Jill Wilkinson

Impact of postgraduate education on advanced practice nurse activity - a national survey

BACKGROUND There is a wealth of international evidence concerning the contribution post-registration masters level education makes to advancing the discipline of nursing. There are approximately 277 nurse practitioners registered in NZ, but they account for only a small portion of nurses who have undertaken masters level education. The additional contribution these nurses make to the work environment through advanced practice activities has not, hitherto, been documented. OBJECTIVES To report the extent of advanced practice nurse activity associated with various levels of nursing education in a sample of nurses working in clinical practice in New Zealand. METHOD A replication of recent Australian research was done via a national cross-sectional survey of 3255 registered nurses and nurse practitioners in New Zealand using an online questionnaire to collect responses to the amended Advanced Practice Delineation survey tool. In addition, demographic data were collected including position titles and levels of postgraduate education. RESULTS A positive association was found between postgraduate education at any level and more time spent in advanced practice activities. Independent of level of postgraduate education, the role a nurse holds also effects the extent of involvement in advanced practice activities. CONCLUSIONS There is an additional contribution made to the work environment by nurses with masters level education which occurs even when they are not employed in an advanced practice role. IMPLICATIONS FOR NURSING POLICY These findings are of significance to workforce policy and planning across the globe as countries work to sustain health services by increasing nursing capacity effectively within available resources.

Patient expertise: Contested territory in the realm of long-term condition care:

Objectives The aim of this study was to describe the experience of people with multiple long-term conditions with particular reference to the notion of the ‘expert patient’ in the context of self-management. Methods A multiple case study of 16 people with several long-term conditions, included interviews and contacts over an 18-month period and an interview with their primary care clinicians. Analysis included both case-by-case and some cross-case analysis. Results The findings reveal the patient participants had little capacity to exercise the agency necessary be an expert patient as premised. Weariness, shame, expertise, issues of compliance and control and collaboration are contested areas underpinning clinician encounters. Discussion Patient expertise is at the heart of self-management approaches but the findings surfaced several inherent contradictions between the idealised expert patient and their position within a health care system that is entrenched in biomedicine. Conclusion There is a mismatch between how the self-management approach has been operationalised and what the participants who have multiple LTCs reveal as what they want and need. The research concludes that the self-management approach is inappropriate for people with multiple LTCs and that other ways of offering care should be considered.

The complexity of food for people with multiple long-term health conditions

INTRODUCTION The prevalence of long-term health conditions (LTCs) continues to increase and it is normal for people to have several. Lifestyle is a core feature of the self-management support given to people with LTCs, yet it seems to fail to meet their needs. From a larger study exploring the experiences of this group, this paper reports on the role of food and mealtimes, and the effect of the nutritional advice on the lives of people with several LTCs. METHODS The experiences of 16 people with several advanced LTCs were explored using multiple qualitative case studies. Over an 18-month period, contact with participants included monthly conversations, two longer, semi-structured interviews and one interview with their primary care clinicians. The data were analysed inductively using thematic analysis. RESULTS There was profound social, psychological and cultural significance of food to the participants. These aspects of food were then described using the Whare Tapa Wha model of health. The approach to food and nutrition participants experienced in health care was closely associated with conventional weight management. They found this advice largely irrelevant and therefore ineffective. DISCUSSION The pressure people with several LTCs experience during clinical encounters has perverse effects on wellbeing and reinforces an overall sense of failure. This research challenges the assumption that all people have the will, agency and income to follow the advice they receive about nutrition and exercise. Considering peoples needs using the Whare Tapa Wha model of health offers clinicians a framework to re-conceptualise the core features of self-management support and provide realistic, compassionate care that will optimise the quality of life for people with multiple LTCs.

Self-management support? Listening to people with complex co-morbidities

Objectives The study aimed to explore how people with complex, established co-morbidities experience long-term condition care in New Zealand. Despite the original conception as appropriate for people with early stage disease, in New Zealand the self-management approach dominates the care provided to people at all stages of diagnosis with long-term conditions, something reinforced through particular funding mechanisms. Methods A multiple case study followed the lives of 16 people with several long-term conditions. Data collection comprised two interviews, four weekly contacts with patients over an 18-month period and an interview with their primary health care clinicians. Results This paper reveals a cohort of tired, distracted patients struggling to manage their lives in the face of multiple conflicting challenges, with insufficient energy for the level of personal agency required to deal with the self-management approach. Discussion Participants described aspects of care received, which does meet their needs but sit outside the self-management approach, that resonate with the ideas behind current approaches to palliative care. The potential of an approach to care built upon these ideas is explored as a more compassionate, effective way of meeting the needs of people with advanced, multiple long-term conditions. Further research is warranted to explore the acceptability of such an approach.