Abstract: Rural nursing in the remote context of South Westland is shaped by factors common to rural nursing practice world-wide including geographical and professional isolation, living and working in a small community, providing health care to rural people and the broad, generalist and advanced scope of nursing practice. Tourism is a major industry in the townships in the proximity of the two accessible glaciers in South Westland. The practice of the nurses in these areas is significantly affected by tourists seeking health care and by providing a health service for the large number of migrant seasonal workers who service the tourist industry. Tourists seek health care from the nurses across the full spectrum of health problems and their expectations of the health care required may exceed the service that can be provided. The nurses are challenged to advance their practice to find the personal and professional resources to provide a safe service. This includes the challenge of cultural safety and personal safety. The tourist industry brings significant numbers of young people as seasonal/temporary workers to the glacier areas. This imposes a youth culture onto the existing rural culture. Nursing practice has expanded to include the specialist practice of youth health care that includes the problems of alcohol and drug misuse, sexual and reproductive health, and youth mental health. This work is drawn from the experience of the nurses working in the glacier communities. The impact of the tourism industry on their rural nursing practice includes the increasing volume of work that challenges the viability of the service, the advanced scope of practice required to meet the health needs of tourists and the seasonal tourist industry workers, and challenges to personal and professional safety.

Abstract: This dissertation explores the issues affecting the exposure of isolated rural nurses working in New Zealand to violence from members of the local community, including the visiting public. Discussion on the collaborative role with the New Zealand Police is thematic in the issues presented. Challenges presented include the unique community dynamics of the Stewart Island nursing practice on the Island, with scope of practice, isolation and practice issues included. Role definition, present-day health-care delivery, the potential for violence including causation and reporting are presented. Incident management and risk strategies, including de-escalation are rationalised and described. Evidence for the nurse-police inter-service relationship along with issues including confidentiality and legislation are reviewed. Recommendations and conclusion are provided. The thread and theme of the dissertation is to encourage discussion within nursing circles on the provision of satisfactory safety standards for nurses working in remote isolated parts of New Zealand.

Abstract: Although it is accepted in rural nursing literature that the context shapes nursing practice there is limited opportunity to gain an understanding of how this occurs. This dissertation addresses this issue. Firstly, by employing a social geographical lens to define and examine the dynamic, evolving rural context and secondly, by considering the nursing concepts that arise from those contextual factors that relate directly to rural societal health needs. Defining 'rural' is essential when describing or debating rural nursing practice in context. However, there remains no universally accepted definition of 'rural'. Despite this and even though each location is individually specific, there are socio-cultural, occupational, ecological and health aspects that are common and bespeak rural society. These aspects have been developed into a Rural Framework Wheel as a visual reference to demonstrate the substantial influences which impact on nursing practice within the rural context. The framework encapsulates the distinctive dimensions that are hallmarks of rural nursing practice. Nurses can therefore use the framework to express concisely their individualised practice and competence by employing the two broad themes that have emerged from the literature; that of 'nursing per se' and 'partnership'. The Rural Framework Wheel is recommended as a paradigm to critique the practice of rural nurses from an educational, employment, research and political perspective. It is advocated that this framework be used by rural nurses to describe their practice and therefore to express the distinctiveness of the rural nursing identity.

Abstract: A qualitative framework was used to explore the nature and the quality of interactions between sole on-call primary health care rural nurses and secondary care doctors as a component of rural nursing practice and representative of the primary-secondary care interface. Crucial to patient centred care, the premise was that the quality of this interface would be variable due to multiple influences such as: the historical nurse/doctor relationship that has perpetuated medical dominance and nursing subordination; current policy direction encouraging greater inter-professional collaboration; and changing role boundaries threatening traditional professional positioning. A total of 11 nurses representing 10 separate rural areas participated in semi-structured interviews. Rural nurses typically interact with secondary care doctors for acute clinical presentations with two tiers of interaction identified. The first tier was presented as a default to secondary care doctors for assistance with managing primary care level clinical presentations in the absence of access to a general practitioner or an appropriate Standing Order enabling appropriate management. The second tier presented itself as situations where, in the professional judgement of the nurse, the client status indicated a need for secondary level expertise and/or referral to secondary care. The needs of the rural nurse in these interactions were identified as access to expertise in diagnosis, therapy and management, authorisation to act when intervention would exceed the nurse's scope of practice; the need to refer clients to secondary care; and the need for reassurance, encompassing emotional and professional issues. The quality of the interactions was found to be variable but predominantly positive. Professional outcomes of positive interactions included professional acknowledgement, support and continuing professional development. For the patient, the outcomes included appropriate, timely, safe intervention and patient centred care. The infrequent but less than ideal interactions between the participants and secondary care doctors led to professional outcomes of intraprofessional discord, a sense of invisibility for the nurse, increased professional risk and professional dissatisfaction; and for the client an increased potential for deleterious outcome and suffering. Instead of the proposition of variability arising from interprofessional discord and the current policy direction, the data suggested that variability arose from three interlinking factors; appropriate or inappropriate utilisation of secondary care doctors; familiarity among individuals with professional roles and issues of rurality; and acceptance by the primary care doctor of the sole on-call primary health care rural nurse role and the responsibility to assist with the provision of primary health care. Recommendations for improving interactions at the interface include national, regional and individual professional actions.

Abstract: Despite the widespread acceptance of the value of supervision among practitioners and the large quantity of literature on the topic, there is very little empirical evidence in relation to its effect on clinical practice. It is not clear whether supervision actually produces a change in clinician behaviour, or whether it produces benefits in terms of client outcomes. This thesis evaluates the impact of clinical supervision on five co-ordinators in a rural home care setting. It looks at the impact clinical supervision has on their practice and professional growth. The nurses all belong to one organisation, Access Homehealth Ltd. The study builds on the findings of a clinical supervision pilot, which was trialed within the organisation in 2002. The pilot examined which model of supervision was most beneficial for Access Homehealth staff. Clinical Supervision is defined as a designated interaction between two or more practitioners within a supportive environment, that enhances reflective practice and professionalism, which in turn contributes to improved practice and client outcomes. The methodology of this research was qualitative evaluation. The themes which emerged related to personal support, managing stress and alleviating feelings of isolation, reflection, enhancing practice, improved communication skills and the concept of clinical supervision as a safety net. Participants also revealed that one-on-one supervision appeared more helpful than group supervision, and that phone supervision facilitated in-depth dialogue. These findings are important, as they demonstrate it is feasible to simultaneously offer a number of formats of clinical supervision within one organisation, allowing for the organisation to provide what works best for different workers. They also show that clinical supervision is a valuable and useful support tool for home care co-ordinators in order to facilitate empowerment, reflection and growth in practice. Further research is needed to provide evidence of the benefits of supervision on improving client outcomes.