from the editors · 2020-02-12 · australian journal of advanced nursing 2004 volume 22 number 1...

Australian Journal of Advanced Nursing 2004 Volume 22 Number 1

EDITORIAL

5

The papers in this AJAN caused us to reflect on thechallenges of responding to agenda setting that isfrequently guided by utopian ideals as we confront

the reality of generating policy for varied contexts and thenimplementing policy in context The full suite of complex elements that inhibit or enhance changes in practice consist of social political historical and cultural aspects Diverse practice settings arechallenging to accommodate in practice reform efforts Reform of educational strategies and health services reconceptualising of professional practice re-alignment of professional responsibilities increasedeffectiveness and efficiency demand for greater transparencyand accountability and meaningful guidelines are allconcepts which feature in todayrsquos policy environment

However policy development from its inception throughto complete expression in practice is rarely well understoodor reflected upon in all levels of nursing The importance ofrecognising the impact of agenda in policy and practice isthe focus of our editorial reflection on this occasion

We suggest that the learning organisation provides auseful mechanism to explicate critique and contribute to theagenda setting process Inherently policy development isintended to bring about change This change is expressedthrough both policy generation and through implementationthat requires behavioural change in individuals or in theactivities within their scope of practice

Ensuring there is acknowledgement of the diversity ofnursing practice and that this is recognised during policydevelopment requires that nurse leaders engage in agendasetting The term agenda setting is frequently associatedwith covert activity and may be considered unseemlywork for leaders in nursing However agenda setting isthe necessary precursor to policy development Exertinginfluence during the agenda setting process throughproactive professional involvement in political processesis something nurse leaders have become more proficientin over recent times Despite this increased sphere ofinfluence by nurses in senior government and academicpositions there is sometimes limited understanding ofand support for the implementation of nursing-led policyinitiatives at the lsquograss rootsrsquo levels of nursing

There is potential it seems for many of us to makeassertions about what we believe should be valued inpractice based on beliefs about nurses and nursing thatsimply reinforce and validate our own sometimes limitedviews We do not always seek to determine intendedoutcomes of change While at times the impetus forchange and the subsequent links to the need forheightened awareness of the imperative for change are not

well explored and developed at other times nursesdismiss out of hand policy that which they do not see asspecific to their context of practice or which challengestheir insular world view Such rejection of nurse ledpolicy by nurses results in a perception that nursing is aprofession that experiences dissonance and discord andfosters disarray and disorganisation

While we as editors have noted the potential fordissonance between those who develop policy and thosewho practise nursing within the policy framework thepapers in this AJAN explore other points of apparentdissonance in nursing These include the well-publiciseddissonance among educational experiences and workforceexpectation exemplified in the papers by Hoffman andElwin and Kilstoff and Rochester Hoffman and Elwindiscuss the relationship between confidence and graduatenursesrsquo capacity for decision-making Kilstoff andRochester focus on the lsquovalues dissonancersquo and lsquoroleadjustmentrsquo necessary for new graduate nurses and theclashes between realistic and unreasonable expectationsof the transition to the workforce for enrolled nursesbecoming registered nurses

The paper by Raholm Eriksson Lindholm andSantavirta identifies the dissonance in the rhetoric ofnursing which claims to be holistic in focus and thereality of cardiac patients experience of nursing careThese authors argue for changes in the rhetoricsurrounding spirituality and nursing practice to highlightthe need for a focus on the patientrsquos frame of referenceAdopting more patient-centred practice as the frameworkfor nursing research may be a vehicle through whichnursing can address the dissonance between nursingrhetoric and patientsrsquo reality

Such research must however be coupled withpragmatic considerations Emden and Smithrsquos paperfocuses on the need to develop guidelines for graduatestudents undertaking research projects They make a pleafor realistic project design and process guidelines Ifresearch training for nursing students is to be bothrigorous and ethical these authors suggest that somerestrictions need to be applied in choices of approach andmethods of data collection

Dissonance among other espoused philosophies andnursing practice are also highlighted in this issue Theextent to which nurses are empowered and enabled toengage in ethical practice which is cognisant of humanrights issues are questioned in the study undertaken byJohnstone Da Costa and Turale

FROM THE EDITORS - Margaret McMillan and Jane Conway

DEVELOPING THE PROFESSION AS A LEARNING ORGANISATION A VEHICLE FOR RESPONDING TO DISSONANCE DISCORD AND DISCONTENT


Despite an espoused commitment at policy level tointegrated service delivery and collaborative workpractices Reiger and Keleher express the view thatrestrictive practices for nurses within a child and familyhealth service arise from medically defined surveillanceof service policies and practice

Collectively we must address the dissonances withinnursing Change efforts may not be successful when theyare policy driven without a basis in practice or purelypolitically motivated Realistic solutions to situations thatbecome problematic in the real world of practice have toencompass acknowledgement of ambiguity and thehuman aspects of change processes A failure toacknowledge the reality and inherent complexity of thecoalface can lead to limitations in outcomes of wellintentioned policy Hence there is a need to acknowledgethe uniqueness of challenges of introducing change

One of the challenges in introducing change isavoiding the creation of the perpetuation of the lsquousrsquo andlsquothemrsquo mentalities that pervade organisations wherechange is a constant feature of work

Education and training is frequently identified as amechanism for reducing the popularised lsquogapsrsquo in nursingsuch as the theory-practice gap or the policydevelopment-implementation gap However educationand training strategies remain in the main content drivenindividual learner oriented and expert provider focusedWhile learning has historically been targeted towardindividual learners and their needs increasing reference ismade in the literature to the concept of organisationallearning Organisational learning is seen as the key toorganisational survival It is also thought to offeropportunity for the survival and development ofprofessions in health care

Organisational learning has been characterised as astrategy through which an organisation is able to improveperformance and prevent and respond to error through thedevelopment of practice based insights

Organisational learning recognises the coexistence ofboth the mechanistic and functional elements oforganisational change as well as the lsquosofterrsquo humanisticelements of reform and consists of two interrelatedelements individual learning and development and thedissemination of and elaboration of that learning throughconscious interaction with others While thoroughevaluations can provide evidence of the real worth ofpolicy in practice as well as identifying aspects ofoutcomes that were either not in the original plans ofapproach to change agenda or arose unexpectedly fromthe context of practice there is need to disseminateinformation derived from policy evaluation to the nursingworkforce and communicate reasons for policy retention(or abandonment) The concept of a learning organisationprovides a framework in which to nest dissemination ofpolicy and evaluation of policy in ways that are inclusiveand supportive of nurses

Related to but distinct from organisational learningthe concept of the learning organisation has becomeincreasingly popular in literature related to organisationalchange The learning organisation is one in which thelearning of all its members is encouraged in order for theorganisation (or we would argue the profession) tosustain and transform itself

The concept of workforce development has emerged inrelation to organisational learning and the creation oflearning organisations Workforce development is seen asa key element in meaningfully enacting policy directionsand acknowledges the interface between the lsquointernalrsquopractice context and the external policy context It isimportant to note that workforce development recognisesthe need to have supportive workplace structures fordevelopment to occur More enlightened approaches toworkforce development also acknowledge that thedeveloped workforce shapes its own future throughskilling staff in policy generation and evaluation andaddressing dissonance in ways that are not destructive toeither individuals or the profession

EDITORIAL

6


GUEST EDITORIAL

7

Unlike the real editors of this journal this guest editorhas not had the benefit of reading all the submittedmanuscripts or planning what would be in this issue

In fact I havenrsquot the faintest idea what is in this issue I justappear like a spirit bearing thoughts and observationsgathered here in Australia and in America about the state ofnursing knowledge

When nursing moved into the universities we had tolearn to live in university standards for scholarship andresearch We did it all over the world Nursingrsquos researchpasses the peer review test in our own journals and those towhich we contribute in medicine health servicesmanagement history and other fields

We inherited the scientific traditions of medicine Afterall we deal with physiology and anatomy pharmacologyand related sciences Sometimes we have fed the scientificand research traditions from the social sciences into thediscipline and lately we have embraced some of thephilosophic traditions in philosophy as phenomenology andcritical social theory

That is all splendid

If you sensed a lsquobutrsquo coming yoursquore right

But itrsquos not enough That is nursing is such a hugelycomplex discipline that it is not fully captured by thetraditions of science or social science or the humanities Ifas I believe the role of a distinguished professional journal isto help move the discipline forward then this journal mighttake a leading role to proclaim the potential publishablevalue of nursing writing that doesnrsquot yet have a good label

Itrsquos called lsquonarrative medicinersquo in that field and in theworld of writing itrsquos called lsquonarrative journalismrsquo Inmedicine this means incorporating the patientrsquos own storyinto the diagnosis In journalism it means going beyond theold standards of lsquowho what when why and howrsquo to capturethe feelings and attitudes of the people in the event with arecognisable voice and a defined locale

That doesnrsquot sound like scholarship does it And this is ascholarly journal

Nursing has tapped science social science and thehumanities but there are whole other bodies of knowledgeout there in lsquolettersrsquo - literary criticism and narrative analysisEnglish expository writing These are concerned with theways in which words live in the world to catch both externaland internal human experience

There is some of this kind of writing creeping intomedical and nursing journals but usually as a back-of-the-book section (Occasional Notes in the New England Journalof Medicine lsquoNarrative Mattersrsquo in Health Affairs) aspecially designated page (lsquoReflectionsrsquo in the AmericanJournal of Nursing lsquoA Piece of My Mindrsquo in Journal of theAmerican Medical Association) Interestingly the Australian

Health Review has published quite a lot of essentiallynarrative material so useful in describing how and whythings happen

The practice literature in nursing has a long tradition ofincluding patient and nurse stories Narrative nursing as Irsquomgoing to call it here would go beyond the touching anecdoteabout lsquomy patient with [cancer homelessness painresistance depression etc]rsquo to capture the liveliness thedynamic the majestic ordinariness of nursing usingtechniques of story telling It would more than lsquomyencounter with dyingrsquo or lsquohow hard it was to care for Samrsquo orlsquoainrsquot it awful what the health care system did to FanniersquoThatrsquos journalism more or less unanalysed reporting WhatIrsquom after here is analysed experience (including analysedthinking and feeling) that makes a story

Why a story

Because a story engages people It has tensionsomething to keep the reader reading It has characters arecognisable even if anonymous voice a sense of context inplace and time

I think of this in the late Virginia Hendersonrsquos words thata part of nursing is to be the lsquovoice for those too weak orwithdrawn to speakrsquo Sometimes those are nurses

Narrative medicine and narrative journalism arecontroversial in their own fields so it is not a surprise thatthis form of writing should be controversial in nursing Iwould hope itrsquos not that we find it embarrassing to revealwhat nursing is inside the science and service And I wouldhope itrsquos not because such narrative writing is thought to beun- if not anti-scientific

Nursing is so complicated a discipline that it might profitfrom many traditions of scholarship Science surely servesus as we begin to see nursing research informing policyPhilosophy-based inquiry has made remarkablecontributions to understanding the discipline if not thepractice of it Therersquos yet room for carefully crafted story-telling that reaches behind the acts and theories of practice tothe human experience of living in nursing

This kind of writing is fiendishly difficult to do Just aswe needed to study scientific method in the physical andsocial sciences and the methods of qualitative inquiry wemay need to study again in the disciplines of the letters Wehave millions of stories but telling them for effect is a skillnot taught in nursing programs

The telling is hard enough

The getting them published is harder yet for we have notyet evolved in nursing the standards for judging credibility ofnarrative as we have for detecting methodological orconceptual weakness

We have to start somewhere though

A guest editorial as narrative is one tiny little beginning

GUEST EDITORIAL - Donna Diers RN PhD Adjunct Professor Faculty of Nursing Midwifery andHealth University of Technology Sydney and Annie W Goodrich Professor Emerita Yale University Schoolof Nursing USA

VOICING NURSING

8Australian Journal of Advanced Nursing 2004 Volume 22 Number 1

ABSTRACTNurses make decisions every day while planning

and delivering care within their scope of practiceEffective and appropriate decision-making requiresthe acquisition and utilisation of pertinent data as wellas higher order thinking skills such as decision-making and critical thinking

Research aims The aim of this study was to examine the

relationship between critical thinking and confidencein decision-making for new graduate nurses

Methods Critical thinking scores for two groups of new

graduate nurses were correlated to confidence indecision-making scores for the same nurses

Major findings The study had some surprising and interesting

findings Contrary to prior studies that have foundeither no relationship or a positive correlation betweencritical thinking and confidence in decision-makingthis study found a negative correlation between thesetwo variables These findings have implications bothfor tertiary nursing education and continuing clinicaleducation

Conclusion New graduate nurses who have higher critical

thinking scores and seem more hesitant in decision-making should be encouraged in their questioningattitude There is a need for professional developmentcourses that raise awareness of the importance of anursing culture that encourages a more openquestioning attitude to decision-making

INTRODUCTION

Nurses work in many different roles and settingseither directly or indirectly related to patient careCare delivery has however changed with

advances in technology disease treatment and preventionand nurses need to become skilled in higher-levelthinking if they are to effectively manage the complexchanges resulting from the increasing demands andgreater accountability required of the profession(Simpson and Courtney 2002) Nurses make decisionsevery day while planning and delivering care within theirscope of practice These decisions require the acquisitionand utilisation of pertinent data and higher order thinkingskills such as decision-making and critical thinking needto be encouraged and developed in nursing studentsCritical thinking ability according to Simpson andCourtney (2002) consist of two main aspects cognitiveskills such as interpretation analysis inferenceexplanation evaluation and self-regulation as well asaffective dispositions such as open-mindedness truthseeking and self-confidence These same authors go on todescribe self-confidence as both trusting and using onersquosown reasoning to support decision making It would bereasonable to assume therefore that those nurses withgood critical thinking ability would be more confident indecision-making and this line of reasoning is supportedby Seldomridge (1997) who states that making effectivejudgements requires confidence in onersquos ability to usecognitive skills

This paper reports the results of an investigation intothe relationship between critical thinking and confidencein decision making in new graduate nurses by assessingtheir critical thinking ability as well as their confidence indecision making related to nursing activities within theirscope of practice and experience The study took placeover a twelve-month period across two area healthservices in NSW Australia with a cohort of 83 newgraduate nurses

Kerry Hoffman RN MN BSc Lecturer School of Nursing andMidwifery Faculty of Health University of Newcastle NewSouth Wales Australia

Carolyn Elwin RN MN Nurse Educator Central Coast AreaHealth Service Nurse Education Centre Gosford Hospital NewSouth Wales Australia

Accepted for publication November 2003

THE RELATIONSHIP BETWEEN CRITICAL THINKING AND CONFIDENCE INDECISION-MAKING

RESEARCH PAPER

Key words decision-making critical thinking decision-making confidence new graduate nurses


LITERATURE REVIEW

Critical thinking abilityWhile the definition of critical thinking is broad and

diverse in the literature there is general agreement that itis purposeful reasonable and goal-directed thinking(Halpern 1996 cited in van der Wal 2000) Van der Wal(2000) outlines two types of critical thinking one ofwhich applies to practical situations such as nursingpractice emphasising the importance of skills that supportthe identification of appropriate strategies and thedecision making necessary for effective problem solvingCritical thinking in nursing care is thus the ability toanalyse problems through inferential reasoning andreflection on past situations that share similar clinicalindicators Such reasoning is necessary for effectivedecision making in the delivery of complex patientmanagement The use of critical thinking as a frameworkfor clinical decision-making is thus central to accountabledelivery of nursing care and can be seen as essentialcomponents of nursing practice defined as purposefulthought involving scrutiny assessment and reflection(Daly 1998 Shin 1998)

Critical thinking ability and confidence in decisionmaking

Decision-making is an essential feature of the nursingrole Bandman and Bandman (1995) describe decision-making as providing a basis for intervention utilisingcritical thinking as a framework in the search foralternatives through inferential (higher order) reasoningThese authors suggest that nurses utilise this framework asa foundation for decision-making as a critical reflectiveprocess that supports or refutes the status quo as opposedto problem solving techniques which pre-suppose absolutesolutions Nursesrsquo confidence in this process however maydepend largely on the frequency of their exposure torepeated circumstances with similar patient data reflectionon their inferences about these situations and thus thedevelopment of a deeper understanding which cancontribute to confident practice The development of theseabilities varies however and Seldomridge (1997) notesthat some students are less confident in decision-makingand less willing to act whereas others overestimate theirabilities and act without caution

Although it is generally acknowledged that confidencein decision-making is governed by effective criticalthinking skills research to date is not definitive on thispoint Girot (2000) reported that there was no relationshipbetween the development of critical thinking anddecision-making in clinical practice These findingsresulted from her UK study that utilised the Watson andGlaser Critical thinking assessment tool (WGCTA) tomeasure critical thinking and the Confidence in decision-making in nursing scale (CDMNS) to measure confidencein decision-making This result is in contrast to findingsfrom a Korean study by Shin (1998) who reported a weak

positive correlation between the two using the WGCTA tomeasure critical thinking ability but the NursingPerformance Simulation Instrument (NPSI) to measurenursesrsquo confidence in decision making The CDMNSmeasures perceptions of ability and confidence indecision-making while the NPSI measures decision-making by respondents answering four simulations andbeing scored on each While the different measures forconfidence may have produced the differing results Shin(1998) found only 4 of the variability in clinicaldecision-making could be accounted for by criticalthinking ability and concluded that some of thisvariability could be attributed to respondentsrsquo IQ

Critical thinking ability and confidence was alsoexamined by Beeken (1997) who found no relationshipbetween critical thinking skills using the Californiacritical thinking tool and self-concept or confidence usingthe Tennessee self concept scale although other studieshave found a positive correlation between these twovariables Interestingly Beeken (1997) did find that olderstudents had a more positive self-concept were more self-confident and had higher confidence in decision-makingWhile the development of critical thinking skills may belargely unrelated to the development of confidence indecision making as part of a nursersquos role there is littleconsensus about the relationship between the two which sooften determines the effectiveness of nursing care deliveryand thus further supports the significance of this enquiry

METHODOLOGY

Design and aim of the studyThe relationship between critical thinking and confidencein decision-making was examined in this study usingcorrelational methods

Research question1 Is there a relationship between critical thinking

ability and confidence in decision-making for new graduate nurses

Hypotheses1 There is no relationship between critical thinking


Study sampleThe target population from which the sample for thisstudy was recruited was new graduate nurses entering twoarea health services in Australia one within a majormetropolitan area and one regional area health serviceThe sample size was 83 New graduate nurses comprisedstudents from 11 different universities representing awide range of undergraduate preparation

RESEARCH PAPER

9


Methods of data collectionThe research project used a correlational design Two

groups of new graduate nurses were recruited from twodifferent area health services

The instruments being used were

bull a demographic questionnaire

bull the Watson and Glaser Critical thinking assessment tool (WGCTA) and

bull Confidence in Decision-making Scale

The WGCTA is an 80-item test that yields a total score foran individualrsquos critical thinking ability (Pardue 1987Adams et al 1996) It measures critical thinking as acomposite which includes

a) attitudes of inquiry that involve an ability to recognise the existence of problems and an acceptance of the general need for evidence in support of what is asserted to be true

b) knowledge of the nature of valid inferences abstractions and generalisations in which the weight or accuracy of different kinds of evidence are logically determined and

c) skills in employing and applying the above attitudes and knowledge (Sullivan 1987)

The WGCTA has an established criterion and constructvalidity of 055 and 075 (Pardue 1987) and has been usedin America with nurses in other studies The WGCTAconsists of two alternate forms A and B which can beadministered before and after an intervention and thestability of responses over time on the two forms has acorrelation of 073 (Sullivan 1987)

The lsquoConfidence in decision-making scalersquo measuresperception of confidence in decision-making It was pilottested to determine its face validity which was high Itwas based on a tool used by Rhodes (1985) which hadhigh reliability reported in Rhodes study The statementsin the tool had a Likert scale with a score of 5 indicatinghigh confidence and 0 indicating no confidence

Example of the items on the tool are

lsquoI am confident in deciding what type of bathing tooffer to a patientrsquo

lsquoI am confident in advising patients on healthylifestylesrsquo

lsquoI am confident in prescribing topical pressure areasore treatmentrsquo

The demographic sheet gathered backgroundinformation on participants

Data analysis Questionnaires were collected and the responses

collated using a spreadsheet in the computer programSPSS The SPSS database was used for analysing the data

The data were analysed using

a) Descriptive statistics on the demographic data and raw data from the questionnaires Frequency distributions were made for demographic data obtained as well as for critical thinking ability (WGCTA) scores and confidence in decision-making scores Means and standard deviations were calculated for the WGCTA scores and the confidence scores

b) Critical thinking scores were correlated with confidence in decision-making scores to determine if these two were related

Ethical issuesThe research participants were required to complete

two questionnaires one of which included demographicinformation Participants were not required to identifythemselves by name and have not been identified duringdata analysis or during discussion of the results andconclusions Participants were required to completequestions about their nursing practice that may have hadthe potential to threaten the nursesrsquo perceptions ofthemselves as nurses Full explanation of the purpose ofthe research was given and the researchers were availableto provide information and support as needed

