This study investigates the uniqueness and importance of the Australian National Competency Committee (ANCI) competencies to nurses and other health professionals. Very few Australian studies (Battersby, 1994; Hearn, Smith, Southerly & Close, 1995) have addressed this issue. Although there is widespread confusion of the term "competency", professional bodies regard competency standards as a process for supporting the integrity and control of their respective professions. The problem is that there is confusion across the health professions about competencies and their agenda. ANCI suggest that the nursing competencies reflect unique characteristics of nursing as well as those common with other professions. However, competencies that are unique to nursing have not been identified. ANCI have also not identified how competencies can enhance the development of nursing as a profession. The identification of differences in perceptions of uniqueness and importance of the ANCI competencies within nursing and across health professional groups may contribute to the debate on what is needed to achieve competence and those factors that may influence nursing autonomy, education, and future professional development. This study is important to assist in the identification of nursing as a profession in its own right. It will assist the arguments for and against economic reform in professional education courses and transfer of skills and competence across professions. This study compares the perceptions of nurses, physiotherapists, speech pathologists, and occupational therapists about the uniqueness and importance of the ANCI competencies to their professions. Participants completed a questionnaire that listed the ANCI competencies. They were asked to rate each competency first on uniqueness to their profession, and second, on importance to their profession. Two surveys were conducted; one in 1997 and the second in 2000. Surveys examined any change in perception over time by different cohort groups. The study takes a quantitative approach to data collection and analysis. Inferential analysis determined statistically significant differences and similarities of the four participating health professional groups. The differences are examined in relation to the characteristics that define a profession and implications for nursing are examined in relation to research, autonomy, and patient advocacy within an evidence-based practice framework. Eight hundred and thirty-one of questionnaires distributed were used in this study. The results showed that nursing emerged as significantly different to the other three health professions on perception of uniqueness of the competencies. Nineteen of the sixty-five competencies were perceived by nurses to be more unique to the nursing profession. This perception of uniqueness was found across all the four domains of the ANCI competencies. Although ANCI (2000) claimed that the competencies reflect the unique characteristics of nursing these characteristics have not previously been identified. This finding provides some support for the claim made by ANCI by identifying those competencies nurses perceive as more unique. The study findings showed also that the four participating health professions rated the ANCI competencies as important. However, there was a significant difference between nurses and the other three professional groups on the ratings of importance of the competencies of professional and ethical practice. The study found that nurses rated the competencies of this domain as more important than the other three professions rated these competencies. The findings indicate that the rank orders of importance of the competencies are different across the four professions. This reflects and indicates the different priorities and work roles of each of the four professional groups. It is interesting as well as being of concern to nursing that the participating nurses ranked research and management of care as being the least important of all of the competencies. This finding may help to explain why nursing research has been slow to develop in spite of changes to nursing education. Nurses have a subordinate past and are often described as doers rather than thinkers. It appears that this may not have changed. Current practice also reflects a dependency on other health professions such as the medical profession (Adamson & Harris, 1996). Finally, the study found that there was no change in nurses' perceptions of uniqueness over time. However, there was a slight increase in the nurses' ratings of importance of Critical Thinking and Analysis. There were no statistical significant differences for age, gender, year of graduation, state of residence, and employment status. The discussion chapter commences with an outline of the perceived importance of the competencies across the different health professions. Discussion compares the findings and methods of two important Australian studies of competencies (Battersby, 1994; Hearn et al. 1995, 1996) to this study. Discussion examines professionalism and identifies areas where nursing's perceptions of the competencies meet the criteria of a profession and where the four health professions have similar and different perspectives and qualities. Six characteristics of a profession that are discussed in relation to the perceptions of the ANCI competencies are: high intellectual functioning, special body of knowledge, responsibility and accountability, code of ethics, autonomy, and collegiality. The third part of the discussion highlights the implications of this studies' findings in relation to ANCI competencies as an evaluation tool, the empowerment of nurses, generic courses, scope of nursing, professional development, and curriculum development. The thesis concludes by arguing