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AN INTRODUCTIONSIXTH EDITION

Contexts of Nursing

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AN INTRODUCTIONSIXTH EDITION

EDITED BY

JOHN DALY

DEBRA JACKSON

Contexts of Nursing

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CONTENTSContributors vii

Preface x

1 Presenting nursing … a career for life 1John Daly and Debra Jackson

2 Visioning the future by knowing the past 15Madonna Grehan

3 Nursing and social media 39Caleb Ferguson

4 Key concepts informing nursing: caring, compassion and emotional competence 57Stacey Wilson

5 Becoming a critical thinker 71Steve Parker

6 Reflective practice: what, why and how 89Kim Usher and Zachary Byfield

7 Research in nursing 105Elizabeth Halcomb

8 Ethics in nursing 119Megan-Jane Johnstone

9 An introduction to legal aspects of nursing and midwifery practice 129Amanda Adrian

10 Power and politics in the practice of nursing 165Stacey Wilson and Katheryn Butters

11 Becoming a nurse leader 183Patricia M. Davidson and Binu Koirala

12 Integrated care and multidisciplinary teamwork 203Jane L. Phillips, Claire Fraser and Louise D. Hickman

13 Technology and professional empowerment in nursing 223Caleb Ferguson

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vi CONTENTS

14 Nursing practice and digital health interventions: a focus on improving care 241Deborah Debono, Susan Maree Hanson and Berne Gibbons

15 Healthy communities: the evolving roles of nursing 263Anne McMurray

16 Health disparities: the social determinants of health 285Denise Wilson and Stephen Neville

17 Mental health promotion 301Wendy Cross

18 The challenges and rewards of rural and remote nursing 319Marie Hutchinson and Leah East

19 Cultural safety in nursing and midwifery 335Tamara Power and Kim Usher

20 Connecting clinical and theoretical knowledge for practice 349Jane Conway

21 Global health and nursing 369Michele Rumsey

Glossary 393

Index 403

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CONTRIBUTORSAmanda Adrian RN, BA, LLB, FACN

Amanda Adrian and Associates, President, Climate and Health Alliance, NSW, Australia

Katheryn Janine Butters RN, MPhil

Lecturer, School of Nursing, Massey University, Wellington, New Zealand

Zachary Byfield RN, Bphil, BN, GdipN, MN, Mphil

Lecturer of Nursing, School of Health, University of New England, Armidale, NSW, Australia

Jane Conway RN, BHSc, BNurs(Hons1), Ded

Associate Dean, Teaching and Learning, Faculty of Medicine and Health, Discipline Lead, Nursing,

School of Health, University of New England, Armidale, NSW, Australia

Wendy Cross RN, BAppSc, MEd, PhD

Professor and Dean, School of Health, Federation University Australia, Berwick Campus, Vic, Australia

John Daly RN, HonDNurs, PhD, FACN, FAAN, FFNMRCSI

Professor of Nursing, Head of School & Dean, Susan Wakil School of Nursing and Midwifery, Sydney

Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia

Patricia M Davidson RN, MEd, PhD, FAAN, FACN

Dean and Professor, Johns Hopkins University School of Nursing, Baltimore, MD, USA

Deborah Debono RN, PhD, BA(Psych Hons)

Senior Lecturer, Centre for Health Services Management, Faculty of Health, University of Technology

Sydney, Sydney, Australia

Leah East RN, GradCertAP, BN(Hons), PhD

Associate Professor in Nursing (Primary Health Care), Joint appointment with Hunter New England

Health, School of Health, University of New England, Armidale, NSW, Australia

Caleb Ferguson RN, PhD

Senior Research Fellow, Heart Foundation Postdoctoral Fellow, Western Sydney Nursing & Midwifery

Research Centre, Western Sydney University & Western Sydney Local Health District

Claire Fraser RN, BSc(Nur), MPallCare

PhD Candidate, Centre for Improving Palliative, Aged and Chronic Care through Clinical Research and

Translation (IMPACCT), Faculty of Health, University of Technology Sydney, NSW, Australia

Berne Gibbons RN, Diploma in Nursing

Adjunct Professor, Faculty of Health, University of Technology Sydney, NSW, Australia

Madonna Grehan RN, RM, GradDipHlthEth, PhD

Honorary Fellow, Nursing, School of Health Sciences, The University of Melbourne, Vic, Australia

