds of the 1783

even peripherally, family needs for information.

participants had used the internet to access health information (Honey, Roy, Bycroft, Boyd, & Raphael,

Health professionals, especially nurses, recognised the

2014), which suggests health professionals need to

limitations of resources, time and funding alongside

overcome their discomfort and enhance their digital

the need for timely, quality education for families

literacy skills and expertise to work with families to

post-stroke. For example, they identified the paucity

identify reliable web-based resources to help meet

of information and education material in languages

their information needs.

other than English. Consistent with practice guidelines (Stroke Foundation of New Zealand and New Zealand

Despite the theoretical position espoused by many

Guidelines Group, 2010) and research evidence

of the health professionals, including nurses, about

(Cameron & Gignac, 2008; Cameron et al., 2013),

the importance of identifying the ‘right time’ for

many spoke of the importance of delivering jargon-

information provision, the practice reality that was

free information at the right time and specific to family

evident in both health professional and family data

needs. They identified using ‘teach-back’ techniques

was that of ‘dumping’ information on families in

to assess understanding, yet there was little evidence

case they ‘missed out’, irrespective of family needs.

of any formal consideration of health literacy levels of

Numerous studies have shown that information needs

either the stroke survivor or family members. This is

for stroke survivors and families change across the

consistent with previous research (Eames et al., 2010;

care continuum (Hanger, Walker, Paterson, McBride, &

Gustafsson, Hodge, Robinson, McKenna, & Bower,

Sainsbury, 1998; Mak, Mackenzie, & Lui, 2007; Wiles,

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Pain, Buckland, & McLellan, 1998) and, consistent with

web-based resources as well as advanced nursing

our findings, many families are overwhelmed by the

scopes of practice, as suggested by a RN participant,

information provided in the acute period only to report

have the potential to address unmet needs in this

unmet information needs post-discharge (Cameron et

population. Changes in practice and service delivery

al., 2013; Eames et al., 2010; Perry & Middleton, 2011).

models may be warranted to enable a proactive co-

Ameliorating the gap between actual practice and best

ordinated approach based on assessed needs for each

practice may require reflection on and evaluation of

family across the care continuum.

current education provision and a re-assessment of how best to deliver quality education that meets the

Strengths and Limitations

needs of both stroke survivors and their families. To

A major strength of this study is that we included a

provide best practice for stroke survivors and their

range of family members, not only the primary carer,

family, post-stroke education should be based on

and that we sought the opinions of a range of health

assessment of health literacy and changing needs

professionals who work with stroke families. The

across the post-stroke continuum.

non-inclusion of stroke survivors may be seen as a limitation, however this was a deliberate strategy as

Recommendations for practice

we wanted to focus specifically on family information

Family centred approaches in stroke care are

needs and stroke survivors’ opinions are more widely

advocated to enhance support and improve outcomes

known. Questionnaires were designed specifically

for stroke families (Cameron, 2013; Clarke, 2014;

for this study. Our sampling strategy, sample size

Fischer, Roy, & Niven, 2014). Such approaches must

and limited ethnic diversity within the sample limits

include recognition that family needs are inter-linked

transferability of findings.

with but different from the stroke survivor and that needs change over time, often alongside the stages

Conclusions

of the stroke trajectory. Nurses and other health

Access to appropriate information post-stroke was

professionals need to work in partnership with families,

problematic for most families, in both quality and

assessing individual and family needs for information

timeliness, and was compounded by the nature of

not only about strokes but also in maintaining their

the experience; shock following the sudden onset

own health and well-being. Family education in the

and adjusting to changed family dynamics. Nurses

acute setting tends to be focused on information about

and other health professionals recognised the

stroke and providing care to the stroke survivor on

limitations of resources, time and funding alongside

discharge. Equally important is the inclusion of social

the need for timely, quality information provision

and emotional support resources (Larson et al., 2005).

post-stroke, however, a gap was identified between

Effective provision of information can be complex

health professionals’ theoretical understanding of best

and time-consuming. It cannot be assumed that

practice and their actual practice. Information needs

family members have the same health literacy skills

specific to stroke families are often overlooked. It is

and information needs (Honey, Roy, Bycroft, & Boyd,

important to communicate effectively with families

2014). It is important to raise staff awareness around

and acknowledge that they may have complex needs

the centrality of health literacy as a pre-requisite

that are different to the stroke survivor’s needs.

for health teaching. Nurse-led initiatives that assess health literacy and the credibility of stroke specific

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Nursing Praxis in New Zealand References Burnard, P. (1991). A method of analysing interview transcripts in qualitative research. Nurse Education Today, 11(6), 461-466. doi:10.1016/0260-6917(91)90009-Y Cameron, J. I., & Gignac, M. A. M. (2008). “Timing it Right”: A conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home. Patient Education & Counseling, 70(3), 305-314. doi:10.1016/j. pec.2007.10.020 Cameron, J. I., Naglie, G., Silver, F. L., & Gignac, M. A. M. (2013). Stroke family caregivers’ support needs change across the care continuum: A qualitative study using the timing it right framework. Disability & Rehabilitation, 35(4), 315-324. doi:10.3109/0 9638288.2012.691937 Cameron, V. (2013). Best practices for stroke patient and family education in the acute care setting: A literature review. MEDSURG Nursing, 22(1), 51-55.

Caress, A. L., Luker, K. A., Chalmers, K. I., & Salmon, M. P. (2009). A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 18(4), 479-491. doi:10.1111/j.13652702.2008.02556.x Cecil, R., Thompson, K., Parahoo, K., & McCaughan, E. (2013). Towards an understanding of the lives of families affected by stroke: A qualitative study of home carers. Journal of Advanced Nursing, 69(8), 1761-1770. doi:10.1111/jan.12037 Clarke, D. J. (2013). The role of multidisciplinary team care in stroke rehabilitation. Progress in Neurology and Psychiatry, 17(4), 5-8. doi:10.1002/pnp.288 Clarke, D. J. (2014). Nursing practice in stroke rehabilitation: Systematic review and meta-ethnography. Journal of Clinical Nursing, 23(9-10), 1201-1226. doi:10.1111/jocn.12334 Draper, P., & Brocklehurst, H. (2007). The impact of stroke on the well-being of the patient’s spouse: An exploratory study. Journal of Clinical Nursing, 16(2), 264-271. doi:10.1111/j.1365-2702.2006.01575.x Eames, S., Hoffmann, T., Worrall, L., & Read, S. (2010). Stroke patients’ and carers’ perception of barriers to accessing stroke information. Topics in Stroke Rehabilitation, 17(2), 69-78. doi:10.1013/tsr1702-69 Ellis, C., Grubaugh, A. L., & Egede, L. E. (2013). Factors associated with SF-12 physical and mental health quality of life scores in adults with stroke. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of the National Stroke Association, 22(4), 309317. doi:10.1016/j.jstrokecerebrovasdis.2011.09.007 Feigin, V. L., Forouzanfar, M. H., Krishnamurthi, R., Mensah, G. A., Connor, M., Bennett, D. A., . . . Murray, C. (2014). Global and regional burden of stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet, 383(9913), 245-254. doi:10.1016/S0140-6736(13)61953-4 Fischer, R., Roy, D. E., & Niven, E. N. (2014). Different folks, different strokes: Becoming and being a stroke family. Kai Tiaki Nursing Research, 5(5), 5-11.

Forster, A., Brown, L., Smith, J., House, A., Knapp, P., Wright, J. J., & Young, J. (2012). Information provision for stroke patients and their caregivers. Cochrane Database of Systematic Reviews (11), CD001919. doi:10.1002/14651858.CD001919.pub3 Forster, A., Smith, J., Young, J., Knapp, P., House, A., & Wright, J. (2001). Information provision for stroke patients and their caregivers.

Cochrane Database of Systematic Reviews(3), Cd001919. doi:10.1002/14651858.cd001919 Gustafsson, L., Hodge, A., Robinson, M., McKenna, K., & Bower, K. (2010). Information provision to clients with stroke and their carers: Self-reported practices of occupational therapists. Australian Occupational Therapy Journal, 57(3), 190-196. doi:10.1111/ j.1440-1630.2008.00765.x Hanger, H. C., Walker, G., Paterson, L. A., McBride, S., & Sainsbury, R. (1998). What do patients and their carers want to know about stroke? A two-year follow-up study. Clinical Rehabilitation, 12(1), 45-52. doi:10.1191/026921598668677675 Harwood, M., Weatherall, M., Talemaitoga, A., Barber, P. A., Gommans, J., Taylor, W., . . . McNaughton, H. (2012a). An assessment of the Hua Oranga outcome instrument and comparison to other outcome measures in an intervention study with Maori and Pacific people following stroke. The New Zealand Medical Journal, 125(1364), 57-67.

Harwood, M., Weatherall, M., Talemaitoga, A., Barber, P. A., Gommans, J., Taylor, W., . . . McNaughton, H. (2012b). Taking charge after stroke: Promoting self-directed rehabilitation to improve quality of life: A randomized controlled trial. Clinical Rehabilitation, 26(6), 493-501. doi:10.1177/0269215511426017 Honey, M. L. L., Roy, D. E., Bycroft, J., & Boyd, M. (2014). New Zealand consumers’ health information needs: Results of an interpretive descriptive study. Journal of Primary Health Care, 6(3), 203-211.

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Nursing Praxis in New Zealand Honey, M. L. L., Roy, D. E., Bycroft, J., Boyd, M., & Raphael, D. (2014). Promoting the meaningful use of health information for New Zealand consumers. Studies in Health Technology and Informatics, 201, 11-17. doi:10.3233/978-1-61499-415-2-11 Kickbusch, L., Wait, S., & Maag, D. (2005). Navigating health: The role of health literacy. Bad Gastein. Retrieved from http://www. ilonakickbusch.com/kickbusch-wAssets/docs/NavigatingHealth.pdf Larson, J., Franzén-Dahlin, A., Billing, E., Arbin, M., Murray, V., & Wredling, R. (2005). The impact of a nurse-led support and education programme for spouses of stroke patients: A randomized controlled trial. Journal of Clinical Nursing, 14(8), 995-1003. doi:10.1111/j.1365-2702.2005.01206.x Mak, A. K. M., Mackenzie, A., & Lui, M. H. L. (2007). Changing needs of Chinese family caregivers of stroke survivors. Journal of Clinical Nursing, 16(5), 971-979.

