Nursing Praxis November 2015

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE...

A new model: The family and child centered care model Duty of care following stroke: Family experiences in the first six months Diffusion of the primary health care strategy in a small district health board in New Zealand Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study

Volume 31. No. 3

NOVEMBER 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, Mandie Foster RN, Tineke Water RN,

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

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: A new model: The family and child centered care model

Mandie Foster.............................................................................................................................. 4

ARTICLES: Duty of care following stroke: Family experiences in the first six months

Andrew Duthie, Dianne Roy, Elizabeth Niven ............................................................................... 7

Diffusion of the primary health care strategy in a small district health board in New Zealand

Heather Robertson, Jenny Carryer, Stephen Neville .................................................................... 17

Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study

Anecita Gigi Lim, Michelle Honey, Nicola North, John Shaw ....................................................... 27

NOTES FOR CONTRIBUTORS.............................................................................................................. 37

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand EDITORIAL A NEW MODEL: THE FAMILY AND CHILD CENTERED CARE MODEL In this editorial, I would like to propose a new paediatric

(Foster, Whitehead, & Maybee, 2010). Theorists

model of care that could be developed and utilised

and clinicians suggest developing paediatric nursing

in practice. I recently presented about the history,

frameworks, practice models, interventions and

development and relevance of family centered care

strategies to support the key principles of FCC

(FCC) and child centered care (CCC) to the paediatric

(Coyne, Murphy, Costello, O’Neill, & Donnellan, 2013).

staff at Christchurch Hospital. The following is a

International institutes, institutional endorsements,

summary of my presentation.

governmental policies and directives are further vehicles used to support FCC practice (Shields, 2010).

Family centered care is a model where care delivery is

Nursing experts propose that through increased self-

centered on the whole family, not just the ill child and

awareness, cultural sensitivity, safety and knowledge

includes a partnership approach through negotiation,

of the power differences and symmetries/asymmetries

trust, respect and building therapeutic relationships

of care provision between staff, parents and children

between staff, parents and children (Shields, Pratt,

a more realistic approach to FCC practice is attainable

Davis, & Hunter, 2007). Despite fifty years of ongoing

(Foster, Whitehead, Maybee, & Cullens, 2013).

research, education and theory into the development, translation and impact of FCC there continues to be

Questions on how children’s rights and CCC can be

difficulties in effectively operationalising this model of

operationalised effectively within a FCC model are

care within paediatrics for staff, parents and children.

a recent development (Corlett & Watson, 2014). It appears from the literature that CCC is embedded

Educational facilities, healthcare institutions and

within a FCC model (Foster, 2013). Clinicians propose

clinicians appear to use a mix of theoretical perspectives

that by integrating the socio-political cultural and

to inform family nursing that are contextually or

ethical contexts of children’s nursing into a FCC practice,

personally driven (Bell 2013). Wright and Leahey

a more child centered approach is achievable (Coyne

(1990) refer to family nursing as the ‘family as context’

& Cowley, 2007). Theorists also suggest that by using

approach where the individual is forefront and the

cultural safety and ethical symmetry as adjuncts to FCC

family is situated in the background. Shields (2010)

the social and cultural contexts of children’s lives will

refers to FCC within paediatrics as care provision that

guide practice and support a child focused approach

includes the whole family. Carter, Bray, Dickinson,

(Randall, Munns, & Shield, 2013).

Edwards and Ford (2014) refers to CCC as the child being forefront and visible within a FCC model where

To re-define FCC or CCC when both models

children’s needs and interests are at the centre of one’s

place the family and child as the central focus of

thinking and practice.

healthcare provision seems flawed especially when recommendations for alternatives are limited. Corlett

Debates over rethinking and questioning the concepts that underpin FCC and whether FCC is an appropriate attainable model of care within paediatrics continues

Page 4

Foster, M. (2015). Editorial: The family and child centered care model. Nursing Praxis in New Zealand, 31(3), 4-6.

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand and Watson (2014) suggest FCC needs to be re-defined

providers profess to be culturally, ethically, sensitive

to ‘child and family centered care’ as a way to integrate

and safe when the model of care used fails to address

children’s rights, parents’ rights and contemporary

the client/child within it? There are many tools available

child care policies. I suggest FCC and CCC should be re-

to measure adult perceptions of FCC with no tool

named to ‘family and child centered care’ (FCCC) with

available to measure children’s perception of CCC.

the child coming after family. This would appear a more

The ‘needs of children’s questionnaire’ has just been

realistic title as it is the parents’ legal responsibility and

developed and pilot tested and measures the school

right to safeguard, protect and promote their child’s

aged child’s hospital experience as a means to measure

health, development and welfare and offer guidance

CCC. The tool will set a benchmark for CCC and ways to

to their child in a manner appropriate to that child’s

enact children as active research and care recipients.

developmental level. The parents and family are the child’s main source of strength and support, and are

My presentation to the paediatric staff at Christchurch

the one constant in the child’s care. Staff need to act

Hospital highlighted the absence of a paediatric model

as facilitators for parents to best meet the child’s

of care that includes the family and child as visible and

psychosocial, physical and emotional needs. This then

forefront to healthcare provision. Family nursing and

respects and honors the parents’ and child’s rights and

FCC centers on the family whereas patient centered

is proportionally placed with the child visible yet under

care and CCC centers on the patient/child. In essence

the safe guidance of the family. Family here means

an institution’s vision and mission statement need

whoever has the legal guardianship rights for the child

to include the positive health outcomes for the child

(Carter et al., 2014).

and family. An amalgamation of FCC and CCC needs to occur to create a FCCC model that includes both

I also suggest rewording the Institute of Patient and

the characteristics of FCC and CCC where the family

Family centered Care (2015) FCC definition to: Family

and child are visible, forefront and equal in healthcare

and child centered care is an approach to the planning,

provision. This model then needs to be used by the

delivery and evaluation of healthcare that is grounded

government, organisations and institutions to plan,

in mutually beneficial partnerships among families/

deliver and evaluate child healthcare provision.

parents, children and healthcare providers.

Mandie Foster, RN, PhD, Professional Practice Fellow, To date no framework or tool exists that guides or

Centre for Postgraduate Nursing Studies, University

measures a FCCC approach. How can healthcare

of Otago, Christchurch; Registered Nurse, Paediatric Department, Christchurch Hospital, Christchurch, NZ. Email: mandie.foster@xtra.co.nz

References Bell, J. (2013). Family nursing is more than family centered care. Journal of Family Nursing, 19(4), 411-417.

Carter, B., Bray, L., Dickinson, A., Edwards, M., & Ford, K. (2014). Child-centred nursing: Promoting critical thinking. Thousand Oaks,

California: Sage Publications Inc.

Corlett, J.,& Watson, G. (2014). Family-centred care. In G. Watson & S. Rodwell (Eds.), Safeguarding and protecting

children, young people and families: A guide for nurses and midwives (pp. 117-138). Thousand Oaks, California:

Sage Publications Inc.

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Coyne, I., & Cowley, S. (2007). Challenging the philosophy of partnership with parents: A grounded theory study. International

Journal of Nursing Studies, 44(6), 893-904. doi:10.1016/j.ijnurstu.2006.03.002 Coyne, I., Murphy, M., Costello, T., O’Neill, C., & Donnellan, C. (2013). A survey of nurses’ practices and perceptions of family

centered care in Ireland. Journal of Family Nursing, 19(4), 469-488. doi:10.1177/1074840713508224 Foster, M. (2013). Family centered care, in the paediatric critical care setting: Child, parent and staff perspectives

(Unpublished doctoral thesis). University of Otago Centre for Postgraduate Nursing Studies, Christchurch, New Zealand.

Foster, M., Whitehead, L., & Maybee, P. (2010). Parents’ and health professionals’ perceptions of family centered care for children in

hospital, in developed and developing countries: A review of the literature. International Journal of Nursing Studies, 47(9),

1184-1193. doi:10.1016/j.ijnurstu.2010.05.005.

Foster, M., Whitehead,L,. Maybee, P., & Cullens, V. (2013). The staff’s, parents’ and hospitalized child’s perception and

experiences of family centered care within a paediatric critical care setting: A meta-synthesis of qualitative research.

Journal of Family Nursing, 19(4), 431-468. doi:10.1177/1074840713496317.

Institute for Patient and Family centered Care. (2015). Institute for Patient and Family centered Care. Retrieved from

http://www.ipfcc.org/ Randall, D., Munns, A., & Shields, L. (2013). Next steps:Towards child-focused nursing. Neonatal Paediatric and Child Health Nursing, 16(2), 15-20.

Shields, L. (2010). Questioning family-centred care. Journal of Clinical Nursing, 19(17-18), 2629-2638. doi:10.1111/

j.1365-2702.2010.03214.x.

Shields, L., Pratt, J., Davis, L., &Hunter, J. (2007). Family-centred care for children in hospital. Cochrane Data Base Systematic Review,

1, CD004811.

Wright, L., & Leahey, M. (1990). Trends in nursing of families. Journal of Family Nursing, 15(2), 148-154.

doi:10.1111/j.1365-2648.1990.tb01795.x

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand DUTY OF CARE FOLLOWING STROKE: FAMILY EXPERIENCES IN THE FIRST SIX MONTHS Andrew Duthie, BAppSc(HB), MOst, Private Practice, Auckland, NZ Dianne E Roy, RN, PhD, FCNA(NZ), Associate Professor, Unitec Institute of Technology, Auckland, NZ Elizabeth Niven, RN, PhD, Senior Lecturer, Unitec Institute of Technology, Auckland, NZ

Abstract Stroke is the third largest cause of death in New Zealand and is a major cause of disability. While a lot is known about the stroke survivor and the primary family caregiver, little is known about how stroke affects the survivor’s wider family.

