Tensions in the personal world of the nurse family carer: A phenomenological approach.

The incidence of chronic illness is growing globally. As a result, there are fiscal and social implications for health delivery. Alongside the increased burden on health resources is the expectation that someone within the family will assume the responsibility of carer for those who are chronically ill. The expectation to assume the role of carer may be amplified for family members who are also nurses. Currently, there is little research that investigates the impact of nurses who are carers for family with a chronic illness. Consequently, this qualitative study, based on face-to-face and telephone dialogue, was conducted using unstructured interviews. A phenomenological-hermeneutic approach utilizing the hermeneutic circle was employed to understand the meaning of the transcriptions. Hermeneutic phenomenology inspired by Heideggerian philosophy was used as a framework to clarify themes and build ways of understanding the phenomenon of 'Being' a nurse and a family carer. Themes identified in the analysis of the study included a personal world, a professional world and a practical world. This paper explicates the findings from examination of the personal world of 'Being' a nurse who is also a family carer. Analysis revealed there were three facets to this way of 'Being': a shared experience, a caring experience and a fraught experience. The findings of the study disclosed that participants were informed by experiences that were both enriching and conflicting. These insights can enlighten healthcare professionals to the tensions which exist for nurses who care for family so that these considerations are incorporated into individualized and effective family-centred care.

Miscarriage in Australia: The geographical inequity of healthcare services.

Complications in early pregnancy can lead to pregnancy loss (miscarriage) and ultimately the presentation of a woman to their local emergency department (ED). Miscarriage is a common occurrence, with one in six pregnancies resulting in pregnancy loss.(1) Unfortunately medical and nursing care does not change the likelihood of a threatened miscarriage progressing to pregnancy loss; this is a highly emotional and stressful time for the woman and her family. Research has shown that women have often felt dissatisfied with the care provided in the emergency department and have reported lower levels of satisfaction (Geller et al., 2010(2), Indig et al., 2011(3)). This paper explores the challenges in the provision of emergency department healthcare for women presenting to metropolitan EDs and compares these to those faced by women who present to non-metropolitan EDs with early pregnancy complications.

The accreditation of nursing education in Australia.

This paper aims to explore and discuss the role that ANMAC and the accreditation standards play in pre-registration nursing education nationally. The context of the discussion is situated in the continuum of events that mark the accreditation of nursing education in Australia. The National Registration and Accreditation Scheme has given rise to significant challenges related to the accreditation of nursing programs of education in Australia. Given the importance of accreditation to the quality of nursing education, ANMAC in its appointed role as accrediting authority, must fill the position rather than occupy it. Enhancing transparency and effectiveness is central to ensuring accreditation facilitates quality in nursing education. Given ANMAC's key position, further work is needed in developing a broad base of expertise by fostering scholarly output in the substantive area of nursing accreditation. There is a concerning lack of research centred on the accreditation of programs of nursing education along with the processes associated with it. This problem is not restricted to the Australian context but also extends internationally. In this context, the expertise of accreditors ought to be questioned along with the processes ANMAC use to identify individual capability. As such, the selection of experts needs to be articulated clearly by ANMAC along with the ownership of introducing a research culture into accreditation.

Peeling the onion: understanding others' lived experience.

Society and some healthcare professionals often marginalise pregnant women who take illicit substances. Midwives who care for these women are often viewed as working on the edge of society. This research aimed to examine the lived experiences of midwives who care for pregnant women who take illicit drugs. A phenomenological study informed by Heidegger, Gadamer and Merleau-Ponty was chosen to frame these lived experiences. Using face-to-face interviews, data were collected from 12 midwives making a difference, establishing partnerships and letting go and refining practice. Lived experiences are unique and can be difficult, intangible and couched in metaphor and difficult to grasp. This paper aims to discuss lived experience and suggests that like an onion, several layers have to be peeled away before meaning can be exposed; each cover reveals another layer beneath that is different from before and different from the next. The study provides exemplars that explain lived experiences.

Role clarity and clinical governance: keeping irish hospitals efficient and effective.

The notion of role clarity, and its impact on clinical governance, has not been previously considered within academic literature. The purpose of this research article was to add to theoretical knowledge surrounding the clinical governance and the effect that role clarity has on governance operationally. The context of Irish health care and Irish hospital boards is used to explore this phenomenon. A mixed-methods approach was used to appreciate the central phenomenon. The doctoral dissertation this article was drawn from identified that the adoption of similar or consistent structures and processes between Irish acute care hospitals would aid efficiencies, both human and cost, on multiple levels. Ultimately, the article concludes that role clarity is a significant component in the determination of effective health care. Hospital boards and their individual members should be cognizant of the implications of role clarity and its impact on effective and efficient clinical governance.

Midwives experiences of establishing partnerships: working with pregnant women who use illicit drugs.

