Western nursing has been deeply influenced by Christianity and more latterly by the Nightingale ideal of the good nurse. Both views have, as their foundation, the belief that there is an objectively knowable good way to live. This belief presents problems to the modern nurse and has, in large part, been rejected. However, the rejection of this objective moral foundation for nursing has resulted in a crisis of confidence about the best way to articulate what it is to be a good nurse. Two new ways have emerged in recent times. A scientific approach to nursing has elevated the work of nursing to increasingly complex levels and resulted in significantly improved health outcomes for patients. This scientific approach to nursing has manifested itself in two ways. It has resulted in the development of theories of nursing based on psychological concepts. Parallel to this approach has been the tendency for nursing itself to become increasingly scientific and nurses in turn to be technologists. It was thought that nursing that was increasingly shaped in scientific terms would achieve professional status because it presented a scientifically verifiable knowledge base. At the same time, however, it has resulted in an understanding of what counts as being a good nurse being reduced to the nurse’s ability to perform tasks to a high level of clinical precision. Alternatively, nursing as a care-based activity has made a caring attitude the moral centre point of nursing. On this view objective standards of practice are regarded as secondary to the emotional care that the nurse brings to the patient. This belief arose in part because notions of the objectivity of science were challenged as ideological rather than the dispassionate form of knowledge that scientists claimed. It was fostered by the emergence and dominance of phenomenology and the influence of the feminist care ethic. There was also some anxiety about what had been lost in nursing by the embrace of science. In addition, the care ethic seemed to promise the possibility of defining nursing in its own terms in order to make nursing a distinct professional body. However, the demands of an ethic of care have proven elusive and, in the minds of some, unattainable. Given these criticisms of both these ways of thinking about nursing it is proposed that nursing think of itself as a virtues-based activity. Virtues theory incorporates within it the strengths of the two formerly mentioned ways of describing nursing without being subject to the limitations of each. Virtues such as love friendliness, compassion , courage and conscientiousness and the intellectual virtue of prudence or practical wisdom enable nurses to realise that goal in their practice. In this thesis virtue theory will be analysed and applied to nursing in the following way. Some Aristotelian concepts will be identified and their application t professional ethics by contemporary virtue theorists will be discussed. This involves and explication of some virtues that enhance shared conceptions of the practice of nursing. The significance of the good nurse in the shaping of good nursing practice will be considered alongside a reflection on the place of moral luck in nursing practice. It is argued that when nurses think of themselves as participating in a tradition of health care they find meaning in their work, Finally an understanding of nursing as a virtue-based activity clarifies good practice in such a way that nurses are able to elicit from it the qualities needed for its good practice.