Hermeneutic phenomenology, guided by the work of Max van Manen, was used in this study to investigate the experience of becoming and being a family member of someone who has had a stroke, over the first six months from the initial stroke. It is part of a larger longitudinal four year project exploring the stroke family lifeworld. Three participants from the same extended family were interviewed in 2011-2012 at six weeks, three months and six months following the stroke of a family member. Thematic interpretive analysis showed that the stroke survivor is not the only person who needs care.

The overarching theme was duty of care within and for the whole family. There were three sub-themes: care is different for different people, there are care expectations of self and expectations of others; and care brings strain. The family experience revolved around expectations and obligations of their own duty of care and care needs for themselves and that of the stroke survivor, which were also influenced by issues outside the family. In addition there were considerations of fairness regarding the sometimes competing needs of the survivor and the caregiver. Strains on the family changed over time. Competing values of mercy and fairness within this family took up time and risked shifting the focus away from the stroke survivor.

Keywords Stroke; family; duty; care; experience; New Zealand

Introduction and Background Stroke is the third largest cause of death in New Zealand

primary caregivers’ experience (Bulley, Shiels, Wilkie,

and is a major cause of disability. An estimated 45,000

& Salisbury, 2010; Greenwood, Mackenzie, Cloud, &

people live with a stroke in New Zealand and around

Wilson, 2009; Lutz, Young, Cox, Martz, & Creasy, 2011).

70% are dependent on others to help with their daily

The importance of family in stroke recovery was noted

activities (Stroke Foundation of New Zealand, 2014;

by Vincent et al. (2007) and Brunborg and Ytrehus

Stroke Foundation of New Zealand and New Zealand

(2014) who described how important family, friends

Guidelines Group, 2010). While a lot is known about

and other social networks were to the stroke survivor’s

the impact of stroke on the survivor and the primary

rehabilitation and well-being.

caregiver little is known about how stroke affects the wider family. Impacts such as financial difficulties, strain and isolation have been seen as significant factors on the

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Duthie, A., Roy, D. E., & Niven, E. (2015). Duty of care following stroke: Family experiences in the first six months. Nursing Praxis in New Zealand, 31(3), 7-16.

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand In the New Zealand context Dyall, Feigin, and Brown

stroke where at least two family members agreed to

(2008) and Corbett, Francis, and Chapman (2006)

participate; (2) adequate spoken English to complete

focused their studies on Māori stroke survivors and

consent and the interview. Informed consent was

their caregivers. Dyall et al. (2008), using statistics

obtained in writing at the beginning of the project

from Feigin et al. (2006), argued there is greater health

and on-going verbal consent obtained before each

disparity and financial impact for Māori whānau than

subsequent data collection phase. Consistent with the

non-Māori families, as Māori have strokes at younger

longitudinal project, ‘family’ was defined broadly to

ages; 62 years for Māori compared to 75 years for

include people who live in close relationship with the

Europeans.

stroke survivor. Five families who met inclusion criteria were recruited by intermediaries for the longitudinal

This study is part of a larger longitudinal hermeneutic

project (total participants = 14), with one of these

project

researchers

families consenting to participate in this study. This

from the Department of Nursing, Unitec Institute of

family were recruited as the stroke event coincided

Technology and the Waitemata District Health Board,

with the first author’s availability to complete the

Auckland, New Zealand.

study. The family included the spouse of a stroke

(2011-2015)

undertaken

by

survivor (Ivy) and two other family members (Deb and

Research Design

Jane). All of the participants were health professionals.

To maintain anonymity their specific disciplines are not

Aim

disclosed and other identifying data excluded. All data

The aim of this study was to investigate the phenomenon

were anonymised and stored in password protected

of becoming and being a family member of a stroke

digital format only accessible to the research team.

survivor over the period of six months after the initial

Pseudonyms were chosen by the researcher and are

stroke.

used throughout.

Methodology

Data collection

This was an exploratory study using hermeneutic

Face-to-face,

phenomenological research methodology.Hermeneutic

undertaken at six weeks, three and six months post-

phenomenology aims to understand the significance of

stroke (December 2011 – May 2012). The interviews

practical activities and experiences in everyday lives and

were between one to two hours in length and were

is well suited to studying human issues and concerns

held at a mutually agreed location. Interview questions

(Plager, 1994) such as family experiences post-stroke.

focused on participants’ experiences at the time of the

The processes used in the study were guided by those

stroke and in the weeks and months that followed.

described by van Manen (1997).

Preliminary interpretive analysis of interviews at

semi-structured

interviews

were

each time-point informed questions for subsequent Methods

interviews.

Participants for the study were recruited from the larger longitudinal project (Northern X Regional Ethics

Data analysis

Committee: NTX/11/EXP/062/AM02) using purposive

All

sampling strategies. Inclusion criteria were: (1) family

anonymised prior to analysis. Data were analysed

of a person admitted to the Assessment, Treatment

thematically. Theme consolidation was developed

and Rehabilitation (ATR) ward following a first-ever

over time through writing, reflecting and rewriting

Page 8

interviews

were

transcribed

verbatim

and

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand (van Manen, 1997). Mind maps were also used to

reflexive account provides the information necessary

explore relationships between themes, with analytical

for evaluation of the plausibility (rigour) of the findings

processes and decisions recorded in a reflexive journal.

(Koch & Harrington, 1998).

The researcher had regular meetings with the research

Findings

team to discuss analysis and theme development, which opened the interpretation to critique. The overarching theme evolved from words such as care,

Duty of Care

cope, and expectations, which were derived from key

The overarching theme was duty of care. Societal,

phrases used in the participants’ interviews. These

personal and perceived pressures from health

phrases became the building blocks to the overall

professionals over issues surrounding duty of care were

theme of duty of care. The participants explained their

identified as the principal concern of the family’s stroke

caring actions differently, including such factors as who

experience. Duty of care was expressed through three

provides care and who has particular care obligations,

sub-themes: Different for different people; Expectations

which was reflected in the sub-themes. The overarching

of self and expectations of others; and Strain. These

theme of duty of care was reflective of all participants’

themes interacted and contributed to the primary

experiences, albeit not necessarily mirrored by each

author’s interpretation of the stroke experience

at every time point. The analytical processes used

(Figure 1).

support the credibility of the interpretation and the

DUTY OF CARE FOLLOWING STROKE: FAMILY EXPERIENCES IN THE FIRST SIX MONTHS

Duty of Care

Health system

E DOC Ivy

D

S

Family E = They have a DOC to Ivy & Dave

Key E = Expectations S = Strain D = Differently DOC = Duty of Care

S = Balancing other

E = Mercy?

Ivy

obligations

S

Government E DOC Ivy Just to society

D = DOC Dave

Conflict Mercy for Ivy vs Fairness Dave

Figure 1: Duty of Care - Interaction of themes Page 9

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand According to the Oxford dictionary, duty of care is “a

person, the moral judgement becomes impartial and

moral and legal obligation to ensure safety or well-being

therefore fits in a justice ethic. Therefore the skill and

of others” (“Duty of Care,” 2014). In considering the

maturity of the health professional’s moral perception,

moral basis for caring, Noddings (1986) describes how

and their ability to balance the wider needs and the

caring for someone is not just about a person’s actions.

individual’s needs, have great bearing on a successful

Noddings suggests that caring is about connection,

outcome. In this study, the family’s moral perception

how fully a person considers and has empathy for the

and their view of the health system were challenged

care recipient’s reality. Caring is also a choice which is

by questions of fairness, justice and mercy. Over time

sometimes natural and effortless, but at other times

these perceptions affected how the family care for one

and in other situations requires effort and is a response

another, contributed to family strain and their care

to moral obligation or duty.

capacity.

Nortvedt (1996) discusses the moral aspects of the

Different for different people

ethic of care, contending that moral perception (ability

The research data revealed caring as complex and

to perceive a recipient’s reality) is a crucial skill to fully

multi-layered. Different people show their care in

care for a recipient’s needs. Nortvedt argues that, in

different ways and for different reasons. This relates

caring, principles of mercy, fairness and justice are used

to each participant’s expectations of themselves and

to help all parties achieve an effective care relationship.

others within the family as well as society’s wider

He explains that fairness and justice are used to guide

expectations.

care decisions for large populations, but that in faceto-face relationships, the principle of mercy is more

The consequences of stroke are different for different

appropriate. In this article mercy refers to care actions

people. Ivy and Dave were almost expecting the stroke

that are given to an individual beyond standard care in

to happen. Before the stroke they were forewarned by

recognition of high needs.

their doctor that Dave’s lifestyle and co-morbidities would likely lead to a stroke. The event was quite

When a health professional is engaged in direct care

different for Jane, who was shocked and upset when

of a patient the allocation of a needed resource will

she found out. Deb had expected the stroke and felt

be influenced by the close face-to-face relationship,

much more immediate concern for Ivy than for Dave

as the person-to-person nature of the relationship

when she heard the news.

demands that special consideration should be given.

This may go beyond an equal distribution that is

I mean the stroke was kind of like inevitable really

ethical in a larger, anonymous group, resulting in extra

because of all his health problems. So it wasn’t a

resources being made available for the individual. Thus

surprise … I wouldn’t like to see [Ivy] struggling caring

fairness characterises caring for a large population,

for [Dave] either. I don’t think that’s really fair ‘cause

leading to care decisions that are just and fair for

she’s like worked hard all her life and I don’t think

all patients, whereas the principle of mercy guides

she should have to do that, I don’t, and I’ve already

decisions on an individual basis. An example of the

told her that she shouldn’t become his caregiver and

ethical challenge is where one patient’s care involves

I really wouldn’t want, I wouldn’t let that happen to

a potential use of other patients’ resources. Nortvedt

Ivy. (1, Deb)

(1996) argues that if moral perception is concerned with the patient’s condition, and not the patient as a Page 10

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Deb had personal experience of her own parent’s strain

the sadness was for a life changed. She felt ambivalence

as caregivers and knew what Dave’s stroke could mean

around her duty of care for Dave as, although she would

for Ivy. Deb felt a duty and responsibility for Ivy’s care

have liked to have him home, she acknowledged that

and moved from caring about (she shouldn’t become his

the care in the rest home was better than she could

caregiver) to caring for (I wouldn’t let that happen).

have achieved at home.

