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IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE... Cultural safety: A vital element for nursing ethics The journal Kai Tiaki’s role in developing research capability in New Zealand nursing, 1908-1959   Cigarette smoking and the frequency of colposcopy visits, treatments and re-referral

Volume 29. No. 1

March 2013

Praxis: “The action and reflection of people upon their world in order to transform it.” (FREIRE, 1972)

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



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 W ISSN 0112-7438 HANNAH & YOUNG PRINTERS

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

ARTICLES: Cultural safety: A vital element for nursing ethics Thomas Harding .......................................................................................................................... 4 The journal Kai Tiaki’s Role in developing Rrsearch capability in New Zealand nursing, 1908-1959 Pamela J. Wood, Katherine Nelson ............................................................................................ 12 Cigarette smoking and the frequency of colposcopy visits, treatments and re-referral Jill Lamb, Shelagh Dawson, Mary Jo Gagan, David Peddie ........................................................ 24

NOTES FOR CONTRIBUTORS............................................................................................................. 34 NURSING PRAXIS WEBSITE .............................................................................................................. 37 SUBSCRIPTION INFORMATION.......................................................................................................... 37

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand EDITORIAL As an academic, researcher and member of the

through past editions of Praxis and discovered

editorial board of Nursing Praxis in New Zealand

that editorials over the years have reinforced the

(Praxis) I am very aware both with respect to my

importance of publication, and a series of papers

own work and nursing research generally, that the

has appeared providing a stepwise approach to

research process is not complete until a report has

preparing a manuscript for publication. Certainly

been submitted for publication. Praxis is committed

the requirements associated with the Performance

to publishing New Zealand nursing research in order

Based Research Fund (PBRF) have highlighted the

to develop and disseminate research findings that

need for nurses working in education, (whether

will inform and support clinical practice. Although

they work in a University or Polytechnic) to publish.

the number of manuscripts submitted has increased

However this has not translated into a significant

over time this, in my view, is still not a true reflection

increase in the number of nurses submitting work

of the total number of completed studies. Too many

for publication.

remain unpublished, largely for the reason that researchers tend to omit this last step in the overall

An editorial piece written by Associate Professor


Annette Huntington in 2003 took an encouraging stance by outlining that publication was an integral

For some years now tax payers of New Zealand

component of the research process. Huntington

have funded nurses to undertake postgraduate

states “... New Zealand generated research evidence

nursing education, initially through the Clinical

is vital to support decision-making in policy

Training Agency and now through Health Workforce

formation and practice� (p.3). I agree, but would

New Zealand. This has resulted in a proliferation,

add that the dissemination of research findings is

not only in the number of nurses participating in

also an ethical issue.

postgraduate education, but also in the number of educational institutions offering postgraduate

Gaining ethical approval is one of the first steps

programmes. Some of these institutions have

in the research process. The human ethics

compulsory research projects embedded in their

application form invariably asks how the results

programmes. Consequently, one could expect an

from the project will be shared with participants

increase in the volume of clinically focussed nursing

and disseminated in other forums, for example

research being published. Unfortunately this is not

quality assured publications and conferences. Also

the case. Many theses, dissertations and research

participants frequently consent to participating in

reports remain unpublished, languishing on library

research if they think it will improve health care

and/or office shelves. That situation - the non

practices. Consequently, I suggest it is unethical to

publication of nursing research - is the focus of this

complete research, and not present a report for


publication. While I accept that many people choose to present findings at conferences which, although

In preparation for writing this editorial I browsed

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useful, is only one step in the dissemination process.

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Publication in a quality assured journal is the logical

Besides the earlier Praxis series on the subject, the

vehicle for the dissemination of information and as

editorial in the Journal of Nursing Scholarship (2012)

such should be the seen as the gold standard.

titled “Five Tips on Getting Research Published” provides useful guidelines to ensure success. I

The main barrier to publishing, as I hear from

conclude this editorial with a plea to all those

nurses, is that the review process is overly rigorous.

nurses who have undertaken, are in the process of

Unfortunately many authors take feedback from

undertaking or are planning to undertake research

reviewers personally. This all too often results in a

to accept that publication is integral to the research

loss of confidence and motivation to engage in the


rewriting process. Consequently the manuscript languishes never to be resurrected and so remains


unpublished. The review process is integral to

Gennaro, S. (2012). Editorial: Five tips on getting published. Journal of Nursing Scholarship, 44(3), 203-204. doi:10.1111/j.1547-5069.2012.01461.x

developing a coherent and credible body of knowledge and is pivotal to maintaining quality. It is important to remember that feedback is not

Huntington, A. (2003). Editorial. Nursing Praxis in New Zealand, 19(1), 2-3.

personal; rather it focuses on the content and quality of the manuscript and is designed to assist

Dr Stephen Neville RN, PhD, FCNA(NZ)

with the publication process.

Postgraduate Programme Coordinator and Senior Lecturer

There is a multitude of resources available to assist

School of Health and Social Services

with preparation of manuscripts for publication.

Massey University Subscribe Now

The all New Nursing Praxis website now features • New Nursing Praxis Blog with news on upcoming issues, calls for manuscripts and announcements for special issues etc. Go to the blog page to receive RSS or free Email updates from our Blog. • Subscribe or order backcopies & articles via credit card online. • The new search facility for the database of previous articles/ issues of Nursing Praxis is available now, perfect for research you can search abstracts for free. • All subscribers (including staff & students of company/institution subscribers) can now search and access all available full text articles.

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand CULTURAL SAFETY: A VITAL ELEMENT FOR NURSING ETHICS Thomas Harding, RN, PhD. Associate Professor, School of Nursing, Midwifery & Paramedicine (NSW & ACT), Australian Catholic University; Associate Professor, Department of Health Science, Buskerud University College, Norway.

Abstract This paper argues that the globalisation of nursing and the internationalisation of nursing education have lead to Western values being embedded into nursing curricula in nations where the cultural values and beliefs may be based in quite different philosophies. It argues for critical examination of assumptions underpinning ethics education in nursing and proposes that the principles of cultural safety need to be incorporated into ethics education to create a culturally safe ethic for both nurses and patients in a multicultural healthcare environment. Key words: ethics, cultural safety, nursing education, internationalisation

The internationalisation of nursing education A significant contemporary phenomenon is the

western culture, inclusive of theoretical and practice

globalisation of the nursing workforce and the

underpinnings from other first world English speaking

internationalisation of higher education in nursing

countries” (p. 2). Western cultural perspectives and

(Allen & Ogilvie 2004). Although the large number of

values, embedded in nursing education, practice

students studying out of their home countries may be a

and research have been exported to countries with

relatively recent phenomenon, the internationalisation

different cultural perspectives and practices. They

of nursing education is not. Nursing education has

have been transported by nurses from countries in the

been an ‘export industry’ since the inception of the

Anglo-US axis who have worked overseas, including

professional era in nursing following the Nightingale

teachers and researchers, and many nurse leaders

reforms in the Western world in the 1880s.

from non-Western nations have undertaken some of their education in English-speaking countries. As well,

In New Zealand, as in most nations, the origins of

English is the dominant international and professional

contemporary nursing practice and education lie in

language, consequently many nursing school libraries

the work of Nightingale’s lady-pupils: her disciples

have English language books and journals, most of

who propagated her methods throughout the

which derive from either the United States (US) or the

world dominated by the nineteenth century British

United Kingdom (UK) (Davis, 1999). These books and

Empire. Consequently, Western paradigms have been

journals reflect the value systems of the nations in

highly influential worldwide in the development

which they originate.

of nursing practice and education. In Australia, for example, Dickson, Lock and Carey (2007) note that nursing education and practice “is framed by the values, beliefs and expectations of a dominant Page 4

Harding, T. (2013). Cultural safety: A vital element for nursing ethics. Nursing Praxis in New Zealand, 29(1), 4-11.

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Nursing ethics and education

patients and students is when we consider the values which underpin the teaching and practice of ethics in

Kerridge, Lowe and Stewart (2009) point out that most


health professions require their members to comply with an ethical code or code of conduct. Nursing is no

Whose values underpin nursing ethics?

exception and Todaro-Francheschi (2012) argues that the teaching and facilitation of social/moral roles and

According to Johnstone (2008), in order to understand

ethical behaviour is as important as the teaching of

the basis of ethical professional conduct nurses need

“nurse think”, i.e., practical reasoning skills, and skills

a working knowledge of the concepts and theories of


ethics, and the language which describes these. She traces the history of “ethics, as it is referred to and

Ethics is a branch of philosophy which concerns the

used today” (p. 12) to the works of the Ancient Greek

values underpinning motivations and actions: it is

philosophers: Socrates, Plato and Aristotle.

about both thinking and doing (Kirby & Slevin, 1995).

men laid a foundation for the Western approach to

It also encompasses the consequences that result from

ethics which emphasised moral decision-making,

these thoughts and behaviours.

questions about how we should live and act, based

Whereas nursing

ethics is described more specifically as a:


in unemotional, rational justification (Kerridge et al., 2009).

... domain of inquiry that focuses on the moral problems and challenges that nurses

Johnstone (2008) contends that ethics is culturally

face in the course of their work. It involves an

constructed and culture is the foundation for shared

exploration and analysis of the beliefs, values,

beliefs, customs and values. Yet, although the practise

attitudes, assumptions, arguments, emotions

of nursing is universal, it is rarely questioned whether

and relationships that underlie nursing ethical

nurses globally share the same values (Davis, 1999).

decisions. (Dooley & McCarthy 2005, p. xi)

In the US, for example, a dominant national theme is that of the pioneer, the ‘rugged individual’, and

If, as contended by Dooley and McCarthy, nursing

subsequently the notion of ‘self-reliance’ has become

ethics involves exploration and analysis of beliefs,

deeply engrained in the cultural psyche (Davis).

values and relationships then it follows that there is

Similarly, in Aotearoa New Zealand self-reliance is a

a social dimension which requires consideration of

prized attribute in Pākehā society. It is exemplified in

and respect for others (Kerridge et al., 2009). In terms

the almost legendary figures of Colin ‘Pinetree’ Meads,

of nursing practise, it means being able to practice

Barry Crump, Fred Dagg and Wal Footrot (Harding,

“patient-centred nursing that is congruent with

2006)1. A stereotypical image has been created of the

the personal values of patients, the institution and

New Zealand male which Phillips (1987) summarised

society” (Caldwell, Lu & Harding, 2010, p. 191). This


is apparent in the increased emphasis on meeting the

A rugged practical bloke – fixes anything, strong

needs of a multicultural patient population, as well

and tough, keeps his emotions to himself,

as a culturally diverse nursing student body (Nairn,

usually scornful of women. Yet at heart a

Hardy, Harling, Parumal & Narayanasamy, 2011). It is

decent person, loyal to his mates, provides

questionable, however, how successful this increased

well for the wife and kids … (backcover)

interest in meeting the needs of culturally diverse Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand The idealised values of individualism and self-reliance

culture is subordinate to relationships with others

are embedded in our national psyche. Even though

(Bockover, 2003). Similarly, in Japan the word for self

these cultural constructs now verge on being an

(jibun) means part of a larger whole that consists of

almost mythical image of a vanished colonial past,

groups and relationships; therefore:

they remain influential. Davis (1999) contends that the ethical principle of autonomy and its application

individuals are not essentially apart from the

in ethico-legal practices such as informed consent and

society in which they exist. The individual

advance directives operationalise such values. The

or self attains and maintains form through

problem with such cultural constructs underpinning

relating to other in a variety of ways (Davis

our approach to ethics is that they are not universal

1999, p. 121).

values, but hegemonic constructs which, in Aotearoa New Zealand, reflect a world view of the European

In Aotearoa New Zealand, the cultural values of Tangata


Whenua have far more in common with those societies which can be termed ‘collectivist’ than they do with

World culture can be loosely divided into two different

the cultural values of the ‘individualist’ colonisers.

types: the individualist and the collectivist cultures. The

Māori identity is based in kinship relationships, but

former tends to characterise the hegemonic cultures

has been subject to processes of enculturation into

in Europe, North America and other English-speaking

the dominant Pākehā culture through covert and

countries such as Australia and New Zealand. In such

overt processes of assimilation (Williams, 2001). The

cultures the rights of the individual are predominant.

processes of colonisation have subordinated the

The majority of the world’s cultures, however,

cultural values of the Māori to those of the European

are more like those which can be categorised as


‘collectivist’: where, loyalty to a group may outweigh

powerful tool in this process, based on a Western

individual rights (Davis, 1999). For people acculturated

paradigm of learning with, in particular, an emphasis

in the values of societies characterised by collectivism,

on written language as the basis for rational thinking

autonomy may be inimical because the fundamental

(Jones & Hunter, 2004).