Elizabeth Halcomb RN, BN(Hons), GradCertICNurs, GradCertHE, PhD, FACN

Professor of Primary Health Care Nursing, School of Nursing, University of Wollongong, NSW, Australia

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viii CONTRIBUTORS

Susan Maree Hanson RN, BSc(N), MSc(PHC)

Co-Chair, Palliative Care Network, Agency for Clinical Innovation, Sydney, NSW, Australia; Subject

Coordinator and Adjunct Professor, Faculty of Health, University of Technology Sydney, NSW,

Australia

Louise D Hickman RN, MPH, PhD

Associate Professor, UTS Fellow, Care of Vulnerable Older Populations, Faculty of Health, University of

Technology Sydney, NSW, Australia

Marie Hutchinson RN, BAppSc, GradDipHA, MHSc, PhD

Professor, School of Health and Human Sciences, Southern Cross University, NSW, Australia

Debra Jackson RN, AO, PhD, FACN

Professor, School of Nursing and Midwifery, University of Technology Sydney, NSW, Australia

Megan-Jane Johnstone RN, AO, BA, PhD

Independent Scholar; formerly Professor of Nursing (now retired), Deakin University, Vic, Australia

Binu Koirala RN, MGS, PhD

Assistant Professor, Johns Hopkins School of Nursing, Baltimore, MD, USA

Anne McMurray RN, AM, BA(Psych), MEd, PhD

Emeritus Professor, School of Nursing and Midwifery, Griffith University, Qld; Emeritus Professor, School

of Nursing, Murdoch University, WA; Adjunct Professor, University of the Sunshine Coast, Qld,

Australia

Stephen Neville RN, BA, MA, PhD, FCNA(NZ)

Professor and Head of Department, Nursing, Auckland University of Technology, Auckland, New

Zealand

Steve Parker BEd, PhD

Associate Dean (Teaching & Learning), School of Nursing & Midwifery, Flinders University, Adelaide,

SA, Australia

Jane L Phillips RN, BSc(Nur), PGD-HP, PhD, FACN

Professor, Palliative Nursing; Director, Centre for Improving Palliative, Aged and Chronic Care through

Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney,

NSW, Australia

Tamara Power RN, BN(Hons), GradCertDiabEdM, PhD

Senior Research Fellow, Faculty of Health, University of Technology Sydney, NSW, Australia

Michele Rumsey RN, GradDipHlth, FACN

Director, WHO Collaborating Centre for Nursing, Midwifery and Health Development, Faculty of Health,

University of Technology Sydney, NSW, Australia; Global Network of WHO Collaborating Centres for

Nursing and Midwifery, Secretariat, South Pacific Chief Nursing and Midwifery Officers Alliance

Kim Usher RN, AM, BA, DipAppSc, MNSt, PhD, FACN, FACMHN

Professor of Nursing, School of Health, University of New England, Armidale, NSW, Australia

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ixCONTRIBUTORS

Denise Wilson BA(SocSc), MA(Hons), PhD

Professor, Māori Health and Associate Dean, Māori Advancement, Faculty of Health & Environmental

Sciences; Co-Director, Taupua Waiora Māori Health, Research Centre, Auckland University of

Technology, Auckland, New Zealand

Stacey Wilson RN, MPhil(Dist.), PhD

Clinical Programmes Lead, Mental Health and Addictions Directorate, MidCentral District Health Board;

Adjunct Senior Lecturer, School of Nursing, Massey University, New Zealand

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PREFACEWelcome to the sixth edition of Contexts of Nursing. There has never been a more exciting time to be a nurse! As we write this preface in 2020, the year designated by the Seventy-second World Health Assembly as the International Year of the Nurse and the Midwife; the world is gripped by a deadly pandemic, and nurses everywhere are in active service in

State of the World’s Nursing 2020

editions, this volume introduces students to the theory, language and scholarship of nursing

extend them. This is a good thing, and will hold students in good stead for the future, as the discipline and profession of nursing continues to evolve, mature and develop within

are explored and considered in relation to professional nursing practice and the context of healthcare.

We have explained previously why the notion of ‘contexts’ has appeal for us in concep-

as-fabric’ metaphor provides access to a number of other related ideas, such as weaving

nurses who found previous editions useful in undergraduate and graduate courses and in their educational development and practice.

edition, a number of new strategies have been incorporated to facilitate deeper personal

been learned so far. Stories are used by a number of contributors as case study examples

internalisation of content by the reader.

their ongoing enthusiasm, encouragement, support and assistance in the preparation and

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xiPREFACE

again to the challenge of developing engaging, scholarly and learning- and teaching-oriented

John Daly

Debra Jackson

Sydney, June 2020.