Caring is also dependent on location, knowledge,

The participants showed care for different reasons and

experience and family relationship. Early on Ivy

in different ways. They also had different expectations

explained how she met an old neighbour in the hospital

around care. They had expectations on who should be

after Dave’s stroke. The neighbour’s husband had

doing it, how it should be done and the location. These

recently had a stroke and her way of showing her duty

expectations are explored in the next theme.

of care for him was to stay by his bedside constantly.

Ivy on the other hand made sure she took time to look

Expectations of self and expectations of others

after herself.

Stroke requires a response from family. The responses of family members in this study depended on expectations

I said [to the neighbour], “You’ve got to take care of

around their role in caring within the family. Different

number one … if and when he comes home, you’re

expectations were expressed by different family

going to have to have your health like I am”. And she

members, and were reflected in experiences reported

[Ivy’s old neighbour] said, “Well how many girlie days

by the participants in their interactions with employees

have you had?” I said, “Well I have about two a week,

in government departments and health professionals

I know he’s in good hands”. I just say to [Dave], “that’s

working in a range of healthcare settings. These

it, I’ve got to go to this or do that” and he understands.

expectations of care had to be weighed against the

(1, Ivy)

participants’ capacity to respond, considering their other duties, obligations and their own health.

Perhaps because of her health professional background Ivy could see the need to stay healthy and prepared

Deb and Jane felt they had a role in caring for Ivy and

for the burden of caring. There was already knowledge

Dave immediately after the stroke. This expectation

that caring for the stroke survivor at home would be a

had to be measured against other duties and their

burden.

emotional safety. Caring as part of the stroke family was only one duty among many.

Stroke changes lives. These changes may be different depending on the background of the people affected by

I think, there is a danger [that] certain people [could]

stroke. Three months after the stroke Ivy was coming to

become too dependent on you and that’s not possible

terms with the changes the stroke had made in her life.

because you’ve got another side to your life. So, I’ve always found when I have offered assistance that I

I get the feeling of relief rather than sadness. I mean

need to be just a wee bit careful that I don’t get eaten

there’s sadness there but not that I can’t cope with it

alive, but in this case I’m sure it won’t be so. (1, Jane)

and the fact that he is probably in a better position where he is than here. (2, Ivy)

Jane was concerned that the recipient of her care could become dependent and that she, as a carer, could

The relief Ivy felt was the relief of a burden lifted and Page 11

become overwhelmed. Although both Jane and Deb Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand worried that the care they provided might become all-

At the six month point, Ivy felt threatened by the

consuming, there was an implicit expectation that they

possibility of Dave coming home and her expectation

had a duty of care, especially toward Ivy.

that she would be shown understanding and given mercy by health professionals was not met. Care

There were also expectations wider than the family.

actions were not given in recognition of her needs.

Rest homes have a duty to be fair to all their patients

Her hope that the duty of care would be maintained

and to use their resources wisely. The government

by the rest home staff was not being fulfilled. Instead

also has a duty to be just, with responsibility to the

she felt forced to say: I’m not ready to have him home.

wider society and the taxpayer. The family perceived

Ivy knew the limits of her ability to care for Dave. She

that both health service providers and government

was concerned about what it would mean for her role

departments had expectations that the family should

as Dave’s wife if she relinquished her resolve and took

take on various aspects of the stroke survivor’s care. As

on Dave’s care.

a consequence, at three months Ivy felt pressured to take on the additional caregiving activities.

The stroke burden changed over time for this family.

The family appeared to be challenged by expectations

I get the certain feeling that because they know I’m

and decisions around if, when and how to care for

a [health professional] that I’m actually going to be

one another. As time progressed, questions of moral

in there doing his exercises and doing 110 things, I’m

judgement around care including the values of mercy,

being very careful to withdraw from that because

fairness and justice were raised and became tiring and

I’m his wife and his friend but I’m not his nurse… I

time consuming for the family.

know that some of the wives do do some of the minor exercises etc. (2, Ivy)

Strain The burden of fitting in care around life’s other on-

Ivy consciously chose not to take on the caregiving

going responsibilities and priorities proved draining.

role; she was Dave’s wife and friend. Yet she still felt

By six months the stroke experience became the new

societal pressure and expectations from other wives,

norm for the wider family. The prolonged concern and

rehabilitation staff and employees from government

duty of care became tiring.

departments to take on the duty of care. The other family members also had the strong impression that

For Jane the immediate nature and extra energy

Dave and the health professionals involved in his care

devoted for caring for Ivy and to a lesser extent Dave

expected he would go home following a period of

caused conflict with other now more immediate duties.

rehabilitation. Ivy and Deb reported that the rest home staff asked Ivy to think about selling their family home

I am concerned [about Ivy’s health] and sometimes

and purchase one that better suited Dave’s needs.

I feel I almost need time out. That sounds a bit mean but I just backed off just a couple of weeks

Over time, shifts in needs and capacity to care

ago because I had a few problems with a grown up

influenced care responses, both expected and given.

daughter and I just really needed to have just one

These care responses in turn shaped other family

thing to concentrate on at the time. My work’s lovely

members’ perceptions of what care they deserve and

and very involved and very busy and I just recognise

ought to receive.

that there’s a limit to what I can cope with. (3, Jane)

Page 12

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand While Jane remained concerned for Ivy’s health, by six

within the family to take on such a responsibility. As

months she felt a need for time out from caring. Other

time changed so did the family duties as they were

more immediate duties of care, such as to her daughter

continually reassessed. Over time strain built and

and to her work took precedence. Sometimes the wider

irritation increased.

family may feel the need to pull away, to re-prioritise and recognise self-limits in order to fulfil the duty to self

Like with this whole thing about getting Dave a power

of self-care.

wheelchair, Ivy has been trying to use every avenue that she can [including Deb’s work] to get him a

Financial strain was a consistent theme throughout

power wheelchair and Dave is actually able [to use] a

the interviews. The perception was that dealing

manual wheelchair … I do feel that Ivy has pushed the

with government departments, instead of providing

boundaries. (3, Deb)

assistance to reduce the financial burden, increased the strain on the stroke family.

By the end of the six months Deb was experiencing a number of conflicts. Deb perceived Ivy as blurring her

About three or four days after his stroke I learned,

professional and personal boundaries by using Deb’s

to my horror, that WINZ [Work and Income New

connections to access an electric wheelchair for Dave.

Zealand] will take away his pension … Being on the

Deb’s opinion was that Dave would benefit in the

other side [of the health system] is just no joke …

exercise involved in using a manual wheelchair, and her

The WINZ experience was probably the worst thing

professional view was that other patients had a greater

that Dave and I experienced. You’re just simply not a

need. There were conflicts between the principles of

human being. (1, Ivy)

mercy and fairness.

The financial strain was immense. Ivy and Dave were

Deb became concerned with the amount of energy

faced with potentially losing their home through the

her duty of care towards Ivy and Dave was consuming

inability to pay the mortgage because of the loss of

at the expense of her own immediate family. This

Dave’s pension. This caused significant strain. For Ivy

caused some resentment around the caring role she

it was as if the government was not fulfilling its duty

had assumed. It seemed Deb was disturbed that Ivy

to care for them. The strain was not helped by Ivy’s

demanded mercy for herself in getting Dave an electric

perception of being treated like a case number and not

wheelchair to lessen her burden, but at the expense of

a human being in her interactions with WINZ staff.

Dave’s rehabilitation. Deb appeared to be conflicted between Ivy’s need for mercy and Dave’s right to

The family’s moral perception and their view of the

fairness.

health system were challenged by questions of fairness, justice and mercy. These perceptions affected how the

Discussion

family cared for one another and contributed to family

The overarching theme in this study was duty of care

strain and their care capacity. Early on, out of a sense of

within and for the whole family, which was reflected in

duty Deb took on power of attorney for Ivy and Dave.

the sub-themes: care is different for different people;

While she knew it would only be effective if both Ivy

there are care expectations of self and expectations of

and Dave became incapacitated, Deb still felt a lot of

others; and care brings strain. While caring is a choice

conflicting emotions about whether it was her place

which is sometimes natural and effortless, at other

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Nursing Praxis in New Zealand times and in other situations it requires effort and

Duty of care encapsulated this family’s experience of

is a response to moral obligation or duty (Noddings,

becoming and being a stroke family. Moral judgements

1986). Both such aspects of care were revealed in the

were made around who should provide the care and

experiences of participants in this study.

where Dave should reside. Balancing family expectations and the different care needs increased family strain

The participants were all female family members with

especially when the family’s expectations appeared

no blood relationship but with strong family-like bonds.

to differ from those of the health professionals. This

They were all health professionals which made this

is consistent with research by Lutz et al. (2011) which

sample unusual in that they had professional as well as

found that the expectations of family members in

personal experience of becoming and being a stroke

regard to stroke rehabilitation and discharge planning

family. Their professional backgrounds meant they had

was not always congruent with those of rehabilitation

more knowledge and resources available and were more

providers.

confident in their ability to navigate the health system than other families may have been. Concomitantly,

Ivy knew her limits and what role she was able to play

being a health professional gave them increased

but did not feel that the health professionals showed

awareness of the realities of caring for a stroke survivor,

her any mercy. Instead she felt a sense of enforced

including their own limitations of providing that care to

duty that threatened her health and potentially her

an adequate and safe level. This awareness brought

relationship with Dave. While Ivy was able to recognise

greater stress when the health professionals appeared

her limitations and was able to resist the pressures to

to ignore those limitations and gave the impression that

bring her husband home, other caregivers may not be

the family, especially Ivy, should take on that duty of

able to do so. Similarly, Lutz et al. (2011) described the

care anyway. Also, as a family of health professionals,

importance of caregivers recognising personal limits

they focused on caring for the carer. Both Jane and

to providing care and having a strong sense of self-

Deb discussed caring for Ivy and themselves, alongside

advocacy if they are to avoid the “crisis of discharge”

Dave, and expressed their views and obligations of the

where the stroke survivor’s level of need outweighs the

health system.

caregiver’s capacity to provide care.