This thesis explored the relationship between the discourses of nursing care, the nursing care provision, and the perceived nursing care needs of three highly dependent residents in a residential aged care facility in Australia. Residential aged care in this country has undergone major reforms since 1987 and the nursing profession has struggled with these changes because of the documentation, validation, and accreditation requirements; the inadequate determination of dependency on nursing care for funding; the Registered Nurse (RN) being removed from the bedside to a role of scribe and delegator; the increasing acuity and complexity of the residents' needs; an increase in the turnover of residents; a rise in the nursing staff attrition rate; the delivery of care by untrained and unqualified persons; the RN being accountable and responsible for the care given by 'non-nurses' from a distance; and, the inadequate skill mix and staff to resident ratios provided in these institutions. The interest of this thesis was to research gerontological nursing practice in the context of residential aged care. Residential Aged Care Facilities (RACFs) in Australia that care for the highly dependent elderly were identified in the thesis as disciplinary institutions that used 'subjectivation' as a means to control the efficiency and effectiveness of the labour force and the 'docile' bodies of the residents, whilst at the same time the government rhetoric is that of the quality of life standards and the rights of residents in these institutions. As well as the discourse analysis, an historical overview of the aged care reforms in Australia was undertaken for the period from 1975 to 2006 that demonstrated the effects the reforms have had on the voice of nurses and nursing care in these institutions. This analysis highlighted where nurses have been silenced and found the federal government determining what is nursing care and what is not nursing care, and also who is providing this nursing care. Using a case study approach and discourse analysis each of the three residents was studied using data from five sources namely the resident or relative, a RN, a careworker (CW), the current documentation pertaining to the resident's nursing care, and the non-participant observation of the nursing care provided. These discourses on the nursing care and perceived residents' nursing care needs were analysed using the theoretical base developed from the philosophy and research interest of Michel Foucault (1926-1984), who questioned the apparatus and institutions of Western cultures and searched for discontinuities in the practices of what he termed 'disciplines'. The results of the discourse analysis found nursing care practices that were alarming around the residents' perceived nursing care needs, the documentation of the nursing care provision, and the observed 'actual' nursing care provided. A questionable standard of nursing care was evidenced even though this facility had recently been accredited. A custodial level of mechanistic care was provided to residents in an extremely noisy and public environment within a culture of haste and bustle by unknowledgeable CWs, under the distant gaze of a RN, and the direction of the government documentation requirements. This resulted in unsafe, unethical, unprofessional, and negligent practices, as well as fraudulent, illegal, and dangerously out of date documentation practices. This was ultimately affecting each resident's quality of life, nursing care, and wellbeing and was an added burden on the residents' relatives. Many discontinuities, dissonances, conflicts, and contradictions in nursing practice were uncovered for these three highly dependent residents that may be transferable and similar to other highly dependent residents in this and other institutions. Indeed it may mirror other disciplines that provide care services, such as mental health care, acute care, and disability care provision. The concerns for the nursing profession have epistemological, ethical, and political ramifications for the residents and their relatives, the nurses, the non-nurses doing nursing work, the government, and the industry. Epistemologically new nursing 'knowledges' were being developed that were not resident focussed or based on evidence. Ethically, the legislated rights of residents were not being supported, despite the accreditation, funding, and complaint mechanisms in place - and this has the potential to have punitive ramifications for the industry. Professionally and politically, CWs were identified as non-nurses doing nursing work of a poor standard. This care was not based on accepted nursing practice, but developed through the documentation requirements of the federal government department, the applied constraints, and the CWs themselves. Furthermore, the documentation requirements were found to be a pretence in regard to funding through validation and accreditation, as well as a charade in nursing practice. There is presently a substantial third level of nurses who are identified legally and political as non-nurses doing non-nursing work (known as 'personal' care); but these non-nurses are doing nursing work and are identified by the nursing profession and the public as 'nurses' doing nursing work. These non-nurses who provided nursing care are not educated, licensed, or regulated, and are not accountable professionally to nurses or legally to the public. It is proposed that CWs are in need of licensing under nurses' boards requiring at the very least a minimum of training and education. It is further proposed that documentation requirements resort back to professional nursing documentation; funding be dependent on an predetermined minimum skill mix and staff/resident ratio; and the funding of residents be based on a minimum data set and untied from nursing practice. The professional nursing practice of assessment, planning, implementation, and evaluation of nursing care needs resorting to a nursing domain of knowledge, practice, accountability, responsibility, and documentation. If an acceptable quality of life is to be realised for residents in the residential aged care system, given that highly dependent residents are reliant on quality nursing care that is fundamentally imperative to their very quantity and quality of life, then changes in the residential aged care system and the nursing profession will be necessary. This thesis will contribute to opening up such dialogue between the government, the industry, and the nursing profession in Australia, and it also highlights areas of aged care nursing practice in need of further research.