Ministry of Health. (2010). Korero Mārama: Health literacy and Māori: Results from the 2006 Adult Literacy and Life Skills Survey.

Wellington: Ministry of Health. Retrieved from http://www.moh.govt.nz.Need link to page - remove the fullstop after the URL Moloczij, N. (2009). Sustaining one’s own health and wellness while supporting a stroke survivor: Spouses’ and partners’ perspectives (Master of Health Science thesis, Auckland University of Technology, Auckland, New Zealand). Retrieved from http://hdl. handle.net/10292/654 Newell, R., & Burnard, P. (2011). Research for evidence-based practice in healthcare (2nd ed.). Oxford, UK: Wiley-Blackwell.

Perry, L., & Middleton, S. (2011). An investigation of family carers’ needs following stroke survivors’ discharge from acute hospital care in Australia. Disability And Rehabilitation, 33(19-20), 1890-1900. doi:10.3109/09638288.2011.553702 Reid, S., & White, C. (2012). Understanding health literacy. Best Practice Journal, 45, 4-9.

Smith, J., Forster, A., & Young, J. (2009). Cochrane review: Information provision for stroke patients and their caregivers. Clinical Rehabilitation, 23(3), 195-206. doi:10.1177/0269215508092820 Stroke Foundation of New Zealand. (2015). Facts about stroke in New Zealand. Retrieved from http://www.stroke.org.nz/stroke-factsand-fallacies Stroke Foundation of New Zealand and New Zealand Guidelines Group. (2010). Clinical guidelines for stroke management 2010.

Wellington: Stroke Foundation of New Zealand.

Temize, H., & Gozum, S. (2012). Impact of nursing care initiatives on the knowledge level and perception of caregiving difficulties of family members providing home care to stroke patients. HealthMed, 6(8), 2681-2688.

Wallengren, C., Segesten, K., & Friberg, F. (2010). Relatives’ information needs and the characteristics of their search for information - in the words of relatives of stroke survivors. Journal of Clinical Nursing, 19(19/20), 2888-2896. doi:10.1111/j.13652702.2010.03259.x Wiles, R., Pain, H., Buckland, S., & McLellan, L. (1998). Providing appropriate information to patients and carers following a stroke.

Journal of Advanced Nursing, 28(4), 794-801. doi:10.1046/j.1365-2648.1998.00709.x Wright, L., Hill, K. M., Bernhardt, J., Lindley, R., Ada, L., Bajorek, B. V., . . . Nelson, M. R. (2012). Stroke management: Updated recommendations for treatment along the care continuum. Internal Medicine Journal, 42(5), 562-569. doi:10.1111/j.14455994.2012.02774.x Yu, Y., Hu, J., Efird, J. T., & McCoy, T. P. (2013). Social support, coping strategies and health-related quality of life among primary caregivers of stroke survivors in China. Journal of Clinical Nursing, 22(15-16), 2160-2171. doi:10.1111/jocn.12251

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Nursing Praxis in New Zealand HEALTH PROFESSIONALS PERSPECTIVES OF CARE FOR SERIOUSLY ILL CHILDREN LIVING AT HOME Cynthia Ward, MA (Applied), BN, Chief Executive Officer, True Colours Children’s Health Trust, Hamilton, NZ Alicia Evans, PhD, MBA, BN, Senior Lecturer, Australian Catholic University, Melbourne, Australia Rosemary Ford, PhD, MN, B Hth Mgt., Deputy Head of School, Australian Catholic University, Ballarat, Australia Nel Glass, RN; Dip Neuro Nurs, BA, MHPEd, PhD, FACN, Honorary Professor, Australian Catholic University, Melbourne, Australia

Abstract The aim of this article is to report the findings on health professional’s perceptions of beneficial care for seriously ill children and their families. This paper represents one component of a PhD qualitative evaluation study investigating care provided by a child health Trust in New Zealand. The Trust provides an integrated care model of nursing and psychological support to children with complex health needs and their families who live at home. The research methodology was informed by critical realism. The research method chosen was a focus group. There were twelve health professional participants who worked in collaboration with the Trust team to provide care to seriously ill children. Data were analysed using a realist analysis to identify initial key aspects and subsequent themes. Five themes were identified: collaboration between health providers; effective communication; expert skills; support for colleagues and, after-hours care availability.

Participants perceived the Trust model of care to be integral for children with serious illness, and their families in the community. This study extends our current understanding of models of care for children with complex health needs. It has relevance to health providers who are first ‘on call’ for children with serious illness and their families as well as those involved with continuity of care.

Keywords

2013; McCann, Bull, & Winzenburg, 2012). Parents/

Seriously ill children; health professionals; model of

families are now required to learn how to safely and

care; complex health needs

effectively deliver technical interventions, following instruction from community nurses. Some examples

Introduction

of these interventions are: oxygen and ventilation

Global advances in medical knowledge and technology

therapy, tracheotomy care, suctioning, feeding-tube

have resulted in increased survival of neonates with

care, intravenous nutrition and intravenous drug

complex illnesses. Many of these neonates now live

regimens (Eilas & Murphy, 2012; Maddox & Pontin,

into childhood, however their care requirements

2013; Shuster et al., 2011; Whiting, 2013).

have become more complex (Elias & Murphy, 2012; Maddox & Pontin, 2013; Schuster, Chung, & Vestal,

Shuster and colleagues (2011) described care provided

2011). Previously these children remained in a hospital

by parents/families as a ‘shadow health care’ (p. 91)

setting, however the contemporary care setting is the

system upon which health care services rely. Publically

family home with parents the primary carers and

funded child health care systems would be unable

providers of their child’s technical and personal cares (Dybwik, Tollali, Nielson, & Brinchmann, 2011; Elias & Murphy, 2012; Hewitt-Taylor, 2012; Maddox & Pontin, Page 25

Ward, C., Evans, A., Ford, R., & Glass, N. (2015). Health professionals perspectives of care for seriously ill children living at home. Nursing Praxis in New Zealand, 31(2), 25-34.

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand to function without this level of parental support

Background

(Shuster et al., 2011). Buhler-Wilkerson (2007) argued

It has been well established that families benefit

home care could be the cornerstone of a system to

from health care that is provided in an integrated

meet the needs of the chronically ill. However, the

and co-ordinated way, particularly when the child

management of technical, physical and emotional

is being treated in their home (American Academy

care for children at home has a direct impact on the

of Pediatrics: Council on Children with Disabilities

parent/family in terms of physical, mental health and

and Medical Home Implementation Project Advisory

emotional resilience. Parents often have been found

Committee, 2014; Association for Children with Life-

to experience altered roles, financial burden, marital

Threatening or Terminal Conditions and their Families,

strain, psychological distress (Carnevale, Alexander,

& Royal College of Paediatrics and Child Health, 2003;

Davis, Rennick, & Troini, 2006; Ling, 2012; Santacroce,

Ministry of Health, 2010). Many of these children

2003; Schuster et al., 2011; Whiting, 2013) and low

have complex and disabling health needs, sometimes

quality of life (Al-Gamal, 2013). There continues to

requiring palliation. In response to this, in New Zealand,

be the question of how to deliver funded care that

District Health Boards recommended care models

has the potential to reduce the physical, emotional

for this group of children (Craig, McDonald, Adams,

and financial burden for parent/family carers (Buhler-

Reddington, & Wicken, 2010; Paediatric Society of

Wilkerson, 2007; Shuster et al., 2011).

New Zealand 1997; Paediatric Society of New Zealand, 2008; Smith & Overden, 2007).

It is important that home care for seriously ill children with complex medical needs is provided in the context

In accordance with the District Health Board

of a child health model of care that is family-centred

recommendations and due to identified service gaps

and that a partnership forms between the child, family

(Ward, 2005), a Child Health Trust was established

and health professionals. Fowler et al. (2012) highlight

in 2004 in New Zealand. Its aim was to provide an

that nurse partnership activities are not new to nurses

integrated model of nursing and psychological care for

who work with parents. Fowler and colleagues (2012)

children with serious complex illnesses, being treated

argue that partnership requires nurses to skilfully

at home. There was recognition that parents/families

create the conditions for an effective relationship to

ultimately carried the burden of care for their children

emerge. This then provides opportunity for optimal

at home. This model is based on the Te Whare Tapa

collaboration and coordination to enhance better

Whā health and wellness model developed by Mason

outcomes in care (Barnes & Rowe, 2008; Denboba,

Durie (1996). The model is underpinned by four

McPhearson, Kenney, Strickland, & Newacheck, 2006;

dimensions representing the basic beliefs of life: te

Fowler et al., 2012; Kenny, Denboba, Strickland, &

taha hinengaro (psychological health); te taha wairua

Newacheck, 2011; Price & McNeilly, 2009; Simkiss,

(spiritual health); te taha tinana (physical health); and

2011; Yarwood, 2008).

te taha whānau (family health).

The research reported here aims to contribute to the

At the time the Trust was founded, there was no other

body of knowledge on the topic of health related care

organisation providing continuity of care to children

for seriously ill children living at home and health

with illnesses that were predominantly non-palliative.

service evaluation. This has significance for medical,

Chronicity and complexity of care demanded service

nursing and allied health professionals who care for

delivery that commenced at the time of the child’s

seriously ill children and their families.

diagnosis and to be available throughout the child’s

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand lifespan. While palliative care has significantly

management of health crisis.

developed over the last decade worldwide (Baker, et al., 2008; Ministry of Health, 2012) and hospices

Within the integrated model of care, Trust team

provide holistic care there remains a gap in care and

members and non-Trust health professionals strive to

research for those with chronic complex conditions.

meet the needs of the child and their parents/families.

