Abstract: The focus of this study is the management of unsafe nursing students within the tertiary education context. The moral dilemmas experienced by nurse educators, specifically linked to the issue of accountability for public safety, are explored. The theoretical framework for the thesis is informed by the two moral voices of justice and care identified by Gilligan and further developed using the work of Hekman and Lyotard. Case study methodology was used and data were collected from three schools of nursing and their respective educational organisations. Interviews were conducted with nurse educators and education administrators who had managed unsafe nursing students. Interviews were also conducted with representatives from the Nursing Council of New Zealand and the New Zealand Nurses Organisation to gain professional perspectives regarding public safety, nurse education and unsafe students. Transcripts were analysed using the strategies of categorical aggregation and direct interpretation. Issues identified in each of the three case studies were examined using philosophical and theoretical analyses. This thesis explores how students come to be identified as unsafe and the challenges this posed within three educational contexts. The justice and care moral voices of nurse educators and administrators and the ways in which these produced different ways of caring are made visible. Different competing and conflicting discourses of nursing and education are revealed, including the discourse of safety – one of the language games of nursing. The way in which participants positioned themselves and positioned others within these discourses are identified. Overall, education administrators considered accountability for public safety to be a specific professional, nursing responsibility and not a concern of education per se. This thesis provides an account of how nurse educators attempted to make the educational world safe for patients, students, and themselves. Participants experienced different tensions and moral dilemmas in the management of unsafe students, depending upon the moral language games they employed and the dominant discourse of the educational organisation. Nurse educators were expected to use the discourses of education to make their case and manage unsafe students. However, the discourses of nursing and education were found to be incommensurable and so the moral dilemmas experienced by nurse educators were detected as differends. This study bears witness to these differends.

Abstract: A Grounded Theory approach was taken to explore the concept of the gap between theory and practice, whereby they are seen to be discrete entitites. For this study, the first phase of data collection was a series of computer mediated group discussions, and the second a number of individual interviews. In both sets of interviews participants were asked to describe how they experienced and managed differences they perceived between theory and practice in nursing. The participants referred to different types of theory relevant and central to effective nursing practice. The first was private theory; the second was formal theory and third was situational theory. For the students it was a conflict that produced uncomfortable emotions, distrust of others and personal self doubt. In an effort to reduce this discomfort the students sought an explanation for the differences between theory and practice, some of which challenged their key personal values. However, the most emotionally neutral explanation that also preserved the integrity of their key values was that there was a gap between the theory and the practice of nursing. The theory Negotiating Different Experiences has implications for the education of nurses in that personal knowledge and experiences must be incorporated in a programme of study and the feelings evoked by learning must be acknowledged as a catalyst to enhance learning. Further, the different forms of theory to which students will be exposed must be made explicit and nursing educators who must involve the individual student as an active partner in the mapping of a personalised programme, which includes the creation of individual assessment methods.

Abstract: Advance directives convey consumers' wishes about accepting or refusing future treatment if they become incompetent. There are associated ethical issues for health practitioners and this article considers the features that are relevant to nurses. In New Zealand, consumers have a legal right to use an advance directive that is not limited to life-prolonging care and includes general health procedures. Concerns may arise regarding a consumer's competence and the document's validity. Nurses need to understand their legal and professional obligations to comply with an advance directive. What role does a nurse play and what questions arise for a nurse when advance directives are discussed with consumers? This article considers the cultural dimensions, legal boundaries, consumers' and providers' perspectives, and the medical and nursing positions in New Zealand.

Abstract: This study sought to examine the effects that hospital re-engineering may have on adverse patient outcomes and the nursing workforce. In 1993, New Zealand implemented policies aimed at controlling costs in the country's public health care system through market competition, generic management, and managerialism. The study was a retrospective, longitudinal analysis of administrative data. Relationships between adverse outcome rates and nursing workforce characteristics were examined using autoregression analysis. All medical and surgical discharges from New Zealand's public hospitals (n=3.3 million inpatient discharges) from 1989 through 2000 and survey data from the corresponding nursing workforce (n=65,221 nurse responses) from 1993 through 2000 were examined. Measures included the frequency of 11 nurse sensitive patient outcomes, average length of stay, and mortality along with the number of nursing full time equivalents (FTEs), hours worked, and skill mix. After 1993, nursing FTEs and hours decreased 36% and skill mix increased 18%. Average length of stay decreased approximately 20%. Adverse clinical outcome rates increased substantially. Mortality decreased among medical patients and remained stable among surgical patients. The relationship between changes in nursing and adverse outcomes rates over time were consistently statistically significant. The authors conclude that in the chaotic environment created by re-engineering policy, patient care quality declined as nursing FTEs and hours decreased. The study provides insight into the role organisational change plays in patient outcomes, the unintended consequences of health care re-engineering and market approaches in health care, and nursing's unique contribution to quality of care.

Abstract: The author presents an overview of the impact and management of novovirus infections in New Zealand. The impact of this highly contagious virus on hospital settings is serious. With staff shortages already a problem, any outbreak of contagious disease has the potential to result in unsafe staffing, either through low numbers or poor skill mix. A report from New Zealand Environmental Science and Research (ESR) showed 35 reported norovirus outbreaks in New Zealand in the first quarter of 2004, resulting in 890 cases of the disease. Norovirus outbreaks are characterised by a rapid spread of infection, high uptake rate, and a high proportion of cases presenting with projectile vomiting. The author provides a definition of the novovirus, and looks at transmission, the management of hospital outbreaks, and the impact on emergency departments and hospital wards. Procedures include in-patient isolation. She notes there are no simple answers or “quick fixes” to the problem of norovirus outbreaks. While ongoing surveillance, recognition and isolation are key elements, there are wider structural and political implications that need to be acknowledged. These issues include overcrowding and staff shortages.

Abstract: In this study a qualitative descriptive methodology with focus group interviews was used to explore with users of mental health services, the attitudes, knowledge and skills that they need in mental health nurses. Users of mental health services valued the therapeutic work of mental health nurses, and identified positive attitudes towards users of mental health services as essential in mental health nurses. However, they did not consistently experience a therapeutic approach in their interactions with mental health nurses. In a sociopolitical climate where the views of users of mental health services are increasingly incorporated into education and the planning and delivery of services, there is a need for more research that reflects the perspective of users.