The central purpose of the community health nursing role was found to be ...... making when appropriate, ethical conduct, observation and action, human ...
From Ambiguity to Action: An Insider’s Perspective on the Role of the Community Health Nurse in Australia
Submitted by
Winsome St John R.N., R.M., M.C.H.N., BAppSc (Nursing)(W.A.I.T), GradDipEd (Hawthorn), MNursStud (La Trobe), FRCNA
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy
School of Nursing Faculty of Health Sciences La Trobe University Bundoora, Victoria 3083 Australia November 1996
i
Table of Contents TABLE OF CONTENTS_____________________________________________________ I LIST OF FIGURES AND TABLES __________________________________________ IX LIST OF ABBREVIATIONS ________________________________________________ X SUMMARY _____________________________________________________________ XI STATEMENT OF AUTHORSHIP AND ACKNOWLEDGMENTS ______________ XIII
CHAPTER ONE ___________________________________________________________ I INTRODUCTION __________________________________________________________ I OVERVIEW _______________________________________________________________ I THE PURPOSE ________________________________ ERROR! BOOKMARK NOT DEFINED. SIGNIFICANCE OF THE STUDY _________________ ERROR! BOOKMARK NOT DEFINED. BACKGROUND TO THE STUDY_________________ ERROR! BOOKMARK NOT DEFINED. RATIONALE FOR THE STUDY __________________ ERROR! BOOKMARK NOT DEFINED. NOMENCLATURE OF NURSING ROLES IN THE COMMUNITYERROR! BOOKMARK NOT DEFINED. LIMITATIONS OF THE STUDY __________________ ERROR! BOOKMARK NOT DEFINED. OVERVIEW OF THE THESIS ____________________ ERROR! BOOKMARK NOT DEFINED. SUMMARY OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER TWO __________________________ ERROR! BOOKMARK NOT DEFINED. LITERATURE REVIEW ___________________ ERROR! BOOKMARK NOT DEFINED. OVERVIEW OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED. APPROACH TO REVIEW AND USE OF THE LITERATUREERROR! BOOKMARK NOT DEFINED. AN HISTORICAL OVERVIEW OF COMMUNITY HEALTH NURSING IN AUSTRALIA _______________________________ ERROR! BOOKMARK NOT DEFINED. PROFESSIONALISM AND NURSING _____________ ERROR! BOOKMARK NOT DEFINED.
ii
THEORETICAL PERSPECTIVES ON COMMUNITY HEALTH NURSINGERROR! BOOKMARK NOT DEFIN Health ____________________________________________ Error! Bookmark not defined. Community _______________________________________ Error! Bookmark not defined. Nursing___________________________________________ Error! Bookmark not defined. Towards a Conceptual Understanding of Community Health NursingError! Bookmark not defined. PERSPECTIVES ON ROLE ______________________ ERROR! BOOKMARK NOT DEFINED.
INVESTIGATIONS INTO THE ROLE OF THE COMMUNITY HEALTH NURSEERROR! BOOKMARK NOT Community Health Nursing in Australia _________________ Error! Bookmark not defined. International Perspectives on Community Health Nursing ___ Error! Bookmark not defined. SUMMARY OF CHAPTER ______________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER THREE ________________________ ERROR! BOOKMARK NOT DEFINED. METHODOLOGY AND DESIGN OF THE STUDYERROR! BOOKMARK NOT DEFINED. INTRODUCTION ______________________________ ERROR! BOOKMARK NOT DEFINED. RATIONALE FOR CHOICE OF METHODOLOGY ___ ERROR! BOOKMARK NOT DEFINED. DEFINITION OF TERMS ________________________ ERROR! BOOKMARK NOT DEFINED. STUDY ASSUMPTIONS ________________________ ERROR! BOOKMARK NOT DEFINED. DATA COLLECTION___________________________ ERROR! BOOKMARK NOT DEFINED. Selection of Participants______________________________ Error! Bookmark not defined. Approaching the Participants __________________________ Error! Bookmark not defined. The Interviews _____________________________________ Error! Bookmark not defined. Feedback and Validation Groups _______________________ Error! Bookmark not defined. Questionnaires _____________________________________ Error! Bookmark not defined. Professional, Policy and Formal Documentation ___________ Error! Bookmark not defined. Field Notes, Memos and Logs _________________________ Error! Bookmark not defined. ETHICAL CONSIDERATIONS ___________________ ERROR! BOOKMARK NOT DEFINED. ANALYSIS OF DATA __________________________ ERROR! BOOKMARK NOT DEFINED. Constant Comparison ________________________________ Error! Bookmark not defined. Theoretical Sensitivity _______________________________ Error! Bookmark not defined. The Researcher __________________________________ Error! Bookmark not defined.
iii Analytical Processes ______________________________ Error! Bookmark not defined. Theoretical Saturation _______________________________ Error! Bookmark not defined. Presentation of Data _________________________________ Error! Bookmark not defined. LIMITATIONS OF THE METHODOLOGY _________ ERROR! BOOKMARK NOT DEFINED. SUMMARY OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER FOUR _________________________ ERROR! BOOKMARK NOT DEFINED. PROFILE OF PARTICIPANTS _____________ ERROR! BOOKMARK NOT DEFINED. INTRODUCTION ______________________________ ERROR! BOOKMARK NOT DEFINED. QUALIFICATIONS ____________________________ ERROR! BOOKMARK NOT DEFINED. Highest Formal Qualifications _________________________ Error! Bookmark not defined. Qualifications in Community Health Nursing _____________ Error! Bookmark not defined. Other Qualifications _________________________________ Error! Bookmark not defined. Short Courses and Professional Development _____________ Error! Bookmark not defined. Further Study ______________________________________ Error! Bookmark not defined. EXPERIENCE _________________________________ ERROR! BOOKMARK NOT DEFINED. Participation in Organisational, Policy, Professional and Community GroupsError! Bookmark not defined. CURRENT ROLES _____________________________ ERROR! BOOKMARK NOT DEFINED. Communities Served ________________________________ Error! Bookmark not defined. Coworkers ________________________________________ Error! Bookmark not defined. SUMMARY OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER FIVE _________________________________________________________151 PERSPECTIVES ON HEALTH AND COMMUNITY __________________________151 OVERVIEW _____________________________________________________________151 HEALTH ________________________________________________________________151 HEALTHY COMMUNITIES ________________________________________________154 PRIMARY HEALTH CARE _________________________________________________155 HOLISM AND FAMILIES __________________________________________________157
iv COMMUNITY ___________________________________________________________159 Conceptualising the Community ______________________________________________159 Operationalising the Community ______________________________________________160 Geographical Boundaries _________________________________________________161 The Community as a Target Group or Population ______________________________162 The Community as a Resource _____________________________________________163 The Community as a Network _____________________________________________164 The Community as a Unit of Care _____________________________________________165 SUMMARY OF THE CHAPTER _____________________________________________169
CHAPTER SIX ___________________________ ERROR! BOOKMARK NOT DEFINED.
CONTEXT AND DIALECTICS IN THE COMMUNITY HEALTH NURSING ROLEERROR! BOOKM OVERVIEW __________________________________ ERROR! BOOKMARK NOT DEFINED. THE CONTEXT OF ROLE _______________________ ERROR! BOOKMARK NOT DEFINED. Role Ambiguity ____________________________________ Error! Bookmark not defined. Autonomous Practice ________________________________ Error! Bookmark not defined. DIALECTICS IN COMMUNITY HEALTH NURSING PRACTICEERROR! BOOKMARK NOT DEFINED. The Health-Focus/Disease-Focus Dialectic _______________ Error! Bookmark not defined. The Prevention/Treatment Dialectic ____________________ Error! Bookmark not defined. The Control and Responsibility/Dependence Dialectic ______ Error! Bookmark not defined. Exemplar: Responsibility for the Provision of Physical CareError! Bookmark not defined. The Connected/Disconnected Nature of the Nurse-Client RelationshipError! Bookmark not defined. SUMARY OF THE CHAPTER ____________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER SEVEN ________________________ ERROR! BOOKMARK NOT DEFINED. SITUATED HEALTH COMPETENCE:
ANSWERING THE QUESTION OF
PURPOSE ________________________________ ERROR! BOOKMARK NOT DEFINED. OVERVIEW __________________________________ ERROR! BOOKMARK NOT DEFINED. THE QUESTION OF PURPOSE ___________________ ERROR! BOOKMARK NOT DEFINED.
v SITUATED HEALTH COMPETENCE __________________ ERROR! BOOKMARK NOT DEFINED. Contextuality of Situated Health Competence _____________ Error! Bookmark not defined. Scope of Situated Health Competence ___________________ Error! Bookmark not defined. Level of Client in Situated Health Competence ____________ Error! Bookmark not defined. Judgement About What Constitutes Health Competence ____ Error! Bookmark not defined. Allocation of Responsibility in Situated Health Competence _ Error! Bookmark not defined. The Nurses’ Responsiveness in Promoting Situated Health CompetenceError! Bookmark not defined. Changes in the Context ____________________________ Error! Bookmark not defined. Responsiveness to Issues and Need __________________ Error! Bookmark not defined. Recognition of a Continuum in the Possible Client Achievement of a Gain in Situated Health Competence _______________________________________ Error! Bookmark not defined. DEFINING SITUATED HEALTH COMPETENCE ___ ERROR! BOOKMARK NOT DEFINED. SITUATED HEALTH COMPETENCE: MAKING SENSE OF THE ISSUES AND DIALECTICS _________________________________ ERROR! BOOKMARK NOT DEFINED. SUMARY OF THE CHAPTER ____________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER EIGHT ________________________ ERROR! BOOKMARK NOT DEFINED. “BUT WHAT DO YOU ACTUALLY DO?”:
ROLE ACTIVITIES AIMED AT
FACILITATING SITUATED HEALTH COMPETENCEERROR! BOOKMARK NOT DEFINED. OVERVIEW __________________________________ ERROR! BOOKMARK NOT DEFINED. IDENTIFYING ________________________________ ERROR! BOOKMARK NOT DEFINED. Assessing and Identifying Needs _______________________ Error! Bookmark not defined. Community Assessment ______________________________ Error! Bookmark not defined. Screening and Case-Finding __________________________ Error! Bookmark not defined. Incoming Referrals__________________________________ Error! Bookmark not defined. Follow-up and Outreach______________________________ Error! Bookmark not defined. INTERVENING _______________________________ ERROR! BOOKMARK NOT DEFINED. Case Management and Coordination ____________________ Error! Bookmark not defined. Crisis Management/First Aid __________________________ Error! Bookmark not defined. Advocacy _________________________________________ Error! Bookmark not defined.
vi Filling in the Gaps __________________________________ Error! Bookmark not defined. ENABLING ___________________________________ ERROR! BOOKMARK NOT DEFINED. Health Education and Health Promotion _________________ Error! Bookmark not defined. Problem-Solving, Counselling and Support_______________ Error! Bookmark not defined. Resources and Linking _______________________________ Error! Bookmark not defined. Developing and Empowering__________________________ Error! Bookmark not defined. Consulting, Policy Development and Health Planning ______ Error! Bookmark not defined. SUMMARY OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER NINE __________________________ ERROR! BOOKMARK NOT DEFINED.
ENACTING THE ROLE OF THE COMMUNITY HEALTH NURSEERROR! BOOKMARK NOT DEFI OVERVIEW __________________________________ ERROR! BOOKMARK NOT DEFINED. INTERPRETING _______________________________ ERROR! BOOKMARK NOT DEFINED. DEVELOPING ________________________________ ERROR! BOOKMARK NOT DEFINED. Becoming a Community Health Nurse __________________ Error! Bookmark not defined. Ongoing Personal and Professional Development __________ Error! Bookmark not defined. ALLOCATING ________________________________ ERROR! BOOKMARK NOT DEFINED. Factors Affecting the Allocating Judgements _____________ Error! Bookmark not defined. Exemplar One: Provision of First Aid in School Nursing ____ Error! Bookmark not defined. Exemplar Two: Accessibility as a Health Professional ______ Error! Bookmark not defined. VALIDATING _________________________________ ERROR! BOOKMARK NOT DEFINED. Documentation _____________________________________ Error! Bookmark not defined. Support ___________________________________________ Error! Bookmark not defined. Evaluation and Feedback _____________________________ Error! Bookmark not defined. Literature _________________________________________ Error! Bookmark not defined. Reflection _________________________________________ Error! Bookmark not defined. NEGOTIATING _______________________________ ERROR! BOOKMARK NOT DEFINED. Using Political Processes _____________________________ Error! Bookmark not defined. Networking _______________________________________ Error! Bookmark not defined. Justifying _________________________________________ Error! Bookmark not defined.
vii Establishing Credibility ___________________________ Error! Bookmark not defined. Meeting Needs __________________________________ Error! Bookmark not defined. Outcomes ______________________________________ Error! Bookmark not defined. Just Do It _________________________________________ Error! Bookmark not defined. Trade-Offs ________________________________________ Error! Bookmark not defined. Working Together __________________________________ Error! Bookmark not defined. Persuading and Explaining____________________________ Error! Bookmark not defined. Confronting _______________________________________ Error! Bookmark not defined. Accepting It _______________________________________ Error! Bookmark not defined. SUSTAINING _________________________________ ERROR! BOOKMARK NOT DEFINED. Sustaining Self _____________________________________ Error! Bookmark not defined. Interest and Commitment __________________________ Error! Bookmark not defined. Identifying Personal Success _______________________ Error! Bookmark not defined. Dealing with Dilemmas ___________________________ Error! Bookmark not defined. Sustaining the Role _________________________________ Error! Bookmark not defined. Justifying the Role _______________________________ Error! Bookmark not defined. Promoting the Role _______________________________ Error! Bookmark not defined. Expanding the Role _______________________________ Error! Bookmark not defined. Critique of Others ________________________________ Error! Bookmark not defined. INTEGRATING _______________________________ ERROR! BOOKMARK NOT DEFINED. SUMMARY OF THE CHAPTER __________________ ERROR! BOOKMARK NOT DEFINED.
CHAPTER TEN ___________________________ ERROR! BOOKMARK NOT DEFINED. CONCLUSION ___________________________ ERROR! BOOKMARK NOT DEFINED. SUMMARY ___________________________________ ERROR! BOOKMARK NOT DEFINED. FINDINGS ____________________________________ ERROR! BOOKMARK NOT DEFINED. IMPLICATIONS _______________________________ ERROR! BOOKMARK NOT DEFINED. RECOMMENDATIONS FOR FURTHER RESEARCH ERROR! BOOKMARK NOT DEFINED. CONCLUSION ________________________________ ERROR! BOOKMARK NOT DEFINED. APPENDIX ONE __________________________ ERROR! BOOKMARK NOT DEFINED.
viii APPENDIX TWO _________________________ ERROR! BOOKMARK NOT DEFINED. REFERENCE LIST _______________________________________________________378
ix
List of Figures and Tables
Table 1: Agreement from all occupational groups on the role of the community health nurse (Round a
Table 2: Disagreement between occupational groups on the role of the community health nurse (Round and Sellick, 1984) ______________________ 82
Table 3: Variation in the strength of agreement from all occupational groups (Round and Sellick, 1984) _________________________________________ 83
Table 4: _____________________________________________ Data types accessed
107
Table 5: ________________ Experience of participants in community nursing (years)
145
Table 6: __________ Description of the communities currently served by participants
149
Figure 1: ___________________________ Facilitating Situated Health Competence
241
x
List of Abbreviations ANA
American Nurses’ Association
ANF
Australian Nursing Federation
ANRAC
Australasian Nurse Registering Authorities’ Conference
CHN
Community health nurse
CPHA
Canadian Public Health Association
GP
General medical practitioner
HACC
Home and Community Care
MCHN
Maternal and child health nurse
MRN
Mental retardation nurse
NUD*IST
Non-numerical, Unstructured, Data, Indexing, Searching and Theorising (Computer software program)
OT
Occupational therapist
RN
Registered nurse
RM
Registered midwife
RPN
Registered psychiatric nurse
RFDS
Royal Flying Doctor Service
UK
United Kingdom
USA
The United States of America
WHO
World Health Organization
xi
Summary This study into the role of the community health nurse in Australia provides an explanation about the nature of the community health nursing role, its philosophical bases, purpose, a description of role activities and an analysis of how community health nurses enact their role, from the perspective of the practitioner. Data were collected from seventeen ‘excellent’ community health nurses practising in a range of community health settings in three states of Australia. The data included transcriptions from in-depth interviews, questionnaires, group discussions with participants, job descriptions, agency documentation, and documentation of professional organisations. Data were analysed using grounded theory methodology. This study found that the philosophical perspectives providing a basis for community health nursing practice were related to an holistic, contextual notion of health in which the individual is inextricably linked with the family and community. The community was viewed in terms of geography, target groups, resources, and as a network. Furthermore, where a community had sufficient connectedness, it was conceptualised as an entity. The central purpose of the community health nursing role was found to be facilitating Situated Health Competence. This occurs when individuals, families, groups and communities: identify and manage their own illnesses, health problems, health issues and health behaviours; and have enough knowledge and power to make their own decisions, question matters that impact on their health, and seek out and access appropriate resources on an ongoing basis. In particular, there is a recognition that: Situated Health Competence is achieved within the context of going about one’s everyday life, including work, recreation, relationships and role responsibilities; social, political and environmental factors exert a powerful effect on health; health competes with other matters in the lives of individuals, families, groups and communities; there is a continuum in the ability of individuals, families, groups and communities to achieve Situated Health Competence; and achievement of Situated Health Competence may be defined differently in different situations by different people.
xii Community health nursing activities that were found to contribute to facilitating Situated Health Competence were Identifying, Intervening and Enabling. Identifying activities included: assessment, screening, case-finding, taking referrals, follow-up and outreach. Intervening activities included: case management and coordination, crisis management and first aid, advocacy, and ‘filling in the gaps’. Enabling activities included health education, health promotion, problem-solving, counselling, support, providing resources, linking, developing/empowering and consulting. It was found that all participants’ activities were directed towards achieving a nurse-client relationship where enabling activities were facilitating client Situated Health Competence, or clients no longer needed assistance. In aiming to facilitate Situated Health Competence, the community health nursing role was enacted using the processes of Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating.
xiii
Statement of Authorship and Acknowledgments Except where reference is made in the text of the thesis, this thesis contains no material published elsewhere or extracted in whole or in part from a thesis by which I have qualified for or been awarded another degree or diploma. No other person’s work has been used without due acknowledgment in the main text of the thesis. This thesis has not been submitted for the award of any other degree or diploma in any other tertiary institution. All research procedures reported in this thesis were approved by the Faculty of Health Sciences, La Trobe University Human Ethics Committee. My thanks go to Dr Virginia Bonawit and Associate Professor Victor Minichiello for their support and guidance throughout this study. I would also like to thank Professor Anne McMurray and Dr Peter Milnes for their thoughtful comments and discussion. My special thanks go to the community health nurses who participated in this study. Their insights, humour, passion and creativeness have contributed richness and colour to this project. Their commitment and willingness to share their time, thoughts and feelings has been humbling and I trust my descriptions do them justice. Finally, I would like to express my appreciation to my husband Graham for his unfailing support and encouragement and to my children Desiree, Lloyd and Cameron for their patience and understanding during the time this research was in progress.
(SIGNED) Winsome St John
CHAPTER ONE Introduction OVERVIEW This dissertation contributes to dialogue about the role of the nurse. It presents a study into the role of the community health nurse in Australia which provides an explanation from the perspective of the practitioner about the nature of the community health nursing role, its philosophical bases, purpose, a description of role activities and an analysis of how community health nurses enact their role.
THE PURPOSE The purpose of this research was to uncover the reality of the community health nursing role from an insider’s perspective. This research sought to explore the philosophical underpinnings, purpose, aims, knowledge, meanings and processes embedded in the practice of community health nurses. In particular, this research sought to examine how nurses interpret and make sense of their role within the inherent ambiguity of their role and the social, political and professional contexts of their practice. This study focuses on how community health nurses themselves perceive, define and negotiate their role in a range of practice settings. The aim was to gain an insider’s knowledge while also retaining an ability to theorise beyond the commonsense world of the insider. This general aim will be answered by exploration of more specific questions: 1
What are the philosophical perspectives of community health nurses practising in a range of Australian community health settings?
2.
How do practising community health nurses interpret their role in a range of Australian community health settings?
2 3
What processes do practising community health nurses utilise to enact the role of community health nurse in a range of Australian community health settings?
These questions sought answers that uncover the personal sense which community health nurses make of their role and explore the knowledge and meanings embedded in their practice.
SIGNIFICANCE OF THE STUDY This research has significance in contributing to community health nursing knowledge and theory and the development of a clearer understanding of the community health nursing role. First, by articulating the community health nursing role, this study makes an important contribution that may provide definition and understanding of a role that is ambiguous in nature. Secondly, greater understanding of the community health nursing role may contribute to dialogue and development of community health nursing theory and practice. Specifically, this may contribute to promotion of better understanding of the role; greater purpose in directing nursing activities; provision of a basis for defining competencies in community health nursing practice; guidance for purposeful curricula that prepares nurses for practice in community health; more focussed evaluation of practice; greater accountability; and excellence in practice. Greater understanding may also enable more appropriate preparation of nurses for a role that promotes the health of individuals, families and communities. Thirdly, a clearer articulation of the community health nursing role may provide better focus in practice and more confidence in delineating the boundaries of the nursing role in the community. This could contribute to better use of energies in achieving the purposes of the community health nursing role. Finally, clarity about the practice role may contribute to enabling nurses to better promote their role with other health professionals and clients, obtain funding support and empowering them to fully take on their expanded role. The nursing profession would benefit if the role of the nurse in the community is more widely understood.
3
BACKGROUND TO THE STUDY The last decades of the Twentieth Century have seen an increase in the pace of change. The health system in Australia has felt the impact of continuing political change and reform. Conflicting contexts and agendas surround the practice of the community health nurse in Australia. Internationally, almost two decades have passed since the World Health Organization adopted the target of Health for all by the year 2000 (1977) and made the Declaration of Alma Ata (1978). The vision of the World Health Organization was that: The main social target of governments and of WHO should be the attainment by all the people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.
(World
Health Organization, 1981, p. 11) This goal provided the new public health paradigm (Ashton and Seymour, 1988; Australian Community Health Association, 1989a) within which health could be viewed, policy developed and community health nursing practised. Health for all took cognisance of critique of the medical model such as McKeown (1976) and Kickbusch (1989) together with the limitations of the old public health model. The health for all approach attempted to place the epidemiological paradigm within an ecological framework that dealt with the social determinants of ill health and reaffirmed the meaning of the original World Health Organization (1947) definition of health as a positive entity and not just an absence of disease. Health is conceptualised as a resource for everyday living, emphasising social and personal resources, together with physical capabilities. This aim addressed socioeconomic, cultural and political inequity and recognised that health is rooted in the way society functions. The health system was viewed in terms of health outcomes rather than availability of medical and hospital services. There was a recognition that the causative factors of disease were complex and that inequalities in health occur, with the health of those with less resources being less healthy than those with more resources (Broom, 1984; Jones and Cameron, 1984; McMichael, 1985; McClelland, Pirkis, and Wilcox, 1992).
4 In 1978, the General Assembly of the World Health Organization endorsed the Alma Ata Declaration (World Health Organization and United Nations Children's Fund, 1978) which described primary health care as a strategy for achieving the target of health for all. Primary health care has the major themes of equity, promotion of health and prevention of disease, and a participating community and inter-sectoral cooperation. The World Health Organization (1986) suggested the changes necessary for achieving health for all include: attention to healthy lifestyles; healthy environments; appropriate care; healthy public policy; a focus on health-promotive, curative, rehabilitative and support services that are responsive to local need and attend to the needs of the high-risk, vulnerable and under-served people and groups; inter-sectoral collaboration; integration of resources; and attention to ensuring quality of care. St John (1993), in an analysis of the primary health care literature, outlined the notion as including primary care provision, attention to public health, and community development approaches. The Steering Committee of the Community Development in Health Project (1988) described a community development approach as working with identifiable communities to assist them in achieving their own priorities and addressing community identified problems. The Project proposed that health can be advanced by addressing more general social goals such as equity, poverty, environmental issues and empowerment. Many authors have advocated the use of community development approaches (Mahler, 1981; Australian Health Ministers' Advisory Council, 1988; Steering Committee of the Community Development in Health Project, 1988; Kingsley, 1994) or community participation (Legge, McDonald, and Benger, 1992, pp. 97-108; Commonwealth Department of Human Services and Health, 1994, p. 26; Hudson-Rodd, 1994; Watts, 1994). Dreher (1982, p. 505) took this view when she contended that: Greater attention is paid to the psychological symptoms of poor public health than to its socioeconomic causes; indeed, the symptoms are being taken as its causes.
Because of this, public health nursing will continue to propose
solutions that do not produce real improvement in health care, because they suggest only adjustment to rather than alteration of, structures that have created its current state.
5 The health for all view was reinforced by the adoption of the Ottawa Charter for Health promotion in 1986 (World Health Organization, Health and Welfare Canada, and CPHA, 1986) at an international health promotion conference. The Charter identified a social framework for health promotion that included building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services. Labonte (1987) suggested that empowerment, or being able to make informed health decisions, is a necessary ingredient underpinning the ability of people to take responsibility for their own health. In Australia, similar notions had lead to the implementation of the Community Health Program for Australia in 1973 based the National Hospitals' and Health Services' Commission report. The report argued that there was an urgent need to adjust an imbalance of a major focus on curative care to preventive health and rehabilitation services, and to provide opportunities for education and research. The principles of the Program included using current knowledge and techniques, appropriate staffing, equity, access, coordination, continuity, teamwork and an emphasis on prevention (National Hospitals' and Health Services' Commission, 1973, p. 4). The report proposed a program for establishing integrated community health services with a preventative focus, providing primary medical, nursing and health outreach services, and social advocacy (ibid., 1973, p. 6) and to: ... encourage the provision of high quality, readily accessible, reasonably comprehensive, coordinated and efficient health and related welfare services at local, regional, State and national levels. Such services should be developed in consultation with, and where appropriate, the involvement of the community to be served. (ibid., 1973, p. 4) The report also indicated a need for examination of the emerging role of community health nurses (ibid., 1973, pp. 7-8). As a result of the Program, many health programs were funded and community health centres employing community health nurses were set up around the country (Australian Community Health Association, 1989b). Most centres had multi-disciplinary teams, often encouraged local community input into their management and had “responsibility for protecting and promoting the health of a defined community” (Australian Community Health Association, 1991, p. vi).
6 The Program was reviewed by the Australian Community Health Association in 1986 and it was found that there had been a growth in the number of community health centres throughout Australia, from none in 1972 to 462 in 1986. However, the results of the Program were mixed. Although community health services were an important sector contributing to health in Australia, the original aims expressed in 1973 had not been fully realised. The Review suggested that community health services still had a focus on illness and provision of secondary and tertiary prevention, rather than involving the community and expanding primary prevention. Milio (1988) suggested that the Commonwealth Government had failed to make it clear to the states whether the purpose of the initiatives implemented under the Program were to keep people out of institutions or to prevent them from becoming ill in the first place. She identified that 86% of community health funds were allocated to treatment care projects with only 11% used for primary prevention. Despite the difficulties, limited funding and lack of clear guidelines of the Program, Palmer and Short (1994) argued that the range of services provided had been impressive: Health education and health promotion activities have been fostered, and disadvantaged groups have had their needs met to a degree that would not have been possible in the absence of the Program. In addition, the Program has created a group of people, principally employees of the program, with a different and in our view superior conception of the appropriate aims of a health care system. (1994, p. 126) Although it is almost two decades since the Declaration of Alma Ata and implementation of the Community Health Program for Australia, Palmer and Short (1994, p. 119) suggest that the principles of primary health care and the Community Health Program continue to have an impact on policy in Australia. Primary health care has provided a basis for the development of governmental policy evident at national, state and local level. A landmark document, Health for All Australians (Health Targets and Implementation (Health for All) Committee, 1988), outlined national priorities and targets for the prevention of disease in Australia. Since then there has been revision of these original targets in order to update them (Nutbeam, Wise, Bauman, Harris, and Leeder, 1993; Commonwealth Department of Human Services and Health, 1994). A need to address health issues also saw the
7 establishment of the Better Health Commission that reported in 1986 and health promotion programs and units around the country (Malcolm, 1993). In 1991 an inquiry into the role of primary health care in health promotion was conducted by the National Centre for Epidemiology and Population Health (1991). McClelland et al (1992, p. 14-15) examined the health status of all Australians and argued that a reduction in health status inequalities would require a social view of health with attention to: the distribution of economic resources, education, living standards, access to and conditions of work, and social support. A range of policies have been released that aim to promote the health of identified population segments such as: women (Commonwealth Department of Community Services and Health, 1989), Aborigines (National Aboriginal Health Strategy Working Party, 1989), those with mental health problems (Australian Health Ministers' Advisory Council, 1992) and school children (Thyer, 1996). Queensland Health (1994) developed a health policy based on primary health care that included the principles of equity in health, a population focus, intersectoral collaboration, multiple strategies, community participation, self-reliance, coordination of primary, secondary and tertiary level health services, and the aim of achieving quality care. In some states, local governments have taken a role in improving public health. For example, in Victoria, councils have been required to produce municipal public health plans identifying local health priorities (Smith, 1995). However, there have been dissenting voices in the social and political environment. The new public health has provided ambiguous goals and there has been critique of an unquestioning acceptance of its approaches. The limitations of health promotion (Jackson, 1985) and community development approaches (Dixon, 1989) have been recognised. Authors point to a gap between ideologists’ rhetoric and reality in relation to the role of the professional in community consultation (Davis and George, 1993, pp. 379-382), the extent to which changes in infrastructure contribute to changes in health status (Dixon, 1989; Davis and George, 1993, p. 378), the difficulty of defining or identifying a ‘community’; the basis for, and possible misuse, of community ‘participation’ (The Health Targets and Implementation (Health for All) Committee, 1988, p. 119; Goltz and Bruni, 1995; Sawyer, 1995) and a suggestion that there is a conflict in the rhetoric of environmental holistic approaches and current behavioural approaches to health promotion (Goltz and Bruni, 1995).
8 It has also been shown that despite increasing expenditure on health in the curative sector there has only been modest improvement in the health status of society over the last thirty years, continuing inequity and persistence of many of the contextual problems that provided the original impetus for the new public health, together with new challenges born of a changing society (Davis and George, 1993, pp. 89-91). McClelland et al (1992) found that although those from lower socio-economic groups had poorer health, they had greater use of secondary health services than those from higher socio-economic groups. Davis and George, following a review of morbidity and mortality patterns in Australia, suggested that: ... we have not really come to grips with the fact that the choices people make about their health are conditioned by their position in the social structure. The main health issues remain those of poverty, affecting housing, education, nutrition, occupation and chance of employment. (ibid., 1993, p. 90) The Council of Australian Government's Task Force on Health and Community Services (1995) identified societal changes impacting on the provision of community services as: an increase in the number of older people requiring community services with ageing of the population; changes in the Australian family including increased workforce participation of women, greater cultural diversity, increased mobility, higher divorce rates and re-partnering, longer dependency by studying or unemployed children and the effects of higher rates of unemployment. They also suggested that the traditional role of women as unpaid family carers and community volunteers could no longer be taken for granted. The Task Force (1995) also outlined changes in the health care sector, noting that people were seeking greater personal choice and the availability of community-based services that were constructed around their individual care needs, rather than around the interests of the provider. They observed that there had been an expansion in the range of services and technologies, which enhanced the ability to deliver services in the community. Their concern was that, while there were many highly developed services, they had poor links with each other and suffer from poor integration. They reported over sixty discrete governmental programs for health and community services, and found that boundaries between these services were often rigid. In addition, Kermode, Emmanuel, and Brown (1994) suggested that moves
9 toward privatisation, deregulation and greater exposure of health services to market forces have implications for the provision of nursing services. Another trend is a requirement for greater legal and professional accountability and a commitment to efficiency, cost-effectiveness and cost-containment (Macklin, 1990; Hervey, 1991; Maynard, 1991; Kermode et al., 1994; Prenesti and Tattam, 1994) and attention to addressing community needs (Abel et al., 1995). Increased life expectancy has lead to a concomitant rise in chronic illness and the need for health services. Spiralling costs have seen the introduction of shorter hospital stays, day surgery, casemix (Owens, 1995), policies of deinstitutionalisation, and a greater focus on providing community care of a greying Australia (Minichiello, 1995). Sax (1990) in his examination of the funding of health services in Australia pointed to the continuing dilemmas and decisions, particularly in relation to the provision of health care for the disadvantaged. The health care system has also seen the expansion of health worker categories and rivalries over professional boundaries, together with evolution of new health occupational groups and auxiliary health workers (Gardner and McCoppin, 1995). The Public Health Association Steering Committee (1990, p. 20) in a workforce study stated that the workforce of health and general community workers with a public health focus, which included nurses, comprised at least 300,000 persons in Australia. These included non-nursing workers such as personal health care attendants, who are being used to carry out nursing functions, and others such as health workers who require supervision by the community health nurse. However, a significant number of employees providing community health services were nurses. The Australian Institute of Health (1988, p. 10) reported 4,938 persons, including 358 males and 4585 females, were employed by community health centres in 1986. Community health nurses were also employed in other non-government organisations and health centres. As discussed below, definition and nomenclature of community health nursing roles is unclear, making collation of statistics on the community health nursing workforce in Australia difficult. From a survey of employers carried out in New South Wales, the percentage of all nurses employed in community health nursing as an area of work was 6% in 1982 and 7% in 1988 while in Victoria there were 7% employed in community nursing roles (Manning, Parker, and Kendig, 1991, pp. 22-23). Employment patterns of nurse registration board data analysed by the Australian
10 Institute of Health revealed that in 1987 the proportion of nurses employed in community health was: New South Wales 9%; Victoria 11%; Western Australia 14%; South Australia 13% and Tasmania 14% (ibid., 1991, p. 21). Manning et al. (1991, p. 44) argued that there was an unmet demand in the community, due in part to policies of deinstitutionalisation, and suggested that there is not likely to be a decrease in the demand for community nursing services. They specifically identify an unmet demand and high workloads in areas such as maternal and child health nursing and remote area nursing. They concluded that funding of community nursing services will depend on political choices. Holman (1991) in a review of Community and Child Health Services in Western Australia acknowledged the many achievements of the service and supported a continuing need for provision of these services. Most of these grass-root services are provided by community health nurses and need to be increased to satisfy community needs and demands.
RATIONALE FOR THE STUDY It is within this rapidly changing context that community health nursing must examine, describe and clarify its practice to ensure provision of the most appropriate, effective and efficient health services of a quality standard. The political, social and health care system changes have had an impact on the role of the community health nurse. What have been the responses of the profession to these challenges and what is the status of the current role of the community health nurse? In 1985 Mahler proposed that nurses could be the social force behind the health for all movement and become resources for people, active partners in inter-professional and inter-sectoral teams, leaders and innovators in program planning and evaluations. He further suggested that “... millions of nurses throughout the world hold the key to an acceptance and expansion of primary health care because they work closely with people ...” (ibid., 1985, p. 29). Keegan and Kent (1992) argued for an expanded role and Chamberlain and Beckingham (1987) posited that the nurse was strategically positioned to provide primary health care. Robinson (1990, pp. 10-12) in reviewing the role of the nurse in Australia suggested that nursing will continue to adapt to meet the challenge of an increasing emphasis on health for all, health promotion and health education within the changing social, educational, political and health care
11 environment. Nursing organisations have suggested that the response has been an expansion of nursing roles (Queensland Nursing Council, 1995) and have endorsed the perspective of primary health care (Australian Nursing Federation, 1987; International Council of Nurses, Council of National Representatives, 1989; Australian Nursing Federation, 1990; Royal College of Nursing, Australia, 1994). In 1989, the Australian Nursing Federation, College of Nursing, Australia, New South Wales College of Nursing, and Florence Nightingale Committee, Australia (1989) outlined a collaborative national statement about nursing in Australia. This statement argued that because nursing has a focus on relationships that are context-dependent and changeable, it remains a discipline that is always evolving. Furthermore, they noted that: Nurses have been designated by the WHO (1985) as the key personnel in primary health care and the leaders and managers of primary health care teams. Primary health care occurs in all settings in urban, rural and remote environments. In order to achieve health for all Australians the advantage of promoting a distinct role for nurses in primary health care for the health service and consumers must be recognized. More nurses need to be enabled to become primary health care practitioners. (Page not specified) In spite of this optimism there has also been some pessimism about the role of the community health nurse. Temple-Smith, Johnson, and Dunt (1989, p. 314) found in a study of Victorian community nurses, that they saw little opportunity for job advancement in their current roles. Prenesti and Tattam (1994) reported that the many changes in the Australian health system were placing pressures on community health nurses. However, a perusal of the literature would suggest that pessimism is greater outside Australia. For example, in the United Kingdom (UK), there has been much discussion about the future viability and direction of the health visitors’ role (Fatchett, 1990; Traynor, 1993) and in New Zealand, Shaw (1991) asks “what’s happened to the public health nurse?” Ward (1989) suggested that the many issues faced by community health nurses, such as blurred lines of authority, lack of clarity in organisational policy and poor funding, require a collective political response from community health nurses. Erickson (1987), in a review of the literature identified a number of difficulties facing public health nursing: a reactive rather than proactive
12 approach on behalf of populations at risk; role confusion and fragmentation of services diminishing and obscuring essential practice; continuing debate about what constitutes appropriate educational preparation; lack of educational preparation limiting community leadership and role expansion; a focus on individual and family care threatening an aggregate approach; clinical practice substituting for home visits; and task orientation of the clinic format rather than health teaching. A point on which there was agreement in the literature was that there has been change in the community health nursing role, and that changes will continue. The changes in community health nursing practice roles have been echoed around the world and documented in countries such as Botswana (Naconaco and Stark, 1986), Canada (Whyte and Little, 1992; Halbert et al., 1993), China (Ying and Davis, 1985), Cuba (Swanson, 1988), Fiji (Hope, 1990), the UK (Health Visitors' Association, 1987; Barker, 1993; Dalziel, 1994; Trnobranski, 1994; Cowley, Bergen, Young, and Kavanagh, 1995; Mason, 1995), Jordan (Amasheh, 1990), the Netherlands (Jonkergouw, Kruyt, and Hanrahan, 1990), New Zealand (Shaw, 1991), Norway (Ellefsen, 1992) and the United States of America (USA) (Riner, 1989; Igoe, 1991; McDermott and Burke, 1993; Parrish and Allred, 1995; Robinson, Mead, and Boswell, 1995). The type of community health nursing role developing in each country appears to be related to the needs of the particular community and the professional, social and political climate. However, an ongoing difficulty has been that the role of the community health nurse is so broad, that it is thus ambiguous and difficult to define. Ambiguity and the need to clarify the community health nursing role has been identified by many authors (Cross, Northrop, and Strasser, 1983; Matuk and Horsburgh, 1989; Collis and Dukes, 1991, p. 136; Cowley, 1991; Ellefsen, 1992; Clarke, Beddome, and Whyte, 1993, p 306; McDermott and Burke, 1993). Parsons and Felton (1992) point out that an outcome of role ambiguity is job dissatisfaction and job-related tensions. Laffrey and Page (1989, p. 1047) suggested that role confusion will be a barrier to effective nursing in primary health care. Hamilton and Bush (1988) argue that the confusion over what constitutes community health nursing practice has its origins in the way in which it draws on the conceptualisations of generic nursing and a range of other disciplines such as anthropology, public health science, sociology, politics and economics. There has also been a suggestion that there is a lack of fit between
13 nursing’s meta-paradigm and the epidemiological perspective of the traditional public health model (Hanchett and Clarke, 1988), while Goeppinger (1988) pointed out a lack of attention to the concept of ‘community’. In addition, there has been a trend towards the development of specialist nursing roles in community nursing with a focus on either population groups, such as families and children, women, men, the elderly, migrant populations or Aborigines, or the needs of other groups such those who are diabetics, drug dependant or dying. A lack of clarity about the role and functions of the community health nurse and an inability to articulate and communicate these to others may contribute to a lack of direction, erosion of role and result in practice being shaped more by outside factors and interests, than by the philosophies and directions identified by nurses themselves. Drennan (1986) observes that with increasing cutbacks in funding to community services, community health nurses are being asked to: justify their role, function and identify outcomes; exhorted to practise on a more scientific basis; evaluate their work; and increase their accountability to management. She cites the use of regimented screening schedules that have been implemented so that health visiting activity can be numerically evaluated. Matuk and Horsburgh (1989, p. 170) suggest that when students choose to practise in the community health field, they may lack a clear concept of their diverse role in this setting. They further note that where students lack the necessary specialised skills, they tend to turn to other health care providers for guidance and that, as a consequence, the public health nursing role is weakened. Unless the role of the nurse is clearly articulated, the purpose of nursing work will remain foggy, and evaluation of practice will be inconclusive. An outcome may be inadequate funding and inadequate evaluation of practice. Goodwin (1992), in a survey of directors of public health in the UK, found they were seeking clearer specifications for community health care nursing. In 1986, the International Council of Nurses noted with concern the trend in many countries for nursing functions to be eroded, undermining the quality of nursing care, which together with economic policies and health practices place an undue emphasis on cure rather than care. Based on the International Nursing Council statement, the Australian Nursing Federation issued a policy statement in 1986 reaffirming the profession’s responsibility and accountability for defining the nursing role, stating that this was important in order that standards of nursing care given to the public be protected. Smith (1989) has
14 suggested that the profession should respond by using the public agenda to shape public health nursing practice. On the other hand, Hockey (1995) suggests that the ‘crisis’ in community health nursing can constitute a challenge. Hardy (1988) suggests that role ambiguity is a characteristic of positions occupied by health professionals, arguing that ambiguity results from the limit to knowledge in relation to roles that act to address complex human needs. Gardner and McCoppin (1995) suggest that in the current changing political environment, although nurses face role erosion, the dilemma of generalist/specialist practice and changes in the organisation of work, this also provides the challenge of developing an autonomous role and the possibilities for role expansion. Furthermore, Parsons and Felton (1992, p. 499) suggest that role ambiguity can offer opportunity for role-making, influenced by the individual’s own definition of role. Thus, there is a need for role clarification, redefinition and realignment (United States Department of Health and Human Services, 1984; Burbach and Brown, 1988; Conway, 1988) and understanding of associated competencies (Zerwekh, 1991). The Australian Nursing Federation, National Professional Development Committee (1989) stated that “accountability is also demonstrated by the development and extension of nursing knowledge through reflection, evaluation and research”. Thus with increasing pressure for accountability for practice in the nursing profession, together with development of standards of practice, competencies and role descriptions, there is great need for community health nurses to reflect on the philosophies, direction and aims of their practice. Furthermore, in order to take up the challenge of developing the role of the community health nurse and making it relevant to community needs, there is a need for community health nurses to articulate the nature of their role, based on a distinct philosophy, with lucid goals, and clearly delineated role activities, services and boundaries. Meleis (1991, p. 21) suggested that:
15 ... professional autonomy and accountability are enhanced by theory use in practice. ... Articulation of our actions, goals, and consequences of actions enhances our accountability. If we can clearly talk about our purpose and what we hope to accomplish, perhaps other professionals and patients can do that too. Practitioners, educators and researchers are challenged to articulate clear conceptualisations of community health nursing theory, and to delineate the role and its purpose. An examination of the literature however, fails to provide clear theoretical underpinning of the community health nursing role. Clarke et al. (1993, p. 306) suggest that “the nursing associations’ directives neither describe a framework nor suggest a synthesis of nursing and public health sciences”. Hamilton and Bush (1988, p. 72) contend that after a century of community health nursing in the USA there is a lack of conceptual clarity and a relative paucity of theory development persisting in this field of nursing. Barriball and Mackenzie (1993) reviewed the literature and identified the importance of measuring the impact of nursing interventions in the community, without identifying a clear purpose for role of the community health nurse. Australian authors and organisations have identified the need for research activity to contribute to role definition and clarification (Nursing Research Group, Victoria, 1989; Gray and Price [National Nursing Research Invitation Workshop], 1991) and to addresses questions arising from and providing direction for, current and future nursing practice (Royal College of Nursing, Australia, Australian Nursing Federation, Florence Nightingale Committee, Australia, and New South Wales College of Nursing, 1992). This call has been echoed internationally (Baker, Bevan, McDonnell, and Wall, 1987, p. 216). Hamilton and Bush (1988) outline the sources for material that will contribute to nursing theory in community health nursing as including: the history of community health nursing; the lived experiences of nurses and clients; the structure of community health nursing practice; the process of community health nursing; the outcomes of community health nursing; education of community health nurses; clients of community health nursing and previous research. Much of the existing theory relating to community health nursing roles has been based on concepts and definitions generated by educators, professional organisations and
16 other organisations. Practice has been based on assumptions that have had little verification by research. Dickoff and James (1968) argued that nursing theory arises from practice and exists finally for the sake of contributing to the action of practice. Speedy (1989) identified a concern in the nursing profession with a ‘theory-practice gap’ and suggested strategies for reducing this gap, including a focus by nurse researchers on the world of practice. Lundh, Söder, and Waerness (1988, p. 40) suggest that rather than research focussing on “airy and consensus-oriented nursing theories”, there is a need for research to focus on the “concrete problems of nursing work”. Robinson (1992, p. 25) argued that although there are theoretical formulations for community health nursing, they “... are all expressed at a high level of abstraction. What is missing from the literature is a set of prescriptions for operationalising these principles in terms of practical ... tasks”. Thus, there is a need for theory to be informed by practice and to bring to the surface the ‘tacit knowledge’ (Polanyi, 1966, 1962) embedded in the practical everyday work of the community health nurse. A compounding difficulty in community health nursing is that most studies into the role of the nurse have been based on theoretical frameworks that have been developed for nursing in traditional institutional contexts. Some theory has been examined in the light of community practice, but this has been limited. An example of where this has occurred is the development of practice domains by Benner (1984) that were derived from research on practice in acute settings and applied in research examining expertise in community health nursing community practice in Western Australia (McMurray, 1991). There have been examples where community nurses have been included in studies of role, such as Williams (1989) who also based her study in Queensland on Benner’s work, and included eight community nurses in her group of 100 participants. Furthermore, nursing theory in Australia is dominated by imported ideas. Lawler (1991a) pointed out that there is a need to sift universal phenomena from that which is applicable in the Australian context. This is particularly the case when the history of community nursing in Australia (discussed below) is considered. Australia has its own cultural, political and environmental characteristics. Within this context the development and future directions of community health nursing will have its own unique features. Identifying these through research will assist community health nursing in the Australian context.
17 To date, Australian research has tended to focus on community health nurses’ characteristics, demographic details and function examining: the activities of community health nurses (Katz, Mathews, Pepe, and White, 1976; McMurray, 1984; Dunt, Temple-Smith, and Johnson, 1991), their educational needs (Munoz and Mann, 1982; Kreger, 1991; St John, 1991; Buckley and Gray, 1993), a comparison between the perceptions of health team members of the role of the community health nurse (Round and Sellick, 1984), demographic data (Manning et al., 1991; Buckley and Gray, 1993) and job characteristics such as job satisfaction, mobility, and career options (Temple-Smith et al., 1989). This body of research indicates that there is a lack of understanding of the practice role of the community health nurse. It has tended to answer questions related to community health nursing roles by looking at the activities of the nurse. While these studies have provided quantification, description and categorisation of the activities of community nurses, what is largely absent is description, examination and analysis of the more subtle qualitative aspects of practice. There is description of what nurses do without exploring why, and the study of the nurse as object rather than subject. Tasks have been identified without addressing the underlying issue of identifying how practising community nurses perceive and understand their role within the context in which they work. Understanding the role of the nurse is not a matter of seeing what tasks nurses engage in or reducing the role to a series of small parts. Rather, there is a need to view the role holistically and explore what nurses think about what they do, the philosophies underpinning their practice, their purpose and aims, how they go about enacting their role and why. There has been little research in Australia that has sought to gain a more in-depth knowledge about the meanings of community health nursing by exploring the role of the community health nurse from the emic or ‘insider’s’ perspective, thus failing to explore the processes of practice or uncover the way in which community health nurses conceptualise their own practice. Dickoff and James (1968, p. 199) argued that in nursing:
18 Not only is there a privileged and nonartifical field of observation at any present instance but also ... there is a fund of practical wisdom passed on now often by word of mouth or apprenticeship. This wisdom could, if properly viewed, be precipitated and surveyed ... for the sake of being put into more communicable, more stable, more generalized and hence more amendable form. This is consistent with accounts from the international literature. Baker et al. (1987) states that although there has been continuing discussion in the literature about the role of the health visitor, most of the research to that time had been survey type research, and that “there was a dearth of research into ... [a variety of] aspects of the health visitor’s role”. As Giorgi (1970, p. 291) pointed out, priority has often been given to: ... the measurement perspective, and, in order for something to be measured, only its tangible aspects can be apprehended, and thus the indices itself of a phenomenon become more important than the phenomenon. Research that has explored these aspects in Australia, includes Frith (1975) who provided a diarised account of her role as a public health nurse in Queensland. The most significant contribution, however, has been made by McMurray (1991) who examined expertise in community health nursing practice in a study of Western Australian community health nurses. However, none of this research has sought to specifically focus on the ideas, philosophies, perceptions and thoughts that community health nurses themselves have about their role and their work. Clark (1986b) posited that each individual nurse has values and beliefs which constitute a ‘personal nursing model’. Previous studies (Field, 1983; St John, 1992) have suggested that there were philosophies that appeared to guide the practice of community health nurse participants studied. It is posited that these themes may provide understanding of the aims, purposes and practice of the community health nurse in Australia.
19
NOMENCLATURE OF NURSING ROLES IN THE COMMUNITY Various authors have noted that the terminology relating to community health nursing has continued to change over the years and that this has contributed to confusion and a lack of conceptual clarity (Sills and Goeppinger, 1985; St John, 1991). Dunt et al. (1991) found in a survey of 689 nurses employed outside hospitals and nursing homes in Victoria that subjects offered 281 separate job titles for their community nursing roles. An examination of overseas literature reveals similar confusion, and debate related to the nomenclature used to describe community health nurses is compounded by varied use of terminology. When reviewing the literature this lack of clarity obliges a reader to examine any writing in order to first identify the perspective of the author on the nature of the community nurse role being discussed. The major designations for nurses working in community roles identified were: community health nurse, public health nurse, nurse practitioner, health visitor, home health nurse, district nurse and domiciliary nurse. Rather than engage in debate about which nomenclature should be used, it was found to be more fruitful to focus on the nature of the community nursing role. Analysis of the distinctions made between the nature of different community nursing roles indicate that the characteristics most often used to differentiate nursing roles in the community relate to the geographical location of practice, client focus, the nature of practice in relation to health and disease and educational preparation. A first glance at the literature reveals that community nursing may refer to any nursing that occurs outside a hospital or nursing home setting. Location is often a simple way of defining community nursing for the purposes of research (Baker et al., 1987; Dunt et al., 1991). Dunt et al. (1991, p. 29) defined a community nurse as “a nurse working outside a hospital, nursing home or nursing education centre”. However, although the setting of practice may be important, Round and Sellick (1984, p. 44), in their study of the perceptions of 65 community health centre personnel of the community health nursing role in Australia, concluded that their results “clearly demonstrate that community health nursing is more than simply traditional nursing practised in the community”.
20 Williams (1977) argued that community health nursing is not defined by the setting in which one works, but by the focus on high risk populations and the total community. Williams further argued that it is possible that nurses may be placed geographically in community agencies, but not be focusing their care on the total community. This view was likewise expressed in 1980 by the American Public Health Association (APHA) that issued statements suggesting that public/community health nursing is defined by its scope and orientation rather than its setting. The World Health Organization, Expert Committee on Community Health Nursing (1974) identified three components of community health nursing as: responsibility for services; a focus on vulnerable groups; and client participation as a partner in the planning of care. The Public Health Nursing Section of the American Public Health Association (1980) adopted a definition of public health nursing that included a goal to improve the health of the community by “... identifying aggregates within the population which are at high risk of illness”. They further suggested that activity should be directed toward health recovery and illness prevention (ibid., 1980, pp. 4-5) and expanded on this approach, stating that the focus was on: ... improving the health of the entire community. Health and health care needs are assessed in collaboration with other disciplines to identify sub-populations, families, and individuals at risk of illness, disability, or premature death. A plan is developed to meet identified health needs and includes resources and activities that contribute to health and its recovery and to prevention of illness, disability, and premature death. The community is involved in health planning and self help activities. (American Public Health Association, 1980) It can be seen in these definitions that a population or aggregate focus of care orients both community health nursing and public health nursing towards an aim of health for all members of the community. These definitions recognise that practice is not defined by setting but by approach, and the major elements are also highly consistent with the principles of primary health care. Laffrey and Page (1989, p. 1050) suggested that the primary health care role is identical to the public health nursing role and that:
21 ... it is not necessary to develop new roles for primary health care. It is however necessary to become accountable for carrying out our public health nursing role. (1989, p. 1050) Thus, the focus on the health of populations and vulnerable groups differentiates community health nursing from individually focused care which may be located geographically in a community setting. The nomenclature noted in the literature that was used to describe a community nursing role with a group, aggregate, community or population dimension and was consistent with a primary health care approach included: public health nursing, community health nursing and the health visitor. However, these nurses are sometimes simply referred to by the more generic ‘community nurse’ title. Thus, authors have argued that there should be a distinction between a broader community health nursing role and a second type of role that adapts or extends traditional nursing practice usually carried out in a hospital into the home. The later role is usually referred to in the literature as district nursing, home health nursing, domiciliary nursing, but also at times, community health nursing. Further analysis of this issue was provided by Burbach and Brown (1988) who argued for a need to differentiate between community health nursing and home health nursing, suggesting that while there are similarities, there are also differences. Similarities they identified between community health nursing and home health nursing include: the setting in the community/clients’ home; the autonomous nature of practice; the issues of control and self-care; and the provision of family-centred care. On the other hand, they identified three characteristics that differentiate community health nursing from home health nursing based on the notion of provision of services to a population or group. Firstly, although they acknowledged that groups are made up of individuals, they suggested that while services are provided to meet the needs of individuals, the needs of those not being served are also taken into account and that a major aspect of populationfocused care is aimed at those who do not seek out care. A second distinguishing characteristic was the continuous rather than episodic nature of services. Where clients are clearly admitted and discharged from home health nursing care, in community health nursing they argued that the community health nurse is continually assessing the health status and needs of the population and its subgroups. Thirdly,
22 they suggested that although home health nursing may maintain wellness related goals, in practice the care is illness-oriented. These contentions were supported by Green and Driggers (1989) who found in a study of 32 home health nurses that their practice was focussed on the individual and family, that they had minimal concern for the needs of the larger community and that their concern for the client’s current illness was paramount. Prevention activities were described in terms of avoiding complications from the current illness and only three nurses in their study described an incorporation of health promotion practices into their care. In addition, Green and Driggers (1989) found that the nature of home health nursing was episodic rather than continuous, with a very low frequency of subjects considering themselves to be available as an avenue of access to the health-care system. They questioned whether home health nursing should be considered as acute care nursing in the home or as community nursing directed toward an acutely ill client. The view that acute care can be offered at home is gaining currency in Australia (Clayton, 1995). However, to confound matters, in Australia, some home nursing organisations have been active in areas that have moved away from a traditional focus on the illness needs of individuals and families and have at times embraced an expanded role. Cameron and MacWilliams (1995) described a program of the Royal District Nursing Services in Victoria that takes a community perspective in addressing the needs of homeless people and O'Connor (1995) suggested that nurses working in palliative care considered a ‘sick role’ approach to be unsuitable, preferring a ‘well role’ approach of living life to the full until death. Rothman (1991) contributed to the debate arguing that there is also a need for clear distinction between community health nurses and public health nurses and pointed to a difference in the role definition of community health nursing (American Nurses' Association, 1980) and the definition outlined by the American Public Health Association (1980). Rothman (1991) acknowledged that both definitions include viewing the aggregate as client, although the emphasis may be different. She further suggested distinguishing between different types of community health nurses on the basis of their educational preparation, the client group served, the setting, and type of nursing care provided. She argued that public health nurses are distinctly different from other nurses working in the community because of their educational preparation in nursing theory and practice, and public health sciences and practice; their focus on
23 the geo-political community or segment as client; their setting within tax-supported agencies with legal mandates and nursing care focussed toward detection of health problems; disease prevention; and health promotion. She cited the specific education requirements in public health nursing as described by the Consensus Conference on the Essentials of Public Health Nursing Practice and Education (United States Department of Health and Human Services, 1985, p. 9) as including epidemiology, bio-statistics, community assessment, program planning and evaluation, nursing theory, management theory, change theory, economics, politics, interventions at aggregate level, public health administration, research, history of public health and issues in public health. She distinguished public health nurses from all other nurses working in a community setting, who she suggested should be called community health nurses. In this ‘umbrella’ group she included specialist nurses such as gerontology, school, occupation, maternal and child health, oncology and home health together with nurses working in any community setting where nursing activities are carried out, such as doctors’ offices and street clinics. This argument however has difficulties because it does not acknowledge the overlap between those she designates as public health nurses, and those as community health nurses. She also fails to distinguish between the nurse who works with an aggregate or population group from a community perspective from the nurse providing home nursing or domiciliary services to a similar population group from an individualistic or illness perspective. Rothman argued that it is necessary to distinguish the particular skills of a public health nurse from those of community nurses because it should not be necessary to educate all nurses who work in the community in public health sciences and practice. However, it could be countered that these skills should be a part of the preparation of all nurses working in the community, and that the extra functions she described are in fact a specialty in community health management. Nurse practitioner is another term that has added to the already confused picture of the role of the nurse in the community. Laffrey and Page (1989, p. 1048) point out that the term nurse practitioner has become synonymous with primary health care. The relationship of the nurse practitioner role to primary health care is the provision of care provided at first contact with the client. A nurse practitioner was defined by the American Nurses' Association (1986, p. 3) as a registered nurse who provides a full range of primary health care services to individuals, families and groups in
24 ambulatory settings. The practice of these nurses has ranged from working in the community with families, to working alongside medical practitioners providing medically-oriented practice. The term has begun to be used in Australia (Miller, Dolan, and Boswarva, 1995; Nurse Practitioner Project Steering Committee, 1996). Examination of the literature suggests that the term nurse practitioner is often used to describe a medically-oriented perspective. Bullough (1995, p. 240) defines a nurse practitioner as “engaging in advanced practice with education beyond the basic level of the registered nurse, which enables them to take on an expanded scope of function in the diagnosis and treatment of patients”. Bullough further suggested that most definitions indicate a significant and growing overlap with medicine, including generalist nurse practitioners and specialists such as nurse anaesthetists, nurse midwives and some psychiatric nurses. Trnobranski (1994, p. 135), in discussing the development of the nurse practitioner, argued for an “extension” of the nursing role to include “medical history taking, physical examination, prescribing powers and medical referral”. She further suggested that the nurse practitioner role is an innovation in community nursing practice that could provide a route for community nurses wishing to pursue advanced practice and that it could complement the health promotion/education and counselling functions of community health nurses. There are many instances where community nursing practitioners have been seen as a solution to situations where there are a lack of medical services (Bullough, 1995, p. 241). In particular, nurses have been used where a population is too poor to afford medical services, or the location does not attract medical personnel. For example, Trnobranski (1994, p. 135) suggests that community nurse practitioners were introduced in the USA because: There was a concern regarding the lack of medical care to underserved populations in rural and inner city areas. Such communities were unpopular locations for doctors who preferred to practice in cities and pay their attention to the technological aspects of medical care.
The nurse practitioner was
identified as a means of providing improved availability and access to health care.
25 This approach has been echoed many times, for example in Canada (Stuart, 1992) and Australia, particularly in remote areas that are not served by general medical practitioners (Kreger, 1991; Cramer, 1992). Although the nurse practitioner contributes to primary health care in terms of primary care provision, the usual role described in the literature is inconsistent with the broader notions of a community health nursing role, as it: only takes an individual or perhaps family focus, it does not encompass the community orientation of community nursing practice, nor does it take a socially contextual view of health (St John, 1993). It also appears that the term nurse practitioner is often used to describe a role that is becoming increasingly medicalised and undervaluing of nursing knowledge in relation to medical knowledge. On the other hand, the term nurse practitioner can be used to describe any nurse who is autonomously practising nursing. Bullough differentiated a group of clinical nurse practitioners who, she suggested, have a distinctive nursing role from the group with a growing overlap with medicine. Buckley and Gray (1993, pp. 8-9) distinguish between an extended role that relates to extensions of medical practices, and expanded roles that are an expansion of unique nursing-driven functions. Thus, although community health nurses are not nurse practitioners in terms of a focus on individualised care that does not incorporate a community and a new public health perspective, they are nurse practitioners in the sense of being autonomous practitioners of nursing, often with specialty nursing knowledge and educational preparation. Furthermore, it could be argued that all nurses are practitioners of nursing and that the term practitioner could be considered redundant. Another trend in community health nursing that has given rise to a range of different titles is that of specialisation. There has been debate as to whether community health nursing is itself a specialty, or a generalist role that incorporates various specialties. One view suggests that community health nursing is a single specialty area within nursing. Tansey and Lentz (1988) noted the “lure of technology” in nursing generally, lamenting a trend toward valuing technical expertise and caring for machines, rather than caring for people with an understanding of their contextual needs. They concluded that community health nurses were generalists in a specialised profession. Another perspective sees the development of sub-specialties within community health nursing (Mason et al., 1992). In the home health care area the trend of specialisation has focussed on provision of therapeutic care in specific ‘hands-on’ areas such as
26 diabetic care, stoma care, respiratory care and terminal care (Haste and MacDonald, 1992). In many instances the notion of a specialist role is linked to appropriate educational preparation, usually at master level (Kupina, 1995). The American Nurses' Association (1980, p. 10) identified both generalist and specialist roles in community health nursing. Underwood, Woodcox, Van Berkel, Black, and Ploeg (1991) suggested that while public health nursing could be viewed as a specialty, attempting to undertake too broad a role may lead to an excessive expectation on the nurse and consequential role strain. They observed that there has been a trend toward sub-specialisation within public health nursing in relation to: the knowledge area, such as mental health or family planning; the developmental stage of clients, such as early childhood or adolescence; and the setting where care is provided. In the Australian context, the focus of specialist community health nursing practice has tended to be on population groups such as child health, women’s health, school health, the homeless, workplace employees, migrants and Aborigines. However, there have also been community health nursing specialists addressing the health needs of groups such as of diabetics and the people with drug dependency. A national survey by Pratt (1994) has indicated that there has been a disorderly process of development in specialisation in Australia, although she suggested that specialisation presents challenges for the future. Another distinction often made in Australia is between remote area and community health nurses. Munoz and Mann (1982, p. 38) defined a remote area nurse as a primary care provider, involved in not only the prevention of disease and management of illness, but also dealing with social problems encountered in the remote community. Kreger (1991, p. vi) identifies a remote area nurse as “a registered nurse employed as the health care provider on a 24 hour basis in a community that is isolated from hospital and medical facilities”. Thornton (1992) pleaded for specific educational preparation of remote area nurses. While it is argued that the role of the remote area nurse has many distinct characteristics, there is congruence with community health nursing practice generally in their focus on the health needs of individuals, families, and the community, albeit in a setting that provides its own unique difficulties. Consistent with the discussion above, it is the nature of the role rather than the setting that identifies the community health nurse.
27 In Australia, although there are other titles, the terms community nursing and domiciliary nursing are most often used to refer to more traditional nursing activities, such as home care of individuals and families, that are situated geographically in the community; and community health nursing usually designates the role of a nurse who works with a specific community from a community health centre or health agency. In some situations, nurses have the title community health nurse with a specialty or added designation such as child health nurse, generalist or school nurse. Nurses may also have additional qualifications or expertise without this being reflected in their title. In general, the term public health nurse is not used in Australia. It was decided that for the purposes of this dissertation, attention would be paid to the nature of the role in determining inclusion in this study. The term community health nurse will be used throughout this thesis, referring to the practice of a nurse who is primarily working to promote the health needs of individuals, families, groups and communities with the distinguishing characteristics of a community perspective, an emphasis on health rather than illness, and the provision of continuous rather than episodic care. The definition that best encapsulates this notion of community health nursing is the definition given by the American Nurses' Association (1980, p. 2): Community health nursing is a synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. The practice is general and comprehensive. It is not limited to a particular age group or diagnosis, and is continuing, not episodic.
The dominant
responsibility is to the population as a whole; nursing directed to individuals, families, or groups contributes to the health of the total population. Material that relates to a nursing role with a primary focus on disease and that addresses these needs only in relation to the individual and family will be excluded from this study. Where specific literature uses other nomenclature, this terminology will be used in discussion of that particular material. The term generic nursing will be used throughout this dissertation to describe any type of nursing other than that defined as community health nursing. This term is used only for descriptive convenience and is not intended in any way as a definition.
28
LIMITATIONS OF THE STUDY There are many factors touched by the role of the community health nurse that are not fully addressed by this study. This study focuses on the nature of community health nursing role as it is viewed by nurses themselves. As a consequence, this research is a study of the social world of the community health nurse, and focuses on the microsocial environment of the nurse. The perspective that there are special ‘insider’ understandings and meanings was validated by the comments of one participant (Emily1 572-622) who used the term “outsider” to describe those not working in her particular area of expertise. Many external factors, although important, are not explored. While recognising that power and politics are of importance to community health nursing practice (Ward, 1989), this study does not analyse or explore their impact, except where they are identified by participants. In addition, this study is an exploration of the role of the community health nurse set within the socio-political context of the Australian health system. There are many unique circumstances that contribute to the role of the community health nurse in Australia. However, there may be factors of interest drawn from this study for community health nursing generally. Furthermore, this study also does not consider or examine the impact of nursing action on the client individual, family, group or community. Although much is said about clients and their needs throughout this study, this study has as its focus the perspective of the nurse. In keeping with changes in the educational, social, political and health care systems, there will inevitably be changes in the characteristics of nurses taking up the role of community health nurse in the future. This change was identified by several participants in this study who suggested that with nurses in Australia now requiring tertiary preparation, they were already seeing a difference in expertise of nurses. Thus perspectives of the role of the community health nurse could change in the future.
1
All participants have been given pseudonyms in order to protect their identity.
29
OVERVIEW OF THE THESIS This introductory chapter has outlined the political and social milieu of the health system in which community health nurses practise in Australia. It provides a rationale for the study, delineates the research questions and discusses the significance of the research. In addition, this chapter provides an analysis of the complex nomenclature of the community health nurse and identifies the basis for understanding this notion in this dissertation. Chapter Two provides a discussion and analysis of the literature related to the role of the community health nurse. To provide a contextual picture, a brief discussion of the history of community health nursing in Australia is presented. The concepts of health, community, nursing and role are then explored, followed by an examination of these concepts synthesised to provide a theoretical understanding of community health nursing. Symbolic interactionism was chosen as a theoretical basis for understanding role in preference to other approaches, as it provided a framework for analysing the community health nursing role as interactive. In view of the ambiguity inherent in the community health nursing role a theoretical approach was required that provided a basis for accessing the personal meanings of role, took account of historical, environmental, personal and interactional factors as well as providing a framework for examining how a nurse interacts to negotiate, establish and change his/her role. Finally, Australian and international studies into the role of the community health nurse are presented, analysed and discussed. Chapter Three provides explanation of the methodology chosen for this study, with discussion of the rationale for the choice of research methodology and description of the research design, research procedures and analysis strategies. The questions asked required interpretive answers. A qualitative approach using grounded theory methodology was taken. Data such as dialogue and reflective oral conversations with community health nurse participants, transcripts of audio-taped oral conversations, job descriptions, documentation supplied by participants and nursing organisations, field notes, questionnaires and material from validation and feedback groups were reflected upon, coded and analysed to identify themes. The data, in particular the interview data, proved to be rich, complex and coding of meaning chunks particularly ‘dense’.
30 Emergent themes were examined to develop a theoretical understanding of embedded meanings of the community health nursing practice role. In particular, attention was paid to the philosophical perspectives of participants, the purposes of practice, the role activities undertaken and the processes of enacting the role. As themes emerged the literature was also consulted. The findings of the study and discussion are presented in Chapters Four, Five, Six, Seven, Eight and Nine. Chapter Four presents a descriptive picture of participants that outlines their qualifications, experience, current roles and the communities and coworkers they worked with at the time of data collection. Analysis of data showed that there were patterns in the way in which participants applied meaning to their roles. Chapter Five provides results and discussion that address Research Question One. An examination of the major philosophical perspectives that were described as underpinning practice or were inherent in the descriptions of participants’ practice related to health, primary health care, holism, families and community. The data indicated the importance of context to the role of the community health nurse and the dialectical nature of many aspects of practice. Chapter Six provides a description of the complex context in which the community health nurse works, together with an analysis of the four dialectical themes that were identified in the data: the health-focus/disease-focus dialectic; the prevention/treatment dialectic; the control and responsibility/dependence dialectic and the connected/disconnected dialectic present in the nurse-client relationship. This analysis provides a foundation for understanding material presented in the following chapters. In order to more clearly make sense of the story embedded in the data, the researcher focussed on the question of how the participants understood and described what they actually did in their roles as community health nurses. Through examination of the themes presented in Chapter Six, together with an analysis of the purpose of participants’ roles, a central theme of facilitating Situated Health Competence emerged. This central theme provided an explanation of the aims of the community health nursing practice role. This notion is examined, together with its properties: context, scope, client focus, negotiation of what constitutes Situated Health Competence, responsibility, responsiveness, and the continuum nature of achieving
31 Situated Health Competence. Situated Health Competence provided a framework for understanding the role activities of Identifying, Intervening and Enabling that are presented in Chapter Eight. The role activities described by participants were consistent with an aim of facilitating Situated Health Competence as presented in Chapter Seven. Chapter Nine addresses Research Question Three that asks how practising community health nurses enact the role of the community health nurse in practice. Examination of the data revealed that there were patterns in the way in which participants enacted their roles. The processes of Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating were identified. The implications of participants aiming to facilitate Situated Health Competence are reflected in the processes of role enactment. Finally the Chapter Ten addresses conclusions drawn from the research. The relationship of findings to the literature pertaining to the role of the community health nurse are examined. The implications of findings are explored and directions for further research are identified.
SUMMARY OF THE CHAPTER This chapter provided an introduction to the central question of this inquiry. It provided an analysis of the background to the study, discussion of the rationale, delineated research questions and an outline of the significance of the research. It also provided a discussion of the nomenclature used to describe community health nurses and an overview of this dissertation. The discussion and questions provide a contextual background and rationale for the examination of literature presented in Chapter Two.
32
CHAPTER TWO Literature Review OVERVIEW OF THE CHAPTER This chapter provides an overview of the literature relating to this study. This chapter describes how the literature was accessed and utilised for this study. An historical overview of community health nursing in Australia and an analysis of professionalisation in nursing is presented. An analysis of the major theoretical concepts fundamental to this study follow, exploring: health, community, nursing, community health nursing and role. Finally, Australian and international research studies into the role of the community health nurse, together with studies that examine aspects of the role are reviewed.
APPROACH TO REVIEW AND USE OF THE LITERATURE Material from the literature is important in any research. However, the use of literature when using grounded theory methodology differs from the way in which it is used in quantitative studies. A quantitative study will explore the literature to identify knowledge, and on that basis develop an hypothesis which the research design sets out to test. In contrast, Strauss and Corbin (1990, p. 49) suggested that when using grounded theory methodology, the researcher is seeking to “discover relevant categories and the relationships among them to put together categories in new, rather than standard ways”. Furthermore they argued that if a researcher begins research with an already developed set of variables and relationships, these may constrain and limit discovery: perceptions of the researcher being limited by unrecognised assumptions based on previously developed theory. In this study, although the literature review is placed at this point of the written dissertation, review of the literature was concurrent and ongoing throughout the entire conduct of the research.
33 Much examination of literature was prompted as a result of themes emerging from the data. As a consequence, while literature is presented and discussed here, this does not represent its sequential place as it occurred during the conduct of this study. Some literature will also be introduced as appropriate throughout the presentation of findings and discussion. Chenitz (1986, p. 44) pointed out that while there is an effort to ensure that engaging with the literature does not close the mind of the researcher to new possibilities, it is not that there is no literature review when using grounded theory methodology. Rather she suggested a literature review is essential, and that the issue is how the literature review is done and for what purpose. Strauss and Corbin (1990, p. 48) distinguished between the technical literature and the non-technical literature. Their definition of the technical literature includes research, theoretical and philosophical reports and papers which characterise a profession and discipline, while the nontechnical literature includes material such as biographies, diaries, documents, manuscripts, records, reports, catalogues; that can be used as primary data or to supplement observations. The use of technical literature in grounded theory methodology is described by Strauss and Corbin (1990, pp. 50-55) as having six main uses. First, it can be used to stimulate theoretical sensitivity (discussed below). While a researcher would not wish to enter the field with an entire list of concepts and relationships, it is suggested that there may be concepts that recur over and over again in the literature and thus appear to be significant and should contribute to analysis. These concepts are taken to the field and examined in the light of the evidence and data. Descriptive material, together with the concepts arising from them, may increase theoretical sensitivity if their relevance is examined in the light of what is seen in the field. Philosophical and theoretical writings may also provide a framework for approach to, and interpretation of, the data. In this particular study, symbolic interactionism has been used as a theoretical framework to focus collection and interpretation of data relating to the meanings of the community health nursing role and how that role is negotiated. An analysis of symbolic interactionism as a theoretical basis for understanding role is presented in this chapter. The second use described by Strauss and Corbin (1990, p. 52) is as a secondary source of data. Published material may be descriptive in nature and as such can be used by the researcher in analysis. Examination of published research was carried out during the
34 conduct of this research, particularly for descriptions of the activities and perceptions of community health nurses about their roles. Thirdly, the literature can stimulate questions. The literature may generate questions which may be asked of participants, or provide direction in compiling an initial list of topics to be discussed. Discrepancies between the literature and the data can be identified and lead to exploration of possible reasons for them. In this research some analyses were found to be inconsistent with the literature. This provided a useful basis for analysing reasons for inconsistencies. Using the literature to direct theoretical sampling is the fourth use of the technical literature. The literature may identify sources of data, which the researcher may not have considered, thus adding variation to the study. The final use of the literature is as supplementary validation of theoretical development. The researcher may find that the literature confirms the theoretical themes that have been derived from the data. Conversely, the published literature may differ from the findings of the research, necessitating examination of reasons for this. Strauss and Corbin (1990, pp. 55-56) also discussed the use of non-technical literature, suggesting that this literature is important in supplementing data, and in some instances may be used as primary data. In this study job descriptions, organisational documentation, standards of practice and competency descriptions were used in this way. Chenitz (1986, p. 44) advocated maintaining a cautious and sceptical attitude to the literature in order to prevent the researcher from unconsciously accepting what has been written and consequently not being open in analysis of incoming data. She suggested that the purpose of the literature will change over the course of the study and include: initial review to identify the scope, range, intent and type of research that has been done with an examination of what is known on a subject and the concerns expressed; utilisation as data during the course of the research and analysis; and finally to establish the study’s purpose, background and significance. These uses of the literature were consistent with the way in which literature was used during the conduct of this research. The researcher was particularly aware of the importance of locating newly derived knowledge within the context of current knowledge in community health nursing. Adhering to the approaches identified by Strauss and Corbin (1990) assisted in ensuring that the contribution of this research to the development of community health nursing knowledge had relevance. Maintaining an attitude of scepticism allowed the researcher to be open to new insights while
35 examining the data. Several themes that emerged from the data prompted reviews of the relevant literature. For convenience, material relating to these are also presented in this chapter. An example is self-care, which is examined more closely in this review than perhaps it may have been had the review not been concurrent with the research. The papers, books and dissertations accessed were English language material. Material was identified by a computer search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Australian Public Affairs Information Service (APAIS), Dissertation Abstracts and ERIC indexes. A search was made of literature held at most Australian university libraries and the national Australian Nursing Federation Library. As the nomenclature of the community health nurse is varied and the notion of role diffuse, many combinations of keywords were required to identify material. Many studies were located by branching from documents accessed through computer and manual searches. Particular attention was paid to Australian reports. There was a focus on more recent literature, however, older studies were included where relevant. It should be noted that for the purposes of this review, material was accessed on nurses involved in all roles that could be considered community health nursing roles with the characteristics of: a focus on individual, family, group, aggregate and community; a health focus; and a continuing rather than an episodic approach to care. Material was excluded from this review where the major focus of the role was the provision of physical care, focussed on ill-health.
AN HISTORICAL OVERVIEW OF COMMUNITY HEALTH NURSING IN AUSTRALIA Nightingale (1859, p. 6) stated that “the very elements of what constitutes good nursing are as little understood for the well as for the sick. The same laws of health or of nursing, for they are in reality the same, obtain among the well as among the sick.” Novak (1988) contended that Nightingale began a tradition in nursing that laid a foundation for nursing’s role in health promotion through her concern about the impact of the environment on health and the prevention of ill health. The reform
36 programs she initiated in the Crimea were focussed on the environment and included sanitation, housing, nutrition, physical fitness and recreational facilities (ibid., 1988, p. 81). She also advocated health in the workplace and child health teaching to mothers. Monteiro (1991), in a study of Nightingale’s contribution to community health nursing, identified a continuing emphasis on the need for a healthy environment outlining her advocacy and support of: health programs for the working poor that began in 1865, the development of district nursing programs in London instituted from 1874 by William Rathbone and a need for “health nursing” as well as “sick nursing”. This laid a foundation in nursing for community health nursing. Early health care in Australia was focussed on the provision of medical care. This was despite the continuing incidence of infectious disease (Hicks, 1981). There was little progress toward a coordinated approach to public health prior to the 1850s. Efforts included: some ad hoc efforts to safeguard water supplies; an attempt to regulate the sale of alcoholic liquors and disposal of the dead in the 1820s; measures in the 1930s to improve the urban environment and food supply by controlling the location and operation of slaughterhouses, marketing of foodstuffs and imposing standards for production and sale of bread; and establishment of organisational bodies to control water and sewerage systems in the mid nineteenth century (Dewdney, 1972, pp. 21-22). With the advent of the Commonwealth of Australia in 1901, quarantine was the only specific responsibility included in the legislative powers of the Federal Parliament, with the six state parliaments retaining responsibility for other health matters. At this stage of Australia’s history, there were many infectious diseases (Wood, 1990, pp. 21-22). Dewdney (1972, p. 249) outlined six phases in the development of nursing in Australia. The first phase spanned the first fifty years of settlement in Australia when nursing was carried out by convict nurses. The second phase was from the late 1830s to 1868 when nursing was carried out by servants, but also there was in-patient care, vocational nursing and nurse training. The late 1860s to 1899 saw the development of professional nursing and training with the arrival in Sydney of Lucy Osborn and other Nightingale trained nurses in 1868 (Wood, 1990, p. 4). The period of 1899 to the 1920s saw the development of professional associations and pressure for state registration. The next period was from 1920s to the 1940s with the institution of nurse registration boards. Registration of nurses was introduced in Queensland in 1912 and
37 throughout all states by 1933 (Katz et al., 1975, p. 12) for the purposes of protection of the public and professional advancement. Their responsibilities remain the maintenance of a register of nurses, supervision of nurse training and investigation of alleged misconduct. The final period identified by Dewdney was the post World War II period that involved development of specialisation and stratification in nursing. Further to the six phases identified by Dewdney, there has been a seventh phase marked by the transfer of nursing education to the tertiary sector in the 1970s. Current trends see an increase in hospital outreach programmes, the hospice movement, deinstitutionalisation (Dunt et al., 1991, p. 28) and a focus on health. Community nursing as we know it in Australia today has mainly been a product of the Twentieth Century. Up until 1890, no nurses were employed by any central or local boards of health of the public health services in Australia (Schultz, 1991, p. 252). The first home or district nursing services began in 1885 with the Melbourne District Nursing Society (Burchill, 1992, p. 54). Further district nursing services were inaugurated: the Launceston District Nursing Association in 1893, The District Trained Nurse Society in Adelaide in 1894, the Hobart District Nursing Association in 1896, The Evangelical Nursing Association of Launceston in 1896, the Church of England District Nursing Association in Sydney in 1900 (Schultz, 1991, pp. 339-346), the Silver Chain Association in Western Australia in 1908 and the Blue Nursing Service in Queensland in 1908 (Coombs, 1985, p. 5). The central council of the Victorian Bush Nursing Association was set up in Melbourne in December 1910 (Burchill, 1992, p. 79). These organisations were mainly focussed on care of the sick in the community. However they were instrumental in the development of community health nursing services in Australia. It was not until the first half of the twentieth century that there was an expansion of public health authorities in Australia, including school medical services, services for the care of pregnant women, mothers and babies and immunisation (Dewdney, 1972, p. 22). Medical examination of school children commenced in 1906 in Western Australia and continued spasmodically until 1913. Nurses were employed by the health department, with a primary duty to follow up school medical inspection, make sure corrective action was taken by parents, and to instruct mothers regarding the feeding of infants. In 1921 the first two school nurses were appointed on a full-time basis (Hobbs, 1980, p. 75).