that 1) The ANCI competencies have the potential to increase the professionalism of nursing; 2) Nurses value accountability and responsibility, the code of ethics, and collegiality; 3) Nurses appear uncomfortable with the concept of autonomy; 4) Nurses undervalue high intellectual functioning and the importance of a body of knowledge; and 5) Perceptions are influenced by the context of competencies. The final chapter highlights a number of recommendations for nursing practice that include the need for further investigation of the uniqueness of the ANCI competencies. It is argued that there is a need for a number of changes to the ANCI competency list as well as a greater emphasis on research and management of care and support for discipline specific courses.It is apparent from the findings of this study that nursing education and clinical practice would benefit from the placement of more emphasis on the importance of research. Furthermore, nurses need to take better responsibility for pursing opportunities and funding for research and practice management. It is concluded that nursing research will increase the body of knowledge for the profession and will also increase professional autonomy with an outcome of better client care. Nurses need encouragement from administrators and educators to value management of care and the nursing process, as this will also encourage independence and quality of care provision. It is argued that commonalities in the perception of uniqueness and importance of competencies are not grounds for politicians to suggest the implementation of generic health professional courses. The commonality of the competencies being important to all four professions can be attributed to the complex nature of nursing practice, which captures aspects of other health professional roles and many of the competencies contribute to the characteristics that define a profession. There are differences in the rankings that can be attributed to the nature of knowledge, context, and priorities of the different professions. Each profession has its own governing body that ensures its members obtain an acceptable standard of professional competence and education. It has, and always will be, the responsibility of the profession to shape the service it provides (Pyne, 1998). This study highlights nurses' perceptions of competencies. The recognition of these perceptions could be used to guide nursing's strive toward autonomy, professional development, and recognition as a profession in its own right.

ABSTRACT Cultural beliefs and values implicitly shape every aspect of the way we parent our children and how we communicate about parenting. For parents who are migrants and experiencing parenting in a new country it is essential that child and family health professionals better understand how the cultural self influences practice. Child and family health professionals work with families who come from cultures other than their own on a daily basis. How they communicate with these families is the subject of this ethnographic study into culture and communication in child and family health. Taking culture as its starting point this study explored the everyday communication experiences of child health professionals including child and family health nurses, social workers and doctors in a statewide child and family health service in South Australia. Data included participant observation, video and in-depth interview data. Drawing on insights from cultural studies including postcolonial and feminist scholarship the analysis showed that child health professionals attempted to use contemporary discourses of service provision such as partnership with enthusiasm and with genuine intent. However their application of partnership was limited by unexamined binary constructs within dominant pedagogic tools of culture and communication. Analysis showed that four key binaries structured the communication practice of participants in this study; public or private knowledge, ideologies of sameness or difference, organisational or professional philosophies of practice and the expert or partner in intercultural communication. Three body analysis is introduced as a strategy to work with these binary challenges that seem to present when practice attempts to incorporate theory without consideration of the contexts of use. The combination of postcolonial feminist critique and three body analysis stimulates an explicit examination of health care inequalities as they intersect with the ongoing effects of colonisation. Current professional strategies for working with people who are new arrivals or migrants to Australia focus on understanding differences associated with particular ethic and cultural groups. Despite much work being undertaken to understand difference, in practice this culturalist approach underpinned by a belief in the essential nature of human kind, has resulted in people who are migrants or new arrivals continuing to report poor communication by health professionals as a primary barrier to their health care. Theoretical analysis suggests that this approach ignores differences in power relations among ethnic groups and ultimately manifests in racism. Further, contemporary communication pedagogies in child and family health reinforce this inattention to relations of power when health professionals are instructed to communicate in ways that are regardless of difference. By advocating that people are treated the same, historic and situated issues of gender, race, and socioeconomic inequalities are ignored. In this way binaries of sameness/difference are perpetuated. Those parents located in marginalised positions of difference experience inequities in health care. In this study, child and family health professionals frequently drew from their own personal