The participants’ professional backgrounds shaped

Financial, physical and emotional strains were

their perceptions regarding mercy and fairness in the

significant aspects of the post-stroke experience for the

care of stroke survivors and their families, which was

family in this study. This is consistent with the findings

reflected in their experiences. As family they initially

of Greenwood et al. (2009) and Bulley et al. (2010) who

had a strong sense of mercy for Ivy as Dave’s wife rather

found that financial concerns around entitlements was

than as his caregiver. Ivy was a reluctant caregiver,

a common challenge. Bulley et al. (2010) also described

preferring the role of wife and advocate for Dave,

how emotional burdens of post-stroke care impacted

which was supported by the other family members.

primary caregivers’ self-identity and hope for the

This was tempered as Dave’s rehabilitation progressed.

future. However these emotional burdens were often

Dave’s right to fairness around his rehabilitation and his

prioritised behind physical care by health professionals.

preference to return home conflicted with Ivy’s request

These emotional burdens were reflected in the findings

for mercy. She is a small woman who was concerned

of this study as participants grappled with questions

about being the primary caregiver for Dave who is a big

around the moral and practical aspects of their duty of

man. This value conflict placed strain on the family.

care. The family became preoccupied with what can be

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Nursing Praxis in New Zealand considered as moral and ethical judgments regarding

for stroke survivors in an environment when over

who was most in need of care, the stroke survivor or the

time some challenges diminish and new ones emerge

spouse. Trying to balance their duty of care to the stroke

(Greenwood et al., 2009).

survivor and spouse with other responsibilities brought strain to the extended family. Moral questions around

Conclusion

care distracted family members from the possibility

Becoming and being a stroke family may call forth a duty

of the stroke survivor coming home. Processing these

of care, which is different between family members

moral judgments appeared to separate the family from

depending on what other responsibilities they have.

the stroke survivor’s progress. Considerations of family

Balancing these responsibilities as they continually

dynamics may be useful areas of further research.

change and are reassessed can be a strain on the family. Competing values of mercy and fairness within

Strengths and Limitations

the family in this study took up time and risked shifting

The richness of the data gained from the series of in-

the focus away from the stroke survivor’s progress.

depth interviews with the three participants over a six

Assessing expectations of family members from the

month period helped to give strength to this study’s

beginning of the stroke journey and monitoring moral

findings. Inclusion of family members additional to

questions of fairness, mercy and priorities between

the primary carer was another strength, given the

the stroke survivor and the family as the recovery

“concept of the secondary carer is seldom addressed

progresses is important. Health professionals should

in stroke research” (Greenwood et al., 2009, p. 350).

work with families to identify options for ongoing care

The age range of the participants (40-70 years) allowed

that balance the needs and expectations of not only the

experience between generations to be available for

stroke survivor but also family members.

analysis. The homogeneity of the study participants was a weakness. Participants were all female, Caucasian, and middle class, which limited the study’s perspective and may reduce transferability of findings.

The data and findings of this study contribute to the larger longitudinal hermeneutic project (2011-2015), which will address the need for longitudinal qualitative studies to identify that articulate experiences of caring

References: Brunborg, B., & Ytrehus, S. (2014). Sense of well-being 10 years after stroke. Journal of Clinical Nursing, 23(7-8), 1055-1063.

doi:10.1111/jocn.12324 Bulley, C., Shiels, J., Wilkie, K., & Salisbury, L. (2010). Carer experiences of life after stroke: A qualitative analysis. Disability and

Rehabilitation, 32(17), 1406-1413. doi:10.3109/09638280903531238 Corbett, A., Francis, K., & Chapman, Y. (2006). The experience of whānau caring for members disabled from the effects of a cerebro-vascular accident. Contemporary Nurse: A Journal for the Australian Nursing Profession, 22(2), 255-263.

doi:10.5172/conu.2006.22.2.255 Duty of Care. (2014). In Oxford Dictionaries. Retrieved from http://www.oxforddictionaries.com/definition/english/duty-of-care

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Nursing Praxis in New Zealand Dyall, L., Feigin, V., & Brown, P. (2008). Stroke: A picture of health disparities in New Zealand. Social Policy Journal of New Zealand,

33, 178-191.

Feigin, V., Carter, K., Hackett, M., Barber, P. A., McNaughton, H., Dyall, Dyall, L...Anderson, C. (2006). Ethnic disparities in incidence

of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003. Lancet Neurology, 5(2), 130-139.

doi:10.1016/S1474-4422(05)70325-2 Greenwood, N., Mackenzie, A., Cloud, G. C., & Wilson, N. (2009). Informal primary carers of stroke survivors living at home:

Challenges, satisfactions and coping: A systematic review of qualitative studies. Disability and Rehabilitation, 31(5), 337-

351. doi:10.1080/09638280802051721 Koch, T., & Harrington, A. (1998). Reconceptualizing rigour: The case for reflexivity. Journal of Advanced Nursing, 28(4), 882-890.

doi:10.1046/j.1365-2648.1998.00725.x Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., & Creasy, K. R. (2011). The crisis of stroke: Experiences of patients and their family

caregivers. Topics in Stroke Rehabilitation, 18(6), 786-797. doi:10.1310/tsr1806-786 Noddings, N. (1986). Caring: A feminine approach to ethics and moral education. Berkley, Ca.: University of California Press.

Nortvedt, P. (1996). Sensitive judgment nursing, moral philosophy and an ethics of care. Oslo, Norway: Tano Aschehougs Fonteneserie.

Plager, K. A. (1994). Hermeneutic phenomenology. In P. Benner (Ed.), Interpretive phenomenology (pp. 65-83). Thousand Oaks, CA: Sage.

Stroke Foundation of New Zealand. (2014). Facts about stroke in New Zealand. Retrieved from http://www.stroke.org.nz/stroke-

facts-and-fallacies Stroke Foundation of New Zealand and New Zealand Guidelines Group. (2010). Clinical guidelines for stroke management 2010.

Wellington, New Zealand: Stroke Foundation of New Zealand. van Manen, M. (1997). Researching lived experience: Human science for an action sensitive pedagogy (2nd ed.). London,

Ontario:The Althouse Press.

Vincent, C., Deaudelin, I., Robichaud, L., Rousseau, J., Viscogliosi, C., Talbot, L., & Desrosiers, J. (2007).

Rehabilitation needs for older adults with stroke living at home: Perceptions of four populations. BMC Geriatrics, 7, 20.

doi: 10.1186/1471-2318-7-20

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand DIFFUSION OF THE PRIMARY HEALTH CARE STRATEGY IN A SMALL DISTRICT HEALTH BOARD IN NEW ZEALAND Heather Robertson, RN, PhD, Nurse Leader – Primary and Community, Tairawhiti District Health, Gisborne, NZ Jenny Carryer, RN, PhD, FCNA(NZ), MNZM, Professor, School of Nursing, Massey University, Palmerston North, NZ Stephen Neville, RN, Ph.D, FCNA(NZ), Associate Professor, Head of Department – Nursing, Auckland University of Technology, Auckland, NZ

Abstract The Primary Health Care Strategy (2001) was launched in New Zealand by a Labour-led coalition. This paper reports the findings of a study examining aspects of the implementation of the Strategy on primary health care nursing in a small district health board in New Zealand and contributes new understanding on the depth of issues in the diffusion of the Strategy itself. The research approach was an instrumental case study informed by constructionism and underpinned by a qualitative interpretive design. Data were collected from multiple sources including relevant policy documents and strategic plans as available on organisational websites at the local district health board and primary health organisation level. Qualitative data were obtained using in-depth individual interviews with managers at middle and senior levels at the local district health board and two primary health organisations. Focus groups were held with primary health care nurses. Findings demonstrated that poor diffusion processes negatively influenced the deployment of primary health care nursing in this district; nurses did not understand the intent and potential of the Primary Health Care Strategy. We suggest that policy implementation must include robust diffusion processes in the design and be purposefully inclusive of nursing where relevant.

Keywords Diffusion; innovation; primary health care (PHC); primary health care nursing

Introduction and Background The Primary Health Care Strategy (PHCS) declared

people with chronic conditions (Halcomb, Patterson,

that a strong primary health care (PHC) system was

& Davidson, 2006; Temmnink, Francke, Hutten,

considered fundamental to improving the health of

van der Zee, & Abu Saad, 2000). Changes to service

New Zealanders and for tackling inequalities (Ministry

delivery, shorter hospital stays and an increased focus

of Health (MoH), 2001). The launch heralded a

on population health and health promotion, meant

radical policy change to strengthen service delivery

that the responsibilities for nurses working in primary

in PHC (Workforce Taskforce, 2008) and provided

health care (PHC) had increased (MoH, 2005).

an opportunity for PHC nurses to engage fully with government and their employers in developing

It was imagined that the extensive contribution nursing

new nursing roles and responsibilities (MoH, 2005).

could make to reducing health inequalities, achieving

It coincided with an international call for nursing innovation to produce a new form of health service delivery given an increase in health care demand from

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Robertson, H., Carryer, J., & Neville, S. (2015). Diffusion of the Primary Health Care Strategy in a small district health board in New Zealand. Nursing Praxis in New Zealand, 31(3), 17-26.