38 In 1904 the National Council of Women, concerned at the high mortality rate and ignorance of the feeding and care of babies, began a program aimed at the education of mothers, employing the first home health visitor for mothers of new babies. In 1914, the New South Wales Government introduced the first ‘baby clinic’ in Australia, aimed at educating mothers in the art of mothercraft. A nation-wide service offering professional nursing advice and help to new mothers was seen as a necessity (Burchill, 1992, pp. 101-102). Services were offered through centres and home visiting with the aim of “keeping well babies well’, and any babies detected as having abnormalities or sickness were referred for medical attention (ibid., 1992, pp. 102104). In 1922 infant health services were established in Perth supported by the Silver Chain home visiting service, the Children’s Protection Society, the Red Cross Society and subsidised by the Government. These nurses dealt with healthy babies, advised on infant feeding and were not allowed to prescribe treatment or advise on medical preparations (Hobbs, 1980, pp. 75-76). Training for infant health services varied from state to state. In Perth it was established in 1924 at the King Edward Memorial Hospital (ibid., 1980, pp. 75-76). The District Nursing Service in Melbourne implemented midwifery, and in particular antenatal, services during the 1930s that led to an improvement in birth outcomes and breastfeeding rates (Burchill, 1992, p. 61). By 1946 there were 316 infant welfare centres in Victoria, five mobile road services, 1000 registered Infant Welfare Nurses, and over 8,000 mothers with babies enrolled in a correspondence scheme (Burchill, 1992, p. 116). The services were concerned mainly with the prevention of physical disease, educating mothers in the concepts of basic hygiene, mothercraft skills, infant feeding and nutrition. This was effective in helping to lower infant mortality (Garrett, 1989). By 1972, maternal, infant, preschool and school health services were provided by nurses covering virtually all of Australia, through the use of health clinics, and sometimes specifically equipped trucks, caravans, rail cars and aeroplanes. These nurses also visited mothers and their babies in hospitals, and families in their homes (Dewdney, 1972, p. 258). Another important milestone in community health nursing was the establishment of the Royal Flying Doctor Service (RFDS) by Reverend John Flynn in 1927 (Burchill, 1992, p. 124). This service, staffed by medical and nursing personnel, provided important access to health services for those in remote areas. There were also other initiatives that saw the employment of generalist community health nurses. In
39 Western Australia, public health nurses were employed from 1965 and community health services were instituted in 1974 (Holman, 1991). In Queensland, public health nurses were employed from 1972 to work in the Aboriginal Health Program. Twenty nine teams, that included registered nurses and Aboriginal health workers, addressed individual and community health problems in Aboriginal communities from a perspective that was consistent with the primary health care perspective described later in the decade by the World Health Organization (Perry, 1989). Katz et al. (1975) reported in 1976 that in addition to 386 maternal and child health nurses employed in New South Wales, there were nine generalist community health nurses. They further suggested that the 1970s had seen a great increase in the number of nurses practising in the community with an emphasis on health promotion, prevention of illness and health maintenance (Katz et al., 1975, p. 13). Prior to 1970, there had been a fragmented array of relatively isolated community health services including maternal and child health, school health, venereal disease, industrial health, tuberculosis services (National Hospitals' and Health Services' Commission, 1973) together with some of the initiatives of home health nursing services such as the first family planning clinics for women (Coombs, 1985, p. 5) functioning in a variety of settings such as industries, schools, district nursing services and infant welfare centres (Archer, 1977). These scattered services where bought together with a more focussed philosophy with the advent of the report of the National Hospitals' and Health Services' Commission (1973) and federal funding to the states for the Community Health Program for Australia. The Program supported state projects aimed to promote health, prevent disease and provide primary care, and health maintenance in the community and has resulted in the genesis of the community health nursing services seen in Australia today. Thus, although there has been a progressive development of community health nursing in Australia, it has been keenly affected by political decision-making and often expanded or changed in response to particular pressing social issues. The result has been a context characterised by change, insecurity, challenges and, at times, opportunities.
40
PROFESSIONALISM AND NURSING The history of professionalism and moves to professionalise nursing have been another factor that has had an impact on the role of the community health nurse in Australia. Freidson (1986, p. 31) pointed out that without some definition of profession the concept of professionalisation is virtually meaningless. Traditionally, theories of professions and professionalisation have been typified by medicine and law, with attributes such as autonomy, a body of knowledge and in terms of their position, power, monopoly and legitimation. Etzioni (1969) described nursing as belonging to a group he called “semi-professions” that fell between the established professions and skilled occupations in a hierarchy of occupations. He considered that these occupations had less knowledge-base, less training, less autonomy and less career structure. This assessment had the effect of galvanising the nursing profession. There have been numerous examples of community health nurses attempting to assert their professional status. For example, Drennan (1986) carried out her research into health visitors’ accounts of their work based on a theoretical framework of professionalism. Bullough (1995) reviewed the literature pertaining to nurse practitioners in relation to professionalisation. However, many nursing authors have also argued that nursing does not possess the characteristics that identify it as a profession. Moloney (1986, p. xi) suggested that nursing is deficient in the criteria for full professional status, lacking autonomy, self regulation in education or practice, a distinct self-identity and a body of knowledge. In 1972, Hunt examined community nursing practice in the UK and argued that at that time, health visitors had no clear sphere of work in which they were expert, nor did they have distinct skills not claimed by other professions. Furthermore, Drennan (1986) pointed out that health visiting had not been able to defend its own sphere of work against other aspirant groups such as social workers, or gain recognition for their preventative work from other occupations. As a result of assertions such as these, there has been a focus for developing the professional status of nursing. Moloney (1986) called for: research and theoretical development as a basis for nursing practice; greater control of nursing education, entry to practice, and regulation of practitioners; and moves to create responsibility, autonomy and accountability of nursing practice itself. Butterworth (1990) suggested that in order to
41 take a professional role, nursing must “put its house in order” and drew attention to a need to ensure safe practice, articulate and debate practice activities and assume individual responsibility for action as a way forward. Bruni (1985) suggested that the term profession has been applied to nursing in Australia for many generations. There has been a great deal of activity directed towards improving the status of nursing as a profession in Australia. Nursing education has transferred from hospitals to the tertiary education sector (Wood, 1990). Post-graduate programs in nursing have developed over the last two decades. There have been moves toward the development of nursing knowledge with a National Statement on the Development of Nursing Research Targets into the Twenty-First Century by the four major Australian professional bodies (Royal College of Nursing, Australia et al., 1992). A great deal of work has been done in many spheres of Australian nursing to develop standards of practice. Examples can be found in general nursing (Royal Australian Nursing Federation, 1983; Australian Nursing Federation, National Professional Development Committee, 1989) and community nursing (Australian Council of Community Nursing Services, 1987; Queensland Health, South East Coast Region, 1995). There have been reviews of the Nurses’ Acts of several states, following consultancy periods. National competencies for entry to practice have been developed and defined by registering authorities (Williams, 1989; Australasian Nurse Registering Authorities Conference, 1990) with the purpose of developing a professional rather than an industrial basis for practice; control of nursing practice and nursing education; and providing a basis for assessing entry to practice (Cheek, Gibson, and Gilbertson, 1995). In July 1992, the Australian Nursing Council was instituted with the purpose of establishing and maintaining national standards and processes for the regulation of nursing within Australia (Australian Nursing Council Inc, 1994; Purcival, 1995). A national code of ethics has been developed for nursing (Australian Nursing Council Incorporated, The Royal College of Nursing, Australia, and The Australian Nursing Federation, 1993). Career paths for nurses have been restructured to include an advanced clinical practitioner role (Silver, 1986; Keegan and Kent, 1992, p. 160). However, there has been disquiet among authors related to the notion of professionalisation in more recent times. There was critique of the attribute theory by Freidson (1970) who argued that the way to achieve autonomy was through political
42 and social means, and Roth (1974) who suggested that the attribute theory was a decoy that deflected attention from the use of power by established professions. Larson (1979, p. 609) argued that the aim of professionalisation is that of monopoly: monopoly of opportunities in a market of services or labour, monopoly of status and monopoly of work privileges in an occupational hierarchy. This monopoly, she argued, is gained through controlling the supply of professionals, and enables the professional to gain monetary reward for expertise. Thus, the exercise of deciding the criteria for determining a profession is a judgemental exercise that further reinforces the status of dominant professions. Larson (1979) also argued that there has been a “second wave” of professionalisation. She suggests that the newer professions have grown up in the bureaucracy of the public sector, and have thus lost their traditional autonomy. This change has seen professionalism transformed from the “market professions” and direct services for remuneration to the public into an ideology of professionalisation, a sociological factor that contributes to perpetuation of social inequalities created by linking professional status to the defence of a struggle for appropriate service to the public as a rationalisation. Larson argued that the establishment and bureaucratisation of maintaining these professions within the public sector conflicts with the ideology promoted to the public about the benefit of the professions. Schön (1992, p. 50) has also questioned the notion of professionalism. He pointed to the ground-swell of opinion that has questioned whether professionals were instruments of individual well-being and social reform, or whether professionals were mainly interested in preserving their own status and privilege. McCoppin and Gardner (1994, p. 43-71) observed that nurses in Australia have been politicised in response to analyses such as these. Professional nursing organisations have demonstrated a greater awareness of the importance of political approaches, evidenced by many activities of the Australian Nursing Federation, a greater emphasis on policy and the use of power (Gardner and McCoppin, 1989; Wood, 1990) and the move of the Royal College of Nursing, Australia to Canberra, the national capital. Marles (1989, pp. 12-15) identified that the power inherent in nursing’s occupational identity is derived from its service delivery function, the size of the occupational group, the historical and social identity of its members, in addition to the power vested by regulation of nursing practice. These factors contributed to the success of the nurses’ strike in Victoria in 1988. Among other outcomes of this action was the
43 commissioning of a study into professional issues in nursing (Committee for the Study of Professional Issues in Nursing, 1988), resulting in the identification of many issues relating specifically to professionalisation of nursing in Victoria and Australia. Intellectual scrutiny and debate has turned its focus to the status of professional knowledge, a basic plank in the notion of professionalism. Rather than having a firm grip on an area of knowledge, Freidson (1986, p. 215) pointed out that there is “always a good deal of intellectual untidiness and indeterminacy in what goes on in disciplines”. He further posited that there is never only one approach, and that under a single paradigm there will be found a variety of competing views. Schön (1992) also raised doubts about the conceptualisation of the professional as all-knowing and dominant. He pointed to the overwhelming complexity of the phenomena with which professionals are trying to cope, and suggested a need for scepticism about “... the adequacy of professional knowledge, with its theories and techniques, to cure the deeper causes of societal distress” (p. 50). He described the professions as having practical professional knowledge that he called knowledge-in-action. Rather than professional activity following a model of technical rationality with a hierarchy of theory over practice, he contended that professional practitioners engage in a process of problem-setting. This sees the practitioner addressing the task of deciding what the problem at hand is, which in turn provides the boundaries for identifying the ‘things’ that are relevant to a problem. Another concern expressed about professionalisation is that the power gained in attaining professional status may have the effect of disempowering those who are being ‘served’. Conrad and Schneider (1980) noted the medicalisation of many personal and social problems. For example, Reiger (1986) suggested that the role of the child health nurse assisting new parents may be deskilling mothers in their parenting role. Fuller (1995) outlined the disempowering effects of a ‘professional’ approach when working with ethnic clients in Australia and argued for a need to challenge notions of professionalism and work closely with ethnic health workers. Symonds (1991) suggested that the historical basis of health visiting has added a dimension of class differentiation between nurse and client, with the nurse assuming the contradictory roles of inspector, social worker and teacher. By engaging in professionalising strategies, nursing may be taking on the very features of the professions that they are seeking to be liberated from themselves.
44 It is within the context of this history and ideological climate that community health nurses practise. They contend with the conflicts between a professional perspective and the issues inherent in notions of health for all, primary health care, the new public health and empowerment related to use of power, control of knowledge and community participation. The ideologies and strategies of professionalisation may have limitations in community practice because they may conflict with the notions central to the new public health. Larson (1991, p. 25) suggested that rather than working toward a general theory about professions, there is a need to address the larger and more important theme of the construction and social consequences of expert knowledge. Kent (1989) suggested that a primary health care approach is a solution to the dilemma between professionalism and community empowerment and argued that community nurses should understand that they are responsible to the community for the way in which their expertise is employed.
THEORETICAL PERSPECTIVES ON COMMUNITY HEALTH NURSING In undertaking a study of the community health nursing role, it was important to analyse the literature to explore the meanings embedded in the notions of health, community and nursing. There was also a need to explore a synthesis of these concepts in relation to each other in order to come to an understanding of the current literature pertaining to the notion of community health nursing. An outline of the basis for approaching concept of role in this study is also addressed.
Health The most commonly cited definition of health is that of the World Health Organization (1947) that views health as not just an absence of disease, but physical, mental and social well-being. This view changed the notion of health from a simple single continuum between disease and absence of disease by introducing the notion of wellness. However, this definition has been critiqued by Fuchs (1974) who suggested that it is an unrealistic notion for people in underdeveloped countries and those of low socio-economic status, and Breslow (1972) who suggested that it is difficult to determine scientifically who is or who is not healthy, and at what point a person
45 becomes ill. However, the World Health Organization definition has provided the basis for a wide exploration of the notion of health. Health has since been conceptualised as: a wellness model (Dunn, 1977); an epidemiological model with a dynamic interrelationship of agent, host and environment encompassing both health and illness; and as a belief model that links beliefs about health with actions in relation to health (Rosenstock, 1974). Since the advent of the health for all perspective, there has been a view of health as a resource for everyday living, emphasising social and personal resources, together with physical capabilities. This aim addresses socioeconomic, cultural and political inequity and recognises that health is rooted in the way society functions. The health system is viewed in terms of health outcomes rather than availability of medical and hospital services (Mahler, 1981).
Community The notion of community has given its name to this whole branch of nursing practice. The community is often part of the ‘taken-for-granted’ assumed world of the community nurse. The community can be viewed from diverse perspectives, including geographical, sociological, political and health standpoints. McMillan and Chavis (1986, p. 6) suggest that definitions of community fall into two major frameworks: geographical and relational. The community is also described in terms of power structures by Heller (1989, p. 3). Another perspective which questions traditional notions of community is the concept suggested by sociologists Hunter and Riger (1986, p. 56) who describe a network approach to understanding the community. They suggest that with the advent of modern communication and transport, community networks and social links transcend the confines of geography. The ideas expressed in the general literature are reflected in the community nursing literature, where the major themes included in definitions of community incorporate the dimensions of: people, geography or space, shared features, bonds or interests, and involve some form of interaction (Bullough and Bullough, 1990, p. 25; Clemen-Stone, Eigsti, and McGuire, 1991, pp. 71-91; Cookfair, 1991, p. 39; Goeppinger and Shuster, 1992, p. 254; Clark, 1992, p. 9; Rorden and McLennan, 1992, p.11; Swanson and Albrecht, 1993, pp. 82-83). A definition that incorporates many of these recurring
46 themes was given in the report of the World Health Organization, Expert Committee on Community Health Nursing (1974, p. 7): ... a social group determined by geographic boundaries and/or common values and interests. Its members know and interact with one another. It functions within a particular social structure and exhibits and creates norms, values and social institutions. Other characteristics found in nursing authors’ conceptions of community are: the purpose of communities to meet needs (Rorden and McLennan, 1992, p. 11), an incorporation of collective function (Clark, 1992, p. 8; Goeppinger and Shuster, 1992, p. 254), boundaries (Neuman, 1989; Clemen-Stone et al., 1991, pp. 75-76), and a time element (Swanson and Albrecht, 1993, p. 83). The notion of community is fundamental to community nursing practice. Much of the community nursing literature posits that one of the distinguishing features of the community health nursing role is an engagement with the community as an entity, thus differentiating between services provided to communities, aggregates and groups and the personal services provided to individuals and families. This approach suggests that community nurses provide care to the ‘community as client’ (Sills and Goeppinger, 1985; Anderson and McFarlane, 1988; Bullough and Bullough, 1990; Clemen-Stone et al., 1991, p. 72; Cookfair, 1991). Other authors suggest aggregate (Clark, 1992, pp. 8-9) or ‘population-focussed’ practice (White, 1982; Williams, 1992). Goeppinger and Shuster (1992, p. 255) suggested that partnership with the community is an important aspect of community health nursing practice, defining it in terms of information sharing, flexibility and negotiated distribution of power aimed at improving the health of the community. Cookfair (1991, p. 39) and Bullough and Bullough (1990, p. 227) both point out that prior to undertaking a community assessment, community health nurses must first define the community they intend to assess. The nursing literature also suggests a nursing process approach, including community nursing diagnosis (Turner and Chavigny, 1988; Hamilton and Bush, 1991). Schulte (1992), in a study of public health nurses, found three interacting communities: the local community, communities created by individuals and families, and communities of resources. Schulte found that to create connections among communities, public health nurses used the processes: forging working relationships,
47 being a resource, detecting/asking the next question, making informed judgements, managing a sense of time, teaching, intervening with conditions influencing health, and using physical dexterity. Chalmers and Kristajanson (1989) examined the theoretical basis for a focus on the community as client and identified three models of practice; firstly the public health model that takes an epidemiological perspective and focuses on prevention; secondly the community participation model that involves a shift in power and control from the professional to the community group; and finally the community change model that extends the community participation model and posits that real and more enduring health improvements will only be made with changes to the structures of society and requires action at a political level. When it is considered that community is a conceptualisation rather than something concrete or tangible, understanding what is meant by the community becomes important to community health nurses who require direction in their practice. Although the notion of community is ubiquitous in the community health nursing literature, Clarke et al. (1993) suggested that theoretical understanding of the community is lacking in nursing. Sills and Goeppinger (1985) in a review of theory related to the community in the nursing literature, identified only two studies between 1952 and 1983. Chambers, Underwood, and Halbert (1989) suggested that traditionally public health nursing in Canada has placed more emphasis on individual and group-focussed interventions such as counselling, teaching and health promotion, than participation in public health policy development. Chalmers and Kristajanson (1989) further suggested that, to that time, the preparation of nurses for this role was limited particularly in the areas of epidemiology, community development and community organisation. They also pointed out that nurses’ knowledge more closely fits a lifestyle alteration intervention than a macro-system change. Clemen-Stone et al. (1991, p. 72) observed that many nurses find the transition to viewing the ‘community as client’ difficult, because they are more used to providing services to individuals and families rather than aggregates or communities. Hamilton and Bush (1988, p. 74) posited that without a delimitation of client focus, community health nursing theory development will continue to encompass the broad range of: clients in communities, clients influenced by communities, as well as clients as communities. With this failure to describe the nature of community, there is little to assist the nurse operationalising the notion of community when identifying exactly what constitutes
48 the community they are to ‘partner’ or engage in participatory activities with. A range of approaches are taken to identifying a community of focus. One approach is based on the setting. Some specialty areas of community health nursing take their identity from the setting in which they operate, including: remote area (Kreger, 1991), workplaces, schools or the home, and also disaster situations (Clark, 1992). There is difficulty in this approach however, because the nurse cannot always provide care to all within the particular client community. Choices may need to be made as to which individuals, families or groups within a client community should be the focus of care. Often, a way of solving this problem is to focus on identifiable sub-groups within the population, such as families, women or men, or client groups at particular developmental stages when health issues are considered to be most crucial, such as early childhood and later life (Campbell and Pigott, 1989; Spradley, 1990). Often these client groupings also provide the basis for identifiable specialty areas of community health nursing practice. However, this approach still has difficulties because the nurse may not be able to provide a comprehensive service to all within a sub-population within a given population. It is often necessary to make further decisions about the focus of nursing activity in order to most effectively use resources in achieving health gains. An alternative approach is to focus on providing services to vulnerable (Saucier, 1991) or ‘high risk’ client groups such as: the homeless (Clark, 1992), the mentally ill or drug addicted. The problem is that these approaches all result in narrowing the focus of care from a broad conception of community. A way of resolving this theoretical dissonance is to also conceptualise these sub-groups as communities in their own right. The nexus between a focus on the community and a focus on the individual and family has been a continuing conundrum in community health nursing practice. Although it is argued that the community is the focus of care, communities, aggregates and groups are made up of individuals and families. Nurses working in community health describe provision of care to individuals and families and reflect a tension between casework and the provision of community-focussed and community development services. Jackson, Mitchell, and Wright (1989) examined this issue and proposed a continuum approach. They suggested that community development applied to promoting the health of disempowered people begins with developmental casework, and continues through the stages of mutual support, issue identification and
49 campaigns, participation and control of services, and ends with social movements at the end of the continuum. They suggested that participation will shift back and forth across this continuum over time. Their approach to case work has distinct characteristics. They suggested that by considering developmental case work a part of the community development process, they are giving expression to a central tenet of the second wave of feminism: that the personal is political. The aim of developmental casework is the development of the individual receiving support, and the creation of links between individual service users. They emphasised the need for what they termed outreach case-work, or working on their client's "territory". This was considered important in enabling workers to stay in touch with the realities of people’s lives. This approach is reflected in the argument that the provision of individual and family care is rendered in a qualitatively different way when a community health nursing approach is used. Services are provided to individuals and families with a greater appreciation of the connectedness of individual health problems to the social and structural processes of the family and community. Despite these difficulties, the literature showed examples of community health nurses who addressed the community as client. Williams (1991) described a partnership with an Aboriginal community in order to address the issue of hearing loss in Aboriginal children. Franklin (1991) addressed a local community’s need for resources, particularly for young people. Kuehnert (1991) described a case study where public health nurses took a community advocacy role in order to change public policy on the issue of preventing lead poisoning in a local community. Peckham and Spanton (1994) described a project that used a community development approach to community assessment, arguing that there is a need for community participation networking and responsiveness to local situation and needs. Bless, Murphy, and Vinson (1995) described a community development program with poor inner city urban communities. Brown (1994) described a community development project carried out by health visitors that focussed on nutrition in a disadvantaged area. The community also has an impact on community health nurses as a context of practice. Helvie, Hill, and Bambino (1968) suggest that “the community practice milieu differs considerably from the highly routinised hospital setting which dictates a consistent conduct of practice related to the primary nature of the nursing role”. In contrast to a hospital setting where nurses work closely together, many community
50 health nurses are lone practitioners. In a hospital setting nurses have access to, and are professionally socialised by, role models of various levels of expertise (Kramer, 1985; Cohen, 1987; Green, 1988). Furthermore, Coombs (1989, pp. 2-3) suggested that services provided where people live, work and play engender a recognition that hospital services are only a segment in a range of services that meet health needs. In contrast to a narrow focus on diagnosis and treatment of sick individuals, she suggested that community health services are distinct from those available in hospitals or similar institutions and are concerned with the health and welfare needs of individuals, families and community, using education, prevention, early diagnosis, management and rehabilitation approaches.
Nursing Many have posed the question “what is nursing?” The result has been the impetus for research and the development of a range of theoretical formulations, models and descriptions seeking to define, clarify, organise, explain, verify and describe. The diverse nature of nursing practice, and the attempt to include such disparate practice areas as the nurse academic, nurse researcher, nurse manager, with community and clinical practice has often resulted in general definitions, descriptions or theories that provide little direction for a particular community health nursing practice role. This is illustrated by the definition of the International Council of Nurses who in 1973 defined a nurse as “a person who has completed a program of basic nursing education and is qualified and authorised in his/her country to practice nursing”. Russell (1991, p. 86) suggested that it may never be possible to develop a definition of nursing that encompasses the diversity of nursing specialties and the settings in which nursing occurs, including the community. Brooks and Kleine-Dracht (1983) suggested that “... the glorious thing about nursing is that it cannot be defined. The irony is that we never give up trying”. Although there are theories and models that explain nursing, there is no consensus on what the unique nature of nursing is. Description and definition of the role of the nurse began with Nightingale (1859) who first described nursing as a science and an art, and focussed on the contribution of the nurse to the client-environment interaction. The modern era has seen rapid expansion in theorising about nursing. Henderson’s
51 definition is perhaps the best known and most widely accepted definition of nursing, being accepted and published by the International Council of Nurses in 1969 (p. 4): The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) In Australia there have been efforts to develop more clarity in describing and defining of the role of the nurse and delineating functions. Early undertakings to define nursing occurred at a state level such as in Victoria (Ramsey, 1970) and Queensland (Saint, 1971). The Nurses Education Board of New South Wales (1976) described professional nursing as encompassing professional responsibilities, outlining these as: implementing prescribed care, delegating when appropriate, independent decisionmaking when appropriate, ethical conduct, observation and action, human relations, administration, and education. Functions of the nurse were based on a nursing process approach and focussed on the individual. The Royal Australian Nursing Federation, South Australian Branch (1983, p. 101) developed a single definition that included thirteen role responsibilities that incorporated: accountability and responsibility for nursing actions and maintenance of health care standards; using a planned and systematic approach in assisting the person maintain an optimal level of independence in the performance of daily living activities, problems, and when the time comes achieving a dignified death; facilitating client and family participation in care; supervision of enrolled nurses; functioning within legal, moral and ethical parameters; establishing and maintaining communication, interdisciplinary collaboration and coordination of care; maintaining and improving quality of care; efficient, effective and economical use of resources; professional activity and development of self and other team members; research and quality improvement of practice; and work safety. However, although providing an overview, these definitions did not provide much illumination of what nurses, and in particular community health nurses, actually do from day-to-day. Some progress was made when the National Health and Medical Research Council in 1983, reviewed the role of the nurse in Australia. This document accepted definitions
52 of the International Council of Nurses (1973) and Henderson (1966) and described nursing as occurring in a range of settings, including the community, and stated that: Community nursing is concerned with well people and with the sick and disabled. Nurses in the community work with individuals and families at home, in schools, and at the work place, and provide care for the nonhospitalised sick, the frail elderly, and handicapped. The role of community nurse changes according to where and with whom the nurse is working, the particular health needs of the individual, expectations of the community and the aims of the employing authority.
Community health nurses strive to
prevent disease or retard its progress, and there is an emphasis on health maintenance, health teaching, information sharing, counselling and support. (National Health and Medical Research Council, 1983, pp. 3-4) This definition suggested a responsive role, identified a range of settings, and had a broader client focus than the individual. It also gave some guidance as to the way in which the role is to be achieved. Missing from the description is an understanding of the community as client. Furthermore, although there is an acknowledgment of a health perspective, the statement does not include the notion of health promotion, there is a focus on illness in most of the client groups identified and an absence of wellness nursing. These factors were addressed when the Australian Nursing Federation examined the role of the nurse in 1984 and suggested that the purpose of nursing was to promote, restore and maintain optimal health (or a dignified death) by providing direct health care and education. The Federation identified the nursing process as a way of dealing with human needs and health problems, outlining activities of daily living in relation to personal care, work, social function, spirituality, recreation and learning. However, the Federation statement did not provide any differentiation between a community health nursing role and a generic nursing role. In 1989, a statement was made in a collaborative national statement, Nursing in Australia by the four major nursing organisations in Australia (Australian Nursing Federation et al., 1989, p. 5). This statement outlined a view of health that was consistent with notions of wellness, personal integrity, and an ability to lead a socially and economically productive life. They described the role of the nurse as encompassing promotion of health, prevention of health breakdown and the
53 facilitation of spiritual integrity and identified the impact of the context in which the nurse practises on the role undertaken. The statement suggested that nursing differs from other health professions because of the provision of holistic care by “simultaneously attending to the biological, psychological, socio-cultural and spiritual needs of people”. The statement described the primary role of the nurse as: ... that of clinical practitioner. Nurses engage in clinical practice (ie nursing care) in all settings in society where people are experiencing varying degrees of health, health breakdown and dying. Settings range from community to institutions providing both acute and extended care. The National Health and Medical Research Council again revisited the role of the nurse in 1990 when Robinson refined the previous statement and identified caring as the essence of nursing. The updated statement broadened the notion of ‘client’ suggesting that nursing was concerned with individual, family and group responses to actual or potential health concerns and health maintenance (p. 3). The role of the nurse was outlined as incorporating the general functions of clinician, teacher, manager/coordinator, client advocate, professional development, consultant, educator/academic and researcher and occurring wherever there are individuals, families, groups or communities who demonstrate a need for nursing care (ibid., 1990, p. 9). The community health nursing role was revised with the addition of care provision to “well people”, the activity of “health promotion” and an inclusion of the approach of “identification of appropriate resources”. In many instances, in attempting to define and describe nursing, these statements use the very notion they are aiming to define: for example by using the word ‘nurse’ or ‘nursing’, providing, engaging in ‘nursing practice’ or providing ‘nursing care’. One could also accurately apply many of the statements made to the role of other health professionals in the community. More recent times have seen a change in direction from attempting to define nursing to delineating nurses’ scope of practice and outlining competencies. The Australasian Nurse Registering Authorities Conference (1990) developed a set of competencies related to the role of the nurse: clinician, care coordinator, change agent, counsellor, health teacher, client advocate and clinical teacher/supervisor, with a responsibility to critically examine and incorporate the results of research into practice. However, while providing a broad outline of the
54 capabilities of the nurse, these statements do not provide a basis for specific community health nursing practice. More specificity is provided by examination of statements of scope of practice. The Queensland Nursing Council (1995, p. 2) in a paper designed to promote discussion on the scope of nursing practice in Queensland defines scope of practice as the activities its practitioners are educated and authorised to perform. The danger inherent in this approach is that there will be a return to taskorientated practice. Henderson as far back as 1966 (pp. 4-5) concluded that although major efforts have been made by individuals, small groups and organisations to formulate statements of nursing function, this is still unfinished business: Perhaps it is one of these perennial problems that will always exist because conditions change from one era to the next and change with the culture, or the nature, of a society. However, as long as official definitions are unsatisfying to nurses, or too general to protect the nurse and the public or to guide practice, research, and education, individual nurses will continue to seek statements that fulfil their needs. (Henderson, 1966, pp. 4-5) In tandem with efforts to define nursing, there have been developments in theory describing nursing practice or aspects of it. There is general consensus that the core phenomena that provides a basis for most theory and models in nursing consist of the concepts person, environment, health and nursing. Fawcett (1995, p. 7) describes these concepts as linked by the following four propositions: first, nursing is concerned with the principles and laws that govern the life-process, well-being, and optimum function of human beings, sick or well; secondly, nursing is concerned with the patterning of human behaviour in interaction with the environment in normal life events and critical life situations; thirdly, nursing is concerned with the processes by which positive changes in health status are effected; and finally nursing is concerned with the wholeness or health of human beings, recognising that they are in continuous interaction with their environments. It has also been argued that the concept of person should be expanded to include pluralities such as families, groups and communities (Meleis, 1991; Whall and Fawcett, 1991). However, although nursing may have an identifiable meta-paradigm, it has a multiplicity of theorising within these domains.
55 Early approaches to providing a conceptual understanding of nursing were to identify problems that were the goals of nursing activity and attention. Abdellah, Beland, Martin, and Matheney (1960) identified a typology of 21 nursing problems and Henderson (1966, pp. 16-17) elucidated the activities she considered needed the assistance or intervention of the nurse. The quest to classify nursing practice is a continuing one (Wake et al., 1993). However, listing functions fails to encapsulate all aspects of nursing. There followed a group of theorists who attempted to illuminate a view of nursing as a whole, or provide better understanding of specific aspects of nursing. King (1971) focussed on interaction, describing the nurse and client as perceiving one another and the situation, then acting, reacting, interacting and transacting in order to together set goals and the means of achieving them. Leininger (1991) described a cultural dimension to nursing practice, articulating a need for nurses to be sensitive to their own culturally-based values, as well as the values that the client holds. Rogers (1970), as the first nursing theorist to propose a holistic view of man, provided analysis of the nature of the client in interaction with the environment. Roy (1984) developed theory based on an interactionist approach that viewed persons as adaptive bio-psycho-social beings in constant interaction with a changing environment, with the role of the nurse being to facilitate the physiologic, self-concept, role function and interdependence relations modes of the client. Nurses have also drawn on developmental theory (Chinn, 1980), family theory (Whall and Fawcett, 1991) and behavioural theory (Johnson, 1980). Another important trend in nursing practice has been the development of the nursing process, based on the scientific problem solving method. This approach, originally proposed by Yura and Walsh (1967), involved assessing, planning, implementing and evaluating. To these was added the process of nursing diagnosis (Gordon, 1987; Carpenito, 1992) that identifies diagnoses that are the result of nursing assessments and require specific nursing action. This approach has been applied in community nursing with the development of a system for classifying the problems of individuals more holistically (Martin and Scheet, 1992; Keyzer, 1994) and to the community as client (Anderson and McFarlane, 1988). While acknowledging the usefulness of using the structured reasoning of the scientific process for identifying the purpose of nursing action, there have been critics of the narrowness of this approach in community health nursing (Cowley, 1988), the lack of fit with clinical reality (George,
56 1994) and a suggestion that wholesale application of the nursing diagnosis approach to the community should be greeted with caution (Cooney and Watts, 1992; St John, 1994). In more recent times there has been development of a philosophy of caring and humanistic nursing (Watson, 1979). There has been a shift towards undertaking qualitative research in order to articulate the knowledge embedded in practice rather than engaging in application of externally derived theory. Benner (1984) contributed to understanding the nature of the nursing role when from a qualitative study of nursing practice she identified seven domains of nursing practice: the helping role; the teaching-coaching function; the diagnostic and patient-monitoring function; effective management of rapidly changing situations; administering and monitoring therapeutic interventions and regimens; monitoring and ensuring the quality of health practices and organisational and work-role competencies. Fenton (1985) carried out a subsequent study of advanced nursing roles in thirty master-prepared nurses. Her findings corroborated the findings of Benner and she identified the further competency of consulting. These and other authors have suggested a need for praxis or interplay between action and reflection to uncover the knowledge embedded in practice (Street, 1990). A difficulty with many nursing theories, however, is that they relate only to the individual. Most general definitions of the role of the nurse, when examined in detail have greater applicability to the acute clinical role of providing sick-care to individuals, and provide little or no guidance or explanation for the community health nurse addressing the needs of a family, group or community, within a community context or with a community perspective. Clark (1986a) identifies the assumptions in nursing models that limit their usefulness in community health nursing. First, there is an assumption that the focus of care is an individual when the focus is also on families and communities. Secondly, there is an assumption that nursing is concerned with people’s problems rather than also incorporating a pro-active approach. Next she identifies an assumption of change, when the aim may also be to maintain health. Finally, she notes an assumption of a discrete illness episode that entails admission and ends in discharge. For example, Henderson (1966) refers to the need to include family in the care of the patient. However, there is no way of understanding the family or community in her writings because her approach focuses on holistic
57 individualised care. Furthermore, although many theories suggest a focus on health, a review of literature describing their application in practice and research suggests that they are often more useful in clinical situations where the focus is an individual client with an acute disturbance to health. Schlotfeldt (1987), in reviewing definitions of nursing, suggested that since the time of Nightingale and Henderson, there has been agreement that nursing is concerned with health and wellbeing as a central focus. However, she noted with concern the recent trend toward a focus on disease, health problems and dysfunction, particularly with the nursing diagnosis movement and neglect of the field relating to: ... theory development and systematic inquiry that leads to knowledge of the gamut of health-seeking phenomena available to persons in all relative states of health, illness, and injury and the promulgation of theories concerning nursing strategies that are efficacious in assisting all human beings in various circumstances attain their health goals. (1987, p. 66) There have been attempts to modify existing nursing theories to encompass a community perspective. Examples include: an application of King’s theory to a small locality and the health practices of a group of prostitutes (Babb, Fouladbakhsh, and Hanchett, 1988); Roy’s adaptive systems to a community problem of spousal abuse (McDaniels and Hanchett, 1988); Rogers theory to assessment of a provincial town (Borner, Counsman, deGilling, Lewman, and Wills, 1988). Perusal of the literature shows that the most cited theories in community health nursing are the Neuman’s systems model (Neuman, 1989) that incorporates Gestalt, systems and stress theory in relation to the environment; Orem’s (1991) self-care deficit theory addressing the notion of client self-care; and Pender and Pender (1987) who developed a health promotion model based on social learning theory that outlined cognitive-perceptual factors and modifying factors involved in client participation in health-promoting behaviour. Neuman’ theory (1989) provides an ability to view the individual, family or community client system as a dynamic organism or ‘whole’. Her theory conceptualises how the client interacts with, adjusts to and reacts to stress. There is a holistic, wellness focus with nursing directed towards addressing responses to stressors. Her theory has been applied to public health nursing practice (Benedict and
58 Sproles, 1982) community health assessment (Anderson and McFarlane, 1986; Beddome, 1989), development of standards of practice for community health nurses (Drew, Craig, and Beynon, 1989) and family assessment (Mischke-Berkey, Warner, and Hanson, 1989; Reed, 1989). A limitation of Neuman’s model is that while it provides a way of conceptualising the person in relation to the environment, the relationship is reactive rather than proactive. Furthermore, there is little to differentiate a unique nursing role from the role of other health professionals. Another major concept that has currency in the community health nursing literature is the notion of self-care. The World Health Organization (1994, pp. 9-10) suggested that health care has become the province of all, with individuals, families and communities playing a larger role in both determining and meeting their own health needs. They further argued that the role of nurses will change to become enablers and facilitators, providing information, guidance, education and helping people help themselves. Steiger and Lipson (1985, p. 8) suggested that perhaps 75% or more of health care is self-care. They further suggested that the reasons for interest in self-care is relate to a shift in focus from acute conditions to chronic, the rising costs of health care, disillusionment with traditional models of care and a demand for greater participation (ibid., 1985, p. 3). Gantz (1990, p. 2) describes the notion of self-care as a complex one, noting that at one time or another, self-care has been described as a movement, concept, framework, model, theory, process, or phenomenon. She noted that experts have been unable to derive a consensus definition or to develop parameters to guide the sorting of activities as consisting or not consisting of ‘self-care’. The major nursing theorist who addresses self-care is Orem. Orem (1987) began development of the Self-Care Framework in the 1950s. She lead the Nursing Development Conference Group (1979) who developed ideas on self-care in nursing. Her aim was develop a basis and description of the domain and boundaries of nursing practice that was distinct from other disciplines. She describes her search for meaning in nursing as being focussed on the questions: what do nurses do and what should they do?; why do nurses do what they do?; and what are the results of what nurses do? (Orem and Taylor, 1986, p. 39). The theory is made up of a set of theoretical concepts: self-care, self-care deficit, and the nursing system. Orem (1991, p. 66)
59 explained that “the theory of the nursing system subsumes the theory of self-care deficit which subsumes the theory of self-care”. She defines self-care as: ... the voluntary regulation of one’s own human functioning and development that is necessary for individuals to maintain life, health, and well-being. (Orem, 1995, p. 95) Orem (1995) suggests that self-care agency relates to the human abilities for meeting self-care requisites, including acquisition of knowledge, decision-making, and taking action for change. Self-care agency may vary over time due to developmental change, health state, educability, life experiences, cultural influences and available resources (p. 212). A self-care deficit occurs when a person’s ability to perform self-care (selfagency) is not sufficient to meet his/her therapeutic self-care demand. The function of the nurse is to diagnose, prescribe, design, plan, implement, manage, and maintain systems of therapeutic self-care for individuals who have limited self-care agency (Orem, 1991, pp. 54-55). While her theory makes an important contribution to community health nursing, there are limitations. First, a review of the literature reveals although Orem’s theory has been used to address the needs of families (Orem, 1983a, 1983b; Chin, 1985; Tadych, 1985; Gray and Sergi, 1989), groups and communities (Hanchett, 1988, 1990; Nicolaisen, Gates, and Hanchett, 1988; Taylor and McLaughlin, 1991; Taylor and Renpenning, 1995), most of the published application of Orem’s theory in practice and research has been in acute or institutional settings or with clients experiencing illness and dysfunction (Johnston, 1989, p. 166). This could be considered a logical outcome of the functional, behaviourist and therapeutic nature of her theory and the focus on deficit. Orem’s theory addresses deficits and functional needs such as those things that “support life processes, the formation and maintenance of structural integrity, and the maintenance, promotion of functional integrity” (Orem, 1991, p. 121) and incorporates human development, again with a functional perspective. The consequence is a focus on individual dysfunction, illness or disease or at best health maintenance, rather than wellness and prevention of illness. Although Denyes (1988) applied Orem’s model for use in health promotion, she acknowledged limitations in the theory’s definition of health. Secondly, the dominant and controlling position of the nurse’s decision-making role conflicts with notions of empowerment. The nurse is
60 explicitly identified as more knowledgeable than the client. Thus the client, whether individual, family, group or community is in a dependent situation in relation to the nurse, even though they are learning to self-care. Orem’s theory does not take account of those who do not wish to be assisted with ‘self-care’ or indeed may be selfneglectful for many reasons (Reed and Leonard, 1989). Nor does the theory account for the differences of opinion about the nature of ‘health’ and what is to be achieved. There is no acknowledgment that in the reality of people’s lives, ‘health’ may not be a priority. They are socially and culturally decontextualised. One does not get a sense that nurses should work with the client’s own situation, determining the client’s own ideas about health and accepting the client’s own aims. With the nurse central to the theoretical conceptualisations, there is no sense of the individual being situated in their own lives. Were this approach to be taken, the nurse would become peripheral rather than central as in Orem’s theory. Thirdly, her theory tends to address the needs of individuals rather than families, groups or communities (Fawcett, 1995, pp. 333336). While one can find references to ‘community’ in the writings of Orem, they have been added to original writings by way of clarification, rather than being integral to the genesis of the theory itself. Although Orem recognises the importance of the community and environment, it is seen as a background to the individual, rather than an entity, organism or focus itself. Thus, Orem’s theory is limited mainly because it does not take account of current thinking inherent in primary health care, family theory, understanding of the community, community consultation and community development, community networks, public policy-making and interrelationships between people in families and communities and how the nurse interacts with these factors. Clarke et al. (1993, p. 308) suggest that it is counter-productive to encourage self-care when people lack environments conducive to health. As a consequence they argue for an involvement of community health nurses in shaping public policy for health, beyond the traditional health sector. They argue that there is a need to address the social determinates of health such as housing, employment and literacy. Twinn (1991) also argues that there is a need for nurses to influence health policies at a local and national level. Orem’s theory fits more comfortably with the old public health paradigm than the new public health paradigm embodied by primary health care. As a consequence, while exceedingly useful, and providing great utility for some facets of community health
61 nursing practice, this approach alone is limited. This is demonstrated by the descriptions of community assessments based on Orem’s theory by Nicolaisen et al. (1988) and Taylor and Renpenning (1995). While providing an excellent overview of demography and availability of resources, an analysis of networks and a perspective of the community as an entity were neglected. There was no description of consultation with the community, nor a sense of what the community themselves wanted or saw as their health needs. Rather, their discussion described the community as a background environment for individual health needs. When there was discussion of the ‘community as persons in relationship’, there was no theoretical support from Orem’s theory. Townsend (1994) when reviewing the challenges facing nursing in Australia, suggested that for sustainable nursing there is a need to change from care-giver to care-facilitator, from controller to co-carer and to embrace “a broad flexible basis for interaction such as that embodied in primary health care” and self-care approaches (p. 276). A more useful approach to self-care is taken by Steiger and Lipson (1985) who supplement Orem’s approach to understanding self-care with the holistic theoretical approaches of Rogers (1970) and Leininger’s emphasis on culture (1991). They differentiate between self-care and patient education concepts, suggesting that selfcare promotes: client responsibility rather than professionally prescribed behaviour, client initiated goals rather than professionally initiated goals, an active role in directing health care rather than a passive ‘sick role’, client control of decisionmaking, individualised rather than standardised strategies, the fostering of independence and initiative rather than dependence, and greater transfer of skills to clients. Hill and Smith (1990, p. 10) identified the essential conditions required to meet self-care needs as: knowledge, skills, responsibility, motivation and energy, a high value on health, a fit with cultural values and a perception that new health behaviours will reduce vulnerability to illness.
Towards a Conceptual Understanding of Community Health Nursing Arriving at an understanding that encompasses the complexity and breadth of the specific community health nursing practice role is even more problematic than understanding a generic nursing role. The more clearly defined role of the nurse
62 caring for the sick may not be evident in community health practice that focuses on prevention of illness and promotion of health of the individual, family, aggregate and community. McMurray (1991, p. 6) suggested that: Boundaries of the community health nursing role are much less distinct than those of the hospital nurse because of the broad, variable range of activities involved in community health nursing. Many of these activities include the individual, family and often the socio-cultural group. Helvie et al. (1991) examined the difference between community health nurses and hospital staff nurses and suggested that the identifying factors of community health nursing was: a focus on family and community as well as individual; a focus on health, health maintenance, disease prevention and rehabilitation; inter-sectorial links; autonomy; client control of the situation; legal accountability without medical support; the unpredictability of events; an ability to stimulate events; participation in the intimacy of people’s homes; a coordination role; and undertaking a case-finding and case-holding role. Identifying the concepts of interest to theorists in community health nursing quickly becomes overwhelming, because in addition to nursing theory, concepts are drawn from a range of disciplines including: epidemiology, the social sciences such as anthropology, history, psychology, sociology, philosophy and politics; educational principles; economics; and the physical sciences such as the biological and environmental sciences. Thus, it becomes extremely difficult to delimit variables and discern patterns of phenomena for the purposes of description, explanation and prediction. Various approaches to defining, describing and understanding the community health nursing role have been taken. These approaches include identifying role components, identifying the aims of practice, describing activities and developing conceptual theory. The first approach is to identify the role components carried out by the community health nurse. In general, many of the role components identified for generic nursing are used, with the addition of several more. For example Green and Driggers (1989, p. 84) point out:
63 ... that community health nursing has often been described in terms of the nursing roles which community health nurses (CHNs) can be expected to fulfil. ... includes provider, teacher, adjunct, advocate, manager, collaborator, group leader, case finder, evaluator, health planner, researcher, consultant, coordinator, counselor, health promoter epidemiologist and specialist. Identification of role components has seen the development of standards for community health practice that have made a contribution in providing some definition of the role of the community health nurse. Standards have established guidelines for practice and education and provided criteria for quality assurance. They have also provided community health nurses with a basis for professional identity. In Australia, competencies for community health nursing practice have been based on the Australasian Nurse Registering Authorities Conference competencies (1990). Various organisations have developed standards specifically for community health nursing practice. The Australian Council of Community Nursing Services (1987) identified standards related to the obligations of the nurse, interactions and the provision of effective and holistic nursing care. The Maternal and Child Health Nurses Special Interest Group (1993) and Queensland Health, South East Coast Region (1995) have also developed standards of practice. Internationally, the American Nurses' Association (1986) identified standards based on the nursing process and applied to individual, family and community that included: using a theoretical basis for practice, systematic data collection, diagnosis, planning, intervention, evaluation, quality assurance and professional development, interdisciplinary collaboration, and application of research to practice. Kenyon et al. (1990) identified clinical competencies for community health nursing as: case-finding, screening, assessment (including individual, family and environment), case management, decision making/priority setting, teaching, leadership, collaboration, health care system management, understanding of legal issues, and an orientation to long term as well as short term goals. McMurray (1991) found excellent communication and interpersonal skills to be a crucial basis for nursing competencies. These findings have been supported by evidence from international studies, and are reflected in all nursing standards and competencies accessed. A study by the Public Health Association Steering
64 Committee (1990, p. 59) of the graduates of post-graduate public health courses, found that more than two thirds of all students selected interpersonal skills as the top essential competency, 20% above the next selected competency. Employers also topranked interpersonal skills. West (1989, p. 381) noted that the health visitors’ role requires “autonomy, discretion, responsibility, mature judgement and tolerance for dealing with complex and critical situations for which no easy solution is readily available perhaps to a greater extent than the traditional nursing role”. However, identification of role components alone is limited by the lack of conceptual clarity in describing a unique community nursing role that can be differentiated from generic nursing and the role of other health professionals working in the community. The second approach has been to describe the aim of community health nursing as focussed on health and health promotion and to identify associated activities. Health as the raison d’être of community health nursing is ubiquitous in the community health nursing literature. This is reflected in the statement by Goeppinger and Shuster (1992, p. 254): Community-oriented practice seeks healthful change for the whole community’s benefit. The focus is on the collective or common good instead of individual health. ... Change is intended to affect the whole community, including all units of service - not just the individual, family, or specific aggregate. Helvie (1991) identified four major goals for community health nursing as: helping individuals, families, groups and communities reach the highest level of health compatible with human potential and desire; providing comprehensive care to these clients; preserving autonomy; and improving nursing and public health practice. White (1982) identified the principal priorities of promoting public health as prevention, protection and promotion. She suggested a focus on the human/biological, environment, social and medical/technological/organisational determinates of health, in tandem with the nursing process. Kegan and Kent (1992, p. 158) identified the trends in community health nursing as: changing from a focus on illness and disease to protection and promotion of health and prevention of illness; providing continuing rather than episodic care; relating to a broad network of community members, agencies and professional disciplines; enacting a role that encompasses a generalist
65 orientation, a broad view of health, a variable range of activities and providing a resource to the community; functioning in way that is less predictable and that extends traditional nursing functions; and having a structural framework that is autonomous, has a less rigid structure and utilises a critical inquiry process. In the UK, the Health Visitors' Association (1987) have also argued that the principles and practices of health visitors and school nurses are essentially the same: searching for health needs, patterning health needs, influencing health education, and health enhancement. The American Nurses' Association (1980, p. 110) identified the object of community health nursing as “the prevention of illness and the promotion and maintenance of health”, with activities such as education, counselling, management and advocacy. They further suggest that “the object [is] to assist him to assume self-responsibility for health care. Independence of the client, or the ability to manage self-care, is of the highest priority in primary care” (ibid., 1980, p. 11). These aims are addressed through both direct care of individuals, families and groups and also by considering and addressing community needs, resources and priorities (ibid., 1980, pp. 11-12). A similar approach is taken in Canada: They [community health nurses] provide health-promotion and diseasepreventative services such as health education and screening, life-style and nutrition teaching, counseling, and referrals.
They are the case-finders,
educators, counselors, community resource advisors and service coordinators. (Matuk and Horsburgh, 1989, p. 169) Furthermore, a review of the literature reveals that with the advent of the new public health, the principles of health for all and primary health care have been widely embraced by community health nursing. McMurray (1993) posited that community health nursing was primary health care in practice. This approach can be seen in the statement of the Canadian Public Health Association (1990): ... public health nurses, by their expertise in the provision of accessible and affordable services in the environment where people live, work and participate in leisure activities, are in the unique position of already being involved in primary health care and furthering the goal of health for all by the year 2000 and beyond. (Canadian Public Health Association, 1990)
66 Identification of primary health care as the basis for community health nursing practice has often lead to identification of a range of role activities consistent with this philosophical approach (Cernik and Wearne, 1994). Keegan and Kent (1992, p. 159) described community health nursing in Australia as occurring within a primary health care and community context and stated that: Liaison and coordination with other health and welfare workers and agencies have been established. Health promotion and preventive measures, such as support and education groups for community members, immunisation, adequate nutrition, early detection of developmental delay and vision and hearing defects in infants and children, health education and identification of risks to family health have been focused upon. However, an extension of the role is also occurring, based on a broader knowledge of community selfdetermination and inter-sectoral collaboration. However the notion of primary health care is subject to differing interpretations in the literature. St John (1993) discussed the variation in approach to primary health care and suggested that an integrated approach to the nurses’ role which encompasses primary care, public health, and community development be taken. Furthermore, as Twinn (1991, p. 969) noted, the abstract notion of health provides a “very fragile foundation for the basis of professional knowledge” due to its ambiguity and a propensity to defy definition and quantification. She also identified a polarisation in the beliefs of practitioners between those who believe that practice can be operationalised, measured and quantified and thus be scientific, and those who believe that the concepts of practice are unique and particular to each individual situation (ibid., 1991, p. 969). The solution she posits, is to perceive practice as both an art and a science rather than these two aspects being mutually exclusive and to regard it as requiring action and reflection. She proposed that: This approach to an epistemology of practice will enable practitioners in health visiting to adopt different paradigms of practice appropriate to the identified health need in addition to acknowledging the uniqueness of the practice setting. (ibid., 1991, p. 970)
67 White (1982) suggested that there must be a realisation that health occurs primarily through maintenance rather than achievement, meaning that “often ‘nothing’ happens, at least in a dramatic, immediate sense” (ibid., 1982, p. 528). As a result, Cowley (1988, p. 149) observed that there is a temptation to concentrate on short term aims, because it is easier to achieve results, rather than the important long term aims for eventual health outcomes. The final approach to understanding community health nursing is seen in the activities of theorists who seek to go beyond description and explore the conceptual bases of community health nursing practice. Twinn (1993) suggested that there are four paradigms incorporated within community health nursing practice: individual advicegiving concerned with client welfare and protection; environmental control utilising the public health model; psychological development, focussing on personal support; and finally an emancipatory approach. Turner and Chavigny (1988) argued for an epidemiological approach to community health nursing practice, suggesting that the commonalities of all community health nursing roles relate to: the population aggregates perspective; the educational preparation in public health sciences, nursing science and advanced nursing practice; practice goals and a philosophical foundation oriented toward prevention and rather than the medical model; interdisciplinary practice; and finally cost effectiveness (ibid., 1988, pp. 234-236). While many community health nursing authors take an epidemiological approach (Shortridge and Valanis, 1992), this conceptualises community health nursing only in relation to the old public health paradigm rather than also from the perspective of the new public health. Another approach has been to integrate different paradigms. Community health nursing has been described as a “... a synthesis of nursing practice and public health practice applied to promotion and preserving the health of populations” (American Nurses' Association, 1980). Archer (1982) suggested that in addition to nursing knowledge, community health nursing synthesises knowledge from the fields of: the physical, social and biological sciences; epidemiology; health education; research; community assessment; population-based nursing; and primary prevention. St John (1993) proposed a model for integrating the notions of primary care and public health with notions of development of individuals, families, groups and communities as a basis for community health nursing. The notion of community health nursing as a
68 synthesis of other disciplines was seen in the documentation of one of the regions accessed for this study. They saw community health nursing as: ... a synthesis of nursing practice, public health practice, health education and primary health care. The practice of community health nursing expands into the areas of disease prevention, health maintenance/promotion, empowerment, advocacy, community development and is general, comprehensive, directed towards the individual and family across the life cycle, it is continuous and has impact upon the total population. Community health nurse role definition, regional documentation 15-22 However, combination of several conceptual bases into a formulation which provides theoretical coherence and provides specificity for practice remains a difficulty for community health nursing. There is a need to combine the concepts of care, illness and health in a meaningful way and integrate the notions of the provision of care to individuals within a focus on aggregates. Furthermore, Hanchett and Clarke (1988) examined the compatibility of the nursing meta-paradigm with the epidemiological model of agent, host and environment. They questioned the disease focus of epidemiology and concluded that a true synthesis requires resolution of contradictory ideas. There has also been concern about the compatibility of community health nursing with the theoretical concepts of nursing. Cowley (1988) compared nursing concepts to the concepts of health visiting and outlined the differences. Rather than “person, health, society and environment” she suggested the health visiting concepts include “health, prevention, needs and coping”. In addition, she suggested that the focus of care using nursing concepts was “individual, problem/need, giving treatment, doing for, assisting, comforting and advising” where for health visiting it was “family, situation, finding resources, enabling, supporting, encouraging, teaching”. She suggested that the nursing concepts posited a time-scale of minutes, days and weeks rather than the weeks, months and years involved in health visiting practice. Instead of the nursing team with patient and relatives, she saw greater interaction of the health visitor with mother, child, family and community.
69 The need to integrate seemingly inconsistent ideologies was further examined by Hamilton and Keyser (1992). They undertook a Delphi technique study of 154 members of the Association of Community Health Nursing Educators in the USA, examining the ideologies of community health nursing. They found that community health nursing did not encompass a unidimensional set of beliefs. Instead they were made up of two paradoxical clusters relating to an individually-focussed ideology and a community-focussed ideology. They suggested a dialectical or evolutionary approach to dealing with this bifurcation of ideology may enable an integration of these concepts. Another overview of the approaches used to understand community health nursing practice was provided by Twinn (1991) who examined the range of ways health visiting was practised and suggested that the paradigms used could be placed along two axes: from directive to non-directive and from individual to collective. Thus, she divided practice into four distinct domains: directive/individual (Individual advice giving, maternal and child welfare and protection); directive/collective (environmental control, public health model); individual/nondirective (psychological development, personal support); and collective/non-directive (emancipatory care, networking, community health). More recently, there has been a trend away from developing definitions of community health nursing practice towards using research to explore, access and articulate the knowledge embedded in the every-day practice of nurses. Rather than organisations and academics abstractly theorising and developing definitions, there have been explorations of theory arising out of the thinking and action of the practice field using grounded theory methodology. Clarke et al. (1993) suggested that three concepts emerged from their study as paradigm concepts: health care, the public’s health and public health nursing. They argued that these concepts give community health nursing its orientation. They also identified three process concepts, these being: community development, shared governance and balanced accountability/responsibility, and research. They argued that these concepts offer a potential synthesis of the special nursing orientation to the community. They provided a conceptual model of public health nursing’s preferred future based on their research. In particular, they identified a definition of public health nurse roles, appropriate educational preparation and role enhancement as paradigm concepts, as balancing with the need to focus on the public’s health within the context of the health
70 care system, consistent with a primary health care approach. The principal strategies and processes of achieving a shift to a primary health care approach were seen as prevention, promotion and protection, incorporating community development, nursing governance and involvement of nurses in policy formulation, and a balance in accountability and responsibility for health among members of the community. This research identified many conceptual themes in community health nursing, and contributed to further clarifying a distinct role for community health nursing practitioners. However, as Clarke et al. (1993) pointed out, theoretical constructs which combine these concepts and articulate community health nursing practice are still lacking. Their research provides yet another plea for clarification and articulation of the community health nursing role. Collis and Dukes (1991) in a study of school health nurses identified four principles of practice in school health nursing: that health care of the school child includes both preventative and curative activities; that the nurse is a source of knowledge about health and health services; that the nurse facilitates the school in becoming a health promoting community; and finally that the nurse takes a team approach that acknowledges parents as partners. In view of the diversity within the community health nursing role, some have argued that closely defining the role of the community health nurse may be counterproductive. West (1989) suggested that ambiguity is inherent in a role that is autonomous, extremely varied, and requiring of professional judgement. He further argued that an attempt to too precisely define the role of the community health nurse could be detrimental, not in the best interests of the future of community health nursing or the promotion of excellent practice and that such action may curtail the introduction of innovation, responsiveness and unnecessarily inhibit the role. White (1982, p. 527) further suggested that definitions are restrictive and: ... ultimately disabling to public health nursing’s ability to be socially responsive and relevant.
It is its ingenuity, resourcefulness, and
entrepreneurship that have enhanced public health nursing’s responsiveness to rapidly changing human circumstances - a characterization not easily encapsulated in a simple definition.
71 It can be seen that there are many approaches to understanding community health nursing. They vary, depending on the orientation to practice, sphere of practice and the questions being asked in research. Indeed, it would seem that the development of mid-range theory and exploration of the various aspects of community health nursing would be a more fruitful way forward than attempting to identify an all-encompassing theory of community health nursing. Furthermore, the trend towards identifying theory that is derived from and articulates the knowledge embedded in the practice of community health nurses may give rise to new knowledge, re-value the practice of community health nurses and engender more confidence of practising nurses in the work that they do.
PERSPECTIVES ON ROLE The notion of ‘role’ is a complex one and the term is often used very loosely in the nursing literature. In view of the apparent ambiguity inherent in the community nursing role, a theoretical approach was required that: enabled access to personal meanings of role; provided a framework for examining how a nurse interacts to negotiate, establish and change his/her role; and took account of historical, environmental, personal and interactional factors. There are two major approaches to understanding the notion of role in the sociological literature: structural-functional and interactional. The structural-functional approach sees a role as more or less a fixed position within society, based on an underlying assumption that roles are socially structured by the norms and values associated with a particular social position, and are subject to socialisation, expectations, demands and social reinforcement. Role activities and the possibilities for action occurring in response to social and environmental structures and the opportunity for individuals to alter the patterns of social interaction are limited (Conway, 1988, p. 64). This perspective was considered to be too narrow and restrictive to provide a basis for exploring an insiders’ perspective of the role of the community health nurse and was consequently rejected as a basis for this study. The interactionist perspective was considered to be more useful. In contrast to the structural-functional approach, an interactionist perspective views the creation of roles as a result of humans perceiving, responding, interpreting meaning, transforming and
72 interacting with the social environment and the symbolic acts of others. Hewitt (1984, p. 16) suggested that the way symbolic interaction conceives of conduct is more global, more complex, more social, and more dynamic than that posed by a simple learning model. Roles thus emerge, evolve and change over time, through interaction with the self and the social environment. Thus symbolic interactionism was chosen as a theoretical basis for examining meanings and interactions involved in constructing and re-constructing roles over time and assisting the understanding of both role-taking and role-making. Symbolic interactionism is based on the philosophy of social psychologist George Herbert Mead. Mead was a pragmatist philosopher, known for his theory of the mind. His students assembled the book Mind, Self, and Society in 1931 (Mead, 1934; Punch, 1986). He developed a theory that takes account of inner experience at the same time as the social nature of human life. Mead argued that behaviourism was too individual in its focus. He suggested that human behaviour is rarely disconnected from the acts of others and that behaviour is socially coordinated in very complex ways with those of others, over an extended period of time. In contrast, behaviourism pays attention only to directly observable behaviour and environmental events. He suggested that humans interact with each other using symbols, such as language. These significant symbols have the ability to arouse a response in others. He suggested these symbols can create a common attitude in both the symbol user and the symbol hearer. This common attitude makes it possible for control over conduct. This is because a person can ‘take the role of other’, look back at the self and see the self from the perspective of others, predict and anticipate what the response to symbols will be, and as a consequence plan subsequent responses. The significant symbol not only gives a person awareness and control over their own conduct, but also gives a form of consciousness of self. We are thus able to become objects to ourselves and manipulate the self as an object. The ability to hold a concept of self and to engage in self-interaction forms a basis for formulating meaning in relation to social interaction and experiences of the world. It allows a person to act towards the self as well as others, engage in role-taking and role-making through social interaction and achieve a sense of self. Mead argued that internal mental events, although they may be covert, are important to the explanation of behaviour and can be made accessible to
73 observation. This is because we can report our inner experiences using significant symbols, such as language, and thus they become observable. Herbert Blumer (1969) further developed symbolic interactionism by suggesting that it is based on three basic premises. First, he suggested that “human beings act toward things on the basis of the meanings that the things have for them” (Blumer, 1969, p. 2). He suggested that nothing of itself has intrinsic meaning or inherent value. These ‘things’ may be objects, other human beings, events, institutions, guiding ideals, activities of others, situations or a combination of these. Thus, people construct their reality beyond the objective features in any given situation. Each situation is interpreted according to the way in which the individual and others give objects, sets of objects or circumstances meaning. Secondly, he suggested that the meanings of these symbols arise out of the social interaction that one has with one’s fellows. Finally, he suggested that that these meanings are modified through an interpretive process by the person in dealing with the things encountered. Robinson(1992) argued that the individual does not have to create an entirely original perspective on the world, because they are members of existing social groups with distinct bodies of knowledge. Thus, meaning is created by experience. Objects are defined and redefined through ongoing interaction with the with self and others. Denzin (1989a, p. 5) describes this interaction as “an emergent, negotiated, often unpredictable concern”. Thus, the concepts of symbolic interactionism provided a way of understanding an evolving community health nursing role within a complex and changing social environment, encompassing historical, political and social factors over time. The behaviour of community health nurses in defining, negotiating and enacting their role was seen by the researcher as interconnected to the social environment. Symbolic interactionism provided a view of the nurse in interaction with the environment. Hewitt (1984, p. 49) describes the symbolic interactionist view of the environment as “... a cultural one, composed of ideas, values, knowledge, norms, and symbols”. Symbolic interaction also allows analysis of the individual’s meanings of role in relation to a collective or generalised other. The generalised other is described as:
74 ... abstracting a ‘composite’ role out of the concrete roles of particular persons. In the course of his association with others, then, he builds up a generalised other, a generalised role or standpoint from which he views himself and his behaviour. The generalised other represents, then, the set of standpoints which are common to the group. (Meltzer, 1978, p. 19) Through social interaction, a common language, sharing the meanings of objects and events, people align their behaviour with others and with groups. Manis and Meltzer (1978, p. 281) described the socially sanctioned facets of life in society and the knowledge which is necessary in order for any bona-fide member of that society to function within that society as ‘common-sense’ knowledge. Much of this knowledge is implicit, unconscious, and only recognised when societal norms are violated. In community nursing, there is much interaction with the collective other. Nurses belong to a professional grouping that possesses values and norms, receive educational preparation, deal with clients, co-workers, and the public. Many of the ideas generated in interaction with these generalised others form significant symbols that are important to the way in which the community health nursing role is perceived and enacted by the nurse. Thus, rather than seeing nurses as passive objects on which the environment acts and as responding to biological drives in a determinate environment, symbolic interactionism suggests that acts are mediated and learned. This approach provided a basis for an assumption that community health nurses have an ability to: reflect on their roles, construct the meaning of their roles, engage in self-directed behaviour, and actively negotiate and make their roles. However, it is acknowledged that there are limitations in the symbolic interactionist approach. First, this approach does not necessarily provide an analysis that illuminates differentials in the power relationships between the self and other persons, factors or institutions in the social and political environment. While it is recognised that the community health nurse operates within a social and political environment that contains power structures, this study aimed to access the meanings from the perspective of the nurse. Secondly, it is noted that a greater understanding of one’s role and the relationship of the self to others will not necessarily lead to positive changes. It would be naive to think that if nurses understood their role as a
75 community health nurses, how their role related to those of others and what shapes their role, that they would be better equipped to take on the challenge of an expanded role and address the problems they face.
INVESTIGATIONS INTO THE ROLE OF THE COMMUNITY HEALTH NURSE There have been many studies investigating the role and activities of community health nurses. Most authors articulated an aim to better understand the community health nursing role due to a lack of clarity evident in the literature. Some have addressed the nature of the community health nursing role, however, many have tended to focus on role activities, characteristics and issues in community health nursing. Igoe (1991, p. 153) suggested that school nurses occupy a “boundary dweller position” that places members of a particular role set away from their usual environment, in a different system. In this case, the nurse is located away from the ‘health’ system in the education system. She argues that nurses may enact the characteristic responses of the boundary dweller by discarding their own nursing attributes and take on those of the new environment, usually those of teachers. It could be argued that because of their isolated location in the community, all community health nurses are ‘boundary dwellers’ and subject to the same experience of practice isolation as the school nurses described by Igoe.
Community Health Nursing in Australia There has been little research accessed that has explored the role of the community nursing in Australia from the perspective of the practitioner. There have been several diarised accounts of practice in the community. Frith (1975) provided an account of her activities as a community health nurse. While there was little analysis of the role, she suggested a health orientation rather than an illness orientation, identifying the activities of support, liaison, provision of simple treatments, health education, motivating healthy change and supervision of indigenous health workers (ibid., 1975, pp. 155-156). Davies (1984) outlined a week of practice in a role focussed on child,
76 adolescent and family health in a small community. She described a responsive role with a community perspective that included many activities: screening, follow-up, supporting clients, problem-solving, group work, case management, liaison, consultancy and referring. Another account was given by Thompson et al. (1982) who described a day’s practice in each of child health, school health and generalist community health nursing in Western Australia. The roles showed a diverse focus on health, disease prevention, health maintenance and sometimes treatment, and involvement in support, case management, liaison, follow-up, screening, health education, case-finding and first aid. Tattam (1994) interviewed a Northern Territory remote area nurse, who described a demanding, flexible role encompassing emergency care, diagnosis, treatment, health promotion, health clinics, and working with Aboriginal health workers and the community in a way that was acceptable, under isolated and trying conditions. James, Henrikson, Steiner, and Golds (1990) described a ‘new’ role for nurses in disease prevention programs in the North Coast Health Region of New South Wales. Hall, Lamont, Mackintosh, and St John (1987) describe the activities of four community child health nurses who developed and conducted parenting education programs in Western Australian schools and community groups, aimed at primary prevention. Whittaker (1974) provided a personal analysis of the role of the community health nurse in Australia, suggesting that the role encompassed four dimensions: provision of nursing care, change agent, case-finding and management. An early study that examined the role of the nurse was carried out in New South Wales by Katz et al. (1976) when they explored the role of nurses in five practice areas, not employed in hospitals. They found that coordination of patient needs, family support and health promotion were of growing importance. Participants in this study also saw that they required a greater exercise of responsibility, autonomy (ibid., 1976, pp. 77-78) and a larger repertoire of specific skills, particularly counselling, history taking, decision making and health teaching (ibid., 1976, p. 22-24). Some participants were performing a range of tasks previously carried out by medical practitioners. The baby and child health nurses (n=232) identified their function as related to preventive health, outreach with an emphasis on the provision of care and occurring within the context of the family (ibid., 1976, p. 17). They had assumed greater responsibility for health promotion programs, case-finding and developed
77 greater competency in health teaching, counselling, health screening, assessment and linking with other community resources (ibid., 1976, p. 18). Katz et al. also identified a trend toward a wider view of the community (ibid., 1976, p. 19). All but one of the generalist community health nurses in the study (n=9) worked with Aboriginal communities. Although their function was “to prevent health problems rather than do remedial work”, Katz et al. identified their role as multi-purpose and including both preventive and curative aspects. On the basis of their study, Katz et al. (1976) identified the possibilities for an expanded role of the community nurse as including: preventive care (immunisation, case-finding, screening, individual and community assessment, teaching, advising, counselling, and health education); first contact responsibilities (assessment, diagnosis, screening, emergency treatment, referral); follow-up care (management, continuing assessment, modifying treatment, referral, counselling, advising, supporting); treatment (collection of specimens, measurement and interpretation of results, therapy, fitting apparatus and appliances, physiotherapy, occupational therapy, doing electrocardiograms, immunisation); and coordination of the work of other health professionals. Another early study was carried out by Archer (1977) who reported on a detailed investigation into community health nursing in Australia in 1975-76. Phase one was a pilot study of 48 participants using an open-ended questionnaire. The pilot was used as a basis for developing questions for the main study. Phase two involved a survey questionnaire of 89 community health nurses drawn from all states and territories, together with a survey of their clients. Comments were invited via open ended questions. Respondents came from staff, supervisory and administrative positions in the areas of: generalist community nursing, infant welfare, community mental health, school health, domiciliary, communicable disease and occupational health. Actual time spent in role activities was categorised and comprised of: client (51%), client teaching (16%), communication (13%), administration (8%), personal and professional development (6%), teaching (5%), and supervision and staff development (4%). When respondents were asked how they would prefer to spend their time, they indicated that they would like to spend a greater amount of time in client teaching, personal and professional development, teaching, and supervision and staff development (ibid., 1975, pp. 25-30). Archer also found that respondents saw a range of aspects of their role as qualitatively different from previous nursing roles. Positive
78 aspects identified were: a more holistic perspective; greater work satisfaction due to flexibility, autonomy, personal growth and an increased challenge; greater community involvement; a broader perspective; a greater emphasis on prevention, client teaching and health promotion; working with well people; and addressing problems as people themselves see them. She found that there were negative differences including: less time given to physical care, more difficulty in finding rewards and seeing change, isolation, and a lack of support and communication with colleagues (ibid., 1975, pp. 31-34). Respondents were asked to identify activities that could contribute to future roles for community health nurses. Archer noted that, although the list of identified activities appeared endless, several constellations of activities could be identified including: health education and teaching; prevention of illness and health promotion; provision of specific services in response to client needs; and activities with a psychosocial focus; and liaison, communication and supervisory activities (ibid., 1975, pp. 44-52). Additional skills that respondents identified as a requirement to undertake their job included: psychology, group-work skills, family dynamics/development, communications/interviewing, sociology, psychiatric nursing, human relations, and cross-cultural and anthropological studies (ibid., 1975, pp. 52-58). Data drawn from 363 clients indicated that the services of community health nurses were helpful in almost all cases (ibid., 1977, p. 109) and provided: referrals, assistance with understanding medical treatments, advice, a ‘listening ear’, information, promotion of wellness, individual concern and provision of good physical care (ibid., 1977, pp. 110111). McMurray (1991) provided the most comprehensive recent picture of the role of the community health in Australia when she conducted a qualitative study of 37 community health nurses drawn from the fields of child health, school health and district nursing in Western Australia, examining the issue of expertise. While not specifically focussing on the role of the nurse, her data provided insight into the perceptions of participants about their activities and role. She identified the process of community health nursing practice as including self management, encompassing organising and forward planning for the purpose of enabling client management activities including: establishing rapport (screening, interviewing), making judgements (attending to cues, judging, validating judgements, setting priorities), enabling activities (caregiving, advising, reassuring, explaining, counselling,
79 referring) and monitoring progress (surveillance, coordination, evaluation, documentation). She reviewed the domains of practice as identified by Benner (1984), Fenton (1985) and Brykczynski (1989) who had applied these to the nurse practitioner role, and suggested that participants engaged in the following domains of practice: management of patient health/illness in ambulatory care settings, monitoring and ensuring the quality of health care practices, organisational and work role competencies, the helping role of the nurse, the teaching-coaching function, and the consulting role. In analysing the meanings embedded in the practice behaviours of her participants she found that they had a commitment to a philosophy of holism (ibid., 1991, pp. 143147), client self-care (ibid., 1991, pp. 147-149) and a close bond with clients (ibid., 1991, pp. 149-150). She found that participants considered the family as client (ibid., 1991, p. 104) or in the case of school nurses the whole school community (ibid., 1991, p. 107). She also found that experience was important in: shaping participants’ practice, developing a need to view clients in a socially contextual way (ibid., 1991, p. 154), taking a wellness rather than a sickness perspective (ibid., 1991, p. 156), and contributing to embedded knowledge and expertise. She developed a model of expertise that incorporated personal, educational and experiential factors (ibid., 1991, p. 227) and had the characteristics of: knowledge, empathy, appropriate communication, holistic understanding, an ability to get right to the problem at hand, self confidence in own perceptions, judgements and intervention strategies (McMurray, 1992). While her discussion of role has provided an excellent analysis of the practice of the community health nurse and a picture of expertise, it was limited by a tendency to focus on nurse-client interactions, neglecting examination of the role in relation to a group, aggregate or community focus. She also did not provide analysis of the broader aspects of role related to purpose, philosophies and the possibility of negotiating an expanded role. Another study that provided information about the role of the community health nurse in Australia was conducted by Round and Sellick (1984) who surveyed the perceptions of the role of the community health nurse of 65 personnel, including 23 nurses, 16 social workers, 10 managers and 16 doctors from 10 community health centres in Melbourne, Australia. Subjects were asked to rate the degree to which 22 activity statements were relevant or irrelevant to the role of the community health
80 nurse on a five point Likert scale. Round and Sellick indicated that an activity with a mean score of greater than 3.00 was deemed relevant to the nurse’s role and less than 3.00 as irrelevant. They found that there was a statistically significant difference in perception between community health nurses and other health professionals on eight of the 22 statements. However, an examination of the reported data showed that Round and Sellick had focussed on the degree of agreement or disagreement between the perceptions of different occupational groups, rather than the strength of agreement as to the relevance or irrelevance of the statement to the role of the community health nurse. As a result they reported statistically significant differences between the views of occupational groupings, without regard to whether or not they agreed or disagreed with the relevance of the statements to the community health nurse role. The reported data for the mean scores on each statement for each occupational group was reexamined and the strength of agreement of the relevance of each of the statements to the role of the community health nurse role was calculated. It was found that there were nine activity statements that all occupational groupings felt were strongly relevant to the role of the community health nurse, one activity statement that was felt moderately relevant and one irrelevant. The results of this analysis are presented in Table One.
81 Strongly Relevant (mean score of between 4.00 and 5.00) Working with families of clients with emotional problems relating to a member’s illness, disability or impending death Interpreting the function of the community health centre to other community groups and vice versa Assisting in the education of students and in-service training programs Identifying health and welfare needs in the community and working with appropriate social agencies to initiate or stimulate provision of services to meet those needs Ensuring that all staff connected with a case are aware of all professional services being utilised in that case Making an assessment of a client’s medical condition/home environment in order to secure domiciliary services and arranging for those services Arranging for appropriate care for clients who can no longer function at home Linking the services of hospital and community health personnel in order to ensure continuity of care both pre-admission and post-discharge Working with (as resource personnel) community groups or special interest groups with a common focus on any area of health care
Moderately Relevant (mean score of between 3.00 and 3.99) Planning and coordinating workloads in centres
Irrelevant (mean score of less than 3.00) Administration of the centre, for example allocating resources
Table 1: Agreement from all occupational groups on the role of the community health nurse (Round and Sellick, 1984) There were two activity statements for which occupational groups were found to disagree. The results of this analysis are presented in Table Two.
82 Statement
Relevant
Irrelevant
Assisting clients with financial
Nurses,
Social
Workers,
problems arising from their
Doctors
-
health needs.
(mean score of between 3.00 and
moderately
and
relevant
Managers - irrelevant (mean score of less than 3.00)
3.99)
Assuming
responsibility
team leadership.
for
Nurses,
Social
Doctors
-
Workers,
moderately
and
relevant
Managers - irrelevant (mean score of less than 3.00)
(mean score of between 3.00 and 3.99)
Table 2: Disagreement between occupational groups on the role of the community health nurse (Round and Sellick, 1984) Scores for all other statements indicated that all occupational groupings felt that they were relevant, but there was variation in the strength of agreement with the statements. For these items a mean was calculated for each item from the means of each occupational group and grouped as strongly relevant (mean score between 4.00 and 5.00) and moderately relevant (mean score between 3.00 and 3.99). The results of this analysis are presented in Table Three.
83
Strongly Relevant (mean score of between 4.00 and 5.00) Working with clients or families of clients with social needs (statistical variation between occupational groups insignificant) Helping clients in the formation of self help therapy groups (statistical variation between occupational groups insignificant) Ensuring client’s right to self-determination are upheld by encouraging their participation in establishing treatment programs (statistical variation between nurses and doctors; and nurses and managers statistically significant) Participation in community and individual action to achieve policy changes in health care (statistical variation between occupational groups insignificant) Providing information on the clients’ medical condition/home environment in order to secure domiciliary services and arranging for those services (statistical variation between occupational groups insignificant) Helping the team reach agreement when differences occur (statistical variation between occupational groups insignificant)
Moderately Relevant (mean score of between 3.00 and 3.99) Enhancing client’s psychological functioning (statistical variation between occupational groups insignificant) Facilitating or undertaking research within community health (statistical variation between nurses and managers significant) Deciding if clients should be referred to hospitals, psychiatric clinics, etc for further assistance with psychological problems (statistical variation nurses and doctors statistically significant)
Table 3: Variation in the strength of agreement from all occupational groups (Round and Sellick, 1984) When data were analysed in this way, a clearer picture was gained of the views of participants in this research regarding the role of the community health nurse. What emerges is a broad role that encompasses working with individuals, families, groups and communities with a perspective that is consistent with a primary health care approach including health promotion, assessment, case management, linking and acting as a community resource. A final aspect explored in the literature is related to the responsive nature of the nursing role. Cramer (1992), in an analysis of the remote area nurse role, suggested
84 that they are required to function in a medical substitute role and ‘fill the gaps’ by assuming responsibility for many activities necessary to the functioning of a remote community health facility. This, she argues, presents legal and ethical difficulties associated with the need to provide health care, sometimes outside the authorised ambit of nursing practice, without medical support. This supports an earlier finding of Katz et al. (1976, pp. 31-32) who found that nurses provided ‘stop-gap’ care in new fields of health service that had not previously been the responsibility of other health professionals. Most other Australian research, has tended to focus on the activities and tasks of community health nurses. Dunt et al. (1991) found in a survey investigation into 689 randomly selected community nurses employed outside hospitals in Victoria, Australia that the activities of community nurses include prevention and health promotion, individual and family assessment, direct patient or client care, advocacy, administration, research and evaluation, coordination and supervision, travel and casesharing with other health professionals. They found that, while there was diversity in the job content of the practice areas, there was a core of activities that were frequently and widely performed by community nurses from all categories of community nurse. They argued that despite considerable diversity among the types of nurses working in the community, their research suggested bounds to this diversity. However, they clarified that while the same activity may be performed by nurses in different practice areas, the precise nature of this activity may vary, even between nurses in the same practice area. Community practice areas were identified as community-based district and visiting, maternal and child health, occupational health, community health centre, hospital-based district and visiting and medical clinical nursing. However, they found that medical clinic nurses shared very few job characteristics with the other five categories and they recommended that this group be designated differently to other nurses working in the community. McMurray (1984) also carried out a study examining the role activities of 96 Western Australian community health nurses, including field nurses, outpost nurses, child health nurses and school nurses in a questionnaire survey of the activities carried out in three working days. She found the frequency of tasks as a percentage of the nurses’ total time across the three survey days, in rank order were as follows: documentation (22.77%), history taking (17.99%), teaching (11%), direct care-giving (8.83%),
85 deciding priorities (7.10%), resources identification (6.94%), follow-up and review (6.43%), outcome evaluation (6.24%); and coordination and liaison (4.34%). The source of initiation for tasks was reported as predominantly self-initiated (83% of all sources identified). Other sources identified were client (11.04%), other (4.09%) and supervisor (1.87%). In addition, McMurray interviewed 17 participants relating to their role and elicited descriptions of a ‘typical’ day. She found that the major determinates of activities on a usual day were contextual and responsive to community needs, availability of the nurses’ time and resources. Participants were asked to estimate the proportion of their activities directed toward wellness tasks such as group health teaching, counselling, coordination and liaison, follow-up and review activities. The responses ranged from 40% to 90% with a mean estimate of 75%. Various studies have been undertaken into nursing roles in Australia, that while not focussing on community nursing, have included community nurses in their sample. Wilson and Najman (1982) undertook a study of the activities of a randomised sample of 715 nurses in Queensland, drawn from the members of the Queensland branch of the Australian Nursing Federation that included those in unspecified community/public health settings. They found that their subjects, including community health nurses, engaged in a range of generalist activities that included counselling, supporting clients, health teaching, carrying out invasive technical procedures, and the provision of medications without medical orders. Williams (1989) examined the activities of 100 Queensland nurses, including eight community nurses, using semi-structured interviews and non-participatory observations. They found that their results supported the domains and/or competencies identified by Benner (1984) and the consultancy role identified by Fenton (1985). While these studies identifying and classifying the activities of community health nurses are useful, they do not access the embedded knowledge or perspectives of the community health nurse about how the role is understood and carried out. Other research into community health nursing in Australia, while not examining the role, do provide contextual information about community health nurses and their practice. Temple-Smith et al. (1989) has identified a range of information related to the characteristics of community health nurses in Victoria. They found that the major reason for choosing employment in community health nursing were positive conditions of work, autonomy and a dissatisfaction with hospital nursing, rather than a
86 specific orientation to community nursing. Job satisfaction was high, with 87% of nurses in the study population being satisfied or very satisfied, although only one third of nurses felt there was adequate opportunity for career advancement in their practice area. Subjects identified a need for better preparation in communication, negotiation and interpersonal skills, knowledge of politics and community and government resources, educational strategies, legal issues, and information relating to specific specialist areas (ibid., 1989, p. 313). Eighty three percent of subjects considered ongoing in-service education as essential for community nursing practice.