References

Daly J, Jackson D, Anders R, Davidson P M 2020 Who speaks for nursing? COVID-19 highlighting gaps in leadership. Journal of Clinical Nursing, April. doi:10.1111/jocn.15305

World Health Organization (WHO) 2020 State of the World’s Nursing Report 2020. Online. Available: https://www.who.int/publications/i/item/nursing-report-2020 8 June 2020

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Caleb Ferguson

NURSING AND SOCIAL MEDIA

C H A P T E R 3

LEARNING OBJECTIVES

After reading this chapter, readers should be able to:

define social media and describe a variety of applications for nursing practice;

describe how social media interfaces with nursing across practice, education, research and policy;

apply regulatory policies and guidelines for social media use and discuss their implications for nursing;

describe ethical and professional issues for nurses to consider when using social media in practice;

contemplate the future innovations and horizons for social media and nursing.

KEY WORDSdigital nursing

e-professionalism

ethics

professionalism

social media

social networking

technology

Twitter chat

INTRODUCTIONCommunication is a vital aspect of human interaction. On 10 March 1876 Alexander Graham Bell invented the telephone, sparking the advent of a new telecommunications industry. Within today’s society, the internet is a critical piece of communication infrastructure for many people, and therefore denying or restricting access, while hospitalised for example, is failing to address people’s needs. In today’s world, the internet is a central element of daily life, and has replaced the

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40 CONTEXTS OF NURSING: AN INTRODUCTION

telephone as the main source of communication. The face of the internet is constantly evolving, and social media platforms are rapidly changing living landscapes. Web 2.0 describes a change in the way humans interact with information online. Since the inception of Web 2.0 we have witnessed internet users adjust from being passive recipients of web-based content to active creators and curators of digital content (Ferguson 2013). Social media platforms are wide ranging and include Facebook, Twitter, LinkedIn, Google+, YouTube, Instagram, Pinterest and Snapchat to name a few. Users of these platforms can actively create their own content by posting and uploading photos, sharing content, ‘liking’ or blogging information and ideas. Social media is an umbrella term that includes social networking (such as LinkedIn), content sharing (such as Instagram), web publishing (such as blogging and micro-blogging) and wikis (including Wikipedia) (Department of Education and Early Childhood Development 2013). While nursing has been relatively slow to take up these innovative tools and the social media boom, the potential application within nursing practice, policy, education and research is extremely far reaching and should be embraced (Ferguson 2013). However, social media should be approached with risk at front of mind. Nursing remains one of the most risk-averse professions, and rightly so, as we are charged with caring for vulnerable individuals. Therefore, it is important that when applying social media to nursing practice, this is carefully risk managed and assessed for appropriateness in practice.

There is a vast array of novel examples of social media application in nursing. These include online support blogs for individuals living with atrial fibrillation (AF), stroke survivor support groups on Facebook and social media-facilitated journal clubs and Twitter chats for nursing researchers and clinicians to name a few. An extensive and diverse range of platforms continue to emerge. However, it is important that nurses have a basic understanding of social media and its implications for nursing practice within the context of the contemporary healthcare system.

What is social media?

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41CHAPTER 3 NURSING AND SOCIAL MEDIA

Relevance to nursing and modern healthcare

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FIGURE 3.1

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Social media ethics and e-professionalism

1

2

3

4

Guidance, policy and regulation

Contemporary application in nursing

PATIENT SUPPORT AND NURSING INTERVENTIONS

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Web publishing, blogging and online communities

BOX 3.1

Recommendations for nurses using social media

• Be cognizant and proactive about knowing and understanding the terms and

conditions of each of the social media sites that you use. This can often be

challenging, given the frequency with which these are updated, but it is important to

keep abreast of these updates and review these and their privacy settings on a

regular basis.

• Users of social media should consider all posts as public. It’s very easy for a private

post to become public (such as a ‘friend’ or connection screen grabbing a post and

re-posting it). Therefore, users should adopt a ‘time out’ strategy and develop a

‘think and reflect’-before-you-post attitude. Be careful in crafting posts, as with the

written word; this is easily misconstrued, taken out of context and could have both

damaging and negative consequences for professional relationships and career

prospects.

• Never consider posts to be anonymous.

