Nursing - Theses
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ItemA study of the clinical supervision implementation strategy for nurses at a rural health care organisation in Victoria(University of Melbourne, 2006)
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ItemCrystallising meaning: attitudes of listening to illness narratives( 2008)This study involves listening to illness narratives embedded in in-depth life review processes. The method of multiple interview and multi-modal analysis and reflective responding utilised in the study aims to add to the existing field of research by expanding the understanding of what it is like to be heard or not heard, for people who are either patients, or family members. The study also aims to demonstrate how self-aware ,compassionate and reflective listening, particularly in healthcare relationships, can allow meaning to emerge from within the illness experience, thus enriching the wellbeing of patients, family members and their various healthcare professionals. Stories of disruption arising within healthcare settings often confronted me during more than forty years of nursing experience and also resonated within my personal experiences. These stories express a gulf between patients, family members, or residents in healthcare institutions, and the healthcare organization and its staff. A recurring theme was that these people felt that they had not been listened to by those they trusted to give them care, with a lasting sense of disruption to their wellbeing. In focusing on the dimensions of reflective listening and intersubjective responding, the implications of being heard on the well being of both narrator and listener can be elucidated. An objective of the research became to articulate the attributes and values of compassionate, reflective listening and elucidate the complex nature of the narrating and listening relationship. (For complete abstract open document)
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ItemA study of pain management practices during the prolonged hospitalisation of infants.( 2007-05)Purpose: The purpose of this study was three-fold; to investigate the use of pain assessment tools and pain reduction strategies during minor painful procedures in neonatal units in Australia; to map the history of an infant’s prolonged hospitalisation in a tertiary neonatal intensive care unit with respect to painful procedures and pain management practices, and to describe the effectiveness of oral sucrose in reducing procedural pain during the course of an infant’s prolonged hospitalisation (greater than/equal to 28 days). (For complete abstract open document)
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ItemProfessional aspirations and consumer expectations: nurses, midwives, and women's health( 2009)This thesis undertakes a history of midwifery's present in the arena of Victoria, Australia. It asks: what lies behind midwifery's aspiration to differentiate itself as a profession, separate and distinct from nursing? The thesis applies contemporary and historical inquiry in two parts. In Part I, the contemporary arm, a review of discourses and policies was combined with individual (n=22) and group interviews (n=4) to discover the perspectives of nurses, midwives, consumers, and others, on midwifery's separation from nursing via its professionalising process. In the larger arm, Part II, midwifery's and nursing's historical and professional trajectories in Victoria were mapped from European settlement in the 1840s through to the present. This was achieved by detailed examination of a range of primary sources, including records of the Melbourne Women's Hospital, the Victorian parliament and its delegated authorities, and professional associations. The Foucauldian concept of government frames this interpretation of women's health care history. Government encompasses the themes of regulation and expertise, both of which are key elements in claiming status as a profession, and are argued here to be central in nursing's and midwifery's history. Because tensions over the status of pregnancy and birth as health states or potential illness states are longstanding, the concepts of health and illness also inform this inquiry. Midwifery's history is shown to be a contingent and complex history, intricately intertwined with that of nursing since the earliest days of settler society. Throughout 170 years of history following European settlement in Victoria, two themes dominate the provision of care to women, and the roles of midwives and nurses in that care. The primary theme is the safety of women. An interconnected theme is the politics of women's health, that is, the politics of delivering safety. Stemming from concerns about women's safety and how to achieve it, the arena of women's health care and the roles of midwives and nurses within it is characterised by a perennial cycle of seemingly intractable issues. These issues include: questions about who should practice midwifery/maternity care, under what conditions, what education and training is required for the role, perceived disparities between city and rural services, consumer choice, autonomy, and the cost of services. While the context in which these perennial problems are played out has changed considerably over time, and while the meaning of safety has shifted over time, the issues, themselves, have remained consistent. These intractable issues are a permanent feature of the women's health care arena. Over the 170 years of history examined here, they have not been resolved by the formation or reframing of professional identities, by the reconfiguration of education pathways, or by new models of care. Thus, the promise of a reformed maternity care service for the betterment of all women may not be achieved by midwifery's separation from nursing. In the Victorian setting, midwifery has had, and continues to have, much in common with nursing. A grasp of these historically-enduring commonalities confirms that there may be a lot to lose by midwifery's separation from nursing.