International Perspectives on Community Health Nursing There have been international studies that have shed light on the community health nursing role. In particular, there have been several studies that have aimed to gain an in-depth understanding of the role from the perspective of the community health nurse. Field (1983) undertook an ethnographic study of four public health nurses. She found that the participants’ own life experiences and priorities were a major influence on their personal models of practice. In analysing their beliefs about practice, she found that the goals of practice included health promotion and prevention of illness and crises, achieved by: collecting a database; identifying client needs, potential, or real problems; teaching the client; support; guidance; negotiating with the client; counselling; and referral. The outcome of nursing activity was identified as: client independence, adoption of a healthier lifestyle and measures to prevent illness, increased coping ability, prevention of crises, and/or health restoration. Qualitative research approaches to exploring the role of the community health nurse have uncovered many dialectical issues in community health nursing practice. De Silva (1988) found in a phenomenological study of ten public health nurses that community health nursing practice incorporates dialectical meta-themes between: illness and prevention of illness or unwanted conditions; the individual, family, group and community recipient of care; and the dialectical process in which conflicts between the client’s rights, values or decisions and the nurse’s own values are resolved. She also found that the individual recipient of care and the community were understood holistically, with an awareness of multiple dimensions and interrelatedness. She identified that the relationship between client and participant in public health nursing was experienced as “being in relationship to”, with the nurse
87 choosing between working within the client’s boundaries or working from his/her own personal/professional framework. Another qualitative study carried out by Vongleang (1993) investigated the role of sixteen school health nurses in several Oregon counties in the USA. Her findings indicated that nurses used two different frames of reference to define their role. The first approach focussed on completing tasks and the second, based on social interaction, focussed on meeting needs. She found that participants considered that the social context was very important, their preventative and educative roles as crucial, and that they visualised their role as: advocate, liaison person, teacher, and as a social worker (ibid., 1993, p. 60). Activities participants were involved in included health screening, follow-up of screening, first aid, emergency and initial illness care, health education in the classroom, education of school staff, parent education, health counselling, services for special needs students, monitoring medications taken at school by students, immunisation, home visits, finding resources/being a resource, child abuse cases, consultation within the school health curriculum, safety and health related policy within the school, and health education of staff. Providing health services and consultations was considered to be the most important responsibility by the participants, because this appeared to be the service that was most valued by others (ibid., 1993, p. 115). Several UK studies have explored the role of the health visitor. Clark (1985) conducted a qualitative study of health visitors’ visits to mothers with new babies over a 12 month period. From her analysis of audio-tape recorded visits, she developed a conceptual framework for health visiting that consisted of four key concepts: health, need, prevention, and coping. Drennan (1986) carried out a study eliciting the views of 20 practising health visitors about their role. She found that most health visitors saw their work as focussed on individual families, and in particular individual women and their children, with emphasis on prevention of ill-health, and support and reassurance of individuals. Drennan noted a context of uncertainty, with health visitors articulating a loss of role to other organisations and occupations, together with a lack of recognition by other professionals of their role and confusion in the public’s understanding. Her health visitor participants considered that this was detrimental to their status and ability to work. She also noted the way in which health visitors argued that ‘health’ was separate from ‘social’, particularly in relation to defining a
88 discrete area of work with which they wished to be involved. She found that the requirement for accountability increased the pressure to routinise home visiting and screening procedures, impinging on role aspects such as an ability to autonomously practise according to their professional judgement. As a result of her research, Drennan questioned whether the reality of the work situation had been taken account of in any evaluation of health visiting. Black (1991, p. 58) examined current developments in community nursing in the UK and concluded that the many changes require a role shift from being a “doer” to that of “teacher/educator/supervisor”. Traynor (1993) undertook a survey study of job satisfaction that elicited open-ended comment from 80 health visitors and also gained local feedback in sessions with community nurses. He found that the health visiting was an independent, autonomous role. However, he identified difficulties with the role as a lack of understanding of the role by others, the “never-ending work”, and a difficulty in measuring activities such as prevention and support. A finding that was evident in several research reports related to the way community health nurses tend to ‘fill in the gaps’ in health services. Bremer (1989) in a study of community health nursing interventions in Oregon, USA found that nurses often filled gaps in traditional services offered: in the monitoring of non-acute health conditions not covered by Medicare, frequent identification of intended and unintended effects of medication, a need for teaching and counselling for care-givers, and advocacy for the needs of the population being served. Evers, Badger, and Cameron (1992) in working with a group of community nurses found that defining the limits of their role in providing holistic care in the community was very difficult. Drennan (1986) also found that health visitors addressed a wide range of client problems they considered to be outside their remit, because of the inadequacy of other services, their own accessibility, and their responsiveness to clients. Bless et al. (1995) described a community development program with poor inner urban communities and identified the primary health care/public health nursing roles as: liaison, public health care crusader, collaborator, friend, case manager, mediator, teacher, organiser, coordinator and planner. They also identified the following personal attributes of the nurse and as important to the role: accountability, courage and self confidence, sharing, self analysis, mentoring, innovation and vision, cultural
89 sensitivity, high levels of objectivity, flexibility, realism, caring, personal conviction, love of learning, and an ability to enhance the development of community workers. International studies have also addressed the issue of how community health nurses spend their time. These studies have tended to ask what community health nurses are doing, what skills they are using and how they spend their time. Erickson (1987) carried out a descriptive survey study of the services offered by 24 public health nursing units in Connecticut. Participants in the study offered programs in maternalchild health, adult health, mental health, school nursing, follow-up on communicable diseases and four nurses who delivered care for the ill. She found that a primary focus on health promotion and disease prevention constituted a demarcation between wellness and illness care (ibid., 1987, p. 209); a responsiveness to community need contributed to determining programs likely to be implemented; and that the demographic, societal and health care delivery changes influenced the delivery of care (ibid., 1987, p. 209). McDermott and Burke (1993) conducted survey research into the role of 109 parish nurses drawn from urban, suburban and rural locations in the USA. She examined the way they spent their time by a percentage of their total time, and found that they spent their time as follows: personal health counsellor role including counselling and screening (20%); health teaching (14%); coordinating volunteers and facilitating support groups (6%); resource and liaison role including referring, advocating and talking on the telephone (19%); visiting homes, hospitals and nursing homes (15%); documentation (8%); attending staff meetings (7%); attending in-services (6%); providing hands-on care (2%); and other unspecified activities (3%). They also found that the role factors that were most satisfying were: personal and spiritual growth; an ability to practise nursing holistically; an opportunity to establish long term relationships with parishioners, colleagues, and parish staff; and an opportunity for autonomy and independence. The two major frustrations reported were unrealistic expectations by others of their possible achievement in the allotted time and ambiguity of role definition/boundaries within the parish and/or the nursing profession. Other frustrations reported included: the lack of human, financial, time, material and space resources; inadequate financial compensation; and lack of an adequate support system. McDermott and Burke also examined the way in which subjects evaluated their practice. They found that evaluation source/strategies used were, in rank order: the
90 pastor, self evaluation, hospital faculty, other parish staff, parish health cabinet, parishioner satisfaction survey, and nurse peer evaluation. Identified outcome criteria related in rank order to: enhancement of health knowledge, heightened awareness of personal responsibility for some area of health and illness, heightened awareness of the relationship of health and wholeness, enhanced coping abilities; attitude change, enhanced chronic disease management, optimised matching of referrals and resources, substantive health behaviour change, maximised home safety, delayed institutionalisation (for the better), and physiological change. Their study showed a considerably greater amount of time spent in direct client contact when compared with an earlier study carried out by Cross et al. in 1983. This study of how 109 community health nurses who staffed six community health centres drawn from one county in the USA spent their time, found that: 34% of time was spent in individual or group client contact, 25% in record related activities, 16% in work planning, 10% in professional growth, 9% in case discussion, 4% in travel, and 3% in supervision of para-professionals. A break-down of the largest category of ‘client contact time’ was found to include face-to-face, individual; face-to-face, group; telephone to client; telephone on behalf of client; and letter to client. In the client contact category, it was found that most of the contact time was in spent face-to-face, individual (63%); and telephone to client (17%) activities. The second largest category was related to the percentage of time spent in record-related activities. A break-down of this category found that 68% of this time was spent in professional recording and record review. Cross et al. (1983) also divided activities by purpose and found that nurses were working in the areas of: school health; maternal, child and adolescent health; family planning; maternal health; adult health; communicable diseases; and mental health. Researchers have also investigated factors relating to the way community health nurses fulfil their role. Appleton (1995), in a study of the health visitors’ judgements about client vulnerability, found that the use of checklists was of limited use. She found that participants’ professional judgement was a profound factor in decisionmaking. Alexander (1988) investigated the independence of public health nurses compared with hospital nurses and found that public health nurses had perceptions of greater self-independence. She also found that nurses who had graduated seven or more years previously had perceptions of greater independence than nurses who were
91 less experienced. She examined nurses’ perceptions of patients’ and clients’ autonomy and found that public health nurses and hospital nurses perceived them similarly. Drennan (1986) found that autonomy was an important factor in the health visitor’s role, but that this was sometimes restricted by service structures. Lauri and Salanterä (1995) found in a study of Finnish nurses’ decision-making that public health nurses were more patient-oriented whereas generic nurses were more nurseoriented. Another line of inquiry has been to examine the nature of community health nursing practice. Several studies have examined the nature of the nurse-client relationship. Zerwekh (1991) undertook a qualitative study of 30 public health nurses in Washington, USA, focussing on the nature of the care they provided to families. She found that the primary focus of public health nurses’ visits to vulnerable families was to develop their personal capability to take charge of their lives and make their own choices. Her participants emphasised the responsibility of the client rather than the nurse in this process. She also identified many examples that involved the nurse ‘backing away’ to enable the possibility of an independent choice. Strategies used in facilitating independence were: 1. Believing in the clients’ ability to make choices and helping the clients believe in themselves, 2. Listening to what the clients want and starting there, 3. Expanding families’ vision of options, and 4. Feeding back reality to help them see the patterns of their lives and the implications of unhealthy choices. (Zerwekh, 1991, p. 214) Zerwekh identified a range of processes in the public health nurses’ role. The first of these was laying the groundwork that required building a foundation before self-help could be encouraged. Locating and building trust required three competencies: locating families, which was often difficult due to the stressed social circumstances of clients; building trust involving getting through the door, the necessity to back off at times, listening, discovering and affirming strengths; and finally the process of building strength. The second set of competencies she identified as the encompassing competencies that included: timing that took in the dimensions of detecting the right time, persisting and futureing; and detecting the problems and difficulties occurring within the social, environmental, family dynamics and physiological context of the
92 family. A third competency she called fostering community. This encompassed: being available to clients, mobilising to support and assist the needs of clients, necessitating networking and collaborating with professionals that emphasised the collaborative nature of their work. Two further competencies identified were resolving problems and crises, working through emotions and fostering family understanding and teaching and parent education. A final set of competencies identified were what she called the forceful competencies, that came into play when the nurse was persuading and saving children. This required the nurse to confront, particularly in situations where a child was at risk. “Confrontation boldly opposes denial and blaming to name and face extreme health hazards such as drug abuse or domestic violence” (ibid., 1991, p. 217). Cowley (1991) undertook a grounded theory study that included collection of data from 53 practising health visitors via in-depth interviews, non-participant observation and focus groups. She examined the nature of the role, paying particular attention to the nurse-client relationship. She focussed on the awareness context of health visitors’ interactions with their clients and suggested that nurse-client interactions could be classified by two continua comprised of two parameters: open-closed and consonance or dissonance. She suggested that her participants acted to ‘open’ closed contexts, with the importance of knowing and trust in the developing relationship. Secondly, she found that a high value was placed on respecting the rights, needs and explicit wishes of the client, and achieving consonance between the perspective of the client and the nurse. The processes leading to consonance were clarification and an acceptance of one another’s position and opinions. Cowley suggested that in order to establish an open context, there was a need for: a conscious tolerance of ambiguity and diversity, receptivity to a broad range of perceived needs, and skilful acceptance of a wide variety of individual values. Further research by de la Cuesta (1994) identified the nurse-client relationship as a mechanism for enabling the nurse to: know the client and family; gain and maintain access to the home, and produce reciprocity. Basic to the relationship was trust. She further argued that the labour involved in ‘winning’ and keeping clients is undocumented, rarely discussed in the literature and tends to pass unnoticed by management. She argued against evaluation of practice by numerical measurement, suggesting that ‘success’ should also encompass the intangible aspects of practice.
93 Gaining access to clients’ homes and making referrals are other processes that have been the focus of research. Luker and Chalmers (1990), in a qualitative study of 45 health visitors, examined the process of ‘gaining access’ to clients in their own homes. They found that health visitors engaged in a process of gaining access to the environment, and also that ‘entering’ more fully into the client’s situation was necessary to ensure re-entry into their homes. They found that each encounter was influenced by factors within the client, the health visitor, and surrounding the health visitor-client encounter. Luker and Chalmers (1989) also examined the 45 health visitors’ interactions with 190 cases or families in relation to referral patterns. They found that the purpose of referral was to provide the client with additional expertise, services or resources that were not available within the health visiting service. They referred to other health professionals, other specialist nurses, agencies, community groups, support groups and community services. Referrals were also made on occasion to gain a second opinion. Luker and Chalmers found that the referral was a complex processes that incorporated working up the referral, working up the client or preparing the client for referral, and finally working up the referral agency. At times, participants also used third parties, such as referral networks and agencies to secure access to services for clients. When doing so, they found that professional control of the referral process became an issue. All professionals in the referral network could exert control of the situation by granting or withholding a service, or in some circumstances, enforcing a service on the client, for example in a case of child abuse. There were instances where nurses purposefully did not refer where they made a judgement that: the referral was unnecessary, the client would not meet the referral agency’s criteria, or less commonly where the nurse felt that referral could be detrimental to the client’s well-being. However, layered on the control exercised by professionals was the control exercised by the client. Clients controlled whether or not to accept the referral. This control underlined the importance of the nurse working up the client. The final step in the referral process was a joint assessment by the client and the nurse of the effectiveness of the referral. A qualitative study was conducted by Edwards and Popay (1994) exploring the notion of support in the work of community health workers. They found that workers understood the importance of support, provided support to their clients, and felt it was important, but often felt the need to justify it, and due to time restrictions and role
94 limitations, tended to devalue this ‘work’. They also found that workers provided support with the aim of promoting self-care. On occasion, workers faced the dilemma that provision of services may lead clients to become dependant. However, they suggested that the notion of dependence was complex in the context of poverty, and in terms of social relationships. Research has also sought to determine the particular issues that concern community health nurses. Kenyon et al. (1990), a group of community health nursing leaders in Washington State, suggested that community nurses moving from the acute sector to community-based practice experience ‘reality shock’. This is because the individualised, holistic, short term, curative approaches developed in the acute care setting are in conflict with the values encountered in community health nursing practice. Clarke et al. (1993) carried out a study of community health nurses in Canada using a modified Delphi technique in order to identify major issues in community health nursing. They included all 137 members of the Community Health Nurses’ Group and an equal number of randomly selected non-members. They found that there was strong consensus on the top ten issues identified by participants which were by rank order from the top issue: increased funding of preventive and health promotive programs; public health nurse planning; increasing public responsibility for appropriate self-care; integration of community health services within public health departments and hospitals; the need to define the public health nurse role; ‘enabling’ as a primary health care objective requiring a shift in power base to a facilitative, partner relationship between nurse and client; increased education of the public about health issues; a need for more research on qualitative aspects of health and nursing outcomes; increased teamwork with greater role flexibility; and finally satisfactory working conditions allowing an ability to expand roles and enhance job satisfaction. Vongleang (1993, p. 80-84) identified that the two factors imposing constraints on school nurses’ practice role were time constraints and people’s perceptions and expectations. Vongleang did not discuss how participants prioritised their work. However, she found that they had more ideas for their role than they had time to carry out (ibid., 1993, p. 87-88), with many indicating that a lack of understanding of the nurses’ role was related to excessive and unrealistic demands on the nurse. Vongleang grouped participants according to how they reached their potential. The first group felt they would achieve their potential if they completed all tasks required
95 by their districts or they met all of the needs of the population of that district. The second group perceived that they would achieve their potential when they achieved what they themselves envisaged for their own role. A final group based their practice on a philosophical perspective that they would never reach their potential because there is always room for improvement, and that the context in which they work and the needs of the population they serve are constantly changing (ibid., 1993, p. 117). The second issue of concern was related to others’ perceptions of the nurse. Vongleang found that the perceptions of other people, such as principals, teachers and secretaries, was affected by the availability of the nurse within a school. Specifically this was expressed where there was poor visibility of the nurse, poor role identity as well as unrealistic expectations of the nurse by students and school personnel. Vongleang found that the intensity of the interactions between the nurse and others determined the perceptions these persons individually held about the role of the school nurse. Better understanding of the role was reported where the nurse had worked in a role for longer (ibid., 1993, p. 111). Other difficulties identified by Vongleang were isolation and lack of support from peers (ibid., 1993, pp. 83-84) and an overlap in the role of the school nurse with the school counsellor (ibid., 1993, p. 109). Parsons and Felton (1992) examined factors contributing to satisfaction in a longitudinal study of 98 school nurses. They found that continuing education developed knowledge in the areas of program management and physical, psychosocial, and environmental health. This contributed to an expanded role performance and greater intrinsic role satisfaction such as: creativity, importance, interest, autonomy and work challenge. They found participants had less personal satisfaction with extrinsic factors such as salary, security, promotion, routinisation, and significance of work. An area of concern identified in the literature was a need to demonstrate the effectiveness of community health nursing practice. Barriball and Mackenzie (1993) in a review of the UK literature found that while there is a need for nurses working in the community to demonstrate the effectiveness and value of their services, the evidence suggests that many nurses tend not to measure the effectiveness of their work, or if they do, the results are not published. Kelsey (1995) outlined the difficulties in measuring the outcomes of public health nursing practice as related to: defining the outcomes of community health practice, for example preventing
96 deterioration or empowering a young mother; distinguishing the work of nurses from the work of others; the availability of appropriate tests; over-simplification of outcomes; and identifying change without baseline data. Kelsey advocated the use of aggregate and population approaches to measure outcomes. In addition, authors suggest that there is a need to promote the role of the community health nurse (Murfin, 1993) What has shone through this body of research is the commitment of community health nurses to the purposes of their roles. This is best expressed by West (1989, p. 381) in concluding his study into the needs of health visitors: Throughout the conduct of the research, the researchers were impressed by the care, concern, commitment and genuineness which management and health visitors bring to their services. ... [there] seemed to be a motivating vision of their work, subtly but powerfully changing the quality of the lives of children and families and benefiting both the present and future community.
SUMMARY OF CHAPTER This chapter provided an analysis of the literature pertaining to the major concepts of this study including health, community, nursing, community health nursing and role. The notions inherent in primary health care appear to have had an impact in the philosophical perspectives on community health nursing. In particular, professionalism has provided both opportunities and challenges for community health nurses who are seeking to promote the health of individuals, families, groups and communities. An historical overview of community health nursing in Australia and an analysis of the development of professionalism in Australia was presented. Community health nursing in Australia presents a picture of continuing development and commitment, with moves towards preventative strategies. Finally, there was a review of Australian and international research outlining studies into the role of the community health nurse, together with studies that examine aspects of the role. The picture that emerges from the research literature into the role of the community health nurse presents a fragmented array of processes, activities, role descriptors and issues, without achieving synthesis. Although the literature repeatedly identified the
97 ambiguous nature of the role of the community health nurse, there has been a reliance on generic nursing theory and knowledge from other disciplines as a basis for practice. Most Australian research has focussed on activities and tasks, rather than seeking to draw on the embedded knowledge and experiences of practitioners. Although there has been an increase in international research into the role of the community health nurse, there are few studies that provide explicit description of the community health nursing role in Australia. In particular, research attempting to provide better understanding of the role of the community health nurse within the new public health paradigm has been limited. While not being able to identify a clear overarching theoretical wholeness for the purpose of understanding and enacting the community health nursing role, there appears to be a philosophical commitment to addressing the health needs of individuals, families, groups and communities in a responsive and interactional way. Some authors have drawn together theoretical concepts from nursing and public health practice to assist understanding of the community health nursing role. However, there has been little exploration of whether these understandings are useful in practice, particularly in Australia. Furthermore, there is a need to describe the philosophical perspectives and understandings of everyday practice from the perspective of the practitioner. A further gap in the research literature relates to an understanding of the processes of community health nursing practice. This is particularly relevant when it is considered that community health nurses do not practise in traditional institutional settings, and that the community context has been found to have a great impact on practice. The research literature indicates that there are many qualitative aspects of community health nursing practice that are poorly explained and understood, and thus undervalued. There is a need to identify and describe the processes used by community health nurses in carrying out their role. This chapter provided a context in which the findings of this study can be viewed. Findings of this research are analysed in relation to this body of literature in Chapter Ten.
98
CHAPTER THREE Methodology and Design of the Study INTRODUCTION This chapter addresses issues relating to the selection of methodology and design for this inquiry. Theoretical perspectives which provide a basis for the approaches taken in this study, information relating to the design of this study and research procedures will be described and discussed. Study assumptions, definitions, approaches to analysis, procedures and ethical issues relating to the research are described. As discussed in Chapter One, the aim of this research was to provide a greater understanding of nursing practice from the perspective of practitioners, accessing what practising community health nurses themselves think about their role and what they do. In particular, this research sought to explore the meanings of the practice role to community health nurses, particularly how they perceive, define and translate their role into practice in a range of practice settings. There were many questions raised by the research questions. These included: Is there an over-arching philosophy or model that guides community health nursing practice? Which components of the role are most valued by community health nurses themselves? Are the perceptions of community health nurses congruent with the community health nurse role as outlined in the literature? Is the role of the nurse distinctive when compared with other nursing roles? Do community health nurses make a unique contribution when compared with other professionals working in the community?
RATIONALE FOR CHOICE OF METHODOLOGY Research method is a result of the questions being asked rather than preceding the inquiry. Selection of a research design is based on its appropriateness in exploring the
99 research problem that has been identified. In identifying appropriateness the researcher must consider the nature of the phenomena to be explored, the current state of knowledge related to the specific phenomena and the practical constraints in accessing information about it. In 1985, Field and Morse suggested that given the state of nursing theory it would be legitimate to argue that generation of theoretical understanding is more critical than theory testing to the development of nursing knowledge at this time. As Munhall (1993, p. 57) argued almost ten years later, qualitative approaches aimed at discovery continue to be important in nursing research: We believe that we cannot overstate the importance of this first level activity [exploratory research], for it is within this activity that we avoid what is referred to as a Type III error - solving the wrong problem. The questions in this study required a method which accessed the insiders' views about the meanings of the community health nursing role. Morse and Field (1995, p. 242) define meaning as the interpretation that informants place on the rules, issues and behaviour of the culture under study and suggest that: The role of the researcher is to ... make the implicit knowledge explicit. The interpretation of the meaning is the informant’s privilege, but the mode of explanation is the researcher’s. Hammersley and Atkinson (1983, p. 9) observed that any account of human behaviour requires understanding of the social meanings that inform it. This research aimed to move away from the approaches of previous research which have tended to explore what nurses do, without exploring what nurses think about what they do, and why they do what they do. The aim was to view the world from the perspective of the practising community health nurse, understand the role as the community health nurse understands it, explore interpretations of self in interactions which shape the role, and share their definitions. In an area of little available knowledge, this research sought to examine the social phenomenon of role which encompasses the shifting experiences of self representation, interactions, perceptions, ideas and philosophies, motives, beliefs, assumptions, emotions, tactics, and dilemmas. In aiming to provide a greater
100 in-depth understanding of the meaning of role from an insider’s perspective, there was a need to talk to practising community health nurses using an approach that enabled reflective and unstructured communication in the language of the nurse and incorporated contextual factors. The use of interviews to help tap into the emic or ‘insiders’ point of view is based on the premise that human beings have an understanding of their own actions, values and feelings, and that these are important for understanding what they do. There was a need to choose a methodology that uncovered the contextual meanings inherent in the role of the community health nurse from the perspective of the community health nurse, in a way that linked any derived theoretical understandings to practice. Community health nurses work in a range of far flung settings, usually alone. Benner (1984, p. 40) suggests that an interpretive approach avoids the problem of endless lists of tasks, with no guidelines for determining which ones are most important. An interpretive approach also allows for examination of the context, the implications in the setting and the social and political forces, ideologies and events that shape behaviour, since meanings within a situation are maintained (Blumer, 1969; Denzin, 1989a; Schwandt, 1994). Morse and Field (1995, p. 10) point out that qualitative research is conducted in a naturalistic setting, so that: ... the context in which the phenomenon occurs is considered to be a part of the phenomenon itself . ... all aspects of the problem are explored, and the intervening variables arising from the context are considered a part of the problem. Using this approach the underlying assumptions and attitudes are examined, and the rationale for these are also elicited, within the context in which they occur. Thus, the research questions asked required interpretive answers and an inductive approach which accessed a form of data that enabled ‘thick’ description (Denzin, 1989b, p. 83). When choosing a methodology and research design for this study, several theoretical and philosophical approaches were considered together with their limitations. Phenomenology takes the subjective standpoint of the individual as the central focus of study (Husserl, 1928; Heidegger, 1962). This approach critiques the objectivist
101 approach that views the social world as a reality existing independently of an individual’s perception, and suggests that reality is constituted by our view of it. The phenomenological view point, while providing a basis for accessing the meanings and understanding of individuals, did not, for the purposes of this research, provide a basis for understanding the interaction and relationship of the individual nurse with his/her environment, and the social construction of roles. Hewitt (1984, pp. 18-19) critiques the phenomenological approach which views ‘reality’ very subjectively, suggesting that there is an external world that confronts and constrains the individual regardless of how he/she perceives it. In addition, each person and context is viewed as providing understanding of only that unique situation and viewpoint. He further points out that because there is concern only with how people make sense of what they do, there is no interest in what people actually do, or explaining why people do what they do. Given that the aim of this study was to explore roles and develop a contextual understanding of community health nurses’ perspectives and a theoretical perspective, it was considered that the usefulness of a phenomenologically-based study would be limited. A critical approach (Gadamer, 1975; Habermas, 1987) which may incorporate emancipatory (Freire, 1972) and feminist (Roberts, 1981; MacPherson, 1983; Hedin, 1986) perspectives is another approach to undertaking research. This approach is based on an examination of differences in power relationships and challenges the current ways of thinking about the world with a view to facilitating change. A critical approach was considered to be unsuitable for this research. While this research may uncover dialectics and re-value the skills of the community health nurse, the object of this research was not to provide critique and facilitate change, but rather to uncover meanings present in the contextual situation of the community health nurse, and describe these from the perspective of the community health nurse. It was decided that the role of the community health nurse would be examined using a symbolic interactionist framework (Blumer, 1969). Using this framework, the researcher seeks to understand what symbolic meanings words, gestures, activities, expressions, clothing and artefacts have for groups of people as they interact with one another. From this understanding, derived from the interactants’ standpoint, the researcher aims to construct what participants see as their social reality. Chenitz and Swanson (1986, p. 4) point out that symbolic interaction is:
102 ... an approach to the study of human conduct and human group life. Symbolic interaction focuses on the meaning of events to people in natural or everyday settings and is ... concerned with the study of the inner or “experiential” aspects of human behaviour, that is, how people define events or reality and how they act in relation to their beliefs. For symbolic interactionists, meaning guides behavior and a stage of deliberation or definition of the situations precedes action. Symbolic interactionism provided a way of conceptualising and understanding community health nurses’ perspectives of the interactional components of their role with clients, health professionals and others, within a changing context, together with their perception of objects such as role descriptions and philosophical viewpoints. The theoretical constructs of symbolic interactionism provided an ability to link practice to the theoretical thinking of practising community health nurses. Analysis was made of the meanings of context, the self, the other, the collective other, modifying behaviours, interactions and strategies. In 1967, sociologists Glaser and Strauss proposed a way of discovering theoretical understanding of knowledge grounded in social data, based on the foundations provided by symbolic interactionism. Grounded theory is a qualitative methodology used for social research originally developed by Glaser and Strauss (1967) and further described by Glaser (1977, 1992) and Strauss and Corbin (1990). It uses a systematic set of procedures to develop inductively derived theoretical understandings about phenomena (Strauss and Corbin, 1990 p. 24). Theoretical concepts are: ... inductively derived from the study of the phenomenon it represents. That is, it is discovered, developed, and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon. (Strauss and Corbin, 1990, p. 23) Where descriptive approaches have the aim of faithfully describing a phenomenon from the viewpoint of participants, grounded theory methodology provides techniques that enable interpretation of data to produce theoretical understanding about a phenomenon (Strauss and Corbin,1990, p. 29). This is achieved because a feature of the approach is that as concepts and relationships among concepts are developed, they
103 are also provisionally tested by returning to the data in a cyclic manner. As a consequence, theoretical concepts are grounded in the data, rather than resulting from preconceived notions derived from previous literature or the ideas of the researcher. The researcher attempts to develop new understandings or perspectives on unknown or unclear phenomena, in a way that is closely rooted in social reality. Glaser and Strauss (1979, p. 34) argue that this approach allows the researcher to be more objective and less theoretically biased. The resulting theoretical understanding is more faithful the data, rather than being ‘forced’ to fit an existing theory (Glaser, 1992). Stern (1994, pp. 215-216) points out that when using grounded theory methodology, the researcher enters the scene bereft of preformed ideas, and with observation and questioning, is guided by propositions, themes and ideas that are generated in the field. The result, suggested Glaser and Strauss (1967, p. 103), is a theoretical understanding that is integrated, consistent, plausible and close to the data. In contrast, Glaser and Strauss (1967, pp. 4-6) argued that highly empirical studies may have a “tacked-on” explanation taken from a logically deduced theory as “... the author tries to give his data a more general sociological meaning, as well as to account for or interpret what he found. ... the explanation is added afterward” (ibid, 1967, p. 4). They suggest that an opportunistic approach to theory generation that they call “exampling”, where researchers find examples to support their logically deduced theory after the idea has occurred, cannot occur when using the constant comparative techniques of grounded theory methodology. Grounded theory techniques enable ideas and insights to be developed in close interaction with the data, allowing greater matching of theoretical formulations with social data (ibid, 1967, p. 6).
DEFINITION OF TERMS For the purposes of this research, the term ‘community health nurse’ relates to nurses whose practice is located in a non-institutional setting. However, this definition fails to provide adequate specificity because nurses may be located physically in a community setting, but the scope of their practice may be similar to those operating in an institutional or hospital setting. Although it is recognised that the practice of home visiting nurses may be different in scope from institutional settings, it was considered that it would be likely to be more similar to care provided in institutions than care provided by other categories of nurse working in the community. Thus, these nurses
104 were excluded from this research. This was supported by the data from this research, with participants seeing that there was a difference between domiciliary home visiting nursing and community health nursing: I started working with district nurses, which I saw as a foot in both camps [acute nursing and community nursing]. Because we did a lot of ‘hands on’ stuff, but we also did a lot of education with the people at home ... diabetic education, that sort of stuff. Janet 62-67 I like the sort of helping people in their homes. And yet I wasn’t that fussed on being a [domiciliary organisation] nurse ... doing sort of home nursing. Louise 85-87 For the purposes of this research, a practising community health nurse was operationally defined as a nurse who was, at the time of the study, engaged in community health practice for at least twenty hours per week and who had been employed in a community health nursing role for a period of two years or longer.
STUDY ASSUMPTIONS With any research, there are assumptions inherent in the basis of the research design. This study is no exception. Symbolic interaction posits that people are active participants in shaping and defining their own role. Thus, this research is based on an assumption that community health nurses are active in reflexively shaping their role in response to personal and contextual factors by defining, interpreting and negotiating their role. This assumption was born out in the data: ... well, if you’re interested in why you’re doing the job. Rather than just because you’ve always done it that way ... You try to look at more creative [ways of doing things]... and be a bit more ... smarter in the work practices to see ... and stop and say to yourself sometimes "why am I doing this? And what’s the outcome?” Gwen 616-621 There is an assumption that practising community health nurses will be reflective about their role as a nurse and able to articulate their thoughts and ideas, particularly
105 in relation to their practice in a community health setting. This view is based on the ambiguous nature of the community health nursing role. If a nurse is to successfully fulfil an ambiguous yet fairly autonomous role, there would be a requirement to reflect about the meaning of that role and how it is translated into practice. This assumption was upheld by the reflective nature of the interview data, with instances where participants indicated, without this information being elicited, that they reflected on their practice: ... that my standard of work ... I try to always reflect on that to make sure it's what it should be. Gwen 937-938 According to Fawcett (1991) when using grounded theory methodology, researchers make an assumption that individuals give information that they, the participants, consider accurate.
DATA COLLECTION When using grounded theory methodology, data collection, data analysis and theoretical development “stand in reciprocal relationship with each other” (Strauss and Corbin, 1990, p. 23), occurring concurrently throughout the duration of the study. The result is inductively derived theoretical understanding, generated from, or grounded in, the data. Deductively testing propositions as the study progresses by returning to the data provides further rigour to emerging theoretical development: ... the qualitative approach to understanding, explaining and developing theory is inductive. ... The researcher examines the data for descriptions, patterns, and hypothesised relationships between phenomena, then returns to the setting to collect data to test the hypothesis. ... The theory fits the research setting and is relevant for that point in time only. These data may largely consist of transcriptions of interviews, observations of the setting and of the actors. (Field and Morse, 1985, p. 11) When using grounded theory methods, Glaser and Strauss (1967, pp. 167-183) advocate using a range of data sources in addition to the more traditional sources of data. They suggest that documentary data is often under-utilised, that the literature
106 can be used early in a study to assist understanding of the substantive area of study, and that this material may also be used as secondary data by providing a background for the research. In this study it was decided to use a range of data collection strategies because the role of the nurse is the result of a web of factors and therefore requires the collection of different types of data to provide a full picture of the phenomenon. Denzin (1989a, pp. 235-244) calls this approach data triangulation and suggests that each method of data collection assists in revealing different aspects of the same phenomenon. A range of data types were accessed (see Table 4). The major data collection strategy in this research was via in-depth interviews with nurses working in community health practice settings, based on methods described by Minichiello, Aroni, Timewell, and Alexander (1995). The use of in-depth interviewing techniques with open-ended questions to obtain data was chosen for several reasons. The first was that this method is an appropriate way of accessing the thoughts, ideas, feelings and reflections of practising community health nurses. Secondly, contextual information and body language could be elicited concurrently with interviews. Furthermore, this approach allowed exploration of material arising during the course of the interview and clarification of the issues raised. This was considered to be important given the ambiguity surrounding descriptions of the role of the community health nurse in the literature. A final, rather practical reason, was that it was felt that a personal approach would improve the response rate. In addition to texts such as transcriptions of recorded dialogue and reflective oral conversations, field notes, researcher memos and documents were used as data. The professional literature describing the community health nursing role which includes statements from professional organisations and registering bodies formed part of the data and were accessed and analysed. Documentation relating to the participants’ role was also accessed. Participants were also asked to provide the researcher with documentation relating to their role and a copy of their current job description, if this was available. It was decided that further data would be elicited from participants via a questionnaire. The reasoning for this approach was that, while wishing to access information relating to the background, education, experience in community health nursing, and the
107 context of the current community health nurse role of the participant, there was no wish to clutter interview time with this gathering this information. It was also considered that some participants may wish to write down their thoughts about their role. The interviews were to be solely focussed on the participants’ perceptions of their role. In-depth interviews: 17 participants Questionnaires: 17 participants Job descriptions: 15 participants Validation feedback groups: 7 participants Organisational documentation including: vision mission statements goals philosophy of community health nursing descriptions of services provided Discussion with regional nursing managers: 3 participants Professional documentation: philosophy of community health nursing definitions of community health nursing position statements standards of practice competencies and professional organisational policies Field notes / researcher memos Table 4: Data types accessed
108
Selection of Participants Theoretical sampling methods described by Glaser and Strauss (1967) incorporate the concurrent collection, coding and analysis of data in a cyclic rather than a linear approach. They define theoretical sampling as: ... the process of data collection for generating theory whereby the analyst jointly collects, codes, and analyses his data and decides what data to collect next and where to find them, in order to develop his theory as it emerges. This process of data collection is controlled by the emerging theory whether substantive or formal. (1967, p. 45) They further suggest that initial sampling should be based on the general perspectives of the research subject rather than pre-empting the theoretical framework because, as the research progresses, the concepts used for initial sampling may be found to be irrelevant. Furthermore, the researcher may encounter unanticipated factors and find that unforeseen aspects are relevant to the research. Thus, subsequent collection of data is guided by emerging gaps in theoretical development and the questions which result from analysis of previously collected data. In selecting participants or groups of participants for inclusion in a study, Glaser and Strauss (1967) indicate that the governing criteria should be their theoretical relevance for furthering the development of emerging categories. Choice is based on accessing data that will: ... help generate, to the fullest extent, as many properties of the categories as possible, and that will help relate categories to each other and to their properties. (ibid, 1967, p. 49) Glaser and Strauss (1967, p. 48) argue that the advantages of this approach are that the criteria developed for selection of data are more systematic and relevant because they are sensitive to unanticipated contingencies and are continually tailored to fit the field, unlike a “pre-planned routine” that would be more likely to “force the analyst into irrelevant directions and harmful pitfalls” and result in an inability to vary data collection, no matter how poor the data, in order to maintain control. Strauss and Corbin (1990, p. 176) state that a concept is deemed to have proven theoretical relevance when it is repeatedly present or notably absent, when all pieces
109 of data are compared, and has developed through the coding process to the status of a category. They suggest that events and incidents that are indicative of categories that are emerging in the data are thus identified and direct further sampling, from either persons or pieces of data, and allow provisional testing of propositions about concepts and relationships among them that are being developed in the emerging theory. The principles of theoretical sampling were applied to selection of participants, events, written materials, literature, contexts and incidents that were explored throughout this study. Sampling in this research, while including individual participants, was not confined to people, but included sampling transcriptions, documents, notes and the literature. It was necessary to select participants who credibly represented the field of community health nursing, could articulate their ideas about their role and provide valid information related to the phenomena of interest. Field and Morse (1985, pp. 11-12) suggest that: ... the researcher selects ‘informants’ who are willing to talk and have established relationships of trust with the researcher or who are in ‘key’ positions and have a special knowledge of the phenomena for one reason or another. Another sampling consideration when using grounded theory methodology is that rather than seeking homogeneity, full variation is sought in order to test the developing theory against incoming data from a full range of situations. Glaser and Strauss (1967) argue that the approach of holding groups constant in order to compare variables and achieve control of extraneous variables is not necessary in research using grounded theory methodology, because the goal is not to provide accurate evidence, rather it is to generate theoretical understanding. Although initially they suggest limiting differences while establishing basic categories and their properties, they posit that the generation of theoretical concepts from only a homogenous group of participants would severely limit the generation of theoretical concepts from the data (ibid, 1967, p. 56-57). Glaser and Strauss (1967, pp. 51-56) reason that, given that all the data apply to a similar category or property, then seeking to hold a group constant and excluding difference may prevent examination of a wider range of possibilities and development of the properties of categories. Thus, once the initial basic work of analysing data to establish categories is accomplished, they suggest
110 maximising the differences within categories. Moreover, where similarities are found among diverse groups of participants, this provides for development of concepts with the most generality: Maximizing brings out the widest possible coverage on ranges, continua, degrees, types, uniformities, variations, causes, conditions, consequences, probabilities of relationships, strategies, process, structural mechanisms, and so forth, all necessary for elaboration of the theory. (Glaser and Strauss, 1967, p. 57) They suggest that the types of groups selected for participation in a study will have an impact on the scope of the population and the conceptual level of the theoretical understanding that is developed. Thus the sample was not required to be large, representative, nor meet the requirements of quantitative sampling methods. Rather, the aim was to access data from a wide variety of sources, include people, documents, events and the literature. It was important to choose participants who had gained sufficient experience in a range of fields of community health nursing and had gained an opportunity to reflect on this experience and develop a personal perspective on the role. To assist initial selection of participants into this study, the literature was explored and the possible factors which would influence the perspectives of community health nurses were reflected upon. Three factors were identified as possibly having an impact on the phenomena of interest. These were firstly, the practice setting, secondly the educational background of the nurse and thirdly, the length of time of experience in community health nursing. The first approach considered was to collect data from participants who were from different specialty sub-groups of community health nursing. Categories of community health nursing settings have been identified by Dunt et al. (1991) as: communitybased district and visiting, maternal and child health, occupational health, community health centre, and hospital-based district and visiting. However, communication with practising community health nurses indicated that many community health nurses could not be categorised in this way. Community health nurses appeared to have job mobility, with many working in several different community health settings
111 throughout their careers. There has also been changes in employment structures which have allowed many community health nurses to undertake work in several community health settings within the one job. Furthermore, it was considered that the role of the community health nurse within smaller communities would be difficult to categorise by setting, as community health nurses may work in a range of sectors within one community. An example found in this study, was a participant whose working week consisted of one day in the local school, two days in child health and the final two days in general community health. As a consequence this approach to selecting informants was abandoned. The second aspect considered was that educational preparation in the form of a qualification in community health may be an important factor in shaping the practice of nurses. However, in recognition that community health nurses engage in continuing education, professional activities and personal updating of skills, and that many experienced community health nurses may not have had the opportunity to access formal education in community health nursing, it was decided that this would not be a criteria that would determine participation. Rather, information related to education preparation, continuing professional development and education would be noted in data collection and analysis. The final factor considered was experience. This study sought to access knowledge embedded in practice. There was the need to access informants who understood and could articulate their understanding of their role. It was thought that participants would require an adequate period of experience in community health nursing practice to enable them to reflect on, develop and negotiate their role, and to clarify their own personal view of community health nursing over time. On the other hand, it could also be argued that the length of time practising in community health nursing would not necessarily, of itself, bestow the knowledge and understanding sought by the questions of this research if the nurse did not reflect on his/her practice or pursue personal and professional development during this time. On reflection, it was considered to be important that the investigation uncover quality information related to the community health nursing practice role and that in order to better understand the knowledge embedded in the community health nursing role, the most valid information would be gained from those who had undertaken the role of
112 community health nurse in an excellent and successful manner. Lawler (1991a, p. 224) suggests that “we cannot answer the questions that plague nursing as a discipline unless we know how our best practitioners acquire knowledge and use it”. Schön (1992, p. 51) suggested that there is a need to develop an epistemology of practice that is grounded in observation and analysis of the artistry that competent practitioners sometimes bring to the indeterminate zones of their practice. Benner (1984, p. 3) points out that experience is a requisite for expertise. Experience allows ideas, expectations and theoretical knowledge to be challenged and refined (Heidegger, 1962; Gadamer, 1970). Thus, nursing knowledge and expertise does not occur in a way that is divorced from understandings and meanings embedded in the experiences of the practising nurse. Consequently, rather than use experience as a criteria for inclusion, it was decided to seek nurses who were considered to be excellent or exemplary practitioners for inclusion as participants in the study, and that data relating to periods of experience would be collected with demographic information and noted in analysis. However, identifying participants whose practice is excellent had the inherent difficulty of defining and identifying excellence (Benner, 1984). Shanteau (1988) and McMurray (1991) suggest that in the absence of objective criteria, the best way to identify experts is to canvass the opinion of others in the profession. Consequently, a reputational aspect was included as the major factor in choosing participants. Throughout the study, the criteria of being identified as an excellent practitioner was maintained as a criteria for inclusion. In order to access practitioners who were considered excellent, senior nurses, academic nurses, those in leadership positions in the profession in each region being accessed were canvassed in order to identify community health nurses whose practice was considered excellent. Not all practitioners who were nominated were included in the study. Choice of participants from among those nominated as excellent practitioners was consistent with the need to select participants who were from a range of practice settings. However, where a practitioner was nominated several times, they were included in the study. All participants included in the study were nominated as excellent practitioners by more than one person. It was of note that this approach to selection of participants resulted in a group that were experienced, with none having less than five years of community nursing experience (see Table 5).
113 In addition to seeking diversity in participants, Glaser and Strauss (1967, p. 52) suggest that the researcher should also attend to the context in order to examine the variation in the properties of categories in diverse conditions. Chenitz and Swanson (1986, p. 9) point out that theoretical sampling often leads the researcher to test conceptualisations arising from analysis by accessing sites that are substantively different from the initial site. Glaser and Strauss (1967, p. 52) suggest that generality is enhanced by selecting participants from different regions of a nation as there may be subgroups or classes within groups chosen. Community health nursing in Australia is controlled by state governments and each state has its own health system. As a consequence, the way in which community health nursing is governed is different within each state. It was decided to attempt to access participants from different states of Australia, within the resources of the researcher. The researcher was able to access participants from three states of Australia: one from Victoria, six from Queensland and ten from Western Australia. The sampling strategies of approaching participants via a reputational sample from three states of Australia resulted in access to a group of participants who were articulate and reflective, had a range of qualifications, had a range in length of experience, and had worked in a range of practice areas that was indicative of the types of jobs available in community health nursing practice.
Approaching the Participants Once a practitioner had been identified as being an excellent practitioner and selected for inclusion into the study, they were approached by telephone. The researcher introduced herself and her background and provided a concise explanation of: the purpose of the research, the commitment that participation in the research would involve, the time required to complete the interview and questionnaire, and that they would be requested to provide the researcher with a copy of their job description. They were also informed that the research was to be the basis of a dissertation for a higher degree. On agreement to participate, an appointment was made for a mutually convenient time. Participants were assured of confidentiality and that all material which could identify them would be accessed only by the researcher and her supervisors. They were also assured that they had the right to withdraw from the study at any time. A request was made for permission to audio-tape record interviews,
114 with an explanation that recording the interview would assist the researcher in analysis. The researcher’s name and phone number was left with the participant, with an indication that they should contact the researcher should any difficulties or questions about the research arise. A questionnaire (Appendix 2) eliciting mainly demographic information was forwarded by mail, together with a consent form that included a plain language description of the research and researcher contact information (Appendix 1). All participants approached by the researcher agreed to be interviewed. The researcher encountered great interest in the research from the nurses approached. Some indicated that they often reflected about their role, while others indicated that they considered participating in the study would be a reflective growing experience. At the interview, the researcher collected the consent form, questionnaire and job description from participants, if these were available. Some participants also proffered other documentation relating to their role. These included regional mission statements, a philosophy for community health nursing and written comments. Not all participants had their questionnaires and job descriptions available at interview, but promised to forward these to the researcher via mail. Follow-up letters were sent to participants who failed to send this material, together with a stamped, self addressed envelope. A further two participants failed to return questionnaires and job descriptions following the mail-out. These participants were contacted by telephone. In both instances, participants were positive towards the research, and returned their questionnaire and job descriptions within a week. As a result of this follow-up, all participants returned their questionnaires and fifteen of the seventeen participants provided the researcher with job descriptions. One participant provided no explanation for not providing her job description while the other said that, as her job had changed and the new description had yet to be ratified, she did not feel it appropriate to provide it for the research.
The Interviews Seventeen participants were interviewed. Thirteen interviews were carried out by the researcher in the participant’s own work environment and four interviews took place in the researcher’s office. The later group of participants elected to attend the
115 researcher’s office rather than accepting the offer of the researcher coming to their workplace. The interviews were carried out during the period between during December 1993 and December 1995. All interviews were audio-tape recorded except one where the recorder malfunctioned. Notes were taken during this interview. During all other interviews, the researcher did not take notes, so as to concentrate on listening to and questioning participants. Notes were made, either before or after interviews, relating to the context of the interview, and the researcher’s thoughts and ideas about the interview. These notes included descriptions, observations and reflections, helped to clarify thoughts and ideas, and were important in directing thinking about data collected and in directing further data collection. Most interviews took approximately an hour to an hour and a half, but this varied. The researcher adhered to the time set aside for the interview by indicating to the participant when the allotted time was over. However, some participants seemed willing to talk for longer. Three participants wished to add extra information after the conclusion of the interview, so the audio-tape recorder was turned on again to capture their thoughts. The approach to carrying out in-depth interviews was based on methods described by Minichiello et al. (1995) and in a attitude of listening which Denzin (1989a, p. 109) describes as “the process of interpreting, knowing, and comprehending the meaning intended, felt, and expressed by another”. To guide interviews, an aide memoire that identified major topic areas to be discussed in the interviews was used. Before undertaking each interview, the researcher ‘chatted’ with the participant in order to set a comfortable climate, answered any questions, obtained a written consent and confirmed permission to audio-tape interviews. As an introduction, each participant was asked how they became a community health nurse. Recursive questioning techniques were used. Minichiello et al. (1995, p. 80) describes this approach to questioning as relying on the normal processes of conversation, with the researcher relating the current comments to the next one. They suggest that this method of interviewing allows the researcher to follow a more conversational model, and in doing so treats each participant and their situation as unique. As participants raised thoughts and ideas, these were explored and probed. Affirming strategies and ‘verbal nudging’ such as ‘ah ha’, ‘yes’, ‘mm’ together with reflecting back the researcher’s understanding were used to allow participants to express themselves freely.
116 Transitions in the conversation were mostly made by the participants themselves, in many cases addressing the topics identified by the researcher in her aide memoire. However where a topic had not been addressed, the researcher made transitions in the conversation by connecting a new thought with the comments of the participants. This allowed the questions asked to relate to the meanings expressed by participants themselves and enabled the researcher to match her questions to the style of the participant. This approach resulted in some interviews in this research having a storytelling style, while other participants reflected at a more conceptual abstract level. However, while interviews may have differed in style, all addressed the topics noted on the researcher’s aide memoire. The in-depth interviews sought to uncover the personal sense that nurses make of their role as a community health nurse. Topics canvassed during data collection were based on the research questions and a symbolic interactionist framework. Consequently, areas discussed in the interviews included: the nurse’s view of self as a community nurse, perceptions about their own role as a community health nurse, what participants considered their ‘job’ was, philosophies that underpin their practice, how they felt others viewed them as a community health nurse, relationships with other health professionals and clients, actions they have taken to change others’ perceptions of them, and historical and environmental factors that may have influenced what they do. Consistent with theoretical sampling methods, the topic areas discussed in the subsequent interviews were shaped by analysis of previous interviews. Areas thought to be important in early interviews, such as the role of employers were found to be less relevant than thought, because of the autonomous nature of the community health nursing role. Topic areas that provided a rich insight into the thinking of participants about their role were pursued. An example of a line of questioning that tapped into participants’ ideas was questioning participants’ views about what they thought constituted ‘success’ in their role. The researcher also spent two hours in discussion with a director of community health nursing in one of the health regions from which participants were drawn. This discussion was held in her office. The director expressed interest in the research and expressed a wish to talk to the researcher “even though she was not a practitioner”, but undertaking a management role. During this discussion, which was not recorded, the director provided information about the political context of community health nursing
117 in the region and state, and the changes that had taken place. Organisational documentation relating to the role of the nurse was also given to the researcher. Further discussion about the research, and the contextual factors affecting their region were also held by telephone with the director of community nursing and her deputy in another region accessed by this research. These discussions were important in contributing to the understanding of context for this research.
Feedback and Validation Groups Small group sessions were held in three states in order to provide feedback to participants, validation of data and further clarification. All participants were invited to attend a two hour session that was held in each state during the period December, 1995 - January 1996. These were conducted at University venues: La Trobe University, Victoria; Edith Cowan University, Western Australia; and Griffith University, Queensland. Personal invitations were given to some participants. However it was not possible to personally invite all participants. Consequently, written invitations were sent to all participants stating the time, venue and date of the session. In all, only seven participants and the researcher’s supervisors attended the sessions, because many participants found it difficult to attend the venues during work time, and some participants were on holidays. Although the number attending was disappointing, the small groups allowed discussion and exchange of ideas in a frank and open way that was more personalised. The researcher presented ideas and themes derived from previously collected data. In particular, the central notion of Situated Health Competence, together with its characteristics was discussed with participants at group sessions. Participants were able to give feedback on developing themes, question them and make suggestions. In addition, the researcher further clarified areas of analysis about which she was uncertain. Some ideas were suggested to further develop some of the categories, and these enabled the researcher to return to the data and further clarify themes. Feedback from participants in these groups was very positive, including one participant who said as she left the session “This has made me feel enthusiastic and ready to get back into it!” It appeared to the researcher that the participants in the groups were pleased to feel understood. Their discussion tended to reiterate material in interview data and confirm the major themes that the researcher had identified in
118 analysis of interview and document data. Participants’ body language was generally positive with their heads nodding in agreement with many of the ideas as they were presented. It appeared that participants were having the “ah ha” experience which indicates that the development of themes has good fit and relevance to those who are knowledgeable and in the field. In addition to these feedback sessions, a seminar was held at Griffith University in the Faculty of Nursing and Health Sciences for staff and graduate students. Material was also discussed with academic peers with expertise in community health nursing. These discussions contributed to validation of theoretical thinking.
Questionnaires The questionnaire was designed to obtain information about the participants in order to provide a contextual understanding related to the research questions. To access this information about participants, they were asked to complete a questionnaire (Appendix 1). The questionnaire contained structured questions that elicited demographic information, information about the participants’ qualifications, participation in continuing education, their employment history and their current work role. Participants were also asked semi-structured questions relating their current role, and the skills they felt were required to undertake their current role. Participants were also asked to briefly describe the important skills and characteristics they felt a nurse would need for undertaking their present job. It was felt that some participants may welcome an opportunity to write their thoughts down, rather than providing this orally at interview. This view was validated by a participant, Cheryl, who forwarded written information outlining some additional thoughts following her interview. In order to ensure that the questionnaire was easy to use, contained unambiguous questions and collected appropriate data, this questionnaire was trialled with two community health nurses. It was also assessed by two academic nurses whose area of expertise was community health nursing and the researcher’s academic supervisors. As a result of this process, minor modifications were made to the format of the questionnaire that made it easier for participants to present material relating to education and job experience.
119
Professional, Policy and Formal Documentation Analysis of formal and informal documentation relating to the role of the nurse was carried out as part of this research. The documentation accessed included any material that contributed to the formal determinates of the community health nursing role. These included job descriptions, standards of practice statements, definitions of community health nursing and position statements and policies of Australian and overseas professional nursing organisations. The literature was also reviewed to access material that related to the determinates of the role of the nurse. Research, professional organisations’ publications, book and journal literature were examined to identify professional definitions of nursing, community health nursing, primary health care and nursing theory in relation to the community health nursing role. This material was examined in relation to the understandings of the practising community health nurse participants. The purpose of accessing this material was to examine the fit between formal determinates and the perceptions of nurses in practice. In some instances these definitions and job descriptions were discussed in interviews. However, this type of discussion arose only when initiated by the participant, because the researcher wished to explore genuine understandings and perspectives of participants, rather than ‘expected’ rhetoric.
Field Notes, Memos and Logs The researcher kept a record of research and analysis activity in three forms: field notes, memos and an ongoing theoretical log. Field notes were kept to record activities, note thoughts and describe observations and contexts encountered while undertaking collection of data. These were used in analysis in relation to the preparation of transcriptions of interview data, and provided material about which memos and entries were made into the theoretical log. Extensive memoing was carried out in conjunction with analysis. Strauss and Corbin (1990, p. 197) define memos as written records of analysis related to the formulation of theory and suggest their purpose is to allow the researcher to move away from data to abstract thinking, then return to the data to ground these abstractions in reality.
120 They allow the researcher to keep a record of analytical thinking and conceptual abstractions relating to data throughout the course of the research. In this research, memos were specifically related to the categories emerging from the data during the coding and analysis process. Each memo was dated and included a reference to the document from which it was generated and contained a heading that indicated the category or concept it related to. The computer program NUD*IST (Qualitative Solutions and Research, 1994) (discussed below) provided a filing system that enabled memos to be kept together with their related categories and the data coded at that category. NUD*IST also provided facilities enabling the researcher to write memos quickly when ideas arose during coding, ready access to previous memos about a particular category as well as memos about other categories. When reference was made to any category within any memo or note, it was italicised to allow the researcher to keep track of theoretical links. In addition to the category-related memoing, a separate theoretical log was kept for the duration of this research to allow exploration of more general thoughts and ideas that emerged during analysis, and allow reflection about how different categories were linked. Again, entries were dated and references to theoretical categories were italicised. This log was important for the exploration of ideas, development of analysis and keeping track of thinking during analysis.
ETHICAL CONSIDERATIONS The conduct of this study received approval from the La Trobe University, Faculty of Health Science Human Ethics Committee. There were several ethical considerations in this study apart from consent and confidentiality, these being: the researcher’s relationship with participants, maintenance of data records and the storage of data containing personal material. The first issue was that of the relationship of the researcher to participants. Punch (1986, p. 13) points out that:
121 Entry and departure, distrust and confidence, elation and despondency, commitment and betrayal, friendship and desertion are as fundamental here as are academic discussions on the techniques of observation, making field notes, analyzing the data, and writing the report. ... The dynamics and dilemmas associated with this area of fieldwork can be summarized crudely in terms of getting in and getting out, and of one’s moral and social conduct in relation to the “political” constraints of the field. The researcher has had involvement with the community health nursing field through education, work and teaching for approximately fifteen years. As a consequence, the researcher viewed participants in this research as her colleagues and peers. There was a special effort made to ensure that this research was conducted in a transparent manner, with full information about the study’s aims and purposes being supplied to participants. The researcher’s current position is in nursing education within one of the regions from which participants were drawn. She had worked as a community health nursing educator or a community health nurse in all of the other regions from which participants were drawn. While this assisted entree, this had the potential of the researcher having, or having had, a professional relationship with a participant. The first type of relationship was that of being in a position of teaching possible participants. It was decided to exclude any identified participant if that participant was, or had been, a student of the researcher. In addition, the researcher was acquainted with some of the participants, although none were close friends. There was one instance, where the researcher did not recognise a participant’s name until being informed by her that of course she remembered the researcher - she had been the charge nurse on a ward where the researcher had been a student! However, the researcher was not employed by participants’ employers and strict confidentiality by the researcher in not disclosing any material that could identify those participating in the research was assured. Participants were specifically informed that material would not be disclosed to their employers and that no information which may identify them would be made public. Where participation in the study was disclosed to others, this was only at the instigation of participants themselves.
122 The researcher’s professional connections and networks were found to be an advantage in accessing the field, as it was easy to establish rapport and confidence between researcher and participants. There were several instances during interviews where participants demonstrated their confidence in the researcher by providing more sensitive comments, prefaced by remarks such as “this is confidential, isn’t it”, and suggesting that: It's not something that ... I would feel comfortable talking about with other community nurses. Emily 990-991 Another matter that arose in the course of conducting this research was that most participants asked about when results of the research would be published. Participants were informed that the researcher was first focussing on her doctoral dissertation, but that when publications in the professional literature occurred, details of these would be forwarded to them. The second major issue was storage of data during and after the study. The forms of data collected included audio-tapes of interviews, computer discs containing transcribed interview data, hard copy of transcribed data, researcher notes particularly those relating to accessing the participants, job descriptions, field notes, memos and an analytical log. In order to maintain confidentiality of records, numerical identification codes were assigned to each participant in a sequence relating to the order in which participants were interviewed for the study. Participants’ job descriptions and any further documentation supplied were identified with this numbered code, together with a designation for the type of data, such as ‘j’ for job description. Therefore interview data for the first participant interviewed was labelled CN1, designating that she was the first community health nurse, and subsequent participants were coded sequentially. Her job description was designated CN1j. Throughout the study, and in communication and discussion with supervisors, these codes were used to identify participants. These codes were also used to identify computer files containing data, and within the NUD*IST project. Prior to publication of material, participants were given a pseudonym as a consistent identifier, in order to ‘personalise’ the data. Names, places or anything that could identify the participant were removed from text
123 prior to any material being made public. Where a place name was integral to the participants’ text, the researcher included a term in square brackets within the text that best described it. For example: ‘a regional town’, ‘a remote Aboriginal community’ or ‘a large urban city’. Data were stored in a locked filing cabinet in the office of the researcher. Data on audio-tape, computer disc and hard copy will remain in the possession of the researcher and be accessed only by the researcher and her supervisors. Data will be kept for a period of five years in accordance with the National Health and Medical Research Council, Australian Health Ethics Committee guidelines (1995) after which it will be destroyed.
ANALYSIS OF DATA The aim of this analysis was to develop a theoretical understanding about the role of the community health nurse. Interview transcriptions, documentary and other data were analysed to identify themes and categories. Glaser and Strauss (1967, p. 36) define a category as “a conceptual element of the theory” which stands by itself. They indicate that categories are concepts indicated by the data, and not the data itself. They suggest that: Once a category or property is conceived, a change in the evidence that indicated it will not necessarily alter, clarify or destroy it. It takes much more evidence - usually from different substantive areas - as well as the creation of a better category to achieve such changes in the original category. In short, conceptual categories and properties have a life apart from the evidence that gave rise to them. (ibid, 1967, p. 36) While many of the techniques described by Strauss and Corbin (1990) were used in analysis, Glaser’s (1990) suggestion that the data not be ‘forced’ was kept in mind. Accordingly, the techniques described by Strauss and Corbin (1990) were used where they appeared to fit with the way in which themes were arising from the data. However, in order to retain sensitivity, the researcher attempted to remain focussed on the data, rather than the techniques of analysis.
124 Sproull and Sproull (1982, p. 283) point out that researchers using qualitative approaches face the “cruel trade-off” between large amounts of rich qualitative data and the burdensome need to analyse it. Bryman and Burgess (1994, p. 216) describe the amount of data in qualitative research as “voluminous, unstructured and unwieldy”. Large amounts of text in the form of transcriptions, memos, notes and documents were collected during this study to be included in analysis. There was a need to include all of the data in the analysis and to have a system of filing coded material that allowed ready access and flexibility throughout the research process. Pfaffenberger (1988, p. 12) suggested that the volume of data may restrict the researcher to small data sets and simple analytical strategies unless better approaches are used. He argued that analysis in qualitative research can be likened to the more simple types of analysis that were carried out in quantitative research prior to the introduction to statistical packages. He posits that computer based technology may deliver to qualitative researchers an ability to work quickly and conveniently with much larger units of data, and also allow them to apply more sophisticated analytical techniques. In this study computer technology was used as a basic tool in filing, analysis and retrieval of information. There was a need for an analysis package that allowed for: storage and retrieval of data in categories, analytical induction, comparison of data, searches of large amounts of data at once, an ability to make changes to the way in which material was coded and categorised, and storage, revision and retrieval of ongoing memos and notes. There was also a need to keep verbatim data accessible and together with categories so as not to lose the essence of informants’ words and meanings. The tools used to assist analysis were the word processor package Microsoft Word 6 together with the qualitative data analysis software NUD*IST on an IBM personal computer. NUD*IST is an interactive computer program designed to allow the researcher to undertake much of the sorting and filing that is required in qualitative data analysis. The program enables the researcher to code, re-code, sort and search data files. Other functions include review and printing of text from data files and memos as well as data coded at analytical categories themselves. Data entered into the NUD*IST project as on-line documents for this research included transcriptions of in-depth interviews, field-notes, memos, analytical logs, job descriptions and
125 documentation supplied by participants. Finally, consistent with grounded theory methodology, the literature was included as a source of data. These were analysed as off-line documents. Richards and Richards (1984, pp. 167-168) suggest that the use of NUD*IST has an impact in three ways: the handling of data, the routines of analysis and the interrogation of themes. Firstly, the researcher is using a computer screen rather than paper for dealing with and handling data. Secondly, they suggest that NUD*IST allows the researcher greater freedom in exploration of categories. Finally, they posit that NUD*IST allows interrogation of categories. There were found to be many advantages in using NUD*IST as analysis tool in this research. First, it allowed more rigorous analysis of data. When searching data for themes, the NUD*IST software ensured that all related data were identified and thus considered. Searches that were carried out in this research included string searches for specific words such as ‘primary health care’ and pattern searches for groups of words with a particular meaning such as ‘health / healthy / healthful’ and ‘care / caring / cared’. This facility allowed the researcher to follow cues and ideas about the data, question the data and to check propositions. Secondly, it enabled complex coding procedures to be carried out. Particularly rich data could be coded in more than one category, categories could be overlapped or ‘nested’ within others. Thirdly, it provided analytical flexibility because categories could be changed, moved, redefined or deleted. Consequently, categories could be changed, compared, redefined, merged, collapsed, modified or deleted as the research progressed and theoretical sensitivity increased. In addition, documents, notes and further transcriptions could be added to the project at any time. Furthermore, it enabled the researcher to return to earlier data to re-code material in order to check emerging theory that had resulted from later analysis. Finally, it provided a facility to write easily retrievable memos attached to each analytical category. It was found that this feature of the software allowed the analyst to immediately note thoughts and ideas as coding progressed. Extensive memos and theoretical notes were kept within the NUD*IST project. Another particular advantage in using the program in conjunction with a word processor, was a reduction in repetitive processing of transcribed material and analytical notes. Transcriptions, memos and theoretical notes could be imported into the NUD*IST project and exported into word processing documents for use when writing reports.
126 These functions were important in enabling the researcher to undertake a constant comparative method (discussed below). However, while the advantages of using computer technology to assist analysis were considerable, there is a need to be critical of the use of technology and understand the capabilities and limitations of tools used. Richards and Richards (1994, p. 447) point out that technologies that support, for example coding and retrieval, are not merely an atheoretical technique or tool, but contribute to new ways of making ideas and constructing and testing theories. A criticism of the use of technology in qualitative research, is that the use of transcriptions may strip away the meanings with which inflection and body language imbue words. Language has words that may have many meanings. The meaning of words or phrases are derived from the context, body language and inflection and a meaning may be implied, without using the actual words. This has implications for using string or pattern searches for particular words. There is also a concern that use of technology will reduce data to a level where meaning and context is lost, raising an argument that is consistent with the critique qualitative researchers make of reducing data for numerical analysis. Several steps were undertaken to ensure these concerns were addressed. The audiotapes of all interviews were fully transcribed onto computer disc using a word processor. After each interview was transcribed, it was listened to again carefully, in conjunction with field notes, in order to maintain the meanings of inflections, pauses, context and expressions of emotion and double check that meanings reflected in the voice rather than the choice of words were faithfully represented. A general picture of the major themes in each interview was also gained. Where meanings were not immediately apparent in transcripted words, they were noted by the researcher in square brackets within transcriptions. In addition, an effort was made to punctuate the transcription in a way that preserved the meanings of the speaker. Transcriptions were then entered into the NUD*IST project, which numbered each line of the transcription as a text unit. In addition, all documents and job descriptions provided by participants were scanned, checked and transcribed and entered into the NUD*IST project. These transcriptions were then coded for meanings using the numbered text units as identifiers. Analysis of all transcribed on-line data, including documents, interview transcriptions, job descriptions and questionnaires, together with other off-line data were carried out by the researcher at the same time.
127 Reports of interview transcriptions that incorporated line numbers generated by NUD*IST were produced onto hard copy from the project to enable coding. These printed transcriptions were then used to manually code data concurrently on hard copy and into the NUD*IST project. This coding activity was undertaken prior to using any of the search functions of NUD*IST. When searches were undertaken within the project, the facility enabling the researcher to accept or reject ‘finds’ was used, together with the facility to spread the data to incorporate material either side of the find to ensure adequate contextual data was accessed. Another feature of the NUD*IST software which had an effect on analysis, was the ability to generate categories and sub-categories. This enabled categories to be coded in relation to each other. This facility was used to explore dimensions of specific categories. For example, for the notion of achieving ‘success’ in the role, the different themes of ‘achieving goal’, ‘reaching people’, ‘providing a resource’, ‘positive evaluation’, developing a ‘positive relationship’, ‘promotion’ of self or community nursing, ‘increasing knowledge’ and ‘no criticism’ were identified and made into subcategories of ‘success’. While providing obvious benefits in dimensionalising data related to a category, at times this facility caused difficulty. When data was related to several different categories, or did not quite ‘fit’ any particular category, this resulted in categories which overlapped or were similar. This sometimes resulted in a need to modify the definition of a category, or to combine or delete categories. An example was the category ‘helping’. It was decided after reading data coded at this category that there was a need to examine how the nurse helped rather than simply labelling data as ‘helping’. Another difficulty that was found with the NUD*IST software was the tedious nature of generating reports of data and memos stored at categories for use in analysis and writing. This was a slow process, and it required reports of data and memos to be generated from each of categories individually. Given the large number of categories generated for this research, this was a time-consuming process.
Constant Comparison Data were examined to discover emergent themes and to develop a theoretical understanding of the role embedded in the practice of community health nurses. The
128 constant comparative analysis method (Glaser and Strauss, 1967; Glaser, 1978, 1992; Strauss and Corbin, 1990) was used to code data and develop categories. This approach to analysis involved comparison of each piece of data with all previous pieces of data. Glaser and Strauss (1967, p. 102) define the constant comparative method of analysis as: ... joint coding and analysis ... by using explicit coding and analytic procedures. ... This method of comparative analysis is to be used jointly with theoretical sampling, whether for collecting new data or on previously collected or complied qualitative data. Thus, there was a constant reintegration and redesigning of theoretical notions as material was analysed. This approach is designed to generate theoretical understanding that is “... integrated, consistent, plausible, close to the data - and at the same time is in a form clear enough to be readily, if only partially, operationalised for testing in quantitative research” (Glaser and Strauss, 1967, p. 103). The constant comparative method involved: firstly, comparing incidents relating to each category; secondly, integrating categories and their properties; thirdly, delimiting the theoretical analysis of the role of the nurse, and finally, writing the theoretical formulations (Glaser and Strauss, 1967, p. 105). The first step taken was open coding, which Strauss and Corbin (1990, p. 61) define as the process of breaking down, examining, comparing, conceptualising and categorising data. As new themes emerged, new categories were created. When comparing incidents applicable to each category, the researcher compared each incident in the data to as many categories of analysis as possible. This involved examination of the data already coded at a particular category as data emerged that fit an existing category. Strauss and Corbin (1990, p. 70) state that what emerges for each category are the theoretical properties of the category, the types or continua of the category, the major consequences, its relationship to other categories and so on. Glaser and Strauss (167, p. 37) argued that in generating theoretical understanding the aim is: ... at achieving much diversity in emergent categories, synthesized at as many levels of conceptual and hypothetical generalization as possible.
129 To begin coding (Charmaz, 1994) the researcher compiled a ‘start-list’ of possible categories which had arisen from the research questions, examination of the literature and listening to the first interview (Miles and Huberman, 1994, p. 58). In particular, note was made of major themes and repetitions of incidents or words. As subsequent interviews and further coding were undertaken, further categories were generated and categories which were found to be irrelevant or repetitive of each other were combined with other categories, or deleted. A range of category types were utilised. In this research groupings of categories included those related to the setting or context of the community health nurse, such as ‘change’, ‘organisational factors’; interpretive codes such as the informant’s perspective on ‘health’, ‘primary health care’ and ‘nursing’; interactional codes such as ‘representing’, ‘negotiating’, ‘control’ ‘explaining’ and ‘trade-offs’; role activity codes such as ‘referring’, ‘treating’, ‘assessing’ and ‘linking’; strategy codes such as ‘goal setting’, ‘promoting’ and ‘evaluating’; relationship codes identifying activities related to other nurses, clients, health professionals and others such as ‘being with’, ‘caring’, ‘friends’; personal emotional codes such as ‘anger’ and ‘being valued’; personal and professional categories such as ‘autonomy’, ‘learning’, ‘self-view’ and ‘commitment’. Each category was defined so that there was consistency in coding. As analysis progressed, these definitions required refinement. At times an interesting phenomenon was followed in the data by coding, and then found to have relevance to an existing category. An example of this was the category ‘taxi’ which referred to the transporting of clients. When data coded here were examined in relation to other data, it was found to be relevant to the notions of ‘responsibility’, ‘dependency’ and ‘doing for’. Another important aspect of using the constant comparative methods was that the researcher examined the data for irregularities and unusual occurrences, then examined existing categories in the light of this new evidence. Hammersley and Atkinson (1983) suggest that analysis involves immersing oneself in the data, searching out patterns, identifying surprising phenomena and being sensitive to inconsistencies such as divergent views. In this research, particular note was made of the meanings when comments were ‘politically incorrect’, contradicted themselves, were accompanied by body language or voice inflexions indicating emotion such as laughter, sighing, or lowering of the voice or diverged from the views of other
130 participants. It was found that examination of these differences was very fruitful and often resulted in clarification of theoretical development. An example was when Emily rejected the notion of being a ‘community nurse’. When data was examined closely, it was noted that the notion being rejected was the perception of ‘nursing’ that was tied to the medical model and the ‘sick role’. This strengthened the view that community nurses were focussed on clients’ needs within a wellness model and identified the nature of the difficulties associated with the title ‘community health nurse’. It was not possible to identify how many codes were used during analysis because of the evolving nature of the coding system. However, approximately two hundred different codes were used during this research. The reason for the large number of codes was that, as the range of properties or dimensions of particular categories were identified, they were attached as sub-categories. For example, for the category ‘justifying’, the sub-categories ‘explaining’, being ‘questioned’, ‘qualifications’, ‘meeting needs’, providing a ‘professional or good service’, ‘proving themselves’ and ‘difficulty justifying’ were generated. The second step in analysis was integrating categories and their properties. This involved an examination of the categories being generated, comparison of categories with one another and identification of any theoretical connections between categories. This involved axial coding which Strauss and Corbin (1991, p. 96) define as: A set of procedures whereby data are put back together in new ways after open coding, by making connections between categories. Glaser and Strauss (1967, p. 109) suggest this process forces the analyst to make theoretical sense of each comparison. They suggest that integration of theoretical understanding is similar to development of conceptual categories in that it also should emerge from the data (ibid, 1967, pp. 40-41). In this process the researcher examined the categories to look for themes and relationships among them. Themes were identified which related to each other, were grouped together and examined in relation to each other. An example was the development of themes related to enacting the role of the community health nurse that involved ‘interpreting’, ‘developing’, ‘validating’, ‘sustaining’, ‘negotiating’ and ‘integrating’. The category of ‘sustaining’ the role
131 could be sub-divided into ‘sustaining the self’ and ‘sustaining the role’. ‘Sustaining the self’ could be further sub-divided into ‘autonomy’, ‘interest and commitment’, ‘identifying personal success’ and ‘dealing with dilemmas’. The third step of ‘delimiting’ the theory occurred after the underlying uniformities were identified in the original set of categories and their properties. This allowed theoretical development that had a smaller set of higher level concepts. This activity utilised the process of selective coding, described by Strauss and Corbin (1991, p. 116) as the process of systematically relating categories to a central concept by validating relationships, refining and developing theoretical understandings. Strauss (1987, p. 36) outlined the six essential characteristics of core categories as: being central to the data; recurring frequently in the data; relating easily to other categories; presenting clear implications for more general theory; that they become more detailed as the theoretical development moves forward, and they allow for maximum variation to the analysis. The process of examining the categories and data in relation to the question of the meaning and purpose of the community health nurse role enabled the development of the central phenomena to which other conceptual categories were related. These discussions are presented in Chapters Six and Seven. Major phenomena identified in the data related to both the purpose of the role and the way in which the role is enacted. A central phenomenon identified was Situated Health Competence. Once this notion was identified as a unifying theme, and its characteristics identified, the way in which the community health nurse enacted the role came into focus. Glaser and Strauss (1967, p. 24) point out that conceptual categories allow theoretical predictions to be made until the prediction proves incorrect in the data. At this point they suggest that the researcher will find out what structural conditions have tended to negate the conceptual category, allowing further theoretical development. They suggest that evidence and testing never destroy a theoretical understanding of any generality, rather they enable modification resulting in a better theoretical development. The final step in the process of this analysis was that of returning to the literature and writing. The analytical process in this research continued into the writing process, being accomplished by processing the material that had been generated throughout the analytical process - data coded at specific categories, the series of memos, and the
132 theoretical development outlined in the theoretical log. The researcher also explored the literature further in relation to the major themes that were identified in the data. This process allowed the researcher to examine the literature in the light of theoretical development arising from the research. The researcher was able to note where there was confirmation of theory and findings in the literature and also where findings provided new or different insights.
Theoretical Sensitivity The validity of grounded research is based on the credibility and theoretical sensitivity of the researcher and the rigour with which research procedures are carried out. Strauss and Corbin (1990, pp. 41-42) describe theoretical sensitivity as a personal quality of the researcher which includes: ... an awareness of the subtleties of meaning of data ... the attribute of having insight, the ability to give meaning to data, the capacity to understand, and capability to separate the pertinent from that which isn’t. Furthermore, they suggest that sources of theoretical sensitivity arise from having familiarity with the literature together with professional and personal experience. This experience, they suggest, allows a researcher to have understanding of how things work and an implicit knowledge of the situation. The Researcher Approaches taken in this research viewed the researcher as a participant in the research. Indeed Glaser and Strauss (1967, p. 39) point out that when research is undertaken with the purpose of generating theoretical meaning: … the researcher is no longer a passive receiver of impressions but is drawn naturally into actively generating and verifying his hypotheses through comparisons of groups. Hammersley and Atkinson (1983, p. 14) suggest that the extreme positions of both positivism and naturalism:
133 ... assume that it is possible, in principle at least, to isolate a body of data uncontaminated by the researcher, either by turning him or her into an automaton or by making him or her a neutral vessel of cultural experience. Glaser and Strauss (1967, p. 46) argue that theoretical sensitivity involves the researcher’s personal and temperamental bent, and also their ability to have theoretical insight into their area of research. Furthermore, Boyle (1994) suggests that the reflexive nature of this type of research implies that the researcher is part of the world being studied and is affected by it. Minichiello et al. (1995, p. 182) point out that the fieldworker’s gender, age, prestige, expertise or ethnic identity can limit or determine what he/she can accomplish. This is because the quality of the relationship between the observer and the participant is important and the quantity and validity of the data are grounded in the skill of the investigator to establish relationships with informants, access data and make sense of it. Denzin (1989b, p. 71) suggests that every group develops its own ideolect, or special language, that has special meanings that must be uncovered by the researcher. Newcomers, he suggests do not understand the takenfor-granted meanings in the language used. The researcher has had previous experience in practice, research and teaching in community health nursing. Her educational background includes a Bachelor of Health Science degree with a major in community health nursing, and a primary health care focus in her master degree. Although the researcher was an ‘insider’ in terms of being a community health nurse, she was not an ‘insider’ in terms of being currently employed in community health nursing practice. For this research an attempt was made to ensure that the characteristics of the researcher were of benefit to this research rather than a limitation. The background of the researcher ensured that she understood the context, language and many of the shared meanings of the field because of her experience and knowledge. However, although the researcher had an ‘insider’s’ knowledge of the world of a community health nurse and understood the language and many of the symbols used, there was also an ability to stand back from the field in order to reflect, think and analyse. This is important because closeness to the field may result in being socialised to accept the assumed understandings of the community health nurse without questioning, and consequently result in a failure to identify important cues. Werner and Schoepfle (1987, pp. 60-63) observe that the two
134 views of the insider/outsider, side by side, provide deeper insights than are possible by the insider alone, producing a ‘third dimension’ that ‘rounds out’ the picture. Glaser and Strauss (1967, p. 46) suggest that potential for theoretical sensitivity is lost if the researcher is committed exclusively to one specific preconceived theory. This may lead to insensitivity to other ways of ‘seeing’ the data and defensiveness toward the kinds of questions that cast doubts on the researcher’s preferred theory. Thus it was important that the researcher had the ability to recognise, identify, question and be sensitive to contradictions, assumptions and embedded understandings within the world of the community health nurse. In order to increase sensitivity to the data, the researcher took the following steps. The researcher explored her own personal assumptions and ideas related to the research in her theoretical log. This reflection enabled her personal thinking to be made explicit. Once explicit, the researcher was able to continually question interpretations and analysis of the data, while being aware of her own possible biases and assumptions. An attitude of scepticism was maintained in relation to material that was in agreement with the researcher’s own ideas as identified at the beginning of the research. The researcher also used symbolic interaction concepts to examine the researcher (self) as object and the processes of the research from the informants’ perspective. Care was taken to ensure that the researcher did not introduce ideas into the interview process, and that there was an attitude of careful listening in order to ‘hear’ the meanings being expressed by informants. Where informants’ views diverged from the views of the researcher, these data were specifically explored in order to ensure that this material was not dismissed and that the biases of the researcher were not unduly influencing analysis. This allowed reflection on the possible influence of the researcher’s views and actions on the collection and analysis of data. Analytical Processes Theoretical sensitivity is also derived from utilisation of rigorous analytical processes. Glaser (1992, p. 14) suggests that grounded theory methodology has:
135 ... several methods which reduce and forestall this bias [of the researcher] in large measure, such as constant comparison and saturation and core relevance. ... This is why ... data collection, data analysis and data presentation [are] intimately linked at every step of the way. They constantly adjust each other to the emergent theory through theoretical sampling, memoing and sorting in order to stay close to the data, yet to conceptualize it. In this research several processes were used. Firstly, questions were asked of the data to see if the developing theoretical concepts had a fit with the reality of data. Secondly, an attitude of scepticism was maintained in relation to the emerging themes, with continual checking to see if it was supported by the actual data. Thirdly, there was an adherence to reciprocity between the data collection and analytical procedures (Strauss and Corbin, 1990, pp. 43-47). In addition, use of the searching facility and filing facilities of NUD*IST in the analysis processes ensured that all segments searched for or coded in a particular way were analysed. These processes provided a way of breaking through biases and promoting examination of assumptions and revision of emerging themes, allowing the researcher to question, critique and test emerging theoretical concepts, recognise contradictions and assumptions and enable a ‘fit’ between theoretical development and the reality of data, while still utilising the understandings and knowledge of the researcher.
Theoretical Saturation One of the decisions which must be made in any study which uses grounded theory methodology is when to stop collecting data and when analysis has reached a stage where formulations and propositions can be made. Qualitative research methodologists suggest that the researcher continues to collect and analyse data until similar instances are being seen over and over again. When this occurs, they suggest the researcher can be empirically confident that a category is ‘saturated’ (Glaser and Strauss, 1967, pp. 61-62; Lincoln and Guba, 1985). This they call ‘theoretical saturation’ and suggest that the criteria for determining saturation include a combination of: the limits of the empirical data, the integration and density of theoretical formulations and analyst’s theoretical sensitivity (Glaser and Strauss, 1967, p. 62).
136 Miles and Huberman (1994, p. 62) warn that a researcher’s awareness of the many layers of meaning in the field and data can make the choice of when to close down difficult and painful. In this research, data collection continued until the researcher was satisfied that she was hearing nothing new in relation to the development of categories and theoretical concepts. However, the many layers and interconnections between aspects of the data did make this difficult. Although this research accessed a diverse group of participants, it was found in final interviews and the feedback and validation groups that little more information was being generated and there was reiteration of data that had previously been collected, coded and analysed. Glaser and Strauss (1967) point out that the major aim is not to ‘know the whole field’, to identify all the facts, or provide a perfect description of an area. Rather it is to develop a theoretical understanding that accounts for much of the relevant variation in the data. As a consequence, they suggest: ... that the kind of evidence, as well as the number of cases, is also not so crucial. A single case can indicate a general conceptual category or property; a few more cases can confirm the indication. (ibid., 1967, p. 30)
Presentation of Data One of the major hallmarks of research based on grounded theory methodology is that the resulting knowledge is complex and deep. This was the case with this research. The many themes that emerged from the data were inter-woven and enmeshed. As such, it was difficult to examine one emergent theme without relating it tightly to one, or many others. In addition, the notion of a community health nursing role is one that suggests a broad and wide sweep of information. As a consequence, the material presented below should be read and understood as a whole, and interrelated. As described above, categories were developed until they were saturated. It will also be seen that many categories presented support or are linked with each other. They must however be presented and analysed separately, in order to understand the separate nuances of each category. All of the themes were saturated and had many examples that could have been presented. If there were instances that were at variance with general themes, these are indicated.