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand population health gains and preventing disease,

that supported nurses adoption of an integrated

would be fully realised as a result of the PHCS (Expert

approach to practice incorporating both population

Advisory Group on Primary Health Care Nursing, 2003).

and personal health (Kent, Horsburgh, Lay-Yee, Davis,

The expert advisory group reported that there was no

& Pearson, 2005; MoH, 2005).

nursing voice in decision-making, a noticeable lack of nursing leadership infrastructure in PHC settings and

There is emerging evidence that primary health care

an absence of clinical career pathways. They also noted

nurses do improve health outcomes and should be

that PHC nurses lacked adequate resources to support

utilised accordingly (Cumming et al., 2005; Laughlin &

their education, autonomy and skill development. This

Beisel, 2010; Finlayson, Sheridan, & Cumming, 2009;

study thus explored and examined the situational and

International Council of Nurses, 2008; McMurray,

structural factors contributing to the implementation

2007; Nelson, Connor, & Alcorn, 2009; Sheridan,

of the PHCS in a district health board (DHB) with a

2005). There is also evidence of the nursing potential

particular focus on the utilisation of nurses.

to reduce inequalities in health between the social groups (Hoare, Mills, & Francis, 2012; International

Background

Council of Nurses, 2008; Marshall, Floyd, & Forrest,

There is an abundance of international literature that

2011). The conceptualisation of primary health care is

concentrates on the positive characteristics of PHC

also in harmony with the philosophy of nursing.

(Arford, 2005; International Council of Nurses, 2008; McMurray, 2007; Sloand & Groves, 2005; Starfield

Nonetheless, a WHO (2008) report on PHC identified

& Shi, 2007; Walker & Collins, 2009; World Health

impatience with the inability of health services

Organisation (WHO), 2008). A PHC paradigm privileges

internationally to deliver levels of national coverage

a broader remit than the provision of episodic care for

to meet changing health and societal need. In New

ill health. It works toward the development of health

Zealand, while there may have been small pockets

by putting the emphasis on prevention, community

of change, overall primary health care development

involvement and working with sectors outside of

has been disappointing and many of the features of

health (Keleher, 2000; Sweet, 2010). The International

health services have remained unchanged (Ashton &

Council of Nurses (2008) has said that it is through the

Tenbensel, 2010; Gauld, 2009). Despite the PHCS now

principles of PHC that nursing can make an important

having nearly a 15 year history, the opportunity for real

contribution toward progress in the goal of “health

change for nursing has been obstructed by misaligned

for all” noting that nursing is considered the “very

policy levers and also by custom and practice issues

essence of primary health care” (p.7).

(Carryer & Yarwood, 2015). Greenhalgh, Robert, Bate, Macfarlane and Kyriakidou (2005) argue the

Much of the relevant published New Zealand literature

process of planned change in health is complex. Some

focuses on the introduction of primary health

innovations are readily accepted, whereas others are

organisations (PHOs) and funding models associated

poorly supported.

with the implementation of the PHCS but makes little mention about the impact on PHC nursing. The PHCS promised the effective deployment of nurses to make the best use of nursing knowledge and skills. It was about aligning nursing practice with community need and developing funding streams for service delivery Page 18

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Research Design

was known by research participants. Integrity of the research was strengthened through individual

Aim

interview participant checks and audio taping of

To enhance understanding of the impact of the

the interviews and focus groups. All processes were

implementation of the PHCS on PHC nurses in a small

described in full, personal biases were acknowledged

DHB in New Zealand.

and enhanced by self-critical reflection on author preconceptions that had potential to affect the

Methodology

research.

A qualitative interpretive design informed by constructionism was employed. The diffusion of

Ethical approval was granted after submitting a

innovation theory offered by Rogers (2003) and

detailed ethical application to the Massey University,

Greenhalgh et al. (2005) provided the theoretical

Northern Campus Human Ethics Committee. Advice

lens to collect the data and analyse the findings. This

from the National Coordinator, Health and Disability

theory offered conceptual clarity in designing and

Ethics Committee identified application to a regional

measuring the impact of change in a health setting.

ethics committee was not required as this piece of

It facilitated locating the meaningful components to

research did not involve patients and the risk of harm to

expose the reasoning that underpinned the complex

participants was considered minimal. As an employee

adoption process.

of the DHB of study, the principal researcher (HR) sought approval from the chief executive and clinical

Method

board. The researcher also obtained permission from

Using a single instrumental case study, documentation

the chief executives of other organisations involved.

data were collected from multiple sources including

All ethical requirements were met.

relevant policy and strategic plans as available on the local DHB and PHO websites. A total of 42 people

The diversity of different groups as part of the

participated in the qualitative data collection that took

investigation was considered as central. Cultural

place over a 20 week time period in 2010. In-depth

considerations were of high importance and MÄ ori

individual interviews were held with ten managers at

input was actively sought in each step of the research

middle and senior levels at the DHB and two PHOs.

process.

Five focus groups were held with 32 PHC nurses that included practice nurses, public health nurses, tamariki

Findings

ora nurses, rural nurses, sexual health nurses and Iwi

The organisational and individual diffusion of the

based nurses. While representation was sought from

Strategy in this local DHB negatively impacted on the

all primary health care nursing groups, no district

intended development of the PHC nursing role. Key

nurses or occupational health nurses participated in

themes included: local strategy, local knowledge and

the focus groups.

impacts on understanding.

Thematic analysis was used as the process for

Local strategy

identifying, analysing and describing themes or

There were notable failings in the communication

patterns within the qualitative data. This enabled

channel around the purpose, function and impact

the communication of findings and interpretation

of the whole of Strategy intent. The DHB 2002/2003

of meaning and provided crucial insight into what

District Annual Plan (Tairawhiti District Health,

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 2002a) clearly identified that planners and funders

from basic understanding through to in-depth

understood that there was a MoH requirement to

comprehension:

implement the PHCS. The MoH directed each DHB to develop a local strategic plan to provide direction in

I like its focus in terms of population health…I like

working toward the Strategy objectives. This plan was

its attempt to try and integrate services and health

to have local meaning, local buy in and local support.

professionals in a way that it hasn’t before. (I.10, p.1)

A local PHC discussion document was developed and identified the why, who, and the what, of the PHC plan

Conversely, only four of the thirty-two PHC nurse

although there was little mention of nursing in this

participants had any awareness of the PHCS as the

document. In November 2002, the draft document

following excerpt illustrates:

was presented to the community and public health advisory committee for endorsement (Tairawhiti

May I ask what is the Primary Health Care Strategy?

District Health, 2002b). At this meeting it was

Can we get that right in my head. (FG.1, p.1)

confirmed that once agreement around the discussion document was reached, it would then become the

We found this knowledge gap puzzling initially,

local strategy and guide recommendations for funding

especially as one of the managers firmly believed that

decisions going to the Board. The document was never

information regarding the Strategy had been widely

finalised into a local strategy. This notable absence of

distributed across the district:

a local strategy was confirmed by one manager: I think you would have had to have had your eyes I understood that there was going to be a [DHB]

shut if you were around at that time. (I.8, p.2)

primary health care strategy … and seven years on there still hasn’t been a strategy. (I.5, p.5)

There was evidence that one cohort of nurses had greater appreciation of the PHCS than others. From

We found no evidence of a planned local

the focus groups it became apparent that public health

communication approach. No district annual plans

nurses employed at the local DHB had opportunity to

articulated how information of the Strategy was to be

engage in conversations around the PHCS, both at the

communicated, or how all the stakeholders, including

time the Strategy was launched, and in the years that

nurses, were to be engaged. As a result, nurses and

followed:

other health professionals were alienated from the local development process and unable to gain

When I was at public health, I was more aware

certainty about the cause and effect of the Strategy.

of it because we talked about it and a lot of the

Consequently there were differences in meaning

programmes were based around initiatives … (FG.4,

and understanding of PHC/primary care implications

p.1)

of the Strategy between the managers interviewed and the nurses who participated in the focus groups

Public health nurses were not only provided

confirmed this locally.

information, but actively discussed the Strategy and looked at opportunities for public health nursing to

Local knowledge

contribute to its principles. The irony is that public

Knowledge of the Strategy by the managers ranged

health nurses were largely excluded by the singular

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand national focus on the general practice environment.

Poor engagement suggests there was very little

Whereas nurses in general practice under the auspices

likelihood of shared understanding across the

of newly formed PHOs, or in the non-government

district. Inactivity of Strategy communication and

organisation sector, showed minimal awareness of

implementation caused several participants to

the Strategy.

suggest it was an academic document or a document that sat on the shelf rather than a genuine blueprint

Impacts on understanding

for change:

Disseminating information on the PHCS to PHC nurses was significantly compromised by the lack of

I don’t think the Strategy, like many of the strategies

PHC nursing leadership across the study DHB. Two

that we’ve seen enlighten the life of the health

managers confirmed this was the case:

sector, have become really live working documents.

It is become another nice to have that I go and find

What we need is to have nurse leaders but we do

in the library and refer to if I’m doing academic

not have the funding to do that. (I.1, p.5)

papers. (I.6, p.2)

… advancing primary care nursing from a leadership

In order to reach a point of effectiveness there

perspective and a collective perspective from the

first needed to be a shared understanding of the

ground up is not equitable and quite variable. (I.5,

terminology. Both the MoH and DHB in this research

p.13)

continually struggled with this. The term primary care was frequently used interchangeably with PHC in the

Further, no key person or cluster of people stood out

district annual plans and other strategic documents.

as driving the PHCS forward across the study region.

The Strategy was frequently referred to as the primary

This is supported by the following comment by one of

care strategy (Tairawhiti District Health, 2002a, p.7 &

the managers who was a leading player in PHC at the

52). Further, the MoH website directs readers to their

time the Strategy was released:

PHC publications which are predominantly primary care related documents.

They have relied on the structures to circulate that information. Without having the one message

In a similar vein, the definition of PHC nursing was not

deliverer you have got multiple deliverers all having

well understood across the sector. It could be argued

a take on health. (I.9, p.3)

that there was a shared degree of ignorance about the place, role and contribution of PHC nurses. This was

Multiple

messengers

allowed

for

multiple

confirmed by the significant number of participants

interpretations of the PHCS with personal values

who struggled to articulate the fundamental ideology

and biases added to information. Another manager

of PHC nursing. The limited appreciation of the role and

suggested that communication regarding the Strategy

the difficulty in articulating the depth was illustrated

was less than meaningful engagement:

by managers and nurses alike. The implications of the wrong use of the terminology continued to shape

I suspect that it was more lip service than

communication processes and the decision-making

engagement. (I.2, p.2)

and propensity to act at all levels of the health system in the study area.