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ItemImproving the quality of patient care through a systemic approach to emancipatory practice development( 2006)This study used an emancipatory action research method to explore the significance of practice development as a systemic strategy to improve patient-centred care in a Cardiothoracic Surgical (CTS) Unit. The need for the study arose from recognition that the increasing levels of patient injury and death in healthcare requires a patient-centred and systemic response. The study presents practice development as one such response to engage the whole system of care in improvements and ensure patient-centred care. The study involved the development, implementation and evaluation of a Practice Development Program. An emancipatory action research methodology was used to maximise the participation of staff in the Program and to promote sustainable change. This methodology was also considered suitable as it parallels emancipatory practice development. The Program involved three action research cycles to reflect on patient care in the CTS Unit and make improvements. The first program cycle involved an evaluation of care using an Empowerment Evaluation approach (Fetterman, 2005). This was then complemented with patient and staff interviews and surveys. The evaluation provided the opportunity for staff to see and understand their practice differently and created the momentum for practice change. The second program cycle began with a staff ballot on the value of continuing the Program which identified that ninety percent of staff supported maintaining the Program. At the end of the cycle an evaluation of the Program, to determine opportunities to consolidate successful outcomes, was carried out. This was supported by the development of a local 'Change Achievement Map' or checklist of requirements for successful, systemic practice development. The Map highlighted the challenges involved in implementing a systemic approach and the opportunities to strengthen the Program. Throughout the second program cycle staff continued practice change activities, with 44 staff involved in coordinating projects to improve patient care. As such, the Program established a culture of clinical governance, or held staff accountable for improvements. While staff were held accountable they were also supported to take ownership of change, make sense of it and to work across disciplines and departments to enhance patient care. The third program cycle began with an evaluation of care (similar to the first program cycle) to stimulate a further 12 months of practice development. With the increased ownership that occurred over the course of the Program, staff took more active roles in the evaluation, including facilitating a number of Evaluation Workshops and conducting patient interviews and surveys. The increased level of staff participation led to new insights about the emotional labour of care and the challenges this presented to enhancing patient-centred care. This Program cycle also explored the efforts of staff to sustain the Program beyond the involvement of the External Facilitator. The study involved reflection on the characteristics of practice development and the construction of propositions, or critical theorem, relating to the effects of the Program and how practice development occurred. In addition, propositions about the systemic characteristics of practice development were explored and a new, systemic model of practice development is presented. The study concludes that a systemic approach to practice development is an effective strategy to improve patient care.