experiences of parenting to determine the content of information given to new parents, and to inform their approach to intercultural communication. In doing so they unselfconsciously conflated their personal and professional pedagogies and presented all information as professional. Child and family health practices are deeply cultured. Many practices are not scientifically proven and as such do not fit comfortably with the rational scientific medical paradigm with which they are aligned. Where disciplinary knowledge can be assessed and evaluated, this study found that there was no equivalent place for the evaluation of understanding of cultural knowledge — it was assumed as universal. Deeply cultured personal information tendered by participants represents a normative world that is white, western, middle class and gendered. Participants did not recognise themselves as cultured, nor did they recognise the potential impact of bringing this unexamined cultural self into the professional encounter. This resulted in seepage of practice that was democratically racist. This is where outward commitments to justice equality and fairness paradoxically exist with conflicting personal ideologies of sameness. Challenged to find a place for these constructs to coexist participants outwardly identify with the organisationally preferred position of social justice or evidence-based practice. However, participant observation and discussion of practice demonstrated that when conflicting personal beliefs and values were left unattended they found ways of surreptitiously creeping into and shaping the consultation. It seems that modernist theories do not provide adequate ontological and epistemological understandings for working with, and valuing pluralism in multiculture. Rather they constrict and limit practice which leads to an unrecognised perpetuation of colonising agendas in child and family health. Findings from this study contribute to the growing need to find ways to work with and unsettle existing binaries of communication and culture. The methods also suggest ways forward to support change in practice leading to professional development that is mindful and regardful of plurality in culture and communication. Interweaving three body analyses with postcolonial feminism offers a decolonising strategy for application in the multiculture that is Australia. Due to the spatial and temporal spaces created by using three bodies alongside postcolonial feminism, this combination becomes a tangible approach to deconstruction, for child and family health professionals that is both theoretical and practical.

ABSTRACT Notions of quality of life dictate philosophies and policies for services for people with developmental disabilities. There is an abundance of research on quality of life, much of which has influenced the significant amount of study of quality of life for people with developmental disabilities. According to specialist developmental disability nurses, however, this research has little meaning for one group of people with developmental disabilities with whom they work - people with severe multiple impairments. Nevertheless, judgements and decisions about the lives of this group continue to be driven by the idea of quality of life. While the literature review found that researchers are urged to seek the perceptions of people regarding their own quality of life by asking them, some authors have noted the difficulty in pursuing such a method with people, such as people with severe multiple impairments, who are unable to communicate in the usual ways. Given, then, that it is difficult to directly determine the views of people with severe multiple impairments, this study sought the perceptions of nurses about the quality of life of the people with whom they work. In order to discover and conceptualise nurses' views, a symbolic interaction perspective was chosen to guide this study and data were analysed using the grounded theory approach. The study was conducted in two stages. Stage One consisted of semi-structured indepth interviews with expert nurses to explore their perceptions of quality of life for the people with whom they worked. A significant finding in these interviews was that perceptions of quality of life are mediated by interaction. Consequently, Stage Two involved a participant observation study in which the interactions of nurses and people with severe multiple impairments were examined. Specialist developmental disability nurses have a unique view of quality of life for people with severe multiple impairments. They refer to it as 'just little things', a phrase which masks complex nursing knowledge and skills, and which can be described by four interrelated categories which emerged from the data: humans being, supporting, becoming intimate, and situated belonging. As nurses become more intimate with individuals, they perceive that people with severe multiple impairments are humans being as they wish, and that quality resides in supporting their everyday lives in a context of situated belonging. This thesis represents a new conceptualisation of quality of life for people with severe multiple impairments, a conceptualisation which may have significance for other groups and, indeed, for the whole quality of life enterprise. This conceptualisation draws on knowledge not usually related to quality of life, that is, knowledge of the body, of the emotions, of identity and of humanness. Such findings demonstrate the power of an interpretive approach in explicating the meanings nurses have regarding quality of life. Further, these findings have implications for how the question of quality of life is approached, for how different ways of thinking about people impact on quality of life, and for the importance of the life in quality of life.