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Discussion

implementation activity away from the innovation

The Strategy was a directive from the MoH, the

toward organisations second guessing what they were

principal agency responsible for health policy.

required to do rather than concentrating on local

However,

priorities.

the

operational

decision-making

for

implementation of the Strategy rested locally with newly formed DHBs and resulted in variability in each

Successful dissemination and assimilation of an

DHB’s response across New Zealand (Cumming et al.,

innovation depends on the ability of an organisation to

2005; Finlayson, Sheridan, Cumming, & Fowler, 2011;

be able to manipulate structures and activities in place,

Gauld, 2008; Primary Health Care Advisory Council,

as well as the ability of the stakeholders to understand

2009). This suggests a failure to successfully engage all

the new conceptualisation that accompanies the

potential significant stakeholders, including nurses, at

diffusion process (Greenhalgh et al., 2005). The

both a national and local level in articulating a shared

authors concur that the complexity of organisations

vision or common purpose to support the roll out of

especially those with fragmented internal and external

the Strategy.

structures constrains innovativeness and making it happen requires an orderly, planned and regulated

Diffusion

approach, with all systems ‘properly managed’ in order

The poor diffusion process of the PHCS reduced

to mainstream the innovation within the organisation.

the chance for successful adoption in this local

As this research identified, the PHCS required a

DHB. Greenhalgh et al. (2005) argue adopters of

formulated approach, that involved nursing, to drive

innovations must first ascribe meaning to it and it is

the expected changes forward.

their understanding and belief about an innovation that predisposes their reaction and subsequently

Understanding the role communication plays in

directs actions in response. Numerous innovations

innovation should not be underrated (Leeuwis, 2011).

require a lengthy period of years from the time the

Leeuwis also argues the everyday communication

innovation becomes available to the time it becomes

among stakeholders is critical for the re-ordering

widely adopted (Rogers, 2003). Even so called

of social relationships and the emergence of space

“evidence based innovations undergo a lengthy period

for change in networks. In this study the place of

of negotiation among potential adopters, in which

employment impacted on access to information and

their meaning is discussed, contested, and reframed”

meant that different people knew different things at

(Greenhalgh Robert, Bate, Macfarlane, & Kyriakidou,

different times.

2004, p.594).

The magnitude of organisations having the capacity organisation’s

to absorb new knowledge and be receptive and

predisposition to implementing an innovation. Rogers

ready to change cannot be underestimated (Smith,

(2003) concurs that mandated change or authoritative

McDonald, & Cumming 2008). The change process

decisions are usually associated with a higher rate

deserves greater attention in health care settings

of diffusion and the adoption of an innovation.

(Chreim, Williams, Janz, & Dastmalchian, 2010).

Greenhalgh et al. (2005) also assert that dictating the

Having a dedicated PHC project manager in each DHB

adoption of the innovation is not necessarily conducive

to lead implementation would have been beneficial

to acceptance and implementation. The authors

at the outset. This may have led to the identification

argue the impact of political directives can divert

of common values required, engagement and

Political

Page 22

drive

can

increase

an

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand constructive

conversations

to

increase

mutual

usually within general practice, whereas PHC has a

understanding, respect and commitment to shared

broader more comprehensive remit (Adamson et

gains in personal and population care (Buetow, 2008).

al., 2005; Carryer, 2004; Docherty, 2004; Holdaway, 2002; Keleher, 2001). If the terminology is not well

Impacts on understanding

understood then invariably barriers are created that

Strong leadership and good strategic vision enables

impede the implementation of the Strategy’s intent

systems to respond more easily and quickly to

(Carryer, 2004).

innovation and secure the necessary influence (Greenhalgh et al., 2005; Hamer, 2010; Martin, Weaver,

This particular perception has been at the heart of

Currie, Finn, & McDonald, 2012). Numerous authors

the challenges experienced, aggravated the perceived

argued for a director of PHC nursing to be based within

complexity of the Strategy and contributed to the

each DHB (Carryer, 2004; Expert Advisory Group on

difficulty in articulating a shared vision with common

Primary Health Care Nursing, 2003; Finlayson et al.,

purpose across a range of stakeholders, including

2009). The paucity of nursing leadership was validated

nurses. Previous research undertaken in the DHB of

by the majority of nurses who remain unaware of the

this study, identified PHC nurses did not understand

PHCS nationally with regional diversity and varied

PHC terminology (Adamson et al., 2005) and we found

investment in PHC nurse leadership roles (Sheridan,

that this had not changed in the 5 years following.

2005).

This was concerning given the Strategy explicitly recognised the significance of nursing’s contribution

Many nurses in this study attempted to contribute

to PHC (Expert Advisory Group on Primary Health Care

meaningfully to PHC development but at the same

Nursing, 2003).

time there were and are those who remain content to accept delegated nursing tasks (Docherty, Sheridan,

Limitations

& Kenealy, 2008). Without shared governance and

This was a single case study and is thus viewed by some

collective leadership the ability to impact on planning

as a less desirable form of inquiry (Flyvbjerg, 2004;

and funding decisions or influence their own practice,

Griffiths, 2004; Yin, 2003). Perceived limitations are

allocate resource, or bring about significant change

overridden by the fact that this methodology allowed

was unlikely (Adamson et al., 2005; Attree, 2005;

the capturing of multiple realities to provide evidence

Calverley, 2012; Carryer, 2004; Chreim et al., 2010;

transferable to other PHC nursing settings. Opinions

Expert Advisory Group on Primary Health Care

were confirmed, where ever possible, from supporting

Nursing, 2003; Nelson, Wright, Connor, Buckley, &

literature which was important in mitigating this risk.

Cumming 2009; Robertson-Malt & Chapman, 2008).

Recommendations Terminology confusion

One of the least studied aspects of policy change is

The defective diffusion process was aggravated by a

knowledge on how and why social structures, internal

lack of common understanding of the terminology.

and external influences, and diffusion processes affect

PHC in New Zealand continues to be regarded as

the adoption of policy driven innovations in health.

largely synonymous with general practice (National

These factors are powerful predictors of whether an

Health Committee, 2000). Primary care is defined

innovation will be adopted or not. Policy development

as the first point of entry into a health system,

must include in its design, programmes that are

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand congruent with the values and goals of all major

and other stakeholders as intended adopters of the

stakeholder groups including nurses. If this is not

Strategy. This had a negative effect on the adoption

achieved, then effort must be made towards reaching

decision-making process across the district and the

a common understanding.

substantial lack of nursing engagement.

Conclusion

Implementing the Strategy required engagement,

It was very clear that the PHCS promised so much, but

discussion and debate until a common understanding

delivered so little. Despite the directive to implement

was reached. Instead ineffective diffusion and

the Strategy in a region with high levels of deprivation,

dissemination

very little had changed for service delivery and PHC

understanding. As a consequence there was no

nursing during the study period (2010-2014 years).

shared vision across the health sector. Therefore,

There was little evidence of actions taken in moving

this research reinforces the importance of a planned

toward a state of readiness. The flawed diffusion

approach to change, early attention to detail and the

process was one of the most significant factors in the

necessity for purposeful and meaningful engagement

poor implementation results. This was evidenced by

of all stakeholders, including nurses, following policy

the gap in understanding by various DHB staff, nurses

change or when strategic documents are released.

resulted

in

limited

stakeholder

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Nursing Praxis in New Zealand LEARNING TO BECOME A NURSE PRESCRIBER IN NEW ZEALAND USING A CONSTRUCTIVIST APPROACH: A NARRATIVE CASE STUDY Anecita Gigi Lim, RN, PhD, Senior Lecturer, University of Auckland, Auckland, NZ Michelle Honey, RN, PhD, Senior Lecturer, University of Auckland, Auckland, NZ Nicola North, RN, PhD, Associate Professor, School of Population Health, Auckland, NZ John Shaw, BSc (Hons), PGDipClinPharm, PhD, Professor of Pharmacy, University of Auckland, Auckland, NZ.

Abstract: Prescribing is no longer the sole purview of the medical profession as a wider group of health practitioners in New Zealand, including nurses, may now prescribe. Research on the educational preparation of nurses for a prescribing role is so far limited. This study aims to understand the experiences of postgraduate nurses learning to become nurse practitioner prescribers when undertaking courses that employed a constructivist pedagogical approach. Narrative inquiry, using multiple case analyses, was used to explore the perceptions, views and experiences of ten experienced prospective nurse prescribers. Thematic analysis revealed two main themes: improved clinical practice, and enhanced professional relationships. This study found a constructivist approach to learning facilitated prospective nurse prescribers to confidently draw on their clinical knowledge and experience while developing the knowledge and skills for prescribing.

Limitations of this study include the small sample size, and further research into the development of authorised and designated nurse prescribers in New Zealand is recommended.

Key words Nurse prescribing; constructivism; narrative case study; narrative inquiry; prescribing education

Introduction Medical prescribing, in terms of both education and

This article describes the pedagogical underpinnings of

practice, has been extensively researched but this has

one of the first postgraduate programmes developed

not been the case with nurse prescribing (Coombes,

for nurse practitioners to gain prescriptive authority.

Mitchell, & Stowasser, 2008; Franson, Dubois, de Kam,

Nurses intending to become nurse practitioner pre-

Burggraaf, & Cohen, 2009; Garbutt et al., 2006; Gwee,

scribers were interviewed to gain an understanding of

2009). One reason for this is that internationally, pre-

their experiences of undertaking these postgraduate

scriptive authority differs between countries, and

prescribing programmes.

hence the educational preparation for nurses to prescribe also varies. This has detracted from consistent

Background

research into the educational preparation and practice

Nurse prescribing in New Zealand: A brief history

of nurse prescribing despite the fact that registered

In New Zealand, the nurse practitioner role was intro-

nurse prescribing is well established in some countries, notably the United Kingdom and is generally regarded positively (Latter et al., 2010).