This population group is increasing as more children

This is delivered through effective communication,

now survive and the complexity of the illnesses is more

collaboration and coordination of care. For instance,

intensive on resources and skill.

collaborative home visits or clinic appointments bring together in partnership the child/family and non-Trust

Carter and Thomas (2011) argue a plethora of

health professionals (nurses, paediatricians and allied

agencies and professionals are required to support

health workers) and Trust team members. The history

this population group. In the United Kingdom,

of the development of the service and its evolution has

challenges for these families have been recognised at

been reported elsewhere (Ward, 2009).

a government level, resulting in the implementation of family and child-centred initiatives such as Every Child

Methodology

Matters, the Early Support Programme and Aiming

The aim of the PhD qualitative evaluation study is to

High for Disabled Children (Carter & Thomas, 2011).

investigate the contribution of the integrated model of care to the welfare of the child with a serious

Bolitho and Huntington (2006) argue that the New

complex illness, the child’s siblings, parents, and their

Zealand government has children’s health as a priority.

professional carers. The methodological framework

These are reflected in strategies and frameworks such

was multi-layered critical realism that incorporated

as the: Child Health Strategy (Ministry of Health, 1998);

the identification of key ‘realist’ themes and emergent

He Korowai Oranga (King & Turia, 2002); The New

critical themes. Bhaskar (1975), recognised as the

Zealand Health Strategy (King, 2000); and The Primary

founder of critical realism, was influenced by Marx’s

Health Care Strategy (King, 2001). However, the reality

work. Bhaskar, (1975) divided critical realism into three

is that caring for seriously ill children in the community

domains: the empirical, the actual and the real. The

has huge impact on families in New Zealand (Barnes

‘empirical’ is described as the observable encounter

& Rowe, 2008), with limited resources available to

that happens and exists according to our immediate

meet the need. There is much more to do to improve

experience. The ‘actual’ refers to what happens

services to this population group.

independent of the observer and the ‘real’ refers to objects, their structures and their causal powers, or

The Trust is situated in a residential house, containing

the domain that includes mechanisms that produce

offices and therapeutic spaces. The Trust employs

different events (Alvesson & Skoldberg, 2009). Bhaskar

four clinicians who provide a variety of clinical nursing

(1975) describes ‘reality’ as complex, structured and

and psychological cares for the child/family on-site at

multi-layered.

the Trust, in the family home and in acute inpatient care services. At any time, Trust team members care

Pawson and Tilley (1997), influenced by Bhaskar’s

for 130 – 150 children/families, in terms of symptom

work, extended the realist belief, going on to create

management,

Realist Evaluation which has its roots in realism. Realist

family

counselling/psychosocial non-Trust

Evaluation is concerned with identifying underlying

health professionals, and 24 hour on-call nursing for

causal mechanisms, how they work and under what

support,

Page 27

collaboration/advocacy

with

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand conditions. This produces a closer understanding of

responsible for recruitment and data collection. There

what causes change (Pawson & Tilley, 1997). For this

were 12 focus group participants from the hospital

study, the realist lens allowed the authors to explore

and community. They comprised of nursing, allied

the distinctive nature of the integrated model of care;

health and medical personnel, thus representing the

how it worked, what was involved and what possible

key disciplines and professional expertise required to

causal relationship contributed to the outcomes of

provide care for children. The Child Health Trust works

care for families (Pawson & Tilley, 1997).

with a vast number of health professionals from other agencies. Excluded from the research were those

Data collection

health professionals who were not direct key referrers

Data were collected through three methods: individual

or who did not work in close collaboration with the

interviews, focus group interviews and researcher

Trust team.

reflective

journaling.

Individual

semi-structured

interviews were conducted with children, who were

Data analysis

patients of the Child Health Trust. Separate focus

Utilising a critical realist approach the de-identified

groups were conducted with the child’s siblings,

transcript was read and searched to find emerging

parents, and the health professionals involved in care

aspects, repeated patterns that resulted in realist

of these children. This article focuses on the focus

themes. Interpretation and theorising from the whole

group data from the health professionals and the

story and its meaning was sought, with the attention

identification of realist themes.

of focusing on the ’what’ in the story, rather than ‘how’ it was told (Braun & Clarke, 2006; Liamputtong,

Health professional focus group

2010). A systematic approach determined the rigour of

The focus group was facilitated with open ended

data analysis that was applied within the framework

questions used to elicit information from participants.

of familiarisation, identifying themes, manual coding,

Examples of these questions were; “what are

mapping and recoding of themes for the purpose of

some of the differences you see for families once

understanding until saturation of these themes had

they have started engaging with the Trust”, “how

been attained. Reflexive journaling by the first author,

is communication conveyed, with you as health

kept an ongoing record of experiences and reactions

professionals, the Trust and the families”, “to what

that helped inform the decisions made regarding

extent do you find the Trust helps you find solutions

assumptions and the subject material.

when working with families”? The focus group was audio-recorded, transcribed verbatim and analysed

Ethical considerations

initially for identification of any key emerging aspects

As the first author is employed by the Trust and close to

and subsequently the development of realist themes.

the work, a research assistant that was not associated with the Trust joined the research team specifically

Participants

for participation recruitment, data collection and de-

Participants for this study were health professionals

identifying the original data. The study was approved

who referred paediatric patients to the Child Health

by the Australian Catholic University Ethics Committee,

Trust. They were recruited from the local hospital and

Melbourne (201327V).

community agencies. Fifty-eight health professionals were sent an information pack which included a letter

Findings

of invitation to contact the research assistant who was

Health professionals willingly shared their perspectives

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand of the integrated model of care used by the Children’s

‘that’ [emotional support] is taken care of…

Care Trust. Participants viewed the integrated model

parents don’t need to talk to me about it. [The

of care as both positive and a vital aspect of care

Trust] is more appropriate, so it complements,

delivery. Participants discussed what they valued as

and they know that they are there for the

attributes of the Children’s Health Trust in providing

emotional support and they are very good with

the integrated model of care to children and their

boundaries on what their role is and what our

families. They also acknowledged the attributes they

role is.

valued in their relationships with the Trust. There were five themes that characterised perspectives of

Another participant stated:

the integrated model: collaboration between health

My job is to go in and work with the child who is

providers, transparent communication, expert skills,

acutely unwell, and a lot of the time I will be in a

support amongst colleagues and access to after-hours

room with a child who is extremely unwell and

care.

in fact the [Trust member] will often come and sometimes take the parents from the room, or

Valued Attributes of the Integrated Model of Care

sit with the parent in the room, and it actually

Collaboration between health providers

allows me to focus on just the child, which is,

Participants in this study perceived the integrated

as far as I am concerned really my main job,…

model of care to complement their ability to provide

knowing that the family have that support.

care. Under the auspices of the integrated model

[They] are there at the same time as me, as I am

of care the Trust team members worked with the

providing more of the medical care for the child.

parents and families to provide emotional support.

Participants reported this as a very important aspect

Effective Communication

of care. Non-Trust health professionals reflected that

Communication with the Trust team members was

previous to the integrated model of care, they had

strongly valued by study participants. They reported

endeavoured to appropriately respond to emotional

that effective communication was essential when

disclosures. They now believed their responses did not

multi-agencies were involved with a child’s care. This

necessarily result in the best family outcomes. Clear

transparent communication facilitated the attainment

role definitions and boundaries between non-Trust

of child/family carers’ goals. Participants were highly

health professionals and Trust team members have

appreciative of the role of Trust team members as a

resulted in greater efficacy of care provision. Non-Trust

mouthpiece for the child/family. They thus received

health professionals are now free to use their own

important information about responses to care, and

scope of skill, knowledge and expertise to best effect.

were able to appropriately vary the care. Participants reported

One participant stated:

that

this

transparent

communication

supported their professional relationships with

The integrated model of care kind of

families. This then enabled further very useful

complements our service. Prior to [the

conversations regarding the care of the child.

integrated model of care]…families would disclose something to you and so we would try

One participant said:

and deal with it possibly not in the best way. I

I often talk [with the Trust team member after

find now that I go in and do my job which is to

she has had] a meeting with a family… and she

check medical interventions and knowing that

will say, I have spoken with mother and gained

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand her permission, and there is always that, mum is

what is being said, and what is being reflected.

aware that this is what I am going to tell you….

There is always a plan at the end of it, I think

if she feels that there is something that I need

they are very skilled at that….and they have the

to know to help me give better care, and better

knowledge and the skill to bring people back

support, then she has no hesitation in asking

and settle them down… communication wise

their permission, and seeking me out and telling

they have got it.

me and that has worked really well you know, time and time again. So it’s a very transparent

Expert Skills

process.

Participants

acknowledged

that

medical/nursing

knowledge and medical technology have enabled Study participants noted the important communication

children to survive what were previously fatal

role provided by Trust team members in the event that

conditions. They were also very aware of their need

a sick child was hospitalised. Parent-carers were often

to continually learn and adapt their clinical practice

unsure how to relinquish their care role and allow

in a rapidly changing care environment. Participants

health professionals to take the lead. An admission

acknowledged that Trust team members demonstrated

to acute care provides the parent-carer with a period

advanced skills in symptom management, end-of-

of respite. During this time they were encouraged

life care, and family communication strategies. This

by Trust team members to be fully in their role as

sharing of expertise, guidance and mentoring was an

parent. Participants described the Trust team as being

aspect of the integrated model of care that was highly

committed to finding workable solutions for families,

valued by participants and contributed to their own

and working hard to ensure the voices/needs of the

knowledge and skill base.

child, parent and family were heard.

One participant stated: It was stated that:

[The Trust team members] have the ability to

…it links back to patient advocacy, so when

talk things through, raise issues, sometimes

you have got a family who have a long-term

about my treatment, perhaps with the child…

hospitalisation and there are difficulties for

the nursing background…part of what [they] do

parents to know what their role is and when

is advising health professionals particularly at

they don’t agree with the consultant or some

end of life.

of the medical decisions [the Trust team members] have worked alongside us really well,

In relation to one of the Trust team members, the

and alongside the family really well in order

participant further reflected:

to provide the best care for the baby and the

Because of [her] level of knowledge in terms of

family.

symptom management and pain management, and all that stuff she gives a lot of advice to

Another participant shared:

nursing and medical staff about medications

In patient meetings, [inclusive of parents,

and the right path to take…. [this has resulted

the Trust team members] are very skilled at

in] up skilling all of us in our end of life care.

saying… ‘Now what I am hearing is’… there is a lot of validation so that everybody that is sitting around that table is very clear about Page 30

It was further stated: I think they have skill and sensitivity [in] Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand listening to families and also siblings, who can

is going on and advise them what to do… when

be very young children [about end-of-life care

it is happening, at the time.

and issues]. They really engage in a positive way with them as well, and can normalise it in a good way for some of those families.

Another participant shared: ….when they [the parents] take their baby home from us, they are really scared about what is

Support amongst colleagues

out there, and to know that they have the home

Study participants reported that Trust team members

care nurses and they have [Trust team members]

provided emotional and practical support to children

who have that ‘in the middle of the night stuff’,

and

that phone call to ask that question,… it’s just so

their

families.