There is an enduring and prevailing disparity between the clinical prevalence of alcohol, tobacco and other drug-related problems and the frequency that nurses recognise and intervene in these common problems. The extant nursing literature has long determined an urgent need for further investigation into why nurses do not respond to patients with ATOD-related problems in the consistent and effective manner that the prevalence of these costly health problems require, or in a manner that reflects the opportunities that nurses have to offer brief and timely intervention. This thesis reports and discusses the investigation of factors that determine identification, assessment and interventions of patients with alcohol, tobacco and other drug-related problems by a randomly selected sample of Registered Nurses [n=1281] in practice in New South Wales, Australia. Of particular interest was the relationship between nurses' ATOD knowledge, therapeutic attitudes and clinical activity. Multiple quantitative and qualitative methods were used, firstly to systematically investigate factors within the nurse and their clinical setting that might predict desired clinical behaviour towards addressing ATOD-related problems, and secondly, to analyse and describe nurses' self-reported perceptions, views and experiences of the issue and what aids or impedes it. The research instrument - a 72 item self-completed questionnaire was developed and refined within a process of three (3) pilot studies and test-retest method. A multiple regression model was developed to establish the predictors of key clinical behaviours. Thematic coding was used to analyse the perceptions of these nurses as to the factors that affect their ability to intervene with patients who have ATODrelated problems. Convergent and divergent concerns between quantitative and qualitative findings became apparent. Thematic analysis of open-ended responses demonstrated that nurses report a complex of factors that affect their ability and capacity to intervene with patients who have ATOD-related problems. Among these are factors located within nurses themselves, within their patient(s), within their workplace, within other health professionals and within the broader social/cultural context. The latter part of the thesis systematically considers the relationships between the quantitative and qualitative findings within this large sample of registered nurses. From this comprehensive level of analysis, workforce implications for ATOD education, training and organisational support for nurses, the most numerous group of health care workers, have been readily identified. The major empirical finding of this investigation is that there is a significant difference between positive attitudinal sets and motivation of practicing registered nurses to perform desired ATOD-related clinical activities, and the lower reported frequency at which this occurs. The qualitative findings are highly convergent with the empirical ones. It is the nurse's self-identified lack of knowledge, skills, experience and confidence that is now reported as having the greatest effect on their ability to assess, identify and offer brief and timely intervention for patients with ATOD-related problems, rather than any prevailing beliefs and attitudes that these patients were not worthy of their care, or outside the legitimate framework of their nursing role.

Aim: As a priority for Aboriginal women, in the context of worsening Aboriginal health and lack of clarity about successful strategies to address healthcare needs, this research explored successful strategies in remote Aboriginal women’s health that may be transferable to another community with similar health needs. Methodology: Against a background of cultural and historical events, the study sought to identify existing strategies and frameworks for Aboriginal women’s health. It uses Naturalistic Inquiry situated within the Interpretive paradigm and conceptualised within the philosophical approach of feminist and critical social theory It has examined Aboriginal health providers’ and women’s priorities, practices, perceptions and expectations within the context of primary health care and community development principles by Participatory Action Research (PAR). The successful elements of an established and effective Aboriginal Well Women’s Health (AWWH) program from Central Australia (CA) were identified, transferred and adapted to meet the needs of a willing recipient remote community in South Australia (SA). Working together with healthcare providers from CA and SA, the adapted Well Women’s Health program was implemented in an Aboriginal Community Controlled Health Service collaboratively with local mainstream Community Women’s health services and evaluated. Results: Over a two year period, the research was evaluated through Critical Social Theory examining both the process of implementation and the impact on the Aboriginal community, analysing both qualitative and quantitative data. The AWWH program model and its principles were successfully transferred, adapted and implemented in this community. The AWWH program which included comprehensive health screening, health information and lifestyle sessions have become core business of the Aboriginal health service and an Aboriginal Men’s Well Health program has also been established using the same model. The women have found the AWWH program culturally acceptable and their attendance has steadily increased and the program has reached those women in the community who previously had never experienced a well health check. It has also identified an extremely high incidence and comorbidity of acute illness and chronic disease in diabetes, renal and dental disease, mental and social health problems that require address. Conclusion: Health programs that are well established and effective can be successfully replicated, transferred and adapted to other communities if the elements that made them successful are acknowledged and those principles are then transferred with the program to a willing community with similar needs. This program transfer has potential to save much time and developmental costs that will help to address poor Aboriginal health.