• It is essential to regularly monitor and evaluate your digital presence. At minimum, a

yearly digital presence personal review is recommended.

• Ensure that you are adhering to your professional standards for practice, employer

code of conduct and that you are up to date with privacy and confidentiality

legislation.

• Do not post content outside your area of expertise, and avoid the use of testimonials

(in adherence with new advertising legislation and guidance) (AHPRA 2014a, 2014b).

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Patient support and nursinginterventions

Patient servicesand workforce

issues

Education andprofessionaldevelopment

Policy, procedureand research

FIGURE 3.2

Key areas for social media innovation in nursing

BOX 3.2

Examples of patient support and nursing interventions delivered via social media

• Raising organ and tissue donation awareness (advocating via Twitter, see Fig. 3.3)

• Providing ad hoc supportive care for patients and family members via a digital forum

• Assisting with diabetes management (such as blood glucose tracking)

• Maintaining a personal health diary (e.g. posting via MyFitnessPal to Facebook)

• Connecting patients with similar conditions (National Stroke Foundation Australia’s

EnableMe—online patient community for stroke http://www.enableme.org)

• Providing smoking cessation assistance (ability for real-time feedback from smoking

cessation counsellors)

• A platform to engage with exercise training and management

• Receiving ‘daily health tips’ from credible sources (e.g. secondary stroke prevention)

PATIENT SUPPORT

• Obtaining weight management support (e.g. ‘Lark’ smartphone application)

• Engaging with epilepsy support groups (such as consumer-driven or NGO-led

Facebook page initiatives)

• Engaging with stroke survivor support groups

• Engaging with brain tumour support groups (such as Nurse Consultant-led Facebook

groups after discharge post-surgery)

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Health promotion

-

FIGURE 3.3

An example of social media advocacy for organ and tissue donation through @DonateLifeToday Twitter account

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PATIENT SERVICES AND WORKFORCE

EDUCATION AND PROFESSIONAL DEVELOPMENT

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Twitter chats

BOX 3.3

Examples of social media-delivered patient services and workforce interventions

EXAMPLES OF SOCIAL MEDIA-DELIVERED PATIENT SERVICES

• Patient care reminders in the clinical setting (automated text messaging SMS services

for clinic appointments)

• Prescription management, including pharmacy refill reminders

• Coordinating preoperative, peri-operative and post-operative care

• Arranging outpatient care

• Coordinating allied healthcare services during patient admissions

• Coordinating patient discharges across clinical services

• Post-discharge patient consultations

• Case management functions

• Checking hospital ratings with other healthcare consumers (e.g. MyHospital)

EXAMPLES OF SOCIAL MEDIA-DELIVERED WORKFORCE INTERVENTIONS

• Transmitting critical laboratory values to nurses and physicians

• Augmenting telemedicine

• Remote wound care assistance

• Shift bidding for nurses and other healthcare professionals (e.g. CASCOM, which is

an online open shift-bidding platform for casual staff that can be accessed via

smartphone and desktop devices)

• Recruitment of healthcare staff (advertising on LinkedIn for job opportunities and

vacancies)

• Communicating with nursing supervisors

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Development of clinical skills

POLICY, PROCEDURE AND RESEARCH

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BOX 3.4

Examples of social media-delivered education and professional development

• Clinician opinion-sharing via short tweets and twitter conversations

• Example NCLEX (National Council Licensure Examination) test questions for

preparation for nursing registration in the USA (see Fig. 3.4)

• Reviewing evidence-based byte-size education for clinicians

• Providing an avenue for nurse–mentor relationships and collaboration

• Live-tweeting surgical procedures for education (Watch: https://www.youtube.com/

watch?v=LZycUg4OGhI)

• Live-tweeting nursing conferences and meetings (Example #PCNA2016; Preventative

Cardiovascular Nurses Association 2016 Conference, Orlando, April 2016)

• Connecting genetic and basic science/bench researchers with clinicians

FIGURE 3.4

Example of Twitter being used for NCLEX exam revision

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-

+

BOX 3.5

Examples of social media integration across health policy, procedures and research

POLICY AND PROCEDURE

• Adverse event reporting in the clinical setting

• Drug safety alerts from the Therapeutic Goods Authority (TGA) or new listings on the

Pharmaceutical Benefits Scheme (PBS)

• Tweeting updates on facility policies and safe operating procedures (local health

districts and hospitals dissemination to employers via platforms such as Yammer)

