Abstract: The purpose of this research has been to trace the development of the nurse practitioner role in New Zealand. Using a discourse analytical approach informed by the work of Michel Foucault, the study foregrounds the discourses that have constructed the nurse practitioner role within the New Zealand social and political context. The author suggests that discourses of nursing and of medicine have established systems of disciplinary practices that produce nurses and physicians within defined role boundaries, not because of legislation, but because discourse has constructed certain rules. The nurse practitioner role transcends those boundaries and offers the possibility of a new and potentially more liberating identity for nurses and nursing. A plural approach of both textuality and discursivity was used to guide the analysis of texts chosen from published literature and from nine interviews conducted with individuals who have been influential in the unfolding of the nurse practitioner role. Both professionally and industrially and in academic and regulatory terms dating back to the Nurses Registration Act, 1901, the political discourses and disciplinary practices serving to position nurses in the health care sector and to represent nursing are examined. The play of these forces has created an interstice from which the nurse practitioner role in New Zealand could emerge. In combination with a new state regime of primary health care, the notion of an autonomous nursing profession in both practice and regulation has challenged medicine's traditional right to surveillance of nursing practice. Through a kind of regulated freedom, the availability of assessment, diagnostic and prescribing practices within a nursing discourse signals a radical shift in how nursing can be represented. The author concludes that the nurse practitioner polemic has revolutionised the nursing subject, and may in turn lead to a qualitatively different health service.

Abstract: This thesis uses an autoethnographic method to describe the author's personal journey and the influences on teaching the Treaty of Waitangi in the School of Nursing at Otago Polytechnic, from 1985 to 2005. The author starts this exploration as a beginning teaching practitioner in 1985, and continues on with her attendance at the original workshop for trainers by Project Waitangi in 1990. She discusses the influences of her studies towards a Bachelor of Arts at Otago University, through the development of School Charters which influenced her children's schooling and through the process of teaching and facilitating the workshops for Treaty education, until her position in the School of Nursing changed in 2005. She discusses through reflection, the personal influences, the socialisation process of teaching the history of Aotearoa New Zealand to students, the influences of nursing education on Treaty education, the influences of Irihapeti Ramsden's relationship to her journey and also her lecturers at university. She also traces her journey of beginning teaching practice. The author identifies this work as providing a starting place for potential research into the experiences and reflections of nurse educators over this period of time, and across other educational institutes and disciplines. The experiences of students from this teaching would also add to the profession's and the country's knowledge about the relationship of the Treaty of Waitangi to both education and health.

Abstract: Therapeutic relationships are central to mental health nursing. The nurse's role in maintaining professional yet therapeutic boundaries within this relationship can be challenging. When therapeutic boundaries are breeched within the nurse adolescent relationship the adolescent's safety within this relationship is compromised. There is currently limited literature on how nurses are managing professional boundaries in relationships with adolescents in this setting. The adolescent's nature is to push boundaries; therefore the nurse needs to be acutely aware of this boundary pushing in everyday practice settings. For the safety of the adolescent and the nurse it is vital the nurse understands her role in managing the professional boundary. This thesis explores, through the use of narrative inquiry, four adolescent mental health nurses' experiences of assessing, understanding and maintaining therapeutic boundaries with adolescents in a mental health setting in New Zealand. The unique and specific implications for adolescent mental health nursing are discussed. Three key themes emerged from the analysis and findings: the importance of the nurse clarifying his/her role; the learning that occurs throughout the practice journey; and the role of the nurse in keeping the adolescent and the nurse safe. These findings highlight the importance of clinical supervision and open communication with senior nurses and mentors, which assist the nurse in monitoring practice. When nurses do not have sufficient knowledge of the fundamental principles of adolescent mental health nursing; such as knowledge and skills in both adolescent development and psychodynamic nursing, they are at risk of boundary crossings. Recommendations from this research include more emphasis on psychodynamic nursing principles in nursing education and nursing practice. There is a need for specialised education for nurses in child and adolescent mental health nursing. Nursing entry to practice programmes for new graduate nurses working in mental health, could assist in providing this. There is a call for further research into therapeutic relationships and professional boundaries in this complex nursing specialty.

Abstract: Because nurses work in a wide range of settings they are well-placed to provide support for smokefree environments. The aim of this research was: to assess the knowledge of cessation, attitudes towards smoking, the provision of smoking cessation advice and treatment, and attitudes to and management of smokefree workplaces in a sample of nurses with practising certificates in New Zealand; and to describe the prevalence of smoking in nurses using the 2006 New Zealand census. One thousand questionnaires were posted to a random sample of 1000 nurses (500 community-based nurses, and 500 hospital-based) from the New Zealand Nursing Council register of nurses with current practising certificates. Statistics New Zealand provided results from the New Zealand Census of Population and Dwellings, 2006, for nurses by gender, practice area and cigarette smoking status. Responses were received from 371 (37%) of the nurses. They were enthusiastic about and committed to including smoking cessation in their practice, and to learning more about helping clients who smoke. Nine out of ten felt that it was part of their responsibility to advise clients to stop smoking. Nearly nine out of ten said they would be happy to spend an extra five minutes with each patient who smoked if they could effectively intervene. Over half had not received training for effective evidence-based smoking cessation interventions but three quarters were interested in learning more about how to help people stop smoking. The respondents' knowledge of the health effects of smoking was high, but there were gaps in knowledge of effective smoking treatments and a wide misunderstanding that nicotine causes cancer and heart disease. These gaps may limit nurses' ability to intervene effectively. Nurses supported their smokefree work policies although a fifth did not report support with enforcing these. Results from the 2006 census showed that smoking prevalence among nurses has declined from 18% in 1996 to 14% in 2006. Smoking rates in mental health nurses (29%) remain higher than the New Zealand general population (21%, census data).