Background The incidence of hypertension is increasing in developing countries such as Thailand (Chaiteerapan et al 1997; Ministry of Public Health 2001; National Library of Thailand Cataloguing in Publication Data 2001) as a result of sociological, political and economic changes. These changes are producing enormous alterations in people�s lifestyles, following similar trends in western countries (National Economic and Social Development Board 1997). Negative changes in food consumption, alcohol consumption, level of physical activity, smoking, stress and tension have led to an increase in chronic health problems for Thai people (National Economic and Social Development Board 1997). Age, gender, ethnicity, genetic background, family health history and hyperlipidaemia are likely to influence hypertension (Kaplan, Lieberman & Neal 2002; Mancia et al 2002; Manger & Gifford 2001; National Heart Foundation of Australia 2003). It has been found that health care professionals and patients with chronic disease have increased their use of complementary therapies to help relieve uncomfortable symptoms and suffering (Long, Huntley & Ernst 2001). Foot reflexology is a well known complementary therapy which claims to help the body achieve homeostasis (Byers 2001; Dougans 2002). It is believed that pressing specific areas on the feet related to specific glands or organs of the body can help these glands and organs to function at their peak, allowing the body to heal itself (Byers 2001; Dougans 2002). The principle difference between massage or touch and foot reflexology is that foot reflexology provides not only the relaxation effect obtained from massage or touch is said to also improve body�s immunity contributing to healing process (Byers 2001;Dougans 2002). Foot reflexology has been scientifically researched in many studies to explore the claimed benefits (Bishop 2003; Kohara et al 2004; Oleson & Flocco 1993; Siev-Ner et al 2003; Yang 2005). Some studies have supported its ability to reduce anxiety and pain (Gambles, Crooke & Wilkinson 2002; Launso, Brendstrup & Arnberg 1999; Stephenson, Dalton & Carlson 2003; Stephenson, Weinrich & Tavakoli 2000). However, there has been little scientific evidence to support the claim that foot reflexology can reduce blood pressure and serum lipids, and can improve the quality of life in patients with hypertension (Hodgson 2000; Milligan et al 2002; Park & Cho 2004). The purpose of this study was to begin to fill this gap by investigating the influence of foot reflexology on blood pressure, serum lipids and quality of life. Aim The aim of this study was to investigate the effect of foot reflexology on reducing blood pressure in patients with hypertension. To this end, patients receiving reflexology were compared with patients receiving a light foot massage, thus controlling for any effects contributed by massage or touch alone. Null hypotheses 1. There is no difference in mean blood pressure level between the foot reflexology group and the light foot massage group at the end of four weeks of treatment. 2. There is no difference in mean low density lipoprotein (LDL) cholesterol and triglyceride levels between the foot reflexology group and the light foot massage group at the end of four weeks of treatment.3. There is no difference in mean quality of life scores between the foot reflexology group and the light foot massage group at the end of four weeks of treatment. Sample A sample size of 128 was required to yield a power of 80%, if the difference in mean diastolic blood pressure between the two groups was 5 mmHg. One hundred twenty eight patients with hypertension who attended the hypertensive clinic in the medical outpatients department of Phramongkutklao Hospital, Bangkok, Thailand were enrolled and participated in the study. Methods Data collection This study used a randomized controlled trial design. Participants were randomly allocated into one of two groups � 64 participants in the foot reflexology group (intervention) and 64 in the light foot massage group (control). Data collection took place over 4� months between 26 July and 9 December 2004. Ethics approval was obtained from both the university and hospital ethics committees. Prior to randomization, participants were asked to complete a demographic data questionnaire and the World Health Organization Quality of Life-BREF (WHOQOLBREF) (World Health Organization 1996) questionnaire. Blood was drawn to test LDL cholesterol and triglyceride levels. Using an intervention protocol based on previous literature (Byers 2001), participants in the foot reflexology group received their usual medical treatment and a 50-minute foot reflexology treatment twice a week for four weeks. Participants in the light foot massage group received their usualmedical treatment and a 30-minute light foot massage session without pressure on specific reflexology areas twice a week for four weeks. Blood pressure was recorded before and after each treatment. At the end of the study, participants were asked to complete the WHOQOL-BREF (World Health Organization 1996) again and blood was once more drawn to test LDL cholesterol and triglyceride levels. Data analysis An independent samples t-test followed by analysis of covariance was used to test for difference in mean diastolic blood pressure between treatment groups both unadjusted and adjusted for baseline values respectively. Descriptive statistics were used to present the demographic data. Results Demographic data Control and intervention groups were similar in gender, age, educational background, economic factors, lifestyle characteristics, co-morbidities and medical treatments. Demographic data which were substantially different between groups were marital status, the length of time experiencing hypertension and the length of time having treatment for hypertension. The study showed that fewer participants in the foot reflexology group (57.8%) were