• Issuing emergency updates to hospital services to the general public

• Clinical education coordination (updates to employees about upcoming educational

events, such as opportunities to achieve mandatory training requirements)

COMMUNICATION

• Rural area healthcare communication (providing back channel moderated Twitter

chat to augment an interstate metro-rural education web conference)

• Publishing health-related news

• Tracking evidence-based guideline updates

NURSING RESEARCH

• Clinical trial awareness (updates to clinicians on clinical trial recruitment targets)

• Research finding dissemination

• Sharing peer-to-peer reviews of articles of interest

• Generating streams of authoritative healthcare content online

• Discussing public healthcare policy

• Developing stronger patient–provider–researcher relationships

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You are working as a new graduate registered nurse in a busy acute surgical ward in a major metropolitan teaching hospital. You are caring for Hayley, a 23-year-old female patient who has recently been involved in a road traffic accident and has fractured her

neck of femur. You are administering an injection to her. While obtaining Hayley’s consent for a subcutaneous injection, and checking the five rights of medication administration, Hayley asks you if she can record and live broadcast a short Facebook video of her injection to her friends using her smartphone. Hayley’s mum is also present at the bedside, and thinks this would be pretty ‘cool’ to do too, and is keen to assist in recording this video.

Reflective questions

1 What would your nursing actions be in this scenario?

2 How would this interaction with Hayley affect your therapeutic relationship with her?

3 What could the professional repercussions of your actions be if you allow Hayley to record and broadcast this procedure?

4 What are important factors of consent in this scenario?

STORY

You have been working for three years in the general medical ward of a regional hospital. During this time, you have received many ‘friend requests’ on Facebook from your nursing colleagues in the ward, which you have accepted. You have had a busy morning

shift, and were short of staff and acuity of patients was unexpectedly high. That evening you log onto Facebook at home, and see a post from a colleague that you were working alongside that morning. She is venting about the terrible shift she had experienced, makes note of the intensity of the workload and is insulting and offensive to other colleagues from your unit.


1 What reaction would you have to your colleague’s post?

2 How would you approach your colleague both online and offline?

3 Would you report this behaviour to your nurse unit manager?

STORY

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Deborah Debono, Susan Maree Hanson and Berne Gibbons

NURSING PRACTICE AND DIGITAL HEALTH

INTERVENTIONS: A FOCUS ON IMPROVING CARE

C H A P T E R 1 4

LEARNING OBJECTIVES


consider the design, development and implementation of digital health interventions using co-design principles and approaches;

understand barriers and opportunities for the use of digital health interventions to improve patient outcomes and care;

understand how digital health innovations underpin intelligence-informed healthcare;

appreciate the role of technology in supporting the use of data to improve patient safety and clinical quality;

discuss the innovative technologies available to nurses that can improve patient safety and clinical quality.

KEY WORDSadaptive change

clinical information

digital health interventions

electronic medical records

improving care

safety concerns

workarounds

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INTRODUCTIONRecent research suggests that nurses perceive that they are currently inadequately prepared for the digital age, not ready to lead decision making about the adoption of digital technology, facilitate digital literacy or model digital professionalism in healthcare (Mather et al 2019:1). Given the rapid spread of digital health interventions across healthcare and nurses’ pivotal role in leading and delivering healthcare, it is essential to address this gap.

This chapter provides a high-level overview of the intersection between digital health interventions and nursing practice. Digital health is a rapidly growing field with an ever-expanding body of knowledge and evidence supporting its adoption. It would not be feasible to cover all aspects in a single chapter. This chapter establishes a baseline of understanding that can both inform current nursing practice and form the basis of further study or exploration. The chapter provides the reader with a practical definition of digital health technology that can assist with promoting meaningful use, an overview of the current state of play in the UK, the USA and Australia, and an introduction to the opportunities and challenges that are associated with the digitalisation of healthcare. We have focused on the implementation and impact of digital clinical records, as both nationally and internationally these form the backbone of digital health strategies. Importantly, the chapter should assist nurses to become aware of the frontline clinical practice implications that are associated with digital health interventions.

Data driven careThere is no doubt that the introduction of digital technology in health has brought, and

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243CHAPTER 14 NURSING PRACTICE AND DIGITAL HEALTH INTERVENTIONS: A FOCUS ON IMPROVING CARE

as it is done as it is imagined to be done

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What is a digital health intervention?