A sample of 22 registered nurses participated in an educational program to learn comprehensive physical assessment skills. This study investigated the effects of that program on their nursing practice. Administration of tests and questionnaires provided a measure of the: (a) use of physical assessment skills; (b) knowledge of physical assessment; (c) changes in nursing practice since learning the skills; (d) barriers to the use of the skills. The model used for the program's curriculum development was adult learning theory. The curriculum focused on this theory's key aspects. Namely, adult students build new skills on their past knowledge and already developed skills. Additionally, they must see the relevance of learning the skills and be able to apply them in their current life situation. The findings suggest this model was appropriate. The nurses in the study used the majority of learned skills after they completed the program. Their knowledge concerning these skills also showed dramatic improvement. The major findings regarding the increase in knowledge and use of physical assessment skills, positive changes in nursing practice and lack of barriers to the use of skills indicate that an educational program in physical assessment can be very beneficial to nurses. The results support those of previous studies in that nurses will use the physical assessment skills they have learned in continuing education programs. The implications for nursing practice and education were discussed. Suggestions were then made for future research in this area.

In Canada, the nursing shortage and high turnover rate of nurses are expected to worsen over the next ten years, making the recruitment and retention of nurses a priority for health care. Previous research has indicated that job satisfaction influences the recruitment and retention of nurses. Most of the research on job satisfaction, thus far, has focused on nurses practicing in urban, acute-care settings. There has been little research on job satisfaction of nurses practicing in rural and remote settings in Canada, and even less on nurses practicing in advanced nursing practice (ANP) roles, specifically nurse practitioner (NP) roles. <p>A secondary analysis of data from the national survey The Nature of Nursing Practice in Rural and Remote Canada was conducted with a group of 327 RNs practicing in NP roles and 1,151 RNs practicing in non-NP roles. The objectives of the present study were to describe similarities and differences between RNs in NP versus non-NP practice roles in rural and remote settings in Canada in relation to: (1) demographic profile, (2) job satisfaction, and (3) community satisfaction. The final objective of the study was to explore what the most important work-related attributes for RNs whose practice roles were categorized as NP. <p>A modified version of Stamps (1997) Index of Work Satisfaction (IWS) was used to measure job satisfaction and the Community Satisfaction Scale (Henderson-Betkus & MacLeod, 2003) was used to operationalize community satisfaction. The study found that the reported overall level of job satisfaction was higher for RNs practicing in NP roles versus non-NP roles. Further findings suggested that the reported level of intrinsic job satisfaction factors was higher for RNs practicing in NP roles versus non-NP roles. The themes that were identified during the content analysis of NPs responses to the open-ended survey question related to the most important work-related attributes included: the nature of advanced nursing practice in rural and remote areas, work life, personal and professional development, practice philosophy, and the community. The findings of the present study provide useful information for health care administrators and policy makers on factors associated with job satisfaction of nurses practicing in NP and non-NP roles in rural and remote settings in Canada.

In Canada, the nursing shortage and high turnover rate of nurses are expected to worsen over the next ten years, making the recruitment and retention of nurses a priority for health care. Previous research has indicated that job satisfaction influences the recruitment and retention of nurses. Most of the research on job satisfaction, thus far, has focused on nurses practicing in urban, acute-care settings. There has been little research on job satisfaction of nurses practicing in rural and remote settings in Canada, and even less on nurses practicing in advanced nursing practice (ANP) roles, specifically nurse practitioner (NP) roles. <p>A secondary analysis of data from the national survey The Nature of Nursing Practice in Rural and Remote Canada was conducted with a group of 327 RNs practicing in NP roles and 1,151 RNs practicing in non-NP roles. The objectives of the present study were to describe similarities and differences between RNs in NP versus non-NP practice roles in rural and remote settings in Canada in relation to: (1) demographic profile, (2) job satisfaction, and (3) community satisfaction. The final objective of the study was to explore what the most important work-related attributes for RNs whose practice roles were categorized as NP. <p>A modified version of Stamps (1997) Index of Work Satisfaction (IWS) was used to measure job satisfaction and the Community Satisfaction Scale (Henderson-Betkus & MacLeod, 2003) was used to operationalize community satisfaction. The study found that the reported overall level of job satisfaction was higher for RNs practicing in NP roles versus non-NP roles. Further findings suggested that the reported level of intrinsic job satisfaction factors was higher for RNs practicing in NP roles versus non-NP roles. The themes that were identified during the content analysis of NPs responses to the open-ended survey question related to the most important work-related attributes included: the nature of advanced nursing practice in rural and remote areas, work life, personal and professional development, practice philosophy, and the community. The findings of the present study provide useful information for health care administrators and policy makers on factors associated with job satisfaction of nurses practicing in NP and non-NP roles in rural and remote settings in Canada.