Access to the information collected is restricted to theresearchers and remained confidential Participants wereable to withdraw from the research at any time withoutgiving a reason and no payment was made forparticipation or in compensation for any time lost

Data collected is stored in a locked file at the areahealth service in which the researchers are employed Thedata consists of questionnaires and computer discscontaining the data and final analysis The informationcollected was used for the research only and not for anyother purpose Consent was formally obtained prior tocompletion of the questionnaires

FINDINGS

DemographicsEighty-two new graduates were recruited from the two

hospital sites 61 from the regional hospital and 21 fromthe metropolitan hospital The new graduates representeda total of 11 different universities There were 62 female(75) new graduate nurses and 21 (25) male newgraduate nurses (see table 1) The mean age of the newgraduates was 2405 years with a range of 20-53 years(see table 1) The majority of new graduates were youngbut new graduates encompassed a wide age range of up to53 years

Critical thinking scoresThe mean overall for the critical thinking score was

5023 SD 945 with a range of 32-74 (see table 1) Thetotal possible score was 80 for the critical thinking score

RESEARCH PAPER

10


The mean overall for the confidence in decision-makingscore was 7411 SD 1177 range 32-103 (see table 1)The total score overall was 110 for confidence indecision-making

CorrelationsCorrelations were carried out to examine relationships

between some variables Pearsonrsquos r was used for thosevariables recorded as interval level variables Kendallrsquostau b for those relationships where both variables were atthe ordinal level and Spearmanrsquos Rho for thoserelationships were at least one variable was at the ordinallevel The assumption for using the Pearsonrsquos r that thevariables at interval level are normally distributed wasmet Significance level of 005 was used to accept orreject hypotheses The correlations were analysed as two-tailed correlations as direction of any existingrelationships was unknown

Pearsonrsquos r for the relationship between critical scoreand confidence score

There was a significant weak negative relationship(correlation coefficient -0225 significance 002) (seetable 2) between the score for critical thinking and thescore for confidence in decision-making These tests wereadministered just prior to the new graduates commencingtheir clinical practice

As the score for critical thinking increased the scorefor confidence in decision-making decreased orconversely as the score for confidence in decision-makingincreased the score for critical thinking decreased Thosewho score higher on the critical thinking are lessconfident about being able to make clinical decisions inareas common to nursing before entering the practiceenvironment The hypothesis is rejected

DISCUSSIONThere were some surprising results in the study

namely that critical thinking ability and confidence indecision-making were negatively correlated In contrast toGirot (2000) who found no relationship between criticalthinking and confidence in decision-making and Shin(1998) who found a positive relationship between the twovariables this study had an unexpected finding of a

negative correlation As scores on critical thinkingincreased scores on confidence in decision-makingdecreased Those with higher critical thinking ability wereless confident in decision-making This is an interestingfinding suggesting that those who think more criticallyare more hesitant in clinical decision-making and wouldalso seem to suggest that those with higher scores oncritical thinking ability would be more inclined to spendtime searching for answers to clinical problems Halpern(1996) cited in van der Wal (2000) would seem to supportthis when he states that good critical thinkers aremotivated and willing to check for accuracy to gatherinformation and to persist when a solution is not obviousA good critical thinker takes more time to consider aproblem ask questions and carefully gather informationhence hesitation being prominent as this is accomplishedRuggiero (1998) cited in van der Wal (2000) also echoesthis when he states that critical thinkers review ideasmake a tentative decision then evaluate and refine asituation or belief and thus some hesitation would beexpected in this process

Although confidence in clinical decision-making isconsidered by some to be important in clinical practiceothers have suggested that being overconfident orprejudging in clinical decision-making may in fact bedetrimental as it can lead to poorer clinical outcomes dueto increased error in clinical decision-making Kissinger(1998) describes overconfidence in decision-making andstates that this may negatively affect clinical practice andnursing outcomes adding that overconfidence may in factdetract from nursing judgements and that uncertainty isan unavoidable characteristic of clinical decision-makingThis suggests overconfidence can in fact be dangerous

Paul and Heaslip (1995) outline similar concerns indescribing prejudice or pre judgement in advance ofevidence stating that this leads to flawed modes ofjudging An example of this may occur when nurses cometo conclusions too quickly due to being too confident anda conclusion is reached too soon without enoughinformation leading to poor judgements This phenomenaof being overconfident and reaching decisions too soonwithout enough information is well documented incognitive psychology and is outlined by Plous (1993) whostates that often people tend to be overconfident in theirjudgements He also adds that many studies have shownlittle relation between confidence in decision-making andaccuracy Kissinger (1998) also suggests that those whoare unaware of mental processes and who do not evaluateinferential knowledge critically tend to be overconfidentand to exaggerate the extent of what they know is correct

RESEARCH PAPER

11

Mean SD Range Frequency

Age 2405 577 20-53 -

Male - - - 25

Female - - - 75

Critical score 5023 945 32-74 -

Confidence score 741 1177 32-103

Table 1 Means ranges and frequencies of the demographics

Critical thinkingconfidence -00225 (002)

(decision-making)

Correlation coefficient

Table 2 Correlations of variables in the study


It may be better therefore for nurses to be aware ofknowledge deficits to acknowledge them and to be moredoubtful of their confidence in decision-making Thefindings from this study support the aforementionedpremises that those who think more critically are indeedmore hesitant in decision-making perhaps suggesting thatas they think more deeply about situations they requiremore information before coming to a decision

To become more effective and less overconfident indecision-making Plous (1993) suggests that we stop toconsider reasons why our judgements may be wrong Thisis echoed by Kissinger (1999) who suggests that thosewho are overconfident believe that by asking questionsthey might be looked down on although poor decisionsmay be made when a questioning approach is not madePerhaps what is needed is a much more questioningattitude and a greater willingness to be open to moreinformation gathering Those new graduates who havehigher critical thinking skills and seem more hesitant indecision-making should be encouraged in theirquestioning attitude In summary overconfidence inclinical decision-making may not necessarily be a positiveattribute as there is no evidence to link this with accuracyor quality of decision-making A nursing culture thatencourages an open questioning approach to decision-making in patient care delivery will support safe practiceby all clinicians

LIMITATIONS OF THE STUDYThe study was conducted at two area health services onlyand the results can only be generalised to those areas witha similar make-up The sample used was a conveniencesample and this may also affect the results

RECOMMENDATIONS ANDIMPLICATIONS FOR PRACTICEbull The need for professional development courses that

raise nursesrsquo awareness of the importance of a nursing culture that encourages a more open questioning attitude to decision-making in patient care delivery

bull Further research needs to be done with larger numbers from a more diverse population to test the generalisation of the results obtained in this study

REFERENCESAdams M Whitlow J Stover L and Johnson K 1996 Critical thinking as aneducational outcome An evaluation of current tools of measurement NurseEducator 21(3)23-32

Bandman EL and Bandman B 1995 Critical thinking in nursing (2nd ed)Appleton and Lange Connecticut

Beeken J 1997 The relationship between critical thinking and self-concept instaff nurses and the influence of these characteristics on nursing practiceJournal of Nursing Staff Development 13272-278

Daly WM 1998 Critical thinking as an outcome of nursing education What isit Why is it important to nursing practice Journal of Advanced Nursing28(2)323-331

Girot E 2000 Graduate nurses Critical thinkers or better decision-makersJournal of Advanced Nursing 31288-297

Kissinger JA 1998 Overconfidence A concept analysis Nursing Forum33(2)18-23

Pardue SF 1987 Decision-making skills and critical thinking ability amongassociate degree diploma baccalaureate and mastersrsquo-prepared nurses Journalof Nursing Education 26(9)354-361

Paul RW and Hanslip P 1995 Critical thinking and intuitive nursing practiceJournal of Advanced Nursing 22(1)40-47

Rhodes B 1985 Occupational ideology and clinical decision-making inBritish nursing International Journal of Nursing Studies 22(3)241-251

Plous S 1993 The psychology of judgement and decision-makingPhiladelphia Temple University Press

Seldomridge EA 1997 Faculty and student confidence in their clinicaljudgement Nurse Education 22(5)6-8

Simpson E and Courtney M 2003 Critical thinking in nursing educationLiterature review International Journal of Nursing Practice 8(2)89-98

Shin KR 1998 Critical thinking ability and clinical decision-making skillsamong senior nursing students in associate and baccalaureate programmes inKorea Journal of Advanced Nursing 27414-418

Sullivan EJ 1987 Critical thinking creativity clinical performance andachievement in RN students Nurse Educator 12(2)12-16

Van der Wal A 2000 Critical thinking as a core skill Issues and discussionpaper Newcastle University Notes for discussion seminar May 2000

Watson GB and Glaser EM 1980 WGCTA Watson-Glaser CriticalThinking Appraisal San Antonio Harcourt Brace and Company

RESEARCH PAPER

12


ABSTRACTThe purpose of this study was to explore the

transitional experiences of graduate nurses who hadpreviously trained as enrolled nurses A small surveydesign was utilised to collect data using in-depthinterviews Two themes emerged from the datalsquovalues dissonancersquo and lsquorole adjustmentrsquo Resultsindicate that the transition from student to registerednurse is as stressful and labile for this student cohortas has been reported with regard to graduatetransition generally Industry expectations of thesegraduates must be aligned to their perceptions andabilities Nursing graduates who previously trained asenrolled nurses require the same degree of guidancesupport and understanding afforded other graduatesupon entry into the workforce

INTRODUCTION

Student nurses undertaking their Bachelor of Nursing(BN) who previously qualified as enrolled nurses(ENs) represent a significant cohort within

undergraduate programs both in Australia and overseas(Senate Community Affairs Committee 2002) Themotivation for enrolled nurses to upgrade theirqualification to registered nurse (RN) appears to stemfrom three sources an intrinsic drive for self-development a reaction against the restricted nature ofthe existing EN role and a decline in employmentopportunities (Allan and McLafferty 2001 Parry andCobley 1996) In the United Kingdom for example thegeneral lack of employment opportunities for ENs isexacerbated by the present phasing out of the role withinthe health care and education systems (Francis andHumphreys 1999) In Australia even though the roleremains well supported by both systems the employmentof ENs has declined by over 20 since the late 1980slargely due to the restructuring of aged care services(Shah and Bourke 2001) In addition many universitiesoffer ENS shortened and specifically tailoredundergraduate programs in recognition of their previouseducation (Greenwood 2000a Yates 1997)

Literature reviewIn general it is reported that nursing graduates face a

period of transition (socialisation) where their universityacquired values ideals and expectations are adjusted tomeet the culture and reality of the clinical setting For thenew graduate transition is commonly experienced as aseries of emotional highs and lows where feelings ofstress and anxiety are said to be commonplace (Kelly1996 Maben and Macleod-Clark 1998 Kramer 1974)This role conflict experienced during transition was firstportrayed in the seminal work by Marlene Kramer in the1970s as a period of reality shock and more recently byBridgid Kelly as a process of lsquomoral distressrsquo - it seemsthat the transitional period for many graduate nurses ischaracterised as a time fraught with anxiety and stress(Kelly 1998 Kramer 1974)

Kathleen K Kilstoff RN BA Dip Ed MA (Macq) is LecturerFaculty of Nursing Midwifery and Health University ofTechnology Sydney Australia

Suzanne F Rochester RN RM BA (Macq) MA (Syd) MN(UTS) is Senior Lecturer Faculty of Nursing Midwifery and Health University of Technology Sydney Australia

Accepted for publication August 2003

HITTING THE FLOOR RUNNING TRANSITIONAL EXPERIENCES OF GRADUATESPREVIOUSLY TRAINED AS ENROLLED NURSES

RESEARCH PAPER

Key words graduate nurse role transition reality shock enrolled nurse conversion


Many new graduates feel there has been a lack ofpreparedness in their BN programs for the heavyworkloads shiftwork and managerial responsibilitiesassociated with the role of the RN (Duchscher 2001Chang and Daly 2001 Baillie 1999 Kelly 1998 Mabenand Macleod-Clark 1998 Kramer 1974) This finding isalso confirmed by a more recent Australian study whichfound that during early transition graduates were highlystressed by their lack of understanding of what wasexpected of them in their role (Chang and Hancock 2003)This lack of satisfaction in meeting workloadexpectations and maintaining what they consider to beexcellence in nursing care often leads to feelings of guiltand disillusionment for some graduates (Kelly 1998 delBueno 1995 Ambler 1995 Horsburgh 1989)

Hence for a significant number of newly registerednurses the expectation of a welcoming workplaceenvironment is not always realised One study undertakenin New South Wales Australia reported that many nursegraduates felt unsupported by the employing organisationand their colleagues upon entry to the nursing workforce(Madjar et al 1997) Of major concern is the possibilitythat the personal cost of unsupported adjustment is sohigh that new graduates abandon their profession or losetheir university held values and ideals to the point thatnursing becomes simply technical task driven and largelyunsatisfying (Kelly 1998 Walker 1998)

The onus is on the tertiary sector and industry tounderstand the process of transition more fully to makefurther attempts to improve the continuity betweensectors and to effectively meet new graduatesrsquo needs forpreparation and support (Clare et al 1996 Benner 1984)This would include meeting the special needs ofgraduates who previously trained as ENs

Study aimWhile studies indicate that ENs benefit from

conversion and report positive changes in their nursingknowledge skill acquisition and attitudes towardspractice (Allan and McLafferty 2001 Yates 1997) little isunderstood about how they experience transition The aimof this study was to explore the early workplaceexperiences of new graduates who had originallyqualified as ENs Collecting information about thesegraduates during transition is an important step infacilitating their effective preparation for transition whilstat university and for improving industry receptivity totheir needs on employment

MethodA small survey descriptive design was utilised for this

study (Roberts and Burke 1989 Polit and Hungler 1995Arber 1998) Semi-structured in-depth telephoneinterviews were conducted with each of the participants(Polit and Hungler 1995) In-depth interviews as suchcan be used to augment existing understandings about

nursesrsquo transitional experiences (Kvale 1996 StreubertSpeziale and Carpenter 2003) Each participant in thisstudy was interviewed following approximately three tofour months employment as an RN in a majormetropolitan hospital The reason for this time interval isthat it is generally agreed that after this length ofexperience nursing graduates are able to critically reflectand report on the process of transition (Kramer 1974Kilstoff 1993 Godinez et al 1999 Greenwood 2000b)

Participants in the study consisted of four male andtwo female BN graduates who had previously qualified asENs All participants were aged between 23 to 27 yearsand were experienced ENs with two to three years ofclinical practice at this level The graduate nursessurveyed came from the same university at which theresearchers were employed and as such provided anlsquoopportunity grouprsquo for selection and study Theparticipants were recruited to the study just prior tocompleting their BN Ethics approval was received fromthe tertiary institution where the participants wereenrolled and where the researchers were employedWritten consent was collected from participants prior tothe interview sessions

Participants were interviewed using a questionnairedeveloped for an earlier study on transition that was foundto be valid and reliable (Kilstoff 1993) The questionnairecontained 52 items in six categories each of whichfocused on the experience of nursing role transition Thelength of interview for each participant varied from one totwo hours

DATA ANALYSISContent analysis of the transcriptions was conducted

initially by the use of a general review of the data in orderto locate patterns or themes in the text of each interview(Baxter Eyles and Willms 1992) The interviews werethen coded according to these themes using the NVivosoftware analysis program for qualitative data (Richards1999) The coding process allowed for frequencies andpatterns to be observed and analysed All graduates wereallocated an identification number consisting of twosections for example 112 where the number 1 indicatedthe participant and the number 12 indicated the line in thetranscript from which the quote was taken

Findings and discussionTwo major themes emerged from the data namely

lsquovalues dissonancersquo and lsquorole adjustmentrsquoInterestingly despite the previous workplace exposureof these graduates in an aligned nursing role thesethemes closely mirror findings from other studies ontransition (Duchscher 2001 Chang and Daly 2001Baillie 1999 Kelly 1998 Maben and Macleod-Clark1998 Kramer 1974)

RESEARCH PAPER

14


Values dissonanceFollowing their employment as RNs the graduates in

this study realised that the value system operating in theworkplace differed from their own This value system hadto do with completing a set routine of tasks within acertain time frame and managing a busy workloadGraduates reported that this often prevented them fromcarrying out individualised patient care according to theholistic nursing principles they had internalised atuniversity

the biggest problem the university taught mehellip theytaught me a perfect world for nursing and of course now Iwork in an imperfect worldhellip I just know the ideal way Ishould be working and I canrsquot because of the health caresystemhellip it frustrates me every day Thatrsquos what frustratesme every day because I donrsquot have time to treat mypatients holistically (424)

Initially these graduates expected to have enough timeto care for their patientsrsquo total needs and spend qualitytime with their patients This preconception may havebeen strengthened by the graduatesrsquo enrolled and studentnursing experiences where increased time for patientcontact is the norm

hellipI had a lot more time for spending with a patientWhile I was a student I didnrsquot have eight patients I neededto do everything for in eight hours When I was a student Ihad one or two patients and I could spend some qualitytime with them (178)

Itrsquos not the same as when I worked as an enrollednurse even though I was often busy I felt I still was ableto have more time with my patients (585)

Not being able to spend enough time with theirpatients or organise their work autonomously emerged asa major source of dissatisfaction and distress forrespondents Many times graduates voiced theirfrustration at not being able to provide the level ofpractice they felt their patients required

hellipLike the other day I was talking to a mother givingher a bit of counselling right and I was told not to do itas it was the social workerrsquos job The nurse told me thatwe have social workers to talk to the mothers Like I wasthe only one there at the time and there were no socialworkers aroundhellip (559)

A clash of values eventually occurred that ledgraduates to feel they did not match up to their personalideals of what an RN should be Nor did they feel theymeasured up to the expectations of their colleagues Inother words they were dissatisfied with themselves andfelt their colleagues were also dissatisfied with themFurthermore the graduates seemed confused about whatwas expected of them and suffered similarly to othergraduates - the stress associated with role ambiguity(Chang and Hancock 2003) They often mentioned

feeling different to the other nurses on the ward and notfeeling like part of the team

For me itrsquos difficult Even though I have been anenrolled nurse itrsquos still a hard transition You still feel as ifyou are a student and you feel inadequate still (411)

I miss spending that time and sitting down and talkingwith them but you still try and fit in try to be part of theteamhellip (1178)

Knowledge of the inadequacies of the present hospitalsystem did not prevent graduates from feeling they werepersonally responsible for their inability to provideholistic care They felt they were letting their patientsdown and were expecting far wider recognition by othernursing staff of the importance of emotional support forpatients It seemed to surprise the graduates thatcommunication with their patients was not givenprecedence in the workplace

hellipI donrsquot have enough time to deal with my patientswho are crying I donrsquot have enough time to hold mypatientsrsquo hands I donrsquot have the resources to get mypatients help Thatrsquos the most frustratinghellip (423)

hellipThe politics mainly budgeting as people always turnaround and say you shouldnrsquot use that because it costs toomuch Well hang on a second you should use thatbecause it is better for the patienthellip (242)

Graduates who were ENs were just as unprepared forthe inflexibility of the hospital system as other graduates(Chang and Hancock 2003 Duchscher 2001 Chang andDaly 2001 Baillie 1999 Maben and Macleod-Clark1998 Kramer 1974) They had believed they would beable to organise and plan their work autonomously aroundpatient needs and their work could be more individuallyorganised (Chang and Hancock 2003 Duchscher 2001Chang and Daly 2001) However the reality was that theyhad to complete most aspects of their work within apredetermined routine and little time was left forproviding the level of nursing care they thought wasimportant (Kelly 1998) Despite considerable exposure asENs to the contemporary health care environmentfeelings of disillusionment were evident Graduatesrealised the values they had developed while ENs andover the course of their university studies regarding theRNs role were not consistent with workplace norms andrequired a period of adjustment

Role adjustment It would seem that before transition these graduates

generally held a superficial understanding of the role ofthe RN They largely saw the acquisition of the role asadding skills to their existing EN repertoire rather than arole change These notions may have contributed to amore difficult transition for these graduates particularly inrelation to providing the broad range of prioritised clinicalactivities that are required of the RN (Australian NursingCouncil 2000) Trying to complete the routine tasks of the

RESEARCH PAPER

15


hospital RN role left these graduates feeling stressedstretched and fatigued

What compounded their difficulties was that most of thegraduates were allocated a high number of patients eachshift and five out of the six graduates felt this was too heavya responsibility for them to carry as relatively inexperiencedRNs Prior to transition these nurses had believed theirearlier qualification as ENs would benefit them duringtransition in carrying out the basic responsibilities of an RNThey felt they would be able to carry out their role like theother members of the nursing team However even withtheir previous nursing background four of the six graduatesexperienced stress and role conflict in adapting to the RNrole during transition

hellipBut suddenly having the responsibility of 12 peoplersquoslives or 14 peoplersquos lives in your hands hellip (411)

Well Irsquom dissatisfied in part with the workloadhellip Insome ways being an enrolled nurse made it easier and insome ways it made it harder to adjust It did because meand another enrolled nurse we just said to each otherthat we wanted to go back to the enrolled nurse role Itrsquosso much easier We werenrsquot tired at the end of our shift wedidnrsquot have all this responsibility and we could actuallywalk around and look fluffy (448)

hellipI was put in charge of a night duty once I had to donight duty and there was me and only an agency nursehellipEven though you are an enrolled nursehellip (322)