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DIGITAL HEALTH TECHNOLOGIES

Ohashi et al 2014)

2018, Hydari et al 2018)

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Lessons from global implementation of digital health technologiesGLOBAL STRATEGIES FOR DIGITAL HEALTH TECHNOLOGY ADOPTION

ELECTRONIC HEALTH OR MEDICAL RECORDS

across within a single care

TABLE 14.1

Health-related social networks

SOCIAL NETWORK FOCUS

MedHelp Online health community that partners with hospital doctors and medical research institutions to deliver online discussion boards on healthcare topics

CureTogether Crowdsourcing initiative that brings patients and researchers together to find cures for chronic conditions

Vitals Online search tool to help consumers search for the best medical care

DailyStrength Online social network centred on support groups, where users provide one another with emotional support by discussing their struggles and successes with each other

PatientsLikeMe Online patient network that connects patients with one another, whereby they can share their experience with disease, share their health data to track their progress, help others and contribute to research that advances medicine, improving their outcomes and enabling research

Inspire Online health community providing a safe and secure place for patients and caregivers to support and connect with one another

FacetoFace Health Online health community that connects one-on-one with others who share similar health experiences

Bichel-Findlay et al 2017.

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Electronic health records in the United Kingdom

1

2

3

4

5

6

7

8

9

10

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Electronic health and medical records in the United States

Digital health interventions in Australia

1 Putting users at the centre2

3 Fostering agile collaboration4

5

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6

1

2

3

4

5

6

7

Understanding barriers and opportunities to the implementation of digital health technologiesSUCCESSES AND UNEXPECTED CHALLENGES

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1

2 Extended (i.e. > 4 hours) eHR unavailability (either planned or unplanned)

3 Failure to heed a computer-generated warning or alert

4 System-to-system interface errors

5

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6 eHR time measurement translational challenges

7 Incorrect item selection from a drop-down list of items

8 Open or incomplete orders

SOCIO-TECHNICAL MODELS FOR UNDERSTANDING THE INTERSECTION BETWEEN TECHNOLOGY AND NURSING PRACTICE

Workarounds and adaptations

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James, a nursing student averaging High Distinctions, embraced the call to adopt gold standard practices when delivering patient care. He was excited that the ward he was assigned to for his first placement, as a newly graduated nurse, used an electronic

medication administration system (EMMS). He anticipated this digital health technology would support him to deliver high-quality care.

Three months into this placement, as he prepares to go to work, James reflects on the shifts he has completed since starting on Nightingale medical ward. It was his first ward allocation in the new graduate program. He had felt fortunate to have secured a position in the postgrad program and had been excited to start as a registered nurse. He was, however, rapidly losing his drive to embrace technological innovations for excellent care, and even his passion for nursing.

Each shift James is conscious of the eye rolling, the displeasing looks, the muttering and the obvious judgement and conclusion by the senior nurses that he is too slow. It has been made obvious that his newly graduated peers have been given opportunities that he has not because, based on demonstrated ‘time management’, he has not yet demonstrated that he warrants additional responsibilities. He knows that he is handing on more tasks to the nurses on the next shift than the others, even though he takes much shorter breaks and stays back to write up the patients’ notes. James is also conscious that he takes longer to complete medication rounds than the other nurses, including some of his newly graduated peers. He has noticed that while he is adhering to all the prescribed steps when administering medication using the EMMS, his colleagues do not always do so.

James is acutely aware that he is one of the few nurses on the ward who uses (or tries to use) the technology as it is intended to be used when administering medication. When administering medication James pushes the computer on the dedicated trolley to the bedside so that he is able to conduct the 5Rs when administering medication. Many of his peers have adopted the medication administration practices elected by the more experienced staff. He concludes that this is a major contribution to his time management.

There are some patient rooms in which there are black spots, so the computers do not work at the bedside. In other rooms, it is really difficult to get the computer into the room because of the equipment already in there. James spends time moving equipment and furniture out so that he has the room to take the computer into these crowded rooms so that he can legitimately check the 5Rs at the bedside when administering medication. He then has to move everything back into the room, which is a very time-consuming process.

Some of the computers have a very short battery life, which means the computer has to be plugged in quickly in each room. James recalls several occasions when, because he was talking to a patient and their visitors, he had not plugged the computer in quickly enough and, because of the short battery life, it had shut down, losing the information he had entered (about which medica-tions he had put in the medication cup). In each instance, he had thrown out those medications and had started the process all over again. Rather than taking the dedicated computer trolley (workstation on wheels (WOW)) to the bedside to check the 5Rs when administering medication, some nurses leave it in the corridor outside the patient’s room, sign off the medication before administering it and either memorise the patient’s medical record number and name or write it on a piece of paper to complete the 5Rs.