Nurse practitioners (NPs) have been undergoing a rapid transition in their entry-level degree, from Master of Science in Nursing (MSN) to Doctor of Nursing Practice (DNP). At this time, it is important to establish research evidence on the effects of doctoral education on NP practice. Therefore, a qualitative study of practicing NPs that have returned for the DNP degree was conducted. The purpose was to describe NPs' perceptions of their DNP education, and particularly its influence on their professionalism and patient care. A literature review and evidence synthesis process showed that the available body of research provides little insight into the question of how DNP education affects NP practice; therefore, qualitative description methodology was used to describe this phenomenon. The research questions that guided the study were: 1) What changes do practicing NPs describe about their clinical practice after the experience of completing a DNP?; and, 2) What are the NPs' perceptions of and concerns about the influences of their DNP educational experience on their clinical practice? Two published models and the DNP Essentials (AACN, 2006) informed and guided the data collection and analysis process. Purposive sampling and analyses continued concurrently until data saturation was achieved. Ten DNP prepared NPs were interviewed, and there was wide variation in the sample. The overarching theme Growth into DNP Practice summarizes the participants' perceptions of the changes that have occurred as a result of their DNP educational experience. Four major themes that support the overarching theme are: (a) Broader Thinking and Work Focus; (b) New Knowledge and Interests; (c) New Opportunities; and, (d) "Doctor" Title an Asset. Conceptual categories under each major theme are described. Participants were overwhelmingly positive about the influences of their DNP education on their practice, but the role of the DNP graduate in knowledge translation has yet to be fully operationalized.

Critical care nurses need finely honed critical thinking skills in order to be safe, competent, and skillful practitioners of their profession. If clinical nurses do not learn how to reason effectively, they may make inappropriate decisions about their patients' care, ultimately resulting in increased patient mortality (Fonteyn, 1991). In addition, increasing nurses' decision-making and autonomy has been shown to improve job satisfaction and retention (Prescott, 1986).There are many authors who write about the need for developing critical thinking skills among practicing professional nurses (Creighton, 1984; Jenkins, 1985; Levenstein, 1981, 1983, 1984). However, research assessing the impact of continued education and clinical experience on the development of critical thinking skills is sparse.The purpose of this exploratory study is to determine if there is a relationship between the level of critical thinking skills (as measured by the Watson-Glaser Critical Thinking Appraisal Tool, 1980) in critical care nurses and the length of nursing experience, amount of continuing education pursued annually, and the level of formal nursing education completed. The conceptual framework that provides the basis for this study is Patricia Benner's (1984) application of the Dreyfus Model of Skill Acquisition to clinical nursing practice.Participants (N = 61) were obtained on a voluntary basis from the population of critical care nurses working in the intensive Care Unit, Coronary Care Unit, Cardiac Catheterization Laboratory, or Emergency Care Center of a 600 bed midwestern acute care facility. Each participant in the study was asked to sign an informed consent agreeing to participate after receiving a written and oral explanation of the study. Confidentiality of the participants was maintained by substituting identification numbers for the subjects' names on the data collection instruments. The investigator supervised the administration of the critical thinking instrument and demographic questionnaire.The Pearson product-moment correlation coefficient and a two-tailed t-test for independent samples were used to determine if there were any significant relationships between the WGCTA score and the length of critical care experience, attendance of continuing education programs, or completion of additional formal education. This data analysis supported hypothesis one with the results revealing a significant positive correlation (r = .46, p = <.001) between the WGCTA scores and the length of critical care experience. In addition, a statistically significant but weak positive correlation was found between the WGCTA scores and the length of experience in CCU (r = .52, p = .001). No significant correlation existed between the WGCTA scores and length of experience in ECC, ICU, or CCL. Hypothesis two was supported with a significant difference (t = 3.58, df = 59, p = .001) found between the critical thinking ability of the two groups, with those who have completed an additional formal program of nursing education scoring higher. A significant but weak positive correlation (r = .30, p =.020) was found between the number of continuing education programs attended annually and the WGCTA scores. Multiple regression was performed with the total WGCTA score being the dependent variable and total critical care experience, completion of additional formal education, and attendance of continuing education programs being the independent variables. Only total critical care experience entered the equation (E = 16.03, p = <.001) explaining 21% of the variance.The information gained from this study will provide direction for the review of existing orientation, continuing education, and staff development programs provided at different levels of nursing experience and make suggestions for change to enhance critical thinking skill development. / School of Nursing