In

addition,

much-needed

support was extended to themselves as health

important and brings their anxiety down.

professionals. Participants reported the heavy burden they experienced at times within the emotionally

Considering the strong approval for the 24 hour on-

confronting nature of their care role with children with

call service provided by Trust team members, it was

serious complex illnesses. The collegial support from

not surprising to see health professionals’ anxiety

the Trust team members was very welcome at such

over the vulnerability of the service. Participants were

times; it enhanced their care delivery and made them

concerned for the welfare of Trust team members in

feel less isolated and lonely in their clinical work.

terms of the heavy load that could occur during the overnight call service. They were also concerned about

For example: I first began in NICU [the Neonatal Intensive

the sustainability of the Child Health Trust and the need for ongoing funding.

Care Unit] my second week and we had a crisis in the ward, I just freaked you know…. The Trust

One participant reported:

team invited me back to talk, and really it was a

That is a weakness that I know they are aware

complete debrief… They seem to know when we

of. I have spoken to the [Trust team members]

need them… they just seem to know when you

many times and it is potentially a big issue, that

are going through rough times.

they provide 24 hour service… probably to the detriment of the [Trust team members’] mental

After-hours care availability

health… I worry a lot about that after-hours

After-hours support provided by Trust members was

service.

recognised by participants as an important component of care for the parent/family. This is particularly in

Another participant said:

relation to minimising anxiety when their child’s

I have tried really hard to get [District Health

condition deteriorated. The participants highlighted

Board] funding… it is a problem because they

the benefit and assurance this provides to families.

have a huge proportion of the clients. I just definitely worry about that after hours stuff, it

One participant stated: And the after-hours stuff is huge; I think whether

is a big problem and I know that the [Trust team members] are aware of it.

it’s for a health crisis or an emotional crisis. The family knows that they can call and get [a Trust

Discussion

team member] to talk them through whatever

There is an abundance of literature regarding children

Page 31

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand who live with serious complex illness and rely on

them to increase their own skills, along with improving

technology for their survival (Dybwik et al., 2011; Elias

care to children and their parents/families. There is

& Murphy, 2012; Maddox & Pontin, 2013; Schuster et

a clear need for health professionals who work with

al., 2011). These children are predominately cared for

children to strengthen their knowledge of paediatric

by their parents in the family home, a role that is seen

and family health. A shared understanding between

as the ‘norm’ by health service providers and society in

all those providing health services and a high level

general. Parents provide a ‘shadow health care’ service

expertise ensures better care for children and their

on which health professionals have become reliant

families (Law, McCann, & O’May, 2011). Health

(Shuster et al., 2011, p.91).

professionals in this study found this shared knowledge and competency to be supportive of their care role

This study supports Shuster and colleagues (2011)

with seriously ill children and their families.

previous finding that parents provide high levels of care in the home, care that in previous years was

While after hours care was deemed to be an important

provided in a hospital setting. Participants in this study

benefit to families, study participants also noted

acknowledged the heavy demand faced by parent-

that limited resources might eventually reduce this

carers as they manage the long term care of chronic

aspect of the IMC provided by the Child Health Trust.

complex illnesses in their child.

Participants stressed the need for further funding and resources for this part of the service to strengthen

Study participants reported the integrated model of

capacity and ensure sustainability.

care provided by the Child Health Trust to be a vital service for parents and families through its provision

Limitations

of clinical and psychosocial support. The integrated

The

model of care had positive benefits for children, their

therefore, bias may have been introduced during

families and health professionals, one of which was

data interpretation and analysis, when perceiving

collaboration and communication. The importance

participants words in a particular way. An external

of collaboration between service providers should

research assistant was invited to join the research team

not be underestimated given its role in supporting

specifically for participation selection, data collection

good outcomes (Yarwood, 2008). Hewitt-Taylor (2012)

and de-identification of the data to minimise this risk

stresses the need for collaboration and communication

and strengthen the rigour of the research.

first

author

was

an

insider

researcher,

to achieve a common understanding between all concerned and to ensure service provision directly

Conclusion

meets the needs of parents/families.

There has been a paradigm shift in health care over the last decade due to babies now surviving into

Another benefit of the integrated model of care was

childhood. They also now live at home with complex

the expertise provided by the Trust team members to

illnesses. This brings a greater demand of care from

the non-Trust health professionals. This is a significant

both

finding because it is known that clinical expertise leads

involved. Currently parents provide care that was once

to positive results for both families and other health

provided by clinicians, regardless of the complexity of

professionals providing the care (Carter & Thomas,

care and the technical skill required. In New Zealand,

2011). Health professionals in this study believed the

a Child Health Trust was established in order to assist

expertise provided by Trust team members assisted

families in these difficult circumstances. The findings

Page 32

parents/families

and

health

professionals

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand presented here are one part of an evaluation of this

children and their parents/families. The findings of

service. The findings highlight the importance that

this study are important in providing evidence that the

health professionals place on the contribution that

service is valued by health professionals. That parents

a service such as the Child Health Trust’s integrated

carry a high burden in their caring role is confirmed

model of care brings to children with serious complex

in this study. The integrated model of care provides

illnesses, and their families. Health professionals

a service that is vital in supporting those providing

identified benefits to both the children and their

the care; whether that is parents/families or health

families and to themselves as health professionals.

professionals overseeing this care.

These benefits included; transparent communication, support and collaboration between all parties, expertise in skills and reduced anxiety and fear for

“Thank you to Rodmor Charitable Trust for funding this research project”

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Zoe Tipa, Doctoral Candidate, MPhil, BHS(Nursing), National Advisor Māori Health, Plunket, Auckland, NZ Denise Wilson, MA(Hons), PhD, RN, Professor Māori Health, Auckland University of Technology, Auckland, NZ Stephen Neville, MA(Hons), PhD, RN, Associate Professor, Auckland University of Technology, Auckland, NZ Jeffery Adams, BA, MA (Applied), PhD, Senior Research Officer, The SHORE and Whāriki Research Centre, Massey University, Auckland, NZ

Abstract: A major New Zealand well child care service requires its nurses to establish functional relationships with clients, their family/whānau, and children. The Family Partnership Model is used to develop nurses’ knowledge, skills and techniques to establish partnership relationships and effective communication with vulunerable clients. The cultural responsiveness of the Family Partnership Model for working with Māori (indigenous people of New Zealand) whānau was investigated within the well child context. We asked, does the Family Partnership Model support culturally responsive nursing practice within the well child context? This mixed methods study involved two phases: Phase 1 – an online survey with 23 nurses who had completed the Family Partnership Model training, and 23 who had not; Phase 2 – observation of nurses’ practice and interviews with 10-matched nurse-Māori client pairs. Quantitative data were analysed using descriptive statistics, while qualitative data were thematically analysed. Some differences were found for those who had completed Family Partnership Model training in qualities that are necessary precursors for culturally responsive practice, and in areas indicative of culturally responsive practice. Three themes identified were: having respectful relationships, being client-led, and lacking the skills. The Family Partnership Model appears to support some development of areas necessary for culturally responsive practice with vulnerable clients. However, we recommend further work and research is required to support nurses to develop their cultural responsiveness and translate this into their practice.

Key words Well child care; family partnership model; child and family nursing; Māori; nurse-patient relationship

Introduction

Partnership Model, developed in the United Kingdom the

(Davis, Day, & Bidmead, 2002). The Family Partnership

relationships developed between nurses and clients,

Model is based on establishing relationships and

and is necessary for the clients’ and whānau (extended

communication for working with others, and informs

family) cultural needs to be incorporated into care

a programme to develop knowledge, skills and

delivery. The health and wellbeing of Māori children

techniques for those working with children and their

and their whānau is an ongoing concern for the

families. Plunket nurses undertake a 10-session Family

delivery of health and social services in New Zealand.

Partnership Model training that aims to enhance their

The Royal New Zealand Plunket Society (known as

communication and ability to establish partnerships

Cultural

responsiveness

is

contingent

on

Plunket) provides well child services to 90% of children and their families nationwide, and to 65% of Māori children born in 2010 (Royal New Zealand Plunket Society, 2012). Plunket is committed to the Family Page 35

Tipa, Z., Wilson, D., Neville, S., & Adams, J. (2015). Cultural responsiveness and the family partnership model. Nursing Praxis in New Zealand, 31(2), 35-47.

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand with families. However, it is not clear if the Family

of children (Tipene-Leach, 2012). Yet, despite Māori

Partnership Model supports culturally responsive

reporting good health in the 2012/13 New Zealand

nursing practice. In this article we report the findings

Health Survey, ongoing health inequities for parents

of a study investigating whether the Family Partnership

and their children are evident, such as unmet health

Model influenced culturally responsive practice for

needs (Ministry of Health, 2012b).

nurses working with Māori whānau.

Providing culturally safe and responsive care is crucial

Background

for reducing health disparities and inequities for Māori

Māori, indigenous peoples of New Zealand, experience

(Robson & Harris, 2007; Wilson & Barton, 2012).

persistent inequities in health status and outcomes,

Cultural responsiveness is grounded in worldviews,

similar to other Indigenous peoples who have histories

relationships, cultural contexts, and connecting in

of colonisation. They comprise 14.9% of the New

‘culturally-normed’ ways of functioning (Werkmeister-

Zealand population (Statistics New Zealand, 2013).

