Abstract: The Primary Health Care Strategy (PHCS) has a stated commitment to defined populations who suffer disproportionately from ill health. This thesis examines whether some prevailing discourses actually decrease the focus on health inequalities. A study of the nursing and medical media found that it focused predominantly on professional and industrial issues, leaving health workers focused mainly on their own professional interests, rather than considering the effects on health inequalities. She goes on to suggest that current Ministry of Health discourse values decentralised community health decision making. This may gloss over factors in community health which are affected by Government policy such as employment policy, and thus should be dealt with centrally by legislation. These factors have been found to be the most pertinent in health inequalities. So while models of community partnerships may seem to place communities as agents in their own health, this downplays the determinants of health which are beyond their control. Having shown that discourse can decrease the focus on health inequalities due to other professional and political drivers, the author then looked at health initiative concepts which are effective, efficient and equitable given the current set up of PHOs and nursing innovations.

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: The last twenty years, particularly the early 1990s, ushered in major mental health sector reforms inclusive of deinstitutionalisation policies and subsequent development of community services. Concurrent changes to student nurses' education left registered nurses as the workforce mainstay on inpatient units. However, the author suggests, an emerging global shortage of nurses and implementation of the Employment Contracts Act (1991) negatively impacted on recruitment and retention of registered nurses. Inpatient nurses either left nursing or moved to community positions for better money and increased job status. The author suggests that, as a consequence, the 'critical mass' of experienced and skilled nurses who traditionally provided nursing leadership disappeared resulting in compromised standards of care for patients. As the manager of an inpatient unit, the author proposed the establishment of advanced nursing practice roles as one initiative to provide nursing leadership in order to attract and retain nurses. This study explored five inpatient nurses' perceptions of advanced practice and whether these roles could assist to provide leadership and improve standards of care. The research was a qualitative exploratory descriptive study using a focus group interview as the data collection method. A thematic analysis of the group discussion transcription revealed three key themes: 1) the 'makeup' of advanced nursing practice, 2) moving forwards: establishing roles, 3) moving sideways: barriers to role development. The themes are critically discussed in relation to selected literature. The thesis includes recommendations that could be used by nurses responsible for planning and implementing advanced practice roles on inpatient units.

Abstract: In 2003 the Health Practitioners Competence Assurance Act was introduced and established separate regulatory authorities for nursing and midwifery. This study is designed to explore the experiences of dually registered practitioners affected by this divide, as now there are two separate and possible paths, and two corresponding sets of competencies to fulfil. The design for this qualitative descriptive study utilised the written and oral narratives of three practitioners affected by this professional regulation and demonstrated its impact on their career development. Individual storytelling, as narrative, provided a theoretical lens aiding insight into their experience and pattern of decision making. In addition, symbolic consideration of the study data was provided by collective storytelling via the perennial myth of the hero journey. Shifting professional ground following the Health Practitioners Competence Act 2003 generated a focus for the inquiry into practitioners' modes of adjustment. For the practitioners in the study, transition between the occupational roles of nursing and midwifery comprised the possible career trajectories. A status passage, as the process of change from one social status to another, is described and includes the transitional experience of anticipation, expectation, contrast, and change. The author suggests that the findings from this research provide illumination of the nuances of professional decision making as a lived experience, and highlight how these practitioners dealt with shifting meaning, values, awareness, choices, and relationships. Aspects of group agency and identity, change management, and professional role transition were revealed. Life pattern, revealed through narrative, was an important research construct for exposing the ways in which the participants negotiated change, and displayed the function of their thinking and reasoning through dilemmas. Perception of individual and group identity revealed attitudes of esteem to the dominant discourse, and exposed dynamic tension between work patterns and life stage. Renegotiating arrangements of personal and professional commitment resulted from this dynamic interplay, and the relationship to stress and burnout was explored.

Abstract: This contemporary historical study examines the health sector environment of the 1990s and the turn of the 21st century, and assesses the policy initiatives undertaken to advance nursing in New Zealand during that period. The authors look at the conditions and forces that saw nursing achieve a new emphasis on advanced and expanded scope of nursing practice, less than a decade after the commencement of New Zealand's first pre-registration nursing degrees.

Abstract: An analytical tool of Force Field Analysis was used to identify and describe forces influencing the development of innovative roles, including the nurse practitioner role, in primary health care nursing. At the commencement of the study an initial analysis of research, literature and policy identified forces driving or restraining the development of innovative roles. A mixed research method of surveys and focus group interviews with key stakeholders, namely nurses in innovative roles, general practitioners and nurse leaders, was then used to identify factors influencing development within the Northland District Health Board. Descriptive statistics and interpretative methods were used to analyse the data. A final analysis enabled a picture of forces influencing innovative role development to be presented. Driving forces reflected international trends and were strongly influenced by economics and a political imperative to reconfigure health care services towards a primary health focus. The Treaty of Waitangi was also a key influence. Driving forces had greatest impact on the development of new roles. Forces were identified as drives towards cost-effective evidence-based health care (effective services), equity for Maori, response to local needs and workforce reorganisation. The major forces restraining the development of innovative roles were reinforced by attitudes, customs and support systems. These forces were identified as poor professional identity and support, an outdated nursing image, inadequate education and training and slow transition from traditional practices and structures (tradition). These forces had a negative influence on support for innovative roles. Promotion of kaupapa Maori, involvement of the local community, local Maori and nursing in decision-making and promotion of a team culture have the potential to support further development of innovative roles. Political ideology and the Treaty of Waitangi will continue to be major influences directed through policy and the contracting and funding process.

Abstract: This study explores the development of 'family-centred care' in New Zealand as part of an international movement advanced by 'experts' in the 1950s concerned with the psychological effects of mother-child separation. It positions the development of 'family-centred care' within the broader context of ideas and beliefs about mothering and children that emerged in New Zealand society between 1960 and 1980 as a response to these new concerns for children's emotional health. It examines New Zealand nursing, medical and related literature between 1960 and 1990 and considers both professional and public response to these concerns. The experiences of some mothers and nurses caring for children in one New Zealand hospital between 1960 and 1990 illustrate the significance of these responses in the context of one hospital children's ward and the subsequent implications for the practice of 'family-centred care'. This study demonstrates the difference between the professional rhetoric and the parental reality of 'family-centred care' in the context of one hospital children's ward between 1960 and 1990. The practice of 'family-centred care' placed mothers and nurses in contradictory positions within the ward environment. These contradictory positions were historically enduring, although they varied in their enactment.

Abstract: An overview of the model of nursing practice and nurse roles derived through a programme of nursing research in the context of the policy and strategies directing developments in the New Zealand health system. The emphsis was on the health service configuration model presented diagrammatically to show the position of a new role of family nurse with a distinct form of practice forming the hub.