married than in the light foot massage group (70.3%). The foot reflexology group also had a higher rate (32.8%) of �divorced/separated/widowed� compared with the light foot massage group (20.3%). Participants in the light foot massage group had almost nine times the number of participants who had had hypertension for more than 15 years, and almost eight times the number of participants who had been having treatment for hypertension for more than 15 years, compared with those in the foot reflexology group. Outcome variables For both the unadjusted and adjusted analyses, there was no statistically significant difference between treatment groups post-intervention. Conclusions The results from this study did not support the claim that foot reflexology can decrease blood pressure, LDL cholesterol and triglyceride levels. Similarly, there was no evidence that it could improve the quality of life in patients with hypertension.

Contrary to popular belief, teenage mothers are a declining proportion of birthing women; however they receive much negative public attention. Of particular public concern is the high cost of supporting teenage mothers, in terms of financial, health and welfare resources. Historically, the typical founding mother of white Australia was single, but post-war changes in the family structure incorporated the expectation that children be born into two-parent households with the male as the breadwinner. Policy changes in the seventies saw the introduction of the Sole Parents Pension which meant that many birthing teenage women could choose to keep their infants rather than have a clandestine adoption or an enforced marriage. The parenting practices of teenage mothers have been criticised for being less than optimal, and mother and child are reported as being disadvantaged cognitively, psychosocially, and educationally. One widespread nursing service which provides support for new mothers in Victoria is the Maternal and Child Health Service; however, teenage mothers appear reluctant to use such services. Why this should be so became an important question for this research, since little is known about the parenting practices of teenage mothers. This study therefore sought to explore mothering from the perspective of five sole supporting teenage mothers each of whom had a child over six months of age. The research methodology took an interpretive ethnographic approach and was guided by feminist principles. The data were collected through repeated interviewing, participant observation, informal discussions with key informants, field notes and journalling. Data analysis was aided by the use of the software, program NUD-IST. It was found that the young women in this study each chose to give birth with full realisation that their existence was dependent on the Welfare State. Unanticipated, however, were the many structural barriers which made their lives cataclysmic, but these reinforced their determination to prove themselves worthy and capable mothers. The young women negotiated motherhood through a range of social supports and through maternal practice. Unquestionably, their social dependency on the welfare system forced them into marginal citizen status. Moreover, absolute and intrinsic poverty levels were experienced, brought about by inadequate welfare payments. Formal support agencies, such as the Maternal and Child Health nurses were rarely approached to provide childrearing support beyond the initial months following birthing, since the teenagers' basic needs such as shelter, food and clothing took precedence over their parenting needs. Additionally, some nurses were perceived to hold judgmental attitudes towards teenage mothers. It was far easier to forestall confrontation with nurses and the other 'older' women clientele by avoiding them. Thus XI they turned to charitable agencies who provided a safety net in the form of emergency supplies of money, food, or equipment. Informal networks of friends provided alternative modes of support when family help failed to materialise. The children, however, provided the young women with an opportunity to transform their lives by breaking free of the past, and by creating a new, mature existence for themselves. Despite being abandoned by family, friends, lovers and society, in the privacy and isolation of their own homes, they attempted to provide a more nurturing environment for their children than they themselves had received. Each bestowed unconditional maternal love on the child and were rewarded through the pleasures of watching their children grow and develop into worthwhile individuals. The children became the focus of their attention and their reason for living. In the course of their welfare dependency, the young women became public property, targets of surveillance, and were subjected to stigmatising and condescending public attitudes wherever they went. In this way, it was evident that they were an oppressed group, but each found ways of resisting. Rather than focussing on their oppressive or disabling lives, or dwelling on their disadvantaged status, the young women sought their identities as mature women through motherhood and by demonstrating that they could do this important job well. Through motherhood their lives had meaning and a sense of purpose. The thesis concludes that motherhood in the teenage years is difficult. However, if appropriate supports are made available, teenage mothers need be no different from non-teenage mothers. But with state resources shrinking, and their own resources limited, teenage mothers are disadvantaged. In some ways, this study showed that all levels of support were inadequate, although those provided through the charitable organizations were seen to be the most appropriate. This reflects the current policy of economic rationalism adopted by most Western liberal democracies in the 1980s and 1990s and no less by the former Keating Labor Government in Australia.