137 An important aspect of this dissertation is the presentation of verbatim data from interview transcriptions. People do not speak in sentences. They tend to intersperse ideas with each other by going off on a tangent, then returning to an original thought. They also repeat words or phrases, scatter ‘ums’ and ‘ers’ through their discussion, pause for thought and make errors in grammar and tense. Atkinson (1992) suggests that verbatim material from participants should be edited via a process described as ‘textual conversion’, so that it is coherent, fluent and readable, while retaining the meanings inherent in the original text. There was a wish to hear the ‘voices’ of participants. They were articulate and provided power, colour, passion, humour and reality to discussion. Although some editing was carried out to remove excessive ‘ums’ and ‘ahs’ and interspersed changes of topic in order to make material more readable, the transcripts have been faithfully presented so as to preserve the meanings intended by the speaker. Furthermore, out of respect for the participants in this research, errors such as those in grammar or tense have not been corrected or indicated with (sic). Each audio-tape was transcribed, listened to several times in an effort to preserve the original intent, inflection and meaning. In places, these meanings are indicated by the researcher in square brackets. Changes have also been made to protect the identity of participants. As place names are a possible identifier, place names have been removed and the characteristics of the place have been indicated in square brackets.
LIMITATIONS OF THE METHODOLOGY It is recognised that while there are many discourses which may relate to the role of the nurse, this study focussed explicitly on the thoughts, ideas and meanings from the perspective of the ‘insider’. Thus, while etic data was accessed, this study was derived largely from an emic perspective. While other material was accessed, such as demographic and documentary data, it was the view of the nurse which constituted the primary focus of this research. The contradiction between the need to ‘ground’ theory in the data, and ‘verification’ has been debated in relation to grounded theory methodology. It is clear that the researcher cannot develop theoretical formulations for which there is no supporting data. However, the extent to which verification is the focus of the research appears to
138 be an issue. Glaser and Strauss (1967, pp. 26-27) suggested that if the purpose was to verify propositions or hypotheses, then the researcher’s focus is on verifying. They suggest that a consequence of this would be an analyst who becomes preoccupied with ‘checking out’ an emergent set of propositions. The researcher will then look for negative cases, or deliberately set out to accumulate positive ones in order to gain further evidence for hypotheses. Rather, they suggest that the purpose of using grounded theory methodology is emergence. They state that: Of course, verifying as much as possible with as accurate evidence as possible is requisite while one discovers and generates his theory - but not to the point where verification becomes so paramount as to curb generation.
Thus,
generation of theory through comparative analysis both subsumes and assumes verifications and accurate descriptions, but only to the extent that the latter are in the service of generation. Otherwise they are sure to stifle it. (ibid, 1967, p. 28) On the other hand if the focus is on theoretical development rather than verification, the researcher is more focussed on discovering differences, and different perspectives, and making him/her more alert to emerging themes that will help change, develop and clarify theoretical analysis (Glaser and Strauss, 1967, p. 40). However, it is fair to comment that in checking conceptual development back with the data and attempting to ‘ground’ analysis in the data, then validation is an important aspect of research. May (1986, p. 152) pointed out that grounded theory methodology involves both induction and deduction, with propositions being developed and accepted or rejected continuously as data are collected and analysed. In this research there has been an attempt to explore differences and divergent ideas, and also an effort not to foreclose on theoretical development until all aspects of the data were considered. As a consequence, the period of time spent in open coding using the constant comparative method was considerable. However, in order to ensure that analyses was valid, the researcher also took care to ensure that any theoretical development was consistent, with many instances in the data and that categories were indeed ‘saturated’. One category that was not saturated, possibly because of its diffuse nature was the activity of ‘integrating’. This category was presented as a tentative category to all validation and feedback groups for their comment. The
139 support for it was so overwhelming and unanimous that it was included in the theoretical formulations.
SUMMARY OF THE CHAPTER This chapter described the rationale for the selection of methodology, an analysis of the methodology chosen and a description of the design and implementation of this research. The selection of participants, data collection, data analysis and approaches to validation were described. The methodology was chosen in order to develop an understanding of the meanings of the community health nurse practice role from an insider’s perspective. In particular, this chapter provides a basis for understanding the development of thinking and the results of analyses that are presented in the following chapters.
140
CHAPTER FOUR Profile of Participants INTRODUCTION The sample of informants consisted of seventeen nurses who were practising in client contact community nursing roles. Sixteen of the informants were female and one was male2. Fifteen were Australian-born, one was an English-born resident and the other was a naturalised European migrant. All participants were registered nurses. In addition, one was also a registered midwife, eight were registered both as midwives and child health nurses and two were registered psychiatric nurses. The participants attained their general nursing qualification in five states of Australia: Queensland (five), Western Australia (five), New South Wales (three), Victoria (one), South Australia (one), not specified (two) and one nurse who undertook her initial nursing education internationally.
QUALIFICATIONS Taken as a group, these nurses were well qualified in range of areas of expertise. When fifteen of the participants began their nursing careers, the only available education was hospital-based training, the other two participants undertaking diplomas in nursing. The lack of options available at the time they undertook their initial nursing education is reflected in the diversity of their subsequent formal education. Eight of the participants have since undertaken post-registration bachelor degrees in nursing, with a further two participants currently undertaking bachelor degrees in nursing, and another a master degree in nursing.
141 Three participants had other qualifications in general nursing, each having undertaken hospital-based certificates in one of: accident and emergency nursing, post-basic paediatric nursing and cardio-thoracic nursing.
Highest Formal Qualifications The highest formal educational qualifications of participants ranged from a certificate in nursing to a master degree. Four participants’ highest formal qualifications were certificates in nursing. Of these, one was a general nurse and the other three held multiple registrations that included midwifery, child health and psychiatric nursing in addition to their general registration. For eight participants, the highest qualification held was a bachelor degree in nursing. For all of these participants, this represented further study after their initial qualification as a nurse. Of these, one was currently undertaking a graduate diploma. Three participants had a bachelor degree in areas other than nursing, although all of these studies were related to their role as a community nurse: health studies, health education and promotion, and arts. One was currently undertaking a Master of Nursing and another a graduate diploma in nursing. Another participant held a Post Graduate Diploma in Primary Health Care and another a Master Degree in Education.
Qualifications in Community Health Nursing It is of interest that only one of the participants had formal qualifications specifically in community health nursing. This participant had a Bachelor of Applied Science (Nursing) with a major in community nursing. However, of the participants who were registered child health nurses, five had undertaken a child health program offered collaboratively by their state health department and a local university, with a major in community and family health. One of the participants who had undertaken a diploma 2
Due to the majority of participants being female, and in order to maintain confidentiality for the male participant, all participants in this dissertation will be referred to as females.
142 course also noted that she had taken a community nursing subject in her undergraduate course. However, it would be wrong to assume that these participants were not well qualified in community nursing, as examination of other qualifications and short courses undertaken reveal relevance, in particular to specialty skill development.
Other Qualifications Of note was the number of the participants who held qualifications in education. One participant had majored in nursing education in her post-registration bachelor degree in nursing, another had a Diploma of Nursing Education. Four of the participants in this research had formal qualifications specifically in health education comprising of: an Associate Diploma in Health Education, a Bachelor of Health Studies (Health Education), a Bachelor of Applied Science (Health Education/Health Promotion) and a Master of Educational Studies majoring in youth health education. Two of the participants had previously gained professional experience as health educators, one in schools for five years and the other in antenatal education for two years. Another participant had a concurrent relieving role as an antenatal educator. In addition, two participants indicated that they wished to undertake further studies in the area of health promotion. Other formal studies included one participant who held a Bachelor of Arts (Government Studies) and another who held a Graduate Diploma of Health Sciences (Behavioural Studies). It was interesting to note that participants had undertaken a range of non-award certificate courses including: RET (parent child and adolescent therapy), Nurse Practitioner Course (Family Planning Association), business studies, Emotional Kinesiology, First Aid, and Lifeline Counselling. In addition two participants had undertaken a Certificate in Massage, two child health nurses had undertaken a Lactation Consultant Course, two a Diabetes Education Certificate, and four participants held a Family Planning Certificate.
143
Short Courses and Professional Development In addition to award and non-award courses, participants indicated that they had participated in a wide range of other staff development programs and short courses with topics including: community nursing, primary health care, women’s health, bereavement/grief counselling (adult and children), critical stress de-briefing, HIV/AIDs pre- and post- test counselling, suicide prevention, cardiovascular drug administration, multicultural health, cross-cultural issues, families, audiometry, vision testing, leadership training, programming/self help, immunisation, administration of cytotoxic drugs, orthopaedic nursing, osteoporosis, manual handling, asthma education, incontinence, weight control facilitation, positive parenting, child abuse and neglect, hearing, school screening, an Aboriginal and Torres Strait Islander hearing program, quality management, alcohol and drugs, alcohol and drug counselling, behaviour management, and the teaching role of the nurse practitioner and of the nurse. Several participants also indicated that they had undertaken a range of TAFE short courses in computer applications including: an introduction to computers, Word, Mirage, Excel and word processing.
Further Study Participants were asked about their intentions for further study. Of the seventeen participants, twelve expressed an intention to pursue further studies related to their role as a community health nurse, four did not answer the question and one participant did not intend to undertake further study. Specific areas of interest were identified as: health promotion, primary health care, health promotion, community health, counselling, the ethics of resource allocation, drugs and alcohol, youth health, women’s health, adult education, “whatever it takes to maintain competency” and one participant who simply stated “who knows?” Participants were interested in studying at the non-award certificate, graduate diploma and master levels. Some informants indicated that they were interested in undertaking any course which would develop and up-grade their skills. Two participants suggested they would just like to finish their current programs of study. Three did not specify an area of study.
144
EXPERIENCE As a group the participants had gained substantial experience in a range of community health nursing areas (see Table 5). These included generalist community health nursing, school health nursing, child health nursing, drug and alcohol, diabetes education, occupational health nursing, flight nursing, remote area nursing and home visiting nursing. Their experience had been gained in three states of Australia, and included urban, rural, remote area and one nurse who had three years experience in a third world country. It should be noted that this community experience does not include any general nursing and midwifery experience participants may have gained.
145 Partic-
Generalist Community Health Nursing
School Health Nursing
Child and Family Nursing
Remote Area Nursing
Home Visiting Nursing
Other Community Nursing
Total Community Nursing Experience
1
7
-
-
-
-
-
7
2
3
-
-
-
2.5
-
5.5
3
5
-
-
-
-
-
5
4
5.5
-
-
-
9
1 (Occupational health)
15.5
5
-
-
15
4
-
-
19
6
4
2
-
-
-
-
6
7
-
-
-
-
-
6 (Specialist community)
6
8
10
5
-
-
-
2 (Policy)
17
9
6
-
-
6
-
1 (Staff Development)
13
10
-
-
6
2.5
-
2 (Policy)
10.5
11
-
12
-
-
-
-
12
12
-
-
8
-
2
-
10
13
1.5
12
-
-
1
-
14.5
14
12
-
-
3
-
-
12
15
4
-
1
-
-
-
5
16
-
-
14.5
-
-
-
14.5
17
-
-
9
3
-
1 (Flight RFDS)
12
ipant
Table 5: Experience of participants in community nursing (years)
Participation in Organisational, Policy, Professional and Community Groups As a group, participants were very involved in organisational, policy, professional and community groups. Organisational and policy committee work included committees aimed at: health promotion, pastoral care (school), quality improvement (community
146 health), a regional health service nursing advisory committee, and an alcohol and drug advisory committee. The participants were also engaged in a wide range of general community involvements which included: citizen advocacy, sporting clubs, informal playgroup (child health nurse), a women’s health service, a community house, PALS (Pregnancy After Loss Support), a self help health care organisation, a community service organisation, a Lioness Club, ASSETS (The Association of Services to Torture and Trauma Survivors), a local authority youth access council, a committee of management of a youth refuge, a network of youth workers, committee membership of a community action group, religious organisations, church youth leadership, committee membership of a local neighbourhood centre, hepatitis C support group network, diabetes support group, membership of a local area community development committee, a women’s service club, a domestic violence action group and committee membership of a large benevolent society providing services to women and children. There was also involvement in professional groups including: Community Nurses Special Interest Group, consultative committee for conditions of employment; a Paediatric and Child Health Nurses Association; a primary health care special interest group; the Australian Nursing Federation; the Royal College of Nursing, Australia; the Public Health Association; and membership of a state nursing registration organisational network/advisory panel.
CURRENT ROLES Community health services, in the three states from which participants were drawn, were organised under regional models at the time of this study. All participants indicated that they had current job descriptions, with two indicating that their descriptions were under review. One of these participants supplied the researcher with both the old description and the new one. Altogether, fifteen of the seventeen participants supplied the researcher with their current job descriptions, and several participants also provided additional document information such as regional aims and philosophies of community health nursing. In some instances, the job descriptions from nurses working in the same region were similar or very similar.
147 The current designations of all of the participants was “community health nurse”. It was interesting to note that some participants were working across traditional community health nursing specialty boundaries of generalist, child health and school health which have existed previously in Australia. For example one nurse discussed her role that involved her in combining a generalist role, a school health role and a child health role. However, where participants undertook these combinations of foci, they tended to be demarcated by working in different locations on different days of the week. This has been a trend in the delivery of community health nursing services in the states in which this study was conducted, in some cases, the result of deliberate agency policy. The range of specialty areas of current practice undertaken by participants included: youth health, community development, Aboriginal health, the aged, school health, diabetes education, hospital liaison, antenatal education, child health, and drugs and alcohol.
Communities Served Participants were asked in an open ended question to describe the demographic characteristics of the communities they currently served. Participants described the communities they served in terms of: the developmental stage of the client group, geographical area, socio-economic status and ethnicity (see Table 6). Examination of Table Six shows that the major groups focussed on by participants were children, women and young families, young people, Aborigines, migrants and the aged. Very few served adults in their middle years or men. Nine of the participants were members of the communities they served and seven were not. The other participant did not answer the question which asked for this information.
148 Participant
Developmental group
Defined by Geographical area
Socioeconomic group
Ethnic group
1
All people living in city of [urban region]
Yes
Mainly those disadvantaged
Not stated
2
General population - child, adult, family support, school health (once a week health screening); aged, disabled, young people
Yes
Not stated
Not stated
3
Predominantly clients over 65 year old age group - 20% over 60 years old
Yes
Not stated
95% English speaking background.
4
Polarised age groups - aged and young families
Not stated
Lower socio economic group
No particular background
5
Large youth focus
Yes Population approx 80100,000
Not stated
Multi cultural - NZ [New Zealand], Filipino, Indian
6
Aged - greater than 50% of clients; women, children in schools
Not stated
Not stated
Mostly Australians
7
Main target group IV [Intravenous] /narcotic drug users
Yes
Not stated
Not stated
8
65.6% over the age of 15 years
Not stated
Have no formal educational qualifications
48% population was born overseas; 33.5% speak language other than English; 2.8% Aboriginal and Torres Strait Islander
9
Diabetics, new mothers, primary school children
Not stated
Not stated
Aboriginal clients, diabetics of all ethnicity
10
Families with young children (0-5 years);
Not stated
Middle - lower socio economic groups - large number single parent families
English speaking
11
Adolescents, the parent care-givers [of school children]; teaching and school staff
Not stated
Not stated
Predominantly white, English speaking
12
Young families, children 0-5 years
Not stated
First home buyers, low to middle income earners with a small percentage of professional people
Mostly Australian, approx 20 families of Malays
13
12-18 year olds, teachers, mixed, parents
Not stated
Not stated
Mixed ethnicity
14
Families: Aboriginal mothers and children; caesarean new mothers and babies x 13 newborns per
Not stated
Not stated
New migrants /refugees - 4 families per month, mostly Burmese,
ethnic
149 month, other families-caesarean
Ethiopian, Bosnian
15
Children 0-5 yrs and parents
Not stated
Not stated
Not stated
16
Families of children up to 5 years
Yes
Not stated
Mostly Caucasian, 85% are from UK
17
Families with children 0-5 years
Not stated
Lower economic middle population
socio to class
Mixed population with ethnic and Aboriginal families (12-15 different ethnic groups)
Table 6: Description of the communities currently served by participants
Coworkers Nine of the participants worked in community health agencies with between two and six community health nurses. The other eight worked in agencies in which they were the sole community health nurse. Consequently, almost half did not have the support of another community health nurse in their agency. However, four participants pointed out that the region in which they work employed up to thirty five community health nurses and they had networks with these nurses. Seven participants indicated that they had no other health professional support in the agency in which they worked, including three who were sole practitioners. Two of these participants had support only from Aboriginal and Cambodian health workers. However, the role of the registered nurse in relation to health workers was to train and supervise these workers. The other ten participants indicated that there was a mix of other health professionals and workers working in their agencies or regions, including: medical practitioners, social workers, physiotherapists, speech therapists, clinical psychologists, occupational therapists, dietitians, podiatrists, and psychologists. In addition to these health professionals, there were Aboriginal health workers, ethnic health workers, women’s health workers, home help coordinators, a health aid worker, an allied health assistant, an alcohol and drug counsellor and administration staff identified.
SUMMARY OF THE CHAPTER This chapter presented a profile of the community health nurse participants in this study. The participants had diverse educational backgrounds and wide experience in a
150 full range of community health nursing practice areas. It was found that approaching community health nurses who were identified as ‘excellent’ was effective in identifying appropriate participants who could provide insight into the role of the community health nurse. Participants demonstrated insight and were articulate in describing their ideas and reflections about their role. As such they were an appropriate group to enable insights for the purposes for the purposes of this research. An understanding of their qualifications, experience and current work situations provides a contextual basis for analysis of their philosophical perspectives and descriptions of role.
151
CHAPTER FIVE Perspectives on Health and Community OVERVIEW Research Question One asked: what are the philosophical perspectives of community health nurses who practise in a range of community health settings? These perspectives were found to contribute powerfully to the process of practice. To understand the philosophical basis of the community health nursing role as perceived by practitioners, it was necessary to explore participants’ thoughts about the notions of ‘health’ and the ‘community’, as they are fundamental to the role of the community health nurse. Participants were asked to explain how they made personal sense of their practice and also if there were any ideas, theories or philosophies which assisted their thinking. Major philosophical themes which emerged from the data were noted. The ways participants understood the concepts of health, primary health care, community, holism and the family are explored.
HEALTH Participants were asked how they understood health, from their own perspective. The philosophical approach to understanding the notion of ‘health’ was remarkably consistent for all participants. Health was understood in terms of three major perspectives: an agreement with the WHO definition of health, with specific reference to both absence of disease together with wellness; a contextual understanding of health, and finally a functional definition. It was noted that these philosophical perspectives were also consistent with participants’ descriptions of their practice. Some participants identified the WHO definition of health as encompassing their views. Those who did not identify the WHO definition presented ideas which were consistent with this definition. They included a view that health was not just the
152 absence of disease, but wellness as a positive entity from a physical, psychological and social perspective: I subscribe to the World Health Organisation definition. [laughs] Rhonda 822-825 Well, you’d have to include the absence of illness. [A] positive attitude ... promotion of wellness rather than trying to heal illness. Yeah. I mean just ... I think positive feelings about health and fitness and wellness, and feeling good about life. Anna 469-477 I look at health very broadly. I suppose I look at it from a ... probably along a line ... and I look at the wellness and I look at the sickness ... and I look at what’s going on in between. And I try and focus more on the wellness. And promote with that, the lifestyle patterns. I just see it as a continuum really. Amy 861-867 In addition to understanding health in terms of wellness and not just illness, participants also described an understanding of health as situated within peoples’ environment. Thus, they saw health as socially contextual, and as such they thought that what constituted health could vary depending on the situation and the person: I think health is a way of life really. It’s not just about disease. It’s about your lifestyle, and the way your brain thinks, you know, your mental health ... and your physical health ... and the environment you live in. All of that makes a conglomeration of what health is about. Cheryl 328-332 The other component of participants’ definition of health was related to functionality. When asked to explain health in their own words rather than relying on formal definitions, participants added to notions that are present in the WHO definition by seeing health as enabling people to function, cope and achieve what they want to in life. This approach is consistent with the idea of health as a resource. It also provides a very practical basis for practice in community health nursing, and was reiterated in the aims participants described for their practice and descriptions of their practice activities:
153 I don’t have one [a definition of health]. I suppose it’s the combination of all those things that, you know, the other ... the WHO definition ... the “absence of illness ... mental” ... and the other one we use “the ability to cope with everything that life gives us”. So you are healthy if you can cope with the dayto-day acts of living with the stresses that life puts on you. Kate 435-441 I think ... for me, health means a family having the resources within themselves, or knowing where to find the information, to help them make informed decisions about health ... and that is, [by] health I mean from both the physical but also social [perspective] ... meaning adequate housing ... meaning adequate employment ... meaning discrimination, social justice issues, all those sort of things in that social context … the emotion[al] context in terms of coping with rearing children in the pressures of today’s society. Karen 247-255 Another example of a contextual understanding of health was demonstrated by Louise’s activities in a community development project which set up a community garden in a socially disadvantaged area. She saw health as socially contextual, identifying the benefits of community participation in the garden as relating to: the reduction of violence, facilitating participation and involvement, relieving boredom, improving communication skills, assisting community members in access to employment (as they could include work experience in their curriculum vitae), being environmentally friendly, improving nutrition, helping people in poverty feed themselves, increasing self esteem for illiterate immigrants who had skills in their countries of origin as rural farmers, and bringing the community together. The importance of having a clear understanding of the meaning of health was emphasised by Rhonda who noted the importance of practitioners reflecting about their notions of health. She suggested that in many situations, when the term health is being used, people are actually talking about illness and disease rather then health as a positive entity: ... we were asked that question “What is health, what are you talking about?” ... you know ... that question ... and the nurses ... the die-hard nurses got up and gave a medical model of health ... at that stage in [19]79-[19]83. And I
154 was sitting there thinking “yeah, well I know what health is”. “How do I put that into words”. And ... that was, you know, very, very interesting. “What is health?” “What are you talking about?” “You say that you’re talking about health ... are you talking about illness or are you actually talking about health?” Rhonda 1114-1123
HEALTHY COMMUNITIES It was also evident that participants understood health in relation to communities. The first way healthy communities were conceptualised was in relation to providing community members with appropriate public health facilities and structures: And I’ll use the original political case in point. It [primary health care] gives them an avenue or umbrella under which to stand, to say “I have a right to clean water, I have a right as a human being to live in clean surroundings and have a roof over my head and live properly”. Janet 877-889 A second characteristic was that healthy communities included a psycho-social element. Participants saw that in a healthy community there was respect, support and provision of services for community members at crucial or vulnerable stages of their lives. For example, participants expressed concern about teenagers, families with young children and those with chronic diseases: But back to the healthy communities. I think, [in] healthy communities, people have respect for each other ... the teenagers have something to do. And it’s funny that I should say that ... I would think of an indication of the health of our teenagers community is the graffiti difference. Now you know I have nothing to base that on, but I thought [that] if kids were happy ... and happy often equates to healthy, literally ... then there wouldn’t be a need for that. And maybe, we could measure teenage health by graffiti. [Laugh] Kate 549558 Well, a community that’s supportive of one another ... that provides things for the youth ... as a supporting sort of system for mothers with new babies. Cheryl 341-343
155 A final element of healthy communities related to an ability to work together to address issues and problems: I suppose, a healthy community is where there’s people there that are trying to do something to help. They’re looking after themselves. And are looking after each other as well. I see a healthy community as being an active community. That if they see that there’s a problem, that they don’t have [for] example footpaths ... that they use their initiative and they work together to get a footpath. So I see a healthy community ... not only as being physically fit, but one that works together ... one that they don’t just all look after themselves ... that one looks after their neighbour as well. Lyn 1264-1283
PRIMARY HEALTH CARE The notions of ‘health’ and ‘primary health care’ were closely linked in the data. Primary health care had been adopted as policy in several of the regions in which participants had worked. For example, Queensland Health (1994) the state health department of Queensland have adopted an extensive Primary Health Care Policy as the basis for its community health services. The concept of primary health care was also included in the mission statement of the nursing service of another region from which participants were drawn and mentioned in several job descriptions: Community nurses in the [region] aim to promote community wellness through health services which involve the active participation of the community and utilises the principles of primary health care. Regional mission statement 2831 Participates in development of policies, procedures, standards of model care plans relating to nursing practice and primary health care.
Louise, job
description 54-55 Most participants, however, did not discuss the notion of primary health care itself at great length. Despite this, all participants’ descriptions of practice were highly consistent with the notions of primary health care. However, the idea of primary health care appeared to present difficulties to participants at times because of the
156 breadth of its scope and the difficulty in clearly defining it. Sharon noted that the concept was used differently by different people: The real barrier I find is the concept of primary health care.. Everyone has their own concept ... [about] what primary health care is and how it is utilised. And how it should be bought into a person’s life ... or a community’s situation. Sharon 249-253 Of participants who did discuss primary health care, some identified it as central to their practice. Those who mentioned primary health care were asked to clarify what they meant by it. The most prevalent way of understanding primary health care was in terms of prevention and participation, with several participants seeing primary health care in terms of a social perspective, equity and empowerment: [Primary health care is] preventative medicine ... prevention ... through education, giving people information, letting people make their own choices, but making it available to them at a level that’s OK with them. Marie 52-61 ... its [primary health care] social equality at its basic sense. Everyone’s got a right to be healthy. All the essential [things] ... air, water, food, a roof over your head, if you have had an accident you are entitled to learn how to live properly to the best of your ability ... you are entitled to know as a 13 year old how not to get pregnant, those sorts of things. Janet 908-926 What was very evident in the data was that participants demonstrated a commitment to a primary health care approach: And I see ourselves as primary health care people, which is what we are. Marie 27-48 Participants’ descriptions of practice were very consistent with the basic tenets of primary health care including accessibility, affordability, appropriateness, and acceptability of services provided. They also demonstrated an awareness that primary health care was a philosophy and strategy, and consequently related not only to community practice, but to the whole health sector. Several participants identified a
157 need for better understanding of the concept by the hospital sector and a need for better links with all sectors of the health system: But I think we have to work at the hospitals understanding their role as primary health care workers as well.
Using the principles of self-
determination, self-care, and not just giving someone a Band-Aid to stick on their finger, but what does that really mean ... and some decision-making. It [primary health care] is a perspective. It’s a philosophy and its a way of thinking. But it can be equally so in a hospital as it can in a community. It isn’t only something that only happens in a community. Whereas that is what the belief [that] is held. Karen 974-979; 983-986
HOLISM AND FAMILIES One of the basic philosophies which emerged from the data was an emphasis by participants on the contextual nature of health for their clients. Participants demonstrated an understanding that environmental factors such as social, political, physical and emotional factors are important in addressing their clients’ needs. The emphasis on the impact of the wider environmental and social context was a very strong theme in the data: I think in this particular nursing role they’re all interconnected ... yeah. I think ... I don’t think this service could survive if we were just purely a drug and alcohol service or just purely a methadone service ... or if we just had a client come in and [we] counselled them “Don’t use drugs, or if you do, use them safely, goodbye”. If they’ve got other issues they want to discuss ... that may not be related to drug and alcohol or ... then I think that it is our [brief] ... we have to basically look at these other issues as well. And as nurses it’s ... I think you do have to know a little bit about Social Security and the courts and family services and know all sorts of satellite information as well, yeah. Emily 414-425 But you then ... through that individual assessment also see the ‘whole’ for them in the environment ... in the community. Carol 186-188
158 They saw this approach as integral to community health nursing practice and described it as holism. In some instances they suggested that although there is an aim to provide holistic care in a hospital, this is difficult given the nature of an institutional setting: That you saw them on their own grounds. That they were in their home. And that, I think you needed to consider them more ... their feelings, and that there wasn’t this ... I always had a problem when I was working in hospitals, how you had this routine and you must make the beds by nine. And I really felt that we didn’t always consider the whole person, and that we were very structured and we just told them that you had to get out of bed now, because it was time to make the beds. And I always had a problem with that. I always thought we should be looking more at the person. And taking their feelings more into consideration. I always thought that even though we tried to [give holistic care], it was something that we didn’t do very well. And so I saw this as another opportunity where you could work well with them, and we could assist them and be on their own grounds. Lyn 80-93 This approach took in the environmental context of clients, and included, in particular the family. One of the major issues they identified when talking about their clients’ context was the importance of the family to health. This was of note because the organisation of participants’ case loads are on an individual basis. Case notes and records are not to be kept for families. In spite of this, it was evident that although participants at times saw only individuals, they tended to think and talk in terms of the social context of their clients, particularly the family. In many instances they would refer to their clients as ‘the family’ rather than an individual. Thus there was an awareness of the powerful significance of the family in contributing to the health of its members: They’re [the family] part of a person’s life. You can’t separate a child out of a family. Just like you can’t separate a family out of a community. Kate 80-83
159
COMMUNITY One of the first major themes derived from the data was the importance participants themselves attached to the community context in relation to the health and illness of the individuals and families they served. In so doing they demonstrated a socially contextual understanding of health that was consistent with the World Health Organization definition (1947). Half of the participants indicated in their questionnaires that they considered themselves a member of the community in which they worked: Well I’m a coastal person, so I’m working on the coast. So I mean I know of the people that come there ... that went to school with my kids..[laughs] ... I’ve lived in one place for 34 years. Marie 194-200 The other participants worked with a community of which they did not consider themselves to be a member. These communities tended to be disadvantaged communities, and participants recognised that their perspectives could well be different from those of their clients, due to socio-cultural differences.
Conceptualising the Community There appeared to be two levels at which participants conceptualised the notion of the community. The first level of understanding was at an abstract global level and the second level was at an operational, pragmatic or practical level. At an abstract level, participants described the community in terms that were consistent with definitions found in the literature. Most participants’ described the community globally using definitions characterised by a systems approach. Typically they described parts of the community all linking together to form wholes, which then link together to form increasingly larger entities: The community is a totally ... how can I say it ... it’s alive ... it’s a whole ‘being’ within itself. And there are smaller ‘beings’ within it. Say like the human body. And then there are smaller parts ... I will say concentric spheres. Round. [Indicates a ball shape with her hands.] ... You know like those little
160 dolls, that one fits one inside the other. So it would make it a whole world eventually. Janet 579-611 Well ‘the community’ is everyone, everyone in the [regional area], everyone in Australia and everyone in the world. Emily 658-662 In contrast, the simplest global approach to thinking about the community was as a place or ‘out there’, usually roughly translated as in peoples’ homes and/or anywhere that is not in an institutional setting. This thinking is consistent with the way that any nursing occurring outside hospital walls is sometimes referred to as ‘community nursing’: And I think just the initial concept of wondering what happens to people in the community once they leave the hospital situation got me to think more about the community ... what happens in the community. So I was interested to see what happens out there. Sharon 25-29
Operationalising the Community An aim of the research was to examine how participants understood the community in relation to their own everyday practice. Did these global approaches to understanding the community provide adequate guidance to nurses interacting with the community while carrying out their role in actual practice? The data revealed a multi-faceted view of the community. Participants altered their conceptualisation of the community according to the characteristics of the particular community they were working with. Conceptualisations were chosen according to their utility and participants moved between them fluidly. It was also found that before they could engage and interact with the community, participants first had the task of identifying the dimensions of that particular community and operationalising their understanding in concrete terms. Participants recognised the variation in how the community is understood by different community health nurses. The variation in how the community is understood by community health nurses was noted by one nurse: Well they have a community, and it really depends how that community is defined. Rhonda 255-260
161 Geographical Boundaries Firstly, participants took the most obvious approach and related the community to geographical boundaries. Participants thought of their communities in terms of people within a particular area, region, town or city. These were usually self defined areas such as a small town, Aboriginal community, an urban suburb or an artificially defined organisational health region: Well my intake area is my community. Yeah. And the people in it ... there’s other people in it ... the other professionals, the other resources, just the whole area ... I just consider it to be mine. [laughs] Marie 184-190 ... we do have a geographically defined area ... which I will operate in ... because that’s beyond my control ... that’s defined by the health service. Yeah. So the birth notes will only come for a certain area. Karen 680-687 Participants recognised the need for geographical boundaries. However, particularly in urban areas, they saw difficulties in defining the community in simple geographical terms. Often the boundaries were seen as artificial and not relating to what happened in practice: I do have families that will move ... will come and see me ... because, either [they] shop in the area ... the grand-parents are in the area ... they come to the GP [general medical practitioner]
in the area, or they’ve lived there
previously, or whatever. It’s interesting [that] people travel a distance to seek out a service. ... it can be broader than that geographical location, certainly and I can’t confine it to that. Karen 690-700 And that’s the way it is. I mean crossing boundaries ... I mean sometimes the boundaries are one way and they might live right over the road, from somewhere else. I mean it’s not a practicability. But it’s the way it’s broken up. Marie 324-330 Furthermore, they often saw this approach conflicting with their more global ‘systems’ approach to understanding the interconnectedness of communities:
162 And I suppose now that we have become a health region ... where before I would have looked at a community as a much broader thing ... because, as community nurses we covered the metropolitan area ...now we are broken down into a very small area. And I’ve really tried hard, against my better judgement I think, to bring my thinking back to this small area. Because ... Yeah, it has to be. It has to be. Because our practices are so different from area to area. Our budgeting is so definite. That I just have to bring my focus back to this small area. It would be nice to think, act globally. Kate 488-501 From an organisational point of view, I can accept that [geographical boundaries] as appropriate. Because I can see that I am working for an organisation that has to have some sort of structure, and to run the organisation its easier to say “well this community health centre looks after this area”. Or it is within this area, therefore “you nurses look after this community”.
I can see that structurally.
I don’t perhaps see it
philosophically, because primary health care should be bigger than that, it should be [the] whole community. Janet 549-571 Thus, although there are limitations, geography was an important defining characteristic of the community for participants. However one could envisage that with the advent of modern technology and travel, the importance of geography as a defining characteristic could become less important in the future. The Community as a Target Group or Population A second approach used by participants to operationalise their ‘communities’ was a population approach. Participants discussed their communities in terms of demographic details, target groups and general health issues, identifying ‘at risk’ target groups and their related health issues: ... you could say that I see the community in terms of target groups. Gwen 482 I think it hinders a little bit, because I find that in the area that I work in, its a very much an elderly population. The demographics prove that there are a lot of younger people there as well.
But I’m more often seeing the older
163 population. And I think to me I see that the issues there are social isolation, information on medication, information on safety in the home, things like that ... they’re the problems. Sharon 453-460 This thinking is consistent with an epidemiological paradigm, and was found recurringly in participants’ assessments of the communities they worked with. The Community as a Resource A third way participants operationalised the concept of community in their practice was to see the community functionally, with the purpose of serving its people and as a source of resources for their clients. They described the importance of the community in providing public health amenities, social networks and resources to enable individuals and families to live their daily lives and cope with health problems, issues and behaviours. This approach is consistent with primary health care (World Health Organization and United Nations Children's Fund, 1978) which identifies accessibility as an important tenet, and the World Health Organization definition of health (1947) and the Ottawa Charter for Health promotion (World Health Organization et al., 1986) which both describe health as socially contextual and as a positive entity and not just an absence of disease: ... [so that clients] know where the school is, and who’s a good woman GP ... And then you either see there’s the local school. And they have got to get [their children] into that and they’ve got to find what else can be supportive for them here. We have a community house with lots of services provided. So that’s another way of doing it. So there’s ways of being ... providing a better service to that person which has incorporated all the other agencies that I would deal with at various times ... incorporate all of those and we take the best they have to offer ... and then that’s our community response. And they may need clothes, they may need cheap food, they may need financial counselling and I can put them in touch with all of those things that can be helpful. Louise 340-361 It was evident that participants saw community resources from the perspective of their clients. For example, if their major practice focus was with families with young
164 children, they looked for resources these groups would need to access in the community: So the community for a client of mine includes their day care, includes, enrolling children at school, it includes the problems associated with all the... you know, the shopping centre and where you buy formulas cheaper or who’s got nappysan on special this week. It’s all little things that make being part of the community ... Kate 90-96 ... yeah ... just a human connection. So that would be with the individual. And then if you put another circle around it ... and its a family now. The same inter-connectedness but a little outside ... you still deal with the individual ... you are connected to the family through the individual... and then ... whatever, that family and that individual need in the wider context of their circle ... go one more to the community as in ... even you could say their suburb. So then there may be something that may be required for their care in their suburb. Janet 326-342
The Community as a Network A fourth major conceptual theme in participants’ descriptions was the community as a network. All participants discussed networking as a part of their role. They saw the importance of becoming part of that network in order to understand community issues and having knowledge about the resources they could access in relation to client needs: I think the community part of the title comes because you’re working within [it] ... you’re not just sitting in a centre, you’re actually going into their homes. You’re invited to the various groups that are around, like the high school, to talk to [students] ... or the local kindy or the local sort of nursing mothers groups and things like that. So you’re part of the community. You’ve networked in around amongst there. ... you’re expected to go out in it. Cheryl 364-386 But I found that it was necessary to take things slowly ... maybe that’s a bad word. ... take things as they came. But also, I had to initiate contact with
165 people ... let people know [that] I was there. And someone had made the comment that when you start in community, one shouldn’t rush into doing programmes. And I can understand that now, because... I think that you do need that time to ... make a network ... get your network going. Carol 151-158 In some instances networking was an attempt to create links in a disconnected community. Gwen discussed her practice that spanned schools, child health and diabetes education within her organisationally designated geographical boundaries that covered three disconnected urban suburbs: It’s not quite as easy. I do believe they can encompass ... it’s just up to me to try and do a bit more networking. ... So it’s a little bit fragmented. ... And I’m just trying to sort something out ... all together ... merge it all together. Gwen 494-523 The conception of the community as a network or web is very functional. A network is dynamic and shapeless, with key people changing and groups forming and reshaping at particular times to serve particular purposes. However, if the community is dynamic rather than constituting a fixed entity, there are implications for community development approaches. Identifying who represents the community may become difficult.
The Community as a Unit of Care It had been expected that these experienced community health nurses would have a view of the community consistent with theory outlined in the community health nursing literature, seeing the community as a ‘client’ or as a ‘unit of care’. Transcriptions were examined for instances of where the community was described in terms of being an entity such as “the community thought ...” or “the community wanted ...”. Examples identified included reference to: the “community in general”, a school community, a remote Aboriginal community, a rural town, an urban local council authority, and two urban communities where participants were involved in community development activities with community action groups. However, it was found that viewing the community as an entity was by no means universal in the data. There were many instances where participants did not describe their communities in
166 terms of being an entity. Instances where the community was viewed as an entity were compared with situations where they were not. In practice, it emerged that if a nurse was to interact with a grouping as a community entity it required certain features. All communities discussed as an entity had many interconnections. People knew each other and there was enough contact between community members to share a local knowledge about community happenings and sometimes form collective opinions. In these communities people were usually identifiable as either formal leaders (such as a school principal, a tribal elder or committee chair) or informal leaders (such as a prominent member of a group). It was also evident that not all members of a community had similar views or experiences. Consequently, although there was a connecting interest of some kind, having similar views was not a defining characteristic. For instance, within a school community, there were descriptions of the different interests and views of parents, students, teaching and ancillary staff. The identified communities were also usually broadly based and functioned more widely than, for instance, a single issue group. Any grouping referred to as “the community” appeared to have sufficient representation from various sectors of the specific community to enable the inference that the whole community was represented, although in many instances, representatives were community leaders of some kind. Thus participants differentiated between vocal community groups and the ‘whole’ community. However, the important characteristics that transformed a grouping into a community entity was that people shared local knowledge, familiarity and connectedness; often, but not always, together with some form of organisation. These entities were named connected communities. It was noted that in all instances identified, descriptions of connected communities had all of the general characteristics described above: geography, resources (or lack of them), networks and target groups with identified issues. An example of a connected community was a nurse describing her experience with a remote Aboriginal community: ... so what I’ve decided to do is to see what the community wanted. And of course, the community in those days were not used to [deciding] ... and that was the biggest thing I found frustrating ... because I wasn’t aware ... that after living on stations for so long being, and being told what to do, that they
167 would not have the insight, they would not be able to problem solve or decide what they wanted as a community. Because they didn’t get any power [on the stations]. And they’d never done it before. And everything had been imposed externally. Gwen 226-235 While nurses working in urban areas tended not to describe their communities in terms of being a connected community, there were instances where this did occur. Louise describes the beginning of her four year involvement with a community action group that resulted in implementing a community garden: Louise: And then at that time a [suburb] Development Group was formed because of the violence in the area, initiated by the community ... a very angry community. Researcher:
Who
was
in
that
initial
group?
Louise: Me, the Community Health, the [local multi purpose children’s] Centre, the police, and residents ... a lot of very angry residents. Louise 464471 With evidence of connected community characteristics, some sub-groups of wider communities were seen as communities within communities. This was demonstrated by school nurses who viewed their schools as sub-communities within the broader community. Lyn provided a further example with her ongoing involvement with an active senior citizen’s group in a rural town: I just see the community as having many different groups. And like this whole area, [for] example, you know, well the [rural town area] ... that was a community. But there were many groups within the community ... like the Senior Citizens I saw them ... well they were a group within the broader community, but they were a community themselves. They all had similar things in common. Lyn 1211-1218 The importance of community shared knowledge and connectedness to the everyday practice of community health nurses was strengthened by examination of communities that were not connected. Most were urban communities. This is of importance when it is considered that most of the Australian population live and work in urban settings,
168 and that this is were many community health nurses work. Where nurses could not describe the whole community as a connected entity, they used notions of geography, networking, resources and target groups. The most usual description was as a place, for example “in the community ...”. Gwen compared her experience in a rural setting with practice in an urban setting. When she could not define her urban community as an connected entity, she used the notions of geography, resources, and target groups to describe her community: It’s different in the metropolitan area because in the country it’s very easy if you divide ... if you decide you are a community nurse ... and you have geographical boundaries. ... I guess [in this urban area] you could say that I see the community in terms of target groups ... it would probably be easier because my geographical boundaries are rather haphazardly organised. And I guess I see the community as being a group of people who are living and working in an area, who buy and [and are] working in the same area. And I’m trying to offer them a service if they choose to take it on board ... to help them towards continual wellness. I guess that’s how you would describe it. Gwen 479-489 It was also noted that, while participants identified many potential communities, not all of these were necessarily described as entities where they lacked the characteristics of a connected community: ... and I mean within that community there are sub-groups in that community. You’ve got an ethnic population.
You’ve got an Aboriginal population.
You’ve got unemployed. You know, I mean, it’s quite complex really. Karen 704-707 An inability to identify a connected community, particularly in urban settings, required of the nurse a practical alternative focus of interaction. It was found that participants dealt with the difficulty of not being able to designate the whole community as a connected community, by identifying the next largest connected groupings as their focus of interaction, usually organisations, groups and families. Amy illustrated this when she compared her experience in a remote Aboriginal community with her practice with Aboriginal people in an urban setting:
169 It’s so much easier actually in a [remote Aboriginal] community to do that. ... Yeah ... because you’ve got ... it’s so clear ... the area is defined. The people are defined. You know who the linking people are, and the elders and ... you know, the important people, so it’s all very clear. ... Yes, whereas here [in an urban setting] ... you’ve got so many community ... linkings. I really, as I said haven’t got the whole picture as yet in this area. Amy 708-722 Amy pointed out that even the Aboriginal health workers she worked with in the urban setting had limited linkages. As a consequence of being unable to identify connections and links among the Aboriginal people she worked with, she operated at a different level: I mean I’m only seeing what’s going on really on a family basis. Amy 764-766 As a consequence, all participants in this research had some involvement with groups in the community. Groups identified included special interest groups, age developmental groups, demographic groups, organisational groups and educational groups. These groups were usually seen as operating within the community, rather than being a community themselves. There were also many instances of the participants interacting with groups who came together only for a short time and for specific purposes, such as in health education programs. Participants recognised that groups in the community may not necessarily reflect the whole community, may not necessarily interconnect within the group or with other community groups and that many groupings within the community may be short-lived.
SUMMARY OF THE CHAPTER This chapter has outlined findings in relation to Research Question One. A description of participants’ perspective of health, primary health care, holism and the community have been presented. This material was found to provide a philosophical basis for practice in community health nursing. Descriptions of practice presented below were consistently congruent with the philosophical themes identified in this chapter. These philosophical perspectives also provide a coherent underpinning for the descriptions of role presented in Chapters Six, Seven, Eight and Nine.
170
CHAPTER SIX Context and Dialectics in the Community Health Nursing Role OVERVIEW Research Question Two asked how practising community health nurses perceived and interpreted their roles as community health nurses. As the aim was to provide explanation of the community health nursing role, the data were explored to identify and uncover the meanings in participants’ views of the community health nursing role. Themes emerged from the data that provided a context for the community health nursing role and were important to an understanding of the role. The context in which community health nursing practice occurs was found to have a profound impact on practice. In addition, four dialectical themes related to practice were identified in the data including: the health-focus/disease-focus dialectic; the prevention/treatment dialectic; the control/responsibility dialectic and the dialectically connected/disconnected nature of the nurse-client relationship. These dialectical themes together with those relating to the context of practice are presented in this chapter. They provide a basis for understanding the community health nursing role and contribute to providing the explanation of the community health role presented in Chapters Seven, Eight and Nine.
THE CONTEXT OF ROLE A context relates to the setting or environment. The Macquarie Dictionary (Bernard, 1989) defines context as “the circumstances or facts that surround a particular situation, event”. One early impression left by interacting with participants and textual data was the importance of context to how these nurses understood and enacted their role. This importance was confirmed repeatedly in the data. Community health nurses are ‘out there’ in the ‘cut and thrust’ of peoples’ everyday
171 lives: a world where health is only one of many issues with which people are required to deal. An important theme that presented strongly in the data was the extent to which participants were confronted by ‘reality’ in their everyday practice. They were confronted not only by the ‘reality’ of their clients’ situations, but also by a new set of parameters operating in their own practice. This is the is the “real world [of] ... messy, indeterminate, problematic situations” described by Schön (1992, p. 3). Participants used words such as “real”, “really” and “actually” to describe the situations they encountered. There is a control over nursing work in the constructed reality of a hospital environment that is missing in a community setting. Schön (1992, p. 54) suggests that in the typology of practice, there is the hard high ground of research-based theory and technique, while in the swampy lowlands of real-life practice, problems are messy, confusing and incapable of technical solution. Furthermore, he argued that in the swampy lowlands lie the problems of greatest human concern. The real world contains situations of uncertainty, complexity and uniqueness. For these nurses interacting in the contextual reality of the community and peoples’ homes, there is a need to deal with the palpable reality and explicit views of their clients, the intractability of some health problems, and the sometimes overwhelming nature of social context, all of which are encountered without the protective structures and routines of an institutional organisation. A theme that recurred in the data was that participants’ practice was on their clients’ ‘turf’. They highlighted the subtle but profound difference they found in their community encounters by comparing their practice with previous practice in an institutional setting, that they saw as “our turf”. Participants felt that in a hospital setting, clients were in the nurses’ domain, and their illnesses made them dependent and compliant. By comparison, in a community setting, clients have greater control and choices, including not accessing the service. Clients were in control because it was their ‘turf’, and the nurse is ‘out of control’. Participants saw that the ‘rules’ had changed when they moved from a hospital environment to the community: ...[its] in their context, not mine. Because if you have got a patient in the hospital, in that acute setting, they’re in your territory, if you’re the nurse. This is your ‘playground’, in inverted commas. Therefore they have to play by your rules, if you understand what I mean. So, if you’re in the client’s home,
172 that’s their back yard. So its their rules that you have to play by. Janet 376390 Oh [it is] very different [from the hospital]. Because we haven’t got a captive audience. Marie 601-602 I sort of saw that people were different in their home ... [than] when I had done my general training [in a hospital]. There was a different approach. And people acted differently. Lyn 69-72 At a macro level, participants recognised the magnitude and complexity of the social environment in which they were working. They viewed their practice as encompassed by the whole community, constituting only one small part of a larger fabric of the social, cultural, environmental, political and economic factors. Janet described the difference between her perspective and that of her colleagues in an institutional setting: A very prime example was when I was down South. We had a couple of newborns, young girl babies of Turkish origin who turned up at A & E [Accident and Emergency] with a rip roaring infection from the circumcision. And I watched the staff’s horror. And I thought ... well [sighs] ... you know ... lets go back to the culture and the women’s issues and lets go back to the ... you know ... yeah where it starts. ... its too late now ... its no use ranting and raving. Its done. And now you have got to look after the baby. ... [practice in the community setting] just made it so obvious to me that this [the hospital] was Band Aids. That this wasn’t where it was at. This wasn’t the cure. Everyone was saying “this is the cure”, but it wasn’t, it was the big Band Aid they were putting on. The cure went way before they hit the hospital. ... from my perception ... I should say that. Janet 206-232 Participants also recognised the enormity of the problems faced by people in their everyday lives. These nurses were very aware of how difficult it was for clients to achieve changes in health behaviour within the context of the social fabric of their lives. In the context of the ‘reality’ in which they worked, they encountered clients and communities who had great difficulty in addressing the daily issues that they
173 faced. Consequently they understood their clients’ health issues, problems or needs as socially contextual and complex. Examples include Anna’s description of the needs of school children and Karen’s practice with parents and young children: ... these young people recognise that whatever’s going on in their lives out there [is an issue] ... then they have five or six weeks school holidays, and they have no relief [from it] in terms of coming to school. ... I mean for the majority of kids, school is fine ... but for some kids, coming to school is the only stable thing in their lives ... in these days of [a] high ratio of blended families and this breakdown of the family unit and adults predominantly getting on with their lives, irrespective of what happens to the students ... what happens to the kids. Anna 174-187 Amazing. And the expectations of parents ... nurturing, and children, and rearing children, where society is saying “this is happening because it’s your fault”, because this didn’t ... you know “you didn’t parent properly”, “your child is doing this, this and the other” ... and also I think parenting where ... there’s not the support systems of twenty and thirty years ago. And [parents are] still being expected to provide all that. Karen 259-265 These findings are consistent with Cowley (1991) who found in her research of health visitors, that nurses incorporated an awareness of the highly complex context of social and environmental factors into their practice. The issues encountered in nurses’ practice were very personally confronting, and lead to a concrete realisation that health issues were often a very low priority for the clients and communities in which they worked. There was a recognition that there are many aspects of the community and their clients’ lives that the community health nurse cannot change. In addition, at times, participants had to confront the reality of seemingly unsolvable problems and make sense of them. Participants found that they were personally challenged to re-examine their own ideas, aims and viewpoints. While they may go out into the community with many ideas, plans and skills, the actuality of what is confronted in many instances challenged the nurse to change their strategies or the nature of the way in which they engage with clients, families and
174 communities. There was a need to develop a new set of knowledge and skills, acquired as a result of being emersed in the contextual ‘reality’ of the community: ... because sometimes the hair stands on end, and you think “Now where do I stand in terms of my ‘hat’ as a health educator and a health promotions person here, when this is happening?” And as long as it’s not going to be a risk to the child, I might leave that for the moment, and focus on “how are you feeling today?” “What’s happening for you?” “Can you tell me a bit about that?” And still tucking away the need at some stage, to bring that other issue up [another time]. Karen 436-444 Because I was really keen on trying to ... that was something that I always was keen on doing ... was trying to promote ... trying to do some prevention ... to tell people that “if you’d only, if you just did this then this wouldn’t happen”. And ... I mean there was a very important role to play, but it was a difficult group that you were working with.
They weren’t very receptive.
... I was by myself. And of course I was very young too. So I was quite immature in some aspects. But ... no, it changed me. I looked at things a bit differently after that. Lyn 129-135; 414-416 Another contextual theme was the constant change these nurses were experiencing. Although it is recognised that change is one of the constants in modern society, the amount of change with which participants were required to deal was great. Changes occurred at a socio-political, social, organisational and a personal level. Participants saw that there would be ongoing social change and political uncertainty. Participants were required to deal with constant structural change including: changes in nursing practice, the organisations they worked for, regional boundaries, organisational practices, funding arrangements, the knowledge base required for practice and in their career structures. There were also changes in facilities and in the ability to access to other health professionals, other staff in their organisations and their own designated roles and titles. Ongoing organisational change including changes to health regions, lines of authority and reporting, and relationships with regional hospitals have been a particular feature of the community health structures for all three states from which participants were drawn (Prenesti and Tattam, 1994). An example is the impact of the
175 changes in the nursing career structure and regionalisation in Queensland (Litwin, 1992). In most cases there has been an ongoing series of organisational changes. For example, in 1991, Queensland had a major reorganisation of the state’s public health services (Cooper, 1994, p. 4). With a change in state government in 1996, there has since been another major reorganisation of health regions and boundaries. For some participants the notion of change was structured into their job descriptions. In one health region accessed, a key responsibility in all job descriptions was that the nurse “Participates in review of practice, identifying and supporting the need for change” (Amy, job description 24-25). In most instances participants saw that there was a need for change in their practice to keep pace with social and community changes and that their roles demanded them to be involved in change. There were many examples where participants were actively engaged in change and took on the role of change-agent, particularly in relation to client needs. Examples include Joy and Louise who were involved in large scale community development activities, and Kate and Helen who were involved in committee work designed to develop community resources for client groups. Participants were also involved in changing work practices in the organisations within which they worked. For the most part, participants saw change as positive and themselves as flexible in the face of change: Well the thing is since I’ve been in the role, it has changed quite considerably. And I’ve always taken on change. Marie 524-525 However, while participants were flexible in relation to their clients’ needs, and essentially accepted change as inevitable and at times necessary, they were negative about continuing organisational change. The main reason for this attitude was that it took their energy away from focussing on their practice and the needs of their clients: ... It’s just all government and politics. And, I mean, I don’t mind riding with the changes. But with actually getting the focus on what the public need out there, that’s still, you know, keeps getting put on the back burner.
...
So again ... it’s [the changes] focused very much on the management and who you relate to, and where you get your stores from and administrative type things ... your documentation and your bookwork and your, you know, the legal things ... which are all good things. But not quite ... I just think that the
176 actual ... customer, patient, client ... care ... the public seem to be just forgotten about. Amy 21-32; 36-43
Role Ambiguity Another contextual issue confronted by a nurse fulfilling the community health nurse role is that it is inherently ambiguous. The inherent ambiguity in the community health nursing role was confirmed in many aspects of the data and noted by some participants. When pressed to explain how they understood their role, many participants gave broad, non-specific answers, or alternatively limited answers: But sometimes there are people when you knock on doors and [talk to people] who have never seen you before. And they say “what exactly is a community nurse?” And then I’ve always got to say “we are involved in health education, health promotion” ... you know “[we are involved in] giving you information so you can make choices about your health care”. Louise 680-686 However, participants in this study demonstrated thoughtful reflectiveness about what they did as community health nurses and appeared to be confident in their own understanding of their role. The ambiguity within the role was illustrated in: how participants learned the role, the scope of practice of the role, the difficulty in differentiating the role from that of other allied and health practitioners, and in explaining their role to others. Firstly, the ambiguous nature of the role was illustrated by the reflections of participants on how they lacked understanding when they started in a community health nursing role. They saw that the community health nursing role was very different to their previous nursing roles and in many instances suggested that they had not understood what they were ‘there for’: Initially I had absolutely no idea. No ... my ... I mean yes, you go through and you’re given information about it, I have no idea ... At the time ... it’s twelve years since I came into community health ... at that time you were given an extensive orientation which, sort of when you look at what’s available now, helped a lot. What I realised fairly quickly in the piece, [was] that coming from a hospital setting, I knew quite a lot about sick kids, but I didn’t know
177 anything about well kids. So it was a whole big learning curve for me to work with people who were to all intents and purposes well, but needed information about health. Anna 40-53 In some instances, the lack of understanding of the community health nursing role was related to participants’ lack of preparation for practice in the various settings in which community health nurses work. An explanation for this lack of preparedness may be that it is an indication of the importance of experience in helping to shape skills and ideas about the community health nursing role. Experience was considered an important factor in assisting the nurse to understand and learn the role. ‘Reality’ was an important teacher and participants indicated a need for experience in order to confront and deal with the ‘reality’ of the community context and to develop their understanding. Some participants who had worked as remote area nurses suggested that nothing could have prepared them for their introduction to their new role: I think there’s a limited viewpoint of community [by] hospital based [people] ... unless you’ve worked out in the community, or you’ve had some education that’s helped you to experience work in a community, even though a hospital is part of a community, I think there is a limited vision of it. Karen 759-763 And we went from [regional centre] to [remote area Aboriginal community], which was 118°, with the radiator boiling. And standing on the side of the road for about, oh, gosh, two hours while that cooled down. And after [that] we went to [the remote area Aboriginal community]. And you know it was just like going into this different world altogether. ... I had really no idea. Amy 213-221 Secondly, ambiguity was related to the broad scope of practice. The participants’ primary experience prior to working in community health had been with an illness focus in institutional settings. On the basis of their previous experience as general nurses, participants were skilled in work that was primarily related to illness. Care of the sick and a focus on those with illnesses was known, and had provided a clear focus for previous practice. In contrast, the holistic, health, wellness and prevention approaches taken by participants within a community context gave rise to a very broad role which lacked the specificity of their previous roles. Taking a health perspective,
178 particularly when the perspective of health is based on a broad socially contextual definition of health, created a broad and diffuse role. The clear guidelines, boundaries and routines were gone, with outcomes more difficult to measure: So if I can stretch my role within those limitations a little further, then I will ... or expand it rather than stretch it. So if that means ... I’m really whatever the community needs me to be. So I’m a health educator. If the tennis ladies want me to talk about ... you know, sun, skin care in the sun or something then I’ll do that. If a school wants me to talk about sex ed[ucation] or ... I’m trying to think of examples that I’ve done and so .... a day care ... the parents were worried about HIV and syringes. So I went and spoke to them about that. And you know ... the shop keeper’s worried about their daughter who is teething. Or I’m really able to do things on the spot and deal with problems as they arise. Plus do long term planning of things. But really whatever I’m needed to do. Other than to deal with acute illness of course. Kate 106-121 ... but when you are in the working area [community health] longer ... the biomedical model is still very important of course ... but it is [only] a part of the bigger picture. That bigger picture that a community health nurse is on about. Sharon 849-853 Thirdly, the difficulty in differentiating the community health nursing role from that of other allied and health professionals working in the community created further ambiguity. A health perspective not only broadens the role but it creates the difficulty of blurred professional boundaries, because other health professionals also work with a health perspective. Amy pointed out that: ... [those] from different disciplines ... because everyone out there is ultimately, you know, who’s working for health or community service ... are working basically to the same goals aren’t they ... to get everyone better, one way or another. Amy 74-77 Participants saw their role as overlapping with the roles of other health professionals. In some instances, participants described their community health nursing role in terms of other health professional roles, such as counsellor or social worker. This raised the
179 question of whether the community health nurse role is uniquely different from that of a social worker, counsellor, community development officer or health educator. There were many instances when participants worked side by side with other health workers, with little to differentiate between how their roles appeared. Some participants indicated that sometimes clients had initially thought they were a member of other allied or health professions or did not clearly understand their role: I think ... I have explained working as a community nurse, I see myself as being half being a social worker and a nurse. Because you do the same thing. In the beginning they thought I was a social worker. And they are used to social workers of course, because the social workers come up there. For domestic violence ... or ... so... because I feel that being a nurse ... because it is the same ... we have the same supporting role which we take on with the clients when we go out and see them. When they have a problem and we handle that. If they need long-standing counselling, I refer them to a social worker, out to see them. Otherwise I see myself doing exactly the same thing. I see that as a part of the community nurse [role]. ... I tackle all sorts of problems. Joy 249278 There were instances where this overlap caused friction and difficulty as a result of a lack of congruence between the way in which participants saw their role and the way in which other health workers saw the community health nurse role: I mean the politics, that’s reality I know ... but I think there’s too much powergrabbing that goes on. And everyone wanting to justify their role. And so in that ... because our roles overlap. And there’s no way you’re going to not have an over-lapping of roles. But then, we as community nurses have got to be a lot clearer about some of the things that we can offer, that other people don’t offer too. Karen 939-947 They [other health professionals] just don’t see that [a broader role for nurses]. They’ll just say ... I have had comments made to me “but you should refer that to the social worker, because she’s the counsellor”. You know the fact is that I have never seen my role with a terminally ill person as being just ‘doing for’ them. Janet 759-764
180 Finally, role ambiguity was also illustrated by the recurring lack of understanding of their role that participants encountered and the difficulty which they had in explaining their role to others. Kate (184-187) observed that “... most people haven’t a clue what a community nurse is”: You are not being a nurse if you haven’t got your thermometer under someone’s tongue, with your watch, taking someone’s pulse. And that is the biggest problem. And that is where I find ... other people don’t understand your role [laughs]. And I guess at that stage, you in your own role start to doubt your own role.
You think “goodness, what am I doing then?”
... not many people will ask you straight out “what do you do?” [laughs] Some do. ... Its the same old scenario. They say “well if you don’t go out and administer Band Aids, what do you do?” Its just very hard. Sharon 262-269; 565-578 And then I have to start all over again as to why I’m a community nurse and what a community nurse means. It doesn’t mean that you’re not able to work in a hospital, or that you’re about to retire ... and they’ve put you out to pasture
...
but
it’s
actually
a
dynamic
role.
Some don’t [understand my role]. There’s still a lot of confusion about what a community nurse does.
... our relationship with [a home visiting
organisation]. It’s ... I still get a lot of doctors who ring up ... and a lot of GPs that I work with, still don’t really know what you do. ... And I find sometimes with professionals, it’s probably [they are] the hardest to get through [to]. Gwen 425-432; 528-542 Participants at times expressed negative emotions related to this lack of understanding, although they generally appeared to be resigned to this and looked for ways to counter it. It was also evident that participants felt that clients and other health professionals did not seem to be able to see the ‘full picture’ of the range of activities undertaken by the community health nurse. Participants felt that their role was frequently only understood in terms of the particular services being provided, and that their other activities were ‘invisible’. Where others were described as understanding their role,
181 they tended to be those who the community health nurse had worked with over a period of time, and thus had experienced greater professional contact: Some of the organisations were unaware of all the things we did because mainly it’s only, I only use a particular agency for one particular thing. So they don’t always know that you’re involved [for instance] with ante-natal [or] post-natal. They just see you coming in and working with a refugee over a social matter. It might be a social security issue. So they don’t always know what else you do. Louise 629-635 I think people ... most other people that you work with and come in contact with seem to understand your role better. I think that is just due to them working with us, talking to us, seeing what we do. Sharon 610-613 There were various reasons posited for the ambiguity and lack of understanding of the role by participants. Some participants indicated that they thought that this misunderstanding and difficulty was related to a general lack of commitment to prevention of disease and health promotion in the community: But I think there is a difficulty, I think, in explaining your role, because there’s not a generally held belief about the importance of prevention and early intervention. People use that word, they bandy it around. But often its early intervention once something’s arisen, and there’s a problem.
Then you
intervene. Karen 536-541 It was evident that in some situations, a stereotyped medical model view of nursing was taken by others. This was obstructive because this view interpreted nursing as related to only to sickness. This resulted in some participants questioning the label ‘nurse’ and identifying it as a liability, although it was felt that the label ‘nurse’ did provide entree and respect at times: I sometimes wonder if we should be called community health workers. See the word ‘nurse’ I find ... I have a lot of discussions with my co-workers about this. And I sometimes find the word ‘nurse’ more of an obstruction. And that it’s useful, sometimes ... But then on the other hand, with other workers, they
182 view nursing very narrowly. And they see nursing as skills, clinical skills, basically. It does get in the way. Helen 263-275 In one instance a participant herself saw the ‘nursing’ role as constituting an illness role. Rather than seeing herself in this way she rejected the whole label of ‘community nurse’ and reframed her role in terms of being a counsellor: Yeah. And if they [clients] were coming to a clinic to see a nurse and a doctor, then they would be automatically slotted into the ‘sick role’. Whereas they see us as counsellors ... then there’s not necessarily something wrong with them. ... But I’ve always found that it’s not like a medical clinic. It’s ... they get the medical attention from the medical officers here, but as far as the nurses go, we’re seen more as advocates and as counsellors. I do more counselling than I do nursing, in my position. Emily 351-363
Autonomous Practice Autonomy was an ongoing characteristic of the community health nursing role. As noted above many participants were sole practitioners. All of the participants operated as independent practitioners and exercised independent judgements in decision-making about both broad and narrow issues related to their practice, even when operating out of an agency that included other nurses and allied health workers. They made decisions about the way in which they dealt with clients in their care, they took and made referrals. They were able to pursue the best course of action for their clients as they saw it: We work as independent practitioners, I suppose you would say. And then we come together once a week to discuss cases. ... We are individuals doing our work, but coming in and meeting once a week. Carol 341-347 This is consistent with the findings of Alexander (1988). Throughout collection of the data, participants discussed their roles with the inherent assumption that they had control over their practice and the directions of their work. They indicated things they would or would not do, the plans they made, the programs they would run, the things they changed and the decisions they made about the type of service they would offer
183 to clients. For some participants autonomous practice was an important aspect of their decision to become a community health nurse, and for others autonomy was central in maintaining their interest in the role. For instance Helen was involved in actively making changes at the agency in which she worked. She did not carry on the role undertaken by the previous incumbent in her position, because she had other interests. She took on a role of parenting education that had previously been the domain of the social workers in that agency. In addition she changed the mode of work in that agency by going out into the community more and she changed the clientele by linking up with local youth health centres and agencies. Another participant explained how she related to other professionals with whom she worked: Well, I have certain parameters. I give them the priorities. I give them clear warning of what I plan to do ... so my forward planning ... Rhonda 482-484
DIALECTICS IN COMMUNITY HEALTH NURSING PRACTICE Consistent with the findings of De Silva (1988), major dialectical themes within the community health nursing role were found in the data. Analysis indicated four major dialectical themes: a health-focus/disease-focus dialectic; a prevention/treatment dialectic; a control and responsibility/dependence and ‘doing for’ dialectic and the dialectical connected/disconnected nature of the nurse-client relationship.
The Health-Focus/Disease-Focus Dialectic Cursory examination of the data initially suggested that an explanation for the community health nursing role could be related to a greater focus on health promotion when compared with other categories of nurse. It was clear that participants in this study had rejected a medical model focus as a basis for their practice. A ‘health’ perspective critiques a focus on disease, and may even argue that activities aimed at preventing disease limits the nurse to an epidemiological approach that does not encompass the social and environmental dimensions of the new public health incorporated in primary health care (World Health Organization and United Nations
184 Children's Fund, 1978), the Ottawa Charter (World Health Organization et al., 1988) and community development approaches. Examination of the data revealed that health promotion was a dominant theme that recurred in the data. When asked to describe their role, all participants included health promotion as a major aspect. All participants identified at least one of some form of health education, health promotion, and/or community development, and in some cases all three, when asked in their questionaries to identify the services offered by their agencies. Participants demonstrated a commitment to the promotion of wellness that was compatible with their definition of health as a positive entity and their health promotion activities were consistent with their stated philosophies of health, primary health care and holism. Many participants involved themselves in activities that were designed to promote wellness, rather than simply prevent specific diseases and were consistent with the view that the social fabric of people’s lives such as community resources, employment, social networks, human relationships, recreation were important to health. Thus, participants were engaged at times with more general social aims, rather than narrowly focussing on disease conditions and their prevention. Health promotion strategies employed included health education and individual, family, and community development: ... it’s focussing on a wellness model ... looking at people making decisions about their own well-being ... and a holistic model. More to the physical, emotional [approaches] which are health enhancing, which is going to give them the quality of life for the meagre seventy or eighty years we are on this earth. ... I do a special session for diabetics on stress management ... talking about putting joy and fun back into your life. Gwen 757-765 Then we came away from this education thing and just started on [community development] ... because then they wanted to have change in the community, in the way of street lights, speed bumps, signs for the kids playing ... you know signs to ... you know restrict the traffic ... all sorts of things. So then we started ... and more people came along ... and then we started a newsletter to send out ... a newsletter to tell ... this little group then called themselves [suburb] Action Group. Joy 115-123
185 However, although a health focus may serve to provide some differentiation from many other spheres of nursing practice, it does not provide an explanation of the community health nursing role. First, nurses operating in other spheres of practice may legitimately argue that health promotion is also included in their roles, although perhaps to a lesser degree. This was identified by Gwen who suggested that: And I see that there is a lot of scope for hospital nurses to do a lot more health education and prevention work ... but mainly health education. Gwen 445-448 Secondly, although participants were involved in health promotion, this was by no means the only role activity they undertook. It was found that prevention of ill health was represented more strongly in the data than the promotion of health as a positive entity. Some participants, although they took an holistic approach, did not involve themselves in promotion of health as a positive entity, but rather focussed on prevention of disease. In many instances, participants talked about health promotion, disease prevention and health education together. Furthermore, while participants identified involvement in health promotion as a major focus, for the most part, an examination of descriptions of their activities revealed that most were related to diseases, albeit preventing them. Furthermore, while a wellness and an holistic perspective may provide a philosophy that answers many of the conceptual difficulties these nurses experienced with an approach that is narrowly focussed on disease, it also generates further questions. As a basis for practice, a social or ecological perspective focussed on health as wellness may be so broad that it provides limited guidance for practice or professional boundaries. A health and wellness approach to practice leads one to ask what distinguishes an unique nursing contribution to the improvement of health of a community from that of other community workers such as community development officers or social workers? Indeed if the promotion of health was the only basis for the community health nursing role, one could question why the health worker should be a nurse? Furthermore, a nurse is not equipped to deal with every social and environmental factor that may impinge on the health of a community. Gallagher and Burden (1993) argued that to view that nursing as health promotion is dangerous. They suggested that this may devalue the caring skills of nurses with individuals and families, and place nursing at risk of losing its unique disciplinary knowledge and skills.
186 Finally, while health and ill-health may be viewed as separate entities, most definitions of health recognise that wellness and ill-health are inextricably linked. The findings of this study suggested that there is a need to find a way of integrating disease and ill-health with the broader aims of promoting health and wellness in a way that is meaningful within the community health nursing role.
The Prevention/Treatment Dialectic A second dialectical issue identified in the data was related to the tension between prevention and treatment within the community health nursing role. Are community health nurses different from other categories of nurse because they focus on health promotion or disease prevention rather than providing treatment and cure? There were instances where participants indicated that a focus on prevention was the difference between themselves and nurses who worked in institutional settings: But then again, I [said] “what are these people going home to”. I was in that way
of
thinking
-
prevention
was
better
than
cure
anyway
...
So I just pooled all that information together and thought “Yeah the only way to go is prevention”. Which is why I ended up in community. Janet 92-95; 182-184 Because our focus would be on health promotion and prevention, which is what a community nurse does. Kate 769-770 Many participants described prevention as the way they understood primary health care and all participants expressed a commitment to prevention. All participants described examples where they were involved in activities designed to promote wellness or prevent ill health at primary, secondary and tertiary levels: I think, it was my frustration as a clinical [nurse], an acute care situation really ... because a lot of the things I was seeing could have been prevented. And it was frustrating. Even, for example, some elderly person falling at home. Could that have been prevented? An elderly person mismanaging their medication and coming in with toxic levels of this that and the other. And of course its their choice to do what ever they want to in life, but were they informed? Where they informed that if you do this, the relation or the
187 correlation or the consequence will be that ... so ... I think as an acute care situation nurse, it was situation of … its fine, its wonderful to be able to help these people at this [the acute] stage in their illness while it is continuing ... but I would prefer to be at the front line ... trying to prevent this from happening. Sharon 690-707 ... provide education and information for them. ... [I would do] pre- and posttest counselling for HIV and hep[ititis] C, that sort of stuff ... information and education on HIV, hep[ititis] B, safe sex, safe injecting practices, that sort of thing. And most of my time is spent with counselling purely drug and alcohol type counselling where [I do] relapse prevention ... start with motivation ... motivational issues and things like that. And also what we do would be a bit of family counselling. And we do relationship [counselling] ... Emily 388-397 However, although prevention was a major theme for participants, this notion also presented difficulties in providing an explanation of participants’ descriptions of their practice role. While participants’ primary objective was repeatedly identified as prevention, whether primary, secondary or tertiary, and prevention provided the basis for much of the activity described by participants, health promotion and disease prevention were not the only activities in which participants were involved. Examination of the provision of treatments by participants provided conflicting evidence. It was of note that ‘treatment’ was largely absent from the participants general descriptions of their roles. Most of the discussion of the participants in relation to provision of treatment indicated that they drew definite boundaries and in some instances stated clearly that they did not provide treatments, and that this was not part of their role: They [doctors] want to know whether ... they’ve got someone whose got a burns dressing ... if they can send them down to you to get it dressed. Because you’re a nurse. And a nurse is a nurse is a nurse. And [they say] “you’re a community nurse, so don’t you do that as well?” “I mean we know that you’re in health education, but don’t you also do that as well?” Gwen 528-542
188 That’s a line for me. In my practice as a child health nurse I do suggest treatments that can be done at home. Nappy rash and thrush and things. That sort of thing. But I don’t treat sick children. That’s not my role. I don’t have the facilities or the skill or the legal responsibility to do that. So ... but I do refer them. And I refer them to the appropriate people. So I might say this one’s really good at, you know, asthma. Try that or ... and then give them [clients] ... once they’ve been diagnosed or treated ... give them the support after that, to follow on. Kate 126-139 However, while provision of treatments was not a major focus of the community health nursing role, an examination of the data revealed that there were situations when participants were involved in the treatment of clients. For example, in a school situation, school nurses provided simple treatments to school children, remote area nurses attended clients, Emily monitored drug addicts on methadone treatment and Amy provided treatment when following up a client in a migrant health situation: ... certainly following up on the initial contact, so if the child comes in with, you know, a headache, aches and pains or whatever, you follow up on that and you treat what they think you see ... or what they’re trying to tell you they’ve got. Anna 145-150 ... I always say that “I’ve been ... I have your file from Migrant Health, which they have given me confidentially, and they’ve asked for me to give you back some of your test results ... and from there to follow up on some of your treatments”. Amy 501-505 It was interesting to note that some participants described their initial experiences in community health in terms of providing physical care because this is what they knew and what they were more comfortable with: I had to do quite a mental shift. Probably [it was] the only thing I probably could have done, and that was I was clinically focused. And I felt then ... now how I recognise that, running around after people or doing things for people ... I was comfortable in that role. Because that was the role I knew. Gwen 57-97
189 However, where treatments were provided by participants, the situations were usually scrutinised carefully, and there were instances where misgivings were expressed. Lyn expressed dissatisfaction with a role that was aimed at the provision of treatment and questioned what a treatment approach was achieving: And you had your set of clients. And you had your fifty families, or whatever, that you were responsible for.
And so, you know, you were given these
families to go and visit and to do programs with ... weigh their children ... you know, and take on this whole ... care of them so to speak, and you treated their scabies and their head lice and whatever else. But it still ... it was very interesting, but it wasn’t ... I didn’t find it that fulfilling. Because it was very ... I had this thing in my mind that I might be able to change behaviour. And I realised that changing behaviour was a very long term thing. Lyn 114-124 Rhonda reflected on her dissatisfaction with her role as a home visiting nurse, that had prompted her to take up a community health nursing role: Yeah. I’d go for the dressings, or I would go to do some sort of a skill if you like, for this person. But there were other issues that ... which was preventing them from getting well. It might be their dog that needed placing ... all the social issues. And that was probably just an awareness of the social dynamics of community nursing. I often found that some of the ethnic people, the Italians were abusing drugs that had been prescribed by the GP and the hospital ... and [had] given them to the old man over the back [fence] who didn’t speak a great deal of English. And these issues were really quite large. Rhonda 136-145 ... and I feel that nursing has a much more positive role, than just skills to offer. Helen 357-358 It could also be argued that counselling is also a form of therapy or treatment. In addition, first aid, while not strictly a treatment, was accepted by participants as part of their role. There were also many instances were participants disseminated information to client individuals, families or groups related to the treatment aspects of disease. While this could be considered secondary or tertiary prevention, treatment
190 was clearly an issue participants were concerned about. Furthermore, it can be argued that treatment itself should be considered a form of secondary prevention. Examination of the types of treatments participants described themselves giving revealed that where they were provided, there were distinct characteristics inherent in the situation. The first type of situation in which treatment was provided was in situations where there were no other options or services available. The most usual situation was that there was no medical support on site, such as in remote areas. The generalist skills of the nurse were often called upon because they were the only health practitioners available to a community: Because once working ... the other thing was working ... in a fairly autonomous position with other nurses ... we had no medical staff in [third world country] ... our nearest medical staff was two hours away by sea. And we were dealing with ... which meant that we were dealing with maternity, with paediatric issues, with infectious adults ... and I mean they were basically infectious
diseases
...
the
pneumonias,
leprosy,
TB
[tuberculosis],
gastroenteritis ... traumas, those sort of things. So ... like we would have, perhaps,[like] a remote area nurse [would be] dealing with. Karen 101-124 The second type of situation in which the nurse provided treatment was were the client was disadvantaged or vulnerable in some way. In particular, treatments were provided to the homeless, migrants, children, Aborigines and people who were drug addicted. Participants also placed limitations on the scope of treatments provided. In particular, the context in which treatments were administered was that the client maintained their independence. All clients to whom treatments were given were living independently in the community and consequently they maintained the ongoing responsibility for their own treatments, rather than this responsibility passing to the nurse. For example, Emily who worked with drug addicted clients, indicated that she drew a distinction between what she did and the type of care provided to similar clients in an institutional setting. She conceptualised the service provided differently, seeing the clients she was dealing with as living and ‘acting’ within the community. She did not think of the centre that provided drug and alcohol services to clients as a ‘clinic’. This approach she suggested would indicate a ‘sick role’ for her clients. For instance, she
191 thought of her clients as healthy if they were maintained on the methadone program. She also indicated that she did not use the medical model to think about what happened at the centre: Whereas if I see myself more as a counsellor and, if you like, therapist then ... I’m putting ... all the responsibility onto the client ... rather than me taking it on ... and [its not] “oh ... it’s ten o’clock, I’d better do the pills”. The clients come to me for their medication and I’m putting the responsibility on them so, it’s a different role ... you see what I mean? Emily 1003-1009 In addition, treatment tended to be provided within limited parameters and timeframes, although this was not universal. In most situations, where there was a need for continuing treatments, participants provided initial treatment and then referred clients on to other agencies. There were difficulties related to the treatment aspect of the community health nurse. In many instances treatment activities constituted a threat to health promotion and disease prevention activities. This was because there was a limit to the nurses’ capacity and that the treatment of clients competes as a priority for the nurses’ attention with health promotion and other activities. It did appear that health education and promotion was a priority that competed with other activities offered by agencies: I think that health education, health promotion has gradually worked its way up to be a priority. I think it is a priority. Because it doesn’t matter what you do, if you are caring for one person, you still educate them about health issues. So you do your health education, one to one. Or to a group of people. So you still do that ... I think that health promotion/health education is more ... [long pause]
Joy 649-655
Well I would like to be more involved in health promotion. My ... but I don’t want to drop the [individual and family] clients. In a way ... I would like to maintain that. Sharon 535-540 Yeah, yeah ... that [involvement with community drug education] comes and goes. Sometimes when we’re not so busy I’ll get out and do that sort of work.
192 Whereas now I’m fairly well tied up with [the] methadone [program]. Emily 691-93 Consequently, the notion of prevention, while constituting an important theme in the role described by participants, was only a component of the community health nurse’s role. These findings are consistent with Collis and Dukes (1991, pp. 136-137) who examined the ‘uneasy dichotomy’ between prevention and cure in school nursing, and suggested that the role does incorporate a curative function. This ‘uneasiness’ was evident in this study and reflected in the descriptions of situations where treatments were provided. However, as pointed out by St John (1993) primary care does constitute a component of primary health care, and requires the traditional range of skills relating to physical care. On the other hand, only providing treatments does not provide explanation for a health perspective, nor does it give rise to an holistic approach. It returns the nurse to a medical model perspective. Consequently, participants appeared to act to limit its importance in their role because it provides contradictions to their philosophical perspectives. In addition, provision of treatment as part of the community health nursing role is problematic because it does not provide an explanation of the activities of participants in which they addressed the community as client. Thus, when considered together, activities aimed at each of health promotion, disease prevention and treatment of disease alone constitute a limited perspective of the community health nursing role. Participants were required at some stage to address each of these. Although the nurse may be involved in each of these different aspects of the role in varying amounts, all aspects are present as a component of the community nursing role, albeit leaning towards the ‘health’ end of the continuum. However, each alone does not provide an explanation of the role of the community health nurse. To exclude any of these components would be to limit the role. Any explanation of the role should encompass and integrate all of these.