Rozas & Klein, 2009). Werkmeister-Rozas and Klein go

Ninety percent of Māori live in households with other

further, stating cultural responsiveness is a “cocreated

family members, and of these, 42.9% are couples

reality between worker and client” (p.6). This concept

with children, 26.5% are single adults with children

defies the adoption of universal or one-size-fits-all

and 11.5% in multi-family households (Te Puni Kōkiri,

approaches. In addition to practitioners’ awareness of

2011). Many Māori women have children at a younger

their own cultural positions, cultural responsiveness

age than other women living in New Zealand, are

is informed by a critical analysis of Māori whānau

disconnected from their iwi and lack wider whānau

realities in terms of equity, social justice, rights,

support (Ritchie, 2007). Consequently, Māori whānau

intersectionality, and complex interactions that impact

and children are often deemed at risk and vulnerable.

their daily lives (Anderson et al., 2009; Bellon-Harn

For example, Māori children suffer health disparities

& Garrett, 2008; Kelly, 2009; Pauly, MacKinnon, &

and inequities at higher rates than other children living

Varcoe, 2009). In this article, cultural responsiveness

in New Zealand (Ministry of Health, 2012a, 2012b).

refers to nurses working alongside clients to provide culturally supportive care, which incorporates the

Health inequities occur within a complex context

differences and needs that exist between themselves

that

and clients to optimise safe and responsive well-child

includes

being

indigenous;

experiencing

discrimination, poverty and unemployment; and

care delivery that meets their cultural needs.

having low levels of education. Many Māori children live in areas of high deprivation, with 41% of

Walker (2004) identified that in order to be responsive

Māori whānau living in neighbourhoods with high

to individual Maori needs, issues need to be explored

deprivation (NZDep 2006 deciles 9 and 10) compared

within the context of their wider whānau. For Māori,

with 15% of non-Māori, while 73% of Māori live in

the obligation and orientation of the collective whānau

deciles 6 to 10 neighbourhoods compared with 44% of

and community surpasses the general focus of health

non-Māori (Ministry of Health, 2010). There is a high

services on individuals (Metge, 1995). Therefore,

likelihood that Māori children will live in poverty, an

the nature of the partnership between nurses and

adverse experience that impacts lifelong health and

Māori whānau is fundamental to a culturally safe

social outcomes (Marie, Fergusson, & Boden, 2008;

and responsive well child service delivery. In New

Poulton et al., 2002). The health system has a role

Zealand every registered nurse is required annually to

to manage improvement in the poor health status

demonstrate cultural competence, of which cultural

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand safety is a core component. It is clients who determine

agreement of aims and processes; mutual trust and

whether the quality of their care is culturally safe or

respect; openness and honesty; clear communication

not (Nursing Council of New Zealand, 2011; Ramsden,

and negotiation” (p. 1). They suggested the term

2002). However, a criticism of cultural competence is

‘partnership’ is often not examined or defined within

the lack of client and whānau input into the process

health policy and services, thus professionals and

of determining whether nurses are ‘culturally safe’

consumers have difficulty in determining its success.

practitioners (Wilson, 2008).

While Braun et al. mention the role of personal constructs, an absence of research about the cultural

The Family Partnership Model provides a framework

responsiveness of the Family Partnership Model also

for health professionals to support families considered

exists. We aimed to establish whether this model could

to be vulnerable. Rossiter, Fowler, Hopwood, Lee and

promote culturally responsive practice for Plunket

Dunston (2011) defined vulnerable families as those

nurses working with Māori.

with, “... circumstances characterised by relationship breakdowns, ineffective parenting and disruptions

Research Design

in secure attachment between young children and

A two-phased mixed methods design was used to

parents” (p. 378). They maintained that families’

evaluate the effectiveness of the Family Partnership

vulnerability can be generational, and is often situated

Model training. Due to the word limit, the research

within contexts of inequities and disadvantage that

reported in this paper focuses on the cultural

negatively impacts children’s health and development.

responsiveness component of a larger outcome

The Family Partnership Model is a supportive parent-

evaluation research design – therefore, we report the

centred approach underpinned by the helping process,

findings related to whether the Family Partnership

whereby health professional-parent partnerships aim

Model

to achieve beneficial changes in children’s health,

practice within the well child context (see Table 1).

development, and outcomes (Rossiter et al., 2011).

The evaluation research methodology enabled the

The helping process focuses on parent identified

exploration of complex outcomes for clients and those

problems, and involves health professionals working

undertaking the Family Partnership Model training

with them to clarify the problem(s) and plan actions to

programme.

supports

culturally

responsive

nursing

achieve desired outcomes that are evaluated together.

Helping involves sharing power, working with parents,

Aim

and using the dual expertise of both parents and

The research aimed to evaluate the extent to which

health professionals. Importantly, it requires health

Plunket nurses implement the Family Partnership

professionals to display respect, humility, and effective

Model when working with Māori, and whether it could

communication (Fowler et al., 2012).

be considered culturally responsive. The question driving the research was, “does the Family Partnership

There is an absence of conceptual models to guide

Model support culturally responsive nursing practice

those working in partnership with children and their

within the well child context?”

families (Braun, Davis, & Mansfield, 2006). Central to the Family Partnership Model is the notion that

Method

partnerships promote effective relationships. Braun

The project was approved by Massey University

et al. described partnership as “... active involvement;

Human Ethics Committee Northern and the Royal New

shared decision-making; complementary expertise;

Zealand Plunket Society Ethics Committee. Information

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 1. 1.

Table Overview of Research DesignDesign Overview of Research Phase

1 Does the Family Partnership Model suport culturally responsive nursing practice within the well child context?

2

Method

Online survey

Participants Nurses with: FPM training (n=23) No FPM training (n=23)

Observations

Matched Nurses (n=10)

Interviews

and

Analysis

Descriptive statistics

Thematic analysis

Interpretation Questions

1. What effect does the family partnership training have on nursing practice?

2. To what extent do well child nurses meet the needs of Māori clients?

Clients (n=10)

sheets were provided to potential participants for both

were then statistically analysed using EXCEL version 14

phases of the study. In Phase 1, consent was implied

to generate median scores for each group.

on submission of the survey, while in Phase 2 written consent was obtained. Participation in Phase 2 was

Phase 2: Observation and interview. Nurses who had

voluntary and all participants had a right to withdraw

undertaken the Family Partnership Model training

from the study at any point. Confidentiality was

were invited to participate in Phase 2. Participation

maintained by assigning participants pseudomyns, and

depended on nurses securing a Māori client’s consent

storing data in a secure cabinet or password protected

for the researcher (first author) to observe their

computer files.

practise while assessing an infant, and to take part in a semi-structured interview – 10 nurses and their

Phase 1: Survey. Phase 1 involved an anonymous

clients agreed to participate. Permission was obtained

online survey, using Survey Monkey. Purposive

from The Centre for Child and Parent Support and

sampling involved sending an invitation to participate

developers of the Family Partnership Model to utilise

in the study to 25 nurses who had completed the

the Interpersonal and Communication Skills Rating

Family Partnership Model training, and 25 nurses yet to

Scale to observe the nurses clinical assessment of

complete the training. The invitation was distributed to

the infants (Maras, Faulkner, & Wills, 2006). The

nurses by Plunket Clinical Leaders nationally, because

observation scale was used to assess nurses against

they were aware of who had completed and not

13 communication qualities and skills considered

completed the training. A 30-item questionnaire plus

essential to working in partnership, using a 5-point

three free response questions explored areas such

Likert scale, where 1 represented minimal evidence of

as communication, decision making, service delivery,

the qualities and skills and 5 represented considerable

qualities and skills, confidence, the Treaty of Waitangi

evidence of the qualities and skills.

and cultural safety. Quantitative data were checked for invalid responses and one respondent was removed

Māori clients were invited to include wider whānau

from each group because each person had only

members in the interview/observation process.

registered and neither answered any questions. Data

However, whānau members present during interviews

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

21

Nursing Praxis in New Zealand chose not to participate. Therefore, digitally recorded

involved familiarisation with the data, the generation

and transcribed interviews were undertaken with each

of initial codes, searching for themes, defining,

Māori client with their whānau present directly after

reviewing and reporting the themes. Interpretation

the nurses’ visits, and then with the nurse later that

of the findings involved bringing together the data

day. Separate questions were asked of the nurse and

analysis from Phases 1 and 2, and then presenting

the Māori client (see Table 2). Qualitative data from

these using the two focused questions (see Table 1).

the interviews and surveys were thematically analysed

Our approach to the analysis was inductive and data

CULTURAL RESPONSIVENESS THE FAMILY using Braun and Clarke’s (2006) AND framework.

This PARTNERSHIP driven,MODEL focusing initially on the semantic content of the data.

Table Table 2. 2.

Semi-Structured Interview Questions

Semi-Structured Interview Questions Clients’ Questions

Plunket Nurses’ Questions



How do you feel the visit went today?





Can you tell me about your experience with Plunket as a whole?

Do you have any comments about the assessment today?





What do you think are the most important things for a Plunket nurses to offer your family?

Do you think you approach Māori clients and whānau differently to other clients?





How do you think [Plunket Nurse’s name] works in partnership with you?

What aspects of family partnership do you find useful in your practice?



What do you think Plunket nurses need to do to work more effectively with Māori clients and communities?



What do partnership, protection, participation and equality mean for you in practice?



Do you have any comments you would like to add about today?



Are you given the chance to direct the way a visit is going?



Is there anything else you wanted to add?

Survey. Generally, there were some notable differences

Findings

in the precursors and indicators for culturally responsive

The survey response rate was 92% (n=23) for those who

practice between those who had undertaken the

had completed the Family Partnership Model training,

training and those who had not (see Table 4 and 5).

and 92% (n=23) for those who had not completed the

With regard to the precursors to culturally responsive

training (see Table 3). The Family Partnership Model

practice, those who had completed the Family

training group worked for a marginally less length of

Partnership Model training rated higher technical

time at Plunket. Ten matched nurse-Māori client pairs

knowledge as an essential quality than those who

participated in the observations and interviews. The

had not completed the training. However, there was

findings are presented under the following headings:

no appreciable difference between those who had

The effect of the Family Partnership Model training on

and those who had not completed the training in how

nursing practice, and Meeting Māori clients’ needs.

they rated the qualities of humility, respect, quiet enthusiasm, and personal integrity. Furthermore,

The effect of the Family Partnership Model training

those who had completed the training rated

on nursing practice

interpersonal and emotional attunement and empathy

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CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 4

Table 4.