The majority of women's health nurses in this study work in generalist community health centres. They have developed their praxis within the philosophy and policies of the broader women's health movement and primary health care principles in Australia. The fundamental assumption underlying this study is that women's health nurses possess a unique body of knowledge and clinical wisdom that has not been previously documented and explored. The epistemological base from which these nurses' operate offers important insights into the substantive issues that create and continually shape the practice world of nurses and their clients. Whether this represents a (re)construction of the dominant forms of health care service delivery for women is examined in this study. The study specifically aims at exploring the practice issues and experience of women's health service provision by women's health nurses in the context of the provision of cervical cancer screening services. In mapping this particular group of nurses practice, it sets out to examine the professional and theoretical issues in contemporary nursing and women's health care. In critically analysing the powerful discourses that shape and reshape nursing work, the study raises the concern that previous analyses of pursing work tend to universalise the structural and social subordination of nurses and nursing knowledge. This universalism is most often based on examples of midwifery and nursing work in hospital settings, and subsequently, because of these conceptualisations, all of nursing is too often deemed as a dependent occupation, with little agency, and is analysed as always in relation to medicine, to hospitals, to other knowledge forms. Denoting certain discourses as dominant proposes a relationship of power and knowledge and the thesis argues that all work relations and practices in health are structured by certain power/knowledge relations. This analysis reveals that there IX are many competing and complimentary power/knowledge relations that structure nursing, but that nursing, and in particular women's health nurses, also challenge the power/knowledge relations around them. Through examining theories of power and knowledge the analysis, argues that theoretical eclecticism is necessary to address the complex and varied nature of nursing work. In particular it identifies that postmodern and radical feminist theorising provide the most appropriate framework to further analyse and interpret the work of women's health nurses. Fundamental to the position argued in this thesis is a feminist perspective. This position creates important theoretical and methodological links throughout the whole study. Feminist methodology was employed to guide the design, the collection and the analysis. Intrinsic to this process was the use of the 'voices' of women's health nurses as the basis for theorising. The 'voices' of these nurses are highlighted in the chapters as italicised bold script. A constant companion along the way in examining women's health nurses' work, was the reflexivity with feminist research processes, the theoretical discussions and their 'voices'. Capturing and analysing descriptive accounts of nursing praxis is seen in this thesis as providing a way to theorise about nursing work. This methodology is able to demonstrate the knowledge forms embedded in clinical nursing praxis. Three conceptual threads emerge throughout the discussions: one focuses on nursing praxis as a distinct process, with its own distinct epistemological base rather than in relation to 'other' knowledge forms; another describes the medical restriction and opposition as experienced by this group of nurses, but also of their resistance to medical opposition. The third theme apparent from the interviews, and which was conceptualised as beyond resistance, was the description of the alternative discourses evident in nursing work, and this focused on notions of being a professional and on autonomous nursing praxis. This study concludes that rather than accepting the totalising discourses about nursing there are examples within nursing of resistance—both ideologically and X in practice—to these dominant discourses. Women's health nurses represent an important model of women's health service delivery, an analysis of which can contribute to critically reflecting on the 'paradigm of oppression' cited in nursing and about nursing more generally. Reflecting on women's health service delivery also has relevance in today's policy environment, where structural shifts in Commonwealth/State funding arrangements in community based care, may undermine women's health programs. In summary this study identifies three important propositions for nursing: • nursing praxis can reconstruct traditional models of health care; • nursing praxis is powerful and able to 'resist' dominant discourses; and • nursing praxis can be transformative. Joining feminist perspectives and alternative analyses of power provides a pluralistic and emancipatory politics for viewing, describing and analysing 'other' nursing work. At the micro sites of power and knowledge relations—in the everyday practice worlds of nurses, of negotiation and renegotiation, of work on the margins and at the centre—women's health nurses' praxis operates as a positive, productive and reconstructive force in health care.