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ItemWomen and their journals: navigating depression through consciousness-raising, resistance and action( 2009)Depression in women is a major mental health issue and social work practitioners can, at some stage in their careers, expect to work with women experiencing depression. Journal therapy, the use of writing for therapeutic purposes, is one example of support and intervention offered to women. The use of journal therapy and specifically the use of journalling by women in Women’s Journalling Groups were investigated in this research. Limited research had been undertaken in the area of journal therapy with women experiencing depression. The research was undertaken in four phases and used a modified form of grounded theory to develop the research design and to identify and articulate ideas about women’s use of journalling during depression. Phase one established the baseline knowledge for the research through a Co-operative Inquiry underpinned by feminist research principles. Findings from the Inquiry identified: Two key methods of journalling and women’s responses to depression: • The Considered Acknowledgement, Acceptance and Contemplation framework • The Proactive Resistance, Rehearsal, Agency and Action framework; Four key narratives that women had created about their journalling and their understanding of depression in women: • Identification and expression of emotions; • Identity, sense of self and self-value; • Structural and social roles, relationships and expectations; and • Transformative choices, opportunities and accomplishments; Phase two involved the conceptualising, formalising and transfer of this knowledge into the development of a Women’s Journalling Group program. Through the facilitation of two Women’s Journalling Groups in phase three, the journalling activities were found by women to be relevant and meaningful for them in assisting them to understand their depression and move toward recovery. Phase four included the final stage of knowledge utilisation and transfer. A most significant and new finding from this research was that journalling undertaken by the women was a form of action in response to their depression. Far from being a passive, ruminative, purposeless pastime, journalling was an evolving and sustaining action that enabled the women to gain insights and understandings into themselves and their depression. Journalling activities enabled women to identify and express the many feelings and thoughts that attached to their depression. In reaching clearer understandings of themselves and their depression and in gaining confidence in making choices about their future, women were engaged in processes of consciousness-raising and resistance. Resistance to social and structural expectations, roles and stereotypes was important for the women who could then redefine and redevelop their authentic sense of self and identity. Resistance could occur on an individual level in the journal and on a collective level within Women’s Journalling Groups. The major outcomes of this research have resulted in a model of journalling that has been used to develop a theoretically grounded Women’s Journalling Group program. Whist some further developmental work is required with the program, it nevertheless provides a tested therapeutic intervention that can be offered to women experiencing depression.
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ItemImpact of multiple sclerosis on committed caring relationships: the experience of twelve spousal carepartners dealing with this "uninvited guest"( 2008)This research study explores the perceived impact of multiple sclerosis on “carepartners” in committed caring relationships as the spousal roles change over time. Both quantitative and qualitative methods were used in this study of persons with MS and their spousal carers residing in Australia during ten months of recruitment. Varied recruitment methods were used including the internet. 263 expressions of interest were received, and 203 survey packets were returned with usable data (77%). The demographic instrument and 4 scales measuring mood, reciprocity, life satisfaction and functional wellness were subjected to descriptive statistical analysis. Results from the quantitative phase of the study supported many international epidemiological findings related to gender, age of onset, difficulty in obtaining a diagnosis in the light of vague early symptoms of MS, and high levels of depression in the study sample. The preliminary analysis suggested that these data should be analysed further in dyadic terms (a person with MS and their identified carer). Further inferential statistical analysis examined the data sub-set of ‘pairs only’ which helped to inform formation of a pool of couples in caring relationships from which was selected a sub-sample of 12 spousal dyads residing in Victoria for interview in the second phase of the study. Emerging themes from narrative analysis (n=24 persons) revealed pressing concerns, personal strengths and coping strategies of interviewees. Two themes of special interest relating to (1) differing perceptions by ‘carepartners’ of the importance of cognitive changes to the dyadic relationship, and (2) expectations of health professionals are explored. Most respondents agreed that their expectations left much to be desired, suggesting that improvements could be made in the area of health care delivery to persons with MS, their carers and their families. There are implications for the development of a multidisciplinary, ongoing assessment, educational and support program for these persons. Further research is needed to define and expand the proposed role of a specialized key contact person to be a valuable ‘advocate’ in the delivery of timely health care resources throughout the disease trajectory.