The Control and Responsibility/Dependence Dialectic The notion of responsibility does not simply relate to the role responsibility of the nurse, it also constitutes an important component of the social contract between the client and the nurse. Role responsibility implies responsibility to someone else. In the
193 context of the community health nurse role, there is responsibility to an employer and to the client for the provision of services. However, the notion also applies to assuming responsibility for something. It is the second meaning that assumes importance in the nurse-client relationship in the community health nursing role, where the issue of who is responsible for the activities and behaviour of the client and client outcomes becomes important. The issues of control and responsibility are intertwined. The question of who assumes responsibility for client outcomes is related to the allied issue of who is in control of the nurse-client encounter. With responsibility comes control. All of the participants recognised that in a community setting there is a shift in responsibility and control from the nurse to the client when compared with their practice in a hospital. It is of note that this notion exercised the minds of participants and this theme was repeatedly present in the data. This shift profoundly affected the thinking and language used by participants to describe their activities. There was a need to repeatedly negotiate with clients in relation to all activities carried out by the nurse. They prefaced descriptions of their ideas for activities with comments such as “when they show interest in some aspect of whatever” (Gwen) or “if they wanted it”, thus not making presumptions about their clients’ care. They consulted clients and worked with them to develop strategies to address their health issues, problems and needs. Many participants reflected on the change in control and responsibility by comparing their community role with their previous experience in an acute setting: It is a hard thing to do. Especially if you’ve been bought up ... that’s what your training tells you to do. You are responsible for these patients in such and such a bed. And then all of a sudden someone says “they’re your clients, but they’re responsible for themselves”. Whoa ... that’s a totally different. Janet 1069-1075 Well, I would say that it’s a little different ... in the fact that you talk ... you’re with a group of people who don’t have to be there. Who are there because it’s something they want to do. Marie 671-678
194 The two major factors that contributed to a shift in control identified by participants were related to a change in the context from an institutional setting to the community and a change in focus from acute illness to disease prevention and health promotion. First, there was a change in context. As discussed above, when nursing practice is occurring in the context of the clients’ ‘turf’ there was a consequential change in the ‘rules’, and a shift in the control and power in the nurse-client relationship. The client is not in the hospital under the constant ‘care’ of the nurse. They are at home in their own houses and in their own communities. On the clients’ turf, the nurse does not have the same amount of control. The nurse must make the service provided attractive, earn the trust of clients and cannot ‘boss clients around’. They must also accept the decision of the client and if they do not do this they ‘lose’ the client: ... and they just won’t do it! Well they won’t do it because they are at home and they’re not going to do it. They can do what they want to do at home. All your methods, all your own system ... its different in the [client’s] home. Janet 1017-1021 So yeah, I guess you have to sell yourself as a nurse and that you’re nonthreatening and that you’re not going to sort of ride rough-shod over them ... or tell them what to do and what not to do. So there’s all those sort of negotiating skills I think that need to ... for that ground work ... for them to accept you into their household. Cheryl 60-66 The second factor contributing to a shift in control and responsibility from the nurse to the client was related to the acuteness of the client’s need. There was an indication that, where a client had an illness or a physical need, participants felt there was more likely to be a dependency on the nurse for expertise and skills in acute care, and a consequential loss of control of the situation by the client. In contrast to a role that concerns itself with an existing acute need, the role of the community health nurse has a major health promotion and disease prevention component. When the aim of an encounter is to prevent disease and to promote health, there is less urgency and a concomitant reduction of client dependence on the nurse. Thus with less dependence and a greater scope for decision-making responsibility assumed by the client, there is also greater control by the client. Janet’s reflection on her experience as a domiciliary
195 nurse, prior to taking a community health nursing role illustrates the power that an acute physical need may have to lessen clients’ control: ... that’s why I think the domiciliary [nursing] was such a good intermediate step [to community health nursing]. Because I’m in their home ... but I can still call the shots because usually there’s an acute situation that I am dealing with. But it’s still in their home. Janet 407-411 Analysis of the data also revealed that participants themselves contributed to this shift in control and responsibility by practising with an assumption and a strongly held belief that the client was responsible for their own health: And as long as you don’t fall into the trap of ‘saving’ clients. Emily 130-131 And when you’re talking to them about how you can help them to access services or suggesting to them that they are in fact responsible for what goes in their mouths as far as their diets or their diabetes, or whatever, is concerned ... their perception is that that’s not their responsibility. It’s their doctor’s responsibility. Janet 939-946 This viewpoint was expressed by all participants. A consequence of this approach was that any credit for achieving health competence was also ascribed to the client rather than the nurse. Emily saw that a shift in responsibility to the client meant that any credit for health improvement also remained with the client, and that the corollary was also true: responsibility for problems experienced as a result of client decisions also remained with them: I think my particular belief is that if a client goes through the program ... reduces off their methadone ... doesn’t use drugs ... gets a job ... stops fighting with the girlfriend ... ends up with money in his pocket at the end of the day ... and basically comes off the program, [then] I won’t take any credit for that. Because that’s entirely their doing.
All methadone does is stop people
‘hanging out’. It doesn’t do those other things. So the only person that lets those things happen was the client themselves. The reverse of that of course ... is if clients don’t do very well on the program ... and they find that they might increase their drug use ... or they keep getting into trouble ... or whatever ...
196 then I won’t take any responsibility for that either. It’s entirely the client’s responsibility. And I think [that] most of the clients realise that ... or they do realise that. And most of them do try and help themselves. Emily 288-303 Rather than doing things ‘for’ clients, participants aimed to assist them to ‘do’ for themselves. Some participants stated explicitly that they did not do things ‘for’ clients. Janet questioned Henderson‘s definition of nursing (1966): And that goes back to the ‘acute’ mentality. Where you have got to do it for the patient. In fact that was something that was said in one of my recent tutorials, that nursing care is “doing for the patient what they would do for themselves if they could”. Well in community ... I don’t think that can apply, because you can’t do for anybody what they [won’t do themselves] ... [laughs] ... you can’t do something for somebody in community. Janet 977-988 Participants generally took the approach of encouraging client responsibility by giving them information, choices and options so that they could make informed decisions. The aim was for the client to take responsibility and be able to make informed decisions. Thus they had to balance the aim of providing advice and information with the concurrent aim of assisting them to stay in control: Because sometimes you do have to sit back, even if you know this is not going to work. You have to let the group themselves decide what they want. And what they [want to] do. And I think I have got to go with them .... Sometimes of course ... well you have to ... if there is something inappropriate ... if there is something I really ... I’m sure this is what we have to do. Of course I say that. But I do not make decisions in their community ... other than giving advice. Joy 178-186 However, although all participants held a belief that clients should be responsible for their own behaviour and health, this presented them with dilemmas. Giving responsibility to a client does not simply entail providing a client with information and a range of choices. First, in practice, the implications of a transfer of responsibility to the client, whether an individual, family or community, were that they were then in a position to make decisions which may present a threat to health. In the ‘real’ world
197 clients may engage in health behaviour which is self-neglecting or even dangerous to their health. Not every client will look after themselves. Not every community will make wise decisions: Gently making them understand that they have to own their own ... its behavioural stuff. That have to own their own behaviour. And that I can assist them ... and go back to [the idea of] their back yard too ... that they’re their rules that they’re living by and if they’re happy to live by their rules ... then they’re the consequences [of living by those rules]. But I’ll show you what the consequences are and then ... you know ... of not adhering to your diet if you are a diabetic. This is what may result ... you know ... its over to you ... you decide. And sometimes you just have to ... you just have to turn your back and walk away. That can be really hard too. Janet 958-972 ... well, you know, that’s why there’s so much money being spent ... is because they don’t necessarily care for themselves. Lyn 197-201 Secondly, families and parents may be neglectful of its children or make decisions that may be detrimental to their children. Participants this difficult to deal with: Where I have the most problem, and I don’t ... is when I see that somebody who ... is imposing something which is not good for somebody else ... and ie ... a child. A mother is imposing something. If you are an adult and you are making a decision after you have been given the information ... then that’s your decision. Gwen 683-693 Anyway [you] put a lot of strategies in place. I mean and we try and get the child to five at least at home where it can scavenge around in the fridge and get things for itself. And I know foster homes aren’t the answer either. I mean it’s a real dilemma. I mean what do you do? Louise 160-164 A Code of Ethics has been developed for Australian nurses (Australian Nursing Council Incorporated et al., 1993). It suggests a need to “… respect the rights of persons to make informed choices in relation to their care”. However, it is silent on the issue of actions by clients that may have an negative impact on another person.
198 Thirdly, there are situations where clients are vulnerable and in need and do not have the resources to assume responsibility for their own health. A client may lack the skills and resources in order to access help. However, the notion of client responsibility and control is dialectical to the nursing perspective of care and ‘doing for’ that is inherent in traditional definitions of nursing that would see intervention in situations of vulnerability and need. Finally, in some instances participants had difficulty when the client was comfortable with dependence and did not want to assume responsibility for themselves. Dependence and vulnerability can be very powerful. This was at times frustrating for the nurse: It was hard ... yeah. But if you wanted them to do what you felt was needed ... you ... and an example was immunisations too ... they would attend immunisations, if you transported them. So as a compromise, I suppose ... oh we did change the policy of the cars a bit ... we made it quite clear that we were no longer a taxi service. But that was the most frustrating part. You got results if you were prepared to assist them to do whatever. But if you left it up to them to use their initiative, they didn’t really follow through necessarily ... some families would, but ... And that was the frustrating part, that I had to try and come to terms with that ...Oh I did. I accepted it. But I didn’t like ... didn’t like having to provide the transport. I saw them as ... they should be taking more responsibility for their health. I tried to ... that’s what I was trying to achieve. Lyn 194-197 Despite participants strongly supporting the importance of clients taking responsibility for themselves, an examination of the data revealed that there were clear instances where participants did do things for clients. In doing something for clients, the actions of the nurse may not necessarily serve to assist them to attain responsibility for themselves. This made the decision of whether or not to do something for a client into an issue that had to be resolved by the nurse. The nurse must make more careful decisions about who they will help or do things for and who they will not assist. A major concern arising when doing things for clients, was that participants were creating a dependence in clients rather than an ability to care for themselves. There was a need to assist clients while encouraging independence and responsibility:
199 Yes. Well. That people should ... and this is still the problem I have, that people should take responsibility for their own health. That’s what I think I try and ... to do. That I ... not ... that I don’t want to spoon feed people and make them dependant on us. Lyn 1330-1334 With child health it used to be I couldn’t see why mothers had to keep coming back to us all the time. I thought that if you did your job well then you calm the mother and they contacted you when they thought they had a problem. You didn’t need to have them coming back every week ... with a dependency. You created dependency. Because [if they only came when they wanted to] you were then giving them the power and the confidence that their mothering skills were fine. They didn’t need to come back to you …and [they] really [only needed to] be checked every so often. Gwen 636-651 Discussion about the decision to do things for clients was a recurring theme throughout the data and there was an indication that this issue was also discussed with nursing colleagues. In all instances found in the data these descriptions of ‘doing for’ were accompanied by an explanatory rationale or a justification as to why the participant chose to do something ‘for’ a client. Thus, participants demonstrated a reflective approach to their activities with clients in thinking about what they did and why, and furthermore, felt the need to justify the action of doing things for people. Some participants questioned the balance which needed to be achieved between ‘doing for’ and achieving client self responsibility. Karen felt that handing over responsibility to the client with little thought was simplistic and did not attend to the complexities in any given situation: There are a lot of families that, for one reason or another, have a bad experience. And this can be, this is inter ... this can be generational. And it gets passed down from one generation to the next ... that their own parents had a poor experience or ... of the health system ... And it may be that there was a good reason for that. Because it may be that there was dysfunction in that family.
And so there would have had to be intervention in that family.
... And so it’s in that context that I see health. And helping families to be independent. No one can be completely independent. I mean I think we’re
200 really suffering from a bit of a myth, if we think that. We talk about creating independence. No one human being is completely independent. We’re all dependent for some things on each other. Karen 314-325; 269-283 An examination was made of the participants’ descriptions of situations where they did describe doing things for clients. It was found that participants did not do things for people indiscriminately. There were instances where they would do something for one person, but not do the same thing for another person. There were also instances where they would do something for a person at one time and not at another time. It was found that participants made judgements about clients and situations leading to decisions to do something directly for a client based on three factors: the vulnerability of the client, the seriousness of the situation or health problem and how helpful their interventions would be. Participants made decisions to intervene and do something where clients were vulnerable. Particular examples of clients for whom nurses ‘did for’ included the young, homeless, migrants with few resources, Aborigines in need and in some instances the aged. The most frequently described vulnerabilities related to children and young people. For example, if a client was extremely needy, had less resources, had been the subject of violence or there was a child involved, the nurse would make a judgment about the vulnerability of the client and may act to do something for the client. Louise (379-390) assisted a very young couple with a baby by obtaining them a free piece of equipment for their child’s asthma treatment. In her explanation of this example, Louise included details which indicated the vulnerability of the child, the youth of the parents and the seriousness of the baby’s condition. Another example is given by Helen: ... and they’re only young people ... and they’re are not used to psychologists and psychiatrists in regard to important matters ... and they just avoid it ... because they’re too scared.
The same as going to the STD [sexually
transmitted disease] clinic or something like that. So sometimes ... you know ... I say “I’ll drive you”. They say “Oh I don’t really need to go then” or “I can’t go that day”. I say “When can you go? I’ll take you”. So then its all starting action moving for them. Helen 161-168
201 A community health nurse cannot provide comprehensive nursing care to every client or family they see, because their resources are finite. There was evidence that participants also made judgements about how useful or effective their interventions would be. If their continued ‘doing for’ was not going to serve to improve the client’s health and/or situation, they made a decision to discontinue their services. All three factors are illustrated by the decisions made by Louise. She first provided assistance to a client by ‘doing for’, then withdrew this assistance. The client was vulnerable, had a serious health problem but this was balanced against the effectiveness of the nursing actions: People have to see that it’s their health problem and that they have to make a decision about what they want to do about it. And if I can pave the way to make it as easy as possible for them to get into appointments. Then it’s up to them. And then after a while I stop. You know ... if I make three appointments and they don’t attend ... well I say to them after that “You know it’s time for you to make the appointment now ... I mean I’ve made three appointments”. I’ve made three appointments for a girl to see a cardiologist ... a 16 year old here with a history of rheumatic heart disease, smoking ... smoking dope, drinking, all of those things ... and she missed two of them. And each time its a ... you know the person at [the local major hospital] has to contact the cardiologist to see if he can squeeze her in at the end of the list. And the third one [appointment] I just rang up to check ... she’s missed two, and she’s got another one [appointment] and she actually attended that one. So I give them a few chances and then if they blow it, well I’m not doing it any more because they’re 16 years old and you know ... and because of the importance of it, I have actually taken them to the hospital at one stage and ... but then there’s a limit. People have to take some responsibility for their own health care, and you can’t be expecting other people to be doing it all the time. Louise 430452 The final factor that was evident when participants did things for their clients was that they negotiated an understanding with clients of the boundaries to the possible services provided, and that there was an expectation that clients would work towards
202 gaining resources to enable them to be able to meet their own needs. The aim was to promote a positive change in health for the client. Exemplar: Responsibility for the Provision of Physical Care One area in which the notion of control and responsibility was seen most clearly was in the provision of physical nursing care to clients. It can be seen that nurses working in hospitals or home visiting agencies provide physical hands-on nursing care to clients: doing dressings, giving injections, showering clients, along with fulfilling the many other functions of the nursing role. In these situations, the client is dependent on the skills of the nurse and the nurse assumes responsibility for seeing that this care is provided. Thus, it can be readily seen that nurses working in hospitals or home visiting agencies are charged with the responsibility of providing physical care during an episode of illness or reduced capacity. The situation for community health nurses, however, is different. It was evident that the participants did not describe many instances of providing actual physical care to clients. Some participants expressly identified that they did not provide this type of service. When an episode of physical support and care was required by clients, participants referred them to agencies that could provide these services. Kate reflected on the separation between the service she provided as a community health nurse and those offered by a home visiting service: I think it is appropriate. An appropriate separation. We can’t provide all that, that hands on ... showering and stuff, we can’t do it. Because our focus would be on health promotion and prevention, which is what a community nurse does. So prevention and promotion which is one and the same, but it’s not ... You know ... are quite different to ongoing care. Kate 759-787 However, while these nurses did not provide a great deal of physical care to their clients, they did provide physical care to their clients and have physical contact with them from time to time. For example, there were instances described by participants where they undertook physical assessments, gave injections, provided first aid and accompanied clients as flight nurses. Participants described the provision of treatment where a client was vulnerable, there were gaps in existing services or there was an urgent situation.
203 Examination of the data, in particular the role activities and referral patterns reported by participants, revealed that while this care was provided at times by some participants, they did not take on continuing responsibility for physical support and care of clients for an extended episode of illness. Where a client’s needs indicated that they were likely to require an episode of physical care, they were referred to agencies that could take responsibility for and provide this service. The participants did not assume responsibility in these situations: ... [they] ring up and they expect you to go and visit someone every day. You’ve had to say to them “we haven’t got the resources and we’ve not really got that role to go and visit every day. If you need a nurse to visit every day, then we will refer you on to the dom [domiciliary] nurses”. So those situations ... yes, some of those situations do arise. They are really not too sure what the nurse will do. Sharon 590-606 Examination of the data showed that participants took on responsibility of care for only a short period in order to meet a particular need. For instance, in an emergency situation, participants provided first aid and ensured that a client was transferred to a hospital or general practitioner for ongoing medical or nursing care. If medical problems were identified in screening activities, clients were referred to medical practitioners who could provide treatment. If a client required ongoing assistance with transport, counselling or physical care, participants accessed agencies or home nursing services to undertake this. Thus, they did not assume ongoing responsibility for the client’s situation, although they were involved in follow-up. Although they had ongoing case loads, these did not involve responsibility for the provision of continuing physical support or care of clients. In case management, although participants made initial arrangements as a result of discussion with clients, the focus was problemsolving, enabling the client and providing advice rather than doing things for the client. This approach appeared to consistently hold true for all participants.
The Connected/Disconnected Nature of the Nurse-Client Relationship Another dialectical theme that was evident in the data related to the nurse-client relationship. It was clear that participants considered that the relationship between
204 client and nurse changed as they moved out of the acute sector into the community. In addition to changes related to responsibility and control, there also appeared to be contradictions in the descriptions of the nature of the nurse-client relationship. Aspects related to connectedness and disconnectedness were examined in more detail. There was discussion of a sensitive, close and trusting relationship in which rapport was established: ... Oh much more connected ... much more connected. Much more human to human. Rather than nurse to patient, nurse to client. It’s much more ... I don’t know whether I can use the religious context ... its a much more [of a] Christian perspective of another person needing assistance.
I know I
shouldn’t say just Christian ... I know all of the religions [may have this perspective]
...
yeah
...
just
a
human
connection.
... human interaction ... It can be a spiritual relationship. And I mean that in the highest sense. With someone who is terminally ill for example. Janet 316326; 757-759 Connectedness in the nurse-client relationship was expressed in terms of trust, acceptance, respect and sensitivity. Participants valued a trusting and open relationship with clients, seeing it as important to their work with clients. Participants identified many factors that indicated an honesty and closeness in their relationship with their clients. They felt that if they developed a trusting relationship, then they were more able to work with their clients. The major factors that appeared to contribute to the development of trust in the clientnurse relationship were: a non-threatening approach to the client, an assurance that the nurse was ‘on the clients’ side’, acceptance of and respect for the client, and client confidence in the knowledge, skill and services provided by the nurse. Rapport and trust developed where the nurse demonstrated a sensitivity to clients’ situation, ‘being with’ them and gaining the confidence of the client. Participants took care to present a non-threatening presence to their clients and, particularly, not to be dictatorial in their approach:
205 Generally, they’re very accepting of what you are.
Yeah ... once they
understand what you’re there for, and that generally it’s not a threatening situation. Anna 551-553 A crucial aspect to their relationship was an honesty, realness and trust, based on an acceptance of the client and their situation by the nurse. In other words, there was acceptance of the client ‘warts and all’ together with an understanding of ‘where the client was at’. Participants also demonstrated an ability to adjust their own priorities in relation to client perspectives and needs. Participants demonstrated an attitude of respect for the client and a recognition of the clients’ skills and abilities. This approach was evidenced by the way in which participants indicated that they learned from their clients: ... and I think [it is] just getting back to basics as far as respecting the individual ... never blaming... Emily 127-129 There was a need for the client to have confidence in the knowledge, skills and abilities of the nurse. Participants also indicated that they felt that there was a need for trust to be earned and developed over a period of time: ... that it’s been the right information for them, and that they feel confident in coming to me for information. Cheryl 113-115 Louise noted that, within the nurse-client relationship, nurses need to be aware of their own behaviours. She indicated that there was a need to be a good role model. An interesting outcome of the establishment of trust and a close rapport with clients was that this brought with it a responsibility which is suggestive of Heidegger’s ‘sorge’ or ‘mattering’ (Waterhouse, 1981 p. 140): ... for instance if I were to say to somebody ... “oh, that’s terrible that this has happened to you ... you were sexually abused by your uncle when you were five ... that’s terrible, here’s a phone number to ring”. If I was to do that then I think that for one [thing] the client wouldn’t ring it [the agency] ... and it would be forgotten about.
Because they’re not the type of people who
generally trust people very quickly. And because I may have had a good relationship and close rapport with this person, then I think it’s an obligation
206 of mine to look into it. You know ... as far as they want to that is ... I wouldn’t push the point. But if they wanted to spend some time with me talking about that [their problems] then that’s fine. I don’t know ... I can’t offer them ... the best service as far as rape crisis counselling goes, but I can certainly point them in the right direction [and] give them a little bit of support ... and then refer them on ... and make sure they got in touch with the right people. Emily 429-446 What was also evident was that participants ‘listened’ to their clients, demonstrating sensitivity and an ability to understand the perspective of those with whom they worked. To community health nurses, ‘listening’ is a crucial activity which translates into really ‘hearing’ what clients have to say and having sensitivity to their perspective. At times listening meant that participants needed to be aware of what clients were not telling them and tuning in to cues and body language: I mean little things come in. And being tuned in to body language and things that people don’t say. [Because] sometimes, particularly in areas of domestic violence ... and sometimes it’s what people aren’t telling you. And if you’re tuned in, if your antennas are up, you get all those non-verbal clues. But all of a sudden, sometimes it’s just a word you say, you know, or sometimes you just reach over and say “tell me what’s really happening” and people just dissolve in front of you. Louise 225-233 Primarily it was an ability of participants to sensitively pause and hear the real thoughts, feelings, ideas and problems from the clients’ perspective with an awareness of situation that incorporated the difficulties clients face in their daily lives, that enabled clients to give expression to them. Participants demonstrated an awareness that they were dealing with ‘where the client was at’ and consequently adjusted their own priorities in relation to clients’ perspectives and needs. Participants also demonstrated a clear understanding that their client’s world view, perspective or priorities may well be different to their own, with a recognition that they did not ‘walk in their clients’ shoes’. There was a need for sensitivity to the particular needs and situation of the client:
207 A lot of my clients make decisions I don’t understand.
[laughs] I make
don’t
understand.
decisions
that
other
people
... but then you see my ... what I believe is good for them ... I’m not walking in their shoes ... I mean ... when you go into those client’s houses ... when you see all the other issues that are going on, you can sometimes see why one issue which to you is important is actually quite low on the list of priorities for them. Gwen 668-669; 683-693 There are people who can give information in a very matter of fact business like way. Well the kind of people I deal with here are often people that have been knocked around by life. They’re low income [earners], come from poor parenting backgrounds, and a lot of times people need a bit of softness in there. Just a listening ear, a bit of compassion. I mean ... little things. A hand on somebody’s shoulder when you’re talking to them. Louise 203-210 However, while there was evidence of a close and connected nurse-client relationship, there was also an indication of a disconnectedness in participants’ relationship with clients. Many discussions about closeness in the nurse-client relationships were qualified by a discussion of aspects indicating distance in the relationship: So now I’ve got what you’d call a more professional [relationship] and ... ‘impersonal’ is the wrong word but ... I think there’s difference where you become ... after a while you can just go through the motions of doing the job without any sort of empathy. If I get to that, I’ll get out. Gwen 850-869 An example of this disconnectedness was found in discussion of the nurse-client relationship in relation to ‘friendship’. Although participants sometimes identified their clients as people they would be friends with, they then qualified these statements with observations that they kept their relationships with clients on a ‘professional’ level, which did not extend outside the working situation. Participants did not on the whole see their relationships with their clients as friendships. They made the distinction that although they had close and caring relationships with some clients, they were not their ‘personal’ friends, although they recognised that their clients may see them as a friend:
208 There’s other clients that I honestly believe that I’m probably their only friend. Not that I welcome that ... they put their hand out as friend ... but it’s just something that they see me as a friend. If they come in and want to talk to me about personal issues and they know it’s not going to go any further, then I’m happy for them to do that. Because I know they haven’t got any friends. It doesn’t extend out ... sort of outside working hours. Emily 271-278 This aspect was discussed at validation feedback groups. One participant indicated that there were one or two previous clients that she had maintained contact with sporadically, despite having moved from her previous place of employment. However, this relationship consisted of her client providing her with an update on ‘how she was going’. An examination was also made of the notion of ‘care’ in the data. A pattern search was made for care/cared/caring in all document and interview data. There were many mentions of ‘care’. They occurred in job descriptions, in relation to primary health care and the functional ‘care’ that people receive. However, when instances of ‘care’ related to descriptions of the nurse-client relationship were examined, there were some interesting characteristics. While there appeared to be consensus about a need to be compassionate and sensitive to the ‘reality’ of clients’ situations, there were very few descriptions of the nurse taking on a ‘caring for’ role. There appeared to be ambivalence about the notion of ‘care’. Those instances of ‘care’ that were identified tended to be described as a concern for clients, were described in relation to providing information, or were qualified in some way. There were also some participants who questioned traditional notions of ‘care’: Well, just that they know that it’s not a job ... it’s not just a job to you ... that you ... I’m not saying I care intimately about every single person in that sense, because you can’t do that in this kind of work ... and I can distance myself from it and go home. But that you provide not only good information, but you do it in an as kind and as caring a way ... without being a ‘wuss’... as you possibly can. Because I see so many damaged people. And just to be able to have a sense of humour, you know. I mean to be able to laugh with somebody over things. Or to discuss the most intimate details and make people feel
209 comfortable about things which they find great difficulty doing. Louise 214224 ... while I’m not bagging anyone, I’m just ... all I’m saying is that I know this way works. And the way I see it, if you make me into a ‘nurse’ ... take away and make me a ‘nurse’ primarily, then I would operate in this clinic a lot differently ... than the classic ‘nurse’ would ... you know ... you see somebody who is ... who is nurturing and helpful and always friendly and does care for people to the point that they get too involved ... or .... there’s a line ... there’s a line here you have to draw and ... if I were a ‘nurse’ I’d be stepping over the thing all the time. Emily 994-1003 Participants also appeared to be engaged in a more negotiating, probing and ‘up front’ relationship with their clients at times. While participants took care not to be judgemental of their clients, they sometimes behaved in an assertive manner that could at times border on being confronting. For example: ... people were very happy to have somebody they liked come in. Not that everything you say is something that they like to hear. But I think they learn to trust you and if you make suggestions or give them options about the directions they’re taking they’ll consider it. Louise 60-65 You know, in other words, getting these headaches ... aches and pains ... out of the way. And “let’s get down to the nitty gritty. “Okay, now we can work with what it really is that’s bothering you.” Anna 490-498 However, in addition to elements of distancing in the relationship, participants indicated that there were situations where they did not develop a close rapport with clients, because of the way they undertook their role. In some situations they did not have time to develop a close rapport with clients. In many instances, distancing in the nurse-client relationship was fundamental to enabling the community health nurse to realistically cope with the workload involved with addressing the many community, family and client needs they encountered. Joy describes the difference between her current practice and her practice when she began work as a community health nurse:
210 This is my fifth year. ... before I think I went in and I was determined and ... “I am going to do everything for these people. I am going to help them with this. I am going to be there every week. I was going to see that they were OK” and all these sorts of things. And now I think I am more going for the “teach them how to cope for themselves”. And what to do. And so that they can help themselves. So I am more into education and helping them [know] what to do, [rather] than just feeling responsible myself. ... So now it’s much easier for me. And I guess if you want some sort of theory, then it would be Orem’s theory. Its just that ... they get support from me ... but the support is meant to be to help so that they can be able to help themselves. Joy 443-458 It was also evident that, at times, participants placed a distance between themselves and their clients in order to achieve something for the client. It could also be argued that in order for a client to exercise choices and take responsibility they must have some space in order to make those decisions. The participants appeared at times to be ‘caring’ by not doing things for clients. Always ‘doing for’ may not be ‘caring’ if it encourages dependency and powerlessness: ... this woman I really felt for her today, because, I mean, she was really trying hard and I could really empathise with her. And I was trying to reassure her that it was OK. That what she was doing was OK. But ... and then I knew I had terminate the interview at a certain time, because we weren’t going to get anywhere. I’d done what I needed to do. And she needed to have a sleep. And then I said “Now tomorrow morning ... here’s the child health clinic ... ‘Ann’ ... and I’ll give her a ring ... and you’ll like working with ‘Ann’ and she’ll be able to assist you”. And that’s OK. Gwen 873-883
SUMARY OF THE CHAPTER This chapter sought to explore some of the major themes related to the community health nursing role. In particular the context of practice has a powerful impact on the way in which the community health nursing role is understood and enacted. Dialectical themes were identified in the data, presenting a complex picture of practice that requires incorporation into a coherent understanding of the community health
211 nursing role. These dialectical issues are addressed by community health nurses in their purpose, the role activities they undertake and the way in which they enact their role, that are presented in Chapter Seven, Chapter Eight and Chapter Nine.
212
CHAPTER SEVEN Situated Health Competence: Answering the Question of Purpose Its leading people on a discovery. And it’s just discovering the power within themselves. And building up their own self esteem. I mean everyone’s got different ideas ... different ability ... but being able to give them the opportunity to discover what they’ve got in terms of their own abilities and resources. Gwen 351-356
OVERVIEW Research Question Two asked how practising community health nurses interpret their role in a range of Australian community health settings. This chapter provides further analysis of the participants’ perceptions of their role and an explanation of the underpinning purpose of the community health nurses’ role. This explanation describes a way of understanding the dialectics that were presented and discussed in Chapter Six, and also proposes an explanation for the variation in the role activities undertaken by participants that were found in the data. Understanding of the purpose of the community health nursing role provides clarity for an examination of the role activities presented in Chapter Seven and material presented in Chapter Eight that discusses the way in which community health nurses enact their role.
THE QUESTION OF PURPOSE Chapter Six outlined some of the major dialectical themes that emerged from the data. Examination of these data revealed many instances where participants identified the limitations and boundaries of their role together with statements about which activities
213 were not considered part of the role. While it was important to discover areas of practice that participants did not generally involve themselves in, essentially what was often being identified was a range of activities participants tended not to do. Although providing some understanding and clarification, this approach to analysis did not provide a clear or positive description of what the nurse actually does do and why. There was a lack of clarity about what the role of the community health nurse was actually about, and a need to answer the recurring question “But what do you actually do?” together with the underlying question “what are you aiming to do?” There was a need to identify a way of understanding the conflicting themes in the data and explain the range and variation in practices and activities undertaken by community health nurse participants working in a range of settings. The participants themselves articulated their role in terms of prevention, health promotion, primary health care and health, but as discussed above, these notions of themselves did not provide specificity in describing or understanding the community health nursing role. There did not appear to be any one theme which the researcher had coded for that provided an explanation or unifying concept that explained the role as it was described by participants. It was decided that data would be examined to discover what participants did describe themselves as doing and why. To this end, data were examined to explore the philosophies expressed by participants, what they felt they learned when they began as practitioners in the field, their stated aims and purposes, the activities they described themselves as undertaking as part of their role, the distinctions they made between their own role and the role of others, the way in which they related to clients, referral patterns, how they evaluated their work, the judgements they made, what they viewed as achievements or ‘successes’ in their job and finally how they enacted the community health nursing role. These, together with the variation in role enactment and dialectical themes identified in the data were examined. It was felt that analysis of these aspects of the data may provide an understanding or explanation of the community health nursing role. A major goal that emerged from an examination of all these categories in the data pointed to the issue of client self-care, client self responsibility and assisting the client to manage their own health problems as important. These themes were repeatedly and consistently present in the data from all participants. This approach to thinking about
214 the role of the community health nurse appeared to hold for individual, family, group and occasionally community clients, and for a variety of community health nursing practice settings such as schools, child health, diabetes education, Aboriginal health, generalist community, aged, rural, remote, and drug and alcohol. Participants were asked during the course of in-depth interviews what things were viewed as achievements and successes in their community health nursing role. This line of questioning was found to be productive in eliciting thoughts and ideas, and uncovering the purposes and aims of participants. In the main, participants were working in a role that aimed to facilitate health and prevent disease: Well I think ... for them to feel as though they are capable of solving their own problems ... yeah ... rather than me saying “this is what you do”. That they can make ... that eventually they will gain enough knowledge to function by themselves without a problem. Cheryl 124-128 And if I can make [suburb] Health District healthier, then that’s all I can hope to achieve. Kate 916-918 However, the aim of promoting health and the preventing of disease is a broad aim and long term in nature. In addition, its outcomes are general, ill-defined and indeterminate. Participants indicated that it was very difficult to apply quantitative measures, or in some instances to really know specifically what the outcomes of their work was: ... but it’s all long term. It’s not immediate. I think a lot of it is measuring the out-comes, that are difficult. How do you measure ... I mean is the family that I see at birth and five years down the track ... I mean what’s the difference? What’s been the outcome for that? How do we measure that? Karen 564-571 How do you measure the outcome of sitting here for half an hour, talking to a person about a domestic violence situation or her marital breakdown ... and those sort of things. How do you measure that ... when you compare it to measuring a wound getting better after three days of treatment. Cheryl 502506
215 As a consequence, participants had to identify other indicators that were more immediate, and possibly in some cases less satisfying in terms of real outcomes. However, although indicating that quantitative measures were difficult to apply, it is obvious that if no one wished to use their services, then their work could not be judged as successful. Participants recognised that statistics were important in outcomes, and provided their employers with required statistical reports. They indicated that they felt that it was important to justify what they did and noted numbers in terms of client participation, services provided and where possible outcomes. Thus participation in activities, utilisation of the services provided by the nurse, together with an acceptance of nurses themselves by clients was seen as important: ... it was all funded ... 465 children had breakfast. And there was a lot of publicity about it. Lyn 1015-1018 ... and they turned up. So that was my measure of achievement. And plus ... just the way that they approached me. I felt that, you know, they were friendly. So I felt they must be thinking “this nurse is OK ... what she’s doing is all right”... And I suppose another measure of my achievement was how I was readily accepted into the house. I wasn’t kept out on the doorstep, which is what used to happen in the beginning. Lyn 257-261; 314-317 Although participants did consider the importance of quantitative measures and took account of the numbers of people attending events and accessing their services, they saw that statistical information was limited in providing a valid assessment of their achievement. Participants mainly viewed their achievement in qualitative terms. If, for example an educational session does not reach those who would most benefit by it, then it is arguably less successful. The qualitative factors that participants used were examined. Factors that were identified included: reaching people in need, being utilised appropriately, ‘not being needed’, providing a resource, and improving processes. First, participants saw that there is less usefulness in “preaching to the converted”. Participants indicated that at times, an activity may not be successful in terms of gross
216 numbers. However reaching those in need was viewed by them as an indicator of success. At times participants found this aspect difficult to outline in the provision of statistical information to their employers: ... but you know, getting three or four people here to anything is a bonus. I mean, people don’t come because their priorities are different ... but I think I’ve got about five or six people to this asthma thing and each one of them had two kids with asthma. So I probably reached around about twenty kids all told of the people I’ve had there. So they tell other people who tell other people ... so
I’ve
got
to
look
at
that
as
a
way
of
doing
things.
... and I mean the asthma thing couldn’t be judged a great success by numbers ... but it did reach some people I would have liked it to reach. And so ... in that terms ... it’s how you define outcomes ... and that’s the most difficult thing in community. Louise 271-378289-395 ... at the moment, what we are mainly doing is we are just getting people back after three months [after a diabetes education program] ... and they’re still in the honeymoon period [after diagnosis]. I want to see, two or three years down the track ... have they made the changes necessary to keep their blood sugar levels under control. Or does the threat of the complications diminish the longer you are away from the course. So what I’m starting doing next year, is instead of having review groups like we were doing, I’m staggering my course. And I’m having a second one, which will probably be about ... oh eight months after they have done the first one. It’s going to be an increased ... a knowledge based, problem solving one. So I’m going to give them a bit more. Gwen 1012-1023 Secondly, participants felt that appropriate utilisation of their services and independent accessing of the resources and services provided by others, such as community groups, screening services, immunisation, follow-up of medical conditions and so on was also a very important indicator of whether the nurse has been successful in their role. If clients themselves accessed resources appropriately, participants felt that they had understood the importance of health information given to them, and taken action based on their own choices:
217 I guess ... well it’s not on numbers [determining success]. I mean it’s on the appropriateness of people’s attendance. I mean ... not exactly on numbers, but people knowing that the service is there, and it’s available for them. And people using it appropriately. Mary 406-410 Or that they’ve actually got themselves into hospital ... and you know, followed through on the steps that you’ve encouraged them or advised them to do in the first place. I suppose that’s the biggest thrill, getting that satisfaction. Or even for ... you know going to the local immunisation centre ... they’ve actually, you know, made that step. They’re actually doing more things for themselves, once they’ve got that information. Amy 804-808 Thirdly, where the participants saw that the client was acting to do things for themselves, this was seen as an achievement. Participants recognised that it may be appropriate that clients not utilise their services. They indicated that if a client was developing their own skills, making choices and solving their own problems, then they may not need to access the services of a nurse. All participants taking the view that clients doing things for themselves and consequently ‘not needing them’ was a success indicator, qualified this by indicating that clients did need to be able to access them as a resource, if a problem did arise: So that’s an indicator. If I have mothers who are coping well and have healthy babies and breast-feeding is established ... and you think ... who don’t return on a weekly, monthly or whatever basis ... that’s good. Because they obviously feel confident in their parenting.
They come back for the recommended
scheduled screenings, that’s good too. But mothers who come back every week, there’s either got to be a problem, that we actually have identified and we’re working with, or [the] mum’s got a problem in that she hasn’t got any confidence or self esteem or whatever in her parenting. Kate 588-597 Or that you’re seeing that they’re actually doing things for themselves. They’ve actually ... I mean it’s the biggest joy if you know that they let you know that their diabetes is, you know, their sugar level is down ... under control, down to the right level. Amy 797-808
218 A further measure of success, was the achievement of goals participants set themselves. If they were running a program aimed at increasing knowledge, then achieving this goal was a measure of their success: And then I did a follow up survey [to a whole school nutrition program and a healthy breakfast activity]. And I think ... and I sort of ... I did all the high school and every second year ... like I did two, four, five, six and sevens ... I think I did ... the whole lot. So it was hundreds of people ... children ... filled in their forms ... their surveys. And one of the questions was “What is two or three foods that is healthy to eat for breakfast?” or something ... “what is two foods?” And every child gave me an example of three good foods and two bad foods. So I felt that I had at least ... they had internalised that this was what a good food was. Whether they were genuine or not is a different matter, but in actual fact, as long as they had gained some knowledge from it. Lyn 10341048 At times, these goals did not necessarily relate expressly to client outcomes. In particular, participants identified that linking with or provision of resources for clients was important. If they either provided or contributed to providing a resource, then this was viewed as successful: OK. Yeah. Well I finished, I felt that they did know why I was there. Because that was my aim ... to try and get them to know that there is a Community Nurse in their area, and that she could possibly assist them. Lyn 973-976 Yeah, I think, sometimes that they’re surprised at the amount of information that you do have. Cheryl 165-170 Finally, participants saw that forming networks, processes and relationships, whether with clients, community organisations or other professionals, was worth spending time on. Participants saw that promotion of their role and establishment of networks within the community as an important achievement. These links then were used to contribute to their future activities. For example, Lyn described how she took some time to develop a positive relationship with the Aboriginal population of the country town in which she was working. When established, this relationship enabled her to run a child
219 health clinic specifically for Aboriginal clients that was well attended, Previously, there had been little attendance at the local child health centre by Aboriginal clients. Anna identified opportunities to develop networks: She organised a health screening session for skin cancer. All right. And tapped into local GPs.
And got this done for staff on a professional
development day. Okay, so she’s looking after the health of staff. And she knows she’ll get spin offs from that. Anna 328-332
Situated Health Competence Self-care as an aim can be found in many spheres of nursing practice. However, closer examination of data indicated that the way in which self-care approaches were described by participants incorporated a range of characteristics that went beyond the notions of self-care outlined in the literature, and those generally incorporated into nursing practice in an institutional setting. First, participants assisted clients to deal with their health problems or to incorporate healthy living patterns into the context of their ‘real’ everyday lives - including work, recreation, relationships, roles and responsibilities. As a consequence, the objectives of the nurse to achieve self-care when working with individuals, families, groups and communities was contextual and ‘situated’. Secondly, the notion of self care identified in the data encompassed a broader scope than that found in the literature: ... but if people are managing their own blood sugar levels ... they’ve got, they’re getting a reasonably good control ... and they’re taking control of their disease, rather than saying “well I’ve got no control over the doctor who tests my blood and tells me what I should and shouldn’t eat.” They become more assertive. Which is what I’m hoping comes out in education. And [they] take control of a working partnership with their GPs. And they come to me and they say “I’m coming to see you because I’ve got a problem, this is my problem.” Then I think we’ve achieved something. Because they actually feel
220 as if they’ve got some power and some control over what’s going on. Gwen 627-641 Yeah. To me it is the critical theory acted out, empowering people to make choices. It’s providing them with somewhere to go to know how to make a change ... whatever the change may be. Whether it be family problems, or whether it’s diet, or whether it’s accessing services because they are already physically disabled, it’s ... social equality basically ... Janet 908-914 Participants aimed to promote, advance, facilitate or assist health competence, including management, decision-making and accessing of resources in relation to disease, illness, rehabilitation or preventative or health promoting behaviours in clients, including individuals, families, groups or communities. It could be argued that this notion constitutes ‘empowerment’: And I get a really quite a kick out of seeing people being able to take ... empower ... Now I’m a great believer in health ... in what I call health consumerism. And when I talk to groups, I say “you know if you’re not happy with your doctor or your child health nurse ... or you’re not happy with me ... you go to another place, until you’re happy with somebody else. You don’t have to put up with it. Because you are a consumer, and you purchase services, be it by Medicare or whatever you do, you are a consumer”. So I guess ... I hate the word ‘empowerment’ ... but that’s what I like to do. Gwen 329-338 However, the scope and range of participants’ activities were not fully described by the notion of empowerment. As described above, participants engaged in activities that were aimed at health promotion, disease prevention, and in some cases ‘doing for’ clients. Although participants described their practices as aimed at empowering clients, some expressed ambivalence about the term and questioned the notion: And I think that if empowerment occurs, in it’s truest sense, we help to heal some of those scars. And it’s not easy. It’s not ... and that’s why I think it’s ... it’s ... “we’re going to ‘empower’ the community”. We can’t ‘empower’ them. People have to do it themselves. We can only provide the environment for it to
221 happen. It’s a bit like teaching and learning. We can’t ‘learn’ people. We can only create an environment for them to learn. And I think that the same thing applies with empowerment. Karen 329-337 Mary: I hate to say that kind of statement ... but because they need, the clients need to be empowered themselves ... and I hate that saying as well ... but they have got to ... they are quite capable of doing everything themselves. Researcher:
Why
do
you
hate
the
word
‘empowered’?
Mary [laughs] Because it’s hackneyed. It so over done. [laughs] But it’s quite a good word. Mary 606-614 The notion of empowerment was included in some job descriptions and organisational documentation accessed in this study: Utilisation of advanced nursing skills to encourage optimal health for clients (individual, family, community) by the provision of information, resources, support and the organisation of appropriate services.
This involves
development of strategies that organise and empower people to change the agents, institutions and circumstances that affect their health adversely and acknowledges individual autonomy and responsibility for their own health care. Helen, job description 29-36 Community wellness, Cultural Sensitivity, Education, Early detection, Prevention, Empowerment, Restoration and rehabilitation, Support and Advocacy. Vision, The Philosophy of the Community Nurse 23-25 Thus, the primary aim was to facilitate the client, whether individual, family, group or whole community, in gaining the competence to deal with their health issues, whether the issue was dealing with an illness, assuming behaviours that will prevent ill-health or engaging in behaviours that will promote health as a positive entity. The notion of ‘self-care’ that was identified as the aim of community health nursing practice in the data was called ‘Situated Health Competence’ by the researcher and its distinguishing characteristics were the basis of further analysis in order to clarify it and identify its properties. There were seven distinct properties identified in the data related to Situated Health Competence. These included context, scope, definition, allocation of
222 responsibility, level of client, responsiveness and a recognition of a continuum in possible client achievement.
Contextuality of Situated Health Competence As described above, the context was a powerful factor in community health nursing practice. Contextuality constituted a first crucial property of Situated Health Competence in the data. In facilitating the health competence of an individual, family, group or community, the nurse is located or placed in a setting that is very different from that of an institutional setting. These nurses were not just focussing on functional aspects of self care. They were assisting and promoting health competence, but doing this in the context of the ‘reality’ of their clients’ everyday lives. Rather than operating in the decontextualised or artificial environment of an institution, the contextual ‘place’ for addressing health issues was where people ‘live, work and play’ and integrated into the fabric of peoples’ everyday living patterns, in their everyday environment. This involved the nurse in assisting clients to integrate health behaviours or deal with health problems in the context that took cognisance of the idiosyncratic nature of peoples’ own situations or the ‘messy reality’ and variation of peoples lives. Participants’ ‘nursing’ was not simply focussing on decontextualised ‘functions’, but assisting people to undertake their ‘real’ lives, in their ‘real’ communities’ in the ‘real’ world. In other words, if a client is: diabetic, incontinent, a new parent, or addicted to drugs; or a community dealing with teenage smoking, poor nutrition, violence, poverty or unemployment; then these problems must be dealt with in the context of people’s ‘real’ daily lives and within ‘real’ daily living patterns. This is the ‘reality’ of what the community health nurse is dealing with. The ‘environment’ is not a peripheral factor in relation to the health issues and needs of the client, it is integral. The social and physical environment have a profound impact on disease, illness and the health behaviours of clients: Yeah.
But if you approach somebody in their own home and you make
suggestions for them for change ... you have to make them in such a way that they’re acceptable to that person ... and within the context of their environment, their cultural setting. Janet 1037-1041
223 In addition, as clients were engaging in the normal or usual activities and responsibilities of their everyday lives including work, recreation, relationships and role responsibilities, the role of clients identified in the data was a ‘well’ role rather than the assumption of a ‘sick’ role. In some instances, nurses worked to engage clients in changing from a sick role to a well role: Ah certainly if people are sick, you have a slightly different approach. People who
are
well
often
need
to
be
informed
that
they’re
well.
... because what you see, probably more with adolescents, which is where I work now, the sick role is adopted. Because they are not sick ... but because other
things
are
happening
in
their
lives.
... but trying to get them out of this thinking “I am sick”, you know this sick role. Anna 117-119; 123-126; 160-162. But I think with community nursing there is that ... the nurses’ role with well people ... who are basically well. Carol 307-309 There was a recognition by participants that in the context of people’s everyday lives, health may not be the highest priority and it may compete with other factors for attention: But it’s very difficult if you are a woman with a couple of kids, living in a state housing [dwelling], just to sit there and talk to her about stress management ... it doesn’t relate. But you can talk to her about the fact that she is not too well, in our courses. And for maybe for an hour, two hours a week she can do something for her. And not feel the pressure ... while the kids are looked after by a creche. Maybe that gives her enough to get on with the rest of her life. Gwen 1059-1067 A further contextual difference is that, in contrast to the role of a nurse in an institutional setting, in the community the nurse is not ‘there’ for clients all the time, and has limited resources. The clients that participants were working with are not able to be constantly monitored or supervised. The nurse cannot ‘take care’ of the client in an ongoing way. When this is compared to care delivered in an institutional setting, nurses are ‘there’ and if a problem arises, a nurse can assist and, where necessary, ‘do
224 for’ a client. When a client is discharged from an institutional or home care situation, the nurse is not there to ‘do for’ the client and the client is ‘on their own’. Thus the individual, family, group or community must make decisions and cope with the health issue or problem themselves, and do so in a way that fits with their own situation. This context is considered by the nurse: ... somebody to come out and do an assessment. And nobody cares for the carers. You know we run the carers into the ground, and then they become ... you know they need a service. Anna 1012-1014 A further contextual factor was that participants were aware of the resource context of their clients. They saw their role as providing or linking clients to resources and services, and assisting them to use them appropriately. They also saw themselves as a resource to their clients. As such, they themselves are a factor in their clients’ context. Their knowledge of health and the health system was of value to clients, and their ability to assist clients in accessing appropriate resources was an important part of their role. Participants were constantly aware that their own knowledge, experience and expertise were important in their interactions with clients. Barnum (1994, p. 23) suggested that in many nursing theories, context is unstated and must be inferred from the general discussion of the theory. She suggests that older theories of nursing tended to envisage nursing as occurring in an acute context. More recently theorists, such as Leininger (1991), have developed theories that incorporate technological, religious, philosophical, kinship, social, cultural values and lifeways, political, legal, economic and educational contextual factors. However, few incorporate an explicit context that encompasses the ‘well role’ and addresses the client within the context of their day-to-day lives, where health is competing with other facets of clients’ lives. This research suggests that situatedness is fundamental to the community health nurses’ perspective of role.
Scope of Situated Health Competence The second property encompassed by the notion of Situated Health Competence related to the breadth of participants’ practice focus, based on their philosophical views of health and primary health care. Their health focus was not limited to
225 activities of daily living such as mobility, hygiene, and so on, that are intimated by nursing theorists such as Henderson (1966), or managing and coping with the immediate sequelae of disease. While participants included these factors in their scope of practice, they were also interested in their clients’ ability to: cope with and manage their own illnesses on a longer term basis; have enough knowledge and ability to manage not only their illnesses, but also incorporate health enhancing behaviours into their daily lives; question and make decisions about their health; appropriately seek out and use health and community resources; and to do this while going about their daily lives. This approach was of interest because it moves the practice of community health nurses away from medical model approaches, to a primary health care model that addresses the full range of factors identified in participants’ definitions of health, and incorporates a spectrum that ranges from disease, illness, prevention through to health as a positive entity: I find that I am working ... I am still working with people in the community at those different stages of health ... primary, secondary and tertiary. I see my role as enabling people to have the maximum quality of life, at whatever stage they are at. Sharon 215-219
Level of Client in Situated Health Competence The third property was related to the level of client. Participants in this research addressed the needs, not only individuals, but also of families, groups, target groups and occasionally whole communities. This aspect was evident in the connected way in which they saw individual clients as situated within their families, groups and communities, and also in the way in which they understood an aggregate notion of a ‘healthy community’. There was also evidence that when the needs of individual clients were being addressed, activities were carried out in a way that demonstrated an awareness of the population to which the individual belonged: So the needs of the individuals can be different from the general needs of the community ... which could be having a problem with no transport ... or ... and that may not be an individual need though ... if they had the transport. Lyn 1219-1225
226 I suppose it’s the same thing that I think of [the definition of] health as, but just larger. Absence of disease in the community, can mean good public health. You know, so we’ve got good garbage and drainage and toilets and all those things. But also that the community has a good attitude towards other people ... towards disabilities, towards mothers and babies ... which they don’t have in my particular council [area]. Kate 481-487
Judgement About What Constitutes Health Competence The fourth property was related to the flexible way in which participants defined client ‘health competence’. Participants made individual judgements about what constituted health competence in relation to each particular client in each particular contextual situation. Participants worked alongside clients and were sensitive to their views, resources and their specific social and physical environments. Thus, for a particular client, health competence was inextricably linked to the clients’ specific context. In addition, they also drew on their own experiences and knowledge in making judgements by considering the seriousness of the health issue and the extent of the impact of health behaviour on a persons’ physical, emotional and social health: ... to me it’s helping to create within a person, or within a family a sense of wellbeing about the decisions they make. Now whether those decisions are, from a professional view-point, the “right” decision ... as long as the decision does not in some way put that child at risk, or that family at risk, who am I to judge whether that is a “right” decision. Karen 300-306 Well I guess the way they find themselves to be healthy, not how I find it.[laughs] Mary 143-148 An example of a judgment which defined health competence contextually was given by a participant in one of the focus group discussions. The participant described a client of hers as a person who ‘did drugs’ but felt that he was healthier than he had been previously, because he had ‘given up drugs’ and was instead drinking a bottle of beer every night. The nurse felt that, for this client, this was achieving a higher level of health competence. Other examples are given by a child health nurse and a nurse working with clients with drug addictions:
227 I suppose I look at ... no I don’t suppose, I know. I would look ... as an example at a mother who is ‘losing it’ with a two and a half year old, and think “yeah, that’s healthy”. That’s a normal response to a long day. That’s not abnormal. I can do things to help her, but she’s healthy. Because it’s healthy to be angry. It’s healthy to be frustrated. It’s healthy to be sad. Kate 452-458 And they will take methadone for the rest of their lives. And if any outsider were to look at our books and see all the clients’ names they’d know that all those clients had IV drug problems in the past. And [they] may or may not sort of have biases or prejudices or whatever towards IV drug users. Whereas there’s a few clients on the program that are on methadone now ... they’ve been on it for 15 years and they’ll be on it until they’re eighty. They don’t use drugs any more ... they don’t ... they’re normal functioning members of the community. And I think ... it’s a shame that they have to be tagged as addicts when they’re probably straighter than you or I ... if you know [what I mean] ... it’s just like ... they’re not doing anything wrong ... they’re ... and I think that’s a little bit sad as far as ... I see them as healthy yeah ... yeah. Emily 574-591
Allocation of Responsibility in Situated Health Competence The fifth defining property was related to responsibility for achieving Situated Health Competence. As discussed in Chapter Seven, control and responsibility were major issues for the participants in this study. With an understanding that a community health nurse is aiming to facilitate Situated Health Competence, the reason that control and responsibility was such a major issue for participants becomes clearer. Health competence is not something the nurse can ‘do’ for the client. They must achieve it themselves. Thus, participants place the responsibility for health competence with the client. Their role is to support and promote this competence: Giving people encouragement, and drawing out their strengths. And giving them responsibility, but encouraging them along with that responsibility. Giving them goals, and socially oriented goals. I found that it was a really useful way of working. Helen 530-536
228 And you know, maybe [I may] not have solved all her problems ... but [I have] given her information so she will make better decisions, I hope, about her own health care. Louise 304-306
The Nurses’ Responsiveness in Promoting Situated Health Competence The sixth property related to Situated Health Competence was the way in which participants’ practice was responsive to changes and to need - whether at an individual, family, group or community level. This responsiveness required flexibility on the part of the nurse in addressing changes in context and need. Participants also saw that their location in the community and consequent accessibility, was a factor which was important to development of a responsive role. It appeared that nurses modified the way in which they represent themselves, depending on factors such as the length of client contact, the type of client, the needs of the client, the perspective and understanding of the client. Changes in the Context The participants’ responsiveness was evident at many levels that included responsiveness to changes in: the particular client situation; the client needs; the wishes of the client; the cultural, physical, social and political environment; the resources available; and their own professional knowledge. The awareness they demonstrated was consistent with the view of Leininger (1991) who suggests that there is a need to take into account the individual and groups’ caring behaviour patterns, values, and beliefs based on culture. Participants responded to issues in order to assist clients to manage their own health issues, problems and needs in the context of their own daily lives in the changing situation of the ‘real’ world. Responsiveness to the unique client context is essential if a community health nurse is to practise in a way that incorporates the contextual nature of Situated Health Competence. Thus participants’ practice also took cognisance of changes in context. The researcher found that these participants were very aware of, and responsive to, the most recent social, cultural and political changes in society that could impact on people’s health.
229 An example of this was an awareness of the needs of a recent influx of newly arrived refugees from a country from which Australia had not previously had many migrants. Other examples included changes in resources and the nature of the area: ... or you might have found in your community profile, that [for example] the [suburb] area doesn’t have any sort of community health centre ... community centre. Since the hall burnt down, anyway. You know you might be looking at your community as a whole. And trying to ... [for example] you might have high teenage pregnancy rates, so you try to get HRE [human relationship education] programs established in the schools. Janet 787-795
Responsiveness to Issues and Need The property of responsiveness encompassed not simply identifying issues, problems or needs of individual, family, group or community clients, but also working with them to clarify needs or issues and responding with action. The clients’ understanding of their own health issue, problem or need was an important factor in this assessment process. Once the importance of a health issue, problem or need had been established, it was significant in determining the goals of the nurse in addressing them and directing action. It was this responsive translation into doing and action that was characteristic of the nurses’ role in facilitating Situated Health Competence. It was also evident that this responsiveness relied on the closely inter-connected networks and links the nurse had within the community: My role as a community nurse is really providing whatever the community requires of me, within [laugh] the limitations of my job description and budget. ... I’m really able to do things on the spot and deal with problems as they arise. Plus do long term planning of things. But really whatever I’m needed to do. Kate 106-122 Yes, so ... a person comes in ... its getting in touch with that person, and trying to find out what their needs are. And from then on, you link up with other agencies. Helen 21-23
230 Although participants were responsive, they did not always undertake to address an identified client need themselves directly. They chose from a range of options. For instance, in responding to an issue, the nurse may choose to conduct a health education session or alternatively organise for someone else to do it. At times participants referred to others who perhaps could more appropriately meet a particular need, or could meet a need in a more ongoing way than they themselves could provide for: And some of the needs a client presents with, I can refer them to another agency or other individuals, and some things I will deal with directly. So my role involves providing resources, and networking or linking clients with other agencies and other disciplines. Helen 11-15 It also appeared that participants’ responsiveness to need involved them in stepping in to provide services, when these were not available to their clients in the community in which they lived. The participants’ role was often affected by who else was employed in their own service and the availability of other health professional services in the local community. The role of the nurse was flexible enough to encompass the needs created by an absence of other health professionals. Once other health professionals were employed, the role shifted and changed, demonstrating the breadth, flexibility and generalist nature of the nursing role. This was particularly so for the nurses who worked in remote areas and also the nurse who worked in a Third World remote community: So they didn’t have access to the big hospitals in the major towns. So the service combined both, really. We provided a curative service in the health centre, but we provided a preventative service with immunisation programs, screening, health education, you know, maternal health, all those things ... Karen 75-84 ... but you see we have just one occupational therapist [in the whole area] ... even now when we have got two [occupational therapists] ... and they do hand splints, they do one morning in hospital ... they haven’t got time to do ... I mean if I am there ... So then I advise people about safety ... hand rails,
231 bathroom rails ... all those things ... toilets ... So then you do it at the same time ... when you are there. Joy 317-330 The community nurse will venture into expanded professional territory if this is important in terms of client needs. It appeared that because of their connectedness, participants saw their client’s needs as a moral imperative. It was pointed out by one participant in the focus groups that in many instances there is no one else to fulfil some needs. However, participants indicated that when they moved to a different location - for example from a remote area to an urban location, they did not necessarily continue to provide services for which they had ‘filled in’ where these were lacking. They acted instead to connect and refer clients to existing services: ... well, we’re basically [in remote communities] for health care.
But I
suppose I’m looking at it ... I mean it’s a bit different to down here [large urban city]. It’s really more up to [what] the needs are at the time. And the needs in the most of the [remote area] communities are very acute. Like it’s more illness-related. Not so much the wellness. We had a lot more injuries and trauma and more ... or we had things like really really bad anaemia or ... mostly all of the public health issues that you were concentrating on. Amy 356-370
Recognition
of
a
Continuum
in
the
Possible
Client
Achievement of a Gain in Situated Health Competence A final and very crucial property related to Situated Health Competence evident in the data was that participants recognised that not everyone can or will achieve the same level of health competence. Some clients do not want to improve their level of health competence; some do not have the personal, physical, social or financial resources to be able to achieve gains in their health competence; while others may not even be aware that they have a health problem, or that certain behaviours may have a negative impact on health.
232 This is consistent with the views of Rosenbaum (1989) who suggested that it is not simply necessary to have the capability for action, but that in order for self-care to occur, a person must have self-understanding, self-awareness, self-esteem, knowledge, motivation and a strategy for positive change: ... and just in whatever way we can ... health education and assistance in whatever stage of their health they are at. ... it is hopefully to improve it. Sharon 235-237 During analysis, the activities or role components of participants had been categorised and coded for. These categories were analysed and found to address a range of client ability in achieving Situated Health Competence. It appeared that participants recognised that there was a continuum in the ability of clients to make gains in achieving Situated Health Competence. This continuum in the ability of clients to achievement health competence provided an explanation for the range of activities carried out by participants and the inconsistencies in what participants ‘did for’ some clients but not others. The categories related to the activities of participants were further examined. It was found that their activities were directed in three main groupings which were called Identifying, Intervening and Enabling by the researcher (Figure 1). These are described in detail in Chapter Eight. These major themes were analysed. It was noted that whenever participants were engaged in activities related to Identifying or Intervening, they expressed an aim of increasing clients’ health competence to a level that would see the nurses’ role become Enabling, and then finally unnecessary. Thus, although participants did engage in Identifying or Intervening activities, they remained consistent in their aim of facilitating a higher level of client health competence: I guess ... its [my belief] that people have a lot of strength and a lot of abilities to be able to help themselves. And there are times ... in some people’s lives, when they just need extra support and encouragement. discouraged, especially young people. circumstances.
People get
They come from just appalling
And there are stages in their lives when they need some
encouragement ... and support. Helen 112-117
233 And I guess that ... that there’s sort of healthy independence and independence that’s not so healthy, I guess.
So I suppose it’s really working on
independence, in the sense of making decisions that that family feel happy about, and feel right about, and has positive outcomes for the children concerned. Karen 278-283
DEFINING SITUATED HEALTH COMPETENCE Based on the foregoing analysis, the concept of Situated Health Competence is defined as follows: Situated Health Competence is when individuals, families, groups and communities: Identify and manage their own illnesses, health problems, health issues, and health behaviours; and Have enough knowledge and power to make their own decisions, question matters that impact on their health and seek out and access appropriate resources on an ongoing basis. Recognising that: Situated Health Competence is achieved within the context of going about one’s everyday life, including work, recreation, relationships and role responsibilities; Social, political and environmental factors exert a powerful effect on health; Health competes with other matters in the lives of individuals, families, groups and communities; There is a continuum in the ability of individuals, families, groups and communities to achieve Situated Health Competence; and Achievement of Situated Health Competence may be defined differently in different situations by different people.
234
SITUATED HEALTH COMPETENCE: MAKING SENSE OF THE ISSUES AND DIALECTICS An understanding of Situated Health Competence as the major aim of the community health nurse role provided clarification and explanation of a number of the themes, dialectics and issues that were consistently present in the data. In particular, Situated Health Competence clarified factors relating to the philosophical perspectives of participants and the issues of: the relationship between health and disease in participants’ practice; control and responsibility; and the client-nurse relationship. The aim of assisting clients, whether individual, family, group or community, to achieve Situated Health Competence had close congruence with the philosophies expressed by participants. The philosophical approaches taken by these community health nurses included their perspectives of a socially contextual view of health, holism and primary health care. They had a major focus on prevention, health education and promotion and an inclusion of the family in discussion of individual clients. These philosophies can be understood in the light of an aim to facilitate Situated Health Competence. Understanding the aim of facilitating Situated Health Competence also assists in making sense of participants’ approach to health and disease. One of the recurring issues in the role of the community health nurse was the tension between health and disease in their practice. In many instances, community health nurses identified strongly with a disease prevention and health model, and rejected the medical model. Perhaps this is a response to the precedence that illness and disease has in traditional nursing, and also a fear that prevention and health promotion activities will be sidelined or negated by the immediacy and dominance of ill-health. However, as described above, participants did have a distinct focus on both health and disease within their role. The difficulty has been to provide a model that explains the relative place of both in the community health nursing role. The notion of Situated Health Competence provides a way of thinking about the nurses’ activities that incorporates disease, illness, prevention and health in a meaningful way. At every stage of Identifying, Intervening and Enabling (discussed below) the aim is to move clients towards health competence. Thus, while the nurse
235 may be addressing a whole range of health issues, needs and behaviours, the unifying factor is that while the nurse is focussing on the responses of clients, which is the essence of nursing, they are now understood to be acting within a wellness and contextually situated model rather than within a constructed environment and an illness model. This approach is based on a philosophy that upholds the connection between prevention and cure, and health and illness. The nurse is focussed on the client gaining health competence in their own ‘situated’ environment. Thus there continues to be a requirement for up-to-date knowledge not only of disease and illness processes but also related to health, wellness and health promotion. The notion of Situated Health Competence also assists in providing an understanding of the conflicts associated with the issues of control, responsibility and ‘doing for’ found in the data. When the concern of a nurse is for clients to gain health competence in their own particular situation, the need to balance between ‘doing for’ and promoting the clients’ own ability to ‘do for’ themselves comes into focus. The concern for clients being responsible for their own health, being able to manage their own health situation, learning to make decisions themselves and constant encouraging of clients to ‘do for’ themselves is logical. The nurse is aiming to assist clients to be independent rather than becoming dependent on the nurse. The notion of Situated Health Competence also provides a logical explanation for the issue related to the provision of ‘hands on’ care and treatment by community health nurses. As described above, participants tended not to provide ‘hands on’ care, but did so on occasion. If the nurse is treating, then the nurse is ‘doing for’. This is not the aim of the nurse. The nurse is aiming for the client to ‘do for themselves’. When the provision of community health nursing services are being rendered with the aim of Situated Health Competence, one can see that there would, at times, be a requirement for nurses to make a judgement not to do things for the client, but to ‘put their hands behind their backs’ in order to assist clients to learn to do things for themselves and undertake their own physical care. Thus, while these activities may remain as a part of the role in some situations, they are not carried out to the same extent by community health nurses. This results in a limitation to the amount of ‘hands on’ physical care activities carried out by the community health nurse. If the client requires an episode of physical care, then this becomes a matter for a referral to an agency that can provide physical care during this episode.
236 When the activities of the community health nurse are understood in relation to the aim of facilitating Situated Health Competence the variation in participants’ role activities and the boundaries set also make sense. It was noted that there were contradictions between what different nurses would do and even between what a single nurse would do in different situations. When it is understood that the nurse is aiming to assist clients to achieve Situated Health Competence, one can see that there is a requirement to make assessments and judgements. These judgements would include: assessments about community, group, family and individual health needs and their importance; the impact of the client situation; the ability of clients to undertake to meet those needs; and the activities that would be most effective in addressing the issue, problem or need. Thus community health nurses make judgements about the vulnerability of the client, the seriousness of the need and the effectiveness of their own activities. As each client, situation, need and ability is different, this would require a range of actions on the part of the nurse in response, and results in variations in the role activities and boundaries set by the nurse. Situated Health Competence also explains why participants placed the boundaries of their role where they did. Community health nurses are concerned that the immediacy of client need, for example, assistance with dressings or showering, not become their primary focus. In this situation, the nurse would consider that the client needs more supportive assistance, care and attention that may be more appropriately offered by home nursing services, in an institutional setting, or from a range of other health professionals, and would refer them. Situated Health Competence also provides a basis for differentiating the nursing role from that of other professional practitioners, particularly health educators and social workers in the community, even though they may at times undertake similar activities that ‘look’ the same. There was a recognition that the perspective of other health professionals was different. One participant pointed out that nurses frequently: ... can’t see past “nursing is only valuable if it meets human needs”. And it wasn’t until I did that [education] course [with other health professionals, that] I realised that not everybody thinks like nurses do. And I realised I had a problem. Because if I’m seeing things like that, other nurses were [also] seeing things like that, and they [other nurses] needed to grow. And find out
237 ... because ... unless as a community nurse you can grow, and understand where other people [are coming from] ... you can’t achieve your nursing goals. Rhonda 1082-1089 It has been pointed out by many authors that one of the distinguishing characteristics of the nurse role is a licence to touch people’s bodies (Hickson and Holmes, 1991; Lawler, 1991b). In contrast, a health educator or social worker is not licensed to do so. It could be argued that the ability to engage physically with clients may be a factor which distinguishes the community health nursing role from that of other allied and health practitioners in the community. As a consequence, the employment of a nurse in a community role invokes the particular skills and abilities that belong to the nurse, which other health professionals do not possess and enable a wider range of skills to be bought to bear in the contract between the nurse and the individual or family client. The ability to physically engage with clients also suggests that this aspect of nursing practice, while de-emphasised in the community health nursing practice role, is indeed present, and provides a maintenance of the role as another form of nursing practice that is distinct from other disciplines operating in the community. While physical contact with clients may provide an explanation for differentiation from some other health professionals, it does not provide an explanation which differentiates it from other spheres of nursing practice. The aim of facilitating Situated Health Competence provides an explanation. The difference lies in: the situated, contextual nature of the role; the nurses’ focus on the range from illness and disease through to health and wellness; the scope of the nurses’ practice that includes physical touching and care; and the breadth of the nurses’ generalist or specialist knowledge base. The traditional foci of nursing practice are still present, but are incorporated within a broader role. Situated Health Competence also provided an explanation of the dialectical connectedness and disconnectedness found in the nurse-client relationship. The connectedness, flexibility, trust and sensitivity expressed in the nurse-client relationship results from the aim that the client achieve health competence in their own real world, in other words - situated. Thus there is a need for respect and honesty in order to uncover and deal with the ‘real’ problems and the ‘real’ actions of the client.
238 However, the aim is also for the client to function independently of the nurse and assume control and responsibility for their own health. Facilitating health competence requires that the nurse maintains an aim of independent client competence, while at times making judgments to ‘do for’ clients. This may require the nurse to have a more disconnected relationship with the client at times. This approach does not fit with traditional notions of caring in nursing. The aim of promoting independence also explains the angst expressed by participants about situations where clients appear to become dependent on the services of the nurse. Finally, when it is considered that the role of the community health nurse is based on judgements made to facilitate Situated Health Competence, the reasons that participants have such difficulty in articulating a coherent understanding of their role becomes clearer. Inherent in facilitating Situated Health Competence are the dialectics, nuances, contradictions and judgments, all of which must be balanced by the nurse enacting the role.
SUMARY OF THE CHAPTER This chapter presented a discussion of the notion of Situated Health Competence as a central aim of the role of the community health nurse. This notion provides a clear understanding of the aim of the community health nurse role and an explanation of how the dialectics presented in Chapter Six are resolved. The contextual and situated nature of this aim also explains the variation in the decision making of individual community health nurses and between community health nurses. In addition, this aim provides a basis for the explanation of role activities of the community health nurse, described in Chapter Eight, and a rationale for the processes of enacting the community health nursing role that is presented in Chapter Nine.
239
CHAPTER EIGHT “But What Do You Actually Do?”: Role Activities Aimed at Facilitating Situated Health Competence And I guess I see my role now as applying all those sort of principles, of primary health care and health promotion, health education and support, advocacy, counselling ... all those sort of things, for families in that age group ... helping to lay for them, some informed foundations of health in its narrowest and its broadest sense. Karen 234-239
OVERVIEW This chapter presents an overview of participants’ descriptions of the range of activities they engaged in while fulfilling the role of the community health nurse. Many of the role activities of the community health nurse are intertwined and overlap with each other. An examination of the role activities described by participants demonstrate that they were aimed at facilitating Situated Health Competence and promoting health in a manner that is consistent with the philosophical perspectives outlined in Chapter Five, that is: definitions of health and primary health care; and an holistic, contextual and family-centred approach. The activities they described address the needs of clients across a continuum of Identifying, Intervening and Enabling (Figure 1). Participants’ recognition of a continuum in the ability of clients to achieve health competence was evidenced by the way in which the aim of activities while Identifying, Intervening and Enabling, was to facilitate a higher level of health competence. It was also evident that at any level of Identifying, Intervening or Enabling activities, participants’ interconnectedness with resources in their communities was demonstrated by referrals to other appropriate resources.
240 The limitations of language mean that there is an inevitable meshing of the meanings of descriptors used to identify activities. For example, although the terms ‘health education’ and ‘health promotion’ can be defined differently, many participants used these two terms either together or inter-changeably. One could question whether provision of information is the same as health education or health promotion. Does giving advice that provides information in order to solve a client problem constitute information-giving, problem-solving or health education? Within the obvious limitations of the descriptors used here, the major role activities as they were identified by participants are presented in this chapter. An example of how enmeshed these activities are is the description given by Kate about her role: Education, information. Just providing information to people. Or formally educating. Or, you know, running groups, or counselling. Counselling in that sense of listening to people and being a sounding board on a one to one basis for whatever they need [me] to be.
Liaising with the hospitals and the
community. Being some sort of ... trying to connect them at some point ... which hasn’t been done before. The stuff that we do as part of our child health role, which is ... you have the developmental screening ... and again,
Enabling
Identifying Assessing and Identifying Needs: Individual, Family, Community
Health Education / Health Promotion Problem Solving, Counselling & Support
Intervening ‘Doing For’
Resources and Linking
Incoming Referrals
Case Management and Coordination
Developing and Empowering
Outreach and Follow-up
Crisis Management / First Aid
Consulting, Policy Development and Health Planning
Screening and Case-Finding
Advocacy Filling in the Gaps
Refer
Refer
Refer
241 education, outreach ... Kate 228-236
Figure 1: Facilitating Situated Health Competence
IDENTIFYING Participants recognised that some of their clients were either unable to identify their own health problems or needs, or did not have the knowledge they required to engage in health enhancing behaviours. To this end, participants were involved in activities designed to identify health problems or needs. Identifying role activities noted in the data included: carrying out individual, family and community assessments, screening, attending to incoming referrals and follow-up and outreach. Identifying activities were similar in intent to the notion described by Benner (1984) as diagnosing. Identifying activities were interconnected with Intervention and Enabling activities. When a health issue was identified, the nurse was required to make a decision about their next action. The outcome of judgements made by participants could include referral, Intervention activities or acting to Enable the client to address the health problem, issue or need that had been identified.
Assessing and Identifying Needs The importance of carrying out assessments was reiterated many times in participants’ descriptions of practice. Assessment was an integral part of the community health nurses’ role activities, and there were many embedded descriptions of assessment in the data. Assessment formed the basis of the nurse determining that health problems, issues or needs exist, prior to deciding what to do about them. Judgements about the goals of nursing activity and how to go about responding to needs were based on these assessments. Assessment of individuals, families and communities were included in all job descriptions, with some specifying target client groups. In addition, several participants explicitly identified assessment as an important skill in their questionnaire responses, and most other participants identified activities that implicitly included assessment. Assessments described by participants demonstrated an application of the
242 philosophical perspectives of participants. They considered clients holistically, taking a contextual and social view: Well I look at what these people really need in maintaining themselves in their home ... safety features, social support, everything that the holistic sort of assessment for that family or that person [would include]. Joy 391-394 So it is a full assessment. Not just their physical well-being, but their ability to cope in their environment. Sharon 405-407 Participants also saw that it was important that their assessments took in the clients’ viewpoint. This approach was also explicitly included in some organisational documentation: People are encouraged to identify and express their needs. They can then be provided with information and support enabling them to make informed decisions about their health. Description of services, regional documentation 31-33 But I see myself now in terms of the role of a health educator, and the person who assists other people to determine their own health needs. Gwen 324-326 It was also apparent that the ability to develop a non-judgemental, trusting relationship that was sensitive to clients’ unique situation as described in Chapter Six was important in making assessments. The sensitivity, acceptance and ability to develop client trust and confidence in the nurse-client relationship while undertaking an assessment was illustrated by an example given by Louise: ... I’ll give you a good example. I come out here and there’s a woman from in the flats over there ... and she’s in here hovering around my sexually transmitted diseases stand.
So straight away you know that she’s too
embarrassed to ask. There must be something there. And I said to her “is there anything special there [that] you’d like to know?” And she said “Oh, um ah genital warts”. I said “oh, genital warts ... Yeah, I’ve got quite a bit of information about that you know. Look come on, here’s a pamphlet, you know. Is there anything else?” “Well” she said, “I’ve got genital warts ... me
243 and my husband. Me and my defacto”. So we discussed genital warts and management and things like that. And then you get talking. And she says “my fellow’s on drugs”. (Which I already know). And then she’s got a child with behavioural problems. Which I know because I’ve seen the kid kicking the kids out the front here. And I’ve recommended her to go somewhere else, because the child has got major problems ... little kid ... you’ll probably see [him] as you go out the door. [He is a] vicious little boy ... mainly because [of what] he sees going on at home. And the husband has fits ... fits when he drinks alcohol. And I’ve had to almost resuscitate him here ... and have the ambulance out. So what starts out as genital warts ends up with sexual abuse, developmental problems with the child, basically ... major problems with the relationship. And so from that thing comes a lot more. So what would have been a ten minute conversation ... in and out the door ... becomes an hour where you’re referring to the child health ... or then refer on to the child development unit. And then you’re looking at your GP because she said her husband ... I said ... because he’s using intravenous don’t you [know] ... [I said] “have you thought about hepatitis B or C”. And she said “Well, I think he had a touch of hepatitis C”. And I said “What do you mean, a touch?”. She said “I think that’s what the doctor said he had a touch of it”. And I thought, “well, you don’t have a touch of it” [it doesn’t] go away next week ... So I then had to talk to her about hepatitis C and hepatitis B. And so genital warts all of this led to major problems. And ... which we are gradually working through. And she feels at least comfortable enough to come in here. Louise 263-300
Community Assessment The implications of how participants understood the ‘community’ were incorporated into the way in which they assessed their communities. Many participants suggested that they needed time with clients, groups or communities to identify what the most pressing issues were. Time spent getting to know a community and becoming part of a community was seen as especially important when participants were first placed in a new setting. Participants saw that it was important to connect with the networks, get to know people, and ‘not do very much’ when they started in a new community.
244 Some participants seemed slightly defensive about spending this time developing networks prior to mounting major programs and provided justifications. However, what they described was the carrying out assessments, making connections, identifying needs, and consulting to determine what people and communities really wanted, rather than hastily implementing ill-conceived programs. This approach is very consistent with a ‘development’ approach: I see that when one rushes in ... which perhaps I did ... rushed in and said ... “Oh I can try and do this and that” ... and then I find out that I haven’t really found out different information [about community needs]. Joy 212-224 I think that’s the only way you can go. There are so many community support groups out there that are doing their little thing ... and that’s where we also have to look at what is going on ... to try and prevent reinventing the wheel. Because that’s using a lot of resources ... that is unnecessary. Carol 687-691 It was of note that there were only a few participants who had carried out a full formal community assessment that included formal surveys and formal consultation with their communities, despite some acknowledging that perhaps they should do this. Where formal community assessments were carried out, they tended to be undertaken when the nurse moved to a new location: But as my role as the community nurse, I would be doing, if I’d moved ... new into an area, I would certainly do a community assessment. And by that I would be finding out all I can about the profile of the community ... the age groups represented there, the type of health issues that are represented in the community, the availability of services, the type of environment in terms of housing, the levels of unemployment. Karen 641-648 One example where a full formal community assessment was carried out was a participant who took six months to undertake a community assessment of a small rural town: So I proceeded to do this community assessment that took me six months to do. And I had to go the Shire and collect all the statistics and from the Bureau of Statistics ... looking at how many families were there and, you know,
245 composition of different ethnic groups and I went and did some surveys. ... But I wanted to know, was what they thought their health needs were. That was the whole basis [of it]. And we were looking ... trying to ... what other sorts of questions ... and asking what had been there. I didn’t want to duplicate what had been done before. So I was really getting what they felt they needed in an area, and seeing if I could assist with any of it. And looking at what they saw their own health needs [as]. And then addressing some of them. Lyn 613-669 However, because many participants did not tend to undertake full formal participatory community assessments, the conclusion should not be drawn that they did not assess their communities. They all described their communities in terms of a profile that included geographic and demographic details, community resources and also some of the prevailing health problems encountered in the community: In my area I have two maternity hospitals I’m responsible for. That’s about 2000-2200 births a year. That doesn’t count the births that occur outside [this area]. I know [with]in that number of women I will have between 220 and 600 women who will suffer post natal depression in varying degrees. Kate 507519 This is consistent with the view that where a community lacks connectedness, it cannot be viewed as an entity. Assessment was also an ongoing activity that was intertwined with their practice, in an assumed way. Their assessments were responsive and took cognisance of the changing nature of their specific community: ... I would have been doing another survey [now], because I was there twenty one months. So I thought it was time to go and look at [things again] ... because people had moved in. What was happening next. Lyn 718-723 It was also evident that knowledge gained from networking and being a part of the community assisted the nurse in making assessments of communities and groups. Networking, interaction with community members and assessments of individuals and families contributed to their overall community assessments:
246 ... to find out what is in the community ... and network those things ... and through that process, maybe there will be a need that comes out of the information that you get from all the areas ... Carol 219-222 Now I’m not going to bring together ... or at least I haven’t in the area [I am working in] ... bring together the community and say “Well, what are your needs?” in terms of the group of people. Because I may not have been able to do that. But I would do it through possibly groups of parents, when I’m doing group work in parent education. And also just the one to one ... and saying well “what do you see as a need in your community?” And helping people to bring that up in our discussion. So that’s a way it can happen, as opposed to the true community assessment,
When one is trying to bring together a
community in terms of ... I mean it’s easy in terms of a smaller [rural] community to do that, than a metropolitan area [community]. ... because you would have had a much more definable geographical area. Karen 658-675 Another factor that was a major theme was the inclusion of an examination of the availability of community resources in any assessment of the community. This aspect was consistent with their view of health as a resource. This involved participants in making an assessment of the resources available to people living within a community, particularly those at risk. A feature of assessments made by participants was that they tended to be focussed on resources that may meet the needs of the groups of clients they served. For instance, if they worked with families with young children they assessed the community in terms of resources available to parents and children: ... I feel it’s my responsibility to make sure we have services in our area, and not depend on other health districts to provide those services ... which we are doing presently. So that women who live in the [regional] Health District have the right to be provided with those services within our district. So I look at those services. The parents in our health district have a right to good parenting education in our district. Not just ante-natal classes and some isolated post-natal classes, but something where we would reach people who wouldn’t normally wouldn’t attend those very middle-class type situations. So part of my role as parenting education ... is to look at ways that we can include
247 those people who really need it, but in ways that will reach them. Kate 507524 At community level, assessment incorporating the clients’ viewpoint involved community consultation. At times the approach to community consultation became complex and involved discussion with key groups, surveys and seminars: Yeah, so I did. I went round to client ... to different groups. I went to like the CWA [Country Women’s Association] and the Senior Citizens and playgroups and the Red Cross Association. And I asked questions like, you know, “What do you see the health needs in this area [are]?” ... So I was really getting what they felt they needed in an area, and seeing if I could assist with any of it. And looking at what they saw their own health needs [as]. And then addressing some of them. So that involved, you know, running some, well what I called seminars, but of course that’s not in the true sense of the word. But like a women’s health seminar. Addressing their concerns for breast cancer. ... And, you know, after doing all these after these surveys ... I did a hundred ... where there was different themes, depending on the age groups. And so there was a lot in the elderly that were concerned with heart disease and incontinence, and things like that. Lyn 650-672
Screening and Case-Finding A second Identifying activity was screening. Screening was identified repeatedly as a role activity within the community health nursing role. Screening activities identified by participants tended to be aimed at case-finding in children (vision, hearing, growth, development, headlice and so on) and ‘at risk’ groups such as migrants (type of screening not specified) and Aboriginal communities (Hansen’s disease, trachoma). However, there were instances where nurses targeted the elderly (blood pressure readings, weights), workers such as teachers and employees of a large corporation (skin checks, blood pressure), women (pap smears, ante-natal ‘checks’) and young people (AIDs screening, self breast examination, testicular self examination). Screening appeared to be an accepted and unquestioned role activity of participants, particularly those working with children, vulnerable or ‘at risk’ groups. One nurse
248 described screening as a ‘commitment’ she had. Screening was only identified specifically in two of the job descriptions and organisational documents accessed: Monitor health needs to ensure early detection of problems and continuity of care. Joy, job description 21-22 However, it could be argued that within the context of community health nursing, screening constitutes a form of ‘assessment’, a component of the role which was widely included in job descriptions. In most instances participants saw the significance of screening in terms of its contribution in leading to some type of preventative activity that they understood as secondary prevention: ... well we generally try and encourage people to have ... always do ... the three and a half to four year old check [age related physical and developmental screening carried out by child health nurses], because that’s really important. And we do have posters up around and we usually ... well I do anyway, go and speak to the pre-schools and the day care ... not necessarily the day cares ... [but speak to] the play-group coordinators, because, you know, that [the four year old screening check] is really an important one. Because ... if a child is disadvantaged when they go to school ... if they have a vision problem, a speech, hearing, co-ordination problem ... life is hard out there. And if they’re disadvantaged with a physical concern, then it’s going to be extra hard ... But I do know that it’s disadvantaging [for] the children not to be functioning at the best of their ability. Marie 431-459 Another interesting aspect of screening was that, at times, participants used screening activities not simply for their intrinsic value in identifying possible health problems, but strategically, or as part of an ongoing plan or project with a particular focus. They also used screening activities to assist them in achieving goals they set themselves, such as networking, changing attitudes or as the first stage of an ongoing program. In some instances, screening was an activity that was used in conjunction with health teaching: Yes. On the teacher’s days I targeted the teachers, as the ones to do the skin cancer checks on. Because they are the ones that reinforce the behaviour
249 within the school. The kids wearing hats ... putting sun screen on. I had quite a significant outcome. I got 26% that were referred on. That’s in the teachers who are quite a ... you know ... sort of informed group of people. From there, it then gave me license to report back to the parents ... that we had done this within the school, and then to put out a little newsletter to them about children’s skins. Rhonda 319-331 In addition, there were instances when screening served: to justify the focus and activities of the nurse, as a strategy for legitimising their role, and in raising their profile. Screening appeared to give participants a concrete focus activity they could point to when negotiating their role: Rhonda: And they [a networked group of General Practitioners] say there should never, ever, not be a registered nurse in a high school. They are very adamant
indeed
Researcher:
Why
for do
you
having think
they
that
service.
are
[adamant]?