One graduate found that the only way to manage thehigh number of patients in the busy ward environmentwas to provide a lower standard of care This createdfurther disillusionment with aspects of the RN role as thegraduate recognised that he was not practising inaccordance with the national competency standards forRNs (Australian Nursing Council 2000) that wereemphasised continuously during his university education

hellipYou really have to do it Itrsquos a huge workloadphysically and mentally but you have got to learn how tocope with it Well thatrsquos the problem What you have gotto do is you have got to turn around and you have got tofind short cuts for yourself that you feel comfortable withThe only way is surviving some shortcuts you do and youthink okay Irsquom happy doing that shortcut other shortcutsyou wonrsquot do and you think well okay Irsquom not doing thatshortcut Thatrsquos fine and Irsquoll live with the consequences ofthathelliptherersquos no time with staffing levels so low no timeon the ward to help any one else outhellip its hard work nopay and no rewardshellip (46-8)

Workload and coping difficulties were compounded bythe level of tiredness experienced by four of the six newgraduates as they tried to cope with the requirements oftheir hospital work role Problems adjusting to shift workoccurred even though graduates had previously worked arotating roster in the final semester of their BN

hellipShift work is horrible I think just doing the shiftwork itrsquos harder to socialise with your friends out of

work and working weekends Thatrsquos the only thing - tofinish work late at night and be back at work by earlymorninghellip itrsquos tryinghellip (32)

hellipFor the first three months most people in my grouphad what we call lsquonew grad sleepsrsquo New grad sleeps - thatmeans no life for three months you have to come home andhave a sleep before you do anything else and you are justtotally exhausted the whole three months basically Itrsquos ahuge steep learning curve for a lot of ushellip (417)

All respondents in this study found the working role ofan RN quite complex broad and more mentally andphysically trying than they had anticipated Like othernew graduates these beginning practitioners reported alack of preparedness for the workload shiftworkteamwork and managerial responsibilities associated withthe role of the RN (Commonwealth Department ofEducation Science and Training 2001 Baillie 1999 Kelly1998 Clare et al 1996 Moorehouse 1992 Horsburgh1989) The responsibility associated with being an RNand the fact that for the first time there was often no oneto turn to appeared to be a major role adjustment

LIMITATIONS OF THE STUDYGeneralisation of this studyrsquos results will depend upon

the correspondence between the experience of theseparticular nursing graduates from one BN program andbeginning RNs with other nursing experiences That isthe interpretation of the findings should be undertaken inrelation to the specific context in which the data wascollected The small size of the sample may also decreasegeneralisation

CONCLUSIONIn general the nursing literature describes transition as

a series of highs and lows where graduatescharacteristically experience periods of anxiety and stress(Kilstoff and Rochester 2001) It would appear from thisstudy that transition is no smoother for graduates who hadpreviously trained as ENs The benefits of clinicaldexterity and familiarity that these graduates previouslypossessed as ENs were undermined by a superficial andincomplete understanding of the breadth of their new roleLikewise other studies have demonstrated that graduatevariables such as employment history age and previousnursing experience appear to make little impact onrelieving the stressful nature of transition (Dixon 1996Dufault 1990 Oechsle and Landry 1987) Dixon (1996)goes even further by suggesting that the negative aspectsof transition may be amplified by these variables and thatthey should attract greater research attention

In light of the findings from this study intuitivenotions that graduates who previously trained as ENs are more prepared than other graduates to adopt the role of the RN need to be reassessed These graduates should not be considered lsquostreetwisersquo or able

RESEARCH PAPER

16


to lsquohit the floor runningrsquo (Greenwood 2000a)Furthermore misconceptions of this kind are likely to becompounded in times of acute nursing shortages whichhave resulted in declining working conditions andincreased workloads for all nurses (Chang and Daly 2001Walker 1998) Industry expectations of graduates whowere trained as ENs need to be aligned to theirperceptions and abilities and recognition needs to begiven to the unique aspects of their transition Thesegraduates require the same degree of guidance supportand understanding afforded any other nursing graduateentering the health care sector

REFERENCESAllan J and McLaffetty I 2001 The perceived benefits of the enrolled nurseconversion course on professional and academic advancement NurseEducation Today 21118-126

Ambler N 1995 The beginning practitioner 1st year RN adaptation to theworkplace Paper read at Conference Proceedings Research for Practice atNewcastle University

Arber S 1998 The research process In Gilbert N (ed) Researching sociallife Thousand Oaks Sage Publishing

Australian Nursing Council Inc 2000 ANCI national competencies standardsfor the registered and the enrolled nurse ACT Australian Nursing Council Inc

Baillie L 1999 Preparing adult branch students for their management role asstaff nurses An action research project Journal of Advanced NursingManagement 7225-234

Baxter J Eyles J and Willms D 1992 The Hagersville tire fire Interpretingrisk through a qualitative research design Qualitative Health Research2(2)208-237

Benner P 1984 From novice to expert Menlo Park California Addison-Wesley Publishing Company

Chang E and Daly J 2001 Managing the transition from student to graduatenurse Transitions in nursing Sydney Maclennan and Petty

Chang E and Hancock K 2003 Role stress and role ambiguity in new nursinggraduates in Australia Nursing and Health Sciences 5155-163

Clare J Longson D Glover P Schubert S and Hofmeyer A 1996 Fromuniversity student to registered nurse The perennial enigma ContemporaryNurse 5(4)169-175

Commonwealth Department of Education Science and Training 2001 NationalReview of Nursing Education Our duty of care ACT Commonwealth ofAustralia

del Bueno D 1995 Ready willing able Staff competence in workplacedesign Journal of Nursing Administration 2214-16

Dixon A 1996 Critical case studies as voice The difference in practicebetween enrolled and registered nurses Adelaide School of Nursing Facultyof Health Science Flinders University of South Australia

Duchscher J 2001 Out in the real world Newly graduated nurses in acute-carespeak out Journal of Nursing Administration 31(9)426-439

Dufault M 1990 Personal and work milieu resources as variables associatedwith role mastery in the novice nurse Journal of Continuing Education inNursing 21(2)73-78

Francis B and Humphreys J 1999 Enrolled nurses and the professionalisationof nursing A comparison of nurse education and skill-mix in Australia and theUK International Journal of Nursing Studies 36(2)127-35

Greenwood J 2000a Articulation of pre-registration nursing courses inWestern Sydney Nurse Education Today 20189-198

Greenwood J 2000b Critiques of the graduate nurse An internationalperspective Nurse Education Today 2017-23

Godinez G Schweiger J Gruver J and Ryan P 1999 Role transition fromgraduate to staff nurse A qualitative analysis Journal for Nurses in StaffDevelopment 13(3)97-110

Horsburgh M 1989 Graduate nursesrsquo adjustment to initial employmentNatural field work Journal of Advanced Nursing 14610-617

Kelly B 1996 Hospital nursing lsquoItrsquos a battlersquo A follow-up study of Englishgraduate nurses Journal of Advanced Nursing 241063-1069

Kelly B 1998 Preserving moral integrity A follow-up study with newgraduate nurses Journal of Advanced Nursing 281134-45

Kilstoff K 1993 Evaluation of the process of transition from college student tobeginning nurse practitioner Masters Thesis School of Education MacquarieSydney

Kilstoff K and Rochester S 2001 Preparing for role transition In Chang Eand Daly J (eds) Transitions in nursing Sydney Maclennan and Petty

Kvale S 1996 An introduction to qualitative research interviewing ThousandOaks Sage Publishing

Kramer M 1974 Reality shock Saint Louis The CV Mosby Company

Mabon J and Macleod-Clark J 1998 Project 2000 diplomatesrsquo perceptions oftheir experiences of transition from student to staff nurse Journal of ClinicalNursing 7(2)145-153

Madjar I McMillan M Sharkey R and Cadd A 1997 Report of the projectto review and examine expectations of beginning registered nurses in theworkforce Sydney Nurses Registration Board of New South Wales

Moorehouse C 1992 Registered nurse 1st years of practice Melbourne LaTrobe University Press

Oechsle L and Landry R 1987 Congruity between role expectations andactual work experiences A study of recently employed registered nursesWestern Journal of Nursing Research 9(4)555-571

Parry R and Cobley R 1996 How enrolled nurses feel about conversionNursing Times 92(38)44-6

Polit D and Hungler B 1995 Nursing research Philadelphia JB LippincottCo

Richards L 1999 Using NVivo in qualitative research Thousand OaksCalifornia SAGE Publications

Roberts C and Burke S 1989 Nursing research A quantitative andqualitative approach Boston Jones and Bartlett Publishers

Shah C and Bourke 2001 Job growth and replacement needs in nursingoccupations Report 0118 to the Evaluations and Investigations ProgrammeHigher Education Division Canberra ACT Department of Education Scienceand Training

Streubert Speziale H and Carperter D 2003 Qualitative research in nursing(3rd ed) New York Lippincott Williams and Wilkins

Walker W 1998 The transition to registered nurse The experience of a groupof New Zealand graduates Nursing Praxis in New Zealand 13(2)36-43

Yates M 1997 From enrolled nurse to registered nurse Enrolled nurses accessBachelor of Nursing programs The Lamp 54(7)33

RESEARCH PAPER

17


ABSTRACT

Aim To explore the relationship between the spiritual

experience and the physical well-being of patientsfollowing coronary bypass surgery

Method The design of the study was cross-sectional The

dependent variables were the patientsrsquo spiritualexperiences and their physical well-being Theindependent variables were gender age and previousmyocardial infarction

Results A significant gender difference was found both for

physical well-being and for spiritual experience

Conclusion The results of this study demonstrate an

interrelationship between spiritual and physicaldimensions of illness and gender

INTRODUCTION

Coronary heart disease (CHD) remains a majorcause of morbidity in western society In Finlandmany people suffer from CHD which is markedly

more common in men than in women (Lukkarinen andHentinen 1998)

Although there is an ever-increasing array ofinterventions designed to ease the symptoms of CHD andevade mortality (Mortasawi et al 2000) there is someevidence to suggest that there is increased risk of deathfollowing myocardial infarction (MI) in patients withdepressive symptoms (Baker et al 2001) According toFrasure-Smith and Lesperance (2003) there is consistentevidence that symptoms of depression are a predictor ofmortality following MI It is acknowledged that there is aspiritual dimension to illness and that depression may bean indicator of spiritual distress The study reported inthis paper sought to examine the interrelationships amonggender age and spiritual experiences of patients who hadundergone cardiac surgery in order to inform nursingpractice

REVIEW OF LITERATUREThe diagnosis of severe CHD warranting major heart

surgery is regarded as serious by patients because theheart is in many cultures considered the bodyrsquos centralorgan and the source of both life and emotion Patientssuffering from CHD fear lsquosomethingrsquo (Silva andDamasceno 1999) When a patient undergoes coronaryartery bypass graft (CABG) surgery the focus of staff isoften the technical dimensions of the procedure and theprocesses involved in care delivery The lsquohumandimensionrsquo or lsquopatient perspectiversquo may be overlooked(Lindsay et al 2000) This is also apparent where there is

Maj-Britt Raringholm RN PhD Head of Degree Program inNursing Vasa Central Hospital and Tampere UniversityHospital Department of Caring Science Vasa Finland

Katie Eriksson RN Director of Nursing and Professor HelsinkiUniversity Hospital Department of Caring Science VasaFinland

Lisbet Lindholm RN PhD Lecturer Department of CaringScience Faculty of Social and Caring Science Vasa Finland

Nina Santavirta PhD Docent Lecturer Department ofEducation University of Helsinki Finland

Accepted for publication December 2003

ACKNOWLEDGEMENTThis study received a research grant from the Medical Research Fund ofTampere (Finland) University Hospital and from the Medical Research Fundof Vasa (Finland) Central Hospital District

PERSPECTIVES OF CORONARY BYPASS SURGERY IN TERMS OF GENDERAGE PREVIOUS MYOCARDIAL INFARCTION AND SPIRITUALITY

RESEARCH PAPER

Key words caring health spirituality coronary surgery


fragmentation of health service delivery which results inchronically ill people (such as those with CHD)consulting many specialists who often fail to take aholistic view of their problems (Jonsdoacutettir 2001)

Despite a slower rate of physical recovery Conaway etal (2003) found that older patients derived similar healthstatus benefits from CABG when compared with youngerpatients In one study depression was more evidentamong younger patients (Haumlmaumllaumlinen et al 1998)Although older patients may require more medicalsupport younger CABG recipients may need morespiritual support because of the impact of having a life-threatening disease at an earlier age (Haumlmaumllaumlinen et al1998) In addition older patients are more prone thanyounger ones to ischemic cardiac disease and tend toexperience worse outcomes Perioperative CABGmortality is three to seven times higher in elderly patients(MacDonald et al 2000) According to Herlitz et al(2000) the relief of symptoms and improvement inphysical activity is not associated with age whereasimprovement in other aspects of health-related quality oflife is less marked in older people

The quality of life experienced by older people afterCABG surgery has not been well studied and whenstudied it has usually been with retrospective designssmall samples and a variety of quality-of-lifequestionnaires (MacDonald et al 2000) In addition olderpatients are more prone to ischaemic cardiac disease andperioperative CABG mortality is three to seven timeshigher (Gersh et al 1983)

Studies of post-operative CABG recovery haveindicated there are gender differences in response to thesurgery Literature focusing on women having CABGappeared in the medical literature during the late 1970sand did not emerge in the nursing literature until the late1980s (King and Paul 1996) There have been a numberof studies addressing womenrsquos perspectives of sufferingfrom CHD andor experiencing CABG (Rosenfeld andGilkeson 2000 Edeacutell-Gustafsson and Hetta 2001DiMattio and Tulman 2003) Researchers have focused ongender differences with CHD in relation to evaluationdiagnosis treatment recovery activity levelsrehabilitation and psychosocial factors

For example women are more likely than men tocontact a family member when experiencing symptomsand are also more likely than men to experience post-operative depression (Horsten et al 2000 Lerner 2000)As domestic responsibilities are a source of concern forrecovering women they may return to high-demandactivities sooner than is advisable Some studies reportpost CABG rehabilitation program uptake andcompliance and significantly higher drop-out ratesamong women (Salmon 2001) In contrast other studiesfocusing on gender differences in cardiac surgeryrecovery indicate fewer differences between men andwomen (King 2000)

Pain anxiety and uncertainty appear to be key featuresof a patientrsquos response to heart disease When and if apatient thinks about the meaning and purpose of theillness it is because the experience has imposed a captivestate that moves the subjective gaze to the ontological(Lidell et al 1997 Kendrick 2000) Inviting patients toshare their stories including their spiritual experienceshas allowed them to reclaim their right to talk about theirown experiences and to reclaim a voice over and againstthe medical voice and a life beyond illness (Frank 1994)

In Leacutevinasrsquo (1988) vision the human being is not alsquocasersquo to be measured documented and quantified but anlsquoinfinityrsquo In patientsrsquo stories about the reality of carethere are also references to an ontological reality of thepatient having CABG beyond plain words describableonly in metaphorical terms (Sivonen 2000)

A study by LaCharity (1999) indicated that thespirituality of younger women with CHD includedreligious faith as well as inner personal strengthParticipants held positive attitudes focusing on thegoodness of life while admitting limitations imposed bytheir illness King and Jensen (1994) identified the themelsquofear of deathrsquo as a primary component of womenrsquoswaiting period for surgery Fleury et al (1995 p477)define womenrsquos survival from a cardiac event such as MICABG or angioplasty as a time of lsquointense feelings ofinner chaos isolation and a need to critically examinepreviously held values and beliefsrsquo The life-deathdichotomy that is apparent in the experiences of thesewomenrsquos spirituality can be interpreted as the unifyingforce that shapes and gives meaning to the pattern ofonersquos self-becoming (Burkhardt 1994)

Spirituality including religious faith as well as innerpersonal strength allows patients to think positivelyfocusing on the goodness of life while admittinglimitations imposed by their illness (Vande Creek et al1999 LaCharity 1999) The spiritual dimension touchesthe deepest human level the world of being which isbeyond words (Sivonen 2000) The concept of spiritualitydoes appear to be resistant to language (Wright 1997Byrne 2002) The language of spirituality provides a wayof talking about meaning and purpose and about theeffects this life-long search has on people

There is increasing recognition of the relevance of thespiritual dimension to illness evidenced by the increasein published articles about spirituality and its relevance tonursing and health (Woods 1994 p35) Several authors(McSherry 2000 Swinton 2000) state that spiritual care isnot an added extra rather an essential part of care Thereis also a potential for the spiritual dimension to emerge asa health category of its own distinct from psychosocialemotional and biophysical categories (Sivonen 2000)

Even if a human being is seen as an entity of bodysoul and spirit the spiritual dimension emerges as acategory of its own distinct from psychosocial emotionaland biophysical categories (Sivonen 2000) There is a

RESEARCH PAPER

19


health improving potential in the spiritual dimension butthis potential is often not identified nor capitalised uponOn the one hand no words are found to describe it Onthe other it is considered to be a taboo (Sivonen 2000)Patients with CHD and post CABG get an awareness ofthe tragic a deep awareness of human pain suffering anddeath and that life has a value These experiences are verydifficult to explain in words (Raringholm 2003)

It is argued that the area of spiritual assessment needscareful consideration both nationally and internationallyby those professionals involved in the provision ofspiritual care so that potential dilemmas of spirit can beidentified and addressed (McSherry and Ross 2002) Asnurses spend more time with patients than most (Emdon1997) they have opportunity to engage with the spiritualdimension of the patient and speak the language ofspirituality However many nurses say they lack the timeconfidence and comfort to explore these issues with theirpatients (Kristeller et al 1999) In a descriptive survey inwhich he examined nursesrsquo perceptions of spirituality andspiritual care McSherry (1998) discovered that whilethere is an increasing importance placed on holism inhealth care there is a dichotomy in that nurses receivelittle or no theoretical grounding in the spiritualdimension The subject of spirituality is not stronglyevident in medical or nursing curricula nor in the trainingand development of staff In order for spirituality to beincorporated in nursing and caring it must be articulatedin relation to the spiritual dimension of the patient as a person

DESCRIPTION OF THE STUDY The design of the study was a cross-sectional survey

The research questions were

bull What was the strength of patientsrsquo spiritual experiencesfollowing CABG

bull Was spiritual experience and physical well-being relatedto gender age and having a previous MI

bull Was there a relationship between spiritual experienceand physical well being

The dependent variables in the study were the patientsrsquospiritual experiences and their physical well being whilstthe independent variables are gender age and previous MI

The research questions were addressed through thedevelopment of a questionnaire guided by the results ofan earlier study (Raringholm and Lindholm 1999) and aliterature review In order to measure spiritual experienceand physical well being a set of questions wasconstructed These items included assessing spiritualexperiences (meaninglessness loneliness uncertaintyabout the future fear of death sorrow freedom anddesire) and seven items measuring physical well-being(chest pain during exertion chest pain limiting daily

living out of breath out of breath during exertionpalpitation weakness and sleep disturbances) Responsecategories were presented on a five-level timedimensional scale lsquoneverrsquo lsquosometimesrsquo lsquoquite oftenrsquolsquooftenrsquo and lsquocontinuouslyrsquo the lower level represented amore favourable outcome

A pilot questionnaire was distributed among a group ofseven in-patients who had undergone CABG duringOctober 1998 Minor adjustments were needed to thefinal survey For example reconciliation a conceptrevealed as difficult to understand was left out of the finalquestionnaire which included five demographic questions

The study sample was drawn from all patients at onecentral hospital in western Finland who had undergoneCABG between 1994 and 1997 Questionnaires wereposted to all of them (n=832) The contact details ofpatients were taken from the hospital register Thequestionnaire was coded and sent to the participantsrsquohomes with a covering letter The data were collected overa short period of four to five weeks and no comparisonswere made according to year of surgery No reminderletters were sent

Five men and four women were reported as deceasedA number of patients completed and returned thequestionnaire with a response rate of 678 Anadditional 15 patients were identified who had undergonetheir bypass operation in 1998 These 15 patients alsocompleted and returned the questionnaire resulting in afinal sample size of 564 participants

Participants were informed that involvement wasentirely voluntary They were assured of strict anonymityaccording to the ethical guidelines of the NorthernNurses Federation (1995) and as approved by thehospital committee

Data analysis consisted of univariate analyses testingof hypotheses and multivariate analysis Frequencies andpercentages were presented for nominal data whilst themean median and range were used to describe data onordinal and interval levels All variables were tested fornormality by the Kolmogorov-Smirnov Goodness of FitTest (Munro 2001) For skewed variables nonparametricmethods for testing of hypotheses were applied (Mann-Whitney and Kruskal-Wallis test) The correlationbetween the variables was tested by Spearmanrsquos rankcorrelation coefficient Construct validity of the scalemeasuring spiritual experiences and physical well-beingwas evaluated through application of PrincipalComponent Analysis To determine the potential numberof factors extracted from the data Kaiserrsquos criteria andCattellrsquos Scree Test were applied The rotation methodwas Varimax In interpreting the rotated factor pattern anitem was said to load on a given factor if the loading was040 or greater The reliability of the scales found wastested by Cronbachrsquos alpha Statistical significance wasaccepted if plt005