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ItemUsing the emancipatory values of social work as a guide to the investigation: What processes and principles represent good practice with people on community treatment orders?( 2009)This research explores good practice with people on CTOs - via a case study of one area mental health service in Victoria. The emancipatory values of Social Work were used to guide the investigation, thereby ensuring the involvement of consumers and their families or carers. Critical Social Work theory provided an important theoretical base for the research, and both critical theory and pragmatism supported the methodology. A mixed methods approach was undertaken. This included a cluster analysis of 164 people on CTOs. Three clusters emerged from the exploratory cluster analysis. These clusters, labelled ‘connected’, ‘young males’ and ‘chaotic’ are discussed in relation to their particular characteristics. The results from the cluster analysis were used to inform the recruitment of four people on CTOs who were the central focus of case studies that represented the different clusters. Semi-structured group interviews were also undertaken to enhance the triangulation of data collection and analysis. This resulted in 29 semi-structured interviews with multiple informants, including consumers, family/carers, case managers, doctors, Mental Health Review Board members and senior managers. The data analysis was guided by a general inductive approach that was supported by the use of NVivo 7. Five principles, and the processes required to enable them, emerged from the qualitative data: 1) use and develop direct practice skills, 2) take a human rights perspective, 3) focus on goals and desired outcomes, 4) aim for quality of service delivery, and, 5) enhance and enable the role of key stakeholders. These principles are discussed and then applied to the case studies in order to consider their potential relevance to practice within a diverse community of CTO recipients. The application of the principles identified two further findings: 1) that the principles are interdependent, and 2) the relevance of the principles varies depending on the characteristics of the consumer. The two most important findings to emerge from this thesis are that: 1) people on CTOs, their family/carers, and service providers are a diverse community of people who have a range of problems, needs and preferences in relation to either being on a CTO or supporting someone on a CTO; and 2) the implementation of CTOs is influenced by social and structural issues that need to be considered in developing any recognition or understanding about what represents good practice. Recommendations relating to each of the principles are made, along with identification of future research questions. A particular focus is whether application of the principles will enable improvements in practice on a range of measures, including reducing the use of CTOs, and the experience of coercion by consumers.
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ItemUnfractionated heparin therapy in paediatrics( 2009)Unfractionated heparin (UFH) therapy is frequently used in tertiary paediatric healthcare facilities despite a lack of paediatric-specific research informing the optimal therapeutic intensity, monitoring recommendations or side-effect-profile in infants and children. As a result, the majority of clinical recommendations regarding UFH management in children have been extrapolated from adult evidence. The process of developmental haemostasis, in association with the variable pathogenesis of thromboembolic disease (TED) in children compared to adults, suggests that extrapolation of adult guidelines for UFH management to children is not ideal. This study hypothesised that the process of developmental haemostasis would influence both the action and effect of UFH in children of different ages. This hypothesis was tested by addressing the following aims: 1. To determine the pharmacokinetics (PK) of UFH in children of different ages; 2. To compare the different methods of monitoring UFH in children of different ages; 3. To identify the impact of competitive plasma binding of UFH in children of different ages; 4. To determine the impact of UFH upon tissue factor pathway inhibitor (TFPI) release in children. A prospective cohort study of children receiving a single bolus dose of UFH for primary thromboprophylaxis in the setting of cardiac angiography was conducted. Venous blood samples were collected prior to the UFH, then at 15, 30, 45 and 120 minutes post-UFH bolus. Laboratory assays performed included activated partial thromboplastin time (APTT), anti-Xa assay, anti-IIa assay, thrombin clotting time (TCT), protamine titration and TFPI. Levels of two plasma proteins known to competitively bind UFH (vitronectin and platelet factor 4) were determined and the impact of competitive plasma binding upon UFH activity, as measured by the anti-Xa assay, was quantified. A population approach to pharmacokinetic analysis, based on protamine titration results, was performed using WinNonMix™ Professional 2.0.1 (®1998-2000 Pharsight Corporation, Mountain View, CA, USA). Results were analysed according to the following age-groups: less than one year; one to five years; six to ten years; 11-16 years. Sixty-four children were recruited, ranging in age from six months to fifteen-and-ahalf years. The mean dose/Kg of UFH across the entire cohort was 90.9± 15.5 IU/Kg. Pharmacokinetic model specifications were