Rhonda: I think because the nurse picks up things that the first aider couldn’t pick up, and nobody else picks up, and sometimes the parents miss. And they [the GPs] are aware of it. Rhonda 716-723 It was also noted that for some of the participants screening was a comfortable thing to do, particularly when they began their in role as community health nurses, because it was concrete and related to their knowledge of ill-health and approaches they were used to in the acute setting: And I had enough clinical work initially ... because I was doing a Hansen’s survey ... I didn’t know what Hansen’s disease was either because we didn’t talk about it ... Hansen’s disease in city hospitals. ... So I had enough clinical work there, I was really comfortable there initially. Gwen 59-67 However, while accepting screening activities as an important aspect of their role, participants recognised that screening had limitations and that there could be problems associated with this component of their role. Screening activity of itself does not actually constitute prevention or contribute to better health: it only identifies that there may be a health problem. It is necessary to have some follow-up action and other
250 intervention in order to achieve health benefits and to justify the carrying out of screening activities. Most screening activities resulted in the referral of clients. Participants saw that follow-up on positive results of screening was of particular importance and they expressed concern if they felt that follow-up was inadequate. Participants also indicated an awareness that screening could become the object of activities rather than a means to an end, and that there was a danger in being so focussed on screening that other activities were not addressed: I could see a broader perspective. I changed my school health activities from tasks and screening etcetera to programs and education ... Lyn 23-24
Incoming Referrals A third Identifying component of the community health nurses’ role was to address incoming referrals. This was seen as a ‘duty’ or an integral part of the role and was included in job descriptions: We have a primary duty to ... take in referrals from the community and to assess
that,
and
that’s
an
important
part
of
our
role.
Yes, and we try to see them within five days of receiving the referral ... that’s rung in ... generally. So that is one thing I know that we all do. And how we do it is up to each individual [nurse]. But we have to follow some of the criteria ... Carol 326-328; 332-336 Accept referrals on health related problems for a geographically defined area. Joy, job description 4-5 ... the situation unfortunately is we don’t really get [much choice] ... when people are referring to us, they are referred. We have got to go and see them anyway ... so ... we will do what we can with that person. Sharon 366-372 An examination was made of the nature of referrals received by participants. The types of clients who were referred varied with the type of service offered by the nurse. Referrals tended to come for clients who were experiencing problems, and were often
251 drawn from minority groups such as Aborigines, the disadvantaged or low socioeconomic groups. Referrals came from a variety of sources. Many clients self-referred, particularly where the nurse had networked and was known within the community. Other sources included health professionals and workers in social security governmental departments. Further referrals came from other health professionals such as medical practitioners, nurses and allied health professionals. The final source of referrals was through the organisational structures within which participants were employed. These included connections between hospitals and community services (where these were linked organisationally), the use of liaison nurses, and inter-professional referrals from within an agency. In addition to these types of referrals, there were ‘structured’ referrals. ‘Structured’ types of referrals resulted from a structured continuous flow of clients, for example: the process whereby a child health nurse received notification of all births within her designated geographical area; assessing people requesting assistance through the HACC (Home and Community Care) program; or clients referred through early discharge programs. Another factor that was noted was that the number of reported incoming formal referrals (as opposed to self-referrals) varied depending on the sphere of practice the participant was engaged in. The number of formal referrals appeared to increase for three major reasons: the nurse had specialist knowledge, the nurse had contacts and was known in the community, or there were organisational elements that facilitated referral. First, where the participant had a particular specialty focus they appeared to have more referrals from other health professionals, who drew on their particular area of knowledge. Areas of expertise for which participants had clients referred included: breast-feeding (lactation consultant), diabetes education, drugs and alcohol or a focus on a particular client groups such as children, migrants, Aborigines or families: They might say “Would you go and have a talk with Mrs so and so”. Now that to me means ... a) they’ve recognised that I may have some expertise in the area, they see me as a colleague, a peer, and that I have different skills to them. Kate 597-608
252 Secondly, participants gained referrals from having contacts or networks within the community. These referrals arose out of the networks and contacts that participants built up in the community, or as a result of education programs conducted in the community. These contacts were also a major source of self-referrals: And I worked closely with the community centre ... they gave me quite a lot of referrals of families, of problems ... you know, families that were having problems, whether it be domestic violence or whatever else. Lyn 705-709 Finally, more referrals were received where there were organisational structures in place that facilitated communication between sectors of the health care system, such as hospital and community, or between different health professionals within one health sector. Some services employed specific staff to facilitate liaison between the hospital and community sectors. It is of note that within community health agencies, other health professionals saw nurses as playing a more major role where there was a physical problem, rather than where there was a social problem, although this was not universal: And ... we have these internal referrals ... where [if] we feel that “well this is not really mine, I should really speak to a social worker” or “I should speak to the speech pathologist or OT [occupational therapist], physio” ... and then we will refer these [cases] on ... or discuss the situation, or do joint visits. And it’s a very grey area. ... the social workers are very good at referring ... physios and OTs too. Carol 374-378 However, it was manifest that in some spheres of practice the nurse appeared to be ‘invisible’ and participants received very few formal referrals from other professionals, including other nurses and other community nurses. Participants expressed concern about this and indicated that they felt that there needed to be better follow-up of people being discharged from hospital into the community (discussed below): I think some of them forget that we’re there. They just forget that we’re there. ... Anna:
Researcher:
So
you
don’t
get
many
referrals
... No.
253 Researcher: Anna:
When you do get referrals, where do they come from? Occasionally
from
a
GP.
... I’ve never, never ever had a nurse ring me from the hospital to give me any information about any child. Anna 612-613; 620-644; 843-844 The role nurses took on receiving a referral was to make contact with clients and families, make an assessment, identify the health issue, problem or needs of a client, and then to negotiate the nurse-client relationship and the provision of services. On occasion, there were difficulties, particularly with structured referrals, because the client may not necessarily have requested the particular service being offered. In this case, the nurse was required to negotiate with the client regarding their services: But it’s often when we are seeing the individual in the system, it’s someone who has been referred in ... whether they have done it themselves or someone has done it for them. But we have to go out and initiate that contact and say ... and find out what it is they feel they need ... to see if we can offer this advice or information that they want. But you then ... through that individual assessment also see the ‘whole’ for them in the environment ... in the community. Carol 181-189 Yeah. Generally I say what I’m about. And what I’ve been asked to do ... from ... or why the referral. And then I offer ... I generally say “Look this is up to you. I can give you the results if you like. Or if you would prefer I can pass this on to your general practitioner, if that’s what you’d like”. I have ... generally I’ve been invited in by most of the migrant families. And they’re very grateful to have any information they can get. Because I think a lot of the time
they
don’t
get,
you
don’t
get
any
feedback
whatsoever.
And it’s really ... its just how you pick up from what you sense from the mother generally, or whoever it is. Whether they want you there, whether they’ve actually chosen ... Amy 511-519; 528-530
Follow-up and Outreach Follow-up and outreach was a final Identifying role carried out by participants. It was noted that participants made a specific effort to ‘reach’ people who: are ‘at risk’, make
254 up the most vulnerable groups in society, are in target groups, or have serious health problems. This activity was sometimes a result of referrals from community service organisations, schools and hospitals, but was also at times initiated by the nurse as a result of community assessments undertaken. Innovative strategies were often implemented to identify those who may be in need of health advice, care and treatment and who, for many reasons, may not necessarily access or avail themselves of appropriate resources in the community. Thus, participants often provided outreach to those clients who were most likely to be in need and tended to use health services least. In some instances, outreach activities were an attempt to address the needs of client groups at particular developmental stages that incorporate specific health needs. Participants targeted these groups as an opportune time to introduce health education and promotion activities. Examples of developmental targeting included early childhood, becoming a new parent and aging: ... that whole sort of new life style ... sort of coming out of the work-force ... having their first baby ... putting them in contact with people in similar situations and springing them off in a little support network. So that they not isolated and things like that. Cheryl 195-199 Participants also became involved in follow-up and outreach where there were serious health problems that if left unchecked could have serious sequelae: And if they didn’t ... if they really needed to go to the doctor to follow up, I did keep going back, so I think they knew that “she’d come back if we didn’t” [go]. [Laughs] they knew that “she’d come back if we didn’t”. [Laughs] So I think that that was ... I followed-up. So I think that they realised that I felt that this is what they needed to do, and this was important. I think if you just went and said that you know “all of you have giardia [lamblia]” ... because there were a lot of those sort of diseases ... “you have to go to the doctors” and never came back ... well then, you know ... like I just kept following through. Lyn 541-550 In many instances, outreach role activities saw nurses working to reach multi-problem families from very vulnerable sections of the community such as migrants, Aborigines, the elderly, homeless youth and so on.
255 A recurring theme in the data was the concern expressed by participants about the importance of follow-up of clients from the acute sector on discharge into the community. They felt that there could be a great improvement in linkages and communication between hospital and community health sectors. They expressed frustration at the lack of communication with nursing staff in hospitals, who they felt demonstrated a lack of understanding about the importance of the needs of individuals and their families once patients were over the acute phase of their illness and discharged back into the community and resuming normal activities. The need for better discharge planning was felt to be of greater important as a result of the trend towards early discharge: In terms of hospitals I think we’ve got a long way to go before we convince hospitals that there is a need for them to network with us. They don’t see us as needing to know anything. I mean they’re quite happy to discharge children out into the community without any follow-up ... without checking whether there’s a school nurse, who’s going to be following this child back into the high school.
You know, what ... they don’t see the significance or the
importance of us knowing that the child is coming out who might be immobilised for some particular reason or might have a particular condition that requires people to know about it. They just don’t see the need for it. I chase the hospital. I ring the hospital ... it is [a worry], but they don’t [see the need]. And in fact I was at a meeting some months ago now, where I met with ... as part of a group ... with people up at the hospital ... And one of the things that I said, was, discharge planning. Anna 752-763; 780-786 ... that we need to break down the barriers a little bit. I don’t know that the midwives say to the clients strongly enough “If you have any problems contact your child health nurse”. Cheryl 447-449
INTERVENING The second grouping of role activities involved Intervention or ‘doing for’ clients. Participants’ recognition that there is a continuum in the ability of clients in achieving Situated Health Competence was expressed in activities where they made a judgement
256 to ‘do for’ clients. There was a recognition by participants that some clients and client groups cannot or will not care for themselves. There are some individuals, families and groups in society who are particularly vulnerable or are in particular need. As a consequence of this vulnerability or need, participants made the decision to make a special effort to reach or work with these particular groups. It is of note that when asked what their role was, although analysis of data revealed they did engage in the activities in which they ‘did for’ clients, participants generally left these ‘doing for’ activities out of their descriptions. Participants Intervened to advocate, model something and ‘do for’ usually on a one-off basis. They also acted to address issues that presented a high risk to a client. In addition, there were situations where a client may normally only require short-term intervention, but this need was particularly threatening to a clients’ health. Examples included provision of first aid and crisis management. However, Intervention or ‘doing for’ someone conflicts with the major aim of the nurse, that is, to promote Situated Health Competence. Their difficulty was in providing help while still promoting independence and without creating dependency in the client. It was of note that wherever there was an example of ‘doing for’ it was accompanied by an explanation of why it was important to ‘do for’ in this particular situation. What is significant is that, as discussed above, participants did not take on continuing responsibility for these activities. In all instances of Intervention described by participants, it was evident that while participants undertook to ‘do for’ clients, whether individual, family, group or community, the intervention was short term and their aim remained that of having the client eventually achieve the independence of Situated Health Competence. This is consistent with the observation that where clients were likely to require dependent care for an episode, they were referred to other organisations.
Case Management and Coordination There were many examples where participants took on the role of case manager or coordinator consistent with the definition outlined by the Royal College of Nursing, Australia (1995, p. 13) that states that case management aims to achieve outcomes
257 within effective time-frames and resources and focuses on coordinating care across a continuum of care “negotiating, procuring and coordinating services and resources needed by the patient/family; intervening at key points (and/or significant variances)”. In case management the expertise and skills of the community health nurse are called on to address a situation where there is a problem, the client is not coping or has a particular need. Case management was included in discussion and in some job descriptions: Initiate management plans to meet clients’ needs. Helen, job description 22 Yeah, I think ... well it’s more of a maintenance, management of clients on methadone programs. Emily 748-749 In undertaking case management the nurse must balance the roles of ‘doing for’ with the aim of enabling the client to ‘do for’ themselves. There were several characteristics found in the descriptions of case management. Case management: required assessment, involved working in consultation with clients, was limited in its scope, was focused on problem-solving, coordination of resources and monitoring; and aimed at promoting client independence and Situated Health Competence. First, all descriptions of case management described by participants included an assessment. In some instances, assessment was a major focus of the role: And with I guess working with individuals, it’s looking at the
person
holistically. So when a person comes in with a problem, my role is to look at most facets of a person’s life. And some of the needs a client presents with, I can refer them to another agencies or other individuals, and some things I will deal with directly. So my role involves providing resources, and networking or linking clients with other agencies and other disciplines. So I guess part of my role is diagnosing and coordinating all of that. Helen 8-16 Secondly, all case management situations described by participants saw the nurse working in close consultation with the client. They worked with clients to ensure that the actions taken to meet clients’ needs were appropriate and acceptable.
258 Thirdly, it was noted that there were limitations placed on the role that the nurse negotiated in the provision of services to clients. The nurse may make initial arrangements to meet a client need in consultation with the client and family. However, case management did not involve the nurse taking on responsibility for providing continued physical care of the client, although contact with clients did sometimes extend over a period of time. The role took on a monitoring, surveillance and consulting function rather than assumption of day-to-day responsibility for the client. Where intensive physical support and care was required, referrals were made. In addition, if participants found that a client did assume self-responsibility after a period of time, the nurse negotiated with the client to limit the services provided. For example, Louise (432-452) described a situation where she acted as a case manager. She identified limits to this role, based on her view that the client should be working towards assuming responsibility for her own care. She engaged in monitoring the client, but was considering closing the case if her actions were not providing any improvement in client health. The next characteristic noted was that the aim of case management was to address the identified need, or solve the particular problem. Case management consisted of assisting the client to access a range of services or resources that enable them to meet their own needs, and at times coordinating those resources. The role of case manager was strongly linked to the activity of referring to others and organising resources. Case management usually occurred in relation to referring. Although the nurse refers, the nurse may have ongoing contact with the client in a monitoring role: ... then we go out and do an assessment ... and look at safety in the home ... family circumstances, [to see] if they have any support systems, and I see my role as being ... going out and seeing this person and then calling on all the resources I can think of ... to maintain that person in the home ... that individual or the family. Joy 54-61 One particular school is a three tiered school. She has eight steps to negotiate between ... there are no ramps ... she has eight steps to negotiate between each layer of schooling. Every door has a door closer. So I need to be able to set up some sort of system to make sure that a) she can toilet herself ... and that she knows where to go. Where the students ... where, you know ... where the
259 toilets are for students with disabilities. I need to set up a buddy, who can assist her to carry her things from A to B. ... If we know that before she comes in to school, and we can get it organised ... I don’t have to physically do it but I can let somebody know. Anna 787-799 A final characteristic of the way in which participants undertook case management, however, is that that the focus of problem-solving, coordinating and monitoring was to assist the client towards independence and health competence and doing for themselves, rather than doing things for the client. Again, it can be seen that although the nurse is ‘doing for’, the aim is still for the client to move towards achieving Situated Health Competence.
Crisis Management/First Aid A second ‘doing for’ role that nurses reported undertaking in the community was to intervene in situations of crisis. In these situations the nurse as a health professional was looked to for their medical and nursing knowledge and expertise. The main crisis situation in which nurses reported intervening was first aid. However, participants reported that they provided crisis intervention in other situations. Crisis intervention and first aid both require a short term immediate response to a ‘crisis’ situation. They require some action to stabilise a situation, provision of initial treatment and care perhaps, and then connection of the client/victim to an appropriate facility where comprehensive care appropriate to the persons’ needs can be delivered. It appeared that where participants were working with vulnerable individuals and groups, they were very accepting of this aspect of their role. A nurse working with clients with addictions commented: ... counselling ... and crisis intervention ... things like that. I mean most people do a crisis [intervention] once or twice a day with one of their clients. Emily 379-381 This was also the case with the two nurses who had worked in communities in remote areas with little support from other health professionals. These remote area nurses were also asked to staff the Royal Flying Doctor Service. Undertaking crisis intervention was also included in some job descriptions:
260 Support of clients facing crisis, chronic or terminal illnesses and/or adjustment to disability. Joy, job description 26-27 It is also of interest to examine this role of the community health nurse from the perspective that in providing crisis intervention, they are in effect providing acute care to individuals. To undertake this role, they required medical and traditional nursing knowledge and skills. On further analysis, however it can be seen that although the crisis intervention role engaged the participant in an acute care situation, again, the client was not a continuing responsibility of the nurse. The nurses’ action was to stabilise a situation, provide initial treatment and perhaps to connect the client/victim to an appropriate facility for physical care and support as appropriate. This aspect underpins the importance of the referral component of the community health nursing role.
Advocacy Advocacy was a third Intervening role taken on by clients at individual, family and community level. The provision of advocacy was included in most job descriptions and was present in many of the organisational documents accessed: Act as a client advocate providing information on health and related issues to individuals, families and the community and assist them in accessing resources relevant to their needs. Sharon, job description 57-59 Acts as client advocate and collaborates with them and other members of the health team to achieve health outcomes. Regularly.
Kate, job description
55-56 Participants saw advocacy as an important part of their role. Again, advocacy is a ‘doing for’ role. The decision to undertake this role was related to the vulnerability of the client, the seriousness of the situation or health problem and how helpful their interventions would be. Participants also saw that their advocacy role could be on behalf of the individual, family or community: I think [my role is] being an advocate ... and support person, a
health
educator, and a provider of resources. Like I might go to the doctor with some
261 young people, and give them support, but also model behaviours. Question the doctor, or ask for more information. The same for other service providers. I might go to DSS [Department of Social Security] with them for instance. And model appropriate behaviours. Helen 121-126 A lot of child health nurses, myself included, we’re on committees. So when we come to that committee, we bring the voice of health ... I would like to think ... and what’s appropriate to, you know, whatever they’re doing. But also the voice of the community. You know, “this is what families are asking for. This is what mothers find difficult. This is what’s safe for children”. Kate 244-251 It could be seen that the advocacy role was sometimes carried out in conjunction with a case management role, where participants worked with clients to access suitable services from other health professionals, government departments and other organisations. This was particularly so when they were working with clients who were vulnerable or who had needs with serious implications: ... and there you can become the spokesperson, the mediator, the conciliator, the messenger between them and the doctor or them and the other therapists ... and then ... whatever that family and that individual need in the wider context of their circle ... Janet 334-339 In addition, participants worked with clients to assist them in dealing with organisational bureaucracy. In some situations, participants pointed out that if they themselves found difficulty dealing with bureaucracy, then clients with limited resources, such as a limited ability to speak English, would find accessing information or resources nigh on impossible. They appeared to be particularly well placed to carry out this role, due to the independent and autonomous nature of their practice: You know ... there is a young woman I am seeing ... I have been to the DSS [Department of Social Security] I think four times with her now. And on Friday her benefits still weren’t through ... the youth homeless allowance. And I have been to an interview with the social worker who said it was all fixed up ... it’s fine. The fact is it wasn’t. I mean, now she’s sixteen. She is fairly nonassertive. So I’ll go with her and I’ll just sit down and wait. And she comes
262 back and says well it won’t be there till Monday. And she’s crying. And she was accepting of that. So I went back and said “Well look I’ve been here four times. This is costing the community a lot of money. What’s going to happen. She’s got the weekend again with no money. It’s just not on”. Helen 130-147 It was noted by some participants that the notion of advocacy was fraught with dilemmas. Discussion included reflection on the dilemmas inherent in advocacy and the pitfalls associated with taking on this role: ... I don’t just think it’s the person and their family ... well I say advocate ... how brave am I to say advocate ... Janet 292-300 And then, when you are an advocate, you’re sort of saying well ... I ... to the person, “this woman is finding it very difficult to do this because she doesn’t speak English”. Or “she’s been under enormous stress”. And I’d always ask the person “are you happy for me to give some information ... background ... if I’m trying to be an advocate for you? I mean, you tell me if you don’t want me to”. Louise 642-648 Community advocacy occurred particularly in relation to community development projects. Participants assisted communities with such aspects as accessing funding, engaging staff and dealing with bureaucracies: It is [community name] Action Group Incorporated. And last year we actually got funding from the [local] City Council for a neighbourhood centre. And ‘Helen’ and I applied for funding for a youth worker ... which we got from [regional health organisation]. So we got $47,000 funding ... and [accessed] various other funding [sources] too. Joy 128-136
Filling in the Gaps A third role activity aimed at Intervening or ‘doing for’ clients occurred when participants ‘filled in’ for a lack of services or resources accessible in the local community. As discussed above, where participants saw a need, they ‘filled in’ for the services normally provided by health professionals such as social workers,
263 nutritionists, counsellors, occupational therapists and doctors. This was an instance where the generalist nature of the nurse was exploited to the fullest. In some instances they were the health professional of choice to be employed in a particular setting because of their flexibility and the broad scope of their role. An example of participants acting to fill in the gaps was the contentious issue where the participant ‘did for’ clients and provided transport. Not all participants provided transport, and those who occasionally did agonised to some degree over it. Whenever the issue of transporting clients was mentioned by participants it was accompanied by a lot of explanation, qualification and at times, angst. However, this activity highlighted, and allowed analysis of, participant’s decision-making processes about whether or not to do something for clients as opposed to the expectation that they ‘do for’ themselves. It was clear that participants felt that transporting clients was not really consistent with their professional brief. Again, it would appear, that the interconnectedness of participants with people in the communities they serviced meant that the needs of clients ‘mattered’. The straightforward issue for many nurses was that they did not wish to be seen as a provider of transport by clients: You know, I could drive people, but I’m not the taxi driver. I don’t wish to be the taxi driver. Louise 426-428 The issue for participants was that they wished to assist people with their healthrelated behaviours, while maintaining client responsibility and without creating dependency. Participants recognised that the contextual reality for many clients was that there were structural difficulties in gaining access to services. At its heart, the aim was that clients would undertake a health-related behaviour, in this case accessing health resources, because they had knowledge about it, understood its importance and valued it themselves. Where this was not occurring, this lead to conflict between the aims of the nurse and the perspectives of the client: ... I have a lot of problems then when I was working in [urban suburb] with people from the Middle East ... who felt ... the men felt that if the women needed to go to clinic it was up to me transport them ... it was up to me to organise it. And it wasn’t up to them to do anything. So therefore if they had six cars sitting outside in the front yard and they were sitting there playing
264 cards ... And that I found difficult to cope with. I found it difficult to get the message through ... that I was not prepared to keep transporting them backwards and forwards. And I found that very difficult. Because then I have to say “look I’m sorry but this is the way it is going to be”. And then that was of concern because ... say just sending for a pap smear, you wouldn’t know [whether they had gone]. Gwen 792-804 However, it was clear that some of the participants did transport clients and that the vulnerability of the client, the lack of ability to use their own resources or lack of personal resources altogether, the urgency of the problem, and availability of other resources were factors in the decision to do this. In particular, if the situation involved children, participants appeared more willing to make a judgement to provide transport to clients. At other times the nurse was involved in transporting clients when they were acting as an advocate or in crisis situations, such as when providing first aid: I suppose going to ... transporting people to the hospital at six o’clock in the morning because you know that they’ve got to be there at seven o’clock and there’s ... you know there’s no other way you can get a flexi voucher or something. Or you can’t guarantee that they’re going to get there. And you know that these people ... you only do it because you know that they might sleep in or there might be other influences around at the time, and where they might not make it ... especially where children are concerned. I know this one family where the mum gets boozed quite often. And the child’s missed out on about fifty appointments to [large metropolitan children’s hospital]. And so ... and I mean the hospital don’t make great allowances, for good timing. I mean the kid has to be in at seven thirty and that’s that. And not the night before or anything like that, but that morning. So you know, you try of course to do everything possible for the mother.
I’m certainly all for getting that
independence happening. I’m not one for racing around like a mad duck. Amy 625-642
265
ENABLING The third grouping of activities related to Enabling. These activities were aimed at Enabling the client to achieve independence and increasing the level of Situated Health Competence. These activities did not involve the nurse in ‘doing for’ their client, rather involved activities that were directed at engaging the client in activity that would improve their own health competence. These activities included supporting, linking, health education and promotion, advising, participating in problem-solving with the client and consulting. Enabling encompassed development activities with individuals and families, and community development. In addition, some participants were involved in community or organisational policy development. The philosophies underlying Enabling activities included the features of promoting independence and health, giving a range of choices and resources, and doing so from within the framework of the clients’ own situation. A central aspect of Enabling activities involved providing a range of options, choices and access to resources. At its heart, Enabling activities sought to promote independence and the ability for clients to be competent in addressing their own health needs and issues in the situation in which they find themselves: Well that’s what our aim is, really, isn’t it. [It] is to be able to give them that knowledge, so that they are independent people. Yeah. So I think that’s part and parcel of our role. [It] is to be able to impart that knowledge to people so that they can get on with their lives ... independently. Cheryl 136-140 It is also interesting to note that participants engaged in Enabling activities that were designed to assist clients to learn to Identify their own health problems and needs and also to engage in actions that address health issues and needs. The consequence of this activity is that the client will not require Intervention on the part of the nurse.
Health Education and Health Promotion Material from the data relating to the role of the nurse in health education and health promotion were coded together, although they can be defined differently. This was because they were very closely linked in the data by the participants and often health education was a strategy employed to promote health. This category was saturated
266 very quickly. All participants described themselves engaging in health education activities, although there was variation as to whether their activities were aimed at primary, secondary or tertiary prevention, or aimed at promotion of health as a positive entity. In answering the questionnaire that asked participants to identify the services offered by the agencies they worked for, all of the participants apart from one participant who did not answer the question, identified at least one of some form of health education, health promotion, and/or community development. Specific areas of health educational services offered identified in questionnaires included antenatal and postnatal education, parenting education, diabetes education, women’s health education, ‘support’, osteoporosis, arthritis, living with disabilities and healthy lifestyles. Health education and/or health promotion was universally identified as a component of the community nursing role in all of the accessed job descriptions of the participants in this study. Some of the role descriptions identified the target of health education and health promotion activities. These included individuals, families, ‘selected’ groups, groups and communities. Many of the descriptions also included the role of assessing the need for health education and/or promotion. On occasion, job descriptions directed the nurse to implement programs within the limitations of resources or in conjunction with other health professionals working within their service such as the senior nurse, or in one instance a health promotion coordinator. In some documentation, health promotion and health education activities were closely linked to community development approaches. For example: Community Nursing services collectively include clinical practice and the provision of health education and promotion programs within the context of a community development approach. Community Nursing activities enhance the health and wellbeing of the community in which services are provided. Sharon, job description 8-13 A need for expertise in any or all of health education, health promotion and community development were explicitly identified in many of the descriptions of role and selection criteria. Health education and health promotion were also identified in
267 all documentation from the health regions in which participants worked. They were also identified as a component in organisational documentation accessed that described the philosophy and goals of the community nursing role in two of the regional services in which many of the participants in this study worked: Promote positive health practices through early identification, intervention and health promotion. Goals, health centre documentation 16-17 Community Nurses working in schools are concerned with the promotion of health behaviour and the prevention of disabling conditions for all students within the education system. Description of services, regional documentation 49-51 When asked in the questionnaire to identify knowledge and skills required to undertake their current job, eight of the participants identified health education and health promotion skills as important, including one who identified public speaking as an important skill. One participant did not answer the question, and those not identifying health education and/or health promotion all identified communication skills and/or counselling skills. Examples of the types of skills identified by participants were: using resources, initiating programs, excellent communication skills, education skills, health promotion skills, public speaking, making education fun, effective communication skills, being prepared to run groups, and an ability to find out information if not known and to pass it on. A need for confidence in speaking to groups was identified as an important attribute in interview data. Participants expressed a need for further education and skill development in the area of health education and health promotion. Two participants indicated an intention to undertake further studies at graduate level in the specific area of health education and health promotion. The importance of skills in the area of health education and promotion was expressed by Sharon. She identified the need for better access to education for nurses, suggesting: So a lot of nurses are basically ... self taught. And when it comes to health education/health promotion, we think we are doing the right thing, but are we really? Are there better ways of doing it? Should we have more education.
268 Health education ... are we evaluating it properly? Are we ... well basically ... performing it in a correct manner. Health promotion ... we all think this is health promotion ... we probably have a different concept of what health promotion is. And then are we actually doing it? Is it effective? Should we be doing it in a different way? So a lot of those things, I think, we do the best we can, but I think there is room for information and education of the nurses. Sharon 778-794 An issue related to health education and health promotion pointed out by some participants was the energy and commitment required of them to undertake these programs. Their experience was that this was often underestimated by other nurses and health professionals: ... No ... nurses aren’t doing something. They just ... you say you are doing health education or you’re doing a health promotion program or something, and they just think that you must be enjoying that, that must be fun to do, but you are not actually doing anything. Janet 782-786 Rhonda describes a discussion with a colleague about a program they had run together: ... you know [I say] “how do you feel about it?” [and she says] “Oh, gee that’s been a lot of work”. I mean the penny drops on how much [work] it actually takes to achieve it [a health promotion program]. It’s hard work .... Rhonda 944-952 A feature of the approach taken by participants to health promotion and education was that they were seeking to promote health and prevent disease and assist clients to make informed decisions in order to enable them to achieve their own goals in life. Activities were focussed at individual, family, group and community levels. The strategies most used to achieve promotion of health and prevention of ill health were health education and on occasion, community development approaches. The areas health education and promotion focussed on were very broad. Areas participants chose to address resulted from a combination of their own interests, assessment of client needs, the expressed interest of clients and client groups, a need
269 to address the promotion of health as a positive entity, and a focus on primary, secondary and tertiary prevention areas. Health and wellness topics addressed by participants included sexuality and human relationship education. Health educational services aimed at prevention that were identified in data included primary prevention in the areas of: antenatal and postnatal education, quit smoking, breast feeding, nutrition, child development and behaviour management, parenting education, immunisation, safe sexual practices, women’s health education, skin cancer and sun safety, hygiene, social support networks, healthy lifestyles, home safety (for both children and the elderly), ‘travel bugs’, and prevention of osteoporosis. Secondary prevention included the provision of and teaching first aid, breast self examination, testicular self examination, obesity, pediculosis, heart disease, and ‘worms’. Finally they also engaged in tertiary prevention activities, education and support aimed to prevent the negative sequelae of illnesses and chronic health problems such as: asthma, diabetes, arthritis, incontinence, drug and alcohol addictions, suicide, hepatitis C, safe medication practices, and disabilities experienced by clients. Although there were many examples of health promotion, Emily, Lyn and Sharon provide examples of the diversity of activities participants were involved in: [We would] just park in car parks ... that sort of thing ... outside night clubs and things. And just providing needles and syringes and condoms and HIV [information]. Emily 33-38 But I ran, for the Senior Citizens ... they were very active ... and I went there every three months. And I we got people up [from the city] ... like the Arthritis Foundation ... because there was a lot of people with arthritis. And my other role was diabetes education. And there was a lot of people with diabetes. So I did a lot of educating there. And I used to, I’d go to the Diabetes Support Group in the [regional] suburbs. And I’d do education at [regional] Hospital. So that was a role I was trying to develop. Because there was a lot of people there with diabetes. Lyn 831-839 ... the client ... its a one to one its an assessment, plan, implementation and evaluation ... but in that, there is also education, information, whatever those person’s needs are. And you quite often are. Even a very basic thing, like
270 someone giving an anginine on top of the other. You educate them a bit about their medication. You educate them a bit about home safety if they have got all these things about on the floor. Sharon 397-415
Problem-Solving, Counselling and Support A second theme identified in the data related to Enabling role activities was involvement in problem-solving, counselling and support. These activities were carried out in the spirit of ‘being with’ clients. In some instances this role could almost have been described as a mentoring role. For example, Cheryl 530-541 described her role in relation to working with parents as supporting parents in their new role - giving information, reassuring, and ‘normalising’ all of it. The three aspects of problem-solving, counselling and support are thus discussed together because they were intertwined in the data, and had similar aims: As a community nurse? We go back to the fact that I’ve said it’s a multi faceted role. A combination of resource person, health educator, confidant ... support person ... Gwen 436-438 I offer supportive counselling. Emily 906-907 These Enabling activities were focussed on problem-solving in a way that took regard of the clients’ context and was acceptable to them. The focus was on the client doing things for themselves rather than the nurse ‘doing for’. Most participants were required by their job descriptions to provide counselling and support for clients. Job descriptions required participants to make assessments and address the need for individual, family and community supports and services: Utilisation of advanced nursing skills to encourage optimal health for clients (individual, family, community) by the provision of information, resources, support and the organisation of appropriate services.
This involves
development of strategies that organise and empower people to change the agents, institutions and circumstances that affect their health adversely and acknowledges individual autonomy and responsibility for their own health care. Helen, job description 29-36
271 The need for support was also addressed in organisational documentation supplied by participants: Through this service the [state health department] can work with individuals and families to promote health, prevent disease, identify health problems and intervene early to prevent the development of chronic conditions. People are encouraged to identify and express their needs. They can then be provided with information and support enabling them to make informed decisions about their health. Description of services, regional documentation 27-33 Counselling was a skill used by clients in addressing client problems and providing support. In some instances, participants felt that the notion of being a ‘counsellor’ described their role better than the term ‘nurse’ because it was more explicit about what they did: I’ll explain ... when I first meet clients, I give them my card ... its got “community health nurse/counsellor” written on it. “Counsellor” has been a topic for discussion ever since I have been here. “Nurses do not counsel” you see. ... Oh I have done HIV/AIDs counselling, but I guess I’ve done that mostly through my nursing qualification. ... and I’ve done sexuality counselling, and some short courses ... and just throughout everything I guess. And the family planning
certificate
has
some
on
that
[counselling].
... I think it [counselling] just explains it a bit more. I sort of argued to have that
put
on.
... with the [other] nurses. And with the others. One of the nurses is a psychologist as well. So she has put that on her card. The argument was that nursing should be viewed as encompassing that anyway. So why should it go on. And my argument was that I had to explain at length to clients, whenever I saw them, what my job entailed. And it would be much easier if I had that on as well. So usually now when I see clients I explain that I am a community health nurse, and explain that these are the sorts of things I do, and that there are other workers here who do all these other sorts of things. “And you have a choice about the type of worker you would like to see”. Helen 370-405
272 It appeared that a major focus of the nurses’ role was to ‘address problems’, with participants identifying problem-solving as an important aspect of their role. Many of the clients and community issues were referred to participants because there were ‘problems’. Thus, the way participants approached their role was often designed to address identified issues and ‘problems’. For instance Louise addressed violence, asthma and hepatitis C as community health ‘problems’. She would not have done anything about them had neither she, nor the community, perceived them as ‘problems’. It was also evident that as the nurse established networks in the community and developed relationships, they were seen as a health professional who could assist with a range of problems: I involve them ... and what I actually find, out of that, is that I get a lot of counselling work. A lot of teachers ... they want to talk about their problems, and their health problems. And it’s been very interesting from the beginning of this year to the end of this year, I have had a lot of teachers who bring their health problems ... enormous. Rhonda 494-499 The approach taken to counselling, problem-solving and support were for the client to solve the problem, rather than the nurse. Participants did not ‘own’ the problem. In many instances, the approach was to explore the possibilities, and examine the choices available with clients: I see community nursing as a good place to go if you need self management for ... if you are interested in self management of your disorder that you are taking control of. Gwen 450-452 I see that I’m here as somebody who they can contact ... for most of the day ... and as a resource person. That I am here to help them problem-solve their problems. And if I can’t do it, then I can point them in the direction of where they need to go to get answers to those problems ... and to refer them to ... yeah ... appropriate sources. And just be here for them. If they just want to come and talk, and not be ‘problem-solved’ or anything like that, that they can come, sit down, and be able to do that. Cheryl 89-96
273 Finally, support was seen as an important in assisting people to address their own health needs and in enabling clients to achieve greater health competence. This support could be supplied by the nurse or by other health agencies in the community. Clients’ own informal support networks were viewed as integral to health and health outcomes. In many instances, participants felt that social support networks are lacking in today’s society: But realising that the earlier the right sort of support was given to families, the ... hopefully the outcome for those families ... health-wise ... was going to be better. ... and also I think parenting where ... there’s not the support systems of twenty and thirty years ago. And [parents] still being expected to provide all that [support] ... Karen 29-31; 263-265 Participants saw that they provided support, encouragement and reassurance, at times stepping in to provide this where clients lacked their own support networks. Participants also became involved with established self-health groups related to areas such as diabetes, domestic violence, hepatitis, parenting, breast-feeding, disability and mental health. Where they saw a particular need, they acted to initiate and set up support groups with the aim of establishing supportive networks: ... [clients have a] really good support group that they’ve got going. And certainly I’ve noticed in the post-natal groups that I have done ... and the eldest kids in those groups are now three and a half ... all those mothers still see each other ... they still baby-sit for one another while they’ve gone back to work part time ... and they’ve really networked quite well. Cheryl 184-191 ... [I] get involved with particular groups ... like hep[ititis] C support group networks and stuff like that. Emily 183-188 In addition to seeing themselves as a support to individuals, families, groups and communities, participants saw that it was important to facilitate clients’ own support networks. The aim was for clients to have their own support systems, thus enabling them to be more competent in meeting their own needs and solving their own problems:
274 I see it as important ... you know. I do go into quite a bit of detail ... when mothers come into the clinic as new mothers ... on their support system and that. Because I see it as a big problem in these expanding areas. Because there is a lot of moving and there’s not the extended families. So that that can certainly
cause
problems.
... and [I] try to educate people on what is good health prac[tice] ... and what’s going to keep them healthy and I do spend a lot of time on their social support
networks,
I
think.
Especially ... yeah, because there are just so many people that don’t have ... they don’t know anybody in their communities. And they’re lost. And I just see [that] if we only but all knew our neighbours more and we ... I suppose to try ... to let people know what services are there for them in their community, that people wouldn’t feel so alone and lost. And perhaps they could do a bit more for themselves. Lyn 1235-1241; 1349-1352; 1356-1363
Resources and Linking Participants saw that the provision of resources and linking of clients with resources and others in the community was an important aspect in their role. Participants acted to link clients to resources as well as acting as a resource themselves. The importance of resources is underscored by noting that for many of these participants, health was seen as a resource. As a consequence, the availability of resources to people becomes central. Participants saw that in tandem with promoting independence there was a necessity for clients to have access to assistance, advice, support and resources when they had a problem or difficulty: As long as they know that they can contact me or anybody else and as long as they’ve got resources. Gwen 662-663 ... I feel it’s my responsibility to make sure we have services in our area, and not depend on other health districts to provide those services ... which we are doing presently. Kate 412-515
275 In many instances, participants saw themselves as a resource to individual, family, group and community clients. The perspective taken in ‘being a resource’ was that the problem or issue remained with the client. They assisted the client by providing information and advice, with the aim of promoting health competence: So my belief is that I am there if I need to be [for the client]. And people don’t need to come to see me every week ... just ... because if they’re doing OK, they know I’m there, and if they come every month ... this is in the early months [after the birth] I’m talking about ... then I’ve achieved something then. Because I’ve ... they’re feeling independent, they’re feeling that they’re making their decisions, they’re feeling that they can access me or somebody else, if they need to. But they’ll phone me if they if they need [help]. And so I just think that knowing that you’re accessible [is important for clients]. Karen 608-618 Participants saw that they could assist clients by acting as an information resource. This role activity, while closely allied with health education and promotion, is different in that, rather than educating, they are simply providing clients with information. The information identified by participants that was provided to clients was related to health issues or problems, medical problems, or services available in the community, with the aim of assisting them to make informed decisions: Well I think it should mean that if people want information they can find ... that’s our role I think ... to let them know where they can find it. If they can find it themselves, that’s great. That’s even better. If they can’t and they want some other information, you can supply it for them ... give them whatever you’ve got, and support them, if necessary. Marie 624-629 An activity related to providing support and resources is that of being a ‘linker’. For many clients, the health sector is a maze. They find it difficult to access the right sort of help for their particular health issue or need. In addition, local knowledge is often required to know of the availability of the services in a local community and how to access them. A glance around participants’ places of work indicated large amounts of information about resources in the local community. Participants’ knowledge of the local community and their ability to network provided an important basis for
276 providing information, support and access to community resources. Their own networks contributed to their ability to link clients with appropriate and acceptable services and resources providing material support in the form of access to health and general services, and resources. This theme was related to many other categories including individual and community development, health promotion and education, referral, groups, problem-solving, support and so on. Participants referred to the importance of individuals and families having links and supports within their own social networks in a way that was consistent with a socially contextual view of health. Participants did not just see themselves as providing resources and support. They often undertook to assist people in making links, networks and in accessing specifically appropriate resources available in the community. This linking was often carried out in conjunction with assessment: Try to get in there ... assess what is going on. Bring in services that might help [that person] stay at home. Whatever the situation might be. Sharon 374-376 Often these linking activities were aimed at assisting clients to create their own support systems and links within the local community, allowing clients to develop their own skills, be more competent in meeting their own health needs and solving their own health problems, rather than becoming dependent on the nurse: Well, I like to think that I’m actually giving people information about either health services that are available in the area and health information pertaining to what they actually need, if they ask for it, or if I know that [the] results came back as [showing] that [need]. So it’s sort of offering a wide range of either available resources ... actual medical information and linking in with other agencies. Amy 671-676 ... just talk about health issues in general ... A lot of the young people there are homeless young people ... and have been through the refuge at some stage. So ... and then we see them there and tell them about all the local resources. Sometimes we drive them down there and show them. Helen 60-64 Another linking role taken by some participants was that of liaison between the hospital and community sectors:
277 That I liaise with any problems or concerns they would have between the community and the hospital. Kate 201-205 Well I see ourselves as a ... I really do think that we can ... that people don’t see us enough as a resource. That we do know what other services are out there ... well we should know ... but that’s part of your role ... developing your community ... knowing who ... where the playgroups are, and you know, the Salvation Armies and whatever else that ... that they can come to you ... and you can tell them who these people are ... Lyn 1288-1294 A most important linking activity was that of making referrals. Referrals to others while discussed here, also occurred in conjunction with Identifying and Intervening activities. The decision to refer was a reflection of: the type of client need, the resources or services available in the community, the skills and ability of the nurse, and an assessment of the services provided by the resource being accessed. Examples of agencies and practitioners that clients were referred to included general practitioners, physiotherapists, counsellors, occupational therapists, developmental specialists, ophthalmologists and optometrists, audiologists, other nurses in specialty areas, domiciliary nursing services and a range of community agencies: And we try really hard to work in conjunction with the other health professionals. We do have our, as you know, we have our areas of referral, which may be within our own system or maybe with ... into the medical practitioners in the area. Amy 216-219 In making referrals, participants made an assessment of the appropriateness of the services provided by the person, agency or resource to which they were referring clients. Thus, in referring, participants are matching client needs with the services or resources being offered: And then I started to send him [the GP] a few people on referrals. Because I’ll send people there that don’t ... if they have any things [wrong] from the waist up I send them down. If they’re women I send them somewhere else. But, you know because it’s easy and convenient. A lot of people don’t have cars. And if you’ve got something that’s easy he’ll spot it because he’s not a
278 bad clinician. His communication skills are very poor, very poor. But, there are certain people that like him, elderly people ... and people that hate him. And he is an unusual man, I have to say. Louise 981-990 A cause for complaint from participants was the lack of communication in reply to referrals from other health professionals, particularly medical practitioners. Most participants indicated that although some allied health professionals such as audiologists and therapists were excellent, many health professionals, and in particular general practitioners rarely replied: We don’t get a lot of feedback from GPs even though we do confidential referrals to them. They’re terrible. Rhonda 742-743 We’ve actually just done a project in this area on the number of referrals out to general practitioners and the responses. And the responses are pretty low. I mean nurses refer lots and lots and lots of people out to their own family doctors. But the returns are pretty low. Anna 663-668 Where replies were received from general practitioners, it was usually as a result of a relationship that had been developed and fostered by the participant: Well I used to go there every three or four months [to the local GPs practice]. He knew me quite well. And I used to do a lot of referrals from the school for vision and things like that. And he always was good, in that he promptly ... he responded to the referrals. Lyn 912-915 This lack of communication was felt to be unprofessional and created extra work for the nurse in following-up referrals, particularly if the health problem had the potential to be serious. Some regions had developed referral proformas with tear-off sections in an attempt to improve communication. However, resulting improvement in communication had been limited: Well, it increases my work load. Because I have to follow up to make sure ... I’ve got ring the parent usually. Or the parent rings me ... that’s good ... that’s improved this year. The parent rings me and tells me how the child got on. But
that’s
not
professional.
279 ... And often it ... you don’t know whether they [the referral] have been actioned or not. And whether ... you know, students [have been followed up] ... you’ve got over a thousand students in a high school. That’s quite difficult. Rhonda 751-758; 791-794 But most professional people, and I regard myself professional [do extra]. And that’s why it annoys me if I send an official referral to someone, I want a reply. I’ve done them the courtesy of sending them something on paper. I want something back. And it annoys me when people either never ring back to me any outcomes and things like that. If I’ve referred somebody over the phone, which happens sometimes, I’ll say to them “can you let me know what actually happens” Because I’m ‘living’ here and I need to have that information. And I think ... you know you’ve got to think [of] yourself as a professional. Louise 1144-1155
Developing and Empowering As the notions of ‘development’ and ‘empowerment’ are closely linked, they will be discussed together. Participants were involved in the development of communities. However, the spirit of ‘development’ was also applied to working with individuals and families. This is consistent with a view expressed by St John (1993) that the notion of ‘development’ can be applied to working with individuals, families and communities. Individual and family development was carried out by participants through their Enabling activities, including giving people information, a range of choices, health education and promotion, support, resources and linking. These development activities aim to promote Situated Health Competence. They are particularly aimed at widening choices and enabling clients to make informed decisions themselves. Again, the aim was to assist clients to do things for themselves. This may include accessing resources, engaging in health behaviours, linking with others in the community: ... I like to educate people about their health and their choices. And it’s possible that you can change, and people can develop, not only as people, but also can come to terms with what ever condition they’ve got. Or they can see a way out. Gwen 1055-1059
280 Community development was also included in organisational documentation from two of the regions accessed and was also identified by some job descriptions as part of the role of the community health nurse: Act as a catalyst in the development of community groups and facilitate the implementation of new health services. Joy, job description 31-32 Community Nursing services collectively include clinical practice and the provision of health education and promotion programs within the context of a community development approach. Sharon, job description 7-10 Participate in health advancement and community development activities relevant to the position. Emily, job description 18-19 Community development was also identified by two participants in their questionnaires as a service offered by their agency and skills in community development were identified as important requirements by a further two participants. During interviews, some participants identified community development as part of their role: Part of my role is working with individuals. Another part is doing health promotion, as well as doing community development. Helen 6-8 Although all participants engaged in individual and family development, not all participants engaged in formal community development projects. However, all participants either identified community development as part of their role and/or utilised the principles of community development, including participation and consultation in their practice: And from there we actually spent a lot of time working with some of the community members ... some of the older people ... some of the people who were sort of more prominent in [the community] ... in sort of making the place safer, the environment safer. Amy 266-270 The purpose of community development is to assist communities to solve their own problems, access resources, improve their situations. There were three major
281 community development projects described by participants. They resulted in development of a community garden, a local action group and a health information pack for final year high school students. All of these projects were initiated in response to a need expressed by the communities in which the nurse practised. The nurse did not enter the field in an attempt to ‘do’ a community development project. Rather, while working with the community, an issue was identified and the projects were developed as a consequence of this. The projects arose out of networking and engaging with community groups: Community development ... it started with a group of women which I was concerned about. They had various difficulties. They were all single mothers. And they had children ... and the children were running around the streets … at night ... and they were not fed properly. So … and its very hard to get these people
to
a
course.
So they were occupied with someone talking about how to sort out problems ... So then I asked some other people to come along ... like ‘Helen’ the social worker and so we were two people. Then we came away from this education thing and just started on [community development] ... because then they wanted to have change in the community, in the way of street lights, speed bumps, signs for the kids playing ... you know signs to ... you know restrict the traffic ... all sorts of things. So then we started ... and more people came along ... and then we started a newsletter ... Joy 85-90; 111-121 ... one of the students came in and requested a class on STDs. And I sat down and I talked to her. And she said “why don’t we give all the students a copy of this little booklet on STDs, because they’re changing [the STDs] ... some of them”. And I said “Oh ... right ... OK. So you’ve identified something that you feel that ALL of the year twelves would need as they leave school?. Mm.” She said “yes, everybody should have one of these”. So I said “what else do you think that they might need as they leave school?” Rhonda 599-606 These projects required a sustained commitment from the nurse, in one case over a period of four years. Louise was involved in a project over two years:
282 It’s been an interesting exercise for me. Because it was a major community development project ... major ... and it’s taken two years to get to this stage. And it’s been a lesson in how you can move through the bureaucracy to get something done. Louise 585-590
Consulting, Policy Development and Health Planning A final Enabling activity was consulting. There were many instances where the participant’s expertise was called upon. Participants had input into community and health planning groups and policy development. The aims of these activities were usually directed toward improving the health of aggregates or the community. Examples included development of new services in the community, committees addressing community health needs, policy development and advisory committees: That involves being on a lot of committees where decisions are made about local services. So there’s the [suburb] which is the City of [suburb] Youth Action Committee, that meets regularly and discusses what services are needed for youth.
There’s the [suburb] food group. We just started that
recently in [suburb] . Because the police found that a lot of people were stealing food. And they take them back to the station and take care of them, knowing that they have got to go home with nothing to eat.
So that’s
emergency food supply. Helen 95-103 Participants were also consulted by other health workers and professionals. Several job descriptions included the notion of providing a consultative service. Others were consulted for their specific knowledge areas, such as Marie who was a lactation consultant: And staff ... certainly staff using you as a sounding board or as a consultant if you like ... on some of the health issues. And I don’t just mean merely as a resource person. Anna 569-571 ... or speaking to people who ring up and say “little Johnny’s been smoking dope down the back shed, what do I do?” I do all that sort of counselling or
283 information and education, that sort of thing ... as well as with clients. Emily 383-387 Participants were also consulted by clients. Although similar to the provision of information (described above), this theme is included here because of the subtle difference in the role of the client. When clients take on the role of ‘consulting’ the nurse, they have taken full responsibility and control of their health and are choosing to access a particular resource to obtain information and advice on a specific issue: If upper school students come and see you, it’s usually for a specific reason, or they want advice on health issues. Anna 369-370
SUMMARY OF THE CHAPTER This chapter outlined the role activities of Identifying, Intervening and Enabling carried out by the community health nurse with the aim of facilitating Situated Health Competence. Identifying activities include: assessing, screening and case-finding, follow-up and outreach. Intervening activities included case management, crisis intervention, first aid, advocacy and ‘filling in the gaps’. Further processes saw the nurse Enabling, involving the activities of health education, health promotion, problem-solving, counselling, support, providing resources, linking, development, empowerment, consulting, policy development and health planning. To carry out these activities, community health nurses engage in the processes outlined in Chapter Nine.
284
CHAPTER NINE Enacting the Role of the Community Health Nurse Well, (sigh) it’s so immense. I really can’t put it into words. I can’t categorise it ... because the flexibility that a community nurse needs ... she needs all those skills, every single one of them. Rhonda 221-224
OVERVIEW This chapter provides analyses that address Research Question Three: How do community health nurses enact their role? The nurse has the task of enacting the role of the community health nurse, combining meaning, understandings, philosophies and aims with the concrete reality of everyday practice. Their knowledge arises from praxis, combining theoretical understanding with the reality of practice, and reflecting on that practice. The processes by which community health nurses enact their role are an outcome of the interplay between theoretical understandings, and the experiences embedded in practice and reflection. The processes of enacting the role are understood when viewed within the framework of the aim of facilitating Situated Health Competence. The aim achieving Situated Health Competence for individual, family, group and community clients is a daunting one. When community health nurses arrive at work each day, they must operationalise ideas, values and general aims into specific concrete action that achieves a purpose. The experiences of this action in turn shapes further ideas about practice. This chapter describes the processes by which participants enact their role by Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating. These processes do not occur in the linear manner suggested by the nursing process. Rather these processes occur in an intermingled, enmeshed fashion,
285 with each of the processes affecting the others. Even in the most linear of processes, those of Interpreting and Negotiating, there is an interplay between processes. For example, the nurse will interpret what they see as their role and identify priorities for action, prior to negotiating with others to achieve these goals. However, in the course of negotiations new information may be gathered, a new need uncovered or a new opportunity identified. All of these may alter the nurse’s perception of how the particular role could be interpreted and/or require adjustment of aims and goals.
INTERPRETING One of the first issues faced by a community health nurse is that the aim of Situated Health Competence generates many options and possibilities for action. Each individual nurse must explore the specific possibilities for their particular role depending on their brief or job description, designated community boundaries, organisational targets and reporting requirements, available resources, organisational climate and the needs of the individuals, families, groups or community served: and do so within the context of the nurses’ own beliefs, values, philosophies, educational preparation, experience, interest, expertise and skills. The nurse must interpret their role within the context of the scope and limitations that are placed upon them. The context provides signposts to the nurse that may generate a huge range of possibilities as to what role activities could be undertaken. Interpreting the community health nursing role is a creative and responsive process. There is a need for the nurse to actively reflect on the purpose, aims and boundaries of their role together with personal philosophies relating to health, nursing and community in order to generate possibilities for action. The nurse must answer such questions as “what is my role in this situation?” and “what are the most pressing needs in this particular community?” “What organisational requirements am I required to fulfil?” Thus the nurse explores the ‘territory’ of their role, by making an assessment of needs and contextual factors and ‘brainstorming’ to identify the possibilities: ... well, if you’re interested in why you’re doing the job, rather than just because you’ve always done it that way, you try to look at more creative [ways of doing things]... and [you try to] be a bit more ... smarter in the work
286 practices ... and [you] stop and say to yourself sometimes “why am I doing this? And what’s the outcome?”
Gwen 616-621
As a result, each individual nurse generates a range of possibilities for action and develops their own ideas and vision of the options and opportunities. Many of the participants outlined a ‘vision’ for how their community nursing could be better, or how health services and organisations could be enhanced and improved. Lyn suggested that it is important to think broadly about the community health nurse role, stating that “if you’ve just come from [general] training, ... you’re very narrow minded. You’ve got no idea that community nurses work in all these other areas”. In many instances, participants could see possibilities for a much broader role for themselves than they were currently undertaking: ... we’ve got a long way to go. I think it’s [community nursing] got a lot of potential ... and it’s [community nursing] been doing quite well up until now. But as far as providing the primary health care that we need, we have only just started. ... and I think people are really starting to focus on it [primary health care] ... but I can just see ... there is so much that can be done. And we are nibbling away at it. ... there are quite a few areas ... even the areas we have identified ... are we making a big enough impact? Sharon 727-734; 738-750 I would like to do a million things ... it depends on how you view your job. Gwen 607-612 While identifying the range of options, the nurse also locates the limits and boundaries of the possible activities of the role they are required to undertake. Their limitations and boundaries are characterised by geographical, financial and organisational frameworks. In other instances they have a brief to address a specific area or client grouping. In addition, participants worked within organisational targets and were required to supply employers with reports and statistics outlining the activities they undertook. As a consequence, the reporting structures of the organisation played a part in outlining boundaries of role. An example is where Kate (484-501) outlines how she had to adapt to changes in the organisation of geographical areas, suggesting “And I’ve tried hard, against my better judgement I think, to bring my thinking back
287 to this small area.” Others identified limitations and boundaries impinging on their role: This is the other thing that amazes me that ... you are put into a particular role ... you interpret that role as being a primary health care role ... you do the work that you think is what needs to be done ... but interestingly enough you still find that quite often you are still asked for statistics. Sharon 117-122 Well, the regional priorities of course ... they’re already defined. So I target in ... with stats [statistics] ... I have a look at my stats ... what I’m actually sent. And I target in on the things that are priorities, within the regional priorities. ... I choose from the regional priorities the things that I can be proactive in achieving within my community. Rhonda 274-278; 282-283 It is also evident that the resulting Interpretation of the specific role in a particular situation results from the nurses’ individual perspectives and understandings. Participants indicated that different nurses may have different interpretations of the same role, and that enacting the role is the result of individual perceptions and interpretations: Plus I learnt a lot from the other nurses who handled things differently. Because each one had a different perception of what they saw their role as. Rhonda 212-215 And I think there is slight differences in how people interpret their role. Sharon 727-734 It was also evident that participants’ Interpretation of their role was dynamic and fluid, rather than static. It changed to respond to local circumstances, situations and needs, and as they themselves developed, and also when they moved from one community or role to work in another. Emily felt that she had been able to change her role “slightly over the years”, and that this was “how I’ve survived and come out the other end feeling I’ve accomplished something”. Thus, participants indicated that they engaged in ongoing interpretation and re-interpretation of role, engaging in reflection and
288 responding to change. This responsive, dynamic, fluid Interpretation of the community health nursing role provides an explanation for the variation in how participants undertook role activities. The way participants Interpreted their role was different to the linear approach of assessment and planning incorporated in the nursing process, because the nurse was active in shaping the whole direction and nature of the role. As participants required a clear understanding of their own practice in order to Allocate, Negotiate and carry out their role, Interpretation assumes primary importance.
DEVELOPING Development of the nurse was fundamental in enabling them to appropriately fulfil the role of community health nurse. There were two aspects to the Development of participants within their roles. These were firstly, the aspect of ‘becoming’ a community nurse, and secondly, ongoing professional and personal Development of values, knowledge and skills that were considered by participants to be an important basis for continuing to undertake the community health nursing role.
Becoming a Community Health Nurse Participants engaged in a Development process of ‘becoming’ or taking on the role of the community health nurse. The nurse takes on the role of community health nurse and develops a commitment to the self as a community health nurse. Thus, in addition to Interpreting the role itself, the nurse must identify themselves with the community health nurse role, or with an alternative conceptualisation of the role: So ... I couldn’t see myself at this stage doing anything other than community work. Because I find it so varied, so interesting. It’s not the same thing every day. And perhaps that’s what nursing is all about too ... not having to do the same thing day in day out. Carol 139-143 And it just felt right and I’m happier in the community ... and it was less structured and less rigid ... and there was the opportunity to be creative .... it’s far more exciting I think ... there weren’t the barriers and the sort of rigidness of hospital life. And I just found it was my ‘cup of tea’. Louise 17-22
289 So I really still know no other way of being a registered nurse, other than being a community nurse or a remote area nurse. And it just ‘clicked’. I mean [for me], that was the right way to nurse. Kate 59-62 The view of self is entwined with the view of the community health nurse role per se. This process sees the nurse identifying themselves with the role they have Interpreted for themselves and involves incorporating this role along with their philosophies, values and skills, into a coherent view of themselves as a community health nurse. The participants developed a view of what community health nursing is about and a personal theory to guide action. Thus, there is a link between how the nurse Interprets the role and how the nurse views him or herself within the role: You know, I’m a well qualified professional nurse. motherhood status really shouldn’t affect my practice.
My gender and my And I still partly
believe that, you know. But I also know that it does. So you know, if I’m going to bring those things in, then I have to bring them in as a representative of the other women in the community. Kate 167-172 As the nurse Develops, notions about the role will also change and develop, and as a consequence, Interpretation of the role may change. For example, Sharon reflected on the change in focus she had experienced since starting to work in the community: I think that’s one of the shocks and the changes .... You mentally …you consciously have to change your thinking ... when you come out of the acute care situation. Even when I look at some of the documentation ... of [nursing progress] notes. And I know a new nurse [who] came out to the community. And she was really in the bio-medical model. And her history-taking in the whole file was quite interesting. Yeah. I’m sure I did that when I first came out [laugh]. You change slightly in your perspective. Its not so much the biomedical model. That’s part of it. But you use the whole scope, the more you are in the community. You are assessing the whole person. So ... it was quite an interesting thing for me to see that. And I thought “yeah ...” 830-844
Sharon
290 As discussed above, participants all described an initial learning phase, where they were coming to terms with the changes in aims, context, control and responsibility, Situating their practice in the reality of people’s everyday lives and addressing their personal ‘baggage’ about their view of nursing: Probably as you have more experience you become less rigid. When I say rigid ... the things that seem really important at the beginning, as you become experienced you know, they’re not that important, because they all fall into place. Mary 477-481
Ongoing Personal and Professional Development Further to initial learning, there was also an ongoing Development of values, knowledge and skills as participants undertook the community health nursing role. This was true for all participants, including the most experienced. Professional development activities were explicitly required by some employing agencies: - Membership of professional organisation and/or health service committees. - Contributes own time and resources to professional development. - Maintains and develops professional knowledge and skill through a minimum of sixteen hours of continuing education per annum. Kate, job description 6268 As the participant encountered new issues, health problems and needs, there was a need to continue to develop new skills and acquire new knowledge. Although initial learning development in undertaking the role was important when participants began to work in community health nursing, it quickly emerged from the data that the learning and development was ongoing. Questioning the way in which the role was Interpreted was continuing, and provided a basis for ongoing Development. Changing contexts, knowledge, skills, structures, targets, issues, clients and communities required continuing and flexible developmental responses from the nurse. It was also evident that this change was a process that occurred over a period of time: [It wasn’t] one day I decided “this is my approach”. It has just grown over a long period of time. Joy 472-473
291 ... and they [the changes] were [over] all of those years, I have to tell you. That would have been ... um [I] started in district in [19]79 ... and we’re talking about up to and including ... by the time I got back into community here, we are looking at about [19]89, 89-90. So we are looking at a good ten years of shift [in thinking]. Janet 237-242 All of the participants, including the most experienced, talked about continuing to learn. Participants valued the need to continue to develop and be up-to-date, gain formal and informal knowledge and took on the role of lifelong learners. They attended formal, continuing and professional education, and discussed the need to gain new knowledge and develop new and better ways of doing things: ... there are so many short courses and seminars to do ... that your skills are very dynamic. You are acquiring new skills all the time. So you end up with a whole lot of new skills than when you started. So rather than ... its extremely broad. Helen 259-263 I learnt that I’d have to stop running around ... that it wasn’t actually wrong for me stand underneath a tree and start talking to people. And learn a bit about the people, before I started ‘curing’ them. Gwen 76-82 The rationale participants gave for engaging in ongoing learning was to meet new challenges in the shape of emerging problems, address areas about which they themselves felt they needed more knowledge, increase their own confidence in their own skills and to undertake their role better: But the other thing is that for most community nurses ... I mean you’re constantly having to improve you skills. ... Now it’s depending, I mean, my job for me is like a passion. I mean, I don’t have hobbies and not that I want to be doing this seven days a week either ... I’m very grateful I leave here and go home. But, you know, if you’re going to do it, you do it well. And you do all the things that can help you become better. Louise 1107-1145 It was clear that the impetus for this constant up-dating and ongoing Development was the fluid nature of participants’ Interpretation of their role. Along with identification
292 of new issues, areas of need, or problems came the requirement for new knowledge and skills in order to continue to effectively carry out or action the role. Interpretation and Validation of the role drives the need for ongoing Development. The learning that took place was a times idiosyncratic. For example, Louise’s involvement in a community garden involved her in learning about many things not found on any nursing curriculum: And so we all learned an awful lot about soils and pH of soils and acidity and alkalinity and what makes the soil good for certain types of vegies ... Louise 524-527 Participants were asked in their questionnaires what knowledge and skill areas they considered to be important in their current role. These data, together with interview data were examined. While the areas that participants identified were specifically individual at times, there were themes in the data that indicated particular areas that were important. There were five major areas identified. The first was health education and health promotion skills. This included the need to develop expertise in public speaking, group work and making learning fun. Secondly, participants felt it was important that they had traditional nursing and medical knowledge, together with the body of knowledge that made up their specialty focus. For example, specialty knowledge for a child health nurse would include knowledge about family dynamics, child development, screening procedures, current trends in child health and common childhood problems. The third area participants identified was related to interpersonal and communication skills. Participants suggested that verbal and written skills were important. They identified that counselling skills were important, particularly identifying listening, empathy, non-judgemental approaches, conflict resolution, and negotiation. The fourth strongly emphasised area that participants identified was a large range of personal and professional skills. Personal skills included: common sense, enthusiasm, vision, a positive attitude, patience, trustworthiness, a ‘thick skin’, compassion, personal and professional courage, flexibility, impartiality, initiative, creativity, emotional stability, ‘life experiences’, a work ethic and a sense of humour.
293 Professional skills included: time management, interest, autonomy, independence, an ability to work as part of a team, problem-solving, decision-making, coordination, management, continually updating knowledge and skills, and the ability to access a mentor. A final area identified by participants related to primary health care, networking, referral and community development. Several participants specifically identified a need for community health nurses to develop skills in community development: I feel that community nurses should have a bit more education in the way of community development. ... Find out about it. ... And how to go about. And how to set up groups. Because I think lots is expected of us. We haven’t got any of the background education. I am looking forward to doing this course that is offered. And also I want to do child health. Joy 663-669 Participants engaged in a variety of processes in order to foster their ongoing learning and development. The major processes contributing to Development identified in the data included: experience, education, supervisor, peer and client interaction, and reading. First and foremost, participants found that experience was a crucial ‘teacher’. The realities of the field played a major role in contributing to the learning and Development of these nurses. Interacting with the ‘honesty’ of the field quickly provides feedback as to what works and what does not. Some things that may seem simple in theory do not necessarily work in practice. For example, Lyn had a belief that people should be responsible for their own health. However, in practice she found that some clients and communities do not behave in a way that is most promoting of their own health and commented that some people to not care about their own health. Experience in the field provides constant feedback and experience, enabling practitioners to Develop and hone their judgements and skills, and to learn to recognise the nuances and cues: I couldn’t have ever learnt this out of a text book or lectures or anything. It’s all very much to do with experience I think ... and just the right frame of mind. Emily 95-97
294 I think ... because ... a number our skills are skills one gains from experience. Karen 804-805 It was also evident that with experience participants became more confident in undertaking assessment, and more quickly and effectively identified needs: I pick things up a lot quicker and that’s just the experience. Emily 221-223 I guess the years of nursing has enabled me to assess people without consciously being aware of it ... and perhaps picking up what their needs may be. Carol 283-287 Participants were particularly concerned that community experience be included in the educational preparation of nurses. A second process that contributed to participants’ Development was formal, informal and continuing educational activities. All participants alluded either directly or indirectly to the contribution of education to both their personal and professional development. Participants discussed the important impact of educational processes on their thinking and skill development: ... a growing ... oh yes, very much so ... and I was doing at the time ... my study ... actually I wasn’t studying nursing, I was doing B. A., and I was studying government and women’s studies ... and I was picking up on sociology type things, and social development and the role of women and all this sort of stuff from my degree. And just from reading and still having this ‘prevention’s better than cure’... Janet 130-137 In many instances participants undertook educational programs because they perceived a deficit in their knowledge and skills: And you do all the things that can help you become better. Like I mean, I joined Toastmasters for that reason. ... to get a bit better. The better the public speaker you are, the better you present your facts anywhere, you can stand up in front of anybody and tell people exactly how your centre operates
295 ... and if you’re on committees, you’re not backward in coming forward to be able to promote your service. Louise 1117-1123 ... I realised that I needed more skills. So I then went and did what was the only thing available then was ... [child health] program of six months. Karen 175-181 A third, important learning process was through observing and interacting with supervisors, peers and clients. At times there was a requirement to seek out mentorship: And then I met somebody else who was a community nurse in [remote town]. And she sort of started to talk to me about it. She’d been up there a long time. And she sort of talked to me about what my role was going to be. Gwen 69-87 Reading literature, and talking to other nurses. That was the way I could get into my mind more clearly what the primary health care model was ... what it was all about. Sharon 100-103 However, some participants indicated that they did not receive sufficient support from peers, or felt they had insufficient discussion with peers: And nobody ever ... it never really got discussed much. And people never said “... these are some things that you should know.” I didn’t have any of that. I was only young. I was only twenty three. Lyn 325-329 A further learning process that was evident in shaping and Developing participants was their use of a range of literature. Participants read in a wide range of areas and indicated that this had been important in their Development: But during that time, I was reading all about other approaches to health. And so ... some alternative treatments and doing meditation courses ... and exploring ... Helen 580-582 Yeah and I had to do some reading to get a little more understanding, you know ... and learn some things about their culture, like that they avoid eye
296 contact because that’s seen as being rude. And little things like that that helped me understand a bit more. Lyn 310-317 In addition to these processes, participants were involved in the Development of other community health nurses and student nurses. Preceptoring appeared to be an assumed part of the community health nursing role. Mentoring itself was considered to be a learning and Developmental experience: I would say now, at this stage, that I’m probably a bit of a mentor for other nurses. In practical terms, the high school actually ... competencies ... my competencies have increased enormously. And I think I’m a much, much, better practitioner for the experience. Rhonda 245-249
ALLOCATING An Interpretation of the full range of possibilities for action can be overwhelming for the community health nurse. The nurse may have a brief to address a broad range of issues including: health promotion; prevention; short and long term services for individual, family, group and community clients; and, at times, curative activities. In every community or situation there is a seemingly infinite number of ‘things’ that may be addressed. At the same time it is clear that the community health nurse has limited physical and personal resources and capacity available to address all of these issues. Thus, the nurse is unable to undertake all of the possible activities identified when Interpreting the role: ... I guess when I first started, I felt I had to do everything. And I just couldn’t do everything. And that’s where the disappointment comes in, and that’s where maybe you wait ... and get all of your facts and figures and put things into perspective ... and think “well which one will I try first”. ... “yes, I’ll go and look at that ... there could be continence ... there would be women’s health ... there could be asthma ... diabetes” ... all these different things that I’d like to do a little bit of. But I then found that ... well that’s not realistic. Doing a little bit ... and not getting it done well. Carol 621-642
297 ... but I mean initially there were just so many [issues]. The person I took over from was very respected as a community health [nurse] ... she was absolutely exhausted ... Gwen 265-268 In addition to an overwhelming number of options available for action, the nurse may find that one component of their role, while important and necessary, appears to consume so much time and energy that they do not have the capacity to address other important aspects of their role that are consequently restricted. They may find that the burden of one aspect of their role results in a very tightly proscribed and limited role. Examples of role activities that tended to dominate other role components were: the provision of first aid in school health, screening in child health, and a large individual client case load in generalist community health. Balancing of role activities is particularly pertinent, given that the community health nurse is dealing with people. People’s needs may have an immediacy and urgency about them that cannot be postponed, such as when a crisis occurs. On the other hand, a nurse may, over time, find that activities such as screening tend to dominate to the exclusion of other role activities. When the aim of achieving Situated Health Competence is considered, it can be seen that many of the goals of the community health nurse are long term and therefore not urgent, immediate or necessarily concrete in nature. In this situation there may be conflict between the pressing nature of some needs, while wishing to be engaged in activities aimed toward achieving longer term goals. Strictly speaking the nurse will have the knowledge and skills to undertake all components of the community health nursing role. However, the nurse cannot do everything. Given the breadth of the role possibilities, the nurse must make choices about where energies and skills will be best spent. As a consequence, the nurse has to delimit the possibilities, choose between options, and balance between competing issues in order to develop a manageable, realistically achievable and sustainable workload: [Knowing] that you are delivering a service. And that you can’t be all things to all people. Gwen 832-833
298 I’ve got to bring it down to “I can’t change the world ... the [state health organisation’s] not going to change it ... I just have to try and do something from within”. Kate 916-920 Thus, the nurse actively works to shape their role and engages in ‘allocating’ between the different areas of role activity, in order to make the best use of time, energy and capacity in achieving Situated Health Competence for individual, family, group or community clients. Thus Allocating is a ‘balancing act’ taking place in the contextual reality of the field. For example, a school nurse may have to balance role activities such as first aid, screening, follow-up, individual and family consultation, health education, health promotion and whole school development programs. If the nurse does not engage in Allocating activity, they may find themselves simply reacting and engaging in ‘busy’ work, rather than proactively responding, planning for and addressing the important health needs, issues or problems that they have identified. Consequently, the nurse engages in long term planning in order to balance the many competing possibilities for role activity. By Allocating, the nurse acts to ensure that one role component does not dominate, and as a consequence enables: other issues to be addressed, expansion of the role, response to new challenges, pursuit of an interest, an ability to address a perceived population need, and so on. Allocating has distinctive differences when compared to prioritising. When someone prioritises, they tend to identify which issues are most pressing or important, then undertake tasks in order of importance. In the situations presenting themselves to the community health nurse, the demanding nature and immediacy of many client needs will always be an important priority, particularly if clients are vulnerable. For example, if a client who has just had an accident and sustained an injury presents, the nurse would be morally required to immediately stop working on preparing a health promotion presentation and attend to them. This immediacy tends to have the effect of limiting role activities that address longer term goals such as health promotion, disease prevention and networking activities. The community health nurse faces the dilemma of wishing to expend time and energy engaging in role activities that aim to achieve longer term goals, when the ‘pay-offs’ for these activities are difficult to define and measure and any successful outcomes will probably occur very much in the future.
299 Thus, in order to Allocate time, energy and capacity to longer term, less immediate goals, the nurse must first have clear vision about what they themselves are trying to achieve, in other words, Interpret their role. Unless the nurse has clear goals, targets or directions, they would have difficulty in dividing their time and energies among the many ‘things’ vying for attention: I would say ... my one to one client load is about a third, health promotion is about a third, health education’s a third. Sharon 221-224 Next, the nurse must engage in ongoing negotiation with others in order to develop understanding and acceptance of their Interpretation of their role and establish the ‘rules’ for interaction pertaining to the nature and extent of the services provided by the nurse. This required a variety of approaches. In some instances in order to successfully Allocate and achieve longer term goals, the nurse may be required convince others of the importance of their ‘vision’ in spite of there possibly being a difficulty in evaluating outcomes. This requires the nurse to have personal and communication skills. At times, this was achieved by demonstrating previous ability to successfully undertake activities: And I now have teachers saying “when are you going to do it with us?” [a health education program]. So that’s basically ... you know “we need to be instructed in this too. We want to know about it”. And I just haven’t had time [to do it]. Time has run out. But I certainly will make that a priority for next year. Rhonda 914-918 It was also necessary for participants to plan a way of dealing with issues that were pressing, immediate or task-oriented in situations where these role activities threatened to take over all other aspects or their role. Unless the participant acted to plan for these aspects, the role would be dominated by acute need, curative activities or tasks such as screening. This would render the nurse unable to apply themselves to activities such as health promotion, disease prevention, follow-up, networking and community development. At times, there was a need to act to change the structures and approaches of the organisations they worked for, or the perspectives of the people with whom they
300 worked. This necessitated the nurse to engage in long term planning, strategising and networking. This involved activities such as referring, negotiating for others to take on a responsibility or teaching people to do things for themselves. For example, when Helen began working at a new agency, they had a fairly traditional understanding of the role of the nurse and an expectation that she would simply replace the previous incumbent and be the new “Pat”. Over time, she worked to change this perception, changing the areas she worked in and the programs she was involved with. She relinquished parts of her role to others, shared parts of her role, engaged in teamwork approaches and negotiated to implement new programs with the governing body of her centre. Finally, in order for the nurse to Allocate time and energy to various role activities, it may be necessary to act to limit involvement in some aspects of the role. This may require the nurse to delineate clearly and assertively that there are things that they will not undertake to do, in order that one particular aspect of their role does not overtake all the others. This explains why participants very clearly spelled out what they would not do at times. For example, as outlined above, Kate indicated that she did not “treat sick people” in her child health practice: That’s not my role.
I don’t have the facilities or the skill or the legal
responsibility to do that. So ... but I do refer them. And I refer them to the appropriate people. Kate 129-131 This approach may at times present difficulties and dilemmas. The nurse may be required to limit services to clients where there is great need, but clients are not taking advantage of the service to improve their own health competence. Limiting services is balanced with a judgement as to how vulnerable the client is and how difficult the client or client group was to reach in the first place. For some, the decision to begin Allocating was the result of reflection and was a conscious decision they made: So after my first holidays, I came back and [I] just stopped and thought “well I’m not going to achieve anything at this rate ...”. And [I] just looked at what were the community’s pressing issues. How they perceived them. Gwen 276279
301 Thus Allocating required the nurse to ‘stand back’ from the problems and issues, in order to make an analysis and assessment, see patterns, identify immediate and longer term issues, problems or needs related to their particular community. The nurse then acts to shape the role, or Allocates, by deciding among competing areas and identifying goals.
Factors Affecting the Allocating Judgements Within the contextual, individualised nature of Interpreting and Allocating, it can be seen that participants made judgements about the way in which they Allocated their energy and capacity among the possibilities. At times there was variation in what participants undertook to do from one situation to another and also when compared with other nurses. An examination was made of the data to identify the factors that influenced the way in which participants Allocated between different role components and activities. It was found that there were a range of factors taken into consideration when the participant was Allocating between various role components and activities. Gwen pointed out that decision-making and judgement required expertise on the part of the nurse: But when you’re faced with a whole ... of multi-faceted diseases ... and you have got STDs that are rampant. And [major metropolitan centre] would send down targets and aims which you had to achieve, it’s very difficult to see the wood for the trees. And I think that you have got to be fairly experienced ... which I wasn’t ... to be able to look at the issues and decide which health issues are important. Gwen 255-261 The nurse makes judgements about where they will expend their time, talents and energies, in other words, how they will Allocate. Factors found in the data that contributed to Allocating decision-making and judgments included: the nurse’s philosophy; client issues, problems and needs; the nurse’s own interest and expertise; organisational support, targets and resources; the mode of interacting with clients; and the pay-offs. First, when considering the importance of making decisions about how to Allocate between various components of the community health nursing role, it can be seen that
302 the philosophical basis of the nurse’s thinking is crucial to how the role is carried out. It is on the basis of a philosophical world view that judgements and decisions will be made and directions chosen. Thus, the philosophical perspectives outlined in Chapter Five assume great importance to understanding the role, function, effectiveness or otherwise of the community health nurse. It can be seen that perspectives relating to promotion and prevention of health, primary health care, holism, and community will provide a framework for the decision-making of the community health nurse. The principal factor in Allocating decision-making was based on an assessment of individual, family, group and community issues, problems and needs. As described above, participants were very responsive to client needs. Decision-making also took account of the seriousness of the health issue, problem or need and the vulnerability and reachability of the individual, family, group or community client. Secondly, in addition to responding to need, however, participants also recognised that clients had the option of choosing not to participate or access their services. Thus, there was a pragmatic understanding that any particular activity or service provided should be useful and/or interesting from the clients’ perspective. The client must consider the activity enough of a priority to participate. Thus, the likelihood of the ‘success’ of an activity in terms of client participation was considered by the nurse. These judgements were often based on knowledge and understanding gleaned while networking and made in consultation with the client. A third major factor in Allocating decision-making related to participants’ own expertise and interest. While responding to client needs was considered important, the nurse also required the necessary expertise, capacity and confidence to carry out any program that they developed. This was evident where the nurse possessed specialist expertise. Participants identified areas in which their expertise could most usefully contribute and that their expertise was also important in providing credibility. Emily (175-205) pointed out that as she became more expert in managing her case-load, she was more able to take on a wider variety of activities related to her role. It was found that the individual characteristics of the nurse encompassing a philosophical congruence, interest, enthusiasm and commitment was an important factor in Allocating decision-making. A particular program may require an ongoing drive and
303 passion, in order to successfully negotiate and argue for it, often over an extended period of time. A further factor that had an impact on Allocating decision-making related to an assessment of the personal and material resources available. In many instances, this involved the nurse in garnering further resources, and working to access support from others through networking, negotiating and grantsmanship. The act of Allocating requires the nurse to confront a reality of limited resources such as time, energy, skills, and make decisions about how best to use them in order to make the most gain. Referral of clients was an important activity in regulating the work profile of participants, together with balancing need and resources. All participants engaged in a great deal of referral activity. Involved in this process was an assessment of need, an evaluation of their own skills and the best use of resources. An inescapable fourth factor impacting on the Allocating process was provided by the organisation and structures in which they worked. Policy initiatives, employer goals, goals related to specific fields of work, and their own professional scope of practice provided an important context. Organisation documentation, such as job descriptions and strategic plans, outline boundaries to the nurses’ role activities and direct focus, geographical boundaries, work requirements, reporting requirements and so on. Participants tended to choose from amongst organisational targets when Allocating. The need to justify activities also had an impact on decision-making. At times the nurse was required to make trade-offs between tangible, measurable, short term or process outcomes and difficult-to-measure long term outcomes. In addition to formal determinates, informal organisational processes have an impact on Allocating decision-making. A superior who is sympathetic to projects put forward, and active in providing material and manpower support will provide a very different context when compared with a situation in which activities are discouraged. In some instances, participants were required to actively strategise and negotiate in order to overcome opposition in order to achieve the goals they set for themselves. A fifth factor that had an impact on Allocating was related to the way in which participants interacted with clients. The question of what the nurse will do for a client is an important issue. This is seen in the dilemma over client loads. If the nurse wishes to be engaged in a range of community health role activities, they cannot spend
304 all their time dealing only with individual and family case loads. They need to be able to address individual and family client needs without this aspect of their role engulfing them. Thus, they work with clients in a way that facilitates Allocating. As discussed above, participants worked with clients with the aim of facilitating Situated Health Competence, aiming that clients become competent in addressing their own health issues, problems and needs. This approach was very important in the nurses’ ability to Allocate. The nurse cannot do everything for everybody, otherwise they would find themselves with an escalating list of people for whom they are doing things. Thus, judgements about who they will ‘do for’ and what they will ‘do for’ clients become very important in being able to Allocate time and energy to other role components. In working to develop and enable clients, they are at the same time making their own role sustainable and more effective, while retaining the ability to address a range of options. In many instances, participants addressed the issue of individual client load by reframing their view of the nurse-client relationship. This was essential in allowing the community health nurse to realistically cope with the many community, family and client needs they encountered. They also used group and community development approaches. By using a range of approaches the nurse prevents themselves from being immersed in day-to-day busy work and is able to stand back and address issues of how to deal with problems most effectively. A final factor in judgments related to Allocating was an assessment made by the nurse as to the possible ‘pay-offs’ of a particular role activity. The participant made a judgement about how helpful the role activity would be in achieving their aims. The goals of participants’ activities were found to include both formal and informal aims, and comprise both explicit targets that may be articulated by the nurse and also implicit objectives. Activities were also directed towards achieving the direct health outcome of Situated Health Competence, as well as process aims that did not have any direct health outcome. For example, participants set aside time to engage in networking, improving their own knowledge, and developing and accessing resources.