RESEARCH PAPER

20


The extent of the missing data (non-responses) of eachitem was freedom 211 desire 142 sorrow 137chest pain limiting daily living 133 out of breath 128meaninglessness 124 palpitation 119 uncertaintyabout future 115 loneliness 112 fear of death 108weakness 101 out of breath during exertion 90 chestpain during exertion 78 and sleep disturbances 43These missing data were coded zero (0)

Study limitationsMany of the informants were older people who

expressed difficulties in completing the questionnaireParticularly the terms lsquofreedomrsquo and lsquodesirersquo were felt tobe difficult theoretical concepts which perhaps belong tothe language of professionals The scale items assessingspiritual experience (eight items) were perhaps toogeneral A longitudinal design would have provided moreopportunity to compare for example the four different agegroups Socio-economic status and education in relationto gender and age and how these factors influence thepatientsrsquo physical well-being and spiritual experienceafter CABG were not investigated Overall this studyfrom one site provides scope for more research involvingin-depth interviews and follow-up on some of the issueswhich could benefit from further exploration

RESULTSOf the participants there were 439 (78) male and

125 (22) female patients The mean age was 67 years(range 34-86 years) The participantsrsquo ages were classifiedinto four groups young (34-54 years) middle aged (55-64 years) retired (65-74 years) and seniors (75-86years) Out of the total sample 47 had a previousinfarction while 53 had not

Two factors emerged as a result of the PrincipalComponent Analysis and explained 49 of the variancein the data set According to Kaiserrsquos Criteria threefactors had an eigenvalue gt100 but Cattellrsquos Scree testallowed for testing a two-factor solution

When a two-factor solution was applied the itemswere grouped into two dimensions with the itemsmeasuring spiritual experience loading into Factor Oneand items measuring physical well being loading intoFactor Two

The item lsquosleep disturbancesrsquo was thought to indicatephysical well-being but loaded significantly to FactorOne The items were summarised to sum variables andCronbachrsquos alpha for the scales was =077 for spiritualexperience and for physical well-being =082 The scaleswere significantly skewed (plt00005) The median valuefor the spiritual experience was md=19 (range 1-5) andfor physical well being md=17 (range 1-5) indicatingspiritual experience and physical well-being as good

A significant gender difference was found both forphysical well-being and for spiritual experience The age

groups differed significantly regarding physical well-being but regarding spiritual experience no significantdifferences were found between age groups Consideringwhether a previous MI was related to spiritual andorphysical well being we found a significant differencebetween those who had experienced a previous infarctionand those who had not However in regard to spiritualexperience no significant differences between the twogroups were found

The interaction between the dimensions of spiritualexperience and physical well being was highly significant(r=046 plt00005) indicating a high value for spiritualexperience giving a high value in physical well being andvice versa

IMPLICATIONS FOR NURSINGIn 1990 62 of patients undergoing cardiac surgery

in Finland were over 70 years of age and in 1999 thenumber had increased to 172 Although older patientsmay require more medical support younger CABGrecipients may need more spiritual support because of theimpact of having a life-threatening disease at an earlierage (Haumlmaumllaumlinen et al 1998) In addition older patientsare more prone than younger ones to ischemic cardiacdisease and tend to experience worse outcomes Peri-operative CABG mortality is three to seven times higherin older patients (MacDonald et al 2000) According toHerlitz et al (2000) the relief of symptoms andimprovement in physical activity is not associated withage whereas improvement in other aspects of health-related quality of life is less marked in older people

A significant gender difference was found in this studyboth for physical well-being (plt00005) and for spiritualexperience (plt005)

The results of this study demonstrate aninterrelationship between the spiritual and the physicaldimensions of recovery post CABG The spiritualexperience did not differ significantly between the agegroups The interaction between the dimensions ofspiritual experience and physical well-being was highlysignificant (r=046 p=00005) indicating a high value forspiritual experience giving a high value in physical well-being and vice-versa

The patientrsquos frame of experience may focus upon thefrightening nature of pain sensations lack of control overthe body and these experiences and a symbolic link withdeath With such divergent frames of experience theclinician may ignore the patientrsquos fear and anxiety (Jairath1999) Because we are dependent on metaphor andrhetoric to define our meanings and ultimately ourspirituality it is necessary to radically change themetaphors governing nursing practice One needs to asklsquoIs there a language of spirituality or is spiritual careessentially an unspoken attitude to care expected by

RESEARCH PAPER

21


patientsrsquo as suggested by the Health ServiceCommissioner for England Scotland and Wales (1995)

McSherry (2000) and Swinton (2000) state thatspiritual care is not an added extra rather an essential partof care The subject of spirituality is not strongly evidentin medical or nursing curricula nor in the training anddevelopment of staff In order for spirituality to beincorporated in nursing and caring it must be articulatedin relation to the spiritual dimension of the patient as aperson Spirituality is experienced by everyone butremains beyond the measurements of technology Anadaptation of the caregiverrsquos own attitude to spiritualitypresupposes education and guidance by teachers studentsand professional caregivers (Sivonen 2000)

Fry (1997) lists the necessary skills for deliveringspiritual care as including lsquoactive listening attentivenessand genuinenessrsquo Price et al (1995) have devised anagenda to enable spiritual care to become a part of nursingpractice

1 The nursing profession must define spiritual well-being

2 Nurse educators must show students how to add aspiritual dimension to the care they provide and

3 Every nurse must recognise the obligation to develop anepistemology of spirituality that can help improve thedelivery of care

The findings of this study validate this agenda

CONCLUSIONSpirituality is experienced by everyone but remains

beyond measurement by technology An adaptation of thecaregiverrsquos own attitude to spirituality presupposeseducation and guidance by teachers students andprofessional caregivers (Sivonen 2000) The nurse needsto tune in and listen to his or her own spirituality intuitionand awareness in order to develop what Wright andSayre-Adams (2000) call the lsquoright relationshiprsquo Whenour thinking as nurses is underpinned entirely by thescientifictechnological criteria everything including thespiritual dimension itself can be measured andcalculated Calculation and results become the lsquoframersquothrough which the world is viewed Within thisframework nurses may fail to acknowledge that theywitness suffering and as a consequence fail to respondmeaningfully to patientsrsquo needs

REFERENCESBaker RA Andrew MJ Schrader G and Knight JL 2001 Preoperativedepression and mortality in coronary artery bypass surgery Preliminaryfindings Australian and New Zealand Journal of Surgery 71 139-142

Burkhardt MA 1989 Spirituality An analysis of the concept HolisticNursing Practice 3(3)69-77

Burkhardt MA 1994 Becoming and connecting Elements of spirituality forwomen Holistic Nursing Practice 8(4)12-21

Byrne M 2002 Spirituality in palliative care What language do we needInternational Journal of Palliative Nursing 867-74

Conaway GG House J Bandt K Hayden L Borkon AM and SpertusJA 2003 The elderly Health status benefits and recovery of function one yearafter coronary artery bypass surgery Journal of American CollaborationCardiologists 151421-26

DiMattio MJ and Tulman T 2003 A longitudinal study of functional statusand correlates following coronary artery bypass graft surgery in womenNursing Research 52(2)98-107

Edeacutell-Gustafsson U and Hetta J 2001 Fragmented sleep and tiredness inmales and females one year after percutaneous transluminal angioplasty(PTCA) Journal of Advanced Nursing 34(2)203-211

Emdon T 1997 Cry freedom Nursing Times 9335-36

Fleury J Kimbrell L and Kruszewski MA 1995 Life after a cardiac eventWomenrsquos experience in healing Heart and Lung 24(6)474-482

Frasure-Smith N and Lesperance F 2003 Depression and other psychologicalrisks following myocardial infarction Archives of General Psychiatry60(6)627-636

Frank AW 1994 Interrupted stories interrupted lives Second Opinion20(2)11-18

Fry A 1997 Spirituality Connectedness through being and doing InRonalson S (ed) Spirituality The heart of nursing Melbourne AusmedPublications

Gersh BJ Kronmal RA Schaff HV Frye RL Ryan TJ and MyersWO 1983 Long term (five year) results of coronary bypass surgery in patients65 years old or older A report from the coronary artery surgery studyCirculation 68190-199

Haumlmaumllaumlinen H Smith R Puukka P Lind J Kallio V Kuttila K andRoumlnnemaa T 1998 Social support and physical and psychological recoveryone year after myocardial infarction or coronary artery bypass surgeryScandinavian Journal of Public Health 2862-70

Health Service Commissioner for England Scotland and Wales 1995 AnnualReport Scotland HMSO

Herlitz J Wiklund I Sjoumlland H Karlson BW Karlsson T Haglid MHartford M and Caidahl K 2000 Impact of age on improvement in health-related quality of life five years after coronary artery bypass graftingScandinavian Journal of Rehabilitation Medicine 3241-48

Horsten M Mittleman MA Wamala SP Schenck-Gustafsson K andOrth-Gomeacuter K 2000 Depressive symptoms and lack of social integration inrelation to prognosis of CHD in middle-aged women The Stockholm FemaleCoronary Risk Study European Heart Journal 211072-80

Jairath N 1999 Myocardial infarction patientsrsquo use of metaphors to sharemeaning and communicate underlying frames of experience Journal ofAdvanced Nursing 29(2)283-289

Jonsdoacutettir H 2001 Chronic illness (Editorial) Scandinavian Journal of CaringSciences 1512

Kendrick K 2000 Spirituality Its relevance and purpose for clinical nursing ina new millennium Journal of Clinical Nursing 9701-709

King KM and Jensen L 1994 Preserving the self Women having cardiacsurgery Heart and Lung 23(2)99-105

King KM and Paul P 1996 A historical review of the depiction of women incardiovascular literature Western Journal of Nursing Research 1889-101

King KM 2000 Gender and short-term recovery from cardiac surgeryNursing Research 4929-36

Kristeller JL Zumbrun CS and Schilling RF 1999 lsquoI would if I couldrsquoHow oncologists and oncology nurses address spiritual distress in cancerpatients Psycho-Oncology 8 (2)451-458

LaCharity L 1999 The experiences of younger women with coronary arterydisease Journal of Womenrsquos Health and Gender-Based Medicine 8(8)773-785

Lerner A 2000 Gender differences in quality of life after coronary arterybypass grafting surgery Report from the Department of Biomedical LaboratoryScience Umearing University Sweden

Leacutevinas E 1988 Etik och oaumlndlighet (Ethics and infinity) StockholmSymposium Bokfoumlrlag amp Tryckeri AB

Lidell E Segesten K and Fridlund B 1997 A myocardial infarction patientrsquoscurrent anxiety Assessed with a phenomenological method InternationalJournal of Rehabilitation Health 3205-218

Lindsay GM Smith LN Hanlon P and Wheatley DJ 2000 Coronaryartery disease patientsrsquo perception of their health and expectations of benefitfollowing coronary artery bypass grafting Journal of Advanced Nursing321412-21

RESEARCH PAPER

22


Lukkarinen H and Hentinen M 1998 Assessment of quality of life with theNottingham Health Profile among women with coronary artery disease Heartand Lung 27189-199

MacDonald P Johnstone D and Rockwood K 2000 Coronary artery bypasssurgery for elderly patients Is our practice based on evidence or faith CanadianMedical Association Journal 1621005-6

McSherry W 1998 Nursesrsquo perceptions of spirituality and spiritual care NursingStandard 1336-40

McSherry W 2000 Making sense of spirituality in nursing practice AnInteractive Approach Edinburgh Churchill Livingstone

McSherry W and Ross L 2002 Dilemmas of spiritual assessmentConsiderations for nursing practice Journal of Advanced Nursing 38(5)479-488

Mortasawi A Rosendahl U Schroder T Albert A Ennker IC and EnnkerJ 2000 Isolated coronary bypass operation in the 19th decade of life Zeitung desGerontolgishe Geriatr (in German) 33381-387

Munro BH 2001 Statistical methods for health care research (4th ed) NewYork Lippincott

The Northern Nurses Federation 1995 Ethical guidelines for nursing research inthe Nordic countries The Northern Nurses Federation

Price JL Stevens HO and LaBarre MC 1995 Spiritual care giving innursing practice Journal of Psychosocial Nursing 335-9

Rosenfield AG and Gilkeson J 2000 Meaning of illness for women withcoronary heart disease Heart and Lung 29(2)105-112

Raringholm M-B and Lindholm L 1999 Being in the world of the sufferingpatient A challenge to nursing ethics Nursing Ethics 6528-539

Raringholm M 2003 In the dialectic of struggle and courage DissertationDepartment of Caring Science Aringbo Akademi University

Salmon B 2001 Differences between men and women in compliance with riskfactor reduction Before and after coronary artery bypass surgery Journal ofVascular Nursing 1973-79

Silva LF and Damasceno MMC 1999 Being with coronary disease Amongauthentic life and daily ties Revista Brasileira de Enfermagem (in Portuguese)5291-99

Sivonen K 2000 Varingrden och det andliga (in Swedish Features of spirituality incaring) Dissertation Department of Caring Science Aringbo Akademi University

Swinton J 2000 Spirituality and Mental Health Care London Jessica Kingsley

VandeCreek L Pargament K Belavich T Cowell B and Friedel L 1999The Journal of Pastoral Care 53 19-29

Woods D 1994 Toward developing a theory of spirituality Visions 2(1)35-43

Wright LM 1997 Suffering and spirituality The soul of clinical work withfamilies Journal of Family Nursing 3(1)3-14

Wright S and Sayre-Adams J 2000 Sacred Space Right relationship andspirituality in healthcare London Churchill Livingstone

RESEARCH PAPER

23


ABSTRACT

Research aims To explore and describe registered and enrolled

nursesrsquo experiences of ethics and human rights issuesin nursing practice in the Australian State of Victoria

Method Descriptive survey of 398 Victorian nurses using the

Ethical Issues Scale (EIS) survey questionnaire

Major findings The most frequent and most disturbing

ethical issues reported by the nurses surveyedincluded protecting patientsrsquo rights and humandignity providing care with possible risk to their own health informed consent staffing patterns that limited patient access to nursing care the use of physicalchemical restraints prolonging the dyingprocess with inappropriate measures working with unethicalimpaired colleagues caring forpatientsfamilies who are misinformed not consideringa patientrsquos quality of life poor working conditions

Conclusions Nurses in Victoria frequently experience disturbing

ethical issues in nursing practice that warrantfocussed attention by health service managerseducators and policy makers

INTRODUCTION

Nurses at all levels and areas of practice experiencea range of ethical issues during the course of theirday-to-day work Over the past three decades there

has emerged an impressive international scholarship onnursing ethics offering comprehensive philosophicalcritiques of the kinds of issues nurses face and theprocesses that might be best used for dealing with themThe degree to which nurses are involved in ethical issuesin the work place how effectively they have been able todeal with them and the extent to which their formaleducation has prepared them to deal effectively withethical and human rights issues encountered during thecourse of their work has not however been systematicallyexplored or enumerated either in Australia or with rareexception elsewhere

MethodFollowing ethics approval being obtained from the

RMIT University Human Research Ethics Committee arepresentative sample of 2329 (3) nurses registered indivisions 1 2 and 3 of the register of the Nursesrsquo Boardof Victoria (NBV) was drawn randomly from the NBVdatabase A copy of the questionnaire together with aletter of invitation to participate and a consent form weredistributed by mail to each nurse on the randomlyselected list Three hundred and ninety eight completedquestionnaires were returned (response rate =17) Themajority of respondents were female (92) and employedpart-time (553) On average the respondents were 414years of age (plusmn102 years) had 198 years of nursingexperience (plusmn105 years) and had been in their currentposition 54 years (plusmn56 years) The main areas of practiceidentified were aged caregerontology (123) acutecare (88) psychiatricmental health nursing (6) andcritical care (53) Over 50 of respondents held agraduate degreediploma in nursing

Professor Megan-Jane Johnstone PhD BA RN FRCNAFCN(NSW) is Professor of Nursing and Director of ResearchDivision of Nursing and Midwifery RMIT University VictoriaAustralia

Associate Professor Cliff Da Costa PhD EdS MSc School ofMathematical and Geospatial Sciences RMIT UniversityVictoria Australia

Dr Sue Turale DEd MNursSt BAppSci DAppSci RN FRCNAFANZCMHN Director of Nursing Medea Park Residential CareSt Helens Tasmania Australia

Accepted for publication May 2004

ACKNOWLEDGEMENTSThis research was funded by a grant from the Nursesrsquo Board of Victoria (NBV)Melbourne The views expressed in this report do not necessarily representthose of the NBV Acknowledgement is due to S Fry and the Maryland NursesrsquoAssociation for granting permission to use the EIS survey tool

REGISTERED AND ENROLLED NURSESrsquo EXPERIENCES OF ETHICAL ISSUES INNURSING PRACTICE

RESEARCH PAPER

Key words ethics human rights ethical issues nursing


QuestionnaireAn anonymous self-administered survey tool the Ethical

Issues Scale (EIS) survey questionnaire originallydeveloped piloted and validated by Damrosch and Fry(1993) through contractual agreement with the MarylandNursesrsquo Association (USA) was used for this study Beforebeing distributed to the Victorian population the tool waspiloted using a snowball sample of 40 nurses registered inVictoria The purpose of the pilot was to ensure lsquocultural fitrsquowith Australian nomenclature and the classification ofnursing positions and areas of work The pilot confirmed astrong lsquofitrsquo with the use of nomenclature with only minoramendments being made Proposed amendments wereconfirmed with the toolrsquos authors and approved None of theamendments affected the validity of the tool Some examplesof the amendments made are lsquoConsulted with the nursesassociationrsquo (expanded to include lsquoorgunion eg AustralianNursing Federation Royal College of Nursing Australiarsquo)position classifications expanded to include classificationsendorsed by the Australian Nursing Federation

Data analysis Data analysis was undertaken using the SPSS

statistical package Descriptive statistical analyses wereperformed on the data relating to questions based on threemajor areas The aim of these analyses was to summarisenursesrsquo responses on a number of issues within thesemajor areas These were

bull ethical issues in nursing practice the analysis of the datarelating to questions in this area focussed on finding outwhat issues in their practice disturbed them the most andhow they dealt with them

bull suitability of education responses to questions in thisarea were analysed to document nursesrsquo existingknowledge and level of their education together withpotential for educational opportunities in relation toperceived learning needs

bull workplace support in this area the focus of the analysiswas to summarise responses to questions based on theadequacy of workplace resources in dealing with ethicalissues

An Involvement score was derived for each respondentbased on responses to questions on ethics and human rightsconcerns in their nursing practice This score quantifiedtheir level of involvement on these issues in the workplaceTwo Sample T-Tests were used to determine whethersignificant differences existed among various subgroups inthe sample on the Involvement score Multiple regressionanalysis was used to quantify the influence of the nursesrsquoknowledge of ethical issues their perceived need for ethicseducation in the workplace and the adequacy of resources todeal with ethics and human rights issues in the workplaceon the Involvement score

Additional comments written on the questionnaires byrespondents were analysed using the qualitative researchtechniques of content and thematic analysis (Patton 2002)

RESULTSEthical issues of most concern

The five most frequently cited ethical issues reported bythe nurses surveyed were

1 Protecting patientsrsquo rights and human dignity

2 Providing care with possible risk to your health (eg TB HIV violence)

3 Respectingnot respecting informed consent totreatment

4 Staffing patterns that limit patient access to nursingcare and

5 Usenon use of physicalchemical restraints

A combined analysis of reports revealed the followingas being the most personally disturbing issues faced bythe nurses surveyed

bull Staffing patterns that limited patient access tonursing care

bull Prolonging the dying process with inappropriatemeasures

bull Working with an unethicalincompetentimpairedcolleague

bull Caring for patientsfamilies who are uninformedmisinformed

bull Providing care with possible health risk and

bull Not considering a patientrsquos quality of life

Almost one quarter (239) of the nurses surveyedreported having direct involvement in an ethical andorhuman right issue between one-to-five times per year204 reported being directly involved in an ethicalandor human rights issue between one-to-four times perweek Only 5 reported that they were never involved inan ethics or human rights issue in the past 12 months

Dealing with ethical issuesWhen confronted with an ethical or human rights

issue the nurses surveyed reported that they were mostlikely to handle these issues through discussions withnursing peers (869) and nursing leadership (704)Only 47 of nurses surveyed reported they would discussthe issue with the patientrsquos doctor and only 41indicated they would discuss the issue with anotherprofessional Less than 5 reported they would make adecision without consulting anyone The nurses reportedthey were unlikely to consult with the patientrsquos familyand only 23 indicated they would consult an ethicscommittee for advice (noting however that only 384reported knowing they had an ethics committee at theirplaces of employment)