OBJECTIVE: To present the interpreted experiences of midwives who choose to work with pregnant women who also use illicit drugs. DESIGN: Twelve (n=12) Australian midwives were interviewed. Each interview was audio-taped, de-identified and transcribed. The interviews were analysed using a systematic, thematic analysis approach informed by Heideggarian hermeneutic phenomenology. FINDINGS: Three themes identified from the data that encapsulate the experience were establishing partnerships, making a difference, and letting go and redefining practice. The interpretations of establishing partnerships which includes engagement, genuine regard and compassion, with a subtheme courting the system are presented in this paper. The midwives' experiences were both positive and negative, as they were rewarded and challenged by the needs of women who use illicit drugs and the systems in which they worked. CONCLUSION: The midwives in this study found that establishing partnerships was essential to their work. They appraised their experience of working with pregnant women who used illicit drugs and found strategies that attempted to meet the needs of the women, the system and themselves. The participants revealed that to support women and families who use illicit drugs in their community, partnerships must be based on deep respect and trust. Significant components engagement, genuine regard and compassion that are central to midwifery partnerships require revisiting to address the needs of this vulnerable population of women.

Self-management activities in diabetes care: a systematic review.

OBJECTIVE: To identify the range of self-management activities people diagnosed with diabetes engage in to manage their disease, the frequency of use, and whether self-management practices change over time. METHODS: A systematic review of the literature was undertaken. Thirty-two studies identified through electronic databases met the inclusion criteria and were included in the review. RESULTS: The study found that people living with diabetes undertake regular self-management activities and that compliance with medication regimes is high. Adherence, however, varied with respect to blood glucose testing, diet, physical activity and foot care. Levels of physical activity were not found to change over time. Evidence suggests that some people with diabetes modify their self-management practices in response to factors such as holidays. CONCLUSIONS: The review suggests that the majority of people with diabetes self-manage, although there is variation in adherence to key self-management activities. How self-management practices change over time and whether this impacts on health outcomes is an area for future research.

Hermeneutic phenomenology: a methodology of choice for midwives.

Hermeneutic phenomenology has been used widely by researchers to understand lived experiences. This methodology asserts that individual people are as unique as their life stories. The practice of midwifery is underpinned by a philosophy that values women and the uniqueness of their child-bearing journey. The tenets of hermeneutics phenomenology align with those of contemporary midwifery practice, making it a useful research methodology for providing insights into issues relevant to the profession. The purpose of this paper is to unravel some foundational concepts of hermeneutic phenomenology and recommend it as a methodology of choice for midwives to apply to their application to midwifery-in-action.

Exploring Heideggerian hermeneutic phenomenology: a perfect fit for midwifery research.

BACKGROUND: Heideggerian hermeneutic phenomenology has been used widely to understand the meaning of lived experiences in health research. For midwifery scholars this approach enables deep understanding of women's and midwives' lived experiences of specific phenomena. However, for beginning researchers this is not a methodology for the faint hearted. It requires a period of deep immersion to come to terms with at times impenetrable language and perplexing concepts. OBJECTIVES: This paper aims to assist midwives to untangle and examine some of the choices they face when they first come to terms with an understanding of this methodology and highlights the methodology's capacity to reveal midwifery authenticity and holistic practice. DISCUSSION: The illumination of a selection of various concepts underpinning hermeneutic phenomenology will inform midwives considering this methodology as suitable framework for exploring contemporary midwifery phenomena.

From EN to BN to RN: an exploration and analysis of the literature.

The nursing profession has experienced significant change over the last 100 years. Consequently, the workforce of the 21st century is a diverse entity that is edging toward the specialization of nurses in a specific clinical setting. In such an environment, a common knowledge base is demanded of nurses - a factor that has affected the development of second level, or enrolled nurses (ENs). The forces at play raise questions about nursing roles and scopes of practice. The establishment of education pathways that promote career development has been the stimulus for conversations about the effectiveness of the transition of EN to registered nurse (RN). This paper presents a review of the literature that identifies and explores common emerging themes (making the move from EN; adapting to Bachelor of Nursing; transitioning to RN) associated with this transition through the process of undertaking baccalaureate studies in nursing.

The impact of nursing leadership and management on the control of HIV/AIDS: an ethnographic study.

This paper reports on an aspect of a larger ethnographic study that sought to investigate the impact of HIV/AIDS on the practice of primary care nurses in Jordan. Nursing leadership and the style of management adopted by senior nursing and medical administrators at the Ministry of Heath were identified as factors impacting on the practice of the nurses and their capacity to raise community awareness and contribute to the prevention and control of HIV/AIDS. The study was undertaken in three rural and three urban primary health care centres (PHCC). Data collection included participant observation, key informant interviews, and document analysis. These data informed the development of descriptive ethnographic accounts that allowed for the subsequent identification of common and divergent themes reflective of factors recognized as influencing the practice of the nurse participants.

The decision-making processes adopted by rurally located mandated professionals when child abuse or neglect is suspected.

The reporting of suspected child abuse and neglect is a mandated role of medical doctors, nurses, police and teachers in Victoria, Australia. This paper reports on a research study that sought to explicate how mandated professionals working in rural Victorian contexts identify a child/ren at risk and the decisions they make subsequently.

Critical discourse analysis: understanding change in maternity services.