The education system has been a very

cultural value is that of group cohesion. For example, in China, ethics is deep rooted in general philosophy

In healthcare, an example of rational thinking is the

and culture, and the core of Chinese culture is in

use of normative ethics – principles, rules, theories

three different teachings: Confucianism, Taoism and

and guidelines – which may be used as a template

Chinese Buddhism (Qui, 2006). Arguably, the most

to guide our actions. This approach is fundamental

influential of these philosophical approaches has

to the four principles formulated by the US authors

been Confucianism, which emphasizes virtue, duty

Beauchamp and Childress (2001) in which autonomy,

and context (Caldwell et al.,2010). The ‘self’ in Chinese

beneficence, non-maleficence and justice provide a framework for ethical decision making in health care. A particularly influential development in the latter part


Colin Meads is arguably New Zealand’s most famous former All Black.

Barry Crump, author, characterised in his own life the New Zealand male stereotype. Fred Dagg was the comic alter ego of John. Clarke who satirised the rural New Zealand

of the twentieth century was the emergence of the field of bioethics which Reich (1995) defined as:

male and Wal Footrot was the eponymous hero of the popular comic strip Footrot Flats, which also drew upon the rural New Zealand male stereotype for humorous effect.

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand [t]he systematic study of the moral dimensions

group” (p. 3). Similarly, the pre-eminence of Western

– including moral vision, decisions, conduct

bioethics in ethics education in nursing provides a

and policies – of the life sciences and

‘one-dimensional perspective’, which fails to value

health care, employing a variety of ethical

the moral and ethical traditions of many recipients of

methodologies in an interdisciplinary setting.

health care and also those who provide that care.

(p. xxi) Bioethics represents an approach to ethical decision

Ethics in the nursing curriculum: Where is cultural safety?

making which Johnstone (2008) describes as primarily focused on medical concerns and which has been

In Aotearoa New Zealand, The Nursing Council of

instrumental in propagating “distinctively American

New Zealand (NCNZ) is the statutory authority that

concerns and offering distinctively American solutions

governs the practice of nursing in New Zealand and

and resolutions to the bioethical problems identified”

as such sets the standards for nursing registration

(p. 15). Kerridge et al., (2009) situate bioethics as

and education. Contained within the competencies

part of a family of applied ethical enquiry, practical

(and accompanying indicators) that are required for

ethics, which addresses ethical concerns within

admittance to the register of nurses is the explicit

specific contexts. They describe nursing ethics as

determination that the applicant “accept responsibility

being one part of bioethics, alongside ‘medical ethics’,

for ensuring that his/her nursing practice and conduct

‘psychological ethics’ and ‘environmental ethics’. Over

meets the standards of the professional, ethical and

the last two decades critical debate of bioethics has

relevant legislated requirements” (p. 4). Schools of

occurred, nevertheless the bioethical view has become

nursing are therefore required to ensure that students,

influential worldwide (Johnstone, 2008).

and future graduates, are able to practice within appropriate ethical frameworks.

The notion that nursing ethics is a subset of bioethics would not be a view held by all nurses and much has

Consequently, every nursing curriculum contains ethics

been written about efforts to develop a theory of

teaching, however, the amount of content, degree of

nursing ethics in which care – based on the values of

visibility, and assessment of practice application varies.

concern, compassion and empathy - is the ontological

Some programmes have dedicated ethics courses,

substance. Thus, a number of nurses have promoted

others may have it situated as part of another larger

an ethic of care based upon the notion that women

course, and others may incorporate it as theme which

are naturally predisposed to caring. Kuhse (1997)

runs through a number of courses. However, ethics is

noted the parallels between these developments

positioned within a particular curriculum and whether

and feminist endeavours with respect to formulating

or not the teaching draws upon principilism, bioethics

a woman-centred approach to ethics. Such a position

or an approach based on a feminist ethics the values

has been criticised by women of colour and lesbians.

that are being promoted are predominantly those of

For example, hooks (1984) was critical of white upper-

the Western, largely English-speaking, world. There is

class women for presenting a “one-dimensional

a hegemonic discourse inherent in nursing education

perspective on women’s reality … white women who

and the teaching of ethics and arguably in the

dominate feminist discourse today rarely question

practise of nursing that reflects Western philosophical

whether or not their perspective on women’s reality is


true to their lived experiences of women as a collective Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand Since the late 1980s, nursing in New Zealand has

they are caring. This has the potential to place them in

accepted the need for a focus on cultural safety and

conflicting ethical situations (Caldwell, Lu & Harding,

an understanding of the impact of colonisation on the

2010). As Woods (2010) notes:

health of the Tangata Whenua. In the early stages of

theory development (1988-1991), cultural safety had

problems may arise when nurses attempt to

a strong bicultural focus. This arose from the view that

match notions of desirable ‘universal’ moral

student nurses needed to recognise the importance of

principles, such as autonomy and justice,

the Treaty of Waitangi and the impact of colonisation

with the largely relativistic ‘cultural norms’ of

on Māori. In the decade following, the concept was

different patients under the auspices of the

refined further and subjected to political and public

dominant culture of medicine (p.719).

scrutiny as it became embedded in education and practice (Ramsden, 2002). Following on from the

This is not to suggest that there has been a conscious

seminal work of Irihapiti Ramsden, the concept has

process of disregard for the needs of these students.

evolved from its initial bicultural focus to incorporate

However, as Woods (2005) notes, given that there

a wider multicultural focus (Richardson & Carryer,

are small numbers of nurse educators who have

2006). Yet, even in light of the paradigm shift heralded

postgraduate qualifications and with a multiplicity

by cultural safety education, it has been questioned

of possible and theoretical approaches to teaching

whether the danger remains that nursing education

nursing ethics, it may be that it is the lecturer’s

continues to perpetuate dominant ideologies (Spence,

background and preference that drives the choice of

1994). The question is as pertinent now as it was in the

ethical frameworks. As a corollary, it is likely that there

mid 1990s, as Woods (2010) comments:

will be an even smaller number of nurse educators who

are able to not only teach ethics but also authentically Yet for all of its apparent success in educating

incorporate a Māori perspective into this teaching.

and monitoring the practices of New Zealand nurses, the acceptance of the concept of cultural safety as an approach to guiding effective care, and especially as a guide to

Is it time to critically deconstruct nursing ethics?

ethical nursing practice, remains open to considerable debate (p. 716).

In the early 1990s writers from a diversity of academic disciplines began to question the hegemonic discourse

It is arguable that the teaching of cultural safety may

inherent in Western ethics. Over the last decade in

be perceived as somehow a course of study which

countries of the Pacific rim there has been questioning

stands apart from the teaching of ethics, taught by

of the largely unchallenged primacy of Western

its own groups of ‘experts’, therefore there has been

bioethics in medicine (For example: Qui 2006; Doring

little acknowledgement of the underlying Western

2003; Miyasaka et al., 1999; Fan 1998; Ip et al., 1998).

bias in the expected ethical knowledge and behaviour

Nie (2000), however, cautioned against assuming a

and their reflection of values derived from Western

homogeneous Chinese or American bioethics and

Judeo/Christian philosophies. Nurses and nursing

points out that there is no single approach and

students are, therefore, often required to operate

that both cultural and medical traditions manifest

within ethical frameworks which are either alien to

individualistic and communitarian values.

their cultural norms or those of the patients for whom Page 8

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Within nursing, this debate has been particularly

imperative inherent in this perspective. Conversely,

applied to bioethics. Myser (2003) cautions those

other nurse academics and researchers have explored

working in the field of bioethics to engage in stringent

the discrepancies and tensions between nursing ethics

self-reflection with respect to the construction of

based on Western moral philosophy and cultural

dominant mainstream theories and methods. She

norms with those from a variety of different Asian

emphasizes the apparent lack of critical examination

philosophical and cultural traditions, including Davis

of the “dominance and normativity of whiteness in

(1996), The Working Group for the Study of Ethical

the cultural construction of bioethics in the United

Issues in International Nursing Research (2003), Wros,

States” (p. 2). Myser suggests that in not recognising

Doutrich and Izumi (2004), Xu, Davidzhar and Giger

this privileged whiteness, and then to theorise from

(2005), and Cameron, Schaffer and Park (2001).

a non-reflective ethnocentric standpoint, is to risk perpetuation of cultural colonisation. A process in

In Aotearoa New Zealand, Māori researchers and

which nursing has engaged through the hegemony of

academics have begun developing a framework for

nursing education and practice from an Anglophone

Māori research ethics (Forster, 2003; Smith et al.,

perspective and the assumption that, even though

2009), which will reflect the values of a people for

nursing may be global, nurses share the same values

whom the collective is paramount in contrast to the

throughout the world. For example, in Korea, Han

dominant values expressed in the social, cultural

and Anh (2000) investigated how Korean student

and institutional environments which mainly reflect

nurses made ethical decisions in relation to the Korean

Western moral traditions and a focus on norms, rights

nurses’ code of ethics; however, there is no evidence

and principles. It is critical that nursing educators

that this code reflects Korean cultural values. Similarly,

reflect such developments in our approach to the

Park et al. (2003) replicated a US study, questioning

teaching of ethics otherwise we risk espousing an ethic

whether the study’s results, which explored the use

that may be unsafe for students, nurses and patients.

of five ethical decision-making models, would be relevant in Korea. What was not questioned, however,

Woods (2010) offers a way forward with his concept

was whether a research tool based in Anglo-American

of the socioethical nurse. He posits that cultural safety

values would be appropriate in this context.

contains key ethical elements which reflect “communal values, traditional practices, and co-operative virtues

Nurses are engaged in appraising, exploring and

within a multicultural society” (p. 719). He outlines

scrutinising what is taught and practised in the

the key features of such an ethic as: promoting social

distinctive field of nursing ethics; however, not all

justice and empowerment; maintaining individual/

nurse researchers/writers acknowledge the core of

collective cultural autonomy and identity; and, trust

ethnocentricity rooted in the still dominant Western

and respect. The challenge now lies with those of us

philosophical traditions that inform most nursing

who teach ethics in the nursing curriculum to challenge

ethics curricula and practice. In Europe, for example,

our own assumptions and explore ways in which the

nurse clinicians such as Allmark (2005) and Esterhuizen

principles of cultural safety can enhance our teaching.

(2006) have questioned the value of ethics and the use of professional codes in nursing practice. Despite the


globalisation of nursing and heavy nursing recruitment from non-Western countries neither of these two

The use of Western philosophical ethics, sifted

nurses critiques the dominant Western cultural

through a European cultural lens, has become the

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand standard template for the teaching of nursing ethics

nurses have been global leaders with respect to cultural

worldwide. In doing so it enshrines the notion that all

safety and it is now time to extend that understanding

other cultures should have and use the same values

of cultural safety into the teaching of ethics. By

which predominant in those cultures which can be

doing so it may provide a way forward to facilitate

characterised as ‘individualistic’.

nurses developing understanding and competence to address ethical dilemmas in clinical practice across a

Critical examination of what and how we teach nursing

multiplicity of cultural perspectives, while at the same

ethics is required to ensure that the subject matter is

time the ethical values derived from their own culture

not perceived merely as a sub-category of bioethics

are respected and valued.