RESEARCH PAPER

25


EducationApproximately 80 of the nurses surveyed reported

having ethics content integrated into regular nursingcourses within their curricula Although 88 of nursesreported they were moderately to extremelyknowledgeable about ethicshuman rights in nursingpractice almost 74 believed they had a need for moreeducation on ethical issues Only 7 felt only a lsquoslight orlittle needrsquo for such education

The six most frequently chosen educational topicsthat the majority of nurses (80) identified as beinghelpful were

bull patientsrsquo rights

bull quality of life

bull being an advocate for patientsrsquo rights and autonomy

bull professional issues

bull ethical decision-making and

bull risks to their health

In contrast educational topics addressing emergingtechnologies and organ transplants were rated by thenurses as not very helpful

Adequacy of workplace resourcesOnly 83 of the nurses surveyed believed that their

places of employment provided adequate resources tohelp them to deal with ethics and human rights issues intheir nursing practice In contrast 284 of nursesbelieved their work place resources were only slightlyadequate and 106 rated their work placesrsquo resources astotally inadequate Only 384 of the nurses surveyedsaid they had an ethics committee at their places ofemployment with more than a third (347) reportingthat they did not know whether they had an ethicscommittee at work Of the 153 nurses reporting aworkplace ethics committee 924 reported that it hadincluded nurses and 637 knew how to access thesecommittees when they needed to do so Approximately10 accessed their work place ethics committees in thepast year and close to 73 wanted to have moreinformation about their workplace ethics committees

Involvement in ethical issuesA comparison of subgroups via t-tests in the sample

surveyed found no significant difference in regard to theirinvolvement in ethical issues This would suggest that thenurses working in the various areas identified came acrossethics or human rights issues at about the same frequencyin their practice There was however a significantinfluence (plt001) on the nursesrsquo general knowledge ofethics and human rights by their responses to thefrequency of their involvement in ethical and humanrights issues in practice quantified by the Involvementscore There was also a significant relationship (plt001)between their need for ethics education (Need) and the

Involvement score Resources exerted a significantnegative influence (plt001) on the Involvement scoreKnowledge however was shown to exert a biggerinfluence on the Involvement score than did Need

Other issues A thematic analysis of the comments of 82 (22)

respondents revealed three key areas requiring attentionpoor working conditions the need for further and ongoingeducation on nursing and health care ethics and the needfor improved attention to be given to ethical issues innursing not otherwise addressed in nursing domains Poorworking conditions were described as including poormanagement poor communication among staff nurseshaving to work in under-resourced conditions (especiallyaged care) violence in the workplace (bullying and abuseby other staff and patients) and feeling lsquoundervaluedrsquoand disrespected (especially by attendant medical staff)The need for further and continuing education wasidentified and deemed necessary in order to facilitate thenursersquos roleempower nurses as lsquopatient advocatesrsquoimprove interdisciplinary ethical decision makingimprove knowledge of emerging issues and to meet theneeds of care givers and care recipients Other specificethical issues identified as needing attention includedinformed consent (especially with children and olderadults) family involvement in decision making end oflife decision making nursesrsquo rights reporting unethicalandor incompetent colleagues and confidentialityprivacy issues in telephone counselling

DISCUSSION

This study has sought to ascertain what nursesexperience as problematic ethical issues in nursingpractice and how they have dealt with these issues Thefindings of this study support overseas researchsuggesting that what concerns nurses most are not the so-called lsquobigrsquo or lsquoexoticrsquo issues of bioethics such asabortion euthanasia organ transplantation andreproductive technology which significantly wereidentified as being of least interest to the nurses surveyedRather what is of most pressing concern to registerednurses (and the issues that cause them the most distress)are the frequently occurring issues of protecting patientsrsquorights and human dignity caring for patients in under-resourced health care services (including staffing patternsthat limit patient access to nursing caremanaged carepolices that threaten quality care) informed consent(including patient autonomy and family involvement indecision-making) providing care with possible risk to thenursesrsquo own health (eg TB HIV violence poor workingconditions) ethical decision making ethical issues at theend stages of life (eg prolonging the dying process usinginappropriate means not considering the patientrsquos qualityof life) working with an unethical incompetent orimpaired colleague and the usenon use ofphysicalchemical restraints

RESEARCH PAPER

26


It is significant that less than 50 of the nursessurveyed indicated they would consult either the patientrsquosdoctor or other professionals for assistance to deal withethical issues Just why this is so is a matter forspeculation Historically the medical profession andothers have not been supportive of nursing ethics orrespectful of the legitimate concerns nurses have hadabout ethical issues in nursing and health care domains(Johnstone 1999 1994) Although nursing ethics is nowrecognised as a distinct and legitimate field of inquiry inits own right nurses still lack the legitimate authority theyneed to match their responsibilities as ethicalpractitioners Nurses are still in a position of legitimatedsubordination to the medical profession (Johnstone 1994)and there continues to be some suggestion in the nursingliterature (and even in the findings of this survey) thatnurses donrsquot feel respected or valued by their medicalcolleagues As two respondents to this surveycommented

lsquoI am [a] professional who believes that I am a patientadvocate Having my judgment called into question andbeing patronized by the medical profession annoys mendashespecially when I am right and they are wrong There isno recognition of my contribution to the safety andwelfare [of patients]rsquo (QR020)

lsquoThe biggest issue for me is constant conflict overmedical dominance in childbirth and blatant disregard forwomenrsquos rights to choose Hospital administration offersno support at all to midwives who try to protect womenrsquosrights and in fact punish staff members who defy doctorsin the process of helping women to get what they wantThis is the biggest source of job dissatisfaction and isdirectly resulting in staff shortages I would like to seehospital administrators educated about patient rights tobe fearful of constantly ignoring them to keep the doctorshappy eg denial of waterbirth forced inductionsmisinformed consent to caesarean section denial ofchoice in caregiverrsquo (QR204)

Past experiences of not having their views and practicevalued or respected by medical colleagues may be onereason why the nurses responding to this survey werereluctant to consult with medical colleagues for assistancewhen dealing with ethical issues Another reason may bethat the ethical issues confronting the nurses may havedirectly concerned medical staff and the medicaltreatment of patients and as such not matters easilyaddressed by nurses or from a nursing perspective Insuch instances it is understandable that nurses mightprefer to seek advice and assistance from a nursing peeror a nurse manager before taking the matter further orraising it with a medical colleague

It remains less clear why only 41 of the nursessurveyed would seek assistance from another professionalto help deal with ethical issues and why less than 5 of the nurses surveyed reported that they would make a decision without consulting anyone Possible

explanations include a lack of confidence in the ethicsexpertiseexperience of other professionals Alternativelythe nurses surveyed might have felt competent to dealwith the situations they faced and genuinely did not needto consult with a third party for assistance

It is significant that only 23 of the nurses surveyedindicated they would consult an ethics committee foradvice A key reason for this may lie in the relativelyrecent history of the establishment of institutional ethicscommittees (IEC) in Australia Over the two decadesthere has been a proliferation of IEC established inAustralian health care agencies (McNeill 1993 2001)Today most IEC are concerned primarily with researchethics and granting approval for human research Of thosethat are concerned with clinical ethics most play only aneducative or policy-making role not an advisory role(McNeill 2001)

Characteristically at least during the early years of IECin Australia nurse representation was either non-existenttokenistic or disproportionate (ie in regards to medicalstaff representation) making it very difficult for nurses tohave any significant or lsquorealrsquo influence on the proceedingsof these committees (Johnstone 1999 1998) Althoughnurse representation on IEC has improved in recent years(of the 384 of nurses who indicated they had access toworkplace ethics committees 924 indicated that thesecommittees included nurses as members) IEC may still bedifficult to access Reasons for this may include the natureand purpose of the committee (eg research ethics versusclinical ethics) rules governing who has access to thecommittee composition (eg may be dominated bymanagement) issues of confidentiality and the processesinvolved for advising on ethical issues It may also be thatthe nurses surveyed had little confidence in their IEC toprovide the kind of assistance they needed in a timely anduseful manner

Finally it is significant that the nurses surveyed indicatedthey would be unlikely to consult with the patientrsquos familywhen dealing with ethical issues This reluctance may be dueto a number of factors including a reluctance to burdenfamily members with the problem a reluctance to involve thefamily in what is essentially a confidential matter involvingthe patient and a fear of provoking a complaint and possiblelitigation associated with the complaint The issue of familyinvolvement in patient care and ethical decision-making isone that has yet to be comprehensively addressed in thenursing ethics literature

Ethics educationThe issues identified by respondents are among the

most commonly discussed in nursing education forums(both formal and informal eg workshops seminarsconferences award courses) and the nursing literature (toonumerous to list here) Further support of the findings ofthis study is found in the strong correlation that existsbetween the issues identified by the Victorian nursessurveyed and the issues identified by the nurses surveyed

RESEARCH PAPER

27


RESEARCH PAPER

28

Base data Victorian study New England study

Sample sizeresponse rate N=398 (17) N=2090 (288)

Gender ratio 92 female 944 female

Employment EFTS 553 part-time 355 part-time

Average age 414 years (plusmn102 years) 444 years (plusmn94 years)

Average years of nursing experience 98 years (plusmn105 years) 192 years (plusmn103 years)

Years in present position 54 years (plusmn56 years) 76 years (plusmn7 years)

Percentage of university 500 550college graduate degreesdiplomas

Top clinical areas of practice Aged caregerontology (123) Aged caregerontology (74)Acute care (88) Psychmental health (69)Psychmental health (60) Paediatrics (66)Critical care (53) Critical care (63)

Five most frequently reported ethical 1 Protecting patientsrsquo rights and human dignity 1 Protecting patientsrsquo rights and human dignityandor human rights issues 2 Providing care with possible risk to your health 2 Respectingnot respecting informed consent

(eg TB HIV violence) to treatment3 Respectingnot respecting informed consent to 3 Providing care with possible risk to your

treatment health (eg TB HIV violence)4 Staffing patterns that limit patient access to 4 Usenon-use of physicalchemical restraints

nursing care 5 Staffing patterns that limit patient access to 5 Usenon-use of physicalchemical restraints nursing care

Most personally disturbing issues 1 Staffing patterns that limited patient access to 1 Staffing patterns that limited patient access to nursing care nursing care

2 Prolonging the dying process with inappropriate 2 Prolonging the dying process with measures inappropriate measures

3 Working with an unethicalincompetentimpaired 3 Not considering a patientrsquos quality of life colleague 4 Implementing managed care policies

4 Caring for patientsfamilies who are uninformed threatening quality of care misinformed 5 Working with an unethicalincompetent

5 Providing care with possible health risk impaired colleague6 Not considering a patientrsquos quality of life 6 [Not cited]

Least personally disturbing issues 1 Protecting the rights of patients as research 1 Procuring organstissues for transplantationsubjects 2 Protecting the rights of patients as research

2 Procuring organstissues for transplantation subjects3 Determining when death occurs

Frequency of encountering ethical issues

1-5 timesper year 239 396Never involved over past 12 months 50 68

Dealing with ethical issues by discussing with- Nursing peers 869 838- Nursing leadership 704 665- Patientrsquos doctor 470 588- Other professional 412 601- Ethics committee 23 133Not discussed with anyone 45 62

Knowledgeable about ethics 880 920Have little or no knowledge about ethics 120 70

Need for further ethics education 740 590

Previous ethics education 800 580content integrated into curricula

Topics most helpful 1 Patientsrsquo rights 1 Being an advocate for patientsrsquo rights and 2 Quality of life autonomy3 Being an advocate for patientsrsquo rights 2 Professional issues

and autonomy 3 Patientsrsquo rights4 Professional issues 4 Resource allocation and access to care5 Ethical decision-making 5 Contentinterpretation of ethical codes6 Risks to their health Ethical decision-making

Table 1 Victorian Study and New England Study A comparison of the findings


in other countries such as The Netherlands (van der Arendand Remmers-van den Hurk 1999) Israel (Wagner andRonen 1996) and of particular relevance to this studyNew England where the EIS tool used in the Victorianstudy was first developed and used (Fry and Riley 2000Fry and Currier 1999 2000 Fry and Duffy 2000 2001Mahoney 2000 Redman and Fry 2000) See table 1

The relationship between nursesrsquo knowledge and theirinvolvement in ethical and human rights issues in practiceis particularly noteworthy As has been discussedelsewhere (Johnstone 1999 1998) the ethics education ofnurses (and their associated improved knowledge ofethical and human rights issues in practice) canparadoxically compound the frequency and intensity ofethical and human rights issues experienced by nurses inpractice There are at least two reasons for this

bull ethics education is known to result in nursesexperiencing a lsquoGestalt shiftrsquo in their moral perceptionsresulting in their identifying ethical issues in places ofwork more readily than they did prior to their learningand

bull the level of ethics education among nurses is oftenhigher than that undertaken by allied health workerswhich sometimes means that nurses may identify ethicalissues in practice that their co-workers either do notregard as ethical issues or recognise as ethical issues butlack the moral knowledge and skill for dealing withthem in either case this can result in distressing moraldisagreements (Johnstone 1998 p80)

Workplace resourcesThe inadequacy of workplace resources to help nurses

deal with ethics and human rights issues has not beensystematically identified before although the lsquounethicsrsquo ofpoor working conditions and the implications of unethicalorganisational culture on nurses capacity to provide moralcare is receiving increasing attention in the nursing andrelated literature (Johnstone 2002) Arguably a morepressing issue facing nurses is that while the nursingprofession has lsquoinstitutionalisedrsquo ethical motivation in its

organisations the organisations in which nurses workhave not (Johnstone 1998 pp 80-82 2002)Organisations like individuals are morally accountableand responsible entities This accountability andresponsibility includes an organisationrsquos quality assuranceof moral standards policies and practices Organisationslike individuals must also behave ethically and be madeto account when they fail to do so (Johnstone 2004)Nurses are part of the organisations in which they workThus when nurses are made to account for their moralactions andor inactions so too must the organisations inwhich they work This is an important consideration inthe effective prevention and resolution of moral problemsin work-related contexts It is imperative that work-relatedenvironments are supportive of ethical nursing practiceand that organisations actively create what Curtin (1993)calls lsquomoral spacersquo for nurses to practice ethically

Institutions and organisations can support nurses indealing with ethical and human rights issues in thefollowing ways namely by

bull formulating and articulating through democraticprocesses ethical standards of conduct (for examplein the form of an organisational code of ethicsposition statements and policies)

bull facilitating repeated regular and effectivecommunication of ethical standards and policiesthrough printed information stakeholder access toresource people and role modelling of ethical conduct(for example managers need to not only manageethical problems well but to manage ethically theproblems they have to deal with as managers)

bull supporting the establishment of institutional ethicscommittees and other forums (for example nursingethics forumscommittees) for the purposes ofenabling the discussion of ethical issues in a lsquosafeplacersquo outside of the usual hierarchy of power andauthority characteristic of institutions

bull supporting lsquomoral quality assurancersquo programs and themonitoring of lsquomoral performance indicatorsrsquo (as

RESEARCH PAPER

29


Topics least helpful 1 Emerging technologies 1 Reproductive technologies2 Organ transplants 2 Genetic testing

3 Organ transplants

Workplace resources for dealing with ethical issues- very adequate 83 116- slightly adequate 390 240- totally inadequate 106 123

Access to ethics committee- ethics committees exist at workplace 384 568- donrsquot knowrsquo if ethics committee exists

at work 347 163- ethics committee exists amp includes

nurse membership 924 956- nurses accessing ethics committee

in past year 100 190- desire for more information on

workplace ethics committees 730 530


Scofield [1992 p310] points out lsquoimpairment neednot be fatal to anyonersquos personal or professional lifeThe failure to monitor impairment however is fatal tomaintaining a real accountability and integrity[emphasis added]) and

bull rewarding moral conduct this can include lsquopraiserecognition action on suggestions responsivenesssetting examples making positive examples of peoplefor desired ethical actionsrsquo (adapted from Derry 1991pp121-136 Johnstone 1999 pp 436-438)

LimitationsThe poor response rate (17) of this study is a major

imitation and one that prevents it from being generalisedto the total population of nurses registered or enrolled inthe State of Victoria or elsewhere in Australia Reminderletters were sent out to prospective participants near thespecified timeline for the return of the completedquestionnaires This strategy however had little impact onimproving the response rate Despite this limitation thefindings of the study can nevertheless be generalised tolike populations For example as stated previouslyresponses and findings of the study correlate strongly withthe 1999 study (n=2090) reported by Duffy and Currier(1999) for Fry and Riley (1999) (see table 1)

CONCLUSIONNurses in Victoria frequently experience disturbing

ethical issues in nursing practice that warrant focussedattention by health service managers educators and policymakers Although the findings of this study cannot bebroadly generalised they nevertheless highlight the need fora critical examination of the

1 accredited ethics education programs for nurses andwhether these are effective in terms of assisting nursesto achieve the stated and agreed ethical competenciesexpected of registered and enrolled nurses with respectto professional and ethical nursing practice

2 ethics and human rights content of both undergraduateand postgraduate nursing curricula and whethernursing curricula address the issues that are of mostconcern and are of most relevance to nursing practice -such as those identified by this study and

3 the nature and availability of continuing education professional development programs on ethics andhuman rights for nurses and whether these address theissues that are of most concern and are most relevanceto nursing practice particularly in regard to

bull facilitating the nursersquos roleempowering nurses aslsquopatient advocatesrsquo

bull improving interdisciplinary ethical decision making

bull improving knowledge of emerging issues

bull meeting the needs of care givers and care recipients

bull specific ethical issues identified as needing attention eg

- informed consent (especially with children and older adults)

- family involvement in decision making- end of life decision making - nursesrsquo rights- reporting unethical andor incompetent

colleagues and - confidentiality and privacy issues in telephone

counselling and

4 poor working conditions violence in the workplaceand disrespect of nurses as professionals by otherallied health workers as fundamental ethical issuesrelevant to the profession and practice of nursing

REFERENCESCurtin L 1993 Creating moral space for nurses Nursing Management24(3)18-19

Damrosch S and Fry S 1993 Ethical Issues Scale (EIS) survey questionnaireDeveloped through contractual agreement with the Maryland Nursesrsquo Association8192 Modified by the Nursing Ethics Network with permission of the authorsand the Maryland NursesrsquoAssociation

Derry R 1991 How can an organization support and encourage ethicalbehaviour In Freeman R (ed) Business ethics The state of the art OxfordUniversity Press New York121-136

Duffy M and Currier S 1999 Report on the ethics and human rights in nursingpractice A survey of New England nurses (Prepared for S Fry and J Riley)Boston College School of Nursing Boston Massachusetts

Fry S and Currier S 2000 Ethical issues in nursing practice How frequently theyoccur and how disturbing they are Nursing Ethics Networkhttpwwwbcedunursingethics [accessed 30703]

Fry S and Duffy M 2001 The development and psychometric evaluation of theethical issues scale Journal of Nursing Scholarship 33(3)272-277

Fry S and Duffy M 2000 Ethical issues in nursing practice How they areexperienced and handled by New England RNs Nursing Ethics Networkhttpwwwbcedunursingethics [accessed 30703]

Fry S and Riley J 2000 Ethical issues in clinical practice A multi-state study ofpracticing registered nurses Nursing Ethics Networkhttpwwwbcedunursingethics [accessed April 2002]

Gold C Chambers J and Dvorak E 1995 Ethical dilemmas in the livedexperience of nursing practice Nursing Ethics 2(2)131-141

Johnstone M 2004 Leadership ethics in nursing and health care domains InDaly J Speedy S and Jackson D (eds) Nursing Leadership ChurchillLivingstone Sydney

Johnstone M 2002 Poor working conditions and the capacity of nurses to providemoral care Contemporary Nurse 12(1)7-15

Johnstone M 1999 Bioethics A nursing perspective (3rd ed)HarcourtAustralia Sydney

Johnstone M 1998 Determining and responding effectively to ethicalprofessional misconduct in nursing A report to the Nursesrsquo Board of VictoriaMelbourne

Johnstone M 1994 Nursing and the injustices of the law WB SaundersHarcourtBrace Sydney

McNeill P 2001 A critical analysis of Australian clinical ethics committees andthe functions they serve Bioethics 15(5amp6)443-460

McNeill P 1993 The ethics and politics of human experimentation CambridgeUniversity Press Melbourne

Mahoney M 2000 Ethics and human rights in nursing practice A survey ofMassachusetts nurses Massachusetts Nurse 70(1)1-10

Patton M 2002 Qualitative research and evaluation methods 3rd edn SagePublications Thousand Oaks California

Redman B and Fry S 2000 Nursesrsquo ethical conflicts What is really known aboutthem Nursing Ethics 7(4)360-366

Scofield G 1992 The problem of the impaired clinical ethicist Quarterly ReviewBulletin 18(1)26-32

Van der Arend A and Remmers-van den Hurk C 1999 Moral problems amongDutch nurses A survey Nursing Ethics 6(6)469-482

Wagner N and Ronen I 1996 Ethical dilemmas experienced by hospital andcommunity nurses An Israeli survey Nursing Ethics 3(4)294-304

RESEARCH PAPER

30


ABSTRACTObjective

To examine maternal and child health (MCH)nursesrsquo experiences of the implementation of therationalisation processes and compulsory competitivetendering (CCT) associated with neo-liberalism