Survey Responses: Precursors for Culturally Responsive Survey Responses: Precursors for Culturally Responsive PracticePractice No Family Partnership Model Training (N=23) Frequency Distribution (%(n))

Survey Questions General Communication

Family Partnership Model Training (N=23) Frequency Distribution (%(n))

Not good

Could be better

Quite good

Very good

Median

Not good

Could be better

Quite good

Very good

Median

0

0

43.5 (10)

56.5 (13)

4

0

0

72.7% (16)

22.7 (5)

3

Not important

Quite important

Very important

Essential

Median

Not important

Quite important

Very important

Essential

Median

Humility

4.5 (1)

4.5 (1)

18.2 (4)

72.7 (16)

4

0

4.5 (1)

18.2 (4)

77.3 (17)

4

Respect

0

0

13.6 (3)

86.4 (19)

4

0

0

9.1 (2)

90.9 (20)

4

Communication (verbal, non-verbal and written) Importance of qualities when working with Māori clients and whānau1

4.5 (1)

0

50.0 (11)

45.5 (10)

3

0

0

50.0 (11)

50.0 (11)

3

Technical knowledge

0

22.7 (5)

54.2 (12)

22.7 (5)

3

0

13.6 (3)

54.5 (12)

31.8 (7)

3

Interpersonal and emotional attunement

0

4.5 (1)

18.2 (4)

77.3 (17)

4

0

4.5 (1)

27.3 (6)

68.2 (15)

4

Empathy

0

4.5 (1)

13.6 (3)

81.8 (18)

4

0

9.1 (2)

22.7 (5)

68.2 (15)

4

Personal integrity

0

0

13.6 (3)

86.4 (19)

4

0

0

13.6 (3)

86.4 (19)

4

Not good

OK

Good

Excellent

Median

Not good

OK

Good

Excellent

Median

Attention/active listening

0

0

63.6 (14)

36.4 (8)

3

0

4.5 (1)

45.5 (10)

50.0 (11)

3

Prompting and exploration

0

22.7 (5)

54.5 (12)

22.7 (5)

3

0

0

81.8 (18)

18.2 (4)

3

Empathetic responding

0

4.5 (1)

68.2 (15)

27.3 (5)

3

0

4.5 (1)

63.6 (14)

31.8 (7)

3

Enthusing and encouraging

0

4.5 (1)

63.6 (14)

31.8 (7)

3

0

9.1 (2)

50.0 (11)

40.9 (9)

3

Enabling changes in ideas

0

40.9 (9)

59.1 (13)

0

3

0

40.9 (9)

54.5 (12)

4.5 (1)

3

Negotiating

0

27.3 (6)

59.1 (13)

13.6 (3)

3

0

27.3 (6)

59.1 (13)

13.6 (3)

3

Problem management

0

18.2 (4)

72.7 (16)

9.1 (2)

3

0

22.7 (5)

68.2 (15)

9.1 (2)

3

Quiet enthusiasm

Communication Skills with Māori clients and whānau

Confidence in:2

Not very confident

Moderately confident

Very confident

Median

Not very confident

Moderately confident

Very confident

Median

4.5 (1)

68.2 (15)

27.3 (6)

2

4.5 (1)

54.5 (12)

40.9 (9)

2

Participating in Māori health community initiatives

50.0 (11)

45.5 (10)

4.5 (1)

1

22.7 (5)

59.1 (13)

18.2 (4)

1

Responding to the needs of Māori whānau and communities

27.3 (6)

63.6 (14)

9.1 (2)

2

9.1 (2)

68.2 (15)

22.7 (5)

2

Working with Māori clients/whānau

Note: 1 1 = Not important/Not good

4 = Essential/Excellent; 2 1 = Not very confident

3 = Very confident

Nursing Praxis in New Zealand CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 5

Table 5.

Survey Responses: Indicators of Cultural Responsiveness

Survey Responses: Indicators of Cultural Responsiveness

No Family Partnership Model Training (N=23) Frequency Distribution (%(n))

Survey Questions

Family Partnership Model Training (N=23) Frequency Distribution (%(n))

Not well

Could be better

Quite well

Very well

Median

Not well

Could be better

Quite well

Very well

Median

0

21.7 (5)

60.9 (14)

17.4 (4)

3

0

4.5 (1)

72.7 (16)

22.7 (5)

3

Not well

Could be better

Quite well

Very well

Not well

Could be better

Quite well

Very well

0

0

43.5 (10)

56.5 (13)

4

0

4.5 (1)

54.5 (12)

40.9 (9)

3

Rarely

Sometimes

Often

Always

Median

Rarely

Sometimes

Often

Always

Median

0

4.3 (1)

26.1 (6)

56.5 (13)

4

0

4.5 (1)

72.7 (16)

22.7 (5)

3

Not easily

Could be better

Quite easily

Very easily

Median

Not easily

Could be better

Quite easily

Very easily

Median

0

22.7 (5)

68.2 (15)

13.6 (3)

3

0

9.1 (2)

68.2 (15)

22.7 (5)

3

Not well

Could be better

Quite well

Very well

Median

Not well

Could be better

Quite well

Very well

0

50.0 (11)

45.5 (10)

9.1 (2)

3

0

36.4 (8)

45.5 (10)

18.2 (4)

3

Not well

Moderately well

Above average

Very well

Median

Not well

Moderately well

Above average

Very well

Median

Partnership

0

31.8 (7)

27.3 (6)

40.9 (9)

3

0

13.6 (3)

40.9 (9)

45.5 (10)

3

Participation

0

31.8 (7)

36.4 (8)

31.8 (7)

2

0

18.2 (4)

54.5 (12)

27.3 (6)

3

Protection

0

50.0 (11)

18.2 (4)

31.8 (7)

3

0

36.4 (8)

31.8 (7)

31.8 (7)

3

Equality

0

27.3 (6)

36.4 (8)

36.4 (8)

3

0

18.2 (4)

50.0 (11)

31.8 (7)

3

Communication How well do you communicate with Māori Plunket clients?

Decision Making How well do you think you involve Māori parents/caregivers and/or whānau in decisions relating to their care?

How often do you make clinical decisions mostly upon the client’s needs and preferences (when working with Māori specifically)?

Service How easily do you make contact/engage with Māori Plunket clients?

How well do you think your service/practice meets the needs of Māori Plunket clients?

Delivery of Treaty of Waitangi principles

Note:

1 = Not well/Rarely/Not easily

4 = Very well/Always/Very easily

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

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CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 3 Table 3.

Treaty of Waitangi Training and of Years of Practice Treaty of Waitangi Training and Years Practice No Family Partnership Model Training (N=23)

Family Partnership Model Training (N=23)

Overall

91.3% (n=21)

100% (n=23)

95.6% (n=44)

1-2 years

21.7% (n=5)

9% (n=2)

15.2% (n=2)

3-5 years

26.1% (n=6)

48% (n=11)

34.8% (n=16)

6-10 years

34.8% (n=8)

22% (n=5)

28.3% (n=13)

≥11 years

17.4% (n=4)

22% (n=5)

19.6% (n=9)

No response

4.3% (n=1)

0 (n=0)

2.2% (n=1)

Completed Treaty of Waitangi Training

(N=46)

Years worked for Plunket

as less essential than those who had not completed

to improving health outcomes, there was little

the training. With regard to communication skills,

evidence that nurses evaluated their practice about

those who had completed the training rated higher

what worked or did not work and whether they were

attention/active listening (as excellent), and prompting

making a difference. Two themes were generated from

and exploration (as good or excellent) than those had

the interviews with regard to the effect of the Family

not undertaken the training. The Family Partnership

Partnership Model training on the nurses’ practice:

Model training appeared to improve nurses’ confidence

Having respectful relationships and Being client-led,

in working with Maori clients/whanau, participating

which were consistent with the survey findings.

in Maori community activities, and responding to whanau and community needs (see Table 4). With

Having respectful relationships. Having respectful

regard to indicators of cultural responsiveness, overall

relationships

little difference existed between the two groups except

partnerships with Māori clients. Respect was conveyed

those who had not completed the training were more

in the nurses’ body language and actions (such as being

likely to make clinical decisions based on clients’ needs

courteous and showing an interest in Māori clients

and preferences (see Table 5).

and their extended whānau), and was considered

were

essential

for

establishing

necessary for widening the scope of discussions with Observations. Overall, nurses’ practice demonstrated moderate

evidence

of

interpersonal

and

communication skills (see Table 6). While there was moderate evidence of eye contact (3.9), being non-threatening (3.9), and appropriate sensitivity (3.8), there was less evidence of assertiveness (3.1)

Māori clients.

I think sometimes we’re a bit wary when we shouldn’t be and if we just treat everybody with the same amount of respect... Hopefully you build up that relationship where you know what

and sense of humour (2.6). Nurses’ were reluctant

your client wants from you. (Nurse)

to discuss cultural issues and challenge parenting

It’s just like when she greets you and stuff like

practises not congruent with current evidence, and

that. Then they greet the kids. It makes you feel

avoided being disrespectful to or offending Māori

good about having that person in your house.

clients. Despite generally demonstrating commitment

(Client)

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Nursing Praxis in New Zealand

CULTURAL RESPONSIVENESS AND THE FAMILY PARTNERSHIP MODEL Table 6

Table 6.

Observation of Interpersonal and Communication Skills

Observation of Interpersonal and Communication Skills

Interpersonal and Communication Skills

Median Score (1-5)

Warmth

3.5

Listening skills

3.5

Humility

3.6

Appropriate confidence

3.4

Positive, open body language

3.6

Eye contact

3.9

Assertiveness

3.1

Enthusiasm

3.5

Genuineness

3.5

Non-judgemental

3.6

Non-threatening

3.9

Sense of humour

2.6

Appropriate sensitivity

3.8

Note: Maras et al. (2006); 1 = Very little evidence, 5= Considerable evidence

Establishing respectful relationships was driven

with family that’s working with them all the

by a fear of damaging the relationship with clients

time, and supporting … they want that support

and whānau by a range of complex variables. Thus,

and you don’t want to upset that relationship.

nurses actively avoided discussing cultural issues

It’s quite tricky. (Nurse)

or challenging parenting practices that were not ‘evidence based’, for example, which were considered

Humility, being non-judgemental, empathy, listening,

disrespectful or would cause offence. Nurses were also

understanding clients’ experiences, and being inclusive

sensitive to damaging clients’ relationships with their

and willing to change practice were other qualities

whānau by offering conflicting advice or interventions

nurses believed to be essential in order to establish

that were different to what whānau provided or

trust with Māori clients and their whānau.

suggested. …acknowledging his Mum there, she was like, It’s all very well for us to be in there 20 minutes

“Oh hi, how are you?” That was really good.

every couple of months, but they’re dealing

Because our family is really family oriented,

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand including everyone else was really good. (Client)

are coming from a place that we’re working for them. It’s not just coming down on them. It’s

Being client-led. Being client-led involved providing an

saying, “You love your baby and you want to

approach that created an ‘environment’ that enabled

keep it safe.” (Nurse)

clients to participate freely and willingly. It also required nurses to resist urges to provide solutions.