reflecting hegemonic European values. New Zealand

References Allen, M., & Ogilvie, L. (2004). Internationalization of higher education: Potentials and pitfalls for nursing education. International Nursing Review, 51(3), 73-80. doi:10.1111/j.1466-7657.2003.00226.x Allmark, P. (2005). Can the study of ethics enhance nursing practice? Journal of Advanced Nursing, 51(6), 618-624. doi: 10.1111/j.13652648.2005.03542.x Beauchamp, T., & Childress, J. (2001). Principles of biomedical ethics. Oxford , UK: Oxford University Press. Bockover, M.I. (2003) Confucian values and the internet: A potential conflict. Journal of Chinese Philosophy, 30, 270-273. doi: 10.1111/1540-6253.00112 Caldwell, E.S., Lu, H., & Harding T.S. (2010). Encompassing multiple moral paradigms: A challenge for nursing educators. Nursing Ethics, 17, 189-199. doi: 10.1177/0969733009355539 Cameron, M.E., Schaffer, M., & Park, H. (2001). Nursing students’ experience of ethical problems and use of ethical decision-making models. Nursing Ethics, 8, 432-445. doi: 10.1177/096973300100800507 Davis, A. J. (1999). Global influence of American nursing: Some ethical issues. Nursing Ethics, 6(2), 118-125. doi: 10.1177/096973309900600204 Dickson, C., Lock, L., & Carey, M. (2007). “In my country nurses don’t ...” Australian undergraduate nurse education and the international culturally and linguistically different student. Proceedings of the ISANA International Education Association - 18thInternational Conference, Gleneg, South Australia. Retrieved from Doring, O. (2003). China’s struggle for practical regulations in medical ethics. National Review of Genetics, 4, 233-239. doi:10.1038/ nrg1022 Esterhuizen, P. (2006.) Is the professional code still the cornerstone of clinical nursing practice? Journal of Advanced Nursing 23, 2531. doi:10.1111/j.1365-2648.1996.tb03131.x Fan, R. (1998). Critical care ethics in Asia: Local or global. Journal of Medical Philosophy, 23, 549-562. doi:10.1076/jmep.23.6.547.2562 Forster, M. (2003). Te hoe nuku roa: A journey towards Māori centred research. Ethnobotany Research and Applications, 1, 43-46. Han, S., & Ahn, S.H. (2000). An analysis and evaluation of student nurses’ participation in ethical decision making. Nursing Ethics, 7, 113-23. doi: 10.1177/09697330000070020 Harding, T. S. (2006). Constructing the “other”: On being a man and a nurse. (Doctoral thesis, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand). Retrieved from Hooks, B. (1984). Feminist theory from margin to center. Boston, MA: South End Press. Ip, M., Gilligan, T., Koenig, B., & Raffin, T.A. (1998.) Ethical decision-making in critical care in Hong Kong. Critical Care Medicine, 26, 447-451. doi:10.1177/096973300000700204 Johnstone, M.-J. (2008). Bioethics: A nursing perspective (5th ed.). Sydney, Australia: Churchill Livingstone.

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Nursing Praxis in New Zealand Jones, M.E., & Hunter, J. (2004). Enshrining indigenous knowledge as a public good: Indigenous education and the Māori sense of place. Indilinga: African Journal of Indigenous Knowledge Systems, 3(2), 103-111. Kerridge I., Lowe, M., & Stewart, C. (2009.) Ethics and law for the health professionals. Sydney, Australia: Federation Press. Kirby, C., & Slevin, O. (1995). Theory and practice of nursing: An integrated approach to patient care. Edinburgh, UK: Campion Press. Kuhse, H. (1997). Caring: Nurses, women, and ethics. Oxford, UK: Blackwell. Miyasaka, M., Akabayashi, A., KaiI, I., & Ohi, G. (1999). An international survey of medical ethics curricula in Asia. Journal of Medical Ethics, 26, 514-521. Myser, C. (2003). Differences from somewhere: The normativity of whiteness in bioethics in the United States. American Journal of Bioethics, 3(2), 1-11. Nairn, S., Hardy, C., Harling, M., Parumal, L., & Narayanasamy, M. (2011). Diversity and ethnicity in nurse education: The perspective of nurse lecturers. Nurse Education Today, 32(3), 203-207. Nie, J. B. (2000). The plurality of Chinese and American medical moralities: Towards an interpretive cross-cultural bioethics. Kennedy Institute of Ethics Journal, 10, 239-260. doi:10.1353/ken.2000.0020 Park, H., Cameron, M., Han, S., Ahn, S., Oh, H., & Kim, K. (2003). Korean nursing students’ ethical problems and ethical decision making. Nursing Ethics 10(6), 638-53. doi:10.1191/0969733003ne653oa Phillips, J . (1987). A man’s country? The image of the pakeha male. Auckland, New Zealand: Penguin. Qui, R. (2006). Bioethics: A search for moral diversity. East Mediterranean Health Journal, 12(S1), 21-29. Ramsden, I. (2002). Cultural safety in nursing education in Aotearoa and Te Waipounamu. (Doctoral dissertation, Victoria University of Wellington, New Zealand). Retrieved from Reich, W. T. (1995). The encyclopaedia of bioethics (2nd ed.). New York, NY: McMillan. Smith, B., Russell, K., Reynolds, P., Palmer, S., Milne, M., & Hudson, M. (2009). Developing a framework for Māori Research Ethics. Proceedings of the Hui Whakapiripiri: Health Research Council Annual Hui (pp. 1-17), Auckland, New Zealand. Spence, D. G. (1994). The curriculum revolution: Can educational reform take place without a evolution in practice? Journal of Advanced Nursing, 19, 187-93. Todaro-Francheschi, V. (2012). Compassion fatigue and burnout in nursing: Enhancing professional quality of life. New York, NY: Springer Publishing. Williams D. (2001). Crown policy affecting affecting Māori knowledge systems and cultural practices: Report No. Wai 262. Wellington, New Zealand: Waitangi Tribunal. Working Group for the Study of Ethical Issues in International Nursing Research. (2003). Ethical considerations in international nursing research: A report from the International Centre for Nursing Ethics. Nursing Ethics, 10(2), 122-37. doi:10.1191/0969733003ne587oa Woods, M. (2005). Nursing ethics education: Are we really delivering the good(s)? Nursing Ethics 12(10), 5-17. doi:10.1191/0969733005ne754oa Woods, M. (2010). Cultural safety and the socioethical nurse. Nursing Ethics,17, 715-725. doi:10.1177/0969733010379296 Wros, P. L., Doutrich D., & Izumi, S. (2004). Ethical concerns: Comparison of values from two cultures. Nursing & Health Sciences. 6, 131-140. doi10.1111/j.1442-2018.2004.00184.x Xu, Y., Davidhizar, R. & Giger, G.N. (2005). What if your nursing student is from an Asian culture? Journal of Cultural Diversity, 12, 5-11. The Cancer Connect New Zealand (CCNZ) service

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand THE JOURNAL KAI TIAKI’S ROLE IN DEVELOPING RESEARCH CAPABILITY IN NEW ZEALAND NURSING, 1908-1959 Pamela J. Wood, PhD, RN. Associate Professor, School of Nursing & Midwifery. Monash University, Melbourne, Australia. Katherine Nelson, PhD, RN. Senior Lecturer, Graduate School of Nursing, Midwifery & Health. Victoria University of Wellington, NZ.

Abstract The development of research capability in New Zealand nursing can be seen particularly from the 1970s onwards. However, by analysing past issues of Kai Tiaki – the country’s longstanding nursing journal – over the five decades following its establishment in 1908, the present authors identified two precursors to this later stage. The journal fostered nurses’ awareness of research and consistently promoted nursing scholarship. Successive editors developed nurses’ capability in writing about their practice by publishing case studies, the winning essays in competitions run jointly with the professional association and nursing schools, and nurses’ articles on practice or professional issues. Although promotion of research awareness and nursing scholarship were not deliberate strategies to develop nursing research capability, they were necessary forerunners to it. Keywords: research capability, history of nursing, nursing journal, nursing scholarship, nursing research

The need for strategies and processes to develop

research in New Zealand focuses on the time period

research capability in nursing is receiving increasing

from the 1970s onwards. She explains the impact of

attention in nursing literature. Recently published

earlier overseas study opportunities, shifts in education,

studies suggest a shift in focus from building nursing

professional organisation support and individual nurses’

research capability in academic institutions, to

commitment and success in building the profession’s

developing it in clinical and non-academic settings.


research capacity.4 The establishment in New Zealand

Nevertheless, acceptance of the profession within

of post-registration university education for nurses in

academia has depended on nurses and others

the early 1970s, which enabled the formal academic

recognising nursing as a distinct discipline with its

development of nursing scholarship and research, has

own research and scholarship. One factor Australian

also been addressed.5


nurse scholars recently identified as facilitating the growth of nursing scholarship in that country was the

This present article examines historical precursors to

discipline’s “coming of age”. They were proud that in the

this development of research capability in New Zealand

relatively short period of 25 years Australian nursing had

nursing and places these within an international context.

matured to a point where ‘the discipline had emerged

In particular, it focuses on evidence in historical issues of

as legitimate in its own right’ and its scholarship had developed ‘a particularly Australian character’. 3 A similar trajectory could be traced in New Zealand. Litchfield’s history of the development of nursing Page 12

Wood, P. J., & Nelson, K., (2013). The journal Kai Tiaki’s role in developing research capability in New Zealand nursing, 19081959. Nursing Praxis in New Zealand, 29(1), 12-22. Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Kai Tiaki, the country’s only professional nursing journal

among editors and was a member of the International

and avenue for fostering the publication of nursing

Council of Nurses (ICN) publication committee. The

scholarship or research in the time period before the

strong connection with the ICN continued over the

changes occurring in the 1970s. Through analysis of all

decades, with New Zealand nurse leaders attending its

issues over the five decades from the journal’s inception

congresses and holding positions within the council. In

in 1908, the research identifies mechanisms that

all these developments, New Zealand therefore either

developed nurses’ professional scholarship and sparked

led or was in line with international professional nursing

their awareness of research. In this article it is argued


that, although these strategies were not necessarily a deliberate strategy to build nurses’ research capability,

The international development of nursing research

they were a necessary forerunners to it.

capability, however, was distinctly different. American nurses led the way, well ahead of nurses in other


countries. As early as the 1930s, the ICN made it clear that nurses needed to carry out research

Nursing in New Zealand had, by the early 1900s,

if they wanted to be regarded as belonging to a

achieved recognisable markers of a profession.

profession.6 By the 1950s, many American nurses were

New Zealand’s small population and great distance

confidently undertaking research into nursing education,

from other countries meant considerable effort and

organisation and practice and were completing higher

determination were needed if New Zealand nurses

degrees in universities. Their research had reached a

were to participate in international professional affairs.

critical mass that enabled the 1952 launch of the journal

These same factors also allowed the rapid establishment

Nursing Research.

of other initiatives affecting nursing. It was the first country to have a chief nurse with a national role in

Analysis in a separate, unpublished research project

a central government department, with Grace Neill

by one of the authors of this article (PW) found that

holding the first appointment as Assistant Inspector

three American journals particularly fostered nursing

of Hospitals from 1895. She attended international

research awareness and capability. The first issue of

congresses and drafted the world’s first specifically

Nursing Research carried a lengthy report of a doctoral

nursing legislation for state registration, the Nurses

study. 7 Besides reporting completed projects the

Registration Act 1901. This set up a process for nursing

journal’s three issues annually carried articles on other

registration and regulation, and a mandatory three-year

research matters, special sections summarising studies,

curriculum for all training hospitals. Neill’s successor

and reviews of books that would be helpful to nurses

from 1906, Hester Maclean, instituted two professional

wanting to understand more about research. Readers’

initiatives that were already in place in other countries,

requests for writers to include more information on

such as Australia. In 1908 she founded the journal, Kai

methodology indicated a growing research capacity and

Tiaki, and in 1909 encouraged the separate nursing

capability. The American Journal of Nursing published

associations in the four main cities to amalgamate

lists of research projects twice a year until this function

to form the New Zealand Trained Nurses Association

was taken over in 1954 by Nursing Research. The journal

(NZTNA). As chief nurse and first NZTNA president she

Nursing Outlook, established in 1953, also carried very

ensured the profession’s continuing active participation

brief (sometimes less than 50-word) summaries of

in international affairs. As journal editor she participated

research findings.

in the international exchange of articles and volumes Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 13

Nursing Praxis in New Zealand In other countries, the nursing profession had not reached

sources selected for this research were the issues of Kai

this level of research capability. If nurses were involved

Tiaki published between 1908 and 1959. Besides this

in research, it was usually in large surveys of workforce

familiar and commonly used title within the profession,

issues or studies addressing problems with nursing

from 1908 to 1929 the journal was also known as the

education, often led by non-nurse researchers. The ICN’s

Journal of the Nurses of New Zealand and from 1930

statement that nurses needed to undertake research

as the New Zealand Nursing Journal. The journal had

to be considered a profession had not translated into

errors in the numbering of volumes so only the year and

the deliberate development of research capacity and

month are used here to designate volumes and issues.

capability. Nevertheless, the measures that can now

On Maclean’s retirement in 1923, the NZTNA purchased

be identified as its precursors were underway. These

Kai Tiaki but Maclean remained its editor until her death

were encouraging nurses to write about their practice

in 1932. The journal was initially published quarterly until

and raising nurses’ awareness of research that affected

1930, when it began appearing every second month.

nursing. Editors’ concerted efforts to encourage nurses to

From mid-1938 to1947 it was published monthly, then

write were more than simply a ploy to ensure sufficient

two-monthly until 1959. Although successive editors

material for each issue. They constituted a serious

bemoaned low subscription numbers, the journal was

attempt to promote nursing scholarship. This present

widely read and appreciated in the profession. The journal

research therefore examined the New Zealand journal,

therefore played a key role in the lead-up to the deliberate

Kai Tiaki, to identify its approaches to fostering research

development of research capacity and capability in New

awareness and nursing scholarship.