Page 27

Lim, A.G., Honey, M., North, N., & Shaw, J. (2015). Learning to become a nurse prescriber in New Zealand using a constructivist approach: A narrative case study. Nursing Praxis in New Zealand, 31(3), 27-36.

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand duced to improve patient access to health care services

prescribers gained the same prescriptive authority as

(National Health Committee, 2000). The introduction

doctors, dentists and midwives as authorised prescrib-

of the nurse practitioner role also represented a sig-

ers, and a new category of prescribers called delegated

nificant advance for professional nursing and posi-

prescribers was added to the Act. There are now three

tioned nurses to practice autonomously. Autonomous

levels of prescriptive authority in New Zealand: au-

practice for nurse practitioners includes performing

thorised, designated and delegated. These legislative

comprehensive health assessments, clinical diagnosis

changes bring challenges and potential for confusion to

and prescribing treatments. The introduction of nurse

nurse prescribing roles.

prescribing in New Zealand has developed concurrently with the role of the nurse practitioner (Nursing Council

Educational preparation of nurses for prescribing has

of New Zealand, 2005). Since 1999, nurse practition-

always been considered in the changes to the legisla-

ers in New Zealand can prescribe as long as they have

tion. Educational preparation includes knowledge of

completed the necessary educational preparation (Lim,

applied biological sciences, advanced assessment and

Honey, & Kilpatrick, 2007).

diagnoses, pharmacology and therapeutics, alongside a prescribing practicum where the knowledge is ap-

Prescriptive authority in New Zealand is outlined in the

plied within a clinical context. The educational prepa-

Medicines Act of 1981 and in the Medicines Regula-

ration for all nurse prescribers requires attainment of

tion of 1984. Under the Act, health professionals with

prescribing competencies and these are examined by

prescriptive authority (authorised prescribers) can

the Nursing Council of New Zealand (2007). Research

prescribe all medicines from Part 1A or Part 1B of the

into the effectiveness of the educational preparation of

Schedule 1 of the Medicines Regulations. Three health

New Zealand nurse prescribers has been lacking.

professional groups were authorised prescribers (doctors, dentists and midwives) until 1999 (Medicines

International education for nurse prescribers

Amendment Act 1999) when prescriptive authority for

Internationally, support for master’s degree prepara-

nurses was considered by the New Zealand government

tion of nurse practitioner prescribers, where theory of

and the legislation was amended.

pharmacology and therapeutics is included, has grown (Brar, Boschma, & McCuaig, 2010; Latter et al., 2010;

Educational preparation for prescribing was included

Van Ruth, Mistiaen, & Francke, 2008). In addition, on-

in the undergraduate programme for doctors, den-

going post-registration support and continuing clinical

tists and midwives, which was not the case for nurses.

development in the area of prescribing is also advo-

Therefore the term, designated prescribers, was added

cated (Hemingway & Davies, 2006). Strickland-Hodge

in the amendments to the Act. Unlike authorised pre-

(2008) argue that prescribing is more than the physical

scribers, designated prescribers are required to un-

act of ordering medicines and requires skills in clinical

dergo additional education in pharmacology and ther-

reasoning, decision-making, and medication manage-

apeutics to become prescribers. Since 1999, further

ment. Ross and Loke (2009) noted that the range of skills

amendments to the Act (in 2011) extended prescriptive

required for safe and appropriate prescribing creates a

authority to pharmacists and diabetes nurse special-

major challenge for those involved in designing educa-

ists, so that pharmacists, diabetes nurse specialists and

tional programmes. They observed that while prescrib-

nurse practitioners could become designated prescrib-

ing a ‘one-off’ drug for the younger healthy patient may

ers. The extension was further refined in 2013 (Medi-

be relatively straightforward, rational prescribing in

cines Amendment Act 2013), when nurse practitioner

the case of an elderly patient with co-morbidities and

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand multiple drugs can be difficult and challenging. Writing

supervision and mentoring in prescribing activities. At

a prescription therefore requires more than just text-

the time of this study, the senior colleague was a doctor

book knowledge of pharmacology and therapeutics; it

as there were no senior nurse practitioner prescribers.

requires deliberate judgment and an ability to carry out

This will change over time with the availability of more

practical and complex tasks (Braunwald, 2005).

senior nurse practitioner prescribers.

The prescribing curriculum in New Zealand

A constructivist pedagogical approach

New Zealand educational programmes for nurses in-

The development of a programme for nurse prescribers

tending to become prescribers aim to produce compe-

at one university recognised the characteristics of their

tent professionals with expert skills, able to think criti-

students: the students were experienced clinical nurs-

cally and autonomously, and who are accountable for

es, who were close to completing their master’s degree.

their own practice (Gardner, Gardner, & Proctor, 2004).

Constructivism as a learning theory views learning as

The Nursing Council of New Zealand regulates the edu-

building on the individual’s current understanding

cational requirements and identifies the competencies

and skills by incorporating new information and skills.

required for nurse prescribers. When nurse prescribing

Learning occurs where information and experiences

was introduced into New Zealand a clinically focused

are meaningful and specific to the individual (Powell

master’s degree, or its equivalent, was required for

& Kalina, 2009). Constructivism operates under the as-

entry into practice as a nurse practitioner along with

sumption that learning takes place at multiple levels

additional approved pharmacology courses relevant to

of intelligence, each of which relates to certain modes

the nurse practitioner’s scope of practice (Ministry of

of communication, and is seen to be a natural process

Health, 2002; Nursing Council of New Zealand, 2002).

for learners. A constructivist approach puts the focus

This study uses one New Zealand university programme

on the learner and his/her experiences, on which new

to illustrate how the Nursing Council competencies for

knowledge can be built (Powell & Kalina, 2009; Young &

prescribing are met.

Maxwell, 2007).

Context for the study

Bruner (1996), a seminal constructivist theorist, sug-

In order to prepare nurses for prescribing, the univer-

gests that learning is an active process, stimulated

sity where this study was based provides mandatory

by curiosity. In the university programme described

courses in applied science and assessment and diagnos-

above, utilising a constructivist learning approach sup-

tic reasoning as the foundation for subsequent courses

ports the notion that experienced nurses can build

(Lim et al., 2007). Other specific prescribing courses

their knowledge and skills in interaction with their work

cover the topics of pharmacology and therapeutics,

environments, drawing on prior learning. Thus learning

including practical considerations for prescribing and

is cumulative (Bruner, 1996), and past knowledge and

the principles of medicines evaluation, pharmaco-

experiences can shape future learning for the nurse.

economics and therapeutics. The capstone course is a

According to Biggs (2003) a constructivist approach as-

prescribing practicum that provides the opportunity to

sists learners in their journey of discovery by bridging

apply knowledge and skills in pharmacotherapeutics to

new learning with existing knowledge.

prescribing practice, specific to the nurses’ clinical practice area. In the prescribing practicum the nurse works

There are several reasons for employing a constructivist

closely with, and under the supervision of, a senior col-

learning approach to prescribing education for nurses.

league in the same clinical area, who provides direct

First, the students were nurses with considerable clini-

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand cal experience. Years of clinical experience have been

tal type of case study. Unlike the intrinsic case study

related to clinical expertise (Benner, Tanner, & Chesla,

where interest in individual narrative is the goal, in

2009). Second, a clinical background benefits nurses by

the instrumental case study, case studies are related

providing a context wherein the learning of new skills

to a need for a general understanding and insight into

and knowledge can occur. The expert nurse acquiring

the question by studying particular case narratives

the new skill of prescribing is a practitioner “who per-

(Shkedi, 2005). Ethical approval to conduct the study

ceives situations as a whole, uses past concrete situa-

was obtained from the university’s Human Research

tions as paradigms, and moves to the core of the prob-

Ethics Committee (Ref. 2007/249). Using a purposive

lem without wasteful consideration of a large number

sampling process, ten nurses who had completed the

of irrelevant options” (Dreyfus & Dreyfus, 1996, p. 125).

required programme of study to become nurse prac-

The notion of expertise, as defined by Benner (1984),

titioner prescribers at the university which is the con-

develops through experience as preconceived notions

text for this study were recruited; this is a subset of a

and expectations are challenged, refined, or discon-

larger study. Purposive sampling in qualitative research

firmed by an actual situation.

allows the selection of participants that will best help the researcher understand the phenomena and the

Methods

research question (Creswell, 2009). Data was collected

The qualitative approach employed in this study ena-

in 2008 from nurses intending to be nurse practitioner

bled access to context-specific knowledge embedded

prescribers, who at that time would have been desig-

in learning the practice of prescribing. As prescribing

nated prescribers. The participants were postgraduate

is a complex phenomenon, qualitative research, spe-

students in prescribing, and participant characteristics

cifically multiple case narratives, offer a useful way

are summarised in Table 1.

to describe and explain phenomena narrated by the participants, and to develop theory regarding these

Semi-structured interviews were conducted in which

constructed phenomena (Shkedi, 2005). Multiple case

participants were asked to describe their roles and

narratives are concerned mainly with the instrumen-

their experiences in the process of developing to be-

Table 1: Description of Participants (n=10)

Page 30

Participants

Clinical practice area

Years of experience in practice area

P1

Ophthalmology

10 years

P2

Child Health

10 years

P3

Mental Health

8 years

P4

Primary Care

10 years

P5

Child Health

12 years

P6

Sexual Health

15 years

P7

Emergency Care

10 years

P8

Primary Care

15 years

P9

Gerontology

15 years

P10

Primary Care

10 years

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand come prescribers. The interviews took place at the

That pharmacology preparation was really useful

participants’ convenience and lasted 45 to 60 minutes.

for me…but I looked at what she [patient] was pre-

Recorded interviews were transcribed verbatim. After a

senting with, like headaches, and I looked at what

thorough reading of transcripts, units of data selected

she was on [drugs] I could see there were interac-

from each case were entered in the Narralizer® soft-

tions. (P2)

ware. Narralizer is user-friendly, qualitative research software, which allows the researcher to conduct tex-

Learning for participants occurred in an environment

tual data analysis, develop a comprehensive narrative

that was described as conducive to consolidation, ap-

description, store bibliographic items and build theo-

plication, and integration of concepts applied to patient

ries grounded in data.

situations.

