Nursing work and nursing knowledge : exploring the work of women's health nurses, patterns of power and praxis

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.

Other communities : Box mistletoe (Amyema miquelii) parasitism is not detrimental to the health of grey box (Eucalyptus microcarpa) trees at a regional scale

Mistletoes are hemiparasites that occur worldwide in many types of forest, woodland and shrubland ecosystems (Watson 2001). Some species are regarded as pests due to their detrimental effects on host species (Hawksworth 1983; Reid & Yan 2000). Heavy infestations can affect the growth, productivity and form of host trees, and may cause host death (Reid et al. 1994; Shaw et al.2004, 2008). In south-eastern Australia, mistletoes often are visibly obvious in trees along roadsides, in paddocks and on the margins of open forests; and concerns have been expressed about their potentially detrimental effects on host trees.Despite this, little quantitative information is available on the effects of mistletoes on tree health and mortality (Reid et al. 1994). Are detrimental effects widespread or localized? A first step is to assess whether trees parasitized by mistletoe are less healthy than those without such parasites. Here, we investigate the relationship between parasitism by Box Mistletoe (Amyema miquelii (Lehm. ex Miq.) Tiegh.), a common species in south-eastern Australia, and the health of trees of a widespread host species, Grey Box (Eucalyptus microcarpa (Maiden) Maiden), across a large geographic region.

Modelling the public health consequences of cannabis use in Australia

Aims: To detail and validate a simulation model that describes the dynamics of cannabis use, including its probable causal relationships with schizophrenia, road traffic accidents (RTA) and heroin/poly-drug use (HPU).

Methods: A Markov model with 17 health-states was constructed. Annual cycles were used to simulate the initiation of cannabis use, progression in use, reduction and complete remission. The probabilities of transition between health-states were derived from observational data. Following 10-year-old Australian children for 90 years, the model estimated age-specific prevalence for cannabis use. By applying the relative risks according to the extent of cannabis use, the age-specific prevalence of schizophrenia and HPU, and the annual RTA incidence and fatality rate were also estimated. Predictive validity of the model was tested by comparing modelled outputs with data from other credible sources. Sensitivity and scenario analyses were conducted to evaluate technical validity and face validity.

Results: The estimated cannabis use prevalence in individuals aged 10-65 years was 12.2% which comprised 27.4% weekly and 18.0% daily users. The modelled prevalence and age profile were comparable to the reported cross-sectional data. The model also provided good approximations to the prevalence of schizophrenia (Modelled: 4.75/1,000 persons vs Observed: 4.6/1,000 persons), HPU (3.2/1,000 vs 3.1/1,000) and the RTA fatality rate (8.1 per 100,000 vs 8.2 per 100,000). Sensitivity analyses and scenario analysis provided expected and explainable trends.

Conclusions: The validated model provides a valuable tool to assess the likely effectiveness and cost-effectiveness of interventions designed to affect patterns of cannabis use. It can be updated as new data becomes available and/or applied to other countries.

Strategies for bridging sectors and silos : a training model in mental health promotion

Issue addressed: The determinants of individual and community mental health and wellbeing are diverse and many lie outside the sphere of action of the health sector. Developing the confidence and skills of these other sectors to contribute to improved mental health has been identified as a priority at State and national levels that requires the development of specific workforce capacity-building strategies. Methods: VicHealth developed and implemented a two day short course to raise the capacity of organisations from a range of sectors to contribute to the mental health and wellbeing of communities. The model of this short course was constructed to reflect the diverse sectors targeted, which included health, local government, community arts, sport and recreation, justice, and education. Results: Evaluation of the two year pilot program, with more than 1,000 participants, has identified a high degree of satisfaction with the content and delivery model of the course, with clear changes in knowledge, skills and practice having been achieved. Cross-sector understanding and collaborations between participants increased as a result of the course. Conclusions: Continuing demand for the course demonstrates clearly that mental health and well-being is relevant to the core business of a broad range of community and professional organisations. The course has increased the confidence and capacity of these sector representatives to take action on mental health as well as increased cross-sector dialogue and partnerships. The recruitment of trainers from diverse sectors was successful in promoting a key component of the program, which was the message that mental health promotion should be the business of all sectors.

Health professionals' and dietetics practitioners' perceived effectiveness of fruit and vegetable parenting practices across six countries

Fruit and vegetable intake may reduce the risk of some chronic diseases. However, many children consume less-than-recommended amounts of fruit and vegetables. Because health professionals and dietetics practitioners often work with parents to increase children's fruit and vegetable intake, assessing their opinions about the effectiveness of parenting practices is an important step in understanding how to promote fruit and vegetable intake among preschool-aged children. Using a cross-sectional design, collaborators from six countries distributed an Internet survey to health and nutrition organization members. A self-selected sample reported their perceptions of the effectiveness of 39 parenting practices intended to promote fruit and vegetable consumption in preschool-aged children from May 18, 2008, to September 16, 2008. A total of 889 participants (55% United States, 22.6% Mexico, 10.9% Australia, 4.4% Spain, 3.3% Chile, 2.2% United Kingdom, and 1.6% other countries) completed the survey. The fruit and vegetable intake–related parenting practices items were categorized into three dimensions (structure, responsiveness, and control) based on a parenting theory conceptual framework and dichotomized as effective/ineffective based on professional perceptions. The theoretically derived factor structures for effective and ineffective parenting practices were evaluated using separate confirmatory factor analyses and demonstrated acceptable fit. Fruit and vegetable intake–related parenting practices that provide external control were perceived as ineffective or counterproductive, whereas fruit and vegetable intake–related parenting practices that provided structure, nondirective control, and were responsive were perceived as effective in getting preschool-aged children to consume fruit and vegetables. Future research needs to develop and validate a parent-reported measure of these fruit and vegetable intake–related parenting practices and to empirically evaluate the effect of parental use of the parenting practices on child fruit and vegetable consumption.