This paper provides an example of the use of critical discourse analysis (CDA) in the area of maternity care policy and describes the process of CDA as an effective research method for understanding the influences of change in the context of Australian maternity services. CDA is a methodological approach that examines how discourse is formed and given power, as a result of how power is used, who uses it and the context within which this usage takes place. The application of CDA is described in this study for the purpose of examining key-stakeholder use of knowledge and power for the purpose of influencing the direction of the maternity services reform. The CDA theoretical framework guided discourse identification and analysis of the purpose behind the discourse through examination of power relationships between key stakeholders. The use of a theoretical lens in the form of neoliberalism to supplement the theoretical framework facilitated the exposure of forces intrinsic to the maternity care context driving change.

Primary maternity care reform: whose influence is driving the change?

BACKGROUND: in 2009 the Australian government announced a programme of reform that will change the way maternity services have traditionally been delivered. A shift to a primary maternity care model has occurred despite strong challenges from medicine and a general public that has embraced high technology in all aspects of life including childbirth. AIM: a critical analysis was undertaken for the purpose of identifying discourses that have influenced the direction of the Australian maternity care reform agenda. METHOD: within a critical discourse analysis framework data were collected from state, territory and commonwealth government policy documents, and selected written submissions from national key stakeholder organisations to the National Review of Maternity Services 2008. FINDINGS: three discourses influencing the direction of the reform are described, these include the following: 'Australia is one of the safest place to give birth or to be born, but not for everyone'; 'maternity care is primarily about mothers and babies, not about the service or the health professionals' and 'government must ensure provision of safe and sustainable maternity services'. CONCLUSION: the Australian government has strong support for the primary maternity care reform backed by a strong key stakeholder alliance involving consumers, midwives and rural doctors. On the contrary to the position of the key stakeholder alliance, the obstetric position has been unable to provide government with solutions to escalating costs and workforce deficits in the delivery of safe and sustainable maternity services. Consumers, rural doctors, midwives and government all agree on the need to safeguard excellent safety and quality standards whilst at the same time reducing high levels of medical intervention and providing options for care in a reformed maternity service designed to meet the needs of all Australian women.

The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care.

BACKGROUND: the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships. AIM: critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services. METHOD: a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers. FINDINGS: maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance. CONCLUSION: the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

National review of maternity services 2008: women influencing change.

BACKGROUND: In 2009 the Australian government announced a major program of reform with the move to primary maternity care. The reform agenda represents a dramatic change to maternity care provision in a society that has embraced technology across all aspects of life including childbirth. METHODS: A critical discourse analysis of selected submissions in the consultation process to the national review of maternity services 2008 was undertaken to identify the contributions of individual women, consumer groups and organisations representing the interests of women. RESULTS: Findings from this critical discourse analysis revealed extensive similarities between the discourses identified in the submissions with the direction of the 2009 proposed primary maternity care reform agenda. The rise of consumer influence in maternity care policy reflects a changing of the guard as doctors' traditional authority is questioned by strong consumer organisations and informed consumers. CONCLUSIONS: Unified consumer influence advocating a move away from obstetric -led maternity care for all pregnant women appears to be synergistic with the ethos of corporate governance and a neoliberal approach to maternity service policy. The silent voice of one consumer group (women happy with their obstetric-led care) in the consultation process has inadvertently contributed to a consensus of opinion in support of the reforms in the absence of the counter viewpoint.

Shaping public opinion on the issue of childbirth; a critical analysis of articles published in an Australian newspaper.

BACKGROUND: The Australian government has announced a major program of reform with the move to primary maternity care, a program of change that appears to be at odds with current general public perceptions regarding how maternity care is delivered. METHODS: A critical discourse analysis of articles published in 'The Age', a newspaper with national distribution, subsequent to the release of the discussion paper by the Australian Government in 2008 was undertaken. The purpose was to identify how Australian maternity services are portrayed and what purpose is served by this representation to the general public. RESULTS: Findings from this critical discourse analysis revealed that Australian maternity services are being portrayed to the general public as an inflexible outdated service struggling to meets the needs of pregnant women and in desperate need of reform. The style of reporting employed in this newspaper involved presenting to the reader the range of expert opinion relevant to each topic, frequently involving polarised positions of the experts on the issue. CONCLUSIONS: The general public are presented with a conflict, caught between the need for changes that come with the primary maternity model of care and fear that these change will undermine safe standards. The discourse; 'Australia is one of the safest countries in which to give birth or be born, what is must be best', represents the situation where despite major deficiencies in the system the general public may be too fearful of the consequences to consider a move away from reliance on traditional medical-led maternity care.

Hidden costs associated with the universal application of risk management in maternity care.

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

Member checking and Heideggerian phenomenology: a redundant component.

Although member-checking has long been accepted as the gold standard in quantitative research, it is not the pinnacle for expressing rigour in Heideggerian phenomenology because it contradicts many o the underpinning philosophies. Similarly, employing 'experts' to confirm findings conflicts with the values of interpretivism. In this paper, th authors argue that member-checking is frequently used to cover poor interview technique or a lack of understanding of the methodology chosen to underpin the study. They debate why member-checking is incongruent with Heideggerian philosophy and suggest strategies that enhance the generation of data and render the follow-u interview redundant.