Analysis proceeded using a multiple case narratives

So that’s my background, from a young nurse to 20

approach, based on continual stages. Each level is con-

years later, 30 years later. But for me, I don’t find

structed based on the level “below” and cannot be con-

medications as scary now. But what it does tend to

structed without this previous level of analysis (Shkedi,

do to you, I think, is realize how much I don’t know. So

2005). Four levels of analysis were undertaken result-

even if I didn’t become a prescriber what this paper

ing in two main themes. The resultant narrative based

[pharmacology and therapeutic course] has done for

report is the translation of the participants’ narratives

me is... to be able to critique medication quite care-

into theoretical academic language, within a concep-

fully now. (P10)

tual framework, and includes authentic pieces of narratives from many of the cases.

Extensive prior clinical experience enabled participants to recall previous clinical situations. Better understand-

Findings

ing of the underlying mechanisms of side-effects and

Two main themes that illustrated a constructivist ap-

adverse effects were identified by the majority of par-

proach in postgraduate study for prescribing emerged

ticipants as the most important aspect of their learning.

from the analysis. These were: improved clinical practice, and enhanced professional relationships, de-

...knowledge of the medications and things and just

scribed below in detail using illustrative quotes.

the side effects of those medications, and their systemic effects are important to understanding how

Improved clinical practice

patients are managing. (P1)

As the participants learned more about pharmacology to improve their understanding of drugs, they could

Knowledge of pharmacology enhanced the nurses’ abil-

immediately apply this new knowledge to their clini-

ity to identify potential drug(s) to use in specific situa-

cal work, and draw on that experience to make sense

tions, and increased their confidence and involvement

of new knowledge. Thus, although the participants

as a healthcare team member in managing patients’

were not yet authorised to prescribe, their narratives

regimens.

revealed how application of improved pharmacological knowledge immediately benefitted their day-to-day

…the course, gave me a real overview of what other

practice.

medications were out there and what they did and how they worked. Now that is very important when I

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand come to take a history in a patient, because patients

Enhanced professional relationships

don’t always come knowing their medications. (P1)

The prescribing practicum was viewed by all participants as the most useful of the prescribing education

Participants observed that the new knowledge im-

courses. Participants felt that the mentoring process

proved the way they educated patients about medica-

not only enhanced their relationship with the doctors,

tions. They also considered that the learnt knowledge

as prescribing mentors, but also provided an avenue to

and skills enabled them to improve their critical think-

allow doctors to understand what they (nurses) did.

ing skills in terms of their understanding of patient assessment and clinical management.

Doctors do not really understand what a nurse practitioner does, let alone, nurses prescribing. So the men-

I guess what it’s done is made me think more, a lot

torship experience provided the opportunity for us to

more, about drug interactions, safety with medica-

discuss the role and [nurse] prescribing. (P6)

tions more so …it has given me more depth of knowledge to allow me to think more about what I am do-

Prescribing decision-making and risk-benefit analysis

ing. (P8)

undertaken during the practicum were elements of learning that participants considered essential for pre-

Some participants were initially ambivalent about pre-

scribing. Not only did it provide them with the essential

scribing. They revealed difficulties in understanding the

experience of making risk and benefit choices, it also

complexities involved in making drug choices and deci-

enhanced their understanding of the dilemmas that

sions related to an individual patient’s situation.

doctors face in making prescribing decisions, providing greater insight into what doctors actually do:

Knowledge of the medications and things, and just the side-effects of those medications, systemic ef-

I would say doing the training certainly has changed

fects are all important to understanding how pa-

my practice up to this point… I’m a lot more aware of

tients are managing. (P1)

what’s happening whenever we use medication and I have a greater insight into where some of the doctors

Learning to prescribe increased their knowledge and

are coming from. (P2)

confidence about choices of treatment versus nontreatment, the need for monitoring and evaluation,

Participants felt that they had increased their abil-

dosing considerations related to efficacy of treatment,

ity to communicate with doctors about the drugs that

and the role of patient adherence to treatment and its

patients were prescribed, and were more confident in

consequences.

their contribution to decision-making in the healthcare team. One example illustrates this:

So if I was looking at the medication this patient was on, for example a beta blocker, I can now ask myself,

…I’m more confident in arguing my point of view

is this patient suitable for a beta blocker or not? Now

when I have disagreements, particularly about the

I look at their age and their medical condition. For

medication regimen… Rather than trying to sub-

example, if they are asthmatic or whether they have

tlety influence the doctor now I’ll be hopefully argu-

any chronic cardiac problems or whether they’ve ever

ing with them on a level footing. You know I mean, I

had it before and so on. These can affect the way the

mean having clinical discussions. (P9)

patient will handle the drug. (P1) Page 32

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand A constructivist approach to the educational prepara-

portant as a foundation for a constructivist approach

tion of those becoming nurse practitioner prescribers

to learning. The participants’ past clinical experiences

illustrates how their previous clinical experience en-

and expertise in many aspects of patient care have

hanced their learning to prescribe.

been shown in this study to provide some advantage to learning the new skill of prescribing, as they were able

Discussion

to identify and describe their learning needs and how

Post-graduate education in pharmacology and pre-

these could be applied to practice.

scribing by experienced nurses is a necessary step to acquiring the knowledge and skills to prescribe safely

In the context of postgraduate education in learning to

and competently. This study shows that as participants’

prescribe, the participants revealed how the education

theoretical knowledge of drugs was extended and

process opened up much wider learning opportuni-

improved they were able to apply new knowledge to

ties. As experienced nurses who were active clinically,

many aspects of prescribing, and their application of

they were able to immediately apply new knowledge to

learning immediately improved their clinical practice,

existing clinical situations, an approach often referred

in particular their medication management skills. The

to as ‘situated learning’ (Herrington, Reeves, & Oliver,

learning process described by the participants can be

2014). Situated learning is a concept advocated in so-

seen as dynamic, starting with their existing practical

cial constructivist approaches where knowledge is con-

knowledge and moving both forwards and backwards

ceived as being embedded or connected to the situation

between theoretical and clinical knowledge in a dynam-

where learning occurs, and where what is learned tends

ic and iterative manner, illustrated in Figure 1.

to be context-bound or tied to the situation in which it is learned (Herrington et al., 2014). Learning to pre-

The nurse participants in this study came to prescrib-

scribe, increased participants’ confidence as members

ing education with prior attitudes and experiences, im-

of the healthcare team and to engage in clinical discus-

LEARNING TO BECOME A NURSE PRESCRIBER IN NEW ZEALAND USING A CONSTRUCTIVIST APPROACH: A NARRATIVE CASE STUDY

Pharmacology and therapeutic principles.

PRACTICAL KNOWLEDGE Previous knowledge and clinical experience.

Previous Knowledge of patient context.

Previous knowledge of medication.

Applied to

THEORETICAL KNOWLEDGE Pharmacodynamics Pharmacokinetics Therapeutics

CLINICAL KNOWLEDGE Enhanced knowledge and clinical practice.

Enhanced clinical reasoning skills Prescribing

Figure 1: Nurses’ learning process in developing theoretical, clinical, and practical knowledge in prescribing, reflecting a constructivist approach.

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Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand sions with colleagues. Their professional relationships

research include ongoing research into nurse prescrib-

with doctors, and their experiences with their medical

ing as nurses develop from novice to expert prescrib-

colleagues as prescribing mentors during the prescrib-

ers, and the applicability of a constructivist approach

ing practicum, were described by most participants as

to prescribing education for other health professional.

being very positive. There is growing evidence that certain clinical environments encourage the development

Conclusion

of expertise; such environments are characterised by

In addressing the central question of how experienced

continuity of care, autonomy of practice, a supportive

nurses learn new knowledge related to prescribing,

clinical environment and the opportunity to reflect on

participants revealed how they were advantaged by a

and share clinical experiences; factors which are prac-

constructivist approach where they were able to draw

tised and promoted in the advanced nurses’ current

on their prior experience and to integrate this with new

roles and clinical areas (Benner et al., 2009; Paterson

knowledge, skills and learning experiences. This study

& Higgs, 2008).

found that there are elements already existing in the clinical setting that strengthen and consolidate the skills

Another notable finding related to participants’ in-

and the knowledge learnt in the prescribing courses,

sights into the prescribing roles of doctors. By working

elements fostered by a constructivist approach to pre-

with doctors as prescribing mentors during the practi-

scribing education. It also illustrated that, as postgradu-

cum, participants better understood the complexities

ate students learning to prescribe, nurses have the

involved in the process of prescribing and its applica-

advantage of a rich experiential background on which

tion for specific patients. This experience supported

to draw. As a consequence, their present clinical work

their development of the skills of reasoning and clinical

immediately benefits from new learning being applied

decision-making. Constructivist approaches to learning

and, through a constructivist approach, their learning

make extensive use of cooperative learning, which was

is broader than just understanding pharmacology and

shown as students were exposed to the doctors’ think-

therapeutics. The findings of this study may have impli-

ing processes (Young & Maxwell, 2007).

cations for the educational preparation of nurses who are authorised, designated or delegated prescribers. It

The small sample of only ten nurse participants is a

is also likely that other experienced health profession-

limitation of this study; however, this was negated by

als, for example pharmacists, could similarly benefit

use of a multiple case narrative methodology which

from a constructivist approach to learning to prescribe,

provided an abundance of rich data. Areas for further

and this is an area for further research.

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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, critical review and position papers 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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