Zealand nursing.

Research design

For this project hard copies of these issues were searched for all material relating to research and nursing

Historical inquiry is the analysis and contextualised

scholarship. Although digitised volumes are available

interpretation of historical material to explain continuity

for 1908-1929, all issues were browsed in hard copy to

and change through time. Nurse-historian Siobhan Nelson

capture all relevant material and avoid missing smaller

reminds us that history is ‘the interplay between historical

pieces that did not warrant inclusion in an index or could


data and the fusion of narrative and analytical writing’.

be missed by keyword searches of digitised volumes. The

She justifiably challenged the way nurse-writers have tried

search period ended in 1959 as by then the journal’s focus

to legitimate, regularise, format and constrain historical

had shifted significantly away from nursing practice to

scholarship within the profession’s understanding and

industrial issues. This was also the time when some New

lexicon of qualitative research. Historical inquiry in

Zealand nurses were beginning to study at universities

nursing needs to follow the methodological conventions

overseas. The end of the period therefore marks a

observed by researchers in the discipline of history. The

transition to a different level of research awareness.


explanation of the design of this research is therefore limited to a description of the historical primary sources

In all, 325 past issues of the journal were examined and

and analytical approach.

148 items selected. Two groups of items were selected for analysis: articles, editorials, notices and position

Historical research requires careful selection of primary

advertisements addressing the topic of research or

sources – those created in the time period being studied –

nursing scholarship, and articles reporting nurses’

that will yield relevant and reliable information to address

scholarship and research. Items in the first group were

the aim of the research. The main historical primary

analysed to identify the issues considered important


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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand at the time along with the ideas and strategies for

nurses’ understanding of their work but encouraged

developing scholarship and research awareness and

nurses to similarly contribute. This was a call repeated

capability that were evident. Analysis of the second

by successive editors. In 1938, for example, nurses were

group focused on identifying research and scholarship

told the editorial committee looked forward to the time

topics, style and authorship, and any changes in these

when every nurse not only subscribed but took an active

through time. Analysis of historical primary sources needs

part in maintaining the journal’s position amongst nursing

to interpret the material within its social and cultural

journals of the world.16 Editors referred back to Maclean’s

context. This was addressed by considering the changes

initial request in their own call for nurses’ contributions,

in nursing, its place within the healthcare system and

even in the late 1950s.17 Their success in fostering nursing

professional leadership in this time period.

scholarship overall will be considered in more depth later in this article. Two specific mechanisms for encouraging

Relevant material from major nursing journals in four

nurses to write about practice and professional issues

other countries (Britain, Canada, the Unites States of

will be considered first. These were essay competitions

America and Australia), which had been searched for

and nursing case studies, promoted jointly by the journal,

allied research projects, is also included to provide an

professional association and nurse educators.

international context for this study. In particular, it is used to explain the international growth in nursing research,

Essay competitions

and international alignment of mechanisms within New Zealand to develop research awareness and nursing

In Britain, the Nursing Record began running an essay


competition as early as 1888. The first question to be addressed was ‘What constitutes an efficient nurse?’18

Developing nursing scholarship

Questions became more complex and often focused on hospital management. When the journal became

In her first editorial in Kai Tiaki, Maclean exhorted nurses

the British Journal of Nursing, topics turned to a more

to contribute material. This became a standard, regular

clinical focus.


call. It was common practice internationally for editors to chide and cajole nurses into contributing articles.12

In New Zealand, from 1938 the nursing association ran

Editors drew on ideas from other journals in their

an essay competition for students in hospital schools of

efforts. The editor of the Sydney-based Australasian

nursing. The initial topic was how nursing technique was

Nurses’ Journal, established in 1903, challenged nurses

a link in the prevention of disease, and the first, second

by referring to American nurses’ successful scholarship,

and third prize winners’ essays were published.19 The

hoping to provoke Australian nurses to write.13 The 1925

association’s Nursing Education Committee declared

ICN congress in Finland paid considerable attention to

that 70 per cent of the essays had been of a very high

it, and the Canadian Nurse reprinted an article from

standard.20 The following year the committee decided

the American Journal of Nursing giving practical advice

the competition would continue as an annual event. It

on how to write.

would set the questions, each hospital would select its



best essay and an independent judge would decide the Although Maclean welcomed any material, including

prize winner who would receive a book and a trophy for

news and social items, she particularly wanted nurses

her school. The question that year kept the preventive

to write about their practice. Most issues carried articles

focus, asking candidates to write about personal hygiene

from doctors. Maclean valued these for deepening

and its importance in a nurse’s life.21

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand In ensuing years nurses wrote, for example, about

Qualified nurses and students in New Zealand published

nursing patients with tuberculosis or those having a

case studies related to patients with a range of

hysterectomy, the importance of early treatment in

conditions, including rat bite fever, Addison’s anaemia,

cancer and the part parent visiting should play in a

actinomycosis and a child with tetanus; and on different

hospitalised child’s routine. Psychiatric nurses were

forms of treatment such as the Miller-Abbott tube used

asked, for example, about the value of occupational

for paralytic ileus.30 Four cases of typhoid fever from one

therapy and how a nurse could assist a family adjusting

family were the subject of a New Zealand backblocks

to their young child being admitted to a psychiatric

hospital nurse’s account in 1912.31 Nurses sometimes

hospital.23 Maternity nurses had the chance to write

published together,32 but articles often carried no author

about establishing breastfeeding.24 In 1947, reflecting



the post-war context, they were asked to explain the early labour care of an English bride newly arrived in

Internationally, after its introduction by an American

New Zealand. Occasionally nurses were set more

nurse , the profession gradually incorporated into

general topics, such as Grace Neill’s professional

clinical nursing education a particularly nursing form

contribution, or the principle of doing no harm.


of the case study.34 Canadian nurse educators also

They were also notified of a 1958 ICN competition on

acknowledged the method’s antecedents, both in

incorporating ethics into all nursing subjects taught.

Florence Nightingale’s encouragement of nurses’ written


reflection on patient care and in the use of case studies At times the Education Committee was disappointed

in various avenues of education outside of nursing. They

with entries, either in number or quality. This was

valued case studies for focusing students on the patient,

particularly so in its first case study competition in

developing students’ observation skills and ability to

1943, the focus of which was an obstetric topic.

learn independently, and for combining theoretical


Nevertheless, case studies were another significant

learning and experience.35

means of encouraging nurses to write about their practice.

New Zealand nurses became aware of the case study as an educational method through a paper presented at

Case studies

the 1927 ICN congress in Geneva by Gertrude Hodgman from Yale University. Her paper was published in various

The concept of describing a “case” was familiar in

nursing journals.36 New Zealand nurses’ international

medicine in the nineteenth century. Nurses would

visits in the 1930s also stimulated its acceptance.37

have understood the idea in the Nursing Record’s 1890

Finally, after an article drawing on a Canadian survey of

essay competition requiring them to describe at least

nursing education and Canadian and American literature

four cases they had personally nursed.28 Nurses in

explained the case study’s process and benefits, the

different countries occasionally followed the medical

approach became firmly established in New Zealand.38

profession’s example in writing accounts of “interesting

The significant point on this final article was that it

cases” where the course of illness had been in some

explained the emphasis on nursing, rather than the

way unusual. In 1907, for example, an Australian nurse

previous convention of focusing on a case’s medical

wrote about a case of typhoid fever with numerous

details. The writer noted that it could therefore be


called a nursing study. This was an indicator that the profession was beginning to recognise its distinct area of scholarship, a form of “coming of age”.

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Students’ nursing case studies were sometimes

included the awareness of psychological factors affecting

published in Kai Tiaki. They commonly addressed

nursing,44 and specific accounts of practice.45 Nurses also

care of patients with medical conditions, such as

wrote about work in different practice settings.46 They

agranulocytosis, pyelitis and acute nephritis, or patients

addressed nursing related to (sometimes new) forms

receiving new treatments such as sulphathiazole for

of medical or surgical treatment.47 One nurse wrote

staphylococcal septicaemia. 39 Sometimes student

with a doctor on intravenous practice, another with a

authors were unnamed. Students’ case studies often

hospital pharmacist on drug administration.48 In 1944,

ended with a reflection on the assignment’s value for

two nurses wrote together, describing a situation where

their learning, perhaps as a gesture towards the tutor

the new drug, penicillin, had been successfully used.49


or maybe in hope of a better mark. Nurse B.G. Weir of Auckland Hospital declared the case study had helped

Fourteen of the 22 New Zealand nursing articles

her discover the valuable part a nurse played and the

published in the 1930s carried no author’s name. Of

tremendous responsibility placed upon her. Nurse

these, six gave a descriptor such as “a registered nurse”

N.M. Buckland of New Plymouth Hospital found it had

or “a probationer nurse”, three gave their initials at the

been ‘a great help’. With her tutor’s assistance she

end, and five carried no identifier at all. (Case studies in

had learned which of the various nursing measures to

the 1930s showed similar proportions, with half of the

stress and their order of importance. At the end of this

sixteen studies carrying no author name.) In contrast

study the editor explained that nursing studies could

medical authors in the journal were always named.

be in an essay form that made it more interesting and

The proportion of named and unnamed nursing articles

personal, or in tabulated form that assisted the nurse

was reversed in the 1940-1955 period when only four

to collect her material, learn in an orderly manner, and

of the sixteen New Zealand articles were without an

prepare for examinations.

author name. (Only one author of the ten case studies



in this period was unnamed). Either editorial policy had Whether written by registered nurses or students, case

changed with respect to identifying nurse authors, or

studies varied in style from short, pithy accounts, to

individual nurses themselves were now willing to add

chatty descriptions and to a more serious discursive

their names. Whatever its impetus, the change suggests

style. They therefore differed in their ability to develop

the profession’s greater confidence that nurses had

nurses’ writing but all contributed to the growth of

something worthwhile to say and should therefore be

nursing scholarship, a forerunner to research capability.

identified. This was another indicator of the profession’s “coming of age” in its field of scholarship.

Developing New Zealand nursing scholarship Articles varied in style from discussion papers and Nurses made a substantial contribution to the journal.

essays, to information neatly compressed under

Between 1930 and 1955, for example, besides the

headings or presented as briefly jotted points,

competition essays and case studies, it published

depending on whether nurses wanted to raise issues,

38 articles written by registered nurses and two by

recount personal experiences or instruct. While articles

student nurses, and reprinted six nursing articles that

came mostly from hospital nurses, other contributors

had been published in overseas journals. The pieces by

were those in public health, rural and city district

New Zealand nurses offered opinions on professional

nursing, specialist clinics, mental health, postgraduate

issues or addressed matters affecting nursing, health

study, nursing education and leadership roles. In the

education and nursing education. More clinical topics

late 1950s, however, a significant change occurred in


Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 17

Nursing Praxis in New Zealand editorial policy. The journal gave far more emphasis

an eye-opener.55 Few avenues existed in New Zealand,

to industrial and professional issues and very little to

however, for actively developing research skills. A post-

nursing practice. In doing this, the journal’s role in

registration course had been available to nurses since

fostering scholarship was beginning to change.

1928, but its curriculum did not specifically include research, although it promoted nursing scholarship.