Nurses indicated health literacy influenced their ability

The nature of the client-nurse relationship influenced

to respond to client-centred needs, priorities, and

clients’ determination as to whether a service was

confounding influences. Those clients with higher

appropriate and met their needs.

levels of health literacy were more able to articulate their needs. A fine line exists between challenging

We are not going to be effective just by telling

parenting

practices

and

everybody what to do, that they actually have to

confidence and capability.

undermining

clients’

find out themselves.…If you don’t have a good relationship, it’s not going to be a happening

If she asks more complex questions, she’s

thing. (Nurse)

probably getting a more complex answer from me, whereas a mother with a low level of

Homes were clients’ preferred environment because it

education may not even ask that question. With

reduced anxiety and increased their control within the

the lower health literacy, I’m trying to ask the

partnership. In addition, it eliminated the logistically

questions and fathom out where the thinking is

difficult task of getting to a clinic with small children.

at. (Nurse)

Successful client-led practice involved not only professional and technical expertise, but an ability to

Meeting Māori clients’ needs.

include the client and their whānau, inviting them to

Family Partnership Model training appeared to

ask questions and direct the conversation to identify

improve nurses’ perceptions about how well they

their needs.

communicated with Maori Plunket clients, although they were less likely, than those who received no

The Family Partnership Model Training increased

training, to rate including Maori parents/caregivers

nurses’ focus on engagement and the establishment of

and whanau in care-related decisions as quite well or

meaningful relationships with Māori clients, indicating

very well. However, a difference was noted for those

that they were better positioned to meet their needs.

who had not completed the training indicating that

The following nurse’s comment typifies a shift in

they more often or always made decisions based on

practice:

Maori client needs and preferences. Nevertheless, Family Partnership Model training signified nurses’

The parents make the decisions… we can jump

greater ease when making contact and engaging with

up and down and say this is by far the safest and

Maori Plunket clients, and that their service or practice

these awful things can happen if you continue

met their needs. In terms of delivering the Treaty of

to do this, but I’m not going to go in there each

Waitangi principles of partnership, participation,

night and tuck the baby into bed. They’ve got to

protection, and equality, nurses who had completed

be responsible to make the decision. They need

their training rated they did so as above average or

to trust us so that so that they know that we

very well – higher than those who had not completed

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand the training (see Table 5). The theme emerging from

has different backgrounds and stuff. (Client)

the interview data in relation to meeting the clients’ needs was lacking the skills.

While nurses’ ethnicity was not an issue for many clients, there was a desire to see more Māori nurses

Lacking the skills. The Family Partnership training

who possessed knowledge of Māori language and

qualitatively influenced most dimensions of nurses’

culture, and understood concepts such as humility.

practice (Tables 4 and 5), although nurses did report

Some clients indicated a preference for a Māori nurse,

lacking the skills for working with Māori clients and

as they were better able to understand their social and

whānau. Importantly for clients, being Māori was

cultural realities:

about their culture and identity, which contrasts with stereotypical, deficit views that health professionals

I found that the Māori lady [the nurse] was

often adopt. The following Māori client stressed the

more, she knew our struggles, she didn’t know

importance of their Māori identity while exemplifying

us personally but she knew of our struggles. It

the complexity that occurs when health professionals’

was her that asked about if we needed anything

mistakenly offer stereotyped or deficit views for their

… and … said that she knew how we have

culture:

struggled and she was willing to help. (Client)

I think what a lot of Māori are complaining

Māori clients and some nurses indicated that providing

about is that they’re being classed as Māori,

a culturally safe and responsive service and workforce

which is strange because they’re also wanting

required growing the Māori well child nurse and

to be known as Māori. It’s terrible. We want to

kaiawhina workforce because non-Māori nurses may

be proud as being Māori, but we don’t want to

lack the necessary skills to work with this group. For

be categorised as Māori either. (Client)

example, Māori nurses and kaiawhina (qualified health workers who work with Plunket nurses to deliver

Nurses showed a genuine interest in clients ‘being

services and support parents and whānau) offered

Māori’ (that is, their culture and identity), and this was

different views and ways of engaging with Māori

confirmed by clients. While viewing equal treatment

clients to improve engagement with vulnerable Māori

as important, they did recognise clients may have

whānau, and increase the cultural responsiveness of

different perspectives and priorities, and that

nurses and the well-child service.

identification of culture was essential for supporting clients.

I am often asked if they can have a Māori Plunket nurse. Unfortunately there are none in my area She [nurse] acknowledges the fact that we’re

so I let them know I work in partnership with

Māori, so that’s pretty cool and the fact that

a Kaiawhina and if they want we can co-visit.

when she asks us what books we wanted, what

I don’t think doing a TOW [Treaty of Waitangi]

language - she actually done it for us. (Client)

workshop gives me the skills to work with

I think everyone should be treated equally but at the same time, they should acknowledge everyone’s culture…. I think it would be good in a way because you can relate better. Everyone

Page 45

Māori clients, maybe working with a group of Māori mums and asking what they want from Plunket would be a better way to go and reflect the contract to their needs as well. (Nurse)

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Nevertheless, clients in high need communities

tikanga is built on the foundation of respect for one

reported some nurses’ desensitisation led them to

another and the differences inherent within and

disregard their realities and engage in culturally non-

between groups of people. Family Partnership Model

responsive and disrespectful practice (calling without

training highlights the importance of recognising the

appointments, for example). This contributed to clients

culture of Māori clients and their whānau, encouraging

reporting that they could not plan their days, and led

nurses to take a holistic view in order to be culturally

some to not be at home or keep appointments.

safe and responsive, and make a difference for clients.

However, we found that nurses did not routinely

. . . maybe before she comes, just to text and

evaluate the effectiveness of their practice, and client-

say she’s on her way, because sometimes I’ll be

related health literacy could influence the degree of

in the shower and then she’ll come and I don’t

client engagement in the partnership with nurses.

know if she’s been or not. Or like I wait all day and they don’t come at all, which has happened

While significant differences were noted in terms

to me with some services, not Plunket. (Client)

of the development of qualities considered to be the necessary precursors for culturally responsive

Discussion

practice, translation of Family Partnership Model

Plunket’s organisational philosophy is, “The best start

learning into nurses’ everyday practice with Māori

for every child”. Parents and whānau together with

clients and whānau requires ongoing support. Nurses’

well child nurses play crucial roles in providing that

self-report that they communicate, make contact and

‘best start’ for Māori children. Cultural competence

engage with Māori clients, involve parents in care-

and cultural responsiveness are key components

related decisions, make decisions based on clients’

of quality care, contingent on the development of

needs and preferences, and think they meet their

relationships and trust necessary to promote reciprocal

needs. However, the lack of consistent differences

and open interactions (Wiggins, 2008). Health, social

across all indicators between those who had Family

beliefs and practices are shaped by Māori clients’

Partnership Model training and those who had not

cultural orientation, and are complexly impacted and

(supported by the interview findings), highlighted

compounded by the intersectionality of inequities,

areas that nurses need more confidence with in regard

poverty, colonisation, health literacy, and racism (Kelly,

to being culturally responsive. This highlights the need

2009). Undoubtedly, persistent inequities perpetuate

for the Family Partnership Model training to focus

vulnerability and compromise health outcomes

more on translating, engaging and working with Māori

(Barber, 2013).

into nurses’ practice to improve their confidence and competence. While the suggestion to grow the

Family Partnership Model training appears to develop

Māori nurse and kaiawhina workforce by nurses and

some of the necessary qualities that are precursors for

clients is an area for attention, the reality is the Māori

culturally responsive nursing practice. A well known

nursing workforce remains small (Nursing Council of

whakataukī (Māori proverb), kāhore te kūmara e

New Zealand, 2012) – reinforcing the need to also

kōrero mo tāna reka – the kumara does not speak of its

strengthen the existing well child nursing workforce to

own sweetness, highlights the importance of humility

work with Māori.

within Māori culture, especially for connecting with Māori clients (Mead, 2003; Smith, 2012). In addition,

Page 46

Fowler et al. (2012) found adopting the Family

Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Partnership Model was a “complex and dynamic

Zealand, 2011). Such explorations should be ongoing

process” (p.3306) requiring nurses to take on new

and be experientially based. Bellon-Harn and Garrett

practices and approaches, such as becoming “navigators

(2008) recommend using a VISION model to improve

and shapers” (Hopwood, Fowler, Lee, Rossiter, &

cultural responsiveness, as it provides structure to

Bigsby, 2013, p. 207). In addition to committing to

exploring self, forming client relationships, interaction

changing practice styles and approaches, nurses need

styles, and strategies to achieve needs, expectations

to critically examine their practice in order to make

and goals by both the health professional and family,

necessary changes, including challenging negative

aided by the use of vignettes.

thoughts and beliefs they may have (Fowler et al., 2012). Further areas of development include evaluating

The limitations of this study should be noted and

whether their practice was effective, and assessing and

caution used in using the findings beyond the

adapting practice according to clients’ health literacy

participant group. While the observational assessment

levels. Development of culturally responsive practice

ratings using the Interpersonal Skills Rating Scale

requires ongoing support and guidance in the form of

were relatively subjective, triangulating the interview

mentorship (Wiggins, 2008) and clinical supervision

data with the observation data strengthened the

(Keatinge, Fowler, & Briggs, 2008).

researcher’s assessment of nurses’ practice. The noninclusion of whānau in Phase 2 interviews meant

The desensitisation of some nurses resulted in

that limited feedback was obtained regarding the

disrespectful and culturally non-responsive practice,

partnership between the nurse and the wider whānau.

and is noteworthy. There is an increasing body of

Furthermore, the survey collected self-reported

national and international literature that reports

information that could not be verified. Future research

health professionals’ practice that lacks sensitivity to

would benefit from using a pre-post intervention

clients’ life circumstances and realities, and that is

research design.

discriminatory toward those belonging to Indigenous and minority groups, negatively impacts client

Conclusion

outcomes (Bearskin, 2011; Browne & Fiske, 2001;

The Family Partnership Model training that well child

Harris et al., 2012; Human Rights Commission, 2011;

nurses undertake appears to develop some of the

Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe,

necessary qualities for developing partnerships with

2010). In addition to the cultural responsiveness

vulnerable families. However, with regard to translating

indicators providing areas to focus the development

this training into practice with Māori clients, further

and contextual relevance of the Family Partnership

work is required to support and assist nurses to put this

Model training, such training should also focus on

into practice, particularly when it comes to exploring

exploring nurses’ own socialisation, cultural identity,

clients’ cultural backgrounds and challenging their

and values and beliefs that can impact on their

parenting practices. Culturally responsive practice is

practice and development of relationships (Bellon-

contingent on nurses developing partnerships with

Harn & Garrett, 2008; Ibrahim, 2010). These areas

vulnerable families, often from different cultural

are fundamental for the development of culturally

backgrounds, but to benefit the whānau and work with

safe practice, which is a regulated competency all

them to provide infants with the ‘best start’, they need

registered nurses should meet (Nursing Council of New

ongoing support, mentorship and/or supervision.