"While consumer participation is the focus of 21st century health policy, little is known about this concept from the perspectives of people who require acute hospital services. [...]This project set out to explore older people's perspective of participating in their care. Adopting critical ethnographic method, field work included observation of the inpatient experience. Following discharge home people were interviewed about their experiences including what helped and what hindered participation in their care. Similarly nurses involved in [...] a hospital experience were invited to be involved in individual and focus group discussions aimed at defining how they believed they facilitated people to participate as well as barriers that prevent this style of care." / Doctor of Philosophy

"While consumer participation is the focus of 21st century health policy, little is known about this concept from the perspectives of people who require acute hospital services. [...]This project set out to explore older people's perspective of participating in their care. Adopting critical ethnographic method, field work included observation of the inpatient experience. Following discharge home people were interviewed about their experiences including what helped and what hindered participation in their care. Similarly nurses involved in [...] a hospital experience were invited to be involved in individual and focus group discussions aimed at defining how they believed they facilitated people to participate as well as barriers that prevent this style of care." / Doctor of Philosophy

Nursing has a tradition of subservience and obedience. History provides an account of secular and religious orders of nursing shaping a view of virtuous and tireless dedication in carrying out the doctor’s orders. Nurse Practitioners were first introduced to the health care system in the 1960s as a solution to the medical shortage being experienced in United States of America at that time. They assumed clinical tasks, traditionally regarded as doctor’s work. Since then the Nurse Practitioner movement has expanded globally. Australia introduced the Nurse Practitioner role in 1998, heralding a new era in the health system of that country. Its introduction has created diverging views which are influence role implementation. This study examines social and political discourses that are affecting the development of Nurse Practitioners in Australia, using text and language to identify discursive practices. It has set out to determine whether Nurse Practitioners have the autonomy that professional nursing leaders have described in policy, or whether the introduction of the role has merely shifted nursing’s sphere of influence within a traditional health care system. Using Fairclough’s notion of power behind discourse, the language and discourses of Nurse Practitioners were explored in relation to what was happening around role development and how Nurse Practitioners positioned themselves within the environment where they worked. The use of a Critical Discourse Analysis has allowed for the various social, historical and political perspectives of nursing to be examined. Fairclough’s three levels of social organisation have been used to identify the divergent discourses between the truths of implementation of the role at individual and organisational level and comparing it to that of the rhetoric of health policy. The discourses surrounding the creation of this advanced nursing role have been the focus of analysis. This analysis has revealed how role development is controlled by powerful groups external to the nursing profession. The dominant discourses use the traditional health care divisions of labour to maintain control through a financially driven focus on health care which does not necessarily revolve around clinical need. Further complicating the position of Nurse Practitioners is the internalisation of those dominant discourses by the nurses themselves. It reinforces Fairclough’s view that the dominant power lies behind the discourse, using the system itself to maintain a status quo, rather than overtly opposing it. Nurse Practitioners, despite being held out by the nursing profession as clinical leaders, are not able to influence change in health care or in their own roles. The results have further shown that nursing managers do not have an influence over the direction that health care and nursing takes. Further research is necessary to examine the broader leadership role of nursing within health care nationally and internationally, in order to establish the real position of nursing within the decision making framework of health care service development.