Developing research awareness and skills There is very little evidence to indicate that New The New Zealand journal kept nurses well abreast with

Zealand nurses were directly engaged in research in

international research developments. It frequently

these decades. From 1932 the Association’s Education

carried small items notifying nurses of medical

Committee published its annual surveys of nursing

research, particularly relating to cancer. It also carried

procedures, but these were more an effort to standardise

international nursing research. In 1938, for example, the

practice throughout the country by combining the best

editor translated to the local situation the findings of an

aspects of procedures used in the teaching hospitals. In

experiment by two nurses studying at Teachers College,

the 1930s and 1940s, however, the journal was able to

Columbia University in New York, who had investigated

publish two forms of research by local nurses. In 1933

the most effective lubricant for rubber catheters.

it reported a trial undertaken by four nurses. A school



nurse (Cox), a nurse inspector (North) and two nurses Travel scholarships to other countries in the 1930s

caring for Maori in the rural district (Uniacke and Hill)

and visits of American nurses to New Zealand also

had investigated the best home treatment for scabies,

enhanced awareness of research. Professor Hudson

impetigo and pediculosis. Their study included 333

from Columbia University, for example, travelled to New

cases and compared two treatments for scabies, two

Zealand in 1938 and local nurses acknowledged there

for impetigo and four for pediculosis. The nurses noted

was a great deal to learn from New York, a city unafraid

the number of treatments needed and the number of

to experiment and one that had established the first

days taken to effect a cure. Comparative costs were also

nursing professorship in the world.

calculated. The district’s medical officer of health, Dr


H.B. Turbott, wrote the article, apparently to support The need for nurses to have research skills was

the nurses and ensure their research was published

internationally recognised, though development of such

and therefore available to others practising in similar

was limited. An ICN nursing service survey in 1949, with

settings. He named the nurses, made it clear that it was

detailed information from sixteen countries, commented

a district nursing study and noted his admiration of the

that the nurse’s place in the health team was difficult

nurses’ skill in carrying it out in difficult conditions.56

to define and nurses were presently ill-equipped to do the further research necessary. If however, they

The second report in 1944 was on the nursing care of

were trained in research, the status of the profession

the chronically ill patient. In this the unnamed author

would be improved. In 1955 the ICN issued specific

had gathered observations from matrons in charge of

advice on the method for surveying a nursing school

hospitals for the “chronic sick” and from nurses who had

and this was published in the New Zealand journal.


themselves been patients.57 Although only two nursing

New Zealand’s nursing association had previously in

research projects were reported in this period, they are

1930 reported a survey on the amount of time student

nonetheless significant forerunners of the development

nurses spent on domestic and non-professional work in

of New Zealand nursing research capability.


each year of their training. The result was considered Page 18

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Precursors to developing nurses’ research capability

busy professional lives and they were glad of the help in this final stage of reporting the results. Although the shift to naming authors was starting at the time of the

Research capability in the profession was built on

second study’s publication, the author did not identify

a foundation of nursing scholarship and research

herself. As only the one nursing research article had

awareness. Since the 1920s American nurses had

previously been published, and then with a doctor as

advocated research-mindedness as a vital element in

author, perhaps she felt reluctant to claim the new role

advancing the profession. By 1953 the Nursing Research

as an independent nurse researcher.

editor felt able to say that the ‘spread of the research attitude’ seemed ‘highly significant and promising for

Besides raising research awareness, the journal actively

the future’.58 Elsewhere at this time, however, little had

fostered various forms of nursing scholarship. It was not

happened in developing research capability since the

alone in this venture. Nursing schools adopted the case

ICN’s clear message twenty years earlier. Only a few

study as a method for expressing nursing practice,60 and

nurses outside of the United States of America were

the journal published many from students and registered

joining research teams. Opportunities for employment

nurses. The professional association sponsored an essay

in research were sporadically advertised in nursing

competition, nursing schools encouraged students to

journals. At the international level, applicants in 1950

enter, and the journal published winning entries. This

for the position of the Florence Nightingale International

represented a concerted, joint effort by three major

Foundation’s director were expected, however, to have

sources of influence over the capability and future

not only good nursing qualifications and wide nursing

direction of the nursing profession in New Zealand. It

experience but also experience in research methods.59

needs to be acknowledged that Kai Tiaki would have been expected to publish the essays as it was the

Although by the 1950s there were only a few examples

official journal of the association at this time. At the

of nursing research in New Zealand, the trajectory

same time, editors would have been pleased to receive

of building research capability can be traced from its

this material for its issues. Nevertheless, the journal

two precursors, the growth of nursing scholarship

played a deliberate part in fostering nursing scholarship.

and research awareness. The nursing journal played

Editors encouraged nurses to write about their practice

a significant part in this process. The intent of Hester

and nurses responded to the call. A wealth of articles

Maclean and her successors in publishing reprints or

explained aspects of nursing care, different nursing

excerpts of overseas articles relating to research was

practice settings and professional issues.

to raise nurses’ awareness of research rather than encourage them to engage directly in it. The country’s

Despite New Zealand’s great distance from other

lack of professional education for research until the

countries, small size and population, the editors ensured

1970s meant nurses had little opportunity to acquire

it was in line with international trends in fostering

research skills. It is therefore significant that two

nursing scholarship. Maclean’s involvement with the

accounts of nursing research by New Zealand nurses

ICN publication committee, and later nurse leaders’

were published in the 1930s and 1940s. The fact that

engagement in ICN and international conferences,

the first was written by a doctor on behalf of nurses

meant that the vigorous international push to get

suggests the nurses lacked confidence in their ability

nurses to write for their own professional journals was

in this new area. Or perhaps carrying out the research

incorporated into professional activities in New Zealand.

had taken all the time and energy they had in their Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 19

Nursing Praxis in New Zealand In this review two forms of the profession’s “coming

writers now felt confident adding their name to their

of age” in relation to research have been identified.

submitted work. Either way, it suggests a change in

By the end of the 1930s, nurses had adapted the case

how the profession regarded itself. It signifies growing

study to focus on nursing practice, differentiating it

confidence that nurses had worthwhile opinions and

from the medical case study and therefore identifying

useful perspectives to offer on practice and should

they had their own sphere of professional knowledge

therefore be named. It therefore shows an increasing

and scholarship, or at least their own way of expressing

esteem for nurses’ scholarship. The development of

patient care. In the 1940s and 1950s the proportion of

the nursing case study and the growth in confidence

named authors steadily increased. Instead of up to half

seen through named authorship were earlier forms of

of all nursing articles carrying no author identification,

the “coming of age” that recent nurse scholars have

as in previous decades, only a quarter of articles now

also identified as crucial to the development of nursing

had no author named. It is unclear whether this was

research capability.61

a shift in editorial policy or whether individual nurse

Endnote References 1 B. Green, J. Segrott, H. Priest, A. Rout, M. McIvor, J. Douglas, Y. Flood, S. Morris & C. Rushton, ‘Research capacity for everyone? A case study of two academic nursing schools’ capacity building strategies’, Journal of Research in Nursing, 12, 3 (2007), pp.247-65. 2 P.A. Jamerson, A.F. Fish & G. Frandsen, ‘Nursing Student Research Assistant program: A strategy to enhance nursing research capacity building in a Magnet status pediatric hospital’, Applied Nursing Research, 24 (2011), pp.110-13; L. O’Byrne & S. Smith, ‘Models to enhance research capacity and capability in clinical nurses: a narrative view’, Journal of Clinical Nursing, 20 (2010), pp.1365-71; L. Travis & M.K. Anthony, ‘Energizing the research enterprise at non-academic health center schools of nursing’, Journal of Professional Nursing, 27, 4 (2011), pp.215-20. 3 L. Stockhausen & S. Turale, ‘An explorative study of Australian nursing scholars and contemporary scholarship’, Journal of Nursing Scholarship, 43, 1 (2011), pp.89-96, quotation on p.93. 4

M. Litchfield, To Advance Health Care: The Origins of Nursing Research in New Zealand, New Zealand Nurses Organisation, Wellington, 2009.


N. Chick & N. Kinross, Chalk and Cheese. Trail-blazing in New Zealand: A Story told through Memoir, N. Chick & N. Kinross, Christchurch, 2006; P. Wood & S. Knight, Achieving University Education for New Zealand Registered Nurses: The Role of the C.L. Bailey Nursing Education Trust, Graduate School of Nursing, Midwifery & Health, Victoria University of Wellington, Wellington, 2010.


‘A revision of nursing technique’, Kai Tiaki (KT), March (1933), pp.7-9.


M.J. Mack, ‘The personal adjustment of chronically ill old people under home case’, Nursing Research, 1, 1 (1952), pp.9-30.


S. Nelson, ‘A history of small things’, in J. Latimer, ed, Advanced Qualitative Research for Nursing, Blackwell Science, Oxford, 2003, pp.211-29, quotation on p.216.


J. Tosh, with S. Lang, The Pursuit of History: Aims, Methods and New Directions in the Study of Modern History, 5th ed., Pearson Longman, Harlow, UK, 2012.


P.J. Wood, ‘Understanding and evaluating historical sources in nursing history research’, Nursing Praxis in New Zealand, 27, 1 (2011), pp.25-33.

11 ‘The purposes of the journal’, KT, January (1908), p.1. 12 See for example ‘The new journal’, editorial, Australasian Nurses’ Journal, 3, 3 (1908), pp.81-82; ‘The responsibilities of a nurse to her nursing journal’, Australasian Nurses’ Journal, 17, 12 (1919), p.406. 13 ‘The new journal’; ‘The responsibilities of a nurse to her nursing journal’; ‘Our “journal”’, editorial, Australasian Nurses’ Journal, 8, 2 (1910), p.38; Australasian Nurses’ Journal, 17, 12 (1919), p.406.

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 14 M. Breay, ‘The aims of a professional journal’, Canadian Nurse, 21, 12 (1925), pp.631-2; M. Roberts, ‘How to make a journal useful and attractive’, Canadian Nurse, 22, 1 (1926), pp.8-13. 15 M. Goodnow, ‘Writing – a duty’, Canadian Nurse, 20, 1 (1924), pp.804-06. 16 ‘Editorial. New Zealand Nursing Journal (Kai Tiaki)’, KT, July (1938), pp.171-2. 17 ‘Message from Director, Division of Nursing, Department of Health. The purposes of the “Journal”’, KT, January (1958), p.4. 18 ‘Competitive prize essay’, Nursing Record, 1, 4 (1888), p.46. 19 ‘Nursing as a link in the prevention of disease’, KT, October (1938), p.279 & pp.282-3. 20 ‘The hospital essay competition’, KT, September (1938), pp.245-50. 21 ‘Branch notes. Wellington’, KT, August (1939), pp.294-5. 22 J. Wilson, ‘A nursing study of a case of pulmonary tuberculosis’, KT, February (1949), pp.9-12; E. Lindsay, ‘The pre-operative and post-operative case of a case of hysterectomy’, KT, February (1950), pp.7-10; M. de Latour, ‘What steps are being taken to bring before people of this country the importance of early treatment of cancer? Why is early diagnosis of this disease valuable and how can you as a nurse contribute?’, KT, June (1953), pp.90-93; J. Allen, ‘Discuss the psychological effect on a young child of a stay in hospital and the part parents’ visiting should play in his routine’, KT, April (1955), pp.37-39. 23 G. Cock, ‘The value of occupational therapy in the treatment of mental disorders, and the part played by the nurse,’ KT, December (1953), pp.177-80; R. Maniapoto, ‘A young child is admitted to a psychiatric hospital, What are the family reactions likely to be and how can the psychiatric nurse assist the family to adjust to this situation?’, KT, December (1954), pp.209-10. 24 J.O.M. Pipe, ‘The importance and establishment of breastfeeding’, KT, April (1945), pp.99-101. 25 S. Hickman, ‘The general care of an English bride, newly arrived in New Zealand, who arrives in hospital in the early stages of labour’, KT, March (1947), pp.39-41. 26 H. Campbell, ‘Mrs Grace Neill. Her life and work and her contribution to nursing in New Zealand’, KT, June (1945), pp.146-9; M. Karl, ‘It may seem a strange principle to enunciate as the first requirement of a hospital that it should do the sick no harm. (Florence Nightingale.) What special significance has this statement for the nurse who is responsible for the complete welfare of her patient?’, KT, February (1956), pp.6-8. 27 ‘Obstetrical Case Study Competition, 1943. Criticism of Entries’, KT, January (1944), p.21. 28 ‘Competitive prize essay. Seventeenth competition’, British Journal of Nursing, 4, 114 (1890), p.271. 29 ‘A case of typhoid fever with numerous complications, including perforation-operation-recovery’, Australasian Nurses’ Journal, 5 (1907), p.308. 30 M.E. Burke, ‘Rat bite fever’, KT, September (1938), pp.241-2; N. Knight, ‘Nursing treatment of Addison’s Anaemia’, KT, July (1930), pp.187-8; P. Floyd, ‘A case study: Actinomycosis’, KT, October (1946), pp.274-6; M.B. Mulligan, ‘Case history of a child aged eleven years who had contracted tetanus’, KT, November (1944), pp.258-9; K.F. Dalls, ‘The Miller-Abbott Tube in the treatment of paralytic ileus’, KT, November (1939), pp.393-4. 31 ‘Cases of typhoid fever’, KT, April (1912), p.29. 32 B. Jones & R. Watson, ‘A case of actinomycosis infection of the lung treated with penicillin’, KT, May (1944), pp.112-14. 33 See for example ‘A case of agranulocytosis’, KT, March (1937), pp.67-68; ‘An interesting case of scarlet fever (Haemorrhagic)’, KT, May (1930), pp.159-60; ‘Pyloric stenosis in twins’, KT, July (1936), pp.143-4. 34 M. Domitilla, ‘An experiment suggesting a teaching method for the Head Nurse’, American Journal of Nursing, 24, 7 (1924), pp.537-41. 35

O. Lilly, ‘Case study as a means of teaching nurses to teach themselves’, Canadian Nurse, 23, 4 (1927), pp.193-5; A. McLeod, ‘The student nurses’ monthly case report’, Canadian Nurse, 21, 5 (1925), pp.252-4; E.M. Stuart, ‘The case study method of ward teaching’, Canadian Nurse, 28, 1 (1932), pp.26-28.


