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: The author notes that learning nurses require real clinical experiences in order to apply learnt theory to actual practice. Clinical learning environments have consistently been found to function variably and sub-optimally for both learners and teachers. In order to improve the quality of the clinical learning environment it is necessary to first evaluate how effectively a clinical learning environment is functioning. A number of different methodologies have been used to evaluate clinical learning environments, a recent and successful method being the use of questionnaires or clinical learning environment evaluation tools. The objective of the present study was to develop clinical learning environment evaluation tools for use in a New Zealand hospital health service. Four tools appropriate to evaluate the clinical learning environment from the different perspectives of any type of clinical learner, clinical teacher, clinical manager and programme co-ordinator or nurse lecturer were developed. Six newly graduated nurses, three senior nurses, and the researcher were involved in the development of the evaluation tools over a five month period. A participatory action research methodology was employed. The resultant tools had a unique local focus and were suitably similar to other internationally developed tools. After testing the clinical learning environment evaluation tools, it is hoped that the implementation of the tools will support all stakeholders to understand and consequently optimise the functionality of their clinical learning environment.

Abstract: Respiratory nursing has, as a core clinical concern, the alleviation of distress and suffering associated with respiratory disease. This research describes the ways in which experienced New Zealand respiratory nurses understand, assess, manage and support patients suffering from chronic breathlessness. It reviews the professional context in which these nurses practice, and examines the experiences and beliefs that have lead them to, and maintain them in, this area of practice. This study has been stimulated by the realisation that the skills, understandings and practice wisdom exhibited by experienced Respiratory Nurses is poorly described in the published research literature. This qualitative, grounded theory research is based upon data gathered from in-depth interviews with six experienced New Zealand respiratory nurses. A constructivist research position is adopted. Analysis of these interviews revealed distinct phases of developing respiratory nurse practice including preparing and entering respiratory nursing practice, comprehension of the phenomena of chronic breathlessness and the effect upon the patient and the seeking of possibilities which may alleviate and modify the debilitating effects of chronic breathlessness. Consistent values and beliefs are identified, which are captured in the concepts of professional caring and the movement towards developing expertise in practice. The unifying concept of journeying is employed to draw together these conceptual elements and develop a substantive model describing the work of experienced respiratory nurses with patients with chronic breathlessness. Implications for practice and the health system, and suggestions for further research, are discussed.

Abstract: The authors conduct an audit of medical activity at Christchurch Hospital, a 650 bed tertiary centre, between 2230 and 0800 hours. They measured the volumes of tasks requiring completion overnight and identified the competencies required for this as well as the level of teamwork that existed. They found several organisational areas of concern, that indicate new approaches are required to staff the “hospital at night,” and an Out of Hours Multidisciplinary Team is recommended. Specific issues included the lack of teamwork from the Resident Medical Officers (RMOs), with some overextended while others were inactive. House officer tasks were largely generic rather than specialty specific; there was no formal handover from the afternoon or day shifts and the level of hospital medical staffing did not reflect the activity levels over the time period studied. The researchers also recommend an urgent review of the beep policy. A third of the admissions were to General Medicine, and basic medical activities (including admitting, reviewing, and prescribing drugs and fluids) for patients admitted under all specialties represented the majority of the night workload. Medical registrars had reduced some of the traditional multiple clerking by admitting patients themselves.

Abstract: The author investigates why nurses in New Zealand stay working in rural areas when their Australian counterparts and medical colleagues are leaving rural areas at alarming rates. She looks at international recruitment and retention issues, and particularly compares rural nursing in Australia with New Zealand. Local research shows that over 50% of rural nursing is in the practice environment. Practice nurses report high job satisfaction, specifically around working with diverse populations, autonomy, and working with GPs, the local community, and local iwi. The only perceived barrier identified in the New Zealand literature to job satisfaction and collaborative team behaviour has been the funding of nursing services in rural areas. This contrasts with many barriers to rural nursing in Australia, and the author suggests New Zealand policy makers may learn from Australia's retention issues.

Abstract: The author points to a “waiting list crisis” occurring in ambulatory oncology services at Southland District Health Board (SDHB), and notes that the literature suggests this is occurring both nationally and globally. This is due to factors such as an increase in the number of people aged 65 years and over, many of whom will develop cancer. Furthermore new drug therapies and indications for treatment have led to increased numbers of patients referred for oncological assessment in the out-patient clinics. The author notes that, at SDHB, this delay for patients to be seen at a first specialist assessment appointment is causing concern for patients, managers and the medical and nursing staff involved. This dissertation analyses relevant literature in order to explore the nature and outcomes of nurse-led clinics. A range of studies indicate that effective care can be provided by nurses working in a variety of nurse-led clinics settings. These studies reveal ways in which a nurse-led clinic might be established and delivered in oncology services and, the author suggests, this will go some way to provide a solution for SDHB. These clinics would assess and monitor the follow-up of selected patients with stable disease and established care plans such as patients receiving adjuvant chemotherapy for bowel and breast cancer. This would allow medical oncologists to see more new patients at first assessment and the follow-up of complex cases, and could go some way in relieving the current waiting lists. The educational preparation and competency of nurses leading such a clinic are considered.

Abstract: This dissertation reports on a scholarly journey to better understand the processes of clinical decision-making by nurses. It begins by identifying the various terms used to describe a clinical decision, its components and the contexts within which clinical decisions are made. Two philosophies of decision-making are summarised. Some insight into the history of the phenomenological and the rationalist theories of decision-making is offered. The author notes that it became evident that both of these theories are applicable to all nurses and their clinical decision making competencies. Four studies that were undertaken to analyse the decision-making methods of nurse practitioners are critiqued. Of the studies two are British, one is American and one is Australian. The author has summarised the combined findings that identified that the nurses were using a blend of decision-making processes that involved rational decision making as well as the use of intuition. The studies identified that sound clinical decision-making is determined by appropriate educational and clinical preparation and supported by a formal mentoring process and the use of critical reflective practice. In conclusion, the author reflects on her knowledge of decision making prior to embarking on the dissertation and states her intent to facilitate and support advanced decision-making by her colleagues. She goes on to say that uppermost is the need for an institutional and managerial environment that encourages advanced and independent decision-making by nurses.

Abstract: New Zealand statistics project that the aging population of people aged 65 years and over will more than double in the next decade. This has implications for palliative care providers including hospices and hospitals because long-term inpatient care is not generally provided by hospitals and hospices. When dying patients need long-term care, residential settings become an option. The level of palliative care in these facilities is dependent on staff training and numbers. In general, staff are not trained in palliative care, neither do they provide the multidisciplinary facets that define palliative care as undertaken by hospices. This paper describes a practice development initiative using storytelling as the vehicle for introducing the concept of the Liverpool Care Pathway (LCP) for the dying patient into residential aged care settings. With the emergence of a reflective paradigm in nursing the concept of storytelling as a teaching/learning tool has grown. Many staff in residential care settings come from diverse ethnic backgrounds where for some, English is their second language. Storytelling therefore can be a useful approach for learning because it can increase their communication skills. The author suggests that the Liverpool Care Pathway for the dying patient is a model that can be translated across care settings, hospice, hospital, and community. It can demonstrate a framework that facilitates multiprofessional communication and documentation and embraces local needs, culture and language to empower health care workers to deliver high quality care to dying patients and their family/whanau and carers. This paper also explores the role of a facilitator as an agent of change and discusses how the interplay of evidence, context and facilitation can result in the successful implementation of the LCP into residential aged care settings.