Design Policy analysis survey of all Victorian MCH

nurses interviews and focus groups with MCHcoordinators and some managers of MCH services

Setting Primary health care in maternal and child

health services

Participants Sixty MCH coordinators 300 MCH nurses six

managers (95 female overall)

ResultsThe Victorian MCH workforce is overwhelmingly

female with 30 over 50 years of age and 535working part-time CCT processes in the mid-1990seffectively put maternal and child health services lsquoonthe marketrsquo threatening jobs and creating highlystressful work environments Tenders for about 17of MCH services were won by organisations otherthan local government the traditional provider ofMCH services This created new challenges for MCHnurses In spite of the enormous stress and confusionoccasioned by the restructuring improvements instrategic focus skill development teamwork andflexibility were also reported

Conclusions CCT processes provided MCH nurses with greater

transparency about management and budgetsRestructuring gave MCH nurses greater responsibilitythan they had earlier and they became more aware ofthe need to lsquosellrsquo their service and to understandmanagement contexts Major hurdles still to beovercome related to wage parity workloaddiscrepancies and a restrictive policy legacy about thepractice of MCH nurses

INTRODUCTION AND BACKGROUND

Since the 1920s the Australian state of Victoria hasprovided a highly regarded primary health carenursing service for childbearing women The

Maternal and Child Health (MCH) Service as it is nowknown has traditionally been available through localcentres universally available free of charge on a needsbasis with funding jointly provided by local and stategovernments Although the practice of MCH nurses wasable to be adapted to the particular character of an areatheir professional identity was based on a sense ofbelonging to a state-wide health service Whilst employedby local municipal councils most MCH nurses felt aproprietorial attitude to lsquotheirrsquo centres and it wascommon for nurses to remain in an area for many yearsMCH nurses attained a high degree of independence andautonomy often having little contact even with councilstaff and limited accountability to the State Department ofHealth During the 1990s however significant change inadministrative arrangements and neo-liberal policydirections in the public sector transformed MCH servicesby introducing a market model

Managerialist strategies were introduced into theVictorian public service by 1980s governments tolsquosqueeze more from existing resourcesrsquo (Considine1992 p199) In order to stimulate competition and raiseproductivity the emphasis on outputs goals and targetsincreased Program budgeting and new corporate imageswere introduced Senior staff once secure in theiremployment were put onto fixed term contracts InVictoria from 1992 the neo-liberalist Kennettgovernment introduced a more extreme version of newpublic sector management unreservedly embracing theethos of the private business world (Hancock 1999)Within government departments funding of serviceswas restyled to reflect a lsquopurchasingrsquo rather than alsquoprovidingrsquo role for the state The principles of neo-liberalism underpinned moves to sell off or contract outfacilities and services to the private sector As in 1980sBritain this commercialisation process involved a wholerange of services being lsquopackaged and marketed ascommoditiesrsquo (Whitfield 1992 p72) even when they

Kerreen Reiger PhD Senior Lecturer School of SocialSciences La Trobe University Victoria Australia

Helen Keleher PhD RN Senior Lecturer School of HealthSciences Deakin University Victoria Australia


NURSES ON THE MARKET THE IMPACT OF NEO-LIBERALISM ON THEVICTORIAN MATERNAL AND CHILD HEALTH SERVICE

RESEARCH PAPER

Key words maternal and child health nurses managerialism tendering maternal and child health servicesneo-liberalism


remained under state control Public service units andcommunity services were restructured to make themmore autonomous and accountable oriented to cost-cutting efficiencies technical rationality and values ofcompetitiveness (Hancock 1999)

MCH services were not immune from thesedevelopments Indeed a need for lsquoreformrsquo of the MCHservice was argued consistently in public servicedocuments (Australia Department of Health andCommunity Services 1993 1994) Through the late1980s to early 1990s health policy focused on tightertargeting of service goals establishment of measurablestandards and more efficient data gathering Surveillanceof infants and young children was increasingly seen asthe lsquocore businessrsquo of MCH services (AustraliaDepartment of Health and Community Services 1993)Service users were redefined as clients or consumers

Despite professional and consumer activism toreverse what were seen as alarming trends (Reiger2001) the reform agenda took a different turn in 1993when the Kennett government began a radicalrestructuring of local government The number ofVictorian local government areas (LGAs) was reducedfrom 210 to 78 through a process of rationalisation thatwas overseen by commissioners who were appointed toreplace elected councillors Within 12 months of theamalgamations a whole raft of local governmentservices were restructured into business units to meet arequirement that by 1996 50 of all services were to beput on the market via compulsory competitive tendering(CCT)

Amid lively debate about the lack of democraticprocess the period of local government amalgamationsunder the Kennett government was both tumultuous andchaotic MCH services were directly implicated Firstquite different MCH services with distinctive culturesand histories were suddenly thrown together in new andrapidly changing structures In the formermunicipalities MCH services had been mostly based onlsquobaby healthrsquo centres staffed by a single nurse who oftenhad little to do with other nurses let alone with those inneighbouring municipalities Second in the majority oflocal government areas MCH services were among thefirst to be put out to test their lsquomarketrsquo potential via atendering process MCH nurses found themselvesformed into business units with some required toprepare the specifications to permit the tendering tooccur while other nurses responded to the call fortenders by writing proposals to try to win the MCHservice back for local government For some MCHservices the whole process was repeated two years laterthrough a second round of CCT but this was at thediscretion of the local council

The new administrative arrangements took place in achanging industrial relations environment heightened bythe election of a neo-liberalist Federal Government in1996 Uncertainty and organisational restructuringcontinued during the later 1990s although the worst of

the pressure associated with new administrative regimeswas over by the time the Bracks Labor governmentabandoned CCT shortly after its election in late 1999The decade of change presented a period ofextraordinary challenge for Victorian MCH nurses Thispaper examines the impact of these changes on MCHnurses who were in effect lsquoput on the marketrsquo alongwith their services and reports our research into theimpact these significant changes had on MCH nursesrsquowork environment

METHODBoth qualitative and quantitative research approaches

were used Policy analysis was based on backgrounddocuments and reports related to maternal and childhealth policy planning and services A database wasconstructed with all local government contacts includedEthics approval was obtained from the Human ResearchEthics Committee of La Trobe University (BendigoCampus) in 1998 and later extended to cover follow-updata collection in 2001 A small grant from La TrobeUniversityrsquos Intercampus Research Grants Schemesupported the project

The research benefited enormously from theinvolvement of MCH staff as stakeholders in the studyWe were able to brief nurses at a Saturday in-servicemeeting while individual coordinators providedinvaluable feedback on draft materials MCHcoordinators from metropolitan regional and ruralservices were approached for one-to-one interviews orsmall focus groups with participation by a total of 60coordinators (from 78 LGAs) With participantsrsquoconsent all focus groups and interviews were tape-recorded and transcribed As maintenance ofconfidentiality was very important in view of the climateof apprehension and anxiety engendered by thecompetitive tendering environment all raw data wascoded using identifiers known only to the researchersMCH staff were very cooperative and we were confidentthat good representation of the statersquos services wasachieved In addition to the coordinators a sample of sixlocal government middle managers was drawn frommetropolitan and rural areas The enormous amount ofqualitative data was managed using QSR NVivosoftware (Qualitative Solutions and Research 1999)which allows full transcripts of interviews to be coded inmultiple ways with themes established and explored Adetailed coding frame was developed according to theprojectrsquos conceptual concerns with organisationalchange and professional issues The coding scheme wasmodified as new categories emerged from the dataanalysis

The early qualitative data collection informed thedevelopment of a survey of 58 items which wasdistributed in late 1998 via their coordinators to most ofthe 550 full-time part-time and casual nurses MCHnurses employed in Victoria at the time Eachrespondent was able to return the survey anonymously

RESEARCH PAPER

32


by prepaid mail to the researchers Only one follow-upcall for return of surveys was made and the 55response rate doubtless reflected data collection in thebusy period of December A mix of pre-coded and open-ended questions was used with a high level ofconsistency in the quality of the completedquestionnaires indicating clarity in the framing of thequestions Shorter open-ended question responses werecoded and entered along with pre-coded data into SPSSx(Statistical Package for the Social Sciences)Frequencies and cross tabulations were used to draw outkey findings Longer open-ended answers were enteredinto a database for integration with the qualitative dataThe triangulation of methods provided a very thoroughpicture of the nursesrsquo experience of changes in theVictorian MCH service Although change continues andonly a small amount of policy research and lsquoupdatingrsquo oforganisational data was possible during 2000-2001 weare confident the issues raised here remain pertinentGiven the richness and complexity of the data onlyselected results can be reported but a full report isavailable (Reiger and Keleher 2002)

RESULTS AND DISCUSSION

Profile of respondents and servicesThe survey indicated that the MCH nursing

workforce in Victoria is ageing with over 30 of theworkforce aged over 50 years A high proportion (535of the sample) is in part-time work mostly by choiceThe workforce is overwhelmingly female with morethan half also responsible for caring for their ownchildren The data also points to a high rate ofgeographical stability amongst MCH staff with only10 having worked interstate and 33 working in theircurrent location for over ten years

Two years after the first round of CCT theoverwhelming majority of MCH nurses (83) were stillworking for local government units which hadsuccessfully won tenders As well as a few ruralmunicipalities that continued to run MCH services lsquoin-housersquo without formal tendering processes there was asmall but significant group of 114 who worked forcommunity health services A further 2 worked forhospitals and there were some lsquootherrsquo outsourcedarrangements also in place Of the sample 65 wereemployed in services in Melbourne 19 in rural citiesand 14 in rural shires Few were spared the tumultuouschanges associated with first amalgamations then CCT

The impact of service amalgamations on MCHnurses

Local government rationalisation also amalgamatedMCH services that were often quite disparate inworkloads and pay rates organisational cultures andrelationships with council management Peer relationsand styles of leadership also varied The result wasescalating levels of personal and professional stressuncertainty and confusion about organisational

processes and working conditions as well as tensionsaround workload management The role of coordinatorsgenerally became more formalised with consequencesfor their relationships with both nursing colleagues intheir teams and with others in the organisation

In some areas personal and professional differencesbetween nurses produced a distressing process ofreadjustment Several coordinators reported frustrationat how long it took to build new cohesive teams in theface of different expectations and experience As onecoordinator commented about meeting one year afteramalgamation

It was just incredible I mean all this stuff came upMoney issues because a lot of the nursing staff were onmuch higher awards and of course I mean that sort ofreally hurt them It was them and us and oh it wasdreadful

Others also found the lsquothem and usrsquo mentality oftenproduced personal animosity

Little thingshellip like [such and such]hellip we did it thisway And that would rub the other girls The hostilitieswould come you could see it So we had to be reallyhonest with each otherhellip wersquore all together nowhellip wehad to air that

Conflicts over procedures and ways of organisingtheir practice were further complicated by differences incouncil management structures and how well integratedthe MCH service was into these At one (notuncommon) extreme in a rural shire the acting teamleader commented that mostly they had only ever goneto the council office to collect their mail and had verylittle contact with other staff Geographical distancecould work both to exacerbate differences on occasionsbut mitigate it in others when nursing staff did not haveto work closely together The merger of MCH serviceswas accompanied in many cases by a process ofintegration into other larger council organisations withnew systems of accountability and resource allocation tobe negotiated and new networks established whichfurther complicated nursesrsquo peer relationshipsResistance to change presented many coordinators withthe dilemma of managing nurses who clung to what theytermed a lsquofortress maternal and child healthrsquo philosophyin the face of changed realities

In some LGAs up to six municipalities wereamalgamated but regardless of size and across the statebudget constraints meant work rationalisation and oftenreduction in staff levels In the redrawing of borders fornewly amalgamated services socio-economic and classdifferences also made for conflict especially overdifferent workloads One metropolitan coordinatordiscussed the problems which resulted when her servicein a lsquofairly poor area which ran on the smell of an oilyragrsquo in which nurses carried high workloadsamalgamated with the neighbouring lsquofairly middle classrsquoarea that had quite moderate workloads In rural areasMCH tensions were worsened by geographic distanceand considerable local hostility to the whole

RESEARCH PAPER

33


amalgamation process impacting as it did on local jobsand the identities of entire communities No sooner hadthe amalgamations been partially bedded down than thewave of reform associated with CCT was imposedduring 1996-97

Surviving tender processes Councils varied in how they managed tendering

processes so nurses received varying levels and forms ofsupport Nurses were in general philosophically opposedto tendering and 76 of the survey sample eitherdisagreed or strongly disagreed with CCT In open-endedcomments they noted that CCT was not appropriate for aprimary health service caring for families as it was not acommercial proposition A recurring theme in accounts ofthe impact of tendering processes on MCH nurses wasthat they were lsquoall at searsquo with absolutely no idea abouthow to write specifications tender briefs or tenderproposals - but neither did council staff There wasturmoil as the rules kept changing and very high levels ofdistress among MCH nurses In a field in which nursesrsquotenure had been commonplace in many cases it was clearthat their jobs were on the line Only after the first roundof tenders did many existing or in-house teams and theirmanagers realise what an advantage they had in alreadyrunning the service and in the cost that would have beeninvolved in paying out the nurses if the service had notbeen won in-house Nevertheless they felt vulnerable toexternal competition not knowing where it might comefrom lsquoAll thisrsquo said one coordinator lsquosent anxiety levelsup to the ceilingrsquo In this highly stressful environmentnurses had to maintain their clinical practice andadminister the Service but deal also with the demandsoccasioned by the tendering process

Selling the serviceIn the new competitive climate while the outcomes of

tendering were uncertain there was little doubt that MCHservices had to continue but now be promoted andredefined as lsquobusiness unitsrsquo The extent to which councilssupported their existing Service directly shaped outcomesIn many councils consultants were brought in to helpeither the contract team developing the specifications orthe team developing the proposal but the respective teamswere kept away from each other as a requirement of CCTSome councils but not all provided adequate relievingstaff to backfill positions to allow permanent staff to workon tenders One coordinator told of the nurses being givenspace to work at council offices and help from humanresources staff and commented that the nurses gainedlsquoquite a presencehellip there were lots of jokes about thenurses moving inrsquo In other cases negativity and bitternesswere long lasting legacies requiring good leadership in theensuing years to enable the service to move on

Many of the external consultants or other council staffassisting had little understanding of the MCH service Thenurses had to explain the complex nature of their work topeople who tended to see nurses as mere lsquobaby weighersrsquoAsked about the value of assistance provided onecoordinator commented

They were trying to help us and we were gettingnowhere That probably went on for five or six weekshellip sothen they brought in a consultant He was an engineerhellipthey know a lot about crushed rock but not much aboutmothers and babies

Another coordinator explained that they had put in a lotof groundwork to ensure the role of MCH was understoodlsquoa lot of marketing with the staff and the council in termsof what we are responsible for especially the childprotection issuesrsquo

Going it alone Perceptions of the Department ofHuman Services and the Australian NursingFederation

As MCH nurses and leadership dealt with lsquomarketingthemselvesrsquo little policy direction was available from theVictorian Department of Human Services (DHS) Havinglaid down the program standards governing nursesrsquopractice and the minimal requirements for theircontribution to funding the MCH service DHS otherwiselargely vacated the field Although the survey showedcontinued expectations that DHS had an important role toplay in shaping the direction of the MCHS across thestate it was clear that nurses felt largely left on their ownin a period of tumultuous change Numerous storiesemerged of DHS representatives not being able to answerquestions of nursesrsquo frustration with lack of informationand confused messages Many felt that the centraldepartment was no longer interested in them The cut-backs and turnover of staff at both central and regionallevel presented ongoing problems lsquoTherersquos no-one inthere now They tell you to ring the regional office buttherersquos nobody no nursing adviser there nowrsquo In ruralareas the loss of clear lines of contact was strongly felt

There was always someone who would know what youwere on about in the department you did feel safeguardedby that person but now I wouldnt have a clue who is inthere

Another saidThey change their names that often down there you

wouldnt know [who to contact]Asked about the relationship with DHS more than one

coordinator responded with derisory laughter A ruralcoordinator responded with

What relationship We donrsquot have one Who are theyWe donrsquot have anything to do with 555 Collins Street andat the regional office I think they are more stretched thanwe are If ever you want to speak to somebody they arenot around and they never get back to you either

Others from the metropolitan area described lsquothe cityrsquoas lsquoa dead lossrsquo and lsquohopelessrsquo Organisationalrestructuring and the neo-liberal policy shift to lsquosteeringnot rowingrsquo human services imposed an unacknowledgedburden on nurses in the community

For many the feeling of being virtually lsquoabandonedrsquoapplied also to their industrial representation by theAustralian Nursing Federation (ANF) The context of the1990s lsquoindustrial relations reformsrsquo in which negotiationsover contracts took place was largely antipathetic to

RESEARCH PAPER

34


unions Clearly managements varied in politicalcomplexion but the ANFrsquos role also varied The surveyincluded specific questions concerning ANF support inthe tendering process and negotiation of enterprisebargaining agreements and local area work agreementsJust over half those who answered with regard totendering (54 n=119) said the ANF had givenassistance with information and phone advice but 46had found it inadequate Those dissatisfied claimed thatthe union which was strongly opposed to CCT had beenhard to get hold of had not turned up to meetings and wasof little or no help in scrutinising contracts Othersreported however that the ANF had been much better indealing with industrial issues since tendering givingexamples of significant help to individuals There werestill many critical comments

Who or what is the ANF - We were asking for theirhelp with our LAWA (Local Area Work Agreement) It (theANF) only came in at the very last minute

Another said they had felt lsquolittle supportrsquo andincreasing lsquosense of abandonmentrsquo The feeling of beinglet down by their union which like everyone else had fewrules to go by contributed further to the experience ofbeing abandoned in the market environment in which allthe old rules of authority leadership and policy directionhad changed

Working under contractAlthough the most intense period of stress was over by

the time the research was carried out nurses reported avariety of ways in which altered organisationalarrangements impacted on their practice For many therewas pressure to acquire new skills such as computerusage increased monitoring of client lsquothroughputrsquo andfor those who now worked within new organisations suchas community health often new expectations of theirwork While far fewer services were eventuallyoutsourced than nurses had feared MCH systems thatoperated across all municipalities had been taken forgranted and had to be renegotiated and re-establishedwhen the MCH service moved out of the localgovernment system In some cases the transfer of MCHworked well organisationally and professionally In otherareas mutually respectful relationships developed overtime but required considerable effort to establish Onenurse in a rural community healthhospital-based servicesaid she found it difficult to know who to liaise with andoften felt quite isolated She had trouble getting resourcesas no one was quite sure whose responsibility it was toprovide even minor items Others reported being expectedto undertake lsquowelfarersquo work with non-MCH clients suchas handling requests about anything from bus timetablesto welfare payments as well as a variety of other healthconcerns While in some cases the increased contact withother health professionals was welcomed many felt therewas little understanding of their role

The most appropriate organisational location for theoperation of the MCH services has never been addressedstate-wide It has been an ad hoc localised sometimes

quite idiosyncratic process as to whether MCH Serviceshave remained council-based or ended up in othersettings - either community health a hospital (usuallyrural) or even a private provider Respondents to thesurvey indicated strong support for having team leaders orcoordinators who were themselves MCH nurses becauseof their knowledge of the service In services led bydynamic coordinators new initiatives were seized andeffective relationships established with management Thesurvey responses indicate that nursesrsquo relationships withline management and coordinators had deterioratedbetween 1994 and 1999 They reached a low ebb beforerecovering somewhat but not usually to their previouslevel For example the proportion who reported havinghad excellent or good relationships with seniormanagement five years before was 43 but it dropped to27 for three years before the survey and only thenrecovered to 31 Comparable patterns emerged evenwith coordinators The contracting process was not onlyhighly contentious and stressful but had long-termconsequences Negotiating their working conditionswithin the constraints of contracts involved complexinteractions within teams and with management Some ofthe lsquoin-housersquo teams found that their contracts were moreapparent than real and likely to be varied in the councilrsquosfavour Those lsquotendered outrsquo faced new challenges ofintegrating into organisations with which they hadformerly had little contact For some especially for thosewith good leadership this worked effectively but poormanagement of contracting process generated significantconflict for a few services

In spite of the administrative reorganising andconfusion over central policy direction at the level ofeveryday practice the service continued to provide thetraditional care for mothers and babies along withwidening responsibilities for families in the communityDirect service was affected more in some services thanothers but did not suffer the severe cut backs which theneo-liberal regime imposed across many other health andwelfare services particularly hospitals The MCHrsquos longhistory and levels of community support providedsignificant protection although the nurses experiencedsomething akin to an earthquake across the MCH serviceWhile its intensity varied the impact of firstamalgamation and then tendering processes producedimmediate distress and a good deal of fear and resistanceto change

However there were also new professionalopportunities On the whole it appears that many MCHnurses successfully negotiated the move from being solepractitioners to becoming team players inmultidisciplinary organisations and developed new skillsto deal with the emerging entrepreneurial environmentSeveral coordinators undertook further training inbusiness administration but found some of their nursesquite resistant to taking responsibility for balancingworkloads and planning developments The position ofcoordinators which had been very variable and ofteninformal in the earlier regime now became more clearly

