Doctor of Public Health
University of Wollongong. School of Health Sciences
Apolloni, Lucia, Bringing about behaviour change: nursing practice and cardiac rehabilitation, Doctor of Public Health thesis, University of Wollongong. School of Health Sciences, University of Wollongong, 2010. http://ro.uow.edu.au/theses/3228
The concern that underpins this research is that the impetus for assimilating behavioural models and frameworks into community nursing work is divorced from an informed understanding of how this work is currently being undertaken and what constitutes its elements. While there is considerable evidence that many nurses deliver behavioural interventions for the prevention and amelioration of disease, the literature provides little and generally superficial detail about the way in which this work is actually carried out.
This qualitative research investigates nurses’ behaviour change practice within the context of community based cardiac rehabilitation. The methods of research were designed to explore multiple dimensions of this area of nursing work; namely the theory that informs it, the practice itself and the factors that serve to facilitate and constrain it.
The sample was drawn from four area health services across New South Wales, Australia. Maximum variation sampling was chosen as the sampling method to enable a view that is wide-ranging and inclusive of varied practices. The twenty-seven participants included both specialist and generalist nurses who were responsible for the delivery of Phase II cardiac rehabilitation services conducted in out patient or community-based settings. The data were obtained from a process of semi-structured interviewing and were subjected to thematic analysis and an exploration of discourse.
The research found that generalist and specialist nurses carry out their behavioural interventions in completely different ways, which rules out any distinct theory or explanation for the way this work is carried out. This diversity of practice is underpinned by nurses’ varied and at times conflicting understandings about what this work entails and how it should be performed. It stems not only from differences in nurses’ knowledge and skills, but also from the organisational context that serves to either facilitate or constrain practice for behaviour change. Indeed, organisational practices, including those instigated by nurses themselves, are instrumental in determining whether certain knowledge and skills for delivering behavioural interventions are gained in the first place, as well as whether nurses are enabled to translate these into practice and develop appropriate skills for this area of work.
The findings expose the power relations between the different groups of nurses, which serve to support dominant medical and organisational interests. While the specialist nurses exercised their autonomy to gain new knowledge and develop their expertise, they also employed it to shape and control the work of their generalist colleagues in standardised medically focused ways. Generalist nurses are required to follow clinical pathways or standardised processes whereas the autonomy specialist nurses are accorded in their practice enables innovation and allows the development of expertise in this non-clinical area of nursing work.
An important finding is that behavioural theory plays little part in informing practice. Few generalist nurses demonstrated any knowledge or understanding of behavioural theory. In developing this area of practice, they attempt to mould it into routine patterns of clinically focused practice, which sees the behavioural elements of their work limited to instructional or educative exercises.
Specialist nurses acknowledge that theory grants them an understanding of behaviour change processes yet they adopt an eclectic approach informed by trial and error learning rather than a specific behavioural model or framework. This type of learning isinformed by the nurses’ subjective understanding of individual patients and the way those patients make sense of their reality. It provides nurses with a repertoire of possible strategies, allowing them the flexibility to work with the patterns and nuances that present in practice situations.
The findings have implications for nurse education, which aims to teach how behavioural interventions can be incorporated into everyday nursing work. They also raise issues as to how health care organisations can best facilitate and support knowledge and skill development for this area of practice.