305
Exemplar One: Provision of First Aid in School Nursing Most participants accepted the role of first aid provision and crisis intervention in an assumed way. For these nurses it constituted only a small part of their role. School nurses, however, were required to undertake a greater amount of first aid and the amount of time spent undertaking first aid became an issue: You’re there for a first aid role, certainly in the high school ... [the] first aid role is quite a dominant role. We work very hard at trying not let people see that as the dominant role. Yeah. Because it’s ... and they do. I mean people do see that as the dominant role. “You’re the first aid person”. But injuries and illness do occur when they’re at school. Anna 213-219 In the situation of a particular component of the nursing role, such as crisis intervention, threatening to overtake other components of their role, participants moved to limit this particular component of their role. This was not a particularly easy thing to achieve, given the immediacy of the need of a person presenting in a crisis or following an accident. The nurses were required to undertake longer term planning and negotiation on order to achieve this. Several participants with a school nurse component to their role described discussions they generated with the principals and teachers of the schools they were working in: Well I said that I was here to do the screening, outlined what the screening procedure was ... [and] that I didn’t see myself as a first aid person, and that last year I had had a lot of problems in getting my workload done, because I was asked to so much first aid. And I said, that because I was only visiting one day a week that I felt that the teachers could take responsibility for the children. That I would certainly be more than happy to assist with those things people weren’t sure about ... but that I didn’t see my role as [being] there to put Band-Aids on. And fortunately she agreed. So I went to a staff meeting and outlined all that to the staff again. And so things went well that year. I didn’t have to put on every little Band-Aid ... Lyn 1133-1148 They also engaged in planning strategies to limit this particular component of their role in the longer term, while still addressing the needs of the students. In tandem
306 with setting these boundaries, participants set out their forward plans for programs within the school. This is an example of longer term planning, alleviating responsibility and commitment to one role component to enable involvement in a broader range of health programs: Because basically they see me as a first aider. And when you try to explain to them that the nurse is very rarely are the first aider. I might be the secondaider or the third-aider ... but I’m very rarely the first aider in the situation ... they are the first aiders. And that’s the other thing I’ve been trying to keep going
...
... I haven’t had a great deal of success at getting the first aiding going in the school. So next year I’ve honed in on the students getting their first aid certificate. Because I’m a first aid St John’s instructor. And I think that that will be the breakthrough that makes the teachers realise that they should have it [their first aid certificate]. It has worked for me before. ... once you start to arouse a need for it, you usually find that people have got a better handle ... [on] dangerous situations. The kids raise it you see, because they’re learning about it. And they re-alert the teacher. ... I’ve found this in other schools, where I’ve run them. Rhonda 394-399; 556-593
Exemplar Two: Accessibility as a Health Professional Availability of self to clients was a further example of the nurse being required to make judgements in order to Allocate energies. Participants saw themselves as being professionally accessible, particularly because of their location in the community, situated close to clients. They also discussed the importance of their availability to clients as an important aspect of their professional role. In examining the possibilities for their role, nurses saw their availability and accessibility as fundamental: So basically community health nursing is being available to be able to ... being available to a population ... that population will include the whole lifespan. ... Of course I am available to everyone in this community. So the one to one ... and the aggregates and communities within communities. Sharon 225-22; 299-303
307 At times they contrasted their own availability with the accessibility to clients of other health professionals. They saw that the lack of time being made available to clients by other health professionals may be related the work structures and limited numbers of those professionals in the community. Participants saw that their own location in the community, and consequent accessibility, was an important factor to developing a responsive role: Whereas the GPs can’t offer that service. They can’t offer the service that child health nurses do ... that they [the client] can have a half hour every time [they visit]. And just sit here and talk. Or that [for] their breast feeding problems, that they can bring the baby down here and someone will supervise a breast-feed for them, on a regular basis. Those sort of things, the GP can’t offer those sort of things. I suppose there’s some child health nurses who don’t offer that service either. But I think if you’re going to ‘sell’ your service well, they’re the sort of things that you need to be doing. You need to be available to people. Cheryl 203-219 It could be argued that the whole issue of availability may be related to a lack of value placed on a nurses’ time and that the time of other health professionals is considered more valuable. On the other hand it may be argued that their availability, accessibility and client-centred approach are integral to the role that the nurse is expected to fulfil in the community, and that this is a reason more nurses are employed than other health professionals. It could also be that the orientation of community health nurses toward a contextual, holistic approach and a primary health care philosophy which includes social justice principles encourages them to make themselves available. Incorporated within the need to be available to clients, was the issue of being professionally available and personally contactable: ... make yourself available ... if people want to ring you up and ask you about a particular thing. [You should] get back [to them] when there’s phone calls. If you get back to people and let them know what you did ... or if they want to get in touch with you ... you return the call as soon as you can. All those little things that makes the professional. Louise 1168-1174
308 However, the need to be professionally available also results in a need for nurses to deal with the issue of personal contactability. There is a dilemma in balancing the need to be available to clients in need and Allocating time and energy to a range of other role activities. It was pointed out by several participants that their working hours constituted a limitation to their availability. School nurses pointed out that they worked between several schools so could not always be personally available at any one school. Even the nurse who most highly valued the need to be available to clients indicated that she was not available for all of the time. Thus, although participants indicated that they valued the need to be available, it appeared that there was a limit to the extent to which they actually made themselves immediately available to clients. It was found that the participants in this study who most valued their immediate availability to their clients were specialist in their orientation, and had a greater individual and family orientation to their roles. It was also an understanding that this ‘availability’ did not include provision of ongoing hands-on care. Thus, even in making themselves available to clients, the nurse is placing boundaries on the nature of their availability.
VALIDATING Validating practice was a major process theme found in the data. Validation was important due to the ambiguous nature of the role and the broad scope of practice. The autonomous nature of the community health nurse role, requires that the nurse have the confidence to both Interpret and fulfil the role. However, blurred boundaries of practice can at times leave the nurse seeking validation and on occasion reassurance. At times it was difficult for the community health nurse to elicit feedback on Interpretation or performance of the role because, for the most part, a community health nurse works as a sole practitioner. However, participants engaged in a range of strategies and approaches to Validate their practice. These included: use of documentation, support from others, evaluation strategies, and feedback from clients. In addition to these external Validation strategies they also engaged in reflection about their own practice.
309
Documentation Participants used a range of organisational documentation to Validate their practice. It is arguable, that role descriptions assumed importance because of the ambiguous nature of the community health nursing role. Some participants indicated that they reviewed their job description every year, and there was evidence that participants did reflect on what their role descriptions outlined. Job descriptions were at times fairly generic, and often the guidance in demarcation of the role was in terms of the client group focus, for example ‘child health’, ‘Aboriginal health’, and ‘migrant health’. Many participants had developed considerable knowledge and expertise in these particular specialist areas. While it was evident that there was sometimes a shift in the actual role participants described when compared with their written job description, it appeared that all participants reflected on their role descriptions and were aware of the importance of updating them: Well, normally I would do a role description at the beginning of the year. This particular year I haven’t, because of this joint role ... and I haven’t had the opportunity. Rhonda 362-364 I don’t think we discuss it enough. We have our job description, that we fill ... which is talking about accountability, responsibility, professional role ... and following criteria ... through our professional role. Carol 296-299 While participants were generally directed in the client focus by their job descriptions, the nature of their role with these different populations consistently directed participants to engage in activities that had the same general objectives: ... I see them [the different aspects of role such as school, child etcetera] as all pretty similar the only difference is the type of work. ... And I don’t feel unhappy with that.
I don’t feel like ... at all any ambivalence in my
personality. But I don’t see any conflict in that ... because I see them all as part of a community nurse role. Gwen 398-409 Organisational priorities and strategic plans were also important for participants in Validating their practice. They tended to meld their own assessments and aims with
310 those of their organisation. At times, they found that organisational targets differed from their own major priority. In this situation, they chose their own targets from among organisational targets. On occasion, participants used organisational targets to give them to give them licence to achieve their own plans and programs: They [regional priorities] give me license. As much ... license to be active in getting some result. Rhonda 294-295
Support In Validating their practice, participants perceived that the support received from others was very important. The community health nursing field is a great change from a hospital setting. The community health nurse is a lone practitioner and lacks the supporting organisational and collegial structures of an institutional setting. Participants sought support through both formal and informal channels. At times it was necessary at times to seek out support, particular from peers. Participants often indicated that they talked to their colleagues: And that develops in you, I think, a need to be autonomous. But [also] a need to recognise that you have to develop important networks. You have got to develop support systems. Because you are not, in yourself, able to provide the whole
of
a
service.
... and that’s where you must, from my perspective as a community nurse, ensure that I have the right sort of support too. Karen 112-118; 458-460 But, like I would use someone else if I had a concern. I would speak to one of my other colleagues. Mary 277-279 In talking with colleagues, they not only learned and Developed, they also Validated their thinking and approaches. Where participants had the opportunity to work in teams with colleagues, they found the chance to generate ideas together invigorating: ... well I found that in [regional centre] working together with the CHASP [community health centre accreditation], the document ... it made it ... more pulling together, even though there were personality difficulties. It was doing something together ... it was giving this positive energy ... energising people
311 and looking at it from a different way ... and that’s where that change came. Carol 509 -521 Support from peers also provided support through the difficulties they encountered: Because if I was to come out and I had a particularly bad session with somebody who’s really got to me ... if I come out and just say “Oh, I’ve just spoken to Joe Bloggs and he’s having troubles all over the shop and what am I going to do and blah, blah, blah ...” I can get it off my chest and there’s three or four people who will look up from their desks and say why don’t you [try] such and such. Emily 788-794 The multi-disciplinary nature of community health work was also evidenced by the support they received from members of other professions such as social workers and health workers. In addition, it was evident that participants’ supervisors provided an important support, although this did not appear to be universal. Where a superior was considered to understand a participant’s role and provide support, this was valued: I think we’re fortunate in [this region] because the [senior nursing officer] does have an understanding. She has worked in community nursing before. And so yes, she does have an understanding. Whereas I believe, and this is only hearsay ... that the one in [a neighbouring region] doesn’t ... and hasn’t really bothered ... and so she’s not as sympathetic to what community nursing’s all about. Cheryl 467-473 Participants were concerned in situations where they did not receive support. Participants who indicated that they did not have support expressed disappointment at its lack. Some participants suggested that there was a need to seek out support, where it was missing: School nurses are quite isolated. They’re sort of a lone person in a big educational setting. And they don’t have the same get togethers as child health nurses do to share. So a lot of their sharing and networking is across telephone calls ... to actually get that support. ... It’s an issue that we really do need to address, because I think that it’s a mental health issue if nothing else, for nurses. Rhonda 805-820
312
Evaluation and Feedback Participants engaged in activities that gave them evaluation and feedback. This information was very important in Validating their practice, and contributing to ongoing Development and improvement in approaches to implementation of role activities. They participated in formal evaluation, accreditation, ongoing evaluation, project evaluation and formative evaluation: Well I have to do evaluations all the time. Because if it’s not working you change ... you have to change tack. Rhonda 590-599 Oh yes, justifying what you are doing, if you have done it correctly and evaluating what you have done. The evaluation you can get is from those participating, and from peers of course who come along ... and see that you are doing the right thing. Sharon 170-174 Validation also occurred via feedback from those with whom they worked. Participants valued this feedback. Being valued by colleagues was an affirmation of what they were trying to achieve: It takes a year for them to get to know you. And the headmaster actually called me in the other day, and he said the staff have confidence in me. And that was a real buzz, because I’ve worked hard all year to get that confidence going. Rhonda 533-536 One participant suggested that: [laughs] Yeah, Yeah ... an absence of criticism as being something positive. In other words that they’re happy with what I’m doing. Anna 531-533 Participants also saw that receiving an appropriate referral from other health professionals was an affirmation of their role: And the I was asked to see two women, who they were concerned about ... with their social situation ... the fact that they used me and ... you know, that was a real affirmation of my role here. Kate 633-644
313 Yeah. And attitudes changing yeah. And I think asking you to do programs. And [they have] a knowledge of the programs working out all right. Anna 550-552 Feedback from clients was also of benefit to participants. The nature of the community health field means that it is not always possible to obtain feedback from clients: ... the clients weren’t telling you necessarily that they were happy with what you were doing ... or you were doing a good job. Lyn 286-288 As a result, participants often elicited feedback via evaluation protocols: A lot of the feedback I get is from the people who attend. The participants. They are the true people indicating that I have done something worthwhile. That the information has sunk in and that it was maybe given to them in a way that they can use. That they will then think about it and then they may change their behaviour, if they think it is worthwhile, doing it for their own benefit. Sharon 153-162 And I’ve done an evaluation on that health pack, to see what they would like. [To see] if that’s all they want their health pack, or what else they would like. So that’s my evaluation ... and whether it works. And it’s been very, very, positive and it’s the first time. Rhonda 655-659 And then I did a follow-up survey [following a whole school health breakfast project]. I did all the high school and every second year ... like I did [grades] two, four, five, six and sevens ... I think I did ... the whole lot. So it was hundreds of people ... children ... filled in their forms ... their surveys. And one of the questions was “what is two or three foods that are healthy to eat for breakfast?” or something ... “what is two foods?” And every child gave me an example of three ‘good’ foods and two ‘bad’ foods. So I felt that I had ... at least they had internalised that this was what a good food was. Whether they were genuine [in changing was another matter]. Lyn 1034-1048
314 ... in our recent evaluation to the [local university public health school], they [clients] were asked to say whether they found this centre to be helpful or not, and the people in it. And there have been very positive results. I can just say ... from ... they interviewed twenty five people who were actually clients ... which were considered by the epidemiology researcher to be an appropriate number for this population. And then they interviewed eighteen or nineteen agencies I use to see [whether we] have been an effective service.
And
because I’m probably the only one here full-time, my Cambodian health worker’s three days a week, my Aboriginal [health worker] is one day a week ... so it came out in a very positive light. They had found it very helpful. Louise 613-625 If clients returned to access the services provided by the nurse, participants saw that clients felt that this indicated that previously provided services had been of some benefit: I feel as though, that they ... must feel that the information that I give them empowers them ... that it’s been the right information for them, and that they feel confident in coming to me for information. Cheryl 112-115 Although feedback from clients was not always forthcoming, there were sometimes ad hoc situations where participants received Validation and feedback about their roles. They found this type of Validation of their role to be most gratifying: It’s hard work and ... but I find it very gratifying. Because as I said ... doing the first aid course ... as a person, this is ... I went down to the local nursery. And I remember this kid, he was a little beast, trying to look up my skirt ... that’s why I wear trousers [laugh] for CPR [cardio-pulmonary resuscitation education] ... and oh, he was looking out the window ... and so I had to use all the teaching skills to get him involved and make him stand up and do the next section [laughs] and you know all those [things] ... and [at the nursery] it’s this nice young man came up and said “can I give you a hand”. And I was lifting potting mix back into the car. And I said “Yes, oh that would be lovely, thankyou”. And he said “You don’t remember me do you?” and I’m looking [at him] because they change so much ... And he said “Yeah” ... he said “You
315 taught me first aid at [suburb] High School”. He said “You know it was really handy, because I saved a life”. And I said “Oh”. I was just so ... you know, I mean that’s your reward. There are very few rewards in community. Very few. You get some warm fuzzies. [But you] you get a lot of warm fuzzies in a hospital when you do something and people are coping with drastic shocks ... that ... yes. But you don’t get many in community [nursing]. Rhonda 952-979 When participants had little feedback on their performance, they found it disturbing: But as far as my work went, I never really [knew] ... to this day, I never really felt, um ... how I could measure this ... any sort of satisfaction. We never did. And I think that’s part of the problem. And that’s why when I was in a [previous] management position I tried to see ... even though we were all chronically short staffed ... that staff had performance appraisals. And that they had feedback. Because you really need that. Gwen 210-221 Because it was very hard ... it’s hard to measure, other than the statistics that you collect. You don’t get a lot of positive feedback verbally there aren’t ... I’m um ... you know “you’ve done a good thing here” or whatever ... Lyn 265-269 In the community setting, you are often doing health promotional things, where you are unable to evaluate really what you have done. There is nothing to really measure what you have done. So at the end of the day you think “gee, have I done anything worthwhile today?” Sharon 84-89
Literature Throughout the data, it was found that in addition to contributing to Interpretation and the Development, reading the literature also contributed to Validating the role: Reading literature, and talking to other nurses. That was the way I could get into my mind more clearly what the primary health care model was ... what it was all about. And I actually was doing something worthwhile. And actually, there is no way that I can measure these things. Epidemiologists say that they
316 do all sorts of health promotion things, but they can’t evaluate their work [until] twenty years down the track. So that was just a bit of reassurance. Sharon 100-108
Reflection Finally, participants Validated by engaging in reflection. Reflective processes contributed not only to Interpreting the role, but also to the process of Validating the role. Participants reflected about: their Interpretation of the community health nursing role and what it was achieving, its relationship to ‘nursing’ generally, and finally their own capacity to fulfil the role. First, participants questioned their Interpretation of their role, and reflected on what they were achieving in their role. They considered whether they were meeting needs and providing a good service. In some instances, this entailed looking at small steps towards larger objectives: But I had quite a lot of ... well conflict. I had a lot of conflict within myself for quite a long time ... for probably about the first eight months. Because I started to enjoy sitting underneath the tree talking to the people, and then I became guilty, because that wasn’t ‘working’. Gwen 115-119 A second aspect participants reflected on was the relationship of their own role to notions of nursing generally. There were many times when they compared their role to traditional roles carried out in an acute or institutional setting: Maybe I should get back into the hospital situation and be a ‘nurse’ in inverted commas [laughs]. So it’s [community health nursing] getting out of that Florence Nightingale scenario where you hold someone’s hand. Sharon 273-276 Finally, participants reflected on their own skills and abilities and their capacity to undertake the role: So what I try to do is pretty much like I try to always present in a manner which is acceptable to that group ... that I’m ... well, whatever you call
317 professional. That’s another bandied around word ... that my standard of work ... I try to always reflect on that to make sure it’s what it should be. And that I’m always seen to be reliable. Gwen 935-939 You think ... should I be getting more qualifications in another area ... and a title ... that are more accepted, or continue the way I am. [But] I’m much more comfortable with it now. Helen 332-336 In some instances, participants evaluated their own ability to undertake the role by comparing themselves to others. This included other community health nurses, but also reflection on the practice of other health professionals working in the community: Well it used to make me feel very ... um ... I guess ... I was perplexed, a bit angry. And especially when I see some of the other workers are incompetent. And also questioning of my role. You think ... Well ... I know I want to do what I
am
doing.
I’ve had quite a lot of clients, last year and this year ... involved in with [state community services] ... and had joint case meetings and so on. And so ... it gives you an insight into how some their workers operate ... (laughs) ... and I feel that nursing has a much more positive role, than just skills to offer. Helen 330-336; 345-358 This reflective Validation process often lead participants to: reframe their views about their own practice, refine their Interpretation of the role and Develop further. If the Validation process was successful, participants gained confidence in themselves, and they were able to address the Negotiation process with confidence: Yeah, you are quite right. And you know, later as our role changed and expanded. There was really nothing that we couldn’t do. And I think that’s what I gained from that. That ... being asked to say “could you present something on this?” You’d do it. You’d think “Yeah, I can.” I don’t know the topic, but I know that I can research it. I know that I can get it together enough. And I know that I can stand up in front of ... “how many people do you want me to do it in front of?” You know, so it’s that confidence. And that’s I think, that’s what my boss saw as valuable. Kate 877-886
318
NEGOTIATING The way in which participants enacted the role of the nurse reflected more than a small element of hard-nosed reality. In order to translate ideas to action and achieve health outcomes within their community, it was necessary to work with others. As a consequence, Negotiating is an essential skill. Negotiating was necessary in order to encourage client participation, identify and obtain resources, work with other professionals, and clarify their role with others. A major purpose of negotiating was to obtain material resources. Participants demonstrated a high degree of ability in being able to negotiate in order to obtain resources. Rhonda explains the resources accessed in order to carry out an educational program aimed at raising awareness of breast self examination and testicular self examination: I then negotiated with HBF [hospital benefit fund] to get the shower things to go home ... all the bits and pieces ... which was also funded by the College of GPs ... those little shower things. And we ran the program. Rhonda 910-918 Other participants also accessed resources in the community: And we also link with the refuge and with [local company] to sponsor young people to go on a [youth organisation] programs and go on outdoor experience at [rural camp venue]. For young people involved with substance abuse. And they went on this camp. Which was a quite a challenge. Helen 73-76 ... and organising the breweries to supply Tee-shirts and light beers and stuff like that. And that’s all just health promotional type stuff. Emily 738-740 “Could we look at some of that money that you’re getting as a community project to look at something ... we could do with our hep[ititis] C”. Or do we get health promotion and apply for a health promotion grant. And see what could be done. Could we run a big program up at the local hall up here. Louise 844-848
319 Participants did Negotiate with their clients, in particular to clarify the nature of services to be provided. However, the focus of most of their Negotiating activities were related to their engagement with agencies, community services, key members of the community and other health professionals and health workers, including other nurses. At times the context in which participants were negotiating was difficult. In many instances, participants were working in a context where others had different ideas about the purpose of their role to themselves. Often, others viewed their role as only the provision of ‘sick care’, rather than the broader role participants saw for themselves. This was demonstrated by approaches taken by school nurses who had to “set up a brand new school”. They worked to negotiate the role they wished to play in the school and with the school community. There were situations where participants felt that others undervalued their skills: It makes a difference because they [the other health professionals] feel that they are superior. Joy 302-303 In other situations participants felt that there was an imbalance in their power when compared with other professions: I’m really speaking from a community nurse [perspective] and some of the frustration, I suppose ... and that is, that I really do think that the medical profession, are trying to get their control back again. I think that they’ve been threatened by the tertiary [educated] nurse ... and threatened in the sense that they’ve been losing control ... Karen 882-888 However, in the ‘messy swamp’ of the community, the nurse must Negotiate their role. If the nurse does not successfully Negotiate their role and is unable to play out the role they have Interpreted, instead of Allocating the role in a proactive way, they will be reacting. The resulting role will arguably be less effective and less satisfying. In order to Negotiate the role, the nurse requires excellent interpersonal and communication skills, flexibility, together with an ability to be assertive. Communication skills were felt to be fundamental to the approaches used by participants in negotiating processes used in order to achieve their goals:
320 Communication was the whole [thing]. That’s the whole key to it. Lyn 1111 Approaches to Negotiating included: using political processes, networking, justifying, establishing credibility, meeting needs, pointing to outcomes, “just doing it”, “tradeoffs”, working together, persuading, explaining, confronting, and when all else failed, pragmatically accepting things as they were.
Using Political Processes What was evident in participants’ approach to Negotiation was the political way in which they understood and worked within the micro-political environment of their community. They showed an awareness of the organisational structures in which they worked, and the community they were operating in. This is politics at a grass roots level. A political perspective was evident in their networking, linking activity and the way they accessed resources in order to achieve aims. It was of note that they tended not to involve themselves in macro-political action unless this had an impact on the issues, problems and needs of their local community. Examples of working within the micro-politics of their local community included working on policy-making committees, working toward the development of new services in their local community, lobbying to gain acceptance of programs and projects they wished to implement. Participants demonstrated an understanding of the political environment in which they operated: I talk to ‘Samantha’, the community coordinator, and say [for instance] we’re trying to get some money now for the [program addressing abuse in families] and because [organisation] don’t ... aren’t very fond of the word “domestic violence”, the whole program is to do with domestic violence but because they have a [program] we apply for money under that ... and call ourselves whatever we like - “abusive families” but we’re really the [Suburb] Domestic Violence Action Group. Louise 883-890 However, the most strongly represented way in which participants involved themselves in the micro-politics of their community was the way in which they targeted opinion-leaders and key community members:
321 Well, when I prioritise, program prioritise ... for example ... I did the breast self examination, testicular self examination ... I didn’t start off with the kids. What I did was, I actually started off with the canteen ladies. I went into the canteen
...
So I had the canteen lady, she organised a whole group of mums to come in ... because they’re the ones who are going to be telling other mums about what I’m doing with the kids. Rhonda 854-857; 863-866 I decided it was really important with the new principal at the beginning of the year that I go in ... let myself ... make it quite clear what I was here for. And I stressed that there was quite a few things that I saw as being in need in the area. Lyn 1117-1121 In most instances, the aim was to secure acceptance for their programs, access to resources and promote participation.
Networking A vital strategy in Negotiation was the establishment of networks. The theme of networking was very strongly represented in the data, and all participants had networks and links to key members of the communities in which they worked. Networking saw participants create strategic links with key agencies within their communities and key members of their communities, community workers, professionals, health professionals and other nurses. These links usually involved making personal links, knowing and being known. Participants indicated that they considered the establishment of positive relationships with key people and agencies in their community as a successful work outcome. Participants also felt that community health nurses should do their ‘ground-work’ to establish and maintain their networks, particularly when they started to work in a new area: And some nurses don’t see the longer [term] picture. Like [you should] go round and do your public relations. [You should] take six weeks if you have to ... to make sure you know every organisation, you’ve met people personally ... it’s the personal contact that makes such a difference you know. Louise 11551174
322 ... I’m still at the moment, linking in and finding out who’s actually doing what in the area. I’ve been in this role in ... since February. Amy 436-441 In this process you can’t short circuit it or short cut it. And as I say, I’ve been doing it for a long time. So I know how to go about it. Rhonda 544-546 At times, these networks and links resulted serendipitously from the community involvements of the nurse. However, more usually, they resulted from planned action on the part of the nurse. Participants indicated that developing networks took time and required effort, and felt that creating networks was of sufficient importance to Allocate time and energy to this activity: And I try to become part of ... you can’t as a visitor, you never can become part of the community ... I don’t think until ... and I try to sit at different tables with people I’ve never met before [in the staff room]. And I try to get to know the people. Gwen 392-376 ... because I think that you do need that time to ... make a network ... get your network going. Carol 157-158 Participants paid particular attention to the strategic importance of key members of the community, particularly in relation to their own aims and objectives: It’s taking me time. And I’m just slowly ... I work ... you know even the other day ... with the Aboriginal services I met someone who’s probably the most important person there. Amy 726-730 And one of the doctors that I chose from ... there’s 37 doctors in [the post code area] ... is keen for preventative health [activities]. And so that reinforced his perception. ... and also I was able to thank him, because he always sees the students that I have to transport to him. So it was a very good interaction. And I know that he will feed that back through the College of GPs, to the other doctors who are part of it. And therefore it’s a catalystic thing. We see it as something that that will develop. Rhonda 730-742
323 Another characteristic of networking was their opportunistic nature. Participants took advantage of opportunities to create networks and links: And fortunately one of the ladies ... the secretaries of the school, was on ... was actually the president of the P & C [Parents and Citizens Association]. And she suggested that they fund it. Lyn 1012-1014 At times they found it difficult to justify the time and energy they Allocated to networking. In spite of this they still considered that Networking was of basic importance to their role: I mean if someone had to pay me on my ... at the end of the day, you know, there would be days I wouldn’t be paid, I’m sure. Because the things I see as achieving, you know, a good days work, wouldn’t be seen by anyone else [as achieving a good day’s work]. I mean, I can remember, you know, I went to [suburban hospital] one morning. And [I was] here [at the hospital]. I and went back to the nurses [at the community health centre]. And I said “I had a good day. I had coffee with the staff at [suburban hospital]. Now that’s really important. This was when I started this job [as community/hospital liaison person]. Kate 614-623 The rationale for developing a network was that they allowed participants to: gain knowledge of their community, create links, enable assessment of the community, provide a basis for political manoeuvring, have an ability to access material and personnel resources in order to achieve aims and objectives, and achieve better health outcomes for their clients: And if I want to get a piece information I can get it [just] like that. And if I need to know something, I know who to call, or I know who to contact. And I mean ... my network is fairly broad. It’s sort of Australia-wide. Emily 754758
Justifying In aiming to achieve Situated Health Competence, participants found that they were often questioned about their role:
324 … or “why can’t the GPs weigh the babies ... if that’s all they [the child health nurses] do” ... um ... so yeah. Cheryl 510-512 ... [there has] always been ‘them and us’. And it’s always been the same old story about the lack of understanding, because they don’t know what we do out there. And then again we’re not so good because we get very defensive about [it] when people say “Oh, you know, what are you doing, you’re on the bludge again”. Amy 122-126 Justifying processes were strongly represented in the data. Although the notion of Justifying hints at a feeling of disempowerment within the role, it may also reflect role ambiguity and a need to Negotiate with others to achieve aims. Examination of the data indicated that participants felt strongly that what they were doing was important, and that they needed to convince others of this. This included their employers, their co-workers, health professionals and members of the community. Participants recognised that in the current climate of tighter fiscal control and greater accountability, there was a need to Justify the effectiveness of their role, particularly to their employers: If you can demonstrate to your department that what you do is effective ... nowadays you’ve got to have all the stats [statistics] and everything else. I think you’ve got to be proactive, you’ve got to be going out looking for grants. Louise 1092-1104 At times, where there were differences in opinions as to what activities constituted the nurses’ role, participants found that they were Justifying their participation in a broader range of role activities: Traditionally the social workers had done parenting education ... so there was a difficulty there. They didn’t see that as a nursing role. Helen 214-220 There were also situations where participants found they were not only Justifying their role, but their own expertise to carry it out:
325 And both the foster care worker and the youth workers in the housing project ... and although nothing is said ... you felt they were questioning ... of the way I was operating ... because I was [a nurse] ... They would say “oh what do you do there?” And I’d say “I’m a community health nurse”. And um ... oh they were questioning, I guess, my skills ... my knowledge ... in this particular area. If I had of said [I was a] social worker, they [my knowledge and skills] probably wouldn’t have been questioned. Helen 282-293 Three issues affected the need to Justify the role. The first was how narrowly the role was defined, the second related to the immediacy of the need being addressed and finally, the vulnerability of the client group being served. First, it was noted that participants who worked in the most narrowly defined specialist areas did the least amount of Justifying. For example, participants who had a specific area of expertise, such as diabetes educator or a focus on migrant health, rather than a generalist role, required less explanation of their role. Secondly, role activities that were more disease-oriented required less Justifying. For example, Emily, who worked with people who were drug addicted was less defensive in relation to the purpose of her role. Yet, drug and alcohol programs historically have a very poor track record of ‘success’ in terms of assisting people to become drug-free. Thus, it appeared that there is less need to Justify the meeting of immediate client needs, and more need to Justify the addressing of longer term health promotion and disease prevention issues, problems and needs. Thirdly, participants serving particularly vulnerable groups did not appear to engage in as much justification of their role. For instance, the participant who worked with Aboriginal clients did not Justify the way in which she carried out her role, despite available epidemiological data suggesting a need to examine the effectiveness of any work carried out with this client community. An examination was made of the approaches used to Justify the role. Three major themes were identified: establishing credibility, meeting needs and achieving outcomes.
326 Establishing Credibility There were many times when participants were required to establish their own credibility, particularly when they were unknown or new in an area. As they developed networks, they also established their credibility to undertake their role. In many instances, they established their credibility by demonstrating that they had traditional nursing and medical knowledge and skills. Participants consistently indicated that they felt that ‘traditional’ nursing skills were important in their role. It seemed that before participants could take on a wider scope of practice that community health nursing encompasses, they were required to demonstrate mastery of nursing knowledge related to an acute setting. This was considered to be so important by Kate that, when implementing a hospital liaison component of her role, she went to work in the hospital: When I took on this [liaison] role [with the local hospital], the first thing I did was put on a white uniform and work in maternity for two weeks. Because I thought that was the quickest and most effective way of developing a relationship with the hospital nurses. [It] was to be seen that a) I am a nurse and I can actually ‘nurse’ in their terms. Kate 660-665 Participants also saw that having medical knowledge gave them the respect of fellow health professionals and their clients: ... I had a win because I had a kid with a condition ... a skin condition called molluscum contageosum. I mean you don’t see it very often. And I think I’ve only seen one family with it in my whole life. But I saw another kid come in here from somewhere. And I sent a little note to him [to the GP] saying “Could this be molluscum contageosum” ... question mark. And he tears up the slip and says “Yes, yes, it could be”. You know, so I’m clear ... So from that ... giving him a few people when you show that you also have some clinical skills and some knowledge, I think that has been very helpful. Louise 1029-1040 ... [they] can see first hand exactly what they [the remote area nurses] have to put up with. Or exactly what they have to do. They can see ... you know, they receive patients in hospitals who’ve been sutured or plastered or dripped or
327 resuscitated by a nurse. They can’t ignore that. So … or they’ve worked closely with them in ... under difficult situations and circumstances. Kate 373382 It also appeared that knowledge in a specialty field gave participants credibility. If they could, for instance, point to an area such as diabetes education, child health, drugs and alcohol, this gave them greater standing. Credibility was also established by the qualifications and experience of the nurse. Participants at times pointed to their educational background as a Justification during Negotiation with others: ... I am also in diabetes education ... I just let them know what makes a diabetic [educator], what training you’ve had, and that I am a diabetes educator. Gwen 376-379 In addition, participants found that their credibility was enhanced where they could point to successful examples of their own work: And [they have] a knowledge of the programs working out all right. I’ve done breakfasts before in other schools. And I’ve gone from as little as two hundred students to seven hundred and fifty so that I knew that it was an achievable thing. And I’ve tried to apply this at my new school. Anna 551-564 A difficulty with this approach, however, was that programs and achievements needed to be visible. Meeting Needs A second way of Justifying their role was in terms of the effectiveness of activities in meeting client needs: ... and the doctor’s sort of whitewashed them a little bit. And then they’ve come here, and then the problem’s been solved for them. And that increases your standing in the community. And especially if you’re prepared to give your time to the client. Like ... you do home visits, or you ring twice a week to see how they’re getting on. You know, you’re not actually going to visit them, but you pick up the phone and ring and say “Mary-Lou, how are you? How’s
328 things since we were last talking?” or whatever. I think that raises your profile ... amongst the community. Cheryl 169-177 Health Nurses’ Week or something like that. So ... to say “this is what child health nurses do”, “this is the sort of training that they’ve had”, “this is the sort of services that they can offer you”. Cheryl 151-154
Outcomes Although, as discussed above, outcomes were at times difficult to measure, participants felt that it was important to evaluate their work and examine outcomes. As a consequence they gathered statistical data and submitted this information in reports. They also examined structures and processes: That is why I think if we can prove ... and we can look at evaluating our educational outcomes in terms of whatever reasonable education implies ... unless we can do that I don’t see as a manager ... if somebody came to me and said “I need X number of hours to do with my education program”, I’d say “what are your outcomes’. Gwen 596-603 For example at the beginning of the year I targeted year eights [school students] for asthma. I did asthma awareness. And I developed an asthma action plan with education or information for parents. Plus the plan had to raise the awareness. And they had to return that ... which was clipped into their card ... that was a wellness reading. And if they came in with a illness reading ... I was then able to evaluate the ... From that exercise I ... I’ve only had two Year 8s that have come in needing Ventolin at any stage. Rhonda 671-681. However, participants found that the nature of their role made it difficult to Justify what they were doing at times. In these situations, it appeared that the information provided to others to Justify their role sometimes differed from how they themselves measured success: And I sometimes feel that they are still sifting for some solid measures for what you have been doing. So that is a little frustrating, because you know you
329 can’t give them that.
That’s all you can do.
You can give them stats
[statistics] like “I did a health promotion talk on ...” even say something like “medication awareness for the elderly”. They might not think that’s really health promotion … but its giving them awareness about what they should be doing with their own medication ... who they should be talking to and that sort of thing. And it’s very ... you can write down ... and this is the actual program that has been approved ... it has been accredited throughout the state ... And so many people have attended.
And you can have post-workshop
questionnaires. “Do you think you’ll change your behaviour?” But they’ll tell you that [they will change their behaviour] ... but what they actually do ... you get no feedback on that. You can just give them that kind of information, its all you can give them. Sharon 131-145
Just Do It A characteristic of the participants in this research was their assumption that they were autonomous and had a right to make decisions. Within the fairly broad boundaries of their brief, they demonstrated an internal locus of control. They believed in their own ability to do the job, showed initiative, flexibility, ingenuity, an ability to communicate and get what they wanted. Thus, one approach to Negotiating was to take an assertive approach and ‘get on with the job’. Rather than requiring permission for activities, participants assumed the power, authority and professional approach to do their job, develop projects and get things done. They approached others with confidence in themselves to do the job, despite encountering negative attitudes from others at times. This is a mark of a truly autonomous professional, departing from traditional submissive stereotypes of the nurse: Well, I don’t ... you can ... you can only just keep on ... you know, making contact. You keep dealing with them like a professional.
And hopefully
they’re going to learn to deal with you like professional. Now look, some of them do. Some of them speak to me like a colleague and deal with me like a colleague. Others don’t. And I know then, I know that those who do deal with me as a colleague are going to deal with that parent in a professional [way] ... and will deal well with that parent. Karen 846-853
330 This approach requires the nurse to act from a different set of assumptions and to gain personal power. It requires that the nurse know what areas are within their power and what are not. It involves understanding role boundaries, perhaps questioning them or moving them if doing so would assist in achieving their goals. An outcome of ‘getting on with the job’ is an ability to point to what has been achieved as a way of establishing credibility.
Trade-Offs Engaging in trade-offs was another characteristic of the way in which participants Negotiated. They saw a need to create a relationship with people with whom they were networking. There were many instances where they would do something for someone, with a thought that they may in the future be able to use the link they had forged to access services for their clients. Trade-offs included activities such as sharing information and giving education sessions: That’s right. You know, that they [hospital nurses] had things to offer me, you know, as a way of up-dating my need or whatever. But also that I had ways of ... I had things to offer them. Kate 669-673 And then being able to give him [the local GP] information. I get a lot of information, comes over my desk about lots of things.
And so I often
photocopy something and give it to them to stick in their front room or whathave-you. And talk to his nurse about things, in immunisation, because he never gives all the immunisations ... So, I mean, little ways ... Louise 10441049 There were also situations in which participants made the decision to ‘give’ in order to forge a positive relationship with someone. This often involved activities that were simply aimed at creating a positive climate in their relationship. In doing so, participants sometimes overlooked behaviours and attitudes that they did not like or disagreed with, in order to achieve their own goals. Louise provided an example of trade-offs in the way she formed a working relationship with her local GP: ... I have a very good relationship with the GP down here, that I’ve got. And he is a male chauvinist, racist … male chauvinist and sexist ... very sexist. All
331 those
things.
But anyway, it’s taken me a long time to get past him, where I can go down ... and he says, you know, even now, he’ll say “What on earth do you want?” I mean that’s how he speaks to me. And when I first had my first conversation [with him], when I had to ring up ... and I wanted to speak to him, his nurse wouldn’t put me through ... and she was very embarrassed ... on the phone. His secretary said to me “he said that I had to speak to someone of my own level”. Meaning I was to talk to his nurse, not to talk to him. Now, I went back the next day to see him over that. And I said ... and I did it in a humorous way ... because I mean some people you [have] got to put a bit of honey on their tails. I mean I could have been very affronted you know, and people can be very up splut about these things. But it’s not going to get me anywhere. And it’s not going to get any of my clients [anywhere]. If I need [help in] an emergency, nobody ... he’s not going to help me. But I went in and I said “What’s the story here?” I said “Why wasn’t I allowed to speak to you?” I did it in a sort of more jocular way. And I was able to sort of do it that way. And I’ve always kept that kind of thing [going]. And occasionally I take a bunch of flowers from my garden in ... and just say to ‘Anna’, “Pop one on ‘David’s’ desk” ... when I’ve got some nice roses and stuff. Now it may be a bit crawlish, crawly kind of work ... but it gets me further than [to] stand on my digs about his sexist behaviour. I mean he calls Aboriginals boongs ... he doesn’t
like
Asians
...
I mean when I need ... when I’ve had emergencies here I can put them in my car, I can go straight down there and bypass twenty people in his waiting room, if I say “this person’s in trouble”. Louise 970-973; 980-1015; 10191028 Another example is where Lyn worked with Aboriginal health workers. She did not altogether agree with the approach they took in their work. However, she made traded-offs in her relationship with them in order to establish rapport and gain better access to the Aboriginal community: I worked with them, but I’d ... even though I was ... like ... their overseer, their supervisor in a small manner of speaking, but I didn’t actually ever tell them
332 what to do. Because I didn’t want ... I wanted to have a rapport with them, because I though that was important ... Lyn 298-302
Working Together A foremost approach to Negotiating used by participants was to work with people. In most instances this involved the participant in collaborative efforts. In many instances participants saw themselves as a member of a team. Those they worked with included not only other community nurses, but health promotion officers, speech therapists, physiotherapists, doctors, dietitians, occupational therapists from the health sector; and social workers, youth workers, housing officers, police, counsellors, development officers, community workers and church development officers from other community, voluntary and charitable organisations and governmental departments. Thus, rather than simply linking, the nurse worked alongside others who had the same aims. This occurred when the nurse was working in a team out of the same agency, with some participants carrying out joint visits with other health professionals, but also occurred across organisational boundaries, with those not in the health sector. Participants saw working together as a way of capitalising on the different skills offered by different workers: I have a lot of liaison and networking with other health professionals. We work very closely as a team. It’s an excellent team ... Emily 907-909 I’m just one of ... a team member that works in an area ... there’s everybody, there’s the GPs, there’s the [church] ministers that you may or may not get involved with. There’s the Department of Community Development that you may or may not work with in that particular area. There’s other colleagues ... other child health nurses ... or other community nurses who you’re going to be interacting with ... especially with the school nurses in the school community. So they’re all part of the team in the community. Cheryl 374-386 ... I’ve got mostly the Aboriginal [health workers] ... ‘Nancy’ and I ... ‘Nancy’s’ the health worker who works here, and we work quite closely [together] in Aboriginal health. Amy 448-450
333 In many instances, participants found that working with others enabled them to address problems more effectively. There were times when collaborative efforts enabled participants to access resources: Well, we’ve actually got a seminar planned for the 15th of February, about coordinating services and working with a program that’s been done in [suburb]. A pilot in Australia actually ... in the area of domestic violence. Well, but if we get any money ...
‘Sheila’
will ... because they’re an
incorporated body, she’ll manage the money and we can do it that way. So there are ways and means of getting there.. Louise 895-901 At times, however, participants used collaborative and consultative approaches to overcome opposition. Participants consulted those who could possibly be an obstruction to them achieving their aims: Mm ... There was one person who ... sort of ... was obstructive for quite a while. Eventually we overcame that and we ended up working together on the programs. So it was a matter of trying to overcome ... and perseverance. Helen 245-248 Yes ... programs ... what I’m targeting for the year. And then I get their input on how we can best achieve it. [laughs] [I] take them on board to see how ... I involve them. Rhonda 488-494 Participants also saw that there was greater scope for liaison and linking with those in the hospital sector: I had a director of nursing in [remote rural area] tell me that their hospital practised primary health care. And I found that really interesting. And I think that we are getting very blurred. And I see that there is a lot of scope for hospital nurses to do a lot more health education and prevention work ... but mainly health education. And I see that the hospital is the prime place to go when you have illness, and you need treatment for your illness. And I don’t have ... I mean [I know] a lot of community nurses sort of think “oh hospitals” [negative attitude]. But I just think there is a need to work together. Gwen 446-463
334 It was also evident that ‘working with’ could be a negative experience. One participant talked about a lack of interest and teamwork approaches of colleagues with whom she worked.
Persuading and Explaining Participants were often required to explain their position and persuade while negotiating with others: convincing others about the aims of their work, to participate, and to contribute resources: Then I had problems with the year eleven coordinator, who said “Oh, we shouldn’t have boys and girls in together when you are talking about testicle cancer and breast cancer”. So I had to then diffuse and do a lot of talking with him. “Come on ‘Greg’, you’re a dad, you’re a single dad on your own, you’ve got a daughter. How are you going to approach this subject?” So I ... Right. Mm, “how are you going to approach this with your daughter, because it’s something that we all need to talking about. And if you want me to give you the statistics, I’ll give them to you”. And we sat down and we negotiated. So having him as the coordinator on side, I then explained that I didn’t want a million little groups of this ... this is an awareness raiser ... I would like every student that comes into the group ... how are we going to organise, you know a hundred-odd kids, to get testicular and breast cancer information. So he then was on side to help me. And we got key teachers to be involved. None of them knew how to do it [BSE and TSE]. None of them knew how to do it. So it was their educational [session for them] … as well too for crowd control for [when the students used] the models [for BSE and TSE]. Rhonda 883-906
Confronting There were times when participants were required to assertively confront others in order to achieve goals. It was noted that many of the situations where participants took a confrontative approach involved them arguing on behalf of their client’s issues, problems or needs. It was also noted, that while participants were sometimes accepting of behaviour towards themselves that they did not like, they were often prepared to strongly confront others with client-related issues:
335 I’m seen as a nuisance at the moment. A fair[ly big] one. ... And it seems that it’s [providing appropriate services] all too hard. And so my job is to say “Well yes, it is too hard, but you still have to find and answer”. Kate 319-327 There were also instances where participants confronted others in order to clarify their own role and draw the boundaries. These confrontative approaches required excellent communication skills and an ability to present a case, in order to achieve a positive outcome: [laughs] I think probably it gets down to personalities. I have been in that situation. And I was able to sit across from the Principal and look him in the eye and say very clearly that, you know, “I do have a role to play. Students of this school should not simply see me as the person who gets out a hot water bottle if somebody’s got period pain or as somebody who gives them a BandAid or can put a splint on because they’ve broken something. I do have something to contribute, and if a teacher asks me to go into the classroom as a guest speaker then I will do that”. Anna 256-264
Accepting It It was also evident that there were situations where participants felt that some things were difficult to achieve. In these situations, participants appeared to accept the situation, and instead, worked on things that they could change. Events or behaviours participants felt they could not change were generally at the legal, macroorganisational and societal level. An example was Anna’s view that there should be better discharge planning for clients when they were discharged from the hospital: I don’t ... I mean, I don’t know what I can do ... what else I can do at this level. Because I know that no matter what I do, no matter how I feel, I’m not going to initiate change. It’s got to come from in there [the hospital]. Anna 825-828 However, where she had opportunities to make changes she did. She was a member of a consultative committee, that linked the local hospital and the community. In this venue she raised the issue of a need for improvement. She also stressed the
336 importance of the need for linking with the community with every student that she preceptored.
SUSTAINING An important aspect of enacting the role of the community health nurse was an ability to sustain the role. All of the processes described above were important in Sustaining the nurse in their role. However, there were also specific processes that participants engaged in order to Sustain both the role itself and themselves in the role.
Sustaining Self There are many elements in the community health nursing role that create difficulties for the nurse in personally sustaining themselves in the role. The role itself is ambiguous, broad in scope and misunderstood at times. Its aims are long term in nature. ‘Success’ is difficult to measure and the nurse may lack feedback on work performance. The nurse is required to be autonomous, self motivated, and work mostly alone, Interpreting and re-interpreting the role. Professionally, they are often questioned about their role. The context is in the community where they are closely confronted by complex situated issues, problems and needs of people. Some of the people they deal with have seemingly intractable problems. They are confronted with the reality that often what they do is only ‘a drop in the ocean’. They are required to choose between an overwhelming range of options. They work with an assumption that their clients control their own health. In order to continue in the role they require interpersonal skills and an ability to be a ‘self starter’, practise autonomously, believe in themselves, deal with difficulties and constraints, and maintain motivation over the long term. Emily talks about ‘surviving’ in her role. Louise suggested that there was a limit to the time that she felt she could work productively with one community. The nurse requires a way of Sustaining the self in the role in order to survive and not ‘burn out’, without even considering a need to maintain commitment and enjoyment of the role. Burnout ... for sure ... definitely. And I think that ... I’ve been through phases of ups and downs ... And I think it’s ... this particular job can be very stressful. And I think the fact that I have been able to change my role slightly
337 over the years, is how I’ve survived and come out the other end feeling I’ve accomplished something. Emily 168-173 It is clear that an ability to undertake the processes described above are important to the nurse sustaining the self in the role. In addition to carrying out the role effectively, Allocating, Validating and Negotiating, the nurse must also deal with personal issues inherent in the role so that a realistic role is formulated and the self is Sustained in the role. Factors found to be important were: interest and commitment, living with dilemmas, dealing with their own need to be needed, and identifying personal success. Interest and Commitment It was seen that the interests of the participants was an important factor in the way participants Interpreted their roles. The interest of the nurse provides an important basis for genesis, maintenance and forward momentum of a specialty area or a project, often over a long period of time. When the length of time some projects take is considered, it can be seen that the nurse’s commitment and interest is vital. Some nurses indicated that they were interested in particular areas of practice and that this influenced their decision to go into community practice. In addition, the participants’ interest was often based on their professional, experiential and educational background. It was often the case, that the participants’ area of interest was also their area of greatest expertise: So that’s where you concentrate on those areas of [your own] greater interest. And I feel that if people had the areas of interest and pooled all that, there is so much that could be offered in different areas ... if it was going into a retirement village ... taking a bit of asthma ... a bit of diabetes ... and everyone working together on that ... Carol 635-641 However, this interest is not a matter of the nurse simply doing what they liked. Interest was also important for the nurse personally and was vital in order to personally maintain motivation and enthusiasm over an extended period of time. Interest was important not just in terms of the nurse doing a good job, but also in terms of them continuing to Develop and learn, and maintaining commitment to the
338 role. It was clear that participants had an interest and commitment to their role and the purposes of their job: Because I like kids. [Laugh] Because I mean, I trained at [large metropolitan children’s hospital] because I have a feel for kids and I like children. Anna 24-30 ... in that I’m hoping that the information I gained from different groups or courses that I did ... that I now facilitate [for clients] ... I would have perhaps have done those for my own [benefit] ... for a reason for myself ... to take an interest in it ... but then, hopefully to pass that information on. Because when I was doing certain courses I thought “gee, isn’t that interesting. I didn’t know that”. So I guess I like sharing. I like to see that people are empowered that they have an assertiveness. Carol 255 -264 But I think we all do it [the community health nursing role] for a purpose ... I would find it difficult to think that there are people doing this job because they have to, rather than because they want to. Carol 300-303 This commitment was demonstrated by their ongoing knowledge and skill development. Participants expressed a commitment to their role, and indicated that they enjoyed their role: And I believe in it [community health nursing]. And I enjoy doing it. Mary 743-744 ... one of the people I work with said to me ... um, she said to me “you’re just so boring because you are just so excited about your work”. [Laughs] And I said, “I am ... I probably am”. But I do get enthusiastic about my work. And about new challenges. Gwen 1077-1081
Identifying Personal Success Participants indicated that there was a need to develop ways of identifying personal success in the face of a role that is often professionally isolated, limited feedback on performance, and working on goals they may never see fulfilled. There was a need
339 for participants to develop personal indicators of success in order to Sustain the self in the community health nursing role. Participants who found this difficult and felt that they received little feedback tended to be more pessimistic about their role. Participants indicated that they needed to feel that they were achieving something. Some participants indicated that they had to be satisfied with small changes and had to measure their success in more subtle ways. Dealing with Dilemmas There were many issues and dilemmas which participants encountered in the course of undertaking their role. However, participants identified particular issues which community health nurses needed to come to terms with in order to sustain the self in the role. These were: the need to deal with a shift in control from the nurse to the client, accepting the limits of one’s own abilities, and a need to deal with one’s own need to be needed. The first issue involved a need to come to terms with the shift in control from the nurse to the client, and the reality of a client making their own decisions. It was found that this change in control was not always an easy transition for participants. Participants had to personally deal with a loss of control when they began to practise in community health nursing practice, and some suggested that it took some time to feel comfortable with this change: I think because you come from a model in a hospital where your are used to making all the decisions for people. And saying “this is your pills, this will make you better” or “this is your injection, this will make you better” or “get out of bed now dear because I want to make it” ... and whatnot. So you’re telling them what they will be doing. And in community health it doesn’t work that way. Because they have the choice not to come back again. And then you’ve lost them. So it’s better, I think, to accept that ... well it’s taken me a while to ... not a while, a couple of years, I suppose when I was first new ... that you can’t be dogmatic to people. You have to ... they have to be allowed to make their own choices. Cheryl 273-284 Participants indicated that although subtle, the change from an institutional setting had a profound effect on the way they related to their clients. An intrinsic component of
340 this shift is an acceptance of the client’s decision, when from the nurses’ view it may have negative consequences. In other words, the client really is making their own choices. At times the nurse was required to ‘walk away’ from difficult situations. Emotions expressed included anger, frustration, disappointment and sadness: But if you left it up to them to use their initiative, they didn’t really follow through necessarily ... some families would, but ...
And that was the
frustrating part, that I had to try and come to terms with that. Lyn 186-190 They described a need to accept and deal with this change to their power and control of the situation, together with a need to change their thinking and attitudes. It was clear that all of the participants had come to terms with this shift in control, in a personal and professional sense: No. I don’t have any trouble with it at all. It doesn’t threaten me in the slightest. And I think that the people that it does ... just from watching the people I work with ... that once you take offence to the client saying ‘no’, or not being able to control them ... [or] are actually threatened by the client saying ... you know ... [or] somehow [they] feel as if the client is saying that they [the professional] don’t know and they are not as professional as they want to be and all that ... it doesn’t worry me in the slightest. If I have the knowledge, and I offer it to someone, and they don’t want it ... that’s their loss. Janet 1096-1107 But they’re adults and they make the choices that they make, for the reasons that they make. And as much as we try to change it, if they continue to make that choice, there’s not a lot people can do about it. I’m comfortable with that. It’s taken a little while to learn that, but now I think ... I ... that’s their choice and I have to respect that choice. Cheryl 259-268 A second issue related to a need for participants to identify the limitations of their own abilities. In the context of a community setting they are at times confronted by the reality that their work to promote the health of individuals, families, groups and communities may only result in limited changes:
341 ... and I think some nurses burn out because they think they are going to save the world. Janet 974-975 ... because a number of our skills are skills one gains from experience. I think [one of those skills] is to recognise their ... the limitations in the sense of their role ... and I mean that in the sense that they can’t be all things to all people. So they have to learn that there are some issues, there are some families they’re going to be able to deal with the issues and feel comfortable about ... [and] there are going to be some families that they’re not [going to be able to deal with]. And to not be ... not to be knocking themselves because of that. But to recognise that they need to seek other support and help. Karen 804-818 And I realised that changing behaviour was a very long term thing. And there was actually not a lot that we could do about it. Lyn 123-125 The third issue was dealing with the nurse’s own need to be needed. As a consequence of the aim of enabling the client to ‘do for’ themselves, there was a disconnectedness that was sometimes present in the nurse-client role. In this situation, there was at times a need for participants to come to terms with their own need to be valued, wanted and needed. If participants are Enabling a client to ‘do for’ themselves, then the participant may not be receiving the personal satisfaction that does come with ‘helping’ and ‘doing for’ someone. The client may no longer need their ‘help’. They may have to settle for a relationship that is not quite so close. While being sensitive and compassionate to the reality of clients’ issues, problems and needs, the nurse has to care enough to not need to be ‘loved’ and needed themselves. They need to be able to cope with the client doing so well for themselves that they are no longer required, or even dismissed or argued with. For example, Joy indicated that she did not have the time to develop a close rapport with clients, as she only conducted one or two visits in order to case manage situations. Other participants describe the difference in their approach: ... well now I’ve got to the stage, I think, working through a lot of difficult experiences in remote areas, of the fact of ... I now ... I get more pleasure now out of getting people who come up to me and say “I managed to do it on my own” or “I don’t need to see you”. Whereas before, 15 years ago, I got my
342 buzz out of somebody saying “Oh gosh, I don’t know how we are going to manage
without
you”.
... before the end of my first year, I was starting to see that it was actually quite good having camp nurses and being able to train them. And when I was told ... when I went on holidays ... a camp nurse had successfully dressed a very severe dressing, from a fight, on somebody’s arm while I was away ... I then I began to see ... well maybe it was better to teach people to be independent and to see that they had the self esteem rather than the ‘choccies and the flowers’ type situation. Gwen 123-129; 134-146 Yes ... the other workers ... I stand back more and look at the client’s needs ... and what I am doing in relation to that ... rather than my personal needs to be valued and viewed as competent. So ... I think I worked through a lot of that. Helen 347-350 ... because if they [clients] elected not to attend ... anyway I mean it may not be the best for me, but it may be best for them. Mary 378-380 Participants used a variety of strategies to deal with these issues. In particular, they suggested that they set boundaries, ‘worked through’ issues, sought support, reframed the problem and had a life outside work. Setting boundaries in their relationship with their clients can be seen in the discussion (above) relating to the nurse-client relationship: And I think that my own particular coping mechanism is that I’ve just set boundaries. I’ve set limits. And I know where the line is and I just play on this side of it. Emily 322-325 They also indicated they ‘worked through’ difficult issues, particularly in relation to the difficult decisions they were required to make: ... you just work through it. You just work through it. It’s hard, but you work through it otherwise ... [if] you don’t …I have had a couple of nasty child abuse things that they have taken me a long time to work through. But you
343 work through it. I mean you have to. Also I have my own life. So you have to ... Gwen 705-714 Participants also reframed the way they thought about issues. This was an ongoing part of their Development, and involved them in reading, reflecting, and developing a personal philosophy: Yes, so I guess I’ve done a few things like Mastermind and sort of dabbled a little bit in Buddhism and things like that. And I think those sort of things help you to sort of think well, “people are people. And this is their life journey. And they have a right to lead it how they want to lead it”. You can enrich that by your health teaching, but it’s their choice as to whether they take it up or not. Cheryl 285-291 I don’t ... I’d really hate it ... now I’ve become what I really used to hate ... you know ... professional [Laugh] ... in as much as I don’t take on everybody’s worries and troubles and stagger home with them like I used to. In the [remote area] I used to really hate because people would be sleeping rough and I had a bed. And I discovered that if I wasn’t sleeping nights it wasn’t going to help my clients get an extra night’s sleep. So now I’ve got what you’d call a more professional and ... ‘impersonal’ the wrong word but ... Gwen 850-858 Finally, even participants who were passionately committed to their work, indicated that they felt a need to have a life outside of it. The ability to distance oneself and go home at night seems to be an important factor in personally Sustaining the role.
Sustaining the Role In addition to Sustaining the self in the role, participants acted to Sustain the community health nursing role itself. Participants were at times called on to Justify a need for the very existence of the role. Participants indicated that they often did not feel ‘visible’: I’m not altogether sure that some people in higher positions actually know precisely what school nurses do. Depending on the discipline that they’ve
344 come from, they’re very attuned to that [their own discipline]. But often I don’t think that they have a broader perspective of what the school nurse does. That’s my general feeling. Rhonda 339-344 Community health nurses are working with people in a private domain, often in their own homes. They may be promoting: health, prevention of disease, change, or the longer term goals inherent in Situated Health Competence. A nurse may ‘get on with the job’, provide excellent service, yet their activity not be visible or seen as achieving anything, because they do not provide ‘hands on’ physical care. This is compounded by the ambiguity and low technology nature of the role activities, and the difficulty that community health nurses have in articulating their role at times. Participants noted that people were at times unaware of their qualifications, expertise and skills, or undervalued them: Some administration teaching staff will say very clearly, “I do not want to see you in a classroom. I have teachers who can teach”. You know “what can you do in a classroom that my teacher can’t do?” And yet they will quite happily pay four hundred dollars to bring a guest speaker on something like ... Yes, yeah, okay ... family planning, contraception, okay.
[Laugh]
It’s
incredible that they don’t see you as having anything to contribute. Rhonda 245-252 If the nurse is seen as providing a valuable resource, then the role will be continued and possibly expanded. On the other hand, if the nurse does not have visibility, or is not seen as achieving anything, then the role will be considered unimportant, undermined and possibly be cut, particularly in the current fiscal climate. This adds a political element to the Negotiating activities of the nurse. They are not just Negotiating to achieving aims, but also consolidating and maintaining the importance of the role. It is thus fundamental that ‘what nurses actually do’ is made more visible. Consequently, visibility is essential in terms of successfully playing out the role of community health nurse. The importance with which improving visibility of the role is considered is underscored by the fact that one of the participants had a formally identified component of her role allocated to liaising between the hospital and the community field. Participants saw that it was necessary to raise the profile of the
345 nurse in relation to their employers, clients, other nurses, potential clients, key community members, health professionals, community workers, community agencies, other professionals and members of the public. Data were examined for the ways in which Participants acted to Sustain the role of the community health nurse itself. These were identified as: justifying, promoting and expanding. Justifying the Role As described above, participants engaged in many Justifying processes. Participants engaged in these Negotiating processes, not only to justify their role activities, but also at times, the role of the community health nurse or service itself: And I don’t think ... unless we get smarter about evaluating our outcomes ... I don’t know how we are going to survive. Gwen 596-603 An example of the insecurity of the community nursing role are moves in two of the three states from which participants were drawn to curtail the level of services provided to new parents by child health nurses. However, it was noted that some participants appeared to be called upon to justify their role more than others. Where a participants’ role was more disease-focused, had a longer historical basis, and/or received structured referrals, they focussed more on promoting the role, rather than justifying it. For example, engaging in a diseasefocussed role such as diabetes education and working with people with drug addictions appeared to require less justification than a role that focussed on wellness. Participants with the greatest generalist or health orientation to their role appeared be called on to justify their role to the greatest extent. The more generalist nurse has a brief to respond to a range of different issues. Therefore, they must keep explaining their activities and justifying their importance. The more structured role, including a clearly defined client group, with a clearly defined (usually disease) focus, and provision of a clearly defined service is easier to ‘see’ and easier to justify. However, the dilemma for the nurse is that such a role may be less responsive to client issues, problems and needs.
346 Promoting the Role Promoting the role was an important theme in the data. Participants saw that promoting their role was an important role activity, and that they personally represented community health nursing as a profession: Because I’m the representative of community nursing in this hospital. And if that’s how people see me, then that will brush off onto ... that’s how they see community nurses. Kate 604-608 Many participants indicated that although they did act to promote their role, they felt that perhaps they could have done more. They discussed the importance of ‘selling’ their role in the community: I just feel, probably like everybody else, that our role is totally undersold. And perhaps that’s our fault. Perhaps we’ve sat on our bums a little bit and not got out there and beat our drum often enough to sell ourselves. Cheryl 683686 What’s sadly neglected though, just on the side is that we tend to have a ... not a good image, generally. And we don’t promote ourselves. And even when we have health promo[tion] ...
we have lots of opportunities, so many
opportunities to ext[end] ... to make something of ourselves, in small things like, just health promotional activities, like “Wellness Day” ... which was on not long ago. And there was ... from a community health [nursing] aspect ... we ... there was nothing. You know, the day [Wellness Day] came and went. Amy 3-22 Participants acted to promote three aspects of their role. Firstly participants acted to promote their role activities, particularly health promotion and health education. In many instances promotion of these activities were crucial to their aim of increasing client participation: Well, I have run an asthma morning up here for the community ... ads in the local paper ... Louise 358-359
347 Secondly, participants acted to promote themselves as the community health nurse in order to maintain their personal position in the community: ... and I wanted to let myself be known ... that I was the school nurse. And so I wanted to have a ‘presence’. So I made a conscious effort to go to all the assemblies, so they could see me ... that the parents could see that “she’s the school nurse” as well as the child health nurse and whatever. Lyn 1075-1079 … and if people want you to go and speak here and there like I’ve done at [community organisation] ... I did a half a morning session for them last week on health practices of Asian communities or something like that … I prepared it and then do it because you’re advancing your position. You know, I mean, and then people say “so and so knows a bit about that”. Or ... make yourself available ... if people want to ring you up and ask you about a particular thing. [You should] get back [to them] when there’s phone calls. Louise 1159-1171 It was noted that although participants did act to promote themselves as a community health nurse, some explicitly, they were at times less assertive in promoting themselves in the role, when compared with their assertiveness in addressing and advocating for the needs of their clients. There were situations where they put up with negative behaviours toward themselves as professionals for the sake of achieving the positive outcomes for their clients. Thirdly, participants acted to promote the importance of the community health nursing role itself. They used opportunities to identify for others the knowledge, skills and qualifications required by the nurse: Well, [we promote ourselves by] going around to people in within the area and Community Nurses’ Weeks and you know, two or three times ... well a couple of times anyway ... and said who we are, and what we do and gone and met them. And we try and call into, you know, the playgroup coordinators and the pharmacists, and make ourselves known generally, and offer our services ... [and ask] if there’s anything we can do. Mary 230-236 One of the regions from which participants were drawn had published a video outlining the role of the nurse (Health Department of Western Australia, 1987) and
348 another had created a audio-tape/slide show. Promoting the role required the nurse to examine how they represented the self to others and proactively act to manipulate that image and to persuade others of the importance of themselves in the role. This required personal commitment from the nurse to the role they were undertaking. Promoting their role at times required tenacity: I kept communicating with him. I didn’t let him think well ... if ... he doesn’t see me as doing much in this community ... I just thought “well too bad, I’m going to keep telling him [that] this is what I am doing”. So he would have been ... he knew that I was running different groups ... and I mean ... and different bits and pieces. Lyn 948-954 Participants used a variety of strategies to increase their visibility and promote their role. These included: being seen to professionally fulfil their role, use of promotional activities, working within current structures and utilising networks and contacts. The first approach was that participants saw that effectively and professionally fulfilling their roles, particularly those aspects that are visible, was important in promoting their role. Where a nurse had personally established their abilities and effectiveness, they was accorded respect, greater power in negotiating their role, and a higher profile. Anna suggested that she had “done a few breakfasts in schools over the years. And it’s gradually flowed on to bigger and better things”. This would seem to be particularly important if participants want to create a different sort of role to the one others were expecting: Like those post-natal parenting groups that child health nurses have been running. You’re putting people in touch with one another. But you’re also imparting knowledge. And so then they always relate to you as the person who put them in touch with this really good support group that they’ve got going. Cheryl 179-191 ... and look, the school was a huge area ... I worked a lot in [it]. And they really knew what their school nurse did there then. They didn’t just see them as doing hearing and vision [screening]. Because I did heaps in the school. Lyn 989-998
349 In many instances, participants saw the need to promote client understanding of their services to enable effective utilisation. All participants explained their role to clients. A second way of promoting their role and increasing visibility was to use a variety of promotional strategies. Specific activities and events, such as health promotion, education and community groups were promoted by: advertising, pamphlets, tapping into themed events, publishing in local newsletters, providing news stories, or evaluation reports following an activity: And I did do articles in the local paper. I mean there was always things being advertised, because they were just ... that was my whole approach up there ... was to have something every three months [in the paper] for some part of the community ... whether it be the old, you know the older, the over fifties ... or whether it be the mothers or ... and you know. Lyn 989-998 I think, I guess by ... certainly promoting some of what you do through school newsletters ... the letters that go home to parents once a month ... I have a health hint in there every month ... Anna 380-383 I think you just plug along. And I do ... see I do fliers explaining what my what my role is and what services are available. Gwen 550-552 Participants also used themed promotional activities to raise the profile of the activities of the community health nurse: ... [we] started off with a spiel, a health promotion stand for community nurses. We bought ... we actually did some photographs of a few of the nurses in the role of screening, doing some assessments, working with migrants and Aboriginal people. And we had the display actually in the dining room of the [regional] Hospital. So that was a start. And that again is where you’ve got to try and get the hospital people a little bit ... with this integrated service ... a little bit on side with what you do. Amy 97-106 Thirdly, participants used structures to raise their profile. They saw the need to present themselves in professional forums such as meetings to present their views and
350 activities. Referrals provided a structural basis for making their role more visible. They tapped into existing structures, to make themselves a part of it: And then one of the things that has come up is that each student has to receive their health card when they leave school. So to accomplish that, I got my name put on the ... they have to go through a discharge process to get out of the school ... so I got my name put on that. So when they come down to do their discharge, they come down and pick up their health card and their health pack. Rhonda 648-651 Finally, participants utilised networks and contacts with key players in their community to raise their profile. This was evidenced by the way in which they found that where people had more dealings with them, there was more understanding of their role: I think that raises your profile ... amongst the community ... and they talk amongst themselves. I think the other thing ... if you do a bit of networking ... [that] raises your profile. Cheryl 177-191 ... and even the services [clubs] like I spoke to the [Suburb]
Rotary on
Tuesday morning at a breakfast show. Now, I don’t know, they were all business men, forty business men there. And that was a bit nerve racking, I have to say. Anyway, it went off extremely well. Now, I don’t know at some stage under this purchase and provider bit that I may be wanting to get assistance from them. You know with plum puddings at Christmas or whatever Rotary’s doing. So I mean, if you get the opportunity to do these things ... go and do them. You know, I mean, they don’t pay for my services, it comes free. And I just thought well, it’s a good way of me [being able] to talk to some business people ... (phone rings)..tell them what I do ... promote what I do. Louise 1184-1196 In particular, they targeted those they considered key people in promoting their role. Participants also saw that it was important to educate the next generation of nurses about the role community health nurses play:
351 That’s right, and I think in the [community and child health educational] program there are midwives and paediatric nurses who are choosing to do the program. Not because they necessarily are going to work in the area ... but it’s helping them broaden their view of family health and family nursing. And I think that’s a very good thing. Because the more people that go back into a hospital system that have experienced it [community health nursing] to some extent, the greater is going to be that potential to communicate. Karen-789796 They also saw that it was necessary to take advantage of every opportunity to ‘get their message across’: The dental health services rang up, they were developing a new display on nursing careers. And they wanted a community nurse’s input to the text. ... Now you can’t be too busy to have an input into something like that. You have to make time. Because to have input and to have our name attached to something we don’t have to pay for ... but also something that is going to be state-wide and promoted by another service is just invaluable. We can’t sort of miss that opportunity. Kate 827-840 It was of interest that while participants did feel the need to promote themselves and often mentioned their expertise, very few displayed their qualifications and gave the researcher business cards displaying their position and qualifications. Expanding the Role Participants also engaged in activities designed to expand their role. Participants could see a broad potential for their role and some expressed a vision for their role that went beyond the current role they were carrying out. An example is Kate’s view: Community nurses should be the ‘be all and end all’ of health. I mean the whole health system should rotate around community nursing. Because we [child health nurses] have the ability to do that. We should be running in our own child health centres, well women’s’ clinics. You know, “come along and have your baby’s two year old screening done, and I’ll do your pap smear at the same time, and if you’re pregnant I’ll do your ante-natal check”. Now we
352 have the skills to do all of those things. We have a unique situation where we have our clinics ... and I use that word warily. But we have interview rooms. We are all midwives. You know, we should be doing community ante-natal care. There is absolutely no reason why we can’t do that. We have no doctors working, very few doctors in our district who will deliver public patients. This hospital should be developing community ante-natal care. midwifery.
Now it’s cost effective.
It’s good for women.
Community It’s good for
families, particularly families in lower socio-economic groups. And we’re THERE. You know I’ve got everything I need, bar a couch ... and I’ll do it on the floor if I need to ... at my child health care centre. But we don’t do it ... Kate 718-738 Some of the participants were also very proactive in working to access resources and grants. This activity was very important in Sustaining the role, but also providing a basis for expanding the role into new and innovative areas: I think you’ve got to be proactive, you’ve got to be going out looking for grants. Louise 1092-1104
Critique of Others It was noted that these participants were at times critical of others who did not act to fulfil the community health nursing role in the way they envisaged it should be. It appeared that they felt that this created a poor image of the role of the community health nurse. While they were very tolerant and responsive in relation to their clients, this tolerance did not extend to all of their nursing and other health professional colleagues. Although they worked with them in a flexible manner in order to achieve goals and did not act to undermine them, never-the-less, they were critical. Several participants indicated that they felt that community health nurses undervalued themselves at times. They were less than impressed where there was a lack of interest, ability to change, or belief in their own ability: I have a great respect for community nurses. If this got back to community nursing, I’d be dead. But I think that they undervalue themselves.
353 Because it is too hard and “I’m not good enough” and “I’m too busy” and “I don’t want to change”. And all those pitiful reasons. Kate 712-718; 742-753 And there’s [also] a lot of people getting well paid for sitting on their date and not ... you know ...extending themselves. And I mean the days for those people are numbered now because, you know people want to see outcomes ... Louise 1176-1180
INTEGRATING A final process category identified was that of Integrating. This category was identified from an examination of interview transcripts as a whole. It was noted that participants, particularly those who were very experienced, would move seamlessly between the various components of their role. Those who were less experienced, tended to compartmentalise their roles a little more, perhaps in order to clarify them. For instance, Sharon described her own way of ‘making sense’ of the different components of her role as ‘hanging it on different coat hangers’. Other nurses described definite ‘boundaries’ in the way they perceived their roles. The participants who Integrated their role were: more fluid in their interpretation, more relaxed about traditional nursing and medical aspects of their role, and had a broader Interpretation of their role. It was noted that participants described a period of learning the role, and the complexities of combining the various aspects took some time to Integrate. Participants felt that experience is necessary to help “pick your way through” the issues, and that inexperienced and unprepared nurses do not have the capacity to do this (Gwen 225-306). For example, it was noted that some participants moved fluidly between health promotion, disease prevention and illness. They appeared comfortable with the place of disease within their broad role. It was thought that perhaps these areas required the nurse to explore them separately prior to having the expertise to integrate these together. This ‘integration’ was described by Gwen in her discussion of the place that the acute sector plays in primary health care and seeing a need for integration across sectors: I see community should be addressing the wellness and getting people to the optimum of their health. But I also see it’s hand in glove with hospitals. And
354 I’d like to see some of the small hospitals becoming more multi-focused in what’s the word ... um ... multi-functioning. So that you have a switch from just a hospital being a site of illness, to be an all encompassing health place, where you can get treatment for any illness, but you can also get ideas as to how to prevent getting ill. ... so that they’re not segregated. They actually merged in together and become part of a partnership. Gwen 443-472 Louise also demonstrated this integration. She moved from her activities aimed at community development, that included learning about fertilisers and soil types, through health promotion activities to addressing chronic illness, accessing epidemiological data and providing first aid with little difficulty. It was also noted that where participants were able to undertake their role in an integrated manner, they had mastered all of the processes of Interpreting, Developing, Allocating, Negotiating, and Sustaining their role. It was decided to present this aspect for discussion at the validation feedback groups that were conducted. They were presented by the researcher as a category that was uncertain and inconclusive and participants were asked for comments. Participants in the group discussions strongly supported the notion that they did Integrate their roles to an extent that surprised the researcher. Participants at the focus groups indicated that new nurses tended to focus on tasks rather than seeing the whole picture, and that as nurses gained more experience in the community health nursing field, they could integrate ideas and actions more, combine different aspects of their role and “do more things together”: I think as long as we don’t get totally tied up in task orientation and we [don’t] lose the wellness component in health education ... But you can teach people while you’re doing. If you ... in most encounters ... if you try and ... when they show interest in some aspect of whatever you’re doing, that you can educate. It’s just up to us to be a little bit cluey as to where you get your message over. Look for these ... the opportunities. Gwen 568-575
355
SUMMARY OF THE CHAPTER This chapter outlined the processes required of the community health nurse in order to carry out their role effectively. These include: Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating. These processes require many personal and interpersonal skills, together with autonomy and creativity. They result from the philosophies, contexts, dialectics and activities of the aim of facilitating Situated Health Competence.
356
CHAPTER TEN Conclusion SUMMARY As community health nursing is practised in a changing socio-political and organisational milieu, it requires clear articulation of the philosophical bases, nature and purpose of its role in order to continue to develop into the future. The aim of this study was to explore the role of the community health nurse in Australia and to provide explanation about the nature of the community health nursing role, its philosophical bases, purpose, to describe role activities and analyse how community health nurses enact their role, from the perspective of the practitioner. Studies to date in Australia have examined demographic data, the characteristics of community health needs, their educational needs, their activities and have compared perceptions of community health nurses with the perceptions of other health professionals. None have provided an in-depth examination of the perspectives of the community health nursing practitioner about their role. This study, therefore, sought to access the views of practitioners themselves and focussed on how practising community health nurses perceived, defined and negotiated their role in a range of practice settings. In particular, the study was designed to answer the following questions: 1.
What are the philosophical perspectives of community health nurses practising in a range of Australian community health settings?
2.
How do practising community health nurses interpret their role in a range of Australian community health settings?
3.
What processes do practising community health nurses utilise to enact the role of community health nurse in a range of Australian community health settings?
357 Data were collected from seventeen excellent community health nurses practising in a range of community health settings in three states of Australia. The study was based on a symbolic interactionist perspective that viewed the community health nurse as interacting with individual and collective others; sharing, reflecting on and constructing meanings; engaging in self-directed behaviour; and actively negotiating and making their roles. This view guided collection and interrogation of data derived from in-depth interviews, questionnaires, job descriptions, group discussions with participants, organisational documentation, documentation of professional organisations and the professional literature. Data were analysed using grounded theory methods.
FINDINGS This study found that the philosophical perspectives that provide a basis for community health nursing practice were related to an holistic, contextual notion of health in which the individual is inextricably linked with the family and community and was consistent with notions of health for all, the new public health and primary health care perspectives. It was also found that because services are provided to clients within their own contextual setting, the provision of holistic care becomes a more realistic possibility than when compared to decontextualised institutional settings. The Integration process identified in this study supported notions posited by previous researchers (Hanchett and Clarke, 1988; St John, 1993) and found in definitions of community health nursing (American Nurses' Association, 1980) that suggest that the practice of community health nursing synthesises a variety of approaches. This study suggests that in enacting the community health nursing role, practitioners draw on, integrate and synthesise different theoretical perspectives and approaches derived from: nursing, public health, epidemiology, community development and the social sciences. The argument that community health nursing practice is based on ideologies that are dialectical nature (De Silva, 1988; Hamilton and Keyser, 1992) and that there is a need to integrate preventative and curative activities in community health nursing practice (Collis and Dukes, 1991) was also supported by this study. There is an integration of the dialectical notions of: health and disease; individual and community;
358 connectedness and disconnectedness in the nurse-client relationship; and a professional perspective that aims to facilitate client empowerment. This study demonstrated that the role of the community health nurse has a focus that that extends beyond the individual. The community health nurse searches out and addresses unmet health needs within families, groups and, on occasion, communities and sees their individual and family clients as situated within the complex fabric of the community. However, the findings also suggest that community health nurses require a sophisticated understanding of the community and that operationalising a notion of the community in practice is complex and fluid. It has confirmed the importance of a systems approach and the dimensions of people, geography, space, shared features, bonds or interests as factors in defining and understanding the community. However, it was found that, of these, the most useful conceptualisations of the community incorporate the notions of geography, target groups and their related health issues, with the addition of the provision of resources and the community as a network. An aspect that may require further research is the way in which these nurses thought of the community in terms of being a resource that had importance in meeting the needs of their clients. These approaches to understanding the community will inform those undertaking community assessments. This research has highlighted the dimension of connectedness as a central factor in understanding the community as an entity or ‘client’. Findings indicate that where community connectedness is absent or difficult to identify, nurses may have difficulty using current approaches described in the nursing literature which address the community as ‘client’. The notion of connectedness raises many questions for further research. It would be interesting to investigate whether variation in how the community is conceptualised contributes to changes in community nursing practice. To what extent does the nurse contribute to connectedness? Does the nurse contribute to the development of connectedness via networking and community development approaches? There are also implications for community development approaches in community health nursing. Can community development approaches be used where the nurse is unable to identify a connected community? The findings of this research suggest that although the concept of community as ‘client’ may usefully guide practice, a simplistic view that all communities can be interacted with
359 as a ‘client’ may be flawed. A proposition is offered that a dynamic, multi-faceted approach to understanding each particular community is most useful in practice. The view that community health nursing has a primary focus on health promotion, health maintenance, health education and prevention of illness was supported by this study. These aims of practice are consistent with studies carried out with community health nurses that identified: an aim of health education, health promotion, prevention of illness and crisis intervention (Field, 1983; Drennan, 1986; Vongleang, 1993); saw community health nurses as addressing health needs, prevention and coping strategies of clients (Field, 1983; Clark, 1985) and that they use the processes of reassurance and support (Drennan, 1986). There is also consistency with the findings of Katz et al. (1976), Cramer (1992), Bremer (1989) and Drennan (1986) that community health nurses frequently fill in gaps in services available to clients. The community health nurse role is interconnected with the local community, providing responsive, relevant services with a particular focus on the needs of the most vulnerable. The central purpose of the community health nursing role was found to be facilitating Situated Health Competence. Situated Health Competence occurs when individuals, families, groups and communities: identify and manage their own illnesses, health problems, health issues and health behaviours; and have enough knowledge and power to make their own decisions, question matters that impact on their health and seek out and access appropriate resources on an ongoing basis. In particular, there is a recognition that: Situated Health Competence is achieved within the context of going about one’s everyday life, including work, recreation, relationships and role responsibilities; social, political and environmental factors exert a powerful effect on health; health competes with other matters in the lives of individuals, families, groups and communities; there is a continuum in the ability of individuals, families, groups and communities to achieve Situated Health Competence; and achievement of Situated Health Competence may be defined differently in different situations by different people. It was found that the community health nursing activities that contribute to facilitating Situated Health Competence were located within the domains of Identifying, Intervening and Enabling. Thus, this study supported the five domains of community health nursing identified by McMurray (1991) including the consultancy role
360 identified by Fenton (1985). Identifying activities included: assessment, screening, case-finding, taking referrals, follow-up and outreach. Intervening activities included: case management and coordination, crisis management and first aid, advocacy, and ‘filling in the gaps’. Enabling activities included health education, health promotion, problem-solving, counselling, support, providing resources, linking, development/empowerment and consulting. However, where previous studies and domains of practice have placed an emphasis on Intervening activities such as the monitoring and helping roles, this study has indicated that there is greater development of the Identifying activities such as assessing, screening and case-finding and Enabling activities such as developing and empowering. It was found that the activities of the community health nurse were aimed at achieving a nurse-client relationship where enabling activities facilitated Situated Health Competence, or assisted the client so that they no longer required the services of the nurse. Another issue clarified by this study related to the boundaries between the community health nursing role and the role of other nurses and other health professionals. This study found that, similarly to the findings of Round and Sellick (1984), the role of the community health nurse is qualitatively different to generic nursing roles. Generic nursing theory provides a basis that community health nursing practice builds on and expands. The distinction between the community health nursing role and the role of generic nurses was seen in the aim of these nurses to facilitate Situated Health Competence, and demonstrated by the referral patterns of participants. Where clients required an extended episode of comprehensive care that necessitated ‘doing for’, they were referred to agencies such as home health nursing or institutional agencies where this service could be provided. While this study did not examine the nature of the referral process, the importance and complexity of the referral process as described by Luker and Chalmers (1989) was supported by this study. The community health nursing role as described in this study also enabled boundaries to be drawn between community health nurses and other health professionals working in a community setting. The role was differentiated from, and more extensive than that of, for example, health educators or social workers. The community health nurse overlapped with many areas of these roles. However, in addition to the knowledge required to address family, group and community health and undertake health education, health promotion and disease prevention, the role also required the nurse to
361 address individual health needs and engage in disease detection or screening. As a consequence, this drew on the nurses’ knowledge in areas such as: pathophysiology, pharmacology, physical illness, physical care needs, treatment modalities, first aid, client responses and client assessment. In aiming to facilitate Situated Health Competence, the community health nursing role was enacted using the largely concurrent processes of Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating. The broad range of possible activities that can be undertaken in order to facilitate Situated Health Competence in a specific community are Interpreted by the community health nurse. For role activities to be effective and focussed, the community health nurse engages in Allocating processes. This enables the nurse to deal with short term immediate and sometimes urgent role requirements, while still addressing longer term goals that may be focussed on prevention. To undertake the role, the community health nurse engages in ongoing Negotiating processes. The dynamic nature of undertaking the role of facilitating Situated Health Competence requires that the nurse continually Develop new knowledge and skills in order to respond to new problems, issues or needs. Furthermore, the responsive, situated nature of this role in which the client rather than the nurse is ‘in control’ requires that the nurse engage in Sustaining activities. The flexible and generalist nature of the role requires the nurse to act to Sustain the role itself, particularly promoting it to others. A nurse who has mastered all the activities and processes of the role is able to Integrate all role components and move seamlessly between them. These processes enable the community health nurse to carry out a role that is flexible, proactive, can respond to the contextual needs of clients and respond to the challenges of changing social, political and health care structures. The aim of Situated Health Competence was found to have consequences for the nurse-client relationship. Judgements made in assessing client vulnerability supported the findings of Appleton (1995) who identified the centrality of professional judgement in assessing client vulnerability as opposed to the use of structured checklists. The nurse must be sensitive to client needs and be able to develop trust and rapport. However, in addition to an ability to be sensitive and understanding, there were times when the nurse may be required to make a judgement to engage in a more disconnected relationship, because the aim is for the client to function independently of the nurse. Thus, the complex nature of the nurse-client relationship
362 that requires understanding, negotiation and the development of trust (Luker and Chalmers, 1990; Zerwekh 1990; Cowley 1991; de la Cuesta 1994) was supported. The aim of facilitating Situated Health Competence provided a basis for understanding the complexity and connected-disconnected nature of this relationship and indicated a need for further research into this phenomenon. This study shows that there is a continuing dilemma in relation to professionalism. The findings suggest that while the community health nurse may draw on notions of autonomy, integrity and development of knowledge from professionalisation, these do not include a dominating approach in their practice. Finally, the nature of the community health nursing role has been found to be flexible, responsive and negotiated. Participants perceived, interpreted meaning and reflected on that meaning in interaction with the social environment and the symbolic acts of individual and collective others, acting to shape their roles. This has validated the interactional conceptualisation of role taken in this research.