STORY

Continued

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There are some instances that James has observed when, even though they could have used the technology as intended, some nurses did not because they said it took too long and that they wanted to avoid delays for their patients. They prepare the medications for each of their allocated patients in the medication room, write the patient’s bed number or name on the medication cup, sign all the medications off in the computer in the medication room and then take the labelled cups to each patient to administer them.

James feels extremely uncomfortable with these workaround practices. There are times, however, when not taking the WOW to the bedside seems to be best for the patient. For example, when the patient is isolated, taking the computer to the bedside constitutes an infection risk. In those scenarios James takes the WOW to the bedside and thoroughly cleans the trolley and wheels each time he administers medication—again taking him much longer than his colleagues who use a workaround.

James is concerned that his performance review will not be positive. Last night he had been allocated six patients, one of whom, Mrs Jones, had shown signs of confusion and agitation on previous night shifts. According to handover, the nurses had used a range of strategies to help Mrs Jones remain settled overnight. James was reminded of the noise-reducing strategies embraced on this ward, including soft closing bins, soft-soled shoes, call bells diverted to pagers and, where possible, using the sink at the nurses’ station rather than in the patients’ rooms. Mrs Jones had been asleep since the nurses commenced the night shift. Mrs Breen, in the bed opposite Mrs Jones, was due a medication at 02.00. James had pushed the WOW to her bedside so that he could conduct the 5Rs. The noise of the trolley and the lights of the computer woke Mrs Jones who started calling out, waking the other patients in her room and in the room across the hall. One of the nurses looked pointedly at James and suggested that next time he might consider the impact on patients’ sleep of taking the WOW to the bedside in the middle of the night. James felt torn. He knew that not taking the WOW to the bedside made him professionally vulnerable if he had made a medication error.


1 How does James’ situation reflect the gap between work-as-imagined and work-as-done?

2 How might consideration of the complexity of patients’ responses to hospitalisation, environment, equipment and expectations (e.g. Key Performance Indicators) prior to implementing technology have mitigated James’ dilemma?

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Tamara Power and Kim Usher

CULTURAL SAFETY IN NURSING AND MIDWIFERY

C H A P T E R 1 9

LEARNING OBJECTIVES


explain the concept of culture;

define the terms cultural safety and cultural capability and how these concepts inform nursing care;

discuss culture in the context of nursing and the healthcare system;

examine the role of cultural safety in improving access to healthcare services;

reflect and think critically about own values and beliefs when caring for Aboriginal and Torres Strait Islander peoples, Māori and people from other cultural and ethnic backgrounds;

identify specific considerations for the delivery of culturally safe nursing care for Aboriginal and Torres Strait Islander peoples, Māori and people from other cultural and ethnic backgrounds;

understand how the social determinants of health can impact those who are not part of the dominant culture.

KEY WORDSAustralia

colonisation

cultural capability

cultural safety

culturally safe nursing care

culture

First Peoples

Māori

multiculturalism

New Zealand

social determinants of health

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INTRODUCTIONAustralia and New Zealand’s populations are becoming increasingly culturally and socially diverse due to immigration. To provide effective nursing and midwifery care for all people, nurses and midwives need to be adaptable and able to accommodate cultural considerations and differing constructs of health in their work. In recognition of Indigenous Peoples as the original inhabitants, and their unique healthcare needs that stem from a history of colonisation, marginalisation and racism in both Australia and New Zealand, this chapter will differentiate the healthcare needs of Indigenous Peoples from the needs of people from other culturally and linguistically diverse (CALD) backgrounds.