Mothers' AdvocateS In the Community (MOSAIC)- non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care

Background : Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

Methods : MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months.

Intervention: 12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals.

Main outcome measures: Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up.

Analysis: Intention-to-treat using multivariable logistic regression and propensity scoring.

Results : There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations.

Conclusion : Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care.

The professionalisation of stress management : health and wellbeing as a professional duty of care?

Workplace stress associated with ongoing processes of organizational change is a major occupational and public health concern. It is also a costly economic issue—both public and private. In this paper a framework will be used that draws on Michel Foucault’s genealogies of the Self to suggest that the management of stress by professionals—in a workplace environment increasingly characterized by the practices of risk management—emerges as a key element of the choices and responsibilities that frame what it means to be professional. To be (a) professional means to be a person capable of making choices and accepting responsibilities that are framed by a duty of care to manage one’s health and well-being to maximize organizational performance and effectiveness. The article will examine the ways in which transformations in the organization and practice of teachers’ work have witnessed large numbers of teachers being seen, and seeing themselves, as stressed. These understandings of teacher stress have provoked a number of strategies designed to encourage individuals to take care of themselves—and to take care of themselves in ways that will make schools more effective. The authors are concerned with understanding the processes that are at work which make it possible to imagine that it is a professional duty of care to manage one’s life in such a way as to be both balanced and effective in contexts of uncertainty and risk.

Maternal vitamin D in pregnancy may influence not only offspring bone mass but other aspects of musculoskeletal health and adiposity

Osteoporotic fractures, falls and obesity are major health problems in developed nations. Evidence suggests that there are antenatal factors predisposing to these conditions. Data are emerging from Australia and elsewhere to suggest that maternal vitamin D status in pregnancy affects intrauterine skeletal mineralisation and skeletal growth together with muscle development and adiposity. Given that low levels of vitamin D have been documented in many urbanised populations, including those in countries with abundant sunlight, an important issue for public health is whether maternal vitamin D insufficiency during pregnancy has adverse effects on offspring health. The developing fetus may be exposed to low levels of vitamin D during critical phases of development as a result of maternal hypovitaminosis D. We hypothesise that this may have adverse effects on offspring musculoskeletal health and other aspects of body composition. Further research focused on the implications of poor gestational vitamin D nutrition is warranted as these developmental effects are likely to have a sustained influence on health during childhood and in adult life. We suggest that there is a clear rationale for randomised clinical trials to assess the potential benefits and harmful effects of vitamin D supplementation during pregnancy.

Health burden of hip and other fractures in Australia beyond 2000

Objective: To calculate the expected increase in the number of fractures in adults attributable to the predicted increase in the number of elderly Australians.

Data sources: All fractures in adult residents (> 35 years) of the Barwon Statistical Division (total population, 218 000) were identified from radiological reports from February 1994 to February 1996. The Australian Bureau of Statistics supplied predictions of Australia's population (1996 to 2051).

Main outcome measure: The projected annual number of fractures in Australian adults up to 2051 (based on stable rates of fracture in each age group).

Results: The number of fractures per year is projected to increase 25% from 1996 to 2006 (from 83 000 fractures to 104 000). Hip fractures are projected to increase 36% (from 15 000 to 21 000) because of a substantial rise in the number of elderly aged 85 years and over. Hip fractures are expected to double by 2026 and increase fourfold by 2051.

Conclusions: In contrast to Europe and North America, where numbers of hip fractures are expected to double by 2026 and then stabilise, in Australia hip fractures will continue to place a growing demand on healthcare resources for many decades. These projections can be used for setting goals and evaluating the costs and benefits of interventions in Australia.

Australia's health 2006 : the tenth biennial report of the Australian Institute of Health and Welfare

The report shows that Australians generally have good health and are privileged to have a range of health care services available to them. There are stark exceptions to this that can be confronting—even if well-known already—notably the generally much poorer health status of Indigenous Australians.

Health care service provider and funding arrangements are both increasingly complex and increasingly costly to both individuals and taxpayers. A continuing challenge is how to balance both the complementary and competitive perspectives of government and non-government agencies, professional groups, and small businesses. Overall, national expenditure on health was 9.7% of GDP in 2003–04; and average health expenditure per person has grown by an average 3.8% each year between 1997–98 to 2002–03. Expenditure on aids and appliances, health research and pharmaceuticals contributed more to this growth than other areas.

While the ageing of the population is having a significant impact on the number and type of health care services delivered, high quality services for children continue to be a priority. Australia’s health 2006 has a special chapter focusing on children and their health. The chapter highlights the fact that while our children are generally very healthy, there are concerns that their ongoing health could be affected by more and more of them becoming overweight or obese. Levels of diabetes are now rising among our children and it is a continuing concern that asthma and mental health problems affect so many of them.

Health system expenditure on disease and injury in Australia, 2000–01

This publication presents estimates of health expenditure on disease and injury in Australia in 2000-01, classified by disease or injury group, age and sex. The estimates are available by area of expenditure - hospitals, high-level residential aged care, medical services, other professional services, pharmaceuticals and research.The 2000-01 disease expenditure estimates were based on the 176 disease and injury conditions used in the first Australian burden of disease study (AIHW: Mathers et al. 1999), with the inclusion of some additional sub-categories. This report aggregates these conditions into the 19 broad disease groups used by the burden of disease study. Disease expenditure estimates are also presented for selected conditions in the seven National Health Priority Areas and by age and sex.