RESEARCH PAPER

35


managerial This occasioned considerable resentment insome services and intense personal anguish for thoseresponsible for leading them However manycoordinators demonstrated impressive leadership andstrong commitment to adjusting the service to thechanged administrative circumstances as well as tofamiliesrsquo needs in their local area New initiatives such asoutreach programs developing a computerised data basemore effective workload measures multi-nurse centresand closer relationships with other local family servicesreflected the enterprise of the MCH nurses who rose tothe challenge presented by the CCT processes

CONCLUSION THE POST-CCTENVIRONMENT

With the election of the Bracks government and theremoval of the compulsory aspects of tendering manypressures were relieved The lsquoclientproviderrsquo separationand the general climate of fear created by the inherentcompetitiveness of CCT diminished Communicationbetween service coordinators increased further and as arural coordinator noted lsquothe end of CCT has improvedsecurity for staff and done away with pointless paperworkto meet contract requirementsrsquo Yet the changesimplemented in preceding years have continued to have aprofound impact Uncertainty about the legal status ofcontracts after the Bracks government abolition of CCTwas exacerbated by high levels of council staff turnoverand internal restructuring resulting in further loss ofcontinuity and institutional memory In 2001 coordinatorsgave mixed responses to questions about satisfaction withtheir current organisational structures and the likely impactof lsquobest valuersquo policy development under the Laborgovernment Overall however both those responsible forcouncil and non-council teams reported good support forMCH programs improvements in strategic focusteamwork and flexibility and enhanced workingrelationships with other professional colleagues

There is no doubt that promoting an internal marketwas divisive and something of a distraction Neverthelesssome MCH nurses used the upheaval to createopportunities for empowerment growth and personaldevelopment Of real significance is that the processes ofCCT gave MCH nurses particularly coordinators accessto information about the structure of their budgets andincreased control over expenditure In the past surplusesdisappeared and professional development allowances andmaintenance budgets lacked transparency Howeverthrough CCT processes MCH nurses became much moreknowledgeable One coordinator made the point that post-CCT lsquono-one touches one line of my budgetrsquo Manynurses coordinators especially have developed thecapacity and confidence to access and apply relevantinformation to the management of the services learnt newskills and how to utilise them effectively Restructuringhas given MCH nurses greater responsibility than they hadunder the earlier administrative regime and they have hadto become much more aware of the need to lsquosellrsquo theirservice and to understand the new management context

Although it seems that many continue to prefer thetraditional modes of service delivery and resistcollaboration in teams they are increasingly out of stepwith their profession and organisational realities

Further research is needed in specific areas MCH nursingmay well be asked in the future to justify its existence in stillmore stringent terms than CCT demanded The diverseexperiences of the service users require ongoing researchthrough more detailed evaluation frameworks than customersatisfaction surveys Most importantly a common processacross individual municipalities is needed to ascertainclientsrsquo views across the state As governments are debatingthe nature of universalism studies about the community roleof MCH nursing would be valuable These shouldincorporate analysis of what are legitimate expectations ofmothers from all strata for access to the advice and supportthat they need We suggest that cost-effectiveness studies ofMCH services pay particular attention to maternal health aswell as that of infants and children The shift to communityhealth auspicing of MCH services also warrants furtherresearch as it is not yet clear what effect this new locationwill have on overall policy approaches and service deliveryThe role of private providers also requires attention Therisks of fragmenting the consistency and quality of MCHservices through maintaining contractual arrangements thatvary across municipalities should be examined and means ofensuring effective support for the nurses in coordinationroles explored

Major hurdles still need to be overcome includingwage parity and workload discrepancies along with apolicy legacy of that sought to restrict the practice of MCHnurses to agendas driven by medically definedsurveillance In our view this orientation is at odds withthe developing interest globally and nationally in socialsupport in the early years of life as one of the mostinfluential social determinants of health (Marmot andWilkinson 1999) This requires a broad primary healthcare driven response to the health and welfare of mothersand their children and an important role for well-supportedand directed MCH services

REFERENCESConsidine M 1992 Locating welfare in administration in Beilharz PConsidine M and Watts R (eds) Arguing about the welfare state TheAustralian experience Sydney Allen amp Unwin

Hancock L (ed) 1999 Health policy in the market state Sydney Allen amp Unwin

Australia Department of Health and Community Services 1993 Childrenrsquos andfamily services redevelopment scoping review Melbourne VictorianGovernment Department of Health and Community Services

Australia Department of Health and Community Services 1994 Competitivetendering of HampCS programs A guide for local government MelbourneVictorian Government Department of Health and Community Services

Marmot M and Wilkinson R 1999 Social determinants of health OxfordOxford University Press

Qualitative Solutions and Research Pty Ltd 1999 NUDIST Vivo Melbourne QSR

Reiger K 2001 From tender care to tendered contracts and customer servicingThe case of the Victorian Maternal and Child Health Service The AustralianJournal of Social Issues 36(4)333-340

Reiger K and Keleher H 2002 Surviving the contract state A report on theVictorian maternal and child health service in a decade of change Bundoora LaTrobe University

Whitfield D 1992 The welfare state Privatisation deregulationcommercialisation of public services alternative strategies for the 1990sSydney Pluto Press

RESEARCH PAPER

36


ABSTRACTThis paper offers ideas and guidelines for timely

completion of nursing theses by way of non-intrusiveresearch - research with minimum impact or intrusionupon research participants It arises from lessonslearned in assisting nursing research students submittheir theses within specified timeframes Too oftenstudents embark upon projects unnecessarilyambitious for the purpose of their degree resulting inprotracted finishing dates and disrupted careersDifferent forms of non-intrusive data are addressedtheir advantages disadvantages and ethicalconsiderations Rigorous data analysis fitting to non-intrusive data - content analysis - is describedfeatures measures category requirements andpractical principles Application to nursing theses isprovided and the vexing issue of freedom given tonursing students in designing their research is raised

INTRODUCTION

Timely completion of theses is an issue raised bytheses supervisors research degree coordinatorsand research departments in higher education

institutions Recent discussion about improving researchcompletion rates within the Australian research trainingscheme highlighted lsquolaissez fairersquo supervision andattempting to produce lsquothe great workrsquo as deterrent factors(The Australian Higher Education Supplement 15 Jan2003 p24) This raises questions of expediency versushigh quality outcomes Which is more important a projectbeing completed on time or taking as long as necessary toanswer the research question We argue both are equallyimportant in well-designed research

Well-designed projects require research questions andmethods be developed very carefully These determinantsare addressed at length in numerous texts written forresearchers and supervisors (Roberts and Taylor 2002Langford 2001 Phillips and Pugh 1994 Parry and Hayden1994 Lewins 1993 Van Wagenen 1991) Unfortunatelydespite the resources available we continue to witnesssituations where students become bogged down andseverely delayed in overly ambitious projects in terms ofsize and expected outcomes The research trainingrequired could have been achieved by way of smallermore tightly designed projects

Being tempted to create lsquothe great workrsquo is welladdressed by Mullins and Kiley (2002) They make thepoint (quoting Ballard) that examiners of theses assumecandidates are lsquostill apprentices in the profession ofresearch in their disciplinersquo and thus largely judged ontheir lsquofuture promisersquo (p371) On this note we believe it isin the best interest of advancing the nursing discipline forcandidates to complete theses fitting their lsquoapprenticersquostatus to graduate and move on to postgraduate research -not languish in their candidature

Nursing academics in Australia have voiced their topthree lsquomost preferredrsquo outcomes for 2005 (Sellers andDeans 1999 p55)

Carolyn Emden RN MEd PhD Independent scholar LobethalSouth Australia

Colleen Smith RN MEd PhD Senior Lecturer School ofNursing and Midwifery University of South Australia

Accepted for publication September 2003

Note This material may appear in part in unpublished guidelines developedfor the Bachelor of Nursing Science (with Honours) students at theUniversity of South Australia

NON-INTRUSIVE RESEARCH IDEAS AND GUIDELINES FOR EXPEDIENT THESISCOMPLETION

SCHOLARLY PAPER

Key words non-intrusive research thesis content analysis


hellipthat nursing be fully accepted by other academics asa discipline in its own right that nursing practice be morestrongly guided by research and that nurse academicsbecome more visible within the international researchcommunity

These strongly research oriented desires highlight theneed for timely completion rates by nursing researchstudents more qualified researchers are required toadvance the discipline This need is further borne out bythe results of a recent survey of Australian nursingresearchers showing lsquothat publication of refereed researcharticles by Australian nurses is low in relation to the totalarticles in the journals analysedrsquo (Wilkes et al 2002 p19)publication is integral to the thesis completion process

We believe it incumbent upon thesis supervisors andcandidates to recognise the thesis experience as primarilya research training exercise and only embark upon projectsthat can realistically be achieved within specifiedtimeframes Here we propose one way for researchstudents to expediently achieve the aims of their thesis

Proposed projectThe proposed project is a content analysis of non-

intrusive data That is the method of data analysis iscontent analysis and data comprise information obtainedwithout engaging or disturbing the activity of other people- hence the term lsquonon-intrusiversquo Importantly this meansthe approval of a human research ethics committee willgenerally not be required to conduct the project (individualuniversity regulations may vary) a potentially delayingprocess However this is not to suggest such a project iswithout ethical considerations - a serious point to whichwe return in this paper

Typically the research topic drives project designHowever for a beginning researcher working within astrict timeframe the situation may ideally be a littledifferent The nature of data to be collected and method ofdata analysis may be specified prior to topic selectionWhen non-intrusive data and content analysis are used as away of arriving at a topic we have found any initialfeeling of constraint by students soon gives way toexcitement on discovering a topic of professional interestAs the following material is perused we suggest thesequestions be asked

bull How does this material relate to my situation

bull What interests me especially about this material

bull Does this material remind me of an aspect of practicethat could be investigated

bull Could this material offer a new perspective on an old problem

bull Has this new perspective been studied before in myhospitalsettingcountry

Responses will help topic selection and the definition ofa research question Reading from several sources is

suggested We refer especially to Kellehearrsquos text Theunobtrusive researcher A guide to methods (1993)however the topics will be covered in many research texts

NON-INTRUSIVE RESEARCH

AdvantagesSome advantages of collecting data by non-intrusive

measures are

bull researchers are able to lsquosee for themselvesrsquo (interviewsand questionnaires rely on believing what others say)

bull measures are usually discrete and harmless to others

bull measures are easily repeatable increasing reliability

bull cooperation with others is rarely needed

bull measures are usually inexpensive and

bull because measures are non-disruptive inexpensive andsafe they are ideal for longitudinal studies conductedover a period of time (Kellehear 1993 pp5-6)

DisadvantagesSome disadvantages of collecting data by non-intrusive

measures are

bull original records may be distorted

bull observations from the view point of a stranger may failto grasp important in-group meanings

bull intervening variables may distort data (for examplegarbage analysis not taking into account recyclingpractices)

bull selective recording by observers with different interestsbiases and backgrounds (for example a male observerof women may notice different features than a femaleobserver and vice versa) and

bull the interrogation potential of verbal methods is missing(Kellehear 1993 pp6-8)

Sources of non-intrusive data

Audio-visual recordsThese include photographs film and television and

music (Kellehear 1993 p73-95)

Written recordsThese include official statistics (government and

private) books journals newspapers and popularmagazines government business and other administrativerecords personal diaries letters and journals (Kellehear1993 p51-72)

Simple observations bull Exterior physical signs - eg clothing street signs

menus shoe style graffiti

SCHOLARLY PAPER

38


bull Expressive movements - eg smiling frowning bodilymovements of eyes face limbs or posture

bull Physical location - eg use of physical settings andpersonal space in places like lifts and trains

bull Language behaviour - eg stuttering and conversationalbehaviour

bull Time duration - eg the time paid to a shop or anexhibit (such as a poster presentation at a conference)or different type of interaction (such as question timeat a conference presentation) as an indicator of interest(Kellehear 1993 pp115-138)

Material cultureThese data include any object or trace that indicates the

extent and type of an activity A classical example providedby Kellehear involves a Sherlock Holmes story lsquoHolmescongratulates Watson on his purchase of one of a pair ofprofessional office suites When asked the basis of thisHolmes points to the fact that the steps leading to Watsonrsquossuite were more worn implying more profitable peopletraffic to this suite compared to its twin on the other sidersquo(p96) Akin to this is the idea of examining the wear andtear on books or journals as an indicator of their popularityand use Content analysis of household garbage has beenthe subject of many studies to ascertain such things associal class (working class areas dispose of more beer canswhile middle-class areas dispose of more wine bottles) andlove of dogs (number of dog food cans disposed of)Cemeteries have attracted hundreds of studies to discoverclues about past cultural values and practices as hasgraffiti And so the possibilities go on (Kellehear 1993pp96-114)

Note non-intrusive data do not include informationcollected from interviews questionnaires manipulativeexperiments or tests such as psychometric tests

BEING EXPEDIENT IN COLLECTING DATA

Audio-visual recordsDue to potential confidentiality and sensitivity issues

we advise accessing only public audio-visual records suchas television cinema radio professionally availablevideos or published photographs in newspapersprofessional journals or textbooks For projects requiringcompletion within one or two semesters we suggest notattempting to access any personal audio-visual collectionsgovernment audio-visual records private or public hospitalor other workplace audio-visual records or archivesNegotiations required for these latter sources are likely toconsiderably delay progress

Written records

Again as with audio visual sources due to potentialconfidentiality and sensitivity issues we advise accessingonly public published written records available in public orprofessional libraries (the main non-archival sections)

such as newspapers professional journals or textbooks orprofessionally distributed pamphlets or posters Forprojects requiring completion within one or two semesterswe suggest not attempting to access any personal diary ordocument collections unpublished government recordsprivate or public hospital or other workplace writtenrecords or archives Again (as with audio visual sources)negotiations required for these latter sources are likely toconsiderably delay progress

Simple observation

Like material culture simple observation (also callednon-participant observation) offers vast opportunity fordata collection for the researcher as a detached onlookerWhere human behaviour is being observed however thereare potential ethical dilemmas because some people objectto the idea of being observed and perceive observation aslsquospyingrsquo Objection may increase with the use of notetaking or audio taping (common devices for recordingobservations) - especially when these are performed in aclumsy covert fashion This is a trap for beginningresearchers as Kellehear indicated with his anecdote of thecurious waitress asking lsquoWhy are you writing underneaththe tablersquo (1993 p129)

Because observation involves many features ofethnographic research with its own specialist skills andconcerns including those above we suggest it is likely to beunsuitable for a project of one or two semesters However ifapproval to proceed is received (for example within alonger project) due to potential confidentiality andsensitivity issues we suggest undertaking observations onlyof public settings or things where people are not involvedeg commercial products bill boards street signs or publicmeeting places These observations should take placeoutside of government or professional workplaces orprivate homes (intrusive research)

Material culture

Material culture offers vast opportunity for datacollection but one needs to be aware of some limitationsDue to a host of lsquosocial historical or geographicalconditions objects or traces may be erased or vary becauseof unknown intervening variablesrsquo (Kellehear 1993 p106)This means the researcher cannot be sure what they arelooking at actually represents what they think it does Forthis reason when gathering data from material cultureKellehear recommends researchers also employsupplementary methods such as archival observational andconversational inquiry (p112) This requirement is likely toincrease the complexity of the research process beyondfeasibility for a project of one or two semesters and wesuggest not seeking data from material culture However ifapproval is received to proceed (for example for a longerproject) due to potential confidentiality and sensitivityissues we suggest only accessing physical settings objectsor traces in public places That is outside of government orprofessional workplaces or private homes (intrusiveresearch)

SCHOLARLY PAPER

39


ETHICAL CONSIDERATIONS OFCOLLECTING NON-INTRUSIVE DATA

We stated earlier that non-intrusive methods do notgenerally require the approval of a human research ethicscommittee because they donrsquot involve active participationby people As can be seen though people (or theirproducts or possessions) are part of the non-intrusiveprocess and researchers are obliged to consider issues ofconfidentiality and privacy The basic principle of lsquonoharm shall be donersquo applies to all research

Audio-visual records

Be aware permission to view and use photos foranalysis is different to permission to use them publicly (forexample in a book or exhibition) When commenting uponphotos or film footage appreciate living relatives orindeed those in the photos if still alive may be offendedby the commentary Know also some Indigenous peoplesdo not wish to see images of dead relatives or have theirnames mentioned Reproducing music or film may havecopyright implications and these should be checked with alibrarian (Kellehear 1993 pp94-95)

Written records

Kellehear warned readers not to think just because youare dealing with books that people are not affected bywhat you write For example owners of documentslsquosometimes do not wish to be identified for security orpublicity reasonsrsquo (1993 p71) This raises the issue ofconfidentiality He pointed out one must be careful not tomisrepresent data (cheating) breach copyright regulationsor fail to appropriately reference othersrsquo ideas(plagiarism) It is also important not to misrepresent yourrole and purpose to officials in libraries and archives thusraising the issue of consent (Kellehear 1993 p71)

Simple observation

The main ethical dilemma is lsquoone personrsquos looking isanother personrsquos spyingrsquo (Kellehear 1993 p135) In otherwords should permission always be sought beforeundertaking observational research Kellehear pointed outthe difficulties of this Firstly once someone knows theyare being observed their behaviour is likely to changedefeating the research purpose Secondly consent isimpractical in certain situations such as crowds (eg insports stadiums or on university campuses) where it wouldbe impossible to know from whom to seek permissionThese are issues of privacy Kellehear stated it is lsquodoubtfulthat privacy is invaded by being observed in a publicplacersquo However he also pointed out the controversyobserving private acts in public places can cause (such asobserving physical location of breast feeding practices in alocal shopping centre)

Material culture

As Kellehear pointed out most observations areharmless and cause no offence to others such as studyingwear on door handles or books or commenting on types of

food in certain restaurants (1993 p112) But ethicaldilemmas can still present - consider the unwaryresearcher studying garbage who finds body parts orevidence of crimes such as theft and drug trafficking Suchfinds raise issues of privacy - lsquocan garbage be regarded asrdquonon-privaterdquo once it appears on the nature strip in front ofthe housersquo (1993 p113) Be aware that observations ofmaterial culture in some places may require consent fromowners or local authorities (eg hospitals or health clinics)(Kellehear 1993 p113)

CONTENT ANALYSIS Content analysis is a frequently used means of making

sense of non-intrusive data Basically it is a way of findinguseful patterns in data Two important features are

1 The researcher decides what categories will be searchedfor in the data prior to commencing the search (in contrastto thematic analysis where themes are derived from thedata after the search is underway) This assumes theresearcher knows what they want to search for limitedonly by the imagination

2 The category is frequently quantified eg the number oftimes it occurs is counted lsquoIn observations one may countgrimaces or sitting or eye contact touching dominatingor submissive behaviour and so on In written form onemay count certain words phrases or ideas as these appearin the textrsquo (Kellehear 1993 pp34-35)

Both these features (a priori selection andquantification) are influences from the positivist traditionHowever it is an oversimplification to locate contentanalysis purely in the deductivepositivistquantitativeparadigm As familiarity with the potential of contentanalysis increases we advise it be considered a blend ofmethods For those particularly interested in a qualitativeapproach to content analysis we suggest referring toLupton (in Minichiello et al 1999)

Measures in content analysisbull Time-space measures - eg lsquonewspaper column inches

devoted to a certain topics in a newspaper hours oftelevisionrsquo

bull Simple appearance - eg lsquoHow many televisionadvertisements use male voice-oversrsquo

bull Frequency - eg lsquohow many times does a word or an ideaappear in a policy document or textbook or speechrsquo

bull Intensity - eg lsquoimportance or prominence in thebehaviour text or objectsrsquo (Kellehear 1993 p35)

Category requirements to ensure credibility of contentanalysisbull Comprehensiveness which means lsquoexamining all the

relevant sources and not just those which support yourown theoryrsquo

SCHOLARLY PAPER

40


bull Categories must be specific clear and not overlapping -lsquoto minimise ambiguity and maximise reliabilityrsquo

bull Clear definitions of categories lsquoso that even a computercould locate the data into themrsquo - this strengthensreliabilityrsquo (Kellehear 1993 p35)

Practical principles in content analysisbull Decide on certain categories (from research question)

bull Choose the sample

bull Select the time period for sampling

bull Decide on the number of events to be observed issuesto be read showsfilms to be seen

bull Record the observations systematically tables can beuseful (Kellehear 1993 p36)

Writing the research questionThe research question should be clear concise and

relate directly to the research interest or problem To arriveat a question it is useful to write a short paragraph on theresearch interest or problem For example the beginningresearcher might be interested in how nursing as aprofession is portrayed through public media such as jobadvertisements popular magazines and televisionprograms They may be concerned the general populationis not receiving messages that reflect current thinking aboutnursing as a discipline and a profession Some of their ownfamily members and friends may have made commentsabout nursing that clearly reflect outdated ideas Thisexperience is now the motivating force to research theproblem and a content analysis of job advertisements in thenational newspaper is considered a good place to start It isunderstood as impractical to attempt researching more thanone public medium within one project an analysis ofpopular magazines or television programs would need tocomprise separate projects