IMPLICATIONS The conceptualisation of the community health nursing role described in this study has implications for practice, evaluation of practice, education of future practitioners and the future of community health nursing. A major contribution of this research is that the findings provide greater depth of understanding and clarity in relation to the aim of community health nursing practice. It was noted above that attempts to define the community health nursing role and explain its practice have indicated a need for greater conceptual understanding, analysis and description. Health education and health promotion have not provided a satisfying way of understanding the intangible components of the community health nursing role. This study presents a picture of a complex and dynamic role. What has been captured from the descriptions of the participants in this study is the ‘something’ that has not been previously well described. The findings of this study provide a way of understanding the motivations of the community health nurse. The community health nursing role has been described as a response to clients’ needs in working toward achieving Situated Health Competence. It has made intangible elements of the
363 community health nursing role more explicit. Understanding the responsive and situated nature of the interactions between nurse and client as they work toward a health competence that is negotiated and shared provides a fresh view of the role. One of the ongoing conceptual dilemmas in community health nursing practice has been the difficulty of locating the notions of illness and disease within the role of a nurse whose principal focus is the promotion of health and the prevention of disease. The finding that participants understood that there was a continuum in the ability of clients to achieve Situated Health Competence provided a way of integrating illness and disease within the role of a community health nurse who is primarily focussed on health and prevention of disease. The proposition that the role of the community health nurse aims to facilitate Situated Health Competence provides a way of thinking about those who cannot ‘do for’ themselves while still maintaining an aim of Enabling clients to achieve health competence. However, it extends the continuum of community health nursing practice away from the medical model and extends the scope of practice to incorporate wellness and contextuality. The notion of Situated Health Competence provides critique of the approach of only ‘doing for’ that is implicit in a great deal of nursing theory and confirms self-care as important to community health nursing practice. However, the notion of self-care has been extended by the identification of the centrality of situatedness and the flexible, negotiated nature of the interaction between nurse and client. Instead of simply addressing the needs of those who are ‘sick’, the needs of those in institutional settings, providing care ‘for’ clients or focussing on a set of decontextualised functions such as the activities of daily living, the community health nursing role carries the role of the nurse a step further to become situated and contextual and also involves the nurse in addressing the health problems, needs and issues of the ‘well’. As such, the role focuses the nurse on holistic practice and health competence rather than only self-care. It moves the boundaries of practice to address health needs and issues in peoples’ own everyday context where people ‘live, work and play’, rather than within the structures of a sick role or an institutional setting. This conceptualisation locates community health nursing practice firmly within current tenets of nursing and connects it with the aims expressed for generic nursing that suggests nurses seek to assist clients in relation to health. However, the aim of facilitating Situated Health Competence has expanded the boundaries of nursing by
364 describing a role that: adds the element of a negotiated understanding of health competence, incorporates contextuality or situatedness, and includes the health problems, issues and needs of clients in a ‘well’ role. The findings of this study have also made a contribution to understanding how the community health nursing role is carried out. The findings of this study support the proposition that that within a broad theoretical and philosophical framework that has as its basis a socially contextual view of health and an aim of facilitating Situated Health Competence, there are many ways of Interpreting and enacting a community health nursing role, but that there are predictable processes. As Situated Health Competence is situational, responsive and dynamic, community health nurses engage in the processes of Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating. A new concept found in this study was the process of Allocating. This process suggests that community health nurses must engage in a sophisticated process in order to effectively balance the competing components of their role. Schön (1992, p. 54) suggests that the practice of a professional must employ judgement, artistry, and the work of naming and framing in order to make sense of unique cases. He suggests that where a competent practitioner can make sense of the jumbled maze of factors in a situation they: ... make judgements of quality for which they cannot state adequate criteria, display skills for which they cannot describe procedures or rules. Furthermore, Schön (1992) argued for an epistemology of practice that embraces “reflection-in-action” where practitioners are willing to embrace error, accept confusion and reflect critically on their previously unexamined assumptions. Schön (1992) argued that professions have practical knowledge that he called ‘knowledge-inaction’. He contended that professionals ‘think in action’ and that professional activity does not follow a model of technical rationality strictly informed by theoretical maxims, rather practitioners engage in a process of problem-setting by identifying the boundaries of a problem, identifying the ‘things’ that are relevant to a problem and deciding what the problem at hand is. This means that the practitioner is no longer pursuing a structured and well-known path, but is engaged in a process that is interactive, dynamic, inherently ambiguous and requires professional judgement.
365 These processes are exemplified by the processes of enacting the role of the community health nurse described in this study. An understanding of the contextual, responsive, negotiated nature of Situated Health Competence also supports the proposition that it would be counter-productive to conceptualise any one single paradigm or ideology as encompassing the practice of community health nurses. As Meleis (1991, p. 76) argued, where the nurse is required to deal with human beings and complex health/illness situations, it is not acceptable to adhere to a single paradigm, rather competing paradigms are required to describe and predict the phenomena of its discipline. Rigidly defining the practice of the community health nursing role would: reduce the potential of the nurse to respond; lock out an ability to make judgments based on a particular client and contextual issue, problem or need; and undertake a range of activities. It would appear that Holmes’ observation (1991, p. 451) that nurses prefer the discriminating eclecticism that has long been necessary in the context of contradictory and competing perspectives, and that they actually employ a mixture of theories aimed at meeting the very specific requirements of their particular clinical setting, holds true for community health nursing practice. To achieve the best outcomes in terms of individual, family and community health from the services of community health nurses, there is a need to encourage nurses to Interpret their roles broadly and flexibly. Thus, while this study has not removed ambiguity, it has provided description of a direction and focus for the community health nursing role and mapped out the terrain of practice. Rather than seeing a need for professional judgement as a problem, this characteristic of professional practice provides a challenge, opportunity and perhaps the basis for future development of an expanded community health nursing role. It is of note that a flexible community health nursing role focussed on promoting Situated Health Competence is highly consistent with the principles of primary health care and community demands for health care, as outlined in Chapter One. This suggests that the community health nurse should remain an integral member of the health team in addressing health needs in the community. This study identified the complexity of accountability and evaluation of practice. It found that the notion of success in achieving aims creates a conundrum. ‘Success’ is complex. If a client achieves Situated Health Competence, they may then not require
366 the assistance or services of the nurse, or may only require access to their services as a resource in appropriate situations. In addition, the goals of the nurse may be long term and preventative, rather than more easily measurable short term goals. Additionally, a health problem prevented is difficult to measure when compared with one that has already occurred. The absence of a health problem may be less easy to link back to antecedent causal factors, and it may be difficult to identify that a specific nursing action contributed to improved outcomes. However, while noting these considerations, this study suggests that community health nurses still consider evaluation important, even crucial, in order to justify their position and role. This suggests that, although not emphasised in this study, there is a need for community health nurses to acquire greater research skills. Sax (1990, p.12) noted that there is a danger that the requirements of accountability and regulation may lead to undue emphases on aspects of policy that are easy to quantify at the expense of features that are not. Cowley (1988) also suggested that there is a temptation to concentrate on short term rather than long term goals that may be more important. While there has been some work into evaluation of community health nursing practice in Australia (Keyzer, 1994), this is an area that requires further research. The findings of this study demonstrated that the role of the community health nurse presents a clear individual challenge to the nurse. This study found that these participants were autonomous practitioners consistent with the findings of McMurray (1984) and Alexander (1988) and that this was important to them (Temple-Smith et al., 1989). This autonomous role required a broad range of personal and professional knowledge and skills. The role also presented a personal challenge, requiring personal commitment, a confident self-view, an ability to seek out support, and a capability of not only living with ambiguity, but utilising it to creatively respond and build a dynamic and responsive role. Participants in this study experienced a period of dislocation while accepting the reality of a transfer in control from themselves to the client, learning to live with the decisions of their clients, and coming to terms with their own ‘need to be needed’. These ‘successful’ community health nurses had all come to terms with these aspects of practice, although many described the process as difficult. This is consistent with Schön’s (1992, p. 61) view that uncertainty may be a threat to practitioners who are locked into a view of themselves as technical experts.
367 However, together with the autonomy of the community health nursing role, it was found that practitioners were often lone practitioners and/or professionally isolated. In undertaking this professionally challenging role, the importance of supervisory and peer support and feedback cannot be underestimated. Furthermore, due to the responsive nature of the role, there is a need for ongoing learning and professional development that can flexibly address the ever-changing needs of the nurse undertaking this dynamic role, supporting the importance of continuing education identified by Parsons and Felton (1992). There were also a number of issues raised that have implications for the professional practice of community health nursing. First, this study has raised a concern about the lack of visibility and the lack of understanding of the role by other professional groups. It indicated that there is a need to raise the profile of community health nursing, promote and explain the role, and demonstrate excellent practice. A second issue related to a need to clarify the scope of practice of different types of nurses practising in the community. While this study focussed on the practice of nurses within specifically defined parameters, it is clear that the role described in this study interlinks with and overlaps with the practice of both home health nurses and nurses described as nurse practitioners. All roles have a contribution to make in the community setting. In addition, all of these areas of community health nursing practice contain groups of nurses with specific knowledge and skills that could rightly be described as specialist. Nurses with specialist knowledge and skill could be crucial to developing a raised profile, expanding the role and undertaking research. In counterpoint, there is also a need to maintain the generalist orientation that enables nursing practice to be responsive, flexible and the professional of choice for deployment in a wide range of settings. This study would suggest that there is scope to develop both generalist and specialist community health nursing roles. A third issue is the need for continuing review of definition, job descriptions, and standards of practice to ensure that they accurately reflect the dynamic role of the community health nurse. The findings of this study provide guidance for the education and continuing professional development of community health nurses. The notion of Situated Health Competence, the role activities of Identifying, Intervening and Enabling and the
368 processes of enacting the role provide a clear articulation of the purpose and enactment of the community health nursing role. Community health nurses have been provided with a description of processes that may enable them to respond to the unique health issues, problems and needs of particular client individuals, families, groups or communities. The role described in this study requires broad multi-skilling. In particular, skills are required that prepare nurses to: interact with individuals, families, groups and communities; network effectively; Negotiate; facilitate rather than ‘do for’; Enable, Identify and Intervene. These activities require skills in planning, group-work, liaison, networking, and so on. In particular, these findings suggest that the educational preparation of community health nurses inspire them to see the possibilities for Interpreting their role; provide a basis for making sound and creative judgements about how they apply their energies or Allocate; a love of learning to facilitate Development; foster the personal skills required for Sustaining; together with the knowledge and skills incorporated in Validating and Negotiating. The findings of this research will also assist in understanding the need to Sustain the self and the community health nursing role itself while facilitating Situated Health Competence.
RECOMMENDATIONS FOR FURTHER RESEARCH This research has provided a broad interpretive perspective on the role of the community health nurse in Australia. Any investigation of role will raise as many questions as it answers. While providing further depth to understanding the role of the community health nurse in Australia, this research has raised many questions that could provide impetus for further research. The characteristics encompassed by Situated Health Competence could be explored in more depth, in particular: the processes and decision-making used by nurses and their clients to identify a uniquely individual definition of health competence, the factors to which nurses attend when responding to client needs, and the process of negotiating responsibility and control. Furthermore, the nurse-client processes that are most effective in facilitating Situated Health Competence could be examined. Another area that could be explored further relates to the decision-making of the nurse and the judgements made to ‘do for’ a client in relation to: the vulnerability of the client, the seriousness of the need and the effectiveness of the nurses’ action. The role activities of Identifying, Intervening and
369 Enabling could be studied to examine approaches, effectiveness and acceptability of these processes. An area that requires further investigation are the processes of enacting the role of the community health nurse: Interpreting, Developing, Allocating, Validating, Negotiating, Sustaining and Integrating. There could be more in-depth analysis of individual processes with sub-groups of community health nurses. It would also be of interest to examine these processes with larger samples of nurses or nurses from different sub-groups of community health nurses to see whether further processes emerge or if there are differences between groups. Further research could investigate the importance of connectedness and the way in which nurses network with larger groups of nurses from a broader range of community health settings. It would also be of interest to investigate whether there are differences in the way in which different types of community health nurses operate within the community in relation to connectedness and networking. One aspect not explored in depth by this research is related to the notion of specialisation. It appears that there could well be two approaches to thinking about specialisation in community health nursing practise. One approach is to consider community health nursing itself as a specialty area of nursing practice. However, it could also be argued that there may in fact be as many ‘specialties’ in community health nursing practice as there are in acute nursing, with the development of specialised knowledge or expertise about: a specific client group such as school children, new parents, the aged, and Aborigines; those suffering a particular chronic disease such as diabetes; or expertise in using a particular community health nursing skill such as community development, counselling, policy development or evaluation research. Examination of these specialist areas could form the basis for further research into the role of the community health nurse, in particular: the boundaries of specialisation in community health nursing; and the linkages between community health nurses and nurses in home health and institutional agencies. In exploring the insider’s perspective, this research has focussed on the micro-social world of the community health nurse. However, it has been clear that the macrosocial and political world also has an impact on the nurse. This is an area that could be explored, particularly in relation to power relationships and political structures
370 governing the activities of the nurse. Given that the structures in which community health nurses work appear to be subject ongoing change, it would be of interest to explore the work of the nurse in relation to these changes. Another area of interest would be the way in which nurses network within the community, the nature of the socio-political environment of the nurse, and the impact of different workplace settings on the role of the community health nurse. It is of importance that the notion of Situated Health Competence be explored from the client perspective in relation to their health issues, problems and needs. It would be useful to explore their perceptions and views of: the services of the community health nurse; the effectiveness and acceptability of services provided, and the meaning of Situated Health Competence. Finally, it would be of interest to undertake similar studies with community health nurses from other countries.
CONCLUSION The picture drawn by this research is that the community health nursing role is responsive, dynamic, creative and innovative. The nurse is required to keep many ‘balls in the air’ related to areas such as: treatment, diagnosis, individuals, families, groups, aggregates, communities, first aid/crisis intervention, health education, community action/organisation, health promotion, filling gaps in health services, undertaking research, follow-up, outreach, and being a generalist and/or a specialist. They are required to maintain a wide raft of knowledge and expertise. Although we live in times in which structures are like shifting sands and political pressures are directed towards an individualistic approach, the participants in this study have demonstrated flexibility and have described a role that shows direction for the future. The philosophical perspectives on health resulting from the new public health, health for all and primary health care movements, although questioned and critiqued have made an indelible impression on the philosophical thinking of community health nurses and provide a foundation for future directions in community health nursing. This study suggests that community health nurses will continue to respond to change and shape their role into the future.
371
Appendix One CONSENT TO PARTICIPATE IN RESEARCH THE ROLE OF THE COMMUNITY HEALTH NURSE IN PRACTICE Investigator: Ms Winsome ST JOHN The role of the community health nurse is a complex one. It is often difficult to explain to others just what you "do" in your job. As each nurse takes up their individual role they play out their own interpretation of what it means to them to be a community health nurse. The aim of this research is to explore how nurses interpret the ambiguity of the community nursing role in their practice. I would like to explore what your community health nursing practice role means to you. Rather than just send a questionnaire, I want to listen to your thoughts in more depth. This is why I want to talk to you. I want to capture your thoughts, and what you really mean. I will be asking what you think your job is about, and what has been important in helping you to form your ideas. Participation in the study will involve the following: a written questionnaire an interview which should take approximately one hour I may ask for a short follow-up interview if there are issues from our first interview which I need to verify with you. The information collected will be treated in the strictest confidence and no names of individuals or agencies will appear in the report. Your thoughts about the community health nursing role will assist in many ways. The results of this research may contribute to clarifying the role of nurses working in the community. Nurses who are clear in their role will be better equipped to promote the health of individuals, families and communities. The results of this research may also assist nurse educators in preparation of community health nurses. It is hoped that clarifying the role of the community health nursing role will lead to better
372 understanding of expanded role of the nurse and contribute to knowledge about nursing as a discipline. You are assured that if at any time you do not wish to continue as a participant in the study, you are free to withdraw your consent and participation. Any questions regarding the project titled "The role of the community health nurse in practice" may be directed to Winsome St John c/o Faculty of Nursing and Health Sciences on Telephone (07) 5594 8935. If you have any complaint, or any query which Winsome St John has not been able to answer, you should write to the Chairperson of the School Human Research Ethics Committee - Lincoln School of Health Science, Locked Bag 12 Carlton South, Victoria 3053.
I __________________________ have read (or had read to me) and understood the information above, and any questions I have asked have been answered to my satisfaction. I agree to participate in this research and for the interview to be audio taped, realising that I may withdraw my involvement in the study at any time. I understand that the use of an audio-tape recorder is to facilitate qualitative data analysis and that the information will be transcribed and placed on a computer using unidentifiable identification codes. I agree that research data collected during the study may be published or provided to other researchers, on condition that my name is not used.
PARTICIPANT: _______________________________
Signature: ____________________________ Date: _______________________
373
Appendix Two A Study on the Role of the Community Health Nurse in Practice Part One: Questionnaire Please fill in the answers as best you can. Your answers will help give a background to our discussion when I come out and talk to you. Please feel free to add pages if necessary. The questionnaire should take no more than 15 minutes. Your answers will be kept strictly confidential. PERSONAL DETAILS: 1.
Sex:
Male
Female
2.
Nationality (if not born in Australia): ____________________________________
QUALIFICATIONS 3.
Formal qualifications in nursing: (please specifically identify any community health nursing qualifications)
Qualification
Year commenced
Year completed
Full time/ part time
Institution
Major study area (if appropriate)
374 4.
Short courses/non award courses Course
5.
Time taken to complete (in hours)
Institution/organisation offering course
Major study area
Qualifications other than in nursing
Qualification
6.
Year/s completed
Year commenced
Year completed
Full time/ part time
Institution
Major study area (if appropriate)
Please tick the nursing registrations you hold: RN
RM
MRN
RPN
MCHN
Other (Please identify) ________________________________________________ 7.
Have you been involved in any professional development, seminars, conferences etc. in the last year? No _____ (Go to next question) Yes _____ (please complete the questions below) If yes, please briefly describe: _______________________________________________________________ _______________________________________________________________
375 _______________________________________________________________ _______________________________________________________________ 8.
Do you intend undertaking further study related to your role in the community? No _____ (Go to next question) Yes _____ (please complete the questions below)
8.1
What further study are you intending to undertake?
Area of study _____________________________________ Level
_____________________________________
EMPLOYMENT 9.
Employment (please begin with your current position) Position held
Year/s
Organisation
Current:
10.
Who else works at your agency? Please indicate the numbers of health professional staff in various categories below.
Community health nurses
_________________________
Nurses other than community health nurses
_________________________
Please specify their role/s:
___________________________________________
376 Medical practitioners
_________________________
Physiotherapists
_________________________
Occupational therapists
_________________________
Social workers
_________________________
Speech therapists
_________________________
Other (please specify role)
___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
11.
Please describe the major demographic characteristics of the community/population you mostly serve. eg main target groups, ethnicity, age, etc: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
12.
What are the main health services offered by your agency (please list)
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
13.
Are you a member of the community you serve as a community health nurse? Yes
14.
No
Do you belong to any formal or informal community organisations? (for example committee memberships, community groups or clubs etc?) No _____ (Go to next question)
377 Yes _____ (please describe) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
15.
Do you have a written current job description? Yes
16.
No
Briefly describe the important skills and characteristics you feel a nurse would need for undertaking your present job. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
Thankyou for taking the time to fill this out.
Winsome St John.
378
Reference List Abdellah, F., Beland, I. L., Martin, A., & Matheney, R. V. (1960). Patient-centered approaches to nursing. New York: Macmillan Publishing. Abel, P. E., Boland, M., Durand, B. A., Geolot, D. H., Goodson, J. D., Isham, G. J., & Steele, L. G. F. (1995). Workforce and community health care needs: A model to link service, education, and the community. Community Health, 18(1), 75-59. Alexander, M. L. (1988). Perceptions of independence: Public health nurses and hospital staff nurses in a metropolitan setting. Unpublished doctoral dissertation, The University of Wisconsin, Milwaukee. Amasheh, N. (1990). Primary health care in Jordan.
Conference proceedings:
Development and diversity: Primary health care. Sydney: The University of Sydney. American Nurses' Association. (1980). A conceptual model of community health nursing (Pub No. CH10). Kansas City, Missouri: American Nurses Association, Division of Community Health Nursing. American Nurses' Association. (1985). The scope of practice of the primary health care nurse practitioner. Kansas City, Missouri: American Nurses' Association, Council of Primary Health Care Nurse Practitioners. American Nurses' Association, Council of Community Health Nurses. (1986). Standards of community health nursing practice. Kansas City, Missouri: American Nurses' Association. American Public Health Association. (1980). Definition and role of public health nursing in the delivery of health care: A statement of the Public Health Nursing Section. American Public Health Association Newsletter. Washington, DC: American Public Health Association. Anderson, E., & McFarlane, J. (1988). Community as client: Application of the nursing process. Philadelphia: Lippincott.
379 Appleton, J. (1995). Health visitor assessment of vulnerability. Health Visitor, 68(6), 228-231. Archer, S. E. (1977). A descriptive study of community health nursing in Australia 1975-1976. Melbourne: Royal Australian Nursing Federation. Archer, S. E. (1982). Synthesis of public health science and nursing science: A key to the community health specialist's preparation. Nursing Outlook, 30(8), 442-446. Ashton, J., & Seymour, H. (1988). The new public health: The Liverpool experience. Milton Keynes: Open University Press. Atkinson, P. (1992). Understanding ethnographic texts (Sage university paper series on qualitative research methods No. 25). Newbury Park, California: Sage. Australasian Nurse Registering Authorities Conference. (1990). National competencies for the registration and enrolment of nurses in Australia. Adelaide: Australasian Nurse Registering Authorities Conference. Australian Community Health Association. (1986). Review of the community health program. Sydney: Australian Community Health Association. Australian Community Health Association. (1989a). Review of the community health program (2nd ed.). Sydney: Australian Community Health Association. Australian Community Health Association. (1989b). Community health centres in Australia: A complete listing. Sydney: Australian Community Health Association. Australian Community Health Association. (1991). Manual of standards for community health: Health accreditation and standards program (2nd ed.). Sydney: Australian Community Health Association. Australian Council of Community Nursing Services. (1987). Standards for community nursing practice. Melbourne: Australian Council of Community Nursing Services. Australian Health Ministers' Advisory Council. (1988). Continuing education for primary health care in Australia. Canberra: Australian Government Publishing Service. Australian Health Ministers' Advisory Council. (1992). National mental health plan. Canberra: Australian Government Publishing Service.
380 Australian Institute of Health. (1988). Nurse workforce 1986 (Health workforce information bulletin No. 13). Canberra: Australian Government Publishing Service. Australian Nursing Council Inc. (1994). ANC Newsletter. March 2: 10. Australian Nursing Council Incorporated, Royal College of Nursing, Australia, & Australian Nursing Federation. (1993). Code of ethics for nurses in Australia. Canberra: Australian Nursing Council Incorporated. Australian Nursing Federation. (1984). Nursing: A statement. Melbourne: Australian Nursing Federation. Australian Nursing Federation. (1986). Policy statement: Nurses' accountability for defining the nursing role. Melbourne: Australian Nursing Federation. Australian Nursing Federation. (1987). Position statement: Primary health care. Melbourne: Australian Nursing Federation. Australian Nursing Federation. (1990). Primary health care in Australia: Strategies for nursing action. Melbourne: Australian Nursing Federation. Australian Nursing Federation, National Professional Development Committee. (1989). Standards for nursing practice (2nd ed.). Melbourne: Australian Nursing Federation. Australian Nursing Federation, College of Nursing, Australia, New South Wales College of Nursing, & Florence Nightingale Committee, Australia. (1989). Nursing in Australia: A national statement. Babb, B. A. M., Fouladbakhsh, & Hanchett, E. S. (1988). Interactions on Main Street. E. S. Hanchett (ed), Nursing frameworks and community as client: Bridging the gap (pp. 109-115). Norwalk, Connecticut: Appleton & Lange. Baker, G., Bevan, J. M., McDonnell, L., & Wall, B. (1987). Community nursing: Research and recent developments. London: Croom Helm. Barker, W. (1993). Patch and practice: Specialist roles for health visitors. Health Visitor, 66(6), 200-203.
381 Barnum, B. J. (1994). Nursing theory: Analysis application evaluation (4 ed.). Philadelphia: Lippincott. Barriball, K. L., & Mackenzie, A. (1993). Measuring the impact of nursing interventions in the community: A selective review of the literature. Journal of Advanced Nursing, 18 (3), 401-407. Beddome, G. (1989). Application of the Neuman systems model to the assessment of community-as-client. B. Neuman (ed), The Neuman systems model (2nd ed., pp. 363-373). Norwalk, Connecticut: Appleton & Lange. Benedict, M. B., & Sproles, J. B. (1982). Application of the Neuman model to public health nursing practice. B. Neuman (ed), The Neuman systems model: Application to nursing education and practice (pp. 223-240). Norwalk, Conn: Appleton-Century-Crofts. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley. Bernard, J. R. L. (1989). The Macquarie Dictionary (2nd ed.). Sydney: The Jacaranda Press. Better Health Commission. (1986). Looking forward to better health, Volumes 1, 2 & 3. Canberra: Australian Government Publishing Service. Black, P. A. (1991). A force for the future: The changing role of the district nurse. Professional Nurse, 7(1), 54-58. Bless, C., Murphy, D., & Vinson, N. (1995). Nurses' role in primary health care. Nursing and Health Care, 16(2), 70-76. Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood Cliffs, New Jersy: Prentice-Hall. Borner, S. J., Counsman, M., deGilling, C. B. L., Lewman, P. A., & Wills, M. E. (1988). High on Kalamazoo. E. Hanchett (ed), Nursing frameworks and community as client: Bridging the gap (pp. 151-165). Norwalk, Conn: Appleton & Lange.
382 Boyle, J. S. (1994). Styles of ethnography. J. M. Morse (ed), Critical issues in qualitative research methods (pp. 159-185). Thousand Oaks: Sage. Bremer, A. (1989). A description of community health nursing practice with the community-based elderly. Journal of Community Health Nursing, 6(3), 173-184. Breslow, L. (1972). A quantitative approach to the World Health Organization definition of health: Physical, mental and social well-being. International Journal of Epidemiology, 1, 347. Brooks, J., & Kleine-Dracht, A. (1983). Evolution of a definition of nursing. Advances in Nursing Science, 5(4), 51-78. Broom, D. (1984). Social distribution of health: Is Australia more equal? Social Science and Medicine, 18(11), 909-911. Brown, I. (1994). Defining our terms: Community development and public health. Health Visitor, 67(10), 353-354. Bruni, N. (1985). The professionalization of nursing. Unpublished masters dissertation, Monash University, Melbourne. Brykczynski, K. (1989). An interpretive study describing the clinical judgement of nurse practitioners. Scholarly Inquiry for Nursing Practice, 3(2), 75-104. Bryman, A., & Burgess, R. G. (1994). Analysing qualitative data. London: Routledge. Buckley, P., & Gray, G. (1993). Across the spinifex: Registered nurses working in rural and remote South Australia. Adelaide: The School of Nursing, Flinders University. Bullough, B. (1995). Professionalization of nurse practitioners. Annual Review of Nursing Research, 13, 239-265. Bullough, B., & Bullough, V. (1990). Nursing in the community. St Louis: Mosby. Burbach, C. A., & Brown, B. E. (1988). Community health and home health nursing: Keeping the concepts clear. Nursing and Health Care, 9(2), 97-100.
383 Burchill, E. (1992). Australian nurses since Nightingale 1860-1990. Melbourne: Spectrum Publications. Butterworth, T. (1990). Patient's needs or professionalism? Nursing Standard, 4(2), 3637. Cameron, J., & MacWilliams, J. (1995). Health care needs of homeless people. G. Gray, & R. Pratt (eds), Issues in Australian nursing 5 (pp. 39-53). Melbourne: Churchill Livingstone. Campbell, J., & Pigott, E. (1989). Community nursing for young families. V. Rice (ed), Community nursing practice: The Australian experience (2nd ed., pp. 53-76). Sydney: MacLennan + Petty. Canadian Public Health Association. (1990). Community health, public health nursing in Canada: Preparation and practice. Ottawa: Canadian Public Health Association. Carpenito, L. J. (1992). Nursing diagnosis: Application to nursing practice (4th ed.). Philadelphia: Lippincott. Cernik, K., & Wearne, M. (1994). Promoting the integration of primary care and public health. Nursing Times, 90(43), 44-45. Chalmers, K., & Kristajanson, L. (1989). The theoretical basis for nursing at the community level: A comparison of three models. Journal of Advanced Nursing, 14(7), 569-574. Chamberlain, M. C., & Beckingham, A. C. (1987). Primary health care in Canada: In praise of the nurse? International Nursing Review, 34(6), 158-160. Chambers, L. W., Underwood, E. J., & Halbert, T. (1989). Individual client care and public health policy: The dual challenges for public health nurses. Canadian Journal of Public Health, 80(5), 315-318. Charmaz, K. (1994). The grounded theory method: An explication and interpretation. B. G. Glaser (ed), More grounded theory methodology: A reader (pp. 95-115). Mill Valley, CA: Sociology Press.
384 Cheek, J., Gibson, T., & Gilbertson, J. (1995). Competencies: Really or merely useful? G. Gray, & R. Pratt (eds), Issues in Australian Nursing 4 (pp. 29-60). Melbourne: Churchill Livingstone. Chenitz, W. C. (1986). Getting started: The research proposal for a grounded theory study. W. C. Chenitz, & J. M. Swanson (eds), From practice to grounded theory: Qualitative research in nursing (pp. 39-47). Menlo Park, California: AddisonWesley. Chenitz, W. C., & Swanson, J. M. (1986). From practice to grounded theory: Qualitative research in nursing. Menlo Park: Addison-Wesley. Chin, S. (1985). Can self-care theory be applied to families? J. Reihl-Sisca (ed), The art and science of self-care (pp. 56-62). Norwalk, CT: Appleton-Century-Crofts. Chinn, R. (1980). The utility of systems models and developmental models for practitioners. J. P. Riehl, & C. Roy (eds), Conceptual models for nursing practice (2nd ed., pp. 21-37). New York: Appleton-Century-Crofts. Clark, J. (1985). The process of health visiting. Unpublished doctoral dissertation, Polytechnic of the South Bank, London. Clark, J. (1986a). A model for health visiting. B. Kershaw, & J. Salvage (eds), Models for nursing. Arundel: J. Wiley & Sons. Clark, M. (1986b). Action and reflection: Practice and theory. Journal of Advanced Nursing, 11(1), 3-12. Clark, M. J. (1992). Nursing in the community. Norwalk: Appleton & Lange. Clarke, H. F., Beddome, G., & Whyte, N. B. (1993). Public health nurses' vision of their future reflects changing paradigms. Image: Journal of Nursing Scholarship, 25(4), 305-310. Clayton, L. (1995). Hospital at home: Customer choice for post acute care. Issues in Australian nursing 5 (pp. 297-310). Melbourne: Churchill Livingstone. Clemen-Stone, S., Eigsti, D. G., & McGuire, S. L. (1991). Comprehensive family and community health nursing (3rd ed.). St Louis: Mosby.
385 Cohen, H. (1987). The nurse's quest for professional identity. Menlo Park: AddisonWesley. Collis, J. L., & Dukes, C. A. (1991). Towards some principles of school nursing. B. W. Spradley (editor), Community health nursing (4th ed., pp. 135-139). Glenview, Illinois: Scott, Foresman/Little, Brown Higher Education. Committee for the Study of Professional Issues in Nursing (Chairperson F. Marles). (1988). Report of the study of professional issues in nursing. Melbourne: Ministry of Health. Commonwealth Department of Community Services and Health. (1989). National women's health policy: Advancing women's health in Australia. Canberra: Australian Government Publishing Service. Commonwealth Department of Human Services and Health. (1994). Better health outcomes for Australians: National goals, targets, and strategies for better health outcomes into the next century. Canberra: Australian Government Publishing Service. Conrad, P., & Schneider, J. W. (1980). Deviance and medicalization. St Louis: Mosby. Conway, M. E. (1988). Theoretical approaches to the study of roles. M. E. Hardy, & M. E. Conway (eds), Role theory: Perspectives for health professionals (2nd ed., pp. 63-72). Norwalk: Appleton & Lange. Cookfair, J. M. (1991). Nursing process and practice in the community. St Louis: Mosby. Coombs, E. (1989). An introduction to community health in Australia. V. Rice (editor), Community nursing practice (2nd ed., pp. 1-17). Sydney: MacLennan + Petty. Cooney, C., & Watts, R. (1992). Nursing diagnosis: Implications for health, with particular concerns for community nursing. Contemporary Nurse, 1(2), 101-103. Cooper, U. (1994). A case study of the role of the South Coast Health Region of Queensland Community Health Service in health promotion. Unpublished MEd dissertation, Deakin University, Geelong.
386 Council of Australian Government's Task Force on Health and Community Services. (1995). Meeting people's needs better. Canberra: Australian Government Publishing Service. Cowley, S. (1988). In search of a model for health visiting. Health Visitor, 61(5), 149151. Cowley, S. (1991). A symbolic awareness context identified through a grounded theory study of health visiting. Journal of Advanced Nursing, 16(6), 648-656. Cowley, S., Bergen, A., Young, K., & Kavanagh, A. (1995). Exploring needs assessment in community nursing. Health Visitor, 68(8), 319-321. Cramer, J. (1992). Dilemmas of remote-area practice. G. Gray, & R. Pratt (eds), Issues in Australian nursing 3 (pp. 133-149). Melbourne: Churchill Livingstone. Cross, J., Northrop, C., & Strasser, J. (1983). How community health nurses spend their time: A study report. Nursing & Health Care, 4(6), 314-317. Dalziel, Y. (1994). Integrating a community development approach with mainstream health visiting. Health Visitor, 67(10), 355-356. Davies, E. (1984). Day by day: Inside the community. Australian Nurses Journal, 14(2), 40-41. Davis, A., & George, J. (1993). States of health (2nd ed.). Sydney: Harper Educational. de la Cuesta, C. (1994). Relationships in health visiting: Enabling and mediating. International Journal of Nursing Studies, 31(5), 451-459. De Silva, P. S. (1988). Public health nursing: Phenomenological meaning and dialectical theory. Unpublished doctoral dissertation, The University of Texas at Austin. Denyes, M. J. (1988).
Orem's model used for health promotion: Directions from
research. Advances in Nursing Science, 11(1), 13-21. Denzin, N. K. (1989a). The research act: A theoretical introduction to sociological methods (3rd ed.). Englewood Cliffs, New Jersey: Prentice Hall.
387 Denzin, N. K. (1989b). Interpretive interactionism (Applied social research methods series No. 16). Newbury Park: Sage. Dewdney, J. C. H. (1972). Australian health services. Sydney: John Wiley and Sons Australasia. Dickoff, J., & James, P. (1968). A theory of theories: A position paper. Nursing Research, 17(3), 197-203. Dixon, J. (1989). The limits and potential of community development for personal and social change. Community Health Studies, 13(1), 82-92. Dreher, M. C. (1982). The conflict of conservatism in public health nursing education. Nursing Outlook, 30(9), 504-509. Drennan, V. (1986). Talking to health visitors: Perceptions of their work. A. White (ed), Research in preventive community nursing care: Fifteen studies in health visiting. Chichester: John Wiley & Sons. Drew, L. L., Craig, D. D., & Beynon, C. E. (1989). The Neuman systems model for community health administration and practice: Provinces of Manitoba and Ontario, Canada. B. Neuman (ed), The Neuman systems model (2nd ed., pp. 315341). Norwalk, Connecticut: Appleton & Lange. Dunn, H. L. (1977). What high level wellness means. Health Values, 1, 9. Dunt, D. R., Temple-Smith, M. J., & Johnson, K. A. (1991). Nursing outside hospitals: The working experience of community nurses: Job characteristics. International Journal of Nursing Studies, 28(1), 27-37. Edwards, J., & Popay, J. (1994). Contradictions of support and self-help: Views from providers of community health and social services to families with young children. Health & Social Care, 2(1), 31-40. Ellefsen, B. (1992). The complex role of a community health nurse officer in Norway. Western Journal of Nursing Research, 14(2), 142-156. Erickson, G. P. (1987). Public health nursing initiatives: Guideposts for future practice. Public Health Nursing, 4(4), 202-211.
388 Etzioni, A. (1969). The semi-professions and their organization: Teachers, nurses and social workers. London: Collier-Macmillan. Evers, H., Badger, F., & Cameron, E. (1992). Finding the limits. Nursing Times, 88(30), 60-62. Fatchett, A. B. (1990). Health visiting: A withering profession? Journal of Advanced Nursing, 15(2), 216-22. Fawcett, J. (1991). Approaches to knowledge development in nursing. Canadian Journal of Nursing Research, 23, 23-34. Fawcett, J. (1995). Analysis and evaluation of conceptual models of nursing (3rd ed.). Philadelphia: F. A. Davis. Fenton, M. V. (1985). Identifying competencies of clinical nurse specialists. The Journal of Nursing Administration, 15(12), 31-37. Field, P. A. (1983). An ethnography: Four public health nurses' perspectives of nursing. Journal of Advanced Nursing, 8, 3-12. Field, P. A., & Morse, J. M. (1985). Nursing research: The application of qualitative approaches. Rockville: Aspen. Franklin, M. (1991). Community development in health in Jervis Bay, St Georges Basin. Development and diversity: Remote and rural primary health care. Sydney: The University of Sydney. Freidson, E. (1970). Professional dominance: the social structure of medical care. New York: Aldine. Freidson, E. (1986). Professional powers: A study of the institutionalization of knowledge. Chicago: University of Chicago Press. Freire, P. (1972). Pedagogy of the oppressed. London: Penguin books. Frith, N. C. (1975). Experiences in public health nursing. Canberra: Australian Government Publishing Service.
389 Fuchs, V. R. (1974). Who shall live?: Health, economics, and social choice. New York: Basic Books. Fuller, J. (1995). Challenging old notions of professionalism: How can nurses work with paraprofessional ethnic health workers. Journal of Advanced Nursing, 22(3), 465472. Gadamer, G. (1975). Truth and method. London: Sheed and Ward. Gallagher, U., & Burden, J. (1993). Nursing as health promotion - a myth accepted? J. Wilson-Barnett, & J. M. Clark (eds), Research in health promotion and nursing (pp. 51-58). London: Macmillan. Gantz, S. B. (1990). Self-care: Perspectives from six disciplines. Holistic Nursing Practice, 4(2), 1-12. Gardner, H., & McCoppin, B. (1989). Emerging militance? The politicisation of Australian allied health professionals. H. Gardner (ed), The politics of health: The Australian experience (pp. 303-348). Melbourne: Churchill Livingstone. Gardner, H., & McCoppin, B. (1995). Struggle for survival by health therapists, nurses and medical scientists. H. Gardner (ed), The politics of health: The Australian experience (pp. 371-427). Melbourne: Churchill Livingstone. Garrett, M. P. (1989). The maternal and child health service: The foundation of primary health care in Victoria. G. Gray, R. Pratt, & G. Clark (eds), Primary health care: A collection of papers (pp. 28-39). Melbourne: Australian Nursing Federation. George, M. V. (1994). Nursing diagnosis: A theoretical concept undermining clinical credence. Clinical application of nursing diagnosis: Nexus or nonsense? 2nd National Nursing Diagnosis Conference. Perth: Curtin University of Technology. Giorgi, A. (1970). Psychology as a human science: A phenomenologically based approach. New York: Harper & Row. Glaser, B. G. (1978). Theoretical sensitivity. Mill Valley, California: The Sociology Press.
390 Glaser, B. G. (1992). Emergence vs forcing: Basics of grounded theory analysis. Mill Valley: Sociology Press. Glaser, B. G., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine. Goeppinger, J. (1988). Response to "Theory development in community health nursing: Issues and recommendations". Scholarly Inquiry for Nursing Practice: An International Journal, 2, 161-165. Goeppinger, J., & Shuster, G. F. (1992). Community as client: Using the nursing process to promote health. M. Stanhope, & J. Lancaster (eds), Community health nursing: Process and practice for promoting health (3rd ed., pp. 253-276). St Louis: Mosby. Goltz, K., & Bruni, N. (1995). Health promotion discourse: Language of change. H. Gardner (ed), The politics of health: The Australian experience (2nd ed., pp. 510549). Melbourne: Churchill Livingstone. Goodwin, S. (1992). Community nursing and the new public health. Health Visitor, 65(3), 78-80. Gordon, M. (1987). Nursing diagnosis. New York: McGraw-Hill. Gray, G., & Price, K. (1991). Report: National nursing research invitational workshop. 46 April, Melbourne: Royal College of Nursing, Australia. Gray, V. R., & Sergi, J. S. (1989). Family self-care. P. J. Bomar (ed), Nurses and family health promotion: Concepts, assessment, and interventions (pp. 67-77). Baltimore: Williams & Wilkins. Green, G. (1988). Relationships between role models and role perceptions of new graduate nurses. Nursing Research, 37(4), 245-248. Green, J. L., & Driggers, B. (1989). All visiting nurses are not alike: Home health and community health nursing. Journal of Community Health Nursing, 6(2), 83-93. Habermas, J. (1987). The philosophical discourse of modernity. Cambridge: Polity Press.
391 Halbert, T. L., Underwood, J. E., Chambers, L. W., Ploeg, J., Johnson, N. A., & Isaacs, S. M. (1993). Population-based health promotion: A new agenda for public health nurses. Canadian Journal of Public Health, 84(4), 243-245. Hall, E., Lamont, L.,
Mackintosh, J., & St John, W. (1987). Adolescent parenting
education: The W.A. experience. The Australian Nurses Journal, 17(4), 52-55. Hamilton, P., & Bush, H. A. (1988). Theory development in community health nursing: Issues and recommendations. Scholarly Inquiry for Nursing Practice, 2(2), 145165. Hamilton, P. A., & Keyser, P. K. (1992). The relationship of ideology to developing community health nursing theory. Public Health Nursing, 9(3), 142-148. Hammersley, M., & Atkinson, P. (1983). Ethnography: Principles in practice. London: Tavistock. Hanchett, E. S. (1988). Nursing frameworks and community as client: Bridging the gap. Norwalk: Appleton & Lange. Hanchett, E. S. (1990). Nursing models and community as client. Nursing Science Quarterly, 3, 67-72. Hanchett, E. S., & Clarke, P. N. (1988). Nursing theory and public health science: Is synthesis possible? Public Health Nursing, 5(1), 2-6. Hardy, M. E. (1988). Perspectives on science. M. E. Hardy, & M. E. Conway (eds), Role theory: Perspectives for health professionals (2nd ed., pp. 1-27). Norwalk: Appleton & Lange. Haste, F. H., & MacDonald, L. D. (1992). The role of the specialist in community nursing: Perceptions of specialist and district nurses. International Journal of Nursing Studies, 29(1), 37-47. Health Department of Western Australia. (1987). The role of the community health nurse - with child health duties. [videorecording]. Perth: Health Department of Western Australia, Public Affairs Branch, Video Production Unit.
392 Health Targets and Implementation (Health for All) Committee. (1988). Health for all Australians. Report to the Australian Health Ministers' Advisory Council and the Australian Ministers' Conference. Canberra: Australian Government Publishing Service. Health Visitors' Association. (1987). Health visiting and school nursing reviewed. Health Visitors' Association. Hedin, B. (1986). Nursing, education, and emancipation: Applying the critical theoretical approach to nursing research. P. Chinn (ed), Nursing research methodology: Issues and implementation (pp. 133-146). Rockville, M.D.: Aspen Systems. Heidegger, M. (1962). Being and time. New York: Harper and Row. Heller, K. (1989). The return to community. American Journal of Community Psychology, 17, 1-15. Helvie, C., Hill, A., & Bambino, C. (1968). The setting and nursing practice. Nursing Outlook, 16(7), 27-29. Helvie, C. O. (1991). Community health nursing: Theory and practice. New York: Springer. Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York: Macmillan. Hervey, R. (1991). National health strategy: Making it better: Strategies for improving the effectiveness and quality of health services in Australia (Background paper No. 1). Melbourne: National Health Strategy Unit, Department of Health, Housing and Community Services. Hewitt, J. P. (1984). Self and society: A symbolic interactionist social psychology (3rd ed.). Boston: Allyn and Bacon. Hicks, R. (1981). Rum, regulation and riches: The evolution of the Australian health care system. Sydney: RT Kelly. Hickson, P., & Holmes, C. A. (1991). Nursing the postmodern body: A touching case. Nursing Inquiry, 1, 3-11.
393 Hill, L., & Smith, N. (1990). Self care nursing: Promotion of health (2nd ed.). Norwalk, Connecticut: Appleton & Lange. Hobbs, V. (1980). But Westward look. Perth: University of Western Australia Press, for the Royal Australian Nursing Federation (W. A. Branch). Hockey, L. (1995). Community health nursing in crisis? Changes in the health care system. Health and Social Care in the Community, 3(3), 193-197. Holman, D. (1991). Report of the special consultant on community and child health services: Executive overview and recommendations. Perth: Health Department of Western Australia. Holmes, C. (1991). Theory: Where are we going and what have we missed along the way? G. Gray, & R. Pratt (eds), Towards a discipline of nursing (pp. 435-460). Melbourne: Churchill Livingstone. Hope, J. (1990). The implementation of primary health care in Fiji and the role of the nurse. Conference Proceedings: Development and diversity: Primary health care. Sydney: The University of Sydney. Hudson-Rodd, N. (1994). Public health: People participating in the creation of healthy places. Public Health Nursing, 11(2), 119-126. Hunt, M. (1972). The dilemma of identity in health visiting. Occasional Papers, Nursing Times, 17-20, 23-24. Hunter, A., & Riger, S. (1986). The meaning of community in community mental health. Journal of Community Psychology, 14, 55-71. Husserl, E. (1928). Logische Untersuchungen. (4th ed). Halle, Germany: Neimeyer. English synopsis included in M. Sarber (1962).
The foundation of
phenomenology. New York: Paine Whitman. Igoe, J. B. (1991). Established and emerging roles in school nursing. K. A. Saucier (ed), Perspectives in family and community health (pp. 151-158). St Louis: Mosby. International Council of Nurses. (1969). Basic principles of nursing care. Geneva: International Council of Nurses.
394 International Council of Nurses. (1973). Code for nurses. Geneva: International Council of Nurses. International Council of Nurses, The Council of National Representatives. (1986). Nurses’ accountability for defining the nursing role. (Position statement). Geneva: International Council of Nurses. International Council of Nurses, The Council of National Representatives. (1989). Riga reaffirmation. (Position statement). Geneva: International Council of Nurses. Jackson, T. (1985). On the limitations of health promotion. Community Health Studies, 9(1), 1-9. Jackson, T., Mitchell, S., & Wright, M. (1989). The community development continuum. Community Health Studies, 13(1), 66-72. James, R., Henrikson, D., Steiner, C., & Golds, M. (1990). Case study: Disease prevention - new roles for nurses in rural Australia. Patient Education and Counselling, 16, 43-45. Johnson, D. E. (1980). The behavioural system model for nursing. J. P. Riehl, & C. Roy (eds), Conceptual models for nursing practice (2nd ed., pp. 207-216). New York: Appleton-Century-Crofts. Johnston, R. L. (1989). Orem's self-care model for nursing. J. J. Fitzpatrick, & A. L. Whall (eds), Conceptual models of nursing (2nd ed., pp. 165-184). Norwalk: Appleton & Lange. Jones, I. G., & Cameron, D. (1984). Social class: An embarrassment to epidemiology? Community Medicine, 6, 37-46. Jonkergouw, P. H., Kruyt, J. E., & Hanrahan, M. H. (1990). Community nursing in the Netherlands. International Nursing Review, 37(1), 211-213. Katz, F. M., Mathews, K., Pepe, T., & White, R. H. (1976). Stepping out: Nurses and their new roles. Sydney: New South Wales University Press.
395 Keegan, F., & Kent, D. (1992). Community health nursing. F. Baum, D. Fry, & I. Lennie (eds), Community health: Policy and practice in Australia (pp. 156-169). Leichhardt, N.S.W.: Pluto Press. Kelsey, A. (1995). Outcome measures: Problems and opportunities for public health nursing. Journal of Nursing Management, 3 (4), 183-187. Kent, D. (1989). Primary health care: Community participation. G. Gray, R. Pratt, & G. Clark (eds), Primary health care: A collection of papers (pp. 5-19). Melbourne: Australian Nursing Federation. Kenyon, V., Smith, E., Hefty, L. V., Bell, M. L., McNeil, J., & Martaus, T. (1990). Clinical competencies for community health nursing. Public Health Nursing, 7(1), 33-39. Kermode, S., Emmanuel, N., & Brown, C. (1994). A critical overview of current public policy trends and their implications for nursing. Collegian, 1(1), 14-23. Keyzer, D. M. (1994). Nursing management systems in the context of district nursing: The case of rural Australia. Journal of Nursing Management, 2(1), 2-14. Kickbusch, I. (1989). Approaches to an ecological base for public health. Health Promotion, 4(4), 265-268. King, I. M. (1971). Towards a theory for nursing. New York: John Wiley & Sons. Kingsley, E. (1994). Community development: The challenge of change. C. Cooney (ed), Primary health care: The way to the future (pp. 37-60). Sydney: Prentice Hall. Kramer, M. (1985). Why does reality shock continue? J. McCloskey, & H. KennedyGrace Current issues in nursing (2nd ed., ). Boston: Blackwell Scientific. Kreger, A. (1991). Remote area nursing practice: A question of education. Council of Remote Area Nurses of Australia. Kuehnert, P. (1991). The public health policy advocate: Fostering the health of communities. Clinical Nurse Specialist, 5(1), 5-10. Kupina, P. S. (1995). Community health CNSs and health care in the year 2000. Clinical Nurse Specialist, 9(4), 188-190.
396 Labonte, R. (1987). Community health promotion strategies. Health Promotion, 26(1), 210. Laffrey, S. C., & Page, G. (1989). Primary health care in public health nursing. Journal of Advanced Nursing, 14(2), 1044-1050. Larson, M. S. (1979). Professionalism: Rise and fall. International Journal of Health Services, 9(4), 607-627. Larson, M. S. (1990). In the matter of experts and professionals, or how impossible it is to leave nothing unsaid. R. Torstendahl, & M. Burrage (eds), The formation of professions: Knowledge, state and strategy (pp. 25-50). London: Sage. Lauri, S., & Salanterä, S. (1995). Decision-making models of Finnish nurses and public health nurses. Journal of Advanced Nursing, 21(3), 520-527. Lawler, J. (1991a). In search of an Australian identity. G. Gray, & R. Pratt (eds), Towards a discipline of nursing (pp. 211-227). Melbourne: Churchill Livingstone. Lawler, J. (1991b). Behind the screens: Nursing, somology and the problem of the body. Melbourne: Churchill Livingstone. Legge, D. G., McDonald, D. N., & Benger, C. (1992). Improving Australia's Health: The role of primary health care. Canberra: National Centre for Epidemiology and Population Health, The Australian National University. Leininger, M. M. (1991). The theory of culture care diversity and universality. M. M. Leininger (ed), Culture care diversity and universality: A theory of nursing (pp. 568). New York: National League for Nursing. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverley Hills, California: Sage. Litwin, J. (1992). Regionalisation and the community nurse. The Queensland Nurse, 11(4), 22-23. Luker, K. A., & Chalmers, K. I. (1989). The referral process in health visiting. International Journal of Nursing Studies, 26(2), 173-185.
397 Luker, K. A., & Chalmers, K. I. (1990). Gaining access to clients: The case of health visiting. Journal of Advanced Nursing, 15(1), 74-82. Lundh, U., Söder, M., & Waerness, K. (1988). Nursing theories: A critical view. IMAGE: Journal of Nursing Scholarship, 20(1), 36-40. Macklin, J. (1990). The national health strategy: Setting the agenda for change (Background paper No. 1). Melbourne: National Health Strategy Unit, Department of Community Services and Health. MacPherson, K. I. (1983). Feminist methods: A new paradigm for nursing research. Advances in Nursing Science, 5(2), 17-25. Mahler, H. (1981). The meaning of "health for all by the year 2000". World Health Forum, 2(1), 5-22. Mahler, H. (1985). Nurses lead the way: Health for all through primary health care. World Health, 97, 28-29. Malcolm, L. (1993). Towards health for all and health promotion: The evaluation of the National Better Health Program. Canberra: Commonwealth Department of Health, Housing and Community Services. Manis, J. G., & Meltzer, B. N. (1978). Symbolic interaction. Boston: Allyn and Bacon. Manning, I., Parker, J., & Kendig, H. (1991). National nurse labour market study. Canberra: Australian Government Publishing Service. Marles, F. (1989). The politics of nursing in Victoria in 1987. Geelong: Deakin University Press. Martin, K. S., & Scheet, N. J. (1992). The Omaha system: Applications for community health nursing. Philadelphia: Saunders. Mason, C. (1995). Towards public health nursing. D. Sines (ed), Community health care nursing (pp. 155-175). Oxford: Blackwell Science. Mason, D. J., Knight, K., Toughill, E., DeMaio, D., Beck, T. L., & Christopher, M. A. (1992). Promoting the community health clinical nurse specialist. Clinical Nurse Specialist, 6(1), 6-13.
398 Maternal and Child Health Nurses Special Interest Group. (1993). Standards for practice for maternal and child health nurses. Northcote: Parchment Press. Matuk, L. C. K. Y., & Horsburgh, M. E. C. (1989). Rebuilding public health nursing practice: A Canadian perspective. Public Health Nursing, 6(4), 169-173. May, K. A. (1986). Writing and evaluating the grounded theory research report. W. C. Chenitz, & J. M. Swanson (eds), From practice to grounded theory (pp. 145-154). Menlo Park, California: Addison-Wesley. Maynard, A. (1991). The relevance of health economics to health promotion. H. Badura, & I. Kickbusch (eds), Health promotion research: Towards a new social epidemiology (pp. 29-54). Copenhagen: World Health Organization, Regional Office for Europe. McClelland, A., Pirkis, J., & Wilcox, S. (1992). Enough to make you sick: How income and environment affect health (National Health Strategy research paper No. 1). Canberra: Ministry of Health, Housing and Community Services. McCoppin, B., & Gardner, H. (1994). Tradition and reality: Nursing and politics in Australia. Melbourne: Churchill Livingstone. McDaniels, L. A., & Hanchett, E. S. (1988). Turning point: A community response to spouse abuse. E. S. Hanchett (ed), Nursing frameworks and community as client (pp. 73-78). Norwalk, Connecticut: Appleton & Lange. McDermott, M. A., & Burke, J. (1993). When the population is a congregation: The emerging role of the parish nurse. Journal of Community Health Nursing, 10(3), 179-190. McKeown, T. (1976). The role of medicine: Dream, mirage or nemesis. London: Nuffield Provincial Hospitals Trust. McMichael, A. J. (1985). Social class and mortality in Australian males in the 1970s. Community Health Studies, 9(3), 220-230. McMillan, D. W., & Chavis, D. M. (1986). Sense of community: A definition and theory. Journal of Community Psychology, 14, 6-23.
399 McMurray, A. (1984). Task performance requirements of the community health nurse: Implications for curriculum development. Unpublished M. Ed dissertation, The University of Western Australia, Perth. McMurray, A. (1991). Expertise in community health nursing. Unpublished doctoral dissertation, University of Western Australia, Perth. McMurray, A. (1992). Expertise in community health nursing. Journal of Community Health Nursing, 9(2), 65-75. McMurray, A. (1993). Community health nursing: Primary health care in practice (2nd ed.). Melbourne: Churchill Livingstone. Mead, G. H. (1934). Mind, self and society. Chicago: University of Chicago Press. Meleis, A. I. (1991). Theoretical nursing: Development and progress (2nd ed.). New York: Lippincott. Meltzer, B. N. (1978). Mead's social psychology. J. G. Manis, & B. N. Meltzer (editors), Symbolic interaction: A reader in social psychology. Boston: Allyn and Bacon. Miles, M., & Huberman, M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, California: Sage. Milio, N. (1988). Making policy: A mosaic of Australian community health policy development. Canberra: Commonwealth Department of Community Services and Health. Miller, J., Dolan, G., & Boswarva, P. (1995). HIV/AIDS and the nurse practitioner. G. Gray, & R. Pratt (eds), Issues in Australian nursing 5 (pp. 251-264). Melbourne: Churchill Livingstone. Minichiello, V. (1995). Community care: Economic policy dressed as social concern? H. Gardner (ed), The politics of health: The Australian experience (2nd ed., pp. 453482). Melbourne: Churchill Livingstone. Minichiello, V., Aroni, R., Timewell, E., & Alexander, A. (1995). In-depth interviewing (2nd ed.). Melbourne: Longman.
400 Mischke-Berkey, K., Warner, P., & Hanson, S. (1989). Family health assessment and intervention. P. J. Bomar (ed), Nurses and family health promotion (pp. 115-154). Baltimore: Williams & Wilkins. Moloney, M. (1986). Professionalization of nursing: Current issues and trends. Philadelphia: Lippincott. Monteiro, L. A. (1985). Florence Nightingale on public health nursing. American Journal of Public Health, 75(2), 181-186. Morse, J. M., & Field, P. A. (1995). Qualitative research methods for health professionals (2nd ed.). Thousand Oaks: Sage. Munhall, P. L. (1993). Epistemology in nursing. P. L. Munhall, & C. Oiler Boyd (eds), Nursing research: A qualitative perspective (pp. 39-65). New York: National League for Nursing Press. Munoz, E., & Mann, M. (1982). Nursing in the outback: A survey of training needs. Australian Nurses Journal, 11(10), 38-39. Murfin, M. (1993). Promoting the role of health visitors to general practice staff. Health Visitor, 66(5), 177. Naconaco, V. N., & Stark, R. D. (1986). The development of a family nurse practitioner program in Botswana. International Nursing Review, 33(21), 9-14. National Aboriginal Health Strategy Working Party. (1989). A national Aboriginal health strategy. Canberra: Aboriginal and Torres Strait Islander Commission. National Centre for Epidemiology and Population Health. (1991). Improving Australia's health: The role of primary health care. Final report of the review of the role of primary health care in health promotion in Australia (Primary Health Care Series, Sub-set No. 1). Canberra: Commonwealth Department of Health, Housing and Community Services. National Health and Medical Research Council. (1983). The role of the nurse in Australia. Canberra: National Health and Medical Research Council.
401 National Health and Medical Research Council, Australian Health Ethics Committee. (1995). Ethical aspects of qualitative methods in health research. Canberra: National Health and Medical Research Council. National Hospitals' and Health Services' Commission. (1973). A community health program for Australia. Canberra: Australian Government Publishing Service. Neuman, B. (1989). The Neuman systems model (2nd ed.). Norwalk: Appleton & Lange. Nicolaisen, D. M., Gates, M. F., & Hanchett, E. S. (1988). Community competence in Elm City. E. S. Hanchett (ed), Nursing frameworks and community as client: Bridging the gap (pp. 41-48). Norwalk, CT: Appleton & Lange. Nightingale, F. (1859). Notes on nursing: What it is and what it is not. London: Harrison. Novak, J. C. (1988). The social mandate and historical basis for nursing's role in health promotion. Journal of Professional Nursing, 4(2), 80-87. Nurse Practitioner Project Steering Committee. (April, 1996). Nurse Practitioner Project: Stage 3: Final Report. Sydney: New South Wales Department of Health. Nurses Education Board of New South Wales. (1976). The functions of a registered nurse. Sydney: Government Printer. Nursing Development Conference Group. (1979). Concept formalization in nursing: Process and product. Boston: Little, Brown. Nursing Research Group, Victoria. (16-19 March, 1989). Workshop: Research issues, priorities and strategies. Nursing inputs - research outputs. Melbourne: Nursing Research Group. Nutbeam, D., Wise, M., Bauman, A., Harris, E., & Leeder, S. (1993). Goals and targets for Australia's health in the year 2000 and beyond. Report prepared for the Commonwealth Department of Health, Housing & Community Service. Sydney: University of Sydney, Department of Public Health. O'Connor, M. M. (1995). A better way: Home-based care of the dying. G. Gray, & R. Pratt (eds), Issues in Australian nursing 5 (pp. 195-208). Melbourne: Churchill Livingstone.
402 Orem, D. E. (1983a). The family coping with a medical illness: Analysis and application of Orem's theory. I. W. Clements, & F. B. Roberts (eds), Family health: A theoretical approach to nursing care (pp. 385-386). New York: John Wiley & Sons. Orem, D. E. (1983b). The family experiencing emotional crisis: Analysis and application of Orem's self-care deficit theory. I. W. Clements, & F. B. Roberts (eds), Family health: A theoretical approach to nursing care (pp. 367-368). New York: John Wiley & Sons. Orem, D. E. (1987). Orem's general theory of nursing. R. R. Parse (ed), Nursing science: Major paradigms, theories, and critiques (pp. 67-89). Philadelphia: W. B. Saunders. Orem, D. E. (1991). Nursing: Concepts of practice (4th ed.). St Louis: Mosby. Orem, D. E. (1995). Nursing: Concepts of practice (5th ed.). St Louis: Mosby. Orem, D. E., & Taylor, S. G. (1986). Orem's general theory of nursing. P. Winstead-Fry (ed), Case studies in nursing theory (pp. 37-71). New York: National League for Nursing. Owens, H. (1995). Paying for health care through casemix. H. Gardner (ed), The politics of health: The Australian experience (2nd ed., pp. 284-305). Melbourne: Churchill Livingstone. Palmer, G. R., & Short, S. D. (1994). Health care and public policy: An Australian analysis (2nd ed.). Melbourne: Macmillan Education Australia. Parrish, R. S., & Allred, R. H. (1995). Theories and trends in occupational health nursing. AAOHN Journal, 43(10), 514-521. Parsons, M. A., & Felton, G. M. (1992). Role performance and job satisfaction of school nurses. Western Journal of Nursing Research, 14(4), 498-511. Peckham, S., & Spanton, J. (1994). Community development approaches to health needs assessment. Health Visitor, 67(4), 124-125.
403 Pender, N. J., & Pender, A. R. (1987). Health promotion in nursing practice (2nd ed.). Norwalk: Appleton & Lange. Perry, G. (1989). Primary health care delivery by public health nurses in the Aboriginal health program. G. Gray, R. Pratt, & G. Clark (eds), Primary health care: A collection of papers (pp. 60-71). Melbourne: Australian Nursing Federation. Pfaffenberger, B. (1988). Microcomputer applications in qualitative research (Qualitative Research Methods No. 14). Newbury Park: Sage. Polanyi, M. (1962). Personal knowledge: Towards a post-critical philosophy. Chicago: University of Chicago Press. Polanyi, M. (1966). The tacit dimension. New York: Doubleday. Pratt, R. (1994). The challenge of specialisation: The Australian experience. Collegian, 1(1), 6-13. Prenesti, S., & Tattam, A. (1994). Pressure and change in community nursing. Australian Nurses Journal, 2(4), 12. Public Health Association Steering Committee. (1990). Workforce issues for public health: The Report of the Public Health Workforce Study 1990. Canberra: Public Health Association of Australia. Punch, M. (1986). The politics and ethics of fieldwork (Qualitative research methods series No. 3). Newbury Park: Sage. Purcival, E. C. (1995). Achieving national standards for the regulation of nursing. G. Gray, & R. Pratt (eds), Issues in Australian Nursing 4 (pp. 11-28). Melbourne: Churchill Livingstone. Qualitative Solutions and Research. (1994). QSR NUD*IST (Application software package). Melbourne: Qualitative Solutions and Research. Queensland Health. (1994). Primary health care (Policy Document No. 3). Brisbane: Australian Government Publishing Service. Queensland Health, South East Coast Region. (1995). Standards of practice: Community nursing, South East Coast Region. Southport: Queensland Health.
404 Queensland Nursing Council. (1995). Scope of nursing practice: Discussion paper. Brisbane: Queensland Nursing Council. Ramsey, A. H. (1970). Report of the Committee of Inquiry into Nursing in Victoria. Melbourne: Government Printer. Reed, K. S. (1989). Family theory related to the Neuman systems model. B. Neuman (ed), The Neuman systems model (2nd ed., pp. 385-395). Norwalk, Connecticut: Appleton & Lange. Reed, P. G., & Leonard, V. E. (1989). An analysis of the concept of self-neglect. Advances in Nursing Science, 12(1), 39-53. Reiger, K. (1986). Mothering deskilled?: Australian childrearing and the 'experts'. Community Health Studies, 10(1), 39-46. Richards, L., & Richards, T. (1994). From filing cabinet to computer. A. Bryman, & R. G. Burgess (eds), Analyzing qualitative data (pp. 146-172). London: Routledge. Riner, M. B. (1989). Expanding services: The role of the community health nurse and the advanced nurse practitioner. Journal of Community Health Nursing, 6(4), 223230. Roberts, H. (1981). Doing feminist research. London: Routledge & Kegan Paul. Robinson, D., Mead, M. J., & Boswell, C. R. (1995). Inside looking out: Innovations in community health nursing. Clinical Nurse Specialist, 9(4), 227-235. Robinson, K. (1992). Knowledge and practice of working in the community. K. Luker, & J. Orr (eds), Health visiting: Towards community health nursing (pp. 16-42). Oxford: Blackwell Scientific Publications. Robinson, M. A. (1990). The role of the nurse in Australia. National Health and Medical Research Council. Rogers, M. (1970). An introduction to the theoretical basis of nursing. Philadelphia: F. A. Davis. Rorden, J. W., & McLennan, J. (1992). Community health nursing: Theory and practice. Sydney: Saunders Baillière Tindall.
405 Rosenbaum, J. N. (1989). Self-caring: Concept development for nursing. Recent Advances in Nursing, 24, 18-31. Rosenstock, I. (1974). Historical origins of the health belief model. M. H. Becker (ed), The health belief model and personal health behaviour (pp. 1-8). Thorofare, NJ: Charles B. Slack Inc. Roth, J. A. (1974). Professionalism: The sociologist's decoy. Sociology of Work and Occupations, 1(1), 6-23. Rothman, N. L. (1991). Towards description: Public health nursing and community health nursing are different. Nursing & Health Care, 11(9), 481-483. Round, R., & Sellick, K. (1984). How community health team members perceive the role of the community health nurse. The Australian Journal of Advanced Nursing, 1(3), 37-44. Roy, C. (1984). An introduction to nursing: An adaptation model (2nd ed.). Eaglewood Cliffs, New Jersey: Prentice-Hall. Royal Australian Nursing Federation. (1983). Standards for nursing practice. Melbourne: Royal Australian Nursing Federation. Royal Australian Nursing Federation, South Australian Branch. (1983). Policy statement No. 12: The role of the registered and enrolled nurse in any practice setting. The Australian Nurses Journal, 13(4), 101. Royal College of Nursing, Australia. (1995). Clinical pathways and nursing practice in Australia (Discussion paper No. 4). Canberra: Royal College of Nursing, Australia. Royal College of Nursing, Australia. (1994). Primary health care (Position statement). Canberra: Royal College of Nursing, Australia. Royal College of Nursing, Australia, Australian Nursing Federation, Florence Nightingale Committee, Australia, & New South Wales College of Nursing. (1992). Nursing research targets into the twenty-first century: A national statement. Australian Nurses Journal, 22(4), 19-22.
406 Russell, R. L. (1991). Are we asking the right questions? G. Gray, & R. Pratt (eds), Towards a discipline of nursing (pp. 73-93). Melbourne: Churchill Livingstone. Saint, E. (1971). Report of the Committee of Inquiry in to Nursing: Nursing in Queensland. Brisbane: Royal Australian Nursing Federation. Saucier, K. A. (1991). Perspectives in family and community health. St Louis: Mosby. Sawyer, L. M. (1995). Community participation: Lip service? Nursing Outlook, 43(1), 17-22. Sax, S. (1990). Health care choices and the public purse. Sydney: Allen & Unwin. Schlotfeldt, R. M. (1986). Defining nursing: A historic controversy. Nursing Research, 36(1), 64-67. Schön, D. (1992). The crisis of professional knowledge and the pursuit of an epistemology of practice. Journal of Interprofessional Care, 6(1), 49-63. Schulte, J. A. (1992). Finding ways to create connections among communities: An ethnography of urban public health nurses. Unpublished doctoral dissertation, University of Colorado. Schultz, B. (1991). A tapestry of service: The evolution of nursing in Australia. Volume 1: Foundation to Federation 1788-1900. Melbourne: Churchill Livingstone. Schwandt, T. A. (1994). Constructivist, interpretivist approaches to human inquiry. N. K. Denzin, & Y. S. Lincoln (eds), Handbook of qualitative research (pp. 118-137). Thousand Oaks: Sage. Shanteau, J. (1988). Psychological characteristics and strategies of expert decision makers. Acta Psychologica, 68, 203-215. Shaw, A. (1991). What's happened to the public health nurse? New Zealand Nursing Journal, 84(4), 16-17. Shortridge, L., & Valanis, B. (1992). The epidemiological model applied in community health nursing. M. Stanhope, & J. Lancaster (eds), Community health nursing, Process and practice for promoting health (3rd ed., pp. 151-170). St Louis: Mosby.
407 Sills, G. M., & Goeppinger, J. (1985). The community as a field of inquiry in nursing. Annual Review of Nursing Research, 3 , 4-23. Silver, M. (1986). A program for career structure: A vision becomes reality. Australian Nurses Journal, 16(2), 44-47. Smith, G. R. (1989). Using the public agenda to shape PHN practice. Nursing Outlook, 37(2), 72-75. Smith, J. (1995). Public health and local government. H. Gardner (ed), The politics of health: The Australian experience (2nd ed., pp. 306-322). Melbourne: Churchill Livingstone. Speedy, S. (1989). Theory-practice debate: Setting the scene. The Australian Journal of Advanced Nursing, 6(3), 13-20. Spradley, B. W. (1990). Community health nursing: concepts and practice (3rd ed.). Glenview, Illinois: Scott, Foresman/Little, Brown Higher Education. Sproull, L. S., & Sproull, R. F. (1982). Managing and analyzing behavioral records: Explorations in nonnumeric data analysis. Human Organization, 41, 283-290. St John, W. (1991). An investigation of the views of practicing community health nurses regarding the educational preparation of nurses for practice in primary health care. Unpublished MNS dissertation, La Trobe University, Melbourne, Australia. St John, W. (1993). Primary health care: A clarification of the concept and the role of the nurse. Contemporary Nurse, 2(2), 73-78. St John, W. (1994). Community health nursing: Development or diagnosis? Nursing diagnosis: Nexus or nonsense? 2nd National Nursing Diagnosis Conference Perth: Curtin University. Steering Committee of the Community Development in Health Project. (1988). Resources collection: Community development in health. Melbourne: Preston and Northcote District Health Council. Steiger, N. J., & Lipson, J. G. (1985). Self-care nursing: Theory and practice. Bowie, Maryland: Brady Communications.
408 Stern, P. N. (1994). Eroding grounded theory. J. M. Morse (editor), Critical issues in qualitative research methods (pp. 212-223). Thousand Oaks: Sage. Strauss, A. L. (1987). Qualitative analysis for social scientists. Cambridge: Cambridge University Press. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park: Sage. Street, A. (1990). Nursing practice: High hard ground, messy swamps and pathways in between. Geelong: Deakin University Press. Stuart, M. (1992). "Half a loaf is better than no bread": Public health nurses and physicians in Ontario, 1920 - 1925. Nursing Research, 41(1), 21-27. Swanson, J. M. (1988). Health-care delivery in Cuba: Nursing's role in achievement of the goal of 'health for all'. International Journal of Nursing Studies, 25(1), 11-21. Swanson, J. M., & Albrecht, M. (1993). Community health nursing: Promoting the health of aggregates. Philadelphia: Saunders. Symonds, A. (1991). Angels and interfering busybodies: The social construction of two occupations. Sociology of Health and Illness, 13(2), 249-264. Tadych, R. (1985). Nursing in multiperson units: The family. J. Reihl-Sisca (ed), The art and science of self-care (pp. 49-55). Norwalk, CT: Appleton-Century-Crofts. Tansey, E. M., & Lentz, J. R. (1988). Generalists in a specialized profession. Nursing Outlook, 36(4), 174-178. Tattam, A. (1995). All things to all people. Australian Nurses Journal, 2(6), 26-27. Taylor, S. G., & McLaughlin, K. (1991). Orem's general theory of nursing and community nursing. Nursing Science Quarterly, 4, 153-160. Taylor, S. G., & Renpenning, K. M. (1995). The practice of nursing in multiperson situations, family and community. D. E. Orem (ed), Nursing: Concepts of practice (5th ed., pp. 348-379). St Louis: Mosby.
409 Temple-Smith, M. J., Johnson, K. A., & Dunt, D. R. (1989). Nursing outside hospitals: The working experience of community nurses. Educational characteristics and job perceptions. Community Health Studies, 13(3), 306-315. Thompson, B. H., Sutton, B. B., Lund, B., Stevens, L., Nolan, P., & Bernard, G. (1982). Some aspects of nursing from a community basis in W.A. The Australian Nurses Journal, 12(3), 45-48. Thornton, B. (1992). The remote area nurse: Problems preparing for the role. Australian Nurses Journal, 21(6), 10. Thyer, S. (1996). The 'health promoting schools' strategy: Implications for nursing and allied health professionals. Collegian: Journal of the Royal College of Nursing Australia, 3(2), 13-23. Townsend, J. (1994). Pro-active practice: A sustainable resource for nursing. M. McMillan, & J. Townsend (eds), Reflections on contemporary nursing practice (pp. 270-282). Sydney: Butterworth-Heinemann. Traynor, M. (1993). Health visitors' perceptions of their role. Health Visitor, 66(1), 1416. Trnobranski, P. H. (1994). Nurse practitioner: Redefining the role of the community nurse? Journal of Advanced Nursing, 19(1), 134-139. Turner, J. G., & Chavigny, K. H. (1988). Community health nursing: An epidemiologic perspective through the nursing process. Philadelphia: J. B. Lippincott. Twinn, S. (1993). Principles in practice: A re-affirmation. Health Visitor, 66(9), 319-321. Twinn, S. F. (1991). Conflicting paradigms of health visiting: A continuing debate for professional practice. Journal of Advanced Nursing, 16, 966-973. Underwood, E. J., Woodcox, V., Van Berkel, C., Black, M., & Ploeg, J. (1991). Organizing public health nursing for the 1990s: Generalist or specialist. Canadian Journal of Public Health, 82(4), 245-248.
410 United States Department of Health and Human Services. (1985). Consensus conference on the essentials of public health nursing practice and education. Rockville, MD: U.S. Department of Health and Human Services, Bureau of Health Professionals, Division of Nursing. Vongleang, P. (1993). Roles and Responsibilities of School Nurses in Benton, Clackamas, Lane, Linn, and Marion Counties, Oregon. Unpublished doctoral dissertation, Oregon State University, Oregon. Wake, M. M., Murphy, M., Affara, F. A., Lang, N. M., Clark, J., & Mortensen, R. (1993). Toward an international classification for nursing practice: A literature review and survey. International Nursing Review, 40(3), 77-80. Ward, D. (1989). Public health nursing and ‘The future of public health’. Public Health Nursing, 6(4), 163-168. Waterhouse, R. (1981). A critique of Heidegger's philosophy. Brighton: Harvester Press. Watson, J. (1979). Nursing: The philosophy and science of caring. Boston: Little, Brown. Watts, R. (1994). Community participation. C. Cooney ( ed), Primary health care: The way to the future (pp. 61-72). Sydney: Prentice Hall. Werner, O., & Schoepfle, G. M. (1987). Systematic fieldwork: Foundations of ethnography and interviewing. Newbury Park, California: Sage. West, M. (1989). Prescriptions for health visiting. Health Visitor, 62(12), 378-381. Whall, A. L., & Fawcett, J. (1991). Family theory development in nursing. Philadelphia: F. A. Davis. White, M. S. (1982). Construct for public health nursing: Where it is practiced, in whose behalf and with what desired outcome. Nursing Outlook, 30(9), 527-530. Whittaker, Y. (1974). The community health nurse. Australian Nurses' Journal, 3(8), 3538. Whyte, N., & Little, S. (1992). New directions for health care: A Canadian perspective. Primary health care: Development and diversity: An international conference. Sydney: The University of Sydney.
411 Williams, C. A. (1977). Community health nursing - what is it? Nursing Outlook, 25, 250-254. Williams, C. A. (1992). Community-based population-focused practice: The foundation of specialization in public health nursing. M. Stanhope, & J. Lancaster (editors), Community health nursing: Process and practice for promoting health (3rd ed., pp. 244-252). St Louis: Mosby. Williams, K. (1991). Hearing in Aboriginal children: Its relation to primary health care. Development and diversity: Remote and rural primary care: 2nd Annual primary health care conference. Sydney: The University of Sydney. Williams, L. (1989). Report of the research project to develop role statements for nurses. Brisbane: Board of Nursing Studies. Wilson, D. A. J., & Najman, J. M. (1982). After Nightingale: A preliminary report of work undertaken by nurses in Queensland. The Australian Nurses Journal, 12(4), 31-36. Wood, P. (1990). Nursing: Progress through partnership 1921-1991. Canberra: Australian Government Publishing Service. World Health Organization. (1947). Constitution of the World Health Organization. Chronicle of the World Health Organization, 1. World Health Organization. (1948). Constitution of the World Health Organisation. Geneva: World Health Organisation. World Health Organization. (1981). Global strategy for health for all by the year 2000. Geneva: World Health Organization. World Health Organization. (1986). Targets for Health for All: Implications for nursing/midwifery. Geneva: World Health Organization. World Health Organization. (1994). Nursing beyond the year 2000 (WHO Technical Report Series No. 842). Geneva: World Health Organization.
412 World Health Organization, Expert Committee on Community Health Nursing. (1974). Community health nursing: Report of a WHO expert committee (Technical Report Series No. 558). Geneva: World Health Organisation. World Health Organization, Health and Welfare Canada, & CPHA. (1986). Ottawa Charter for Health Promotion: International Conference on Health Promotion, November 7 - 21, Ottawa, Canada. Canadian Journal of Public Health, 77(12), 425-430. World Health Organization, & United Nations Children's Fund. (1978). Primary health care: Report of the International Conference on Primary Health Care (Health for all series No. 1). Geneva: World Health Organization. Ying, L. J., & Davis, A. J. (1985). Health care and nursing in the People's Republic of China. Journal of Advanced Nursing, 10, 279-284. Yura, H., & Walsh, M. (1967). The nursing process. New York: Appleton-CenturyCrofts. Zerwekh, J. V. (1991). A family caregiving model for public health nursing. Nursing Outlook, 39(5), 213-217.