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Nursing Praxis in New Zealand References Anderson, J., Rodney, P., Reimer-Kirkham, S., Browne, A. J., Khan, K. B., & Lynam, M. J. (2009). Inequities in health and healthcare viewed through the ethical lens of critical social justice: Contextual knowledge for the global priorities ahead. Advances in Nursing Science, 32(4), 282-294. doi:10.1097/ANS.0b013e3181bd6955 Barber, P. (2013). Reducing inequality. In M. Rashbrooke (Ed.), Inequality: A New Zealand crisis (pp. 167-180). Wellington, New Zealand: Bridget Williams Books.

Bearskin, R. L. B. (2011). A critical lens on culture in nursing practice. Nursing Ethics, 18(4), 548-559. doi:10.1177/0969733011408048 Bellon-Harn, M. L., & Garrett, M. T. (2008). VISION: A model of cultural responsiveness for speech-language pathologists working in family partnerships. Communication Disorders Quarterly, 29(3), 141-148. doi:10.1177/1525740108315879 Braun, D., Davis, H., & Mansfield, P. (2006). How helping works: Towards a shared model of process. London, UK: Parentline Plus.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77-101. doi: 10.1191/1478088706qp063oa Browne, A. J., & Fiske, J. A. (2001). First Nations women’s encounters with mainstream health care services. Western Journal of Nursing Research, 23(2), 126-147.

Davis, H., Day, C., & Bidmead, C. (2002). Working in partnership with parents: The parent adviser model. London, UK: Harcourt Assessment.

Fowler, C., Rossiter, C., Bigsby, M., Hopwood, N., Lee, A., & Dunston, R. (2012). Working in partnership with parents: The experience and challenge of practice innovation in child and family health nursing. Journal of Clinical Nursing, 21(21-22), 3306-3314. doi:10.1111/j.1365-2702.2012.04270.x Gifford, H., Wilson, D., Boulton, A., Walker, L., & Shepherd-Sinclair, W. (2013). Māori nurses and smoking: What do we know? New Zealand Medical Journal, 126(1384), 53-63.

Harris, R., Cormack, D., Tobias, M., Yeh, L-C., Talamaivao, N., Minster, J., & Timutimu, R. (2012). The pervasive effects of racism: Experiences of racial discrimination in New Zealand over time and associations with multiple health domains. Social Science & Medicine, 74(3), 408-415. doi:10.1016/j.socscimed.2011.11.004 Hopwood, N., Fowler, C., Lee, A., Rossiter, C., & Bigsby, M. (2013). Understanding partnership practice in child and family nursing through the concept of practice architectures. Nursing Inquiry, 20(3), 199-210. doi:10.1111/nin.12019 Human Rights Commission. (2011). Structural discrimination: The need for systemic change to achieve racial equality (A discussion paper by the Human Rights Commission). Wellington, New Zealand: Human Rights Commission.

Ibrahim, F. A. (2010). Social justice and cultural responsiveness: Innovative teaching strategies for group work. Journal for Specialists in Group Work, 35(3), 271-280. doi:10.1080/01933922.2010.492900 Isaacs, A. N., Pyett, P., Oakley-Browne, M. A., Gruis, H., & Waples-Crowe, P. (2010). Barriers and facilitators to the utilization of adult mental health services by Australia’s Indigenous people: Seeking a way forward. International Journal of Mental Health Nursing, 19(2), 75-82. doi:10.1111/j.1447-0349.2009.00647.x Keatinge, D., Fowler, C., & Briggs, C. (2008). Evaluating the Family Partnership Model (FPM) program and implementation in practice in New South Wales, Australia. Australian Journal of Advanced Nursing, 25(2), 28-35.

Kelly, U. (2009). Integrating intersectionality and biomedicine in health disparities research. Advances in Nursing Science, 32(2), E42-E56. doi:10.1097/ANS.0b013e3181a3b3fc Maras, P., Faulkner, N., & Wills, J. (2006). Working with parents, schools and communities - making a difference: An Evaluation of the Bromley Children Project. London, England: The University of Greenwich. Retrieved from http://www2.gre.ac.uk/__data/ assets/pdf_file/0006/679065/Bromley_Children_Final_Report.pdf Marie, D., Fergusson, D. M., & Boden, J. M. (2008). Ethnic identification, social disadvantage, and mental health in adolescence/young adulthood: Results of a 25 year longitudinal study. Australian and New Zealand Journal of Psychiatry, 42(4), 293-300.

Mead, H. M. (2003). Tikanga Māori: Living by Māori values. Wellington, NZ: Huia.

Metge, J. (1995). New growth from old: The whānau in the modern world. Wellington, New Zealand: Victoria University Press.

Ministry of Health. (2010). Tatau kahukura: Māori health chart book 2010 (2nd ed.). Wellington, NZ: Author.

Ministry of Health. (2012a). The health of New Zealand adults 2011/12: Key findings of the New Zealand Health Survey. Wellington, NZ: Author. Retrieved from http://www.health.govt.nz/publication/health-new-zealand-adults-2011-12

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Nursing Praxis in New Zealand Ministry of Health. (2012b). The health of New Zealand children 2011/12: Key findings of the New Zealand health survey. Wellington, NZ: Author. Retrieved from http://www.health.govt.nz/system/files/documents/publications/health-of-new-zealand-child2011-12-v2.pdf Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of Waitangi, and Maori health in nursing education and health. Wellington, NZ: Author. Retrieved from http://www.nursingcouncil.org.nz/download/97/cultural-safety11.pdf Nursing Council of New Zealand. (2012). The New Zealand nursing workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2011. Wellington, NZ: Author. Retrieved from http://nursingcouncil.org.nz/Publications/Reports Pauly, B., MacKinnon, K., & Varcoe, C. (2009). Revisiting “who gets care?”: Health equity as an arena for nursing action. Advances in Nursing Science, 32(2), 118-127. doi:10.1097/ANS.0b013e3181a3afaf Poulton, R., Caspi, A., Milne, B. J., Thomson, W. M., Taylor, A., Sears, M. R., & Moffitt, T. E. (2002). Association between children’s experience of socioeconomic disadvantage and adult health: A life-course study. The Lancet, 360(9346), 1640-1645.

Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu (unpublished doctoral dissertation).

Victoria University of Wellington, Wellington, New Zealand. Retrieved from http://culturalsafety.massey.ac.nz/thesis.htm Ritchie, J. (2007). Childrearing practices and attitudes. In A. Weatherall, M. Wilson, D. Harper, & J. McDowall (Eds.), Psychology in Aotearoa / New Zealand (pp. 48-58). Auckland, NZ: Pearson.

Robson, B., & Harris, R. (Eds.). (2007). Hauora: Māori standards of health IV. A study of the years 2000-2005. Wellington, NZ: Te Rōpū Rangahau Hauora a Eru Pōmare. Retrieved from http://www.hauora.maori.nz Rossiter, C., Fowler, C., Hopwood, N., Lee, A., & Dunston, R. (2011). Working in partnership with vulnerable families: The experience of child and family health practitioners. Australian Journal of Primary Health, 17(4), 378-383. doi:10.1071/PY11056 Royal New Zealand Plunket Society. (2012). Submission on the Inquiry into the determinants of wellbeing for Māori children. Retrieved from http://www.plunket.org.nz/assets/What-we-do/Submissions/Wellbeing-for-Maori-Children.pdf Smith, L. T. (2012). Decolonizing methodologies: Research and indigenous peoples (2nd ed.). London: Zed Books.

Statistics New Zealand. (2013). 2013 Census quick statistics about Māori. Retrieved from http://www.stats.govt.nz/Census/2013census/profile-and-summary-reports/quickstats-about-maori-english.aspx Te Puni Kōkiri. (2011). Māori families and households. Retrieved from www.tpk.govt.nz/documents/download/227/tpkmaorifamilies-2011.pdf Tipene-Leach, D. (2012). Viewpoint: Is the ‘safer’ sleeping environment the remaining holy grail of SUDI prevention? In E. Craig, J. Adams, G. Oben, A. Reddington, A. Wicken, & J. Simpson (Eds.), Te Ohonga Ake: The health status of Māori children and young people in New Zealand (pp. 29-31). Dunedin, New Zealand: NZ Child and Youth Epidemiology Service. Retrieved from http:// dnmeds.otago.ac.nz/departments/womens/paediatrics/research/nzcyes/pdf/Health_Status_of_Maori_Children_and_Young_ People_in_New_Zealand.pdf Walker, R. (2004). Ka whawhai tonu mātou: Struggle without end (Rev. ed.). Auckland, New Zealand: Penguin.

Werkmeister-Rozas, L., & Klein, W. C. (2009). Cultural responsiveness in long-term-care case management: Moving beyond competence. Care Management Journals, 10(1), 2-7. doi:10.1891/1521-0987.10.1.2 Wiggins, M. S. (2008). The partnership care delivery model: An examination of the core concept and the need for a new model of care . Journal of Nursing Management, 16(5), 629-638. doi:10.1111/j.1365-2834.2008.00900.x Wilson, D. (2008). The significance of a culturally appropriate health service for indigenous Māori women. Contemporary Nurse, 28(12), 173-188.

Wilson, D., & Barton, P. (2012). Indigenous hospital experiences: A New Zealand case study. Journal of Clinical Nursing, 21(15-16), 2316-2326. doi:10.1111/j.1365-2702.2011.04042.x

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Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses. • Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession.

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

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

Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org

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Vol. 31 No. 2 2015 - Nursing Praxis in New Zealand

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