Out of the short statement developed as describedabove the topic can be derived for example lsquoThe publicimage of nursing as portrayed in nursing jobadvertisementsrsquo A clear statement of topic also leads tothe research question for example lsquoHow is nursing as aprofession portrayed in job advertisements for registerednurses in the national newspaperrsquo

APPLYING THE PRINCIPLES IN CONTENTANALYSIS

Deciding categories for content analysisRecalling Kellehearrsquos (1993) measures in content

analysis it might be decided to use a space measure suchas the size of newspaper column space devoted to eachadvertisement (assuming size relates to importanceattached to the content) Or a simple appearance measuresuch as layout of the advertisement whether headings areused and style and size of headings and print used The

choice may be made to examine frequency for examplehow many times do the words lsquoregistered nursersquo (asopposed to just lsquonursersquo) lsquoprofessionalrsquo lsquonursingdisciplinersquo or other words considered important appear ineach advertisement Or an intensity measure to indicateimportance or prominence such as mention in theadvertisement of a degree or higher degree in nursing

Recall also the requirements suggested by Kellehear(1993) to ensure credibility of content analysisComprehensiveness which in the above example wouldmean examining all advertisements according to thecategories not just those supporting onersquos theoryCategories must be specific and not overlapping that iseach must be distinctly different Finally clear definitionsof categories are needed so there is no doubt about whichdata fit into each

These are suggestions only As mentioned before thecategories developed are only limited by onersquosimagination Also as reading extends beyond this paperand Kellehearrsquos (1993) ideas other ideas about categoriesconsidered more useful for a particular situation may befound The important point is that categories are developedbefore analysis is undertaken

Choosing a sampleContinuing with the example of job advertisements for

registered nurses it is necessary to decide whichnewspaper is going to be analysed on what days andwithin what sections Can the advertisements appear onany pages or are only certain lsquopositions vacantrsquo pages orsections within certain pages to be analysed Reachingthese decisions will require familiarisation with thenewspaper in question

Selecting a time periodBe realistic here For example for a project that must

be accomplished within one semester we suggest datacollection occur within a three to four week period (or fora two semester project a six to eight week period)Experience shows being tempted to extend beyond thistime will adversely affect the projectrsquos progress Thesuccess of a project depends more on the quality of thework than the quantity In the newspaper example beaware the three weeks of advertisements could becollected from recent past newspapers one would notnecessarily have to wait week by week for the newspaperto be published

Deciding on the number of events to be observed There are no hard rules on this Using the newspaper

example we anticipate collecting all job advertisementsfor registered nurses in a major weekly newspaper forthree weeks would yield ample data for the purpose (say30-40 advertisements) Enough data for a rigorous analysisis needed but one does not want to be overwhelmed bydata to the point where only a superficial analysis can be

SCHOLARLY PAPER

41


undertaken (reducing the number of categories will helpovercome this problem) Again itrsquos more important to beinterested in quality rather than quantity and theappropriate scope of the project needs constantly bearingin mind

Recording observations systematicallyWhile one should think ahead and plan for how to

record the outcomes of the analysis it will only be whenoutcomes are to hand that some final decisions will bereached Reading research textbooks for ideas on this is agood idea Because analysis will involve numbers andcounting clearly labelled tables can be useful Othermeans of displaying descriptive statistics such as graphsand pie charts are likely to also be useful Remember theimportant point is that the reader of the report can clearlyunderstand the outcomes of the analysis Complex orfancy recording will serve no purpose unless it conveys themessage intended In some instances simple statementswill convey the meaning most usefully

OTHER TOPIC IDEASThe example of the newspaper advertisements is just one

of numerous similar possibilities For example interestmight be held in how nursing is portrayed in other mediasuch as magazines or novels or television or radio Oneneeds to be aware with audio-visual media copying theparticular program will be necessary (librarians are helpful inmaking sure copyright law is not infringed) so the programor footage can be viewed over and over to undertake ananalysis Or onersquos interest might be to analyse an audio-visual product available in the library This is a simpleroption but be aware analysis of audio-visual records isgenerally more complex than written records

Interest might lie in entirely different topics such ashow a particular nursing procedure is recorded in differenttextbooks or journal articles (we suggest avoidingworkplace-based procedure manuals - stay with publishedsources) Or interest might lie in a particular healthpromotion message being distributed in a local area ornationally via pamphlets and posters Or one might wishto analyse the contents of a local or national nursingjournal to ascertain how many articles are research-basedor display other features in which interest is held

The more one thinks and reads about non-intrusive dataand content analysis in relation to onersquos own situation themore ideas come to mind The researcher will eventuallysettle on a topic that is of great interest and which theybelieve could be significant in improving nursing care -which after all is the prime purpose of nursing research

We encourage readers to study research reports usingcontent analysis as a research methodology and to makeuseful links with the ideas presented here For example inthe fields of nursing and health some recent reportsinvolve content analysis of journal articles (Halimaa

2003) historical documents (Meehan 2003) printjournalism (Jamieson et al 2003) news media coverage(Schwartz and Woloshin 2002) television (Zuppa et al2003) and health journals (Weaver et al 2003)

CONCLUSIONImplicit in the practical advice of this paper are vexing

questions about the appropriate degree of freedom given toresearch students in their choice of topic and methodNursing has a tradition of individual students conceivingand conducting individual projects in their researchdegrees However this practice is increasingly underchallenge as the most effective means of advancing thenursing profession with proposals afoot for students to berather linked with existing programs of research (Emdenand Borbasi 2000) Our proposal for non-intrusive researchfalls within this wider search for effectiveness andexpediency It can also be argued that preparing andsubmitting an ethics application is an important researchtraining exercise While not denying this we suggest fortimely completion we cannot afford to expose all studentsto all research processes and methodologies

We believe non-intrusive research is well suited toresearch students completing a thesis Because itminimally disturbs other people (a significant benefit initself) it offers time saving features that can assist inpropelling students toward completion within specifiedtimeframes Combined with content analysis as a means ofanalysing the non-intrusive data collected we consider itto be a rigorous and ethical process with potential to meetthe research training purpose of a thesis at honours ormaster (or indeed doctoral) level We suggest the ideas andguidelines offered here provide a sound basis on which tobase further exploration

REFERENCESEmden C and Borbasi S 2000 Programmatic research A desirable (ordespotic) nursing strategy for the future Collegian 7(1)32-37

Halimaa S 2003 Pain management in nursing procedures on premature babiesJournal of Advanced Nursing 42(6)587-598

Hong T and Cody M J 2002 Presence of pro-tobacco messages on the WebJournal of Health Communication 7(4)273-308

Jamieson P Jamieson KH and Romer D 2003 The responsible reporting ofsuicide in print journalism American Behavioral Scientist 46(12)1643-1651

Kellehear A 1993 The unobtrusive researcher A guide to methods StLeonards NSW Allen and Unwin

Langford RW 2001 Navigating the maze of nursing research An interactivelearning adventure St Louis Mosby

Lewins F 1993 Writing a thesis A guide to its nature and organisationCanberra ANUTECH (now ANU Enterprise)

Lupton D 1999 Content Analysisrsquo in Minichiello V Sullivan G GreenwookK and Axford R (eds) Handbook for research methods in health sciencesFrenchs Forest NSW Addison-Wesley

Meehan TC 2003 Careful nursing A model for contemporary nursingpractice Journal of Advanced Nursing 44(1)99-108

Mullins G and Kiley M 2002 lsquoItrsquos a PhD not a Nobel Prizersquo Howexperienced examiners assess research theses Studies in higher education27(4)369-386

SCHOLARLY PAPER

42


Parry S and Hayden M 1994 Supervising higher degree research studentsCanberra Australian Government Printing Service

Phillips EM and Pugh DS 1994 How to get a PhD A handbook for studentsand their supervisors (2nd ed) Buckingham Open University Press

Roberts K and Taylor B 2002 Nursing research processes An Australianperspective (2nd ed) South Melbourne Nelson

Schwartz LM and Woloshin S 2002 News media coverage of screeningmammography for women in their 40s and Tamoxifen for primary prevention ofbreast cancer Journal of the American Medical Association 287(23)3134-3136

Sellers ET and Deans C 1999 Nurse education in Australian universities in aperiod of change Expectations of nurse academics for the year 2005 NurseEducation Today 19(1)53-61

The Australian Higher Education Supplement 25 January 2002 p24

Van Wagenen RK 1991 Writing a thesis Substance and style EnglewoodCliffs Prentice Hall

Weaver AJ Flannelly KJ Flannelly LT and Oppenheimer JE 2003Collaboration between clergy and mental health professionals A review ofprofessional health care journals from 1980 through 1999 Counseling andValues 47(3)162-172

Wilkes L Borbasi S Hawes C Stewart M and May D 2002 Measuringthe outputs of nursing research and development in Australia The researchersAustralian Journal of Advanced Nursing 19(4)15-20

Zuppa JA Morton H and Mehta KP 2003 Television food advertisingCounterproductive to childrenrsquos health A content analysis using the Australianguide to healthy eating Nutrition and Dietetics The Journal of the DietitiansAssociation of Australia 60(2)78-85

SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL

THE RELATIONSHIP BETWEEN CRITICAL THINKING AND CONFIDENCE IN DECISION-MAKING

HITTING THE FLOOR RUNNING TRANSITIONAL EXPERIENCES OF GRADUATE SPREVIOUSLY TRAINED AS ENROLLED NURSES

PERSPECTIVES OF CORONARY BYPASS SURGERY IN TERMS OF GENDER AGE PREVIOUS MYOCARDIAL INFARCTION AND SPIRITUALITY

REGISTERED AND ENROLLED NURSESrsquo EXPERIENCES OF ETHICAL ISSUES IN NURSING PRACTICE

NURSES ON THE MARKET THE IMPACT OF NEO-LIBERALISM ON THE VICTORIAN MATERNAL AND CHILD HEALTH SERVICE

NON-INTRUSIVE RESEARCH IDEAS AND GUIDELINES FOR EXPEDIENT THESIS COMPLETION


Despite an espoused commitment at policy level tointegrated service delivery and collaborative workpractices Reiger and Keleher express the view thatrestrictive practices for nurses within a child and familyhealth service arise from medically defined surveillanceof service policies and practice

Collectively we must address the dissonances withinnursing Change efforts may not be successful when theyare policy driven without a basis in practice or purelypolitically motivated Realistic solutions to situations thatbecome problematic in the real world of practice have toencompass acknowledgement of ambiguity and thehuman aspects of change processes A failure toacknowledge the reality and inherent complexity of thecoalface can lead to limitations in outcomes of wellintentioned policy Hence there is a need to acknowledgethe uniqueness of challenges of introducing change

One of the challenges in introducing change isavoiding the creation of the perpetuation of the lsquousrsquo andlsquothemrsquo mentalities that pervade organisations wherechange is a constant feature of work

Education and training is frequently identified as amechanism for reducing the popularised lsquogapsrsquo in nursingsuch as the theory-practice gap or the policydevelopment-implementation gap However educationand training strategies remain in the main content drivenindividual learner oriented and expert provider focusedWhile learning has historically been targeted towardindividual learners and their needs increasing reference ismade in the literature to the concept of organisationallearning Organisational learning is seen as the key toorganisational survival It is also thought to offeropportunity for the survival and development ofprofessions in health care

Organisational learning has been characterised as astrategy through which an organisation is able to improveperformance and prevent and respond to error through thedevelopment of practice based insights

Organisational learning recognises the coexistence ofboth the mechanistic and functional elements oforganisational change as well as the lsquosofterrsquo humanisticelements of reform and consists of two interrelatedelements individual learning and development and thedissemination of and elaboration of that learning throughconscious interaction with others While thoroughevaluations can provide evidence of the real worth ofpolicy in practice as well as identifying aspects ofoutcomes that were either not in the original plans ofapproach to change agenda or arose unexpectedly fromthe context of practice there is need to disseminateinformation derived from policy evaluation to the nursingworkforce and communicate reasons for policy retention(or abandonment) The concept of a learning organisationprovides a framework in which to nest dissemination ofpolicy and evaluation of policy in ways that are inclusiveand supportive of nurses

Related to but distinct from organisational learningthe concept of the learning organisation has becomeincreasingly popular in literature related to organisationalchange The learning organisation is one in which thelearning of all its members is encouraged in order for theorganisation (or we would argue the profession) tosustain and transform itself

The concept of workforce development has emerged inrelation to organisational learning and the creation oflearning organisations Workforce development is seen asa key element in meaningfully enacting policy directionsand acknowledges the interface between the lsquointernalrsquopractice context and the external policy context It isimportant to note that workforce development recognisesthe need to have supportive workplace structures fordevelopment to occur More enlightened approaches toworkforce development also acknowledge that thedeveloped workforce shapes its own future throughskilling staff in policy generation and evaluation andaddressing dissonance in ways that are not destructive toeither individuals or the profession

EDITORIAL

6


GUEST EDITORIAL

7














Why a story











VOICING NURSING












INTRODUCTION








RESEARCH PAPER



LITERATURE REVIEW








METHODOLOGY







RESEARCH PAPER

9




























FINDINGS





RESEARCH PAPER

10













RESEARCH PAPER

11


Age 2405 577 20-53 -

Male - - - 25

Female - - - 75





(decision-making)


























RESEARCH PAPER

12




INTRODUCTION









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INTRODUCTION













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ABSTRACT









INTRODUCTION











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DISCUSSION


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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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3 Organ transplants

























counselling and
























RESEARCH PAPER

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health services















RESEARCH PAPER













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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











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measures are








measures are













SCHOLARLY PAPER

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Written records



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SCHOLARLY PAPER

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Written records


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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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GUEST EDITORIAL

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Why a story











VOICING NURSING












INTRODUCTION








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LITERATURE REVIEW








METHODOLOGY







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INTRODUCTION













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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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counselling and
























RESEARCH PAPER

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health services















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measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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FROM THE EDITORS

GUEST EDITORIAL


















INTRODUCTION








RESEARCH PAPER



LITERATURE REVIEW








METHODOLOGY







RESEARCH PAPER

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FINDINGS





RESEARCH PAPER

10













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Age 2405 577 20-53 -

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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counselling and
























RESEARCH PAPER

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health services















RESEARCH PAPER













RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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Written records


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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL








LITERATURE REVIEW








METHODOLOGY







RESEARCH PAPER

9




























FINDINGS





RESEARCH PAPER

10













RESEARCH PAPER

11


Age 2405 577 20-53 -

Male - - - 25

Female - - - 75





(decision-making)


























RESEARCH PAPER

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INTRODUCTION









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RESEARCH PAPER

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

28











































RESEARCH PAPER

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counselling and
























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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL


































FINDINGS





RESEARCH PAPER

10













RESEARCH PAPER

11


Age 2405 577 20-53 -

Male - - - 25

Female - - - 75





(decision-making)


























RESEARCH PAPER

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INTRODUCTION









RESEARCH PAPER

















RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

28











































RESEARCH PAPER

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counselling and
























RESEARCH PAPER

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RESEARCH PAPER













RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL



















RESEARCH PAPER

11


Age 2405 577 20-53 -

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(decision-making)


























RESEARCH PAPER

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INTRODUCTION









RESEARCH PAPER

















RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

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counselling and
























RESEARCH PAPER

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RESEARCH PAPER













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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL






























RESEARCH PAPER

12




INTRODUCTION









RESEARCH PAPER

















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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

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counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





health services















RESEARCH PAPER













RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL










INTRODUCTION









RESEARCH PAPER

















RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

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DISCUSSION


RESEARCH PAPER

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RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

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RESEARCH PAPER

30


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RESEARCH PAPER













RESEARCH PAPER

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33



















RESEARCH PAPER

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RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL






















RESEARCH PAPER

14




















RESEARCH PAPER

15



















RESEARCH PAPER

16









































RESEARCH PAPER

17


ABSTRACT









INTRODUCTION













RESEARCH PAPER














RESEARCH PAPER

19

















RESEARCH PAPER

20


















RESEARCH PAPER

21








































RESEARCH PAPER

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RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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RESEARCH PAPER

30


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RESEARCH PAPER

32
















RESEARCH PAPER

33



















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34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






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SCHOLARLY PAPER

40
























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41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL


























RESEARCH PAPER

15



















RESEARCH PAPER

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RESEARCH PAPER

17


ABSTRACT









INTRODUCTION













RESEARCH PAPER














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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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RESEARCH PAPER

30


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RESEARCH PAPER













RESEARCH PAPER

32
















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33



















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34











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35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL

























RESEARCH PAPER

16









































RESEARCH PAPER

17


ABSTRACT









INTRODUCTION













RESEARCH PAPER














RESEARCH PAPER

19

















RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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RESEARCH PAPER

30


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RESEARCH PAPER













RESEARCH PAPER

32
















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33



















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34











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35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






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40
























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41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL















































RESEARCH PAPER

17


ABSTRACT









INTRODUCTION













RESEARCH PAPER














RESEARCH PAPER

19

















RESEARCH PAPER

20


















RESEARCH PAPER

21








































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





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RESEARCH PAPER













RESEARCH PAPER

32
















RESEARCH PAPER

33



















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34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












Written records



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SCHOLARLY PAPER

39






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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL








ABSTRACT









INTRODUCTION













RESEARCH PAPER














RESEARCH PAPER

19

















RESEARCH PAPER

20


















RESEARCH PAPER

21








































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





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RESEARCH PAPER













RESEARCH PAPER

32
















RESEARCH PAPER

33



















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34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






Written records


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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL



















RESEARCH PAPER

19

















RESEARCH PAPER

20


















RESEARCH PAPER

21








































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



3 Organ transplants

























counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





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RESEARCH PAPER













RESEARCH PAPER

32
















RESEARCH PAPER

33



















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34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






Written records


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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL























RESEARCH PAPER

20


















RESEARCH PAPER

21








































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



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counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





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RESEARCH PAPER













RESEARCH PAPER

32
















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33



















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34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






Written records


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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL
























RESEARCH PAPER

21








































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

29



3 Organ transplants

























counselling and
























RESEARCH PAPER

30


ABSTRACTObjective





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RESEARCH PAPER













RESEARCH PAPER

32
















RESEARCH PAPER

33



















RESEARCH PAPER

34











RESEARCH PAPER

35


















RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






Written records


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SCHOLARLY PAPER

40
























SCHOLARLY PAPER

41
























SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

GUEST EDITORIAL














































RESEARCH PAPER

22






















RESEARCH PAPER

23


ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

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RESEARCH PAPER

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counselling and
























RESEARCH PAPER

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health services















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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















measures are








measures are













SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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RESEARCH PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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RESEARCH PAPER

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33



















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34











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RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








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SCHOLARLY PAPER

38












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SCHOLARLY PAPER

39






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SCHOLARLY PAPER

41
























SCHOLARLY PAPER

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SCHOLARLY PAPER

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ABSTRACT









INTRODUCTION











RESEARCH PAPER





























RESEARCH PAPER

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DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


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28











































RESEARCH PAPER

29



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RESEARCH PAPER

32
















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33



















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RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








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SCHOLARLY PAPER

38












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41
























SCHOLARLY PAPER

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SCHOLARLY PAPER

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FROM THE EDITORS

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RESEARCH PAPER

25



















DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































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36




INTRODUCTION











SCHOLARLY PAPER


















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SCHOLARLY PAPER

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SCHOLARLY PAPER

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SCHOLARLY PAPER

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DISCUSSION


RESEARCH PAPER

26













RESEARCH PAPER

27


RESEARCH PAPER

28











































RESEARCH PAPER

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INTRODUCTION











SCHOLARLY PAPER


















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SCHOLARLY PAPER

43

FROM THE EDITORS

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RESEARCH PAPER

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28











































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INTRODUCTION











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FROM THE EDITORS

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RESEARCH PAPER

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INTRODUCTION











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INTRODUCTION











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FROM THE EDITORS

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INTRODUCTION











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FROM THE EDITORS

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INTRODUCTION











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INTRODUCTION











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FROM THE EDITORS

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INTRODUCTION











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FROM THE EDITORS

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RESEARCH PAPER

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RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















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FROM THE EDITORS

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36




INTRODUCTION











SCHOLARLY PAPER


















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FROM THE EDITORS

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RESEARCH PAPER

36




INTRODUCTION











SCHOLARLY PAPER


















measures are








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SCHOLARLY PAPER

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FROM THE EDITORS

GUEST EDITORIAL










INTRODUCTION











SCHOLARLY PAPER


















measures are








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SCHOLARLY PAPER

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SCHOLARLY PAPER

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FROM THE EDITORS

GUEST EDITORIAL























measures are








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SCHOLARLY PAPER

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FROM THE EDITORS

GUEST EDITORIAL


















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FROM THE EDITORS

GUEST EDITORIAL












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FROM THE EDITORS

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FROM THE EDITORS

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SCHOLARLY PAPER

42












SCHOLARLY PAPER

43

FROM THE EDITORS

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SCHOLARLY PAPER

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FROM THE EDITORS

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from the editors · 2020-02-12 · australian journal of advanced nursing 2004 volume 22 number 1...

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