systematically assessed, investigating the impact of parameter covariates and different error models upon objective function value and/or curve fitting. A first-order kinetic model best fitted the data. This model used weight 0.75 as the covariate of clearance and total weight as the covariate for volume of distribution. Parameter estimates for clearance and volume of distribution both demonstrated variance from adult and small neonatal PK studies of UFH, however methodological differences in PK analysis techniques limited comparisons. The half-life of UFH reported in this study was consistently and significantly shorter than that previously reported for adults, but longer than that reported for neonates. All measures of UFH-effect demonstrated a significant and prolonged increase post- UFH bolus. The mean APTT was 261 seconds 102 ± 25 minutes post-UFH, representing a seven-fold increase from the mean baseline APTT (38 seconds). Anti- Xa assay levels were within the therapeutic range for TED management (0.35 to 0.7 IU/mL), or greater, at every post-UFH bolus timepoint. This prolonged UFH-effect was evident to nearly two hours post-UFH bolus, without concurrent UFH infusion. Age-related differences in UFH-response were evident for anti-Xa, anti-IIa and protamine titration results. Furthermore, during periods of high UFH concentration, the ratio of anti-Xa to anti-IIa activity in children less than one year of age significantly favoured UFH-mediated anti-Xa effect over anti-IIa effect (1.9), compared to teenagers (1.3). This study demonstrated poor correlation between protamine titration and both the anti-Xa assay (r2 = 0.47) and APTT (r2 = 0.56). Use of the anti-Xa assay (0.35 to 0.7 IU/mL) or protamine titration assay (0.2 to 0.4 IU/mL) to establish APTT-based reference ranges for therapeutic management of TED resulted in APTT ranges with upper limits greater than 250 seconds. No age-related quantitative differences in plasma levels of vitronectin or platelet factor 4 were identified across the childhood years. The addition of dextran sulphate (DS) to ex vivo study samples demonstrated no change in anti-Xa activity in samples collected within 20 minutes of UFH bolus, however a significant increase in anti-Xa activity following the addition of DS was evident at all later timepoints post-UFH bolus. The measurement of TFPI before and after a single bolus dose of UFH demonstrated children have a similar immediate increase in TFPI activity following intravenous UFH compared to adults. However, the children in this series demonstrated a significantly prolonged level of increased TFPI activity, out to 102 ± 25 minutes post-UFH, compared to that reported in adult patients. This study has developed the first paediatric-specific PK profile of UFH and has elucidated a number of age-dependent UFH-mechanisms of action that contribute to the previously reported age-dependent response to UFH in children. The results of this study support the hypothesis that developmental haemostasis influences both the action and effect of UFH in children of different ages.
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ItemThe use of assessment tools in child protection: an ethnomethodological study( 2009)This research focused on how child protection practitioners in the Department of Child Safety, Queensland used the Structured Decision Making (SDM) tools in their practice with children and families. SDM is a set of tools designed to assist practitioners with their decision making, promote consistency in practice and target the children most in need of a service. This research focused on how practitioners used four of the SDM tools in the intake and investigation stages of a case: the Screening Criteria (used to assess which cases should be accepted for investigation), the Response Priority Tool (used to assess the urgency with which an investigation should commence), the Safety Assessment Tool (used to assess whether a Safety Plan needs to be developed or a child needs to be removed from parental care) and the Family Risk Evaluation Tool (used to assign levels of risk to cases and assist in decision making about further Departmental intervention). More broadly, the research aimed to address a gap in the literature about how child protection practitioners use risk assessment tools in their practice with children and families. Theoretically the research drew from ethnomethodology to explore the ‘unstated conditions’ (Garfinkel, 1967) in relation to how the tools were used by practitioners. Methods for data collection were drawn from ethnography and involved three months fieldwork at six Child Safety Service Centres in Queensland during 2007/08. The fieldwork involved observing the practice of practitioners in intake and investigation teams at the different offices, interviews with 46 practitioners and audits of 51 case files. A significant finding of the research was that practitioners were not using the tools in the way that they were intended to be used by their designers (primarily to assist decision making). Rather the tools were considered as tools that met organisational requirements for accountability and consistency. The ‘unstated conditions’ that emerged from the research provide not only description about how the tools were used, but also explanation about why the tools were used in certain ways. These explanations provide insights which have implications more generally for the future development and implementation of tools to assist practitioners with assessment and decision making.