See for example ‘The case study method,’ British Journal of Nursing, 75, 1910 (1927), pp.210-02.

37 ‘Items of interest from Miss Barnett’, KT, July (1932), p.157; I. Martin, ‘Nursing education’, KT, January (1939), pp.5-6. 38 ‘The nursing study’, KT, July (1939), pp.237-40. 39

I. Wills, ‘A case of agranulocytosis’, KT, October (1939), pp.384-5; E. Warner, ‘Nursing study of a case of pyelitis’, KT, March (1930), p.62; P. Williams, ‘Case study – acute nephritis’, KT, November (1945), pp.295-7; M. Gough, ‘A case of staphylococcal septicaemia successfully treated with sulphathiazole’, KT, June (1942), pp.183-4.

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand 40

See for example ‘Nursing study’, KT, May (1939), pp.174-8; ‘Intracranial tumours’, KT, June (1939), pp.12-14.

41 B.G. Weir, ‘A case of removal of senile cataract’, KT, January (1941), pp.9-12. 42

N.M. Buckland, ‘A nursing study. Lobar pneumonia’, KT, May (1940), pp.139-42, quotation on p.142.


E.R. Bridges, ‘Hospital social service. The hospital almoner’, KT, September (1937), pp.200-06; F.J. Cameron, ‘Acceptable standards of paediatric nursing service’, KT, October (1953), pp.146-50; E. Paora, ‘Public health and other problems of a Maori Health District and suggestions for improvement’, KT, September (1940), pp.295-6; ‘Lecture to lay audience and farmers’ wives on “hydatids”’, KT, January (1930), p.135; ‘Communicable disease nursing. How to instruct the pupil nurses’, KT, September (1930), pp.257-8.

44 ‘Family forces affect the individual’, KT, December (1954), pp.222-3; ‘Psychology and nursing’, KT, January (1930), pp.16-18; ‘Nursing deals with not only diseases but personalities’, KT, February (1939), pp.50-53. 45 ‘Aseptic technique in limb amputations’, KT, July (1939), p.258; P. Beaumont-Orr, ‘Nursing care of lobectomy’, KT, November (1946), pp.307-08; ‘Cod liver oil treatment of wounds’, KT, January (1938), p.20; E.A. Gell, ‘Nursing cases of congenital dislocation of the hips following manipulations’, KT, December (1941), pp.406-08; ‘The nursing care of patients after intensive X-ray treatment’, KT, August (1938), pp.203-04; ‘The nursing care of the chronic patient’, KT, June (1944), pp.127-30; H. Wallis, ‘Pathological fracture due to parathyroid tumour’, KT, October (1950), pp.174-5. 46 F.J. Cameron, ‘A day in the country with the district health nurse’, KT, January (1946), pp.6-9; M. Corkhill, ‘Bedside care in the home’, KT, March (1946), pp.53-58; C. McKenny, ‘The V.D. clinic’, KT, November (1934), p.199; ‘One wet day in the life of a Plunket Nurse’, KT, January (1930), pp.22-24; ‘Outpatients department’, KT, May (1930), p.136 & p.138; K. Rutherford, ‘My work as the rural district nurse’, KT, December (1953), pp.174-6; ‘The district health nurse at work in the city’, KT, April (1946), pp.77-81; ‘Venereal disease clinic’, KT, May (1930), pp.118-20. 47 D. Barron, ‘Sunlight treatment or actinotherapy’, KT, March (1935), pp.14-16; P.E. Borlase, ‘Treatment for arthroplasty of the hip with vitallium moulds’, KT, June (1950), pp.110-13; C. Braethwaite, ‘Nursing treatment. Trans-urethral resection’, KT, September (1936), pp.182-3; A.M. Brown, ‘The treatment of peripheral vascular disease by venous occlusion’, KT, December (1940), pp.39092; E.M. Irving, ‘Nursing treatment in the oxygen tent’, KT, August (1939), p.276; E. Kellahan, ‘Nursing treatment of schizophrenia by hypoglycaemic shock’, KT, November (1939), pp.390-92; M. Sheehan, ‘The story of sulphanilamide’, KT, February (1939), pp.64-65. 48 H. McCombie & J.S. Aitken, ‘Wellington Hospital intravenous practice and technique’, KT, October (1942), pp.249-53; E.M. Summers & J.S. Peel, ‘Drugs and the nurse’, KT, December (1948), pp.254-5. 49 B. Jones & R. Watson, ‘A case of actinomycosis infection of the lung treated with penicillin’, KT, May (1944), pp.112-14. 50 See for example ‘Cancer research fund’, KT, November (1930), p.319; ‘War on cancer’, KT, March (1930), p.62. 51 ‘Lubricants for rubber catheters’, KT, July (1938), pp.175-7. 52 ‘Visit of Miss Hudson to Wellington’, KT, July (1938), p.195. 53 ‘International Council of Nurses’, KT, August (1949), pp.76-77. 54 ‘How to survey a school of nursing’, KT, February (1955), p.20. 55 ‘Editorial’, KT, March (1930), pp.51-52. 56 H.B. Turbott, ‘Treatment of scabies, impetigo and pediculosis’, KT, January (1933), p.316, p.318 & p.320. 57 ‘The nursing care of the chronic patient’, KT, June (1944), pp.127-30. 58 M. Bridgman, ‘The research attitude’, Nursing Research, 2, 2 (1952), p.51. 59 ‘International Council of Nurses’, British Journal of Nursing, 98, 2182 (1950), p.64. 60 ‘Items of interest from Miss Barnett’; Martin; ‘The nursing study’. 61 Stockhausen & Turale.

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

Reviewers - We need you! Nursing Praxis is currently calling for new reviewers to join our existing panel of reviewers. If you have experience reviewing manuscripts or expertise in any areas of nursing and research, please apply now. Nursing Praxis needs an extensive database of reviewers from many different expertise areas for manuscripts that are submitted across a wide range of subjects related to nursing. Nursing Praxis manuscripts all go through a blind peer review process before the reviews are considered by the Editorial Board for final recommendations, the authors and Editorial Board do not know who is reviewing the manuscripts. As a reviewer you may be sent a few requests each year to review papers. You have aprox 3 weeks to complete the review questionaire. If you are requested to complete a review and you are not able to complete the review in the time frame available, just let us know and we will send it to another reviewer. If you have experience or a specific area of expertise and could spare the time to review one or two papers a year we would appreciate you registering your interest to join the reviewers database. We have an online link for Reviewers to register for our reviewers database go to the Reviewers page under ‘About us’ on the new website - Any questions should be directed to

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 23

Nursing Praxis in New Zealand CIGARETTE SMOKING AND THE FREQUENCY OF COLPOSCOPY VISITS, TREATMENTS AND RE-REFERRAL. Lamb, J. RN, BN, MHSc, Clinical Nurse Specialist, Colposcopy Department, Christchurch Women’s Hospital, Christchurch, NZ. Dawson, S.I. RN, BSC (Hons), MSc and Public Health Research, PhD, Senior Manager, Population Health Manager, BAML, Perth, Australia. Gagan, M.J. PhD, PHCNP, FAANP, CEO, Nurse Practitioners First Ltd. Christchurch, NZ. Peddie, D. FRANZCOG, MRCOG, Consultant Gynaecologist & Obstetrician, Christchurch Women’s Hospital, Christchurch, NZ.

Abstract Current research has confirmed that cigarette smoking is a risk factor for cervical cancer.   Although more recently, there has been a slight decline in smoking rates, the relationship between tobacco use and cervical cancer remains clear. The development of research-based knowledge with which to inform the profession will assist practitioners to promote smoke-free practices for women and their families. The aim of this study was to identify whether female smokers referred to the colposcopy department at a city hospital required more follow-up visits, treatments and re-referrals than did nonsmokers. This retrospective descriptive study observed new patients (n= 494) who attended a city hospital colposcopy department in 2001 over the following six years. When compared to non-smokers women who smoked were found to be three times more likely to need a third follow-up visit, and twice more likely to need further treatments to remove abnormalities. This study also identified that 71% of Māori women attending the clinic were smokers compared to 44% of non-Māori women. It was also found that Māori women were less likely to attend the colposcopy clinic than were nonMāori. This study highlights to health professionals and to the women who undergo colposcopy, that treatment is more likely to be successful for patients who cease smoking. The results have also supported the importance and relevance of smoke-free education to women. This allows the link to cervical abnormalities and smoking to be explained and smoking cessation assistance offered. This information also highlights the need for Māori women, who are more likely to smoke and have higher rates of non-attendance for appointments, to have services provided that will encourage attendance and smoke-free behaviour. Keywords: Cervical cancer, colposcopy, cigarette smoking, ethnicity, cervical intraepithelial neoplasia Many women attending a city hospital for colposcopy

undertaken as a retrospective descriptive study that

visits are current smokers, so this can be a useful time to

compared the persistence and recurrence rates of cervical

highlight the link between cigarette smoking and cervical

intraepithelial neoplasia (CIN) with individual smoking

abnormalities. Identification of a woman as a current

status in women who attended the colposcopy clinic.

smoker presents an opportunity to offer assistance for

Ethnicity was also examined to discover whether Māori

her to become smoke-free. The aim of this study was to

women and other ethnic groups were disproportionately

demonstrate the impact cigarette smoking can have on

represented at the colposcopy department.

the cervix and the need for cigarette smokers to have more follow-up visits, treatments and re-referrals for colposcopy visits than non-smokers. This research was

Page 24

Lamb, J., Dawson, S.I., Gagan, M.J., & Peddie, D. (2012). Cigarette smoking and the frequency of colposcopy visits, treatments and re-referral. Nursing Praxis in New Zealand, 29(1), 24-33. Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Background

once a woman becomes smoke-free, how long it takes before the risk declines is unclear (Dresler, Leon, Straif,

Cervical cancer is the second most common form of

Baan, & Secretan, 2006; ICESCC et al., 2006).

cancer in women, worldwide (Bosch, Lorincz, Munoz,

The incidence of cervical cancer in New Zealand women

Meijer, & Shah, 2002; Sankaranarayanan & Ferlay, 2006)

was recorded at 6.9 per 100,000 in 2002 (Ministry of

and the eighth most common cancer affecting women

Health, 2006b). This rate was the same as in Australia,

in New Zealand (Ministry of Health, 2007a). Cigarette

and lower than the United Kingdom (8.3 per 100,000).

smoking is associated with many cancers, including

The highest incidence of cervical cancer recorded is

cervical cancer, and the likelihood of developing cervical

in Latin America, with an incidence rate of 33.5 per

cancer is lower in non-smokers and former smokers

100,000. Some of the lowest incidence rates have been

(Munoz, Castellsague, de Gonzalez, & Gissmann, 2006).

recorded in China with a rate of 2.7 per 100,000 (Parkin,

While the risk of developing cervical cancer decreases

2006) (see Table 1).

Table 1 . Incidence of Cervical Cancer in 2002 Country

Rate per 100,000

China 2.7 New Zealand


Australia 6.9 Canada 7.7 United States


Sweden 8.2 United Kingdom


Latin America


Note: Sourced from Munoz et al. (2006); New Zealand Ministry of Health (2006b); Wain, (2006).

