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.

Over the course of the twentieth century, the quality, quantity and accessibility of health care services in Nicaragua were remarkably altered in accordance with the agendas of stakeholders in the national government and providers of "development aid", many of whose objectives were as much or more political as they were humanitarian. Much of the international health literature has focused on sociocultural factors that impact health care seeking, yet little research has been conducted on the political economic dimensions. This dissertation examines how sociocultural factors, political economy and social relations interacted in health care seeking decision-making among 50 poor and lower-middle-income households in Nicaragua, a country with high rates of poverty, child morbidity and child mortality. Attending to the ways that global and national policies were experienced in a local setting, the study provides an in-depth analysis of health care services in a country that has undergone three major regime changes within the last 25 years. How did the ideology of each regime influence health care, and how did the state influence both health staff and the lay population, especially with regards to people's expectations and understandings of the allocation of responsibility for health?The data indicate that health care services have significantly worsened during the recent years of neoliberal-oriented governance, concordant with an increase in economic insecurity. In conjunction with these macro-level processes, conditions of poverty have undermined people's ability to maintain longstanding reciprocal exchange relations and health care responsibilities. In ideology and praxis, the struggle between an ethos of solidarity and cooperation, versus one of individual competition and self-preservation, was engaged on a daily basis within and across extended households of kin, as well as between and among health care seekers and practitioners. Local level efforts to make up for the gap in government responsibility were limited precisely because the policies implemented by the government and international bodies undermined them. Neither the state nor civil society currently possesses the capacity to meet the basic health needs of the majority of Nicaraguans. For communities to thrive, the state must restore its safety net of health and other basic services.