Abstract: This dissertation was written to promote the author's understanding of the development of drug calculation competency in the undergraduate student nurse. It explores and critiques the literature surrounding the topic and examines the differing teaching methods that are currently used to promote this competency. Findings from the literature were compared to her experience of teaching drug dosage calculation competency to second year undergraduate nursing degree students. This dissertation suggests that drug dosage calculation may be an ongoing problem for nursing students not only during their course of study but also post registration. It appears that age and educational background may be factors in determining whether or not the student will truly master the concept. Although highly debated, it does appear that the use of a calculator assisted the nursing students within the author's class with their arithmetic operation. However, problems associated with conceptual understanding remain notable. The recommendations from this dissertation include the use of varied methods of instruction, integration of both the theory and practical components and the possible use of the dimensional analysis method in the teaching of drug dosage calculation. The author suggests that further research is required both locally within the School of Nursing where she is employed and nationally to fully examine the extent of this issue. Research which is not only focused on the student's calculation ability and its progression over the course of their study but which also allows the School to collate data on age, educational background, culture and learning style would allow lecturers to gain greater insight into student competency, progress and learning needs. She goes on to say that the continued ongoing exploration of her own practice utilising action research is also required as this would assist her in meeting the needs of students and lead to an overall improvement in her practice.

Abstract: Current New Zealand health policy encourages collaborative health promotion in all sectors of health service delivery. The integrated approach to the acute management of coronary heart disease in a coronary care unit, combining medical therapy and lifestyle change, supports clinical health promotion. The aim of this study was to use the grounded theory approach to discover the main concerns of nurses' promoting health in an acute coronary care setting and to explain the processes that nurses used to integrate health promotional activities into their practice. Seventeen registered nurses from three coronary care units within a large metropolitan city in New Zealand were interviewed. Data were constantly compared and analysed using Glaser's emergent approach to grounded theory.The main concern for nurses promoting health within coronary care was ritualistic practice. In this study, ritualistic practice concerns the medically-based protocols, routines, language and technology that drives nursing practice in coronary care. This concern was resolved via the socio-cultural process of attitudinal shifting that occurs over time involving three stages. The three conceptual categories, environmental pressures, practice reality and responsive action are the main components of the theory of attitudinal shifting. In environmental pressures, nurses experience a tension between specialist medically-dominated nursing practice and the generalist nursing role of promoting health. In practice reality, nurses become aware that the individual needs of patients are not being met. This causes role conflict until the nurse observes colleagues who role model possibilities for practice, working with patients to promote health. Responsive action sees the nurse engaging in self-development, also focusing on the nurse-patient relationship, thereby enabling active patient involvement in individual health-promoting decisions. The author suggests that the findings from this research have implications for nursing practice and education. With the increasing specialisation in nursing practice, these findings may be of interest to nurses working in delegated medical roles where the reality of everyday practice precludes nurses from undertaking their essential nursing role. Health care facilities also need to ensure that there are opportunities for the personal and professional development of nursing staff. The place of health promotion within nursing undergraduate curricula needs to be examined, as many nurses found that they were ill prepared for undertaking health promotional activities.

Abstract: Good nutrition is essential following acute spinal cord injury. Poor nutrition can lead to the deleterious effects of protein-calorie induced hypermetabolism and poor functional and rehabilitation outcomes. Nutritional management for patients with acute cervical or high thoracic spinal cord injury admitted to the Canterbury District Health Board's Burwood Spinal Unit and Christchurch Hospital's Department of Intensive Care Medicine (CHDICM) differ. The Burwood Spinal Unit has a delayed approach to nutritional management in contrast to the implementation of early enteral feeding by CHDICM. This prompted a literature review to critically consider the evidence underpinning clinical practice in this field. Literature revealed that nutritional management in the first 72 hours after spinal cord injury is a complex process. The complexities of when to commence, the method of delivering, and the target dose of enteral nutrition in the first 72 hours after spinal cord injury are due to the perceived risk of a spinal ileus and the ensuing, such as adverse effects on abdominal and respiratory function, resulting from enteral feeding intolerance. Literature revealed that delayed nutrition is largely based on expert opinion, while early enteral feeding has limited but stronger scientific research evidence. Nevertheless, it is desirable to use the best evidence currently available to develop, implement and evaluate an evidence-based, protocol driven, clinical pathway for nutritional management of patients within 72 hours of an acute cervical or high thoracic SCI. The author concludes that to ensure an acute spinal cord injury clinical pathway is based on scientific evidence, prospective, multi-centre, randomised controlled trials are needed to substantiate early enteral feeding and identification of the degree of and risk of complications from spinal ileus after acute cervical or high thoracic spinal cord injury.