Cervical cancer impacts significantly on younger women

cancer is the third most common form of cancer in Māori

and is recognised as a serious cause of years of life lost

women in New Zealand, and the fourth leading cause

for women in developing countries. For example, in

of death for Māori women (Ministry of Health, 2007a).

countries such as those of Latin America and Eastern Europe cervical cancer causes more years of life

Tobacco smoking in New Zealand and ethnicity

lost than tuberculosis, acquired immune deficiency syndrome (AIDS) and maternal circumstances. Globally

Tobacco smoking is recognised as the chief cause of

it is estimated that cervical cancer is responsible for

preventable death in New Zealand. It is estimated that,

2.7 million years of lost life (age-weighted) (Yang, Bray,

on average, 4,700 men and women die each year from

Parkin, Sellors, & Zhang, 2004). In New Zealand, 200

smoking-related illnesses (Health Sponsorship Council,

women are diagnosed annually with invasive cancer of

2007). At all ages Māori have the higher rate (47%) of

the cervix, and approximately 60 women die each year

smoking, with Māori women having the highest rate

from the disease (Ministry of Health, 2006b). Cervical

of 50% (Ministry of Health, 2007b). While 27.5% of 15

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 25

Nursing Praxis in New Zealand to 19 year olds were reported to smoke, Māori girls

their inclusion essential to achieve representativeness.

have a 60% smoking prevalence, almost double that of young Māori men (32%). However, this picture is


reversed for Pacific teenagers – young Pacific girls’

This study examined records from patients who

smoking prevalence is 28% compared to young Pacific

attended for the first time at the colposcopy clinic

men (46%) (Ministry of Health, 2006c).

between 1 January 2001 and 31 December 2001. Of 1100 women seen in 2001, 500 met the inclusion

Research Design

criteria, and 494 participants were followed-up until 31 December 2006. Patients were included in the study if

This was a quantitative descriptive study, using a

they met the criteria and excluded if they had any of

stratified random sample. That approach was used as

the conditions outlined in Table 2.

some of the variables in the population were known and Table 2. Inclusion and Exclusion Criteria Inclusion Criteria

Exclusion Criteria

New patient

Under 20 years of age or over 70 years of age

No previous colposcopy

Previous presentation to the clinic for colposcopy

Presented at the colposcopy department in 2001

prior to referral during 2001. •

Previous colposcopy

Age 20 years of age to 69 inclusive

Treatment to occur at a different facility

Had low grade intraepithelial lesions (LSIL) or

Glandular abnormality

high grade intraepithelial lesions (HSIL) on

Vulval abnormalities that may or may not

their cervix.

include the cervix

Method Data regarding how often clients had attended for

not attend’ (DNA) status.

treatment were collected from treatment registers. All other data were obtained from clients’ clinical records.

Ethical approval from the University of Otago Board

Data available from assessment forms included age,

of Studies was granted. Consultation with a Māori

ethnicity, smoking behaviour, LSIL/HSIL diagnosis,

Research Office representative took place prior to

combined oral contraceptive pill (COCP) usage, parity,

commencement of the study, and a Māori Research

gravida, biopsy, treatment type, number of treatments,

Manager requested that the findings related to Māori

treatment type at each follow-up appointment, cancer,

women be disseminated appropriately to Māori

genital warts, re-referral, weight and height, and ‘did

researchers, health providers and health professionals.

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Data analysis

being 29.83 years (SD. 8.87 years). The participants were

Data were entered onto an Excel spreadsheet by the

84.6% European, 5.7% MÄ ori, and 0.8% Pacific Island,

researcher, and then checked for errors. The checked

which reflected the ethnic distribution of the population

data was imported into the Statistical Package for Social

for the city hospital region.

Sciences (SPSS) version 13. All data variables of interest were found to be normally distributed. Data analysis in

Smoking behaviour

this study utilised descriptive and inferential statistics

The smoking status of women attending the colposcopy

to describe and characterise demographic data. This

clinic was routinely collected at each clinic appointment

information is reported as percentages, frequencies,

in order to complete the medical history. Smoking status

mean, risk ratio, and odds ratio.

at the time of first clinic visit was therefore known for all 494 women and showed that 44.9% (n=222) women


were smoking at the time of data collection. The number of cigarettes smoked per day was identified for 130

Five hundred women were eligible for inclusion in

women, with 64 smoking less than 10 cigarettes per

the study, however, six did not attend and were then

day. For 92 women, this information was not stated

removed from the study. The remaining 494 women

(see Figure 1).

were aged between 20-69 years, with the mean age

Figure 1. Smoking Status

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 27

Nursing Praxis in New Zealand Ethnicity, cervical intraepithelial neoplasia (CIN), and

clinic (two participants took up private care), women

attendance rates

who reported smoking, when compared to women who

While non-Māori women had a 1.28 greater odds ratio

did not smoke were significantly more than twice as

of having CIN, this was not statistically significant (p =

likely to need a further treatment as were non-smokers

0.65). One of the seven women in the study recorded

(RR 2.10, CI 1.37 to 3.21, p = 0.001) (see Table 3). In

as having squamous cervical cancer identified as Māori.

relation to those who reported smoking, 78.4% (n=174

Māori women were found to be significantly more likely

out of 222) had CIN compared to73.9% (n=201 out of

not to attend (DNA) the clinic for colposcopy when

272) of non-smokers. Therefore, smokers were 1.28

compared to non-Māori (OR 3.05, CI 1.41 to 6.63, p =

times more likely to have CIN. However this difference


was not statistically significant (p = 0.29).

Smoking and ethnicity

Treatments to remove abnormalities from the cervix

It was found that women with a non-European ethnicity

were recorded as LLETZ biopsy, cone biopsy, laser

were 1.25 (CI 0.70 to 2.25) times more likely to smoke

treatment, hysterectomy, ablation, private follow-up and

than European women, although this difference was

no treatment. Among the 494 study participants, 74.1%

not statistically significant (p = 0.46). Twenty (71.4%)

(n=366) first treatments were carried out, with a LLETZ

of the 28 (5.7%) Māori women in the study, reported

procedure being the most common and accounting

smoking. Māori women were significantly more than

for 43.3% (n=214) of the procedures. Hysterectomies

three times likely to report smoking when compared to

accounted for only 0.2% (n=1) of the procedures, while

all other women in the study (OR 3.27, CI 1.41 to 7.57,

0.4% (n=2) of the women had private follow-up. Women

p = 0.005), although the numbers of Māori women

who reported smoking were nearly twice as likely to

attending the colposcopy clinic were low.

need a second treatment as non-smokers (RR 1.90, CI 0.84 to 4.31). However, the number of study participants

First treatment at colposcopy clinic and smoking status

needing a second treatment was very low (n = 25), and

Of the 364 (73.7%) women treated at the colposcopy

not statistically significant (p = 0.15).

Table 3. Smoking Status and Number of Follow-up Appointments

Smokers (n=222) (Rate %)

Non-smokers (n=272) (Rate %)




Follow-up 1






Follow-up 2




1.11 to 2.34


Follow-up 3




1.95 to 5.28


Follow-up 4




1.83 to 6.43


Follow-up 5




1.21 to 6.17


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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Follow-up visits and smoking status, ethnicity, age,

The study identified that within the study period 454

gravida, parity and COCP

of the women required one referral to the colposcopy

The cohort of 494 was observed in relation to the

department. In relation to second referral, 40 (7.3%)

number of follow-up visits each participant needed and

required a second referral. For women in this second

their smoking status. Women who smoked compared

referral group, it was found that smokers were more

to those who did not smoke, were 1.61 times more

than twice as likely to have a second referral as were

likely to need a second follow-up appointment, more

non-smokers (RR 2.12, CI 1.12 to 4.23). This difference

than three times more likely to need a third and fourth

was statistically significant (p = 0.03). In relation to

follow-up appointment, and almost three times more

women requiring three referrals, four such women

likely to need a fifth follow-up appointment than

were seen, with two of this group smoking and two

non-smokers. These differences were all statistically

not smoking. No analysis was performed on this group

significant. Ethnicity, age, gravida, parity and COCP

as it was too small for the results to be meaningful.

use were not statistically significantly associated with

Age, ethnicity, gravida, parity and OCP use were not

number of follow-ups.

statistically significantly associated with needing more than one referral.

Number of re-referrals Of the 494 study participants, 91.9% (n=454) required

The results demonstrated that for all second, third,

only one referral, although 8.1% (n=40) required a

fourth and fifth follow-up visits, the women who

second referral after being previously discharged

attended were more likely to be smokers than non-

from the colposcopy clinic. Within the study period,

smokers (see Table 3). At the first follow-up there were

the maximum number of re-referrals for any woman

found to be a 60% (CI 1.11 to 2.34; p = 0.014) likelihood

was three, with only four women requiring a third re-

of the woman having been reported as a smoker when

referral. Of the 40 women requiring second referral,

she presented as a new patient in 2001. At the third and

25 reported smoking. Smokers were significantly more

fourth visits, women who smoked were over three times

than twice as likely to need a second referral (RR 2.12, CI

more likely to attend than women who did not smoke.

1.12 to 4.23, p = 0.03). Although the numbers were too

At follow-up five, the numbers of women needing a

low to carry out any meaningful analysis, two women

colposcopy were 28, with 19/28 of this group reported

needing a third referral reported smoking and two did

as smoking (OR 2.74, CI 1.21 to 6.17; p = 0.018). Unlike

not. Age, ethnicity, gravida, parity and COCP use were

smoking, other variables such as ethnicity, age, gravida,

not significantly associated with the need for more than

parity and COCP use were not statistically significantly

one referral.

associated with number of follow-ups.

The 8.1% (n= 40) of women requiring a second treatment would be considered an acceptable figure


(Ministry of Health, 2005; Sellors & Sankaranarayanan, 2003). For this group of women, it was found that while

During the course of this research, a number of

they were nearly twice as likely to be smokers as non-

limitations that may have impacted on the outcomes

smokers (RR 1.90, CI 0.84 to 4.31), this difference was

were identified. The most significant of these related to

not statistically significant. However, as numbers were

the number of years spent smoking and the number of

low caution is advised when interpreting these results.

cigarettes smoked. While the smoking status of women

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 29

Nursing Praxis in New Zealand was identified in all of the records used in the study,

information to women and health professionals could

information relating to the length of time smoking

improve the smoking cessation rate and thereby reduce

and the number of cigarettes smoked could have been

the number of colposcopy interventions required. It also

helpful when interpreting the results. It would be useful

has the benefits for the colposcopy service in terms of

in a future study to have a prospective design and ask

reduction of numbers of repeat visits for women.

further questions related to the intensity and duration of the participant’s cigarette smoking habit. In addition,

Māori women in New Zealand are shown to have the

caution needs to be taken with respect to analyses

highest rate of mortality from cervical cancer, followed

where small numbers were observed, particularly

closely by Pacific women (Sadler et al., 2004). Māori

with regard to Maori and Pacific women. During the

and Pacific Island women were identified as being three

timeframe of the study, inaccuracies in the recording of

times more likely to not attend appointments than

ethnicity have been noted therefore the numbers may

non-Māori women. This highlights the need to consider

well be under-counted. Some patients had an initial

alternative means of improving ongoing attendance for

colposcopy examination but failed to attend follow-up

colposcopy. This is an area requiring further research.

appointments. As a result, the data related to on-going visits in relation to persistence and recurrence of cervical

Previous research has identified that many women,

abnormalities is incomplete. It is noted that there is

regardless of their smoking status, may come into

a clear link between socioeconomic status, smoking

contact with the Human Papillioma Virus (HPV), but at

and cervical abnormalities (Ministry of Health, 2005);

some point in the disease process cigarette smoking

however, because of the retrospective design of the

either encourages acquisition of the HPV or assists in the

study data relating to socioeconomic status was unable

disease progressing to CIN (International Collaboration

to be obtained.

of Epidemiological Studies of Cervical Cancer et al., 2006; 2005; Munoz et al., 2006). In studies undertaken


throughout 22 countries HPV DNA has been found in 99.7% of all cervical cancers (Clifford, Franceschi, Diaz,

This study has shown that smoking cigarettes can

Munoz, & Villa, 2006). The current study provides further

adversely affect the health of the cervix. Women who

support for this trend. However, although women who

smoke are at greater risk of requiring more referrals

presented with CIN were 1.28 times more likely to smoke

to colposcopy, more follow-up visits and treatments

when compared to non-smokers, this difference was not

to their cervix than women who do not smoke. The

statistically significant. (p = 0.29). McIntyre-Seltman,

risk of cervical abnormalities for women who become

Castle, Guido, Schiffman, and Wheeler’s (2005) study

smoke-free is less than for women who continue to

of 5,060 women found the development of HPV was

smoke; therefore, smoking cessation is potentially

only weakly associated with cigarette smoking; but that

beneficial to reduce the need for women to have on-

the progression of HPV to CIN III was greater in women

going follow-up, treatments and referrals, and to reduce

who smoked compared to women who did not smoke

the risk of cervical cancer (International Collaboration of

(OR 1.7; 95%; CI 1.4 to 2.1).