Before reading this chapter

Culture

The concept of culture and its relationship to nursingCULTURE IS DYNAMIC

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337CHAPTER 19 CULTURAL SAFETY IN NURSING AND MIDWIFERY

Cultural safety

cultural safety

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Aboriginal and Torres Strait Islander peoples in Australia

Info

Info

Info

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Multicultural New Zealand

BOX 19.1

Key dates in New Zealand’s history

1300 East Polynesian people arrive—now known as Māori

1642 Abel Tasman visits

1769 James Cook arrives and claims New Zealand for Great Britain

1835 Declaration of Independence signed by 34 Māori chiefs

1840 Treaty of Waitangi

1865 Wellington declared capital in place of Auckland

1893 New Zealand becomes the first country to give all women the right to vote

1907 New Zealand becomes a dominion

1908 Population reaches 1 million

1933 Adopts own currency

1947 Adopts the Statute of Westminster (1931) and becomes independent of Great

Britain


1967 Decimalisation of currency


1983 Closer Economic Relations (CER) agreement signed with Australia

1985 Waitangi Tribunal given power to hear Māori land grievances going back to

1840



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Refugees and asylum seekers

BOX 19.2

Working with Indigenous people

Things to be aware of when working with Indigenous people include:

• Indigenous people perceive health and illness differently from the Western

biomedical model. Be sensitive to alternative worldviews.

• It may not be appropriate for a nurse to care for an Indigenous consumer of a

different gender. Where possible ask that a nurse of the same gender is assigned to

care for that person or ask if a family member is able to assist in any way. If this is not

possible, explore solutions with the consumer; for example, delaying personal care

till the next shift.

• Indigenous consumers must be consulted and included in all decisions about their

care. Sometimes this may also mean involving family members. Be guided by the

consumer in this matter. Indigenous consumers often have an extended family and

group of carers who all should be consulted.

• Avoid asking questions about ceremonial business, bereavement, sexuality, fertility,

domestic habits and other similar sensitive issues. If you are unsure regarding what is

appropriate to ask, meet with an Aboriginal Liaison Officer for guidance. Engage in

ongoing professional development regarding Indigenous culture.

Adapted from Haswell et al 2009, Westerman 2004.

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TABLE 19.1

Periods in Australian immigration policy development

YEARS POLICY FEATURES HEALTH POLICY IMPLICATION

1945–70 Assimilation Predominantly White Australian Anglo-Saxon policies.

Absence of government assistance.

1970–80 Integration White Australia policy relaxed and gradually abandoned.

Relevant services provided.

Some cultural characteristics tolerated. Welfare needs of migrants being addressed.

1980–89 Multiculturalism Pluralistic approach to immigration.Policies to limit discrimination on racial and ethnic grounds.Cultural and ethnic diversity becoming more accepted in Australian society.Cultural identity, social justice and economic efficiency were adopted.

Provision of various health services.Equality of access to culturally appropriate services.

1983 Mainstreaming Redirecting service delivery from marginal to a central base.

Promotion of culturally sensitive health services.

Concern of government institutions based on social equity and access; economic efficiency and cultural identity.

Equality of access to health services by immigrants.

1999 Inclusiveness Diversity.Multicultural policies built upon civic duty, cultural respect, social equity and productive diversity.The term multiculturalism to remain.Inclusiveness.

Promotion of culturally sensitive health services.Equality of access to health services by immigrants.

2000–08 United in diversity

National agenda for a multicultural Australia.Policy framework including: all Australians are expected to have a ‘loyalty to Australia and its people, and to respect the basic structures and principles underpinning our democratic Society. These are: Constitution, Parliamentary democracy, freedom of speech and religion, English as the National language, the rule of law, acceptance and equality’ (Commonwealth of Australia 2008:1–2).

Main components of ‘Multicultural Australia: united in diversity policy 2003–06’: responsibility, respect, fairness and benefits for all.

2008–12 Benefits of cultural diversity

Celebrate and value the benefits of cultural diversity. Emphasis on justice, inclusivity, trade, racism and discrimination.

The People of Australia: Australia’s multicultural policy launched in 2011.

2013–17 Strength in diversity

Recognise the strength inherent in a multicultural society.

Multicultural Australia—united, strong, successful: multicultural statement released 2017

Source: Commonwealth of Australia 1999, 2003, 2008, Department of Home Affairs 2020, Spinks 2009

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Correlations between disadvantage and the social determinants of health

Providing culturally safe nursing care

CULTURAL AWARENESS

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CULTURAL SENSITIVITY

FIGURE 19.1

The process of achieving cultural safety in nursing and midwifery practice

Cultural Awareness

• Is a beginning step towards understanding difference. Many people undergo courses designed to sensitise them to formal ritual and practice rather than the emotional, social, economic and political context in which people exist.

Cultural Sensi�vity

• Alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own realities and the impact this may have on others.

Cultural Safety

• Is an outcome of nursing education that enables safe service to be defined by those who receive the service.

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