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

The first purpose of this study was to describe the deaths of fifteen nursing home residents with late-stage dementia. The devastating effect of dementia on a person has been called a ‘living death’ (Woods, 1989). The caring which occurs when someone is going through this process in a nursing home was recorded and analysed. In analysing this act of caring, the second purpose was to look for the origins of the structures and the sources of pressure that shaped the context and therefore helped determine the behaviour of the various groups under observation. These groups were residents and their relatives, the staff of the nursing home and the treating doctors. Before commencing observations and carrying out this study, an understanding needed to be developed of: the condition of dementia as it is perceived by health professionals and presented in the media; the institutions in which the majority of people with dementia end their days; the background and conditions of the staff who nurse in them; the models of care that guide and determine policies; and the conceptions of life and death which underpin relevant laws and moral standpoints. Accordingly, in part 1. chapter 1 the history, causes, pathology and effects of dementing conditions are examined. Relevant medical and lay literature including media influences are examined which pertain to the subject of death and dementia and nursing home care. The history of this institutional care is briefly examined together with the growth of the discipline of gerontological nursing. Chapter 2 discusses some of the effects of this history on present day care and the concept of emotional work being carried out within the present day aged care public policy regulations. The moral arguments surrounding illness and dying in Australian society today are briefly discussed. Chapter 3 describes the conceptual framework for the study, the ethnographic method that has been employed and an outline of critical theory as the basis for analysis. The chapter concludes by recounting the practical steps taken to arrange the field work, secure the consent of participants, record data and gather documents, and outlines the ethical considerations given to the undertaking of the study. Chapter 4 describes the context in which the study took place and the first tentative exploration of the culture from an etic perspective. Part 2 describes the death trajectories observed and raises some questions about alternative strategies that may have been considered within a different paradigm of caring. In chapter 5 the death trajectories of each of the fifteen residents in the study are described, each written with a particular emphasis to illustrate aspects of the culture of care that emerged through thematic analysis. Observations, comments and feelings from staff and family are wound in and around these case studies. Chapter 6 looks more closely at the impact of policy and institutional pressure on the milieu in which these deaths took place. Part 3 draws conclusions from the observations and makes suggestions for emancipatory change as viewed from the author's standpoint of critical ethnographic analysis. In the final chapter an argument is presented for policy change that leads a movement towards palliative care practices for people with late-stage dementia. Approaches to implementation of palliative care will need to take account of any expression by the resident such as an advanced directive, indicating a preferred approach to treatment in the period prior to death; a need for a better understanding of such issues as the significance of body breakdown, the manifestations of pain and electrolyte imbalances; the surrounding ethical complexities and shift in public opinion, and perhaps, most of ail, the culture of the institutions in which this dying will take place. A definition of late-stage dementia which might be used in determining patterns of care is set out. A discussion about changes in practice which relate lo communication with treating doctors, the administering of antibiotics, the relief of pain, the mobilisation of residents and the provision of food and water takes place in light of the evidence found. The discussion of these issues is raised in the form of debate. Each aspect needs more rigorous analysis and information so that evidence-based practice, rather than care which is value-laden and emotional, can be used when treatment decisions are made for people with late-stage dementia.