Epidemiological Studies of Cervical Cancer et al., 2006; Richardson et al., 2005). While it is widely known in the

Although smoking is associated with an increased

medical profession that cigarette smoking is a risk factor

risk of squamous cell carcinoma (Koushik & Franco,

for squamous cell carcinoma, this link is not so widely

2006; Richardson et al., 2005; Vaccarella et al., 2008)

known in the general population. Dissemination of this

it is still unclear whether smoking increases the risk

Page 30

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand of developing, or the persistence of, HPV. Two recent

at a greater risk of developing CIN III or SCC than are

studies further support the present study. In these it

non-smoking women (Gunnell et al., 2006; International

was found that women who smoked had an increased

Collaboration of Epidemiological Studies of Cervical

incidence of HPV, and women with a greater smoking

Cancer et al., 2006; McIntyre-Seltman et al., 2005).

intensity were more likely to have HPV (Richardson et

While the Ministry of Health (2006a) found that in 2001

al., 2005; Vaccarella et al., 2008). The two large studies

approximately 23% of the Canterbury female population

previously identified, where women who develop CIN

was smoking, in the present study for the population of

and cervical cancer were found to be more likely to be

women attending the colposcopy clinic that figure was

smokers (International Collaboration of Epidemiological

about doubled (44.9%).

Studies of Cervical Cancer et al., 2006; McIntyre-Seltman et al., 2005; Munoz et al., 2006), also support the


findings of this research. The results show conclusively that cigarette smoking While women who have had a treatment for CIN

increases the likelihood of women requiring further

have been identified as being at an increased risk of

colposcopy visits, treatments and re-referrals. The

developing further CIN (Cestero, 2006; Kalliala, Anttila,

results identified that when compared to non-smokers,

Pukkala, & Nieminen, 2005), the risk that women who

women who smoked were three times more likely to

smoke will require a second treatment is greater than

need a third follow-up visit, and twice as likely to need

that for women who do not smoke (Acladious et al.,

further treatments to remove abnormalities. Women

2002). This study found that women who smoked were

who smoked were also twice more likely to require a

more than twice as likely to need further treatment

second referral than women who did not smoke. The

when compared to women who did not smoke. In a

link between smoking and the frequency of colposcopy

United Kingdom study, the risk of treatment failure was

visits, treatment and re-referrals supports the need for

found to be 3.17 times higher for women who smoked

intervention to encourage smoking cessation. This need

than that for non-smokers. (Acladious et al., 2002).

is particularly the case for MÄ ori and Pacific women

This same study also took account of the intensity and

as they are more likely to smoke than those of other

duration of smoking and confirmed that the greater the

ethnic identities.

number of cigarettes smoked, the greater the tendency for treatment failure (Acladious et al., 2002).

Both the research results and the literature indicate the importance of linking colposcopy interventions

The two studies previously discussed (Acladious et

and promotion of smoke-free behaviour. The literature

al., 2002; Vaccarella et al., 2008) support the research

has also indicated that the link between smoking and

reported here in that they demonstrated that women

CIN needs wider and stronger dissemination to health

who smoke are more likely to have persistence and

professionals, women, and their families. Girls reaching

recurrence of HPV, LSIL and HSIL. It is expected that

puberty should also be targeted with the information

women who experience persistent and recurrent

that cigarette smoking is associated with damage to

HPV and CIN will require more interventions, which

the cervix, and that the risk of HSIL and cervical cancer

may include additional examinations, diagnosis,

is greater for those starting smoking at a young age

and treatments to remove cervical abnormalities. A

(International Collaboration of Epidemiological Studies

number of the other studies examined also support

of Cervical Cancer et al., 2006; Tolstrup et al., 2006).

these findings, showing that women who smoke are Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 31

Nursing Praxis in New Zealand References Acladious, N. N., Sutton, C., Mandal, D., Hopkins, R., Zaklama, M., & Kitchener, H. (2002). Persistent human papillomavirus infection and smoking increase risk of failure of treatment of Cervical Intraepithelial Neoplasia (CIN). International Journal of Cancer, 98(3), 435-439. doi: 10.1002/ijc.10080 Bosch, F. X., Lorincz, A., Munoz, N., Meijer, C. J., & Shah, K. V. (2002). The causal relation between human papillomavirus and cervical cancer [Electronic Version]. Journal of Clinical Pathology, 55, 244-265. Retrieved from Cestero, R. M. (2006). Risk of high-grade cervical intraepithelial neoplasia (CIN 2/3) or cancer during follow-up of human papillomavirus (HPV) infection or CIN 1. American Journal of Obstetrics and Gynecology, 195, 1196-1197. doi:10.1016/j.ajog.2006.08.005 Dresler, C. M., Leon, M. E., Straif, K., Baan, R., & Secretan, B. (2006). Reversal of risk upon quitting smoking. The Lancet, 368, 348-349. doi:10.1016/S0140-6736(06)69086-7 Gunnell, A. S., Tran, T. N., Torrang, A., Dickman, P. W., Sparen, P., Palmgren, J., & Ylitalo, N. (2006). Synergy between cigarette smoking and human papillomavirus type 16 in cervical cancer in situ development. Cancer Epidemiology, Biomarkers & Prevention, 15, 2141-2147. doi:10.1158/1055-9965.EPI-06-0399 Health Sponsorship Council. (2007). Tobacco Control. Retrieved from International Collaboration of Epidemiological Studies of Cervical Cancer (ICESCC). (2006). Carcinoma of the cervix and tobacco smoking: Collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. International Journal of Cancer, 118, 1481-1495. doi: 10.1002/ijc.21493 Kalliala, I., Anttila, A., Pukkala, E., & Nieminen, P. (2005). Risk of cervical and other cancers after treatment of cervical intraepithelial neoplasia: Retrospective cohort study. BMJ, 331, 1183-1185. doi:10.1136/bmj.38663.459039.7C Koushik, A., & Franco, E. L. (2006). Epidemiology and the role of human papillomaviruses. In J. S. Jordan, (Ed.), The cervix (2nd ed., pp. 259-276). Malden, MA: Blackwell. McIntyre-Seltman, K., Castle, P. E., Guido, R., Schiffman, M., & Wheeler, C. M. (2005). Smoking is a risk factor for cervical intraepithelial neoplasia grade 3 among oncogenic human papillomavirus DNA-positive women with equivocal or mildly abnormal cytology. Cancer Epidemiology, Biomarkers & Prevention, 14, 1165-1170. doi:10.1158/1055-9965.EPI-04-0918 Munoz, N., Castellsague, X., de Gonzalez, A. B., & Gissmann, L. (2006). HPV in the etiology of human cancer. Vaccine, 24(S3), S1-S10. doi:10.1016/j.vaccine.2006.05.115 Ministry of Health. (2005). Cervical screening in New Zealand: A brief statistical review of the first decade. Wellington, New Zealand: National Cervical Screening Programme. Retrieved from Ministry of Health. (2006a). Cancer deaths and registrations. Retrieved from$File/Ca ncer+Deaths+and+New+Registrations+2005.doc Ministry of Health. (2006b). Mortality and demographic data. Wellington, New Zealand: Author. Retrieved from Ministry of Health. (2006c). Tobacco trends 2006: Monitoring tobacco use in New Zealand. Wellington, New Zealand: Author. Retrieved from$file/tobacco-trends-2006.pdf Ministry of Health. (2007a). Cancer new registration and deaths 2004. Wellington, New Zealand: Author. Retrieved from http://www.nzhis.$File/Cancer04.pdf Ministry of Health. (2007b). New Zealand smoking cessation guidelines. Wellington, New Zealand: Author. Retrieved from http://www. Parkin, D. M. (2006). The global health burden of infection-associated cancers in the year 2000. International Journal of Cancer, 118, 3030-3044. doi:10.1002/ijc.21731 Richardson, H., Abrahamowicz, M. L., Tellier, P., Kelsall, G., du Berger, R., Ferenczy, A., . . . Franco, E. L. (2005). Modifiable risk factors associated with clearance of type-specific cervical human papillomavirus infections in a cohort of university students. Cancer Epidemiology, Biomarkers & Prevention, 14, 1149-1156. doi:10.1158/1055-9965.EPI-04-0230 Sadler, L., Priest, P., Crengle, S., & Jackson, R. (2004). The New Zealand cervical cancer audit whakamatau mate pukupuku tatiawa o Aotearoa: Screening of women with cervical cancer 2000-2002. Wellington, New Zealand: Ministry of Health. Sankaranarayanan, R., & Ferlay, J. (2006). Worldwide burden of gynaecological cancer: The size of the problem. Best Practice & Research Clinical Obstetrics & Gynaecology, 20(2), 207-225. doi:10.1016/j.bpobgyn.2005.10.007

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Sellors, J. W., & Sankaranarayanan, R. (2003). Colposcopy and treatment of cervical intraepithelial neoplasia: A beginnersâ&#x20AC;&#x2122; manual. France: International Agency for Research on Cancer. Vaccarella, S., Herrero, R., Snijders, P., Dai, M., Thomas, J., Hieu, N., . . . Franceschi, S. (2008). Smoking and human papillomavirus infection: Pooled analysis of the International Agency for Research on Cancer HPV Prevalence Surveys. International Journal of Epidemiology, 37, 536-546. doi:10.1093/ije/dyn033 Wain, G. V. (2006). Cervical cancer prevention: The saga goes on, but so much has changed! Medical Journal of Australia, 185(9), 476477. Retrieved from Yang, B. H., Bray, F. I., Parkin, D. M., Sellors, J. W., & Zhang, Z. F. (2004). Cervical cancer as a priority for prevention in different world regions: An evaluation using years of life lost. International Journal of Cancer, 109, 418-424. doi:10.1002/ijc.11719

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses. • Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession. Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal on publication. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board. Nursing Praxis in New Zealand original research, discursive (including conceptual, position papers and critical reviews that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession

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

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

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

The title must be no longer than 12 words.

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

Include a maximum of six (6) keywords.

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

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

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

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

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

Manuscript Submissions • Please supply manuscripts as a Word Document by e-mail to • Manuscripts must be word processed, with double spacing, the title in the header and page numbers in the lower right of the footer. on each page. • All tables and figures must be included at the end of the document each on a seperate page. • Check you have used a plain font (Calibri, Arial or Times Roman). • No details of the author are to be displayed on the manuscript, please include this as a separate document (see below). A separate submission sheet must accompany the manuscript, detailing: • The full name, academic and professional qualifications of all authors, and current employment details. • An address to which all correspondence should be sent, contact phone numbers and e-mail addresses. • A statement that the work has not been previously published and giving written consent for publications; this must be signed by all contributing authors. • Where a manuscript is co-authored, each author must declare how they have actively participated in the development and writing of the manuscript.

Referencing It is the author’s responsibility to ensure that all references and citations are accurate and that all referencing follows 2010 APA (6th edition) conventions (see the Nursing Praxis website for examples). This includes all electronic references, which must include doi number for journal articles. References in the text should cite the author’s name(s), followed by the date of publication. Where direct quotations are used, page numbers must be given. References at the end of a manuscript should be listed alphabetically on a separate sheet formatted with a hanging indent and italicised, not underlined. E.g: American Psychological Association (APA). (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Smythe, L., & Giddings, L. S. (2007). From experience to definition: Addressing the question ‘What is qualitative research?’ Nursing Praxis in New Zealand, 23(1), 37-57. In the case of historical research, referencing compliant with the New Zealand Journal of History is acceptable.

Review Process All manuscripts will be blind critiqued by at least two reviewers prior to a decision being made by the Editorial Board. Subsequently the author will be notified of acceptance (along with any recommended changes) or rejection of the manuscript. Regular features are not peer reviewed. The review process takes, on average, three months.

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

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

Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

Page 35

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

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

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

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

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

Send all Submissions via: E-mail – as a Word document together with scanned original copy of signed author information to: OR Post – One hardcopy of all documents together with a copy on a disk as a Word document to: Nursing Praxis in New Zealand P O Box 1984 Palmerston North 4440 New Zealand

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

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Vol. 29 No. 1 2013 - Nursing Praxis in New Zealand

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

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