Abstract: The question explored in this research project is: What are inpatient registered nurses' perceptions of the factors which influence therapeutic relationship development? The literature reviewed for this project includes the history of interpersonal relationships in nursing; therapeutic relationships; what constitutes these relationships. Also discussed is literature about phenomenology as the underlying theoretical and philosophical position that informs the research method. To answer the research question a single focus group was used to gather data from a group of registered nurses practising in inpatient mental health units. Focus groups as a data collection method produce data and insights that would not be accessible without the group interaction. The key themes to emerge from the data analysis were; time, environment, knowing / self-awareness, compassion and power imbalance / empowerment. These key themes are discussed in relation to the literature and the wider context of the mental health care environment. The contribution this research makes to nursing includes a list of recommendations to nurses, nurse leaders and managers who aim to provide therapeutic mental health unit environments.

Abstract: This study traces the author's transition from being a mental health nurse to becoming a facilitator of an education programme, the Health and Wellbeing course, for those in recovery from mental illnesses. Within this transition, she describes a journey from disease-focused paradigms toward emancipatory paradigms, evidenced by her application of the recovery approach to her teaching. The 'recovery approach' proposed by the Mental Health Commission in November 1998, and other models of health, are explored using the methodology of descriptive/interpretive philosophical inquiry, autobiographical narrative and a dialectical research design. The author draws from the philosophies of phenomenology and existentialism to present excerpts from her journals, exemplars, poetry and artwork which illuminate epiphanies occurring as she integrates health paradigms in the design of the Health and Wellbeing course. Within this process the recovery approach is revealed as being consistent with the teaching principles of the Health and Wellbeing course. The author goes on to say that the dialectical research design reveals paradoxes and transformations in nursing, medical, psychological, and humanistic paradigms within the New Zealand socio-political context from the 1970s to 2003. The way these are integrated into her practice as an educator, becomes evident in the dialectical research cycles of being, thinking, developing a project, the encounter of teaching, making sense and communication. These cycles reveal her being in the roles of nurse and educator and the thinking through of paradigms that lead to the design and philosophy of a Health and Wellbeing course, the encounter of teaching, and the communication of insights gained. The author's main objective is to show the importance of nurses and educators developing a reflective consciousness when working with sufferers of mental illness. This reflective consciousness involves three levels: The primary level, or raw experience; the social level, or our socio-political contexts and social values, and, the realised level, insights gained about knowledge and experience.

Abstract: Therapeutic relationships are central to mental health nursing. The nurse's role in maintaining professional yet therapeutic boundaries within this relationship can be challenging. When therapeutic boundaries are breeched within the nurse adolescent relationship the adolescent's safety within this relationship is compromised. There is currently limited literature on how nurses are managing professional boundaries in relationships with adolescents in this setting. The adolescent's nature is to push boundaries; therefore the nurse needs to be acutely aware of this boundary pushing in everyday practice settings. For the safety of the adolescent and the nurse it is vital the nurse understands her role in managing the professional boundary. This thesis explores, through the use of narrative inquiry, four adolescent mental health nurses' experiences of assessing, understanding and maintaining therapeutic boundaries with adolescents in a mental health setting in New Zealand. The unique and specific implications for adolescent mental health nursing are discussed. Three key themes emerged from the analysis and findings: the importance of the nurse clarifying his/her role; the learning that occurs throughout the practice journey; and the role of the nurse in keeping the adolescent and the nurse safe. These findings highlight the importance of clinical supervision and open communication with senior nurses and mentors, which assist the nurse in monitoring practice. When nurses do not have sufficient knowledge of the fundamental principles of adolescent mental health nursing; such as knowledge and skills in both adolescent development and psychodynamic nursing, they are at risk of boundary crossings. Recommendations from this research include more emphasis on psychodynamic nursing principles in nursing education and nursing practice. There is a need for specialised education for nurses in child and adolescent mental health nursing. Nursing entry to practice programmes for new graduate nurses working in mental health, could assist in providing this. There is a call for further research into therapeutic relationships and professional boundaries in this complex nursing specialty.

Abstract: Practice development, situated at the nurse-patient interface, is a crucial aspect of professional development as a whole. The Nursing Development Unit (NDU) is one model of structured clinical practice development. NDU have their origin in a desire to provide the best possible care for patient through the support and development of autonomous therapeutic nurses. All possible sources of NDU-related literature from 1983-1999 were reviewed to determine the effectiveness of the NDU model. The purpose of the research was to establish the role of the parent organisation in supporting the ongoing viability of NDU; to describe the key processes and activities of NDU that are instrumental in the development of nursing practice; to clarify the role of the NDU in contributing to improved patient outcome; and finally to identify the critical indicator of successful NDUs for their application in the New Zealand context. The study found that British nursing journals have played a large part in promoting the NDU model. The pioneering units were given positive coverage and this has by and large continued. Accreditation systems have been important in maintaining standards and providing a generic framework for implementation. The trend is now towards internal funding from the parent organisation. The review identified a number of key features for the successful establishment of NDUs. NDUs appear to have under emphasised the development of socio-political acumen in the nursing staff. However, the NDU does offer a model for the development of confident, assertive, autonomous professionals. The NDU model values nursing as professional practice. The author concludes that the NDU model has stood the test of time, and demonstrated the ability to be at the vanguard of contemporary practice development. The model is flexible and its potential is maximised when it is tailored to meet the need of the parent organisation. The model has been successfully established in Australia, and has the potential to be adapted and refined for the New Zealand context.

Abstract: This paper explores the reaction of the author's colleagues when she returned to work disabled after recovering from an injury. In order to understand the new experience of disability and discrimination and to help answer what changed the behaviour of colleagues, the author considered evidence from the published literature. After considering many different models of disability, the social model of disability helped clarify and frame her own experience. Reflecting on this literature and personal experience, she suggests that there is acknowledgement that society's attitudes are changing slowly through governmental action and the activism of the disabled. However, she goes on to say, it is only through progressing education, experiencing disability, and continuing emancipatory research that progress will be made to release people with disabilities from their bonds of prejudice and oppression.

Abstract: New Zealand statistics project that the aging population of people aged 65 years and over will more than double in the next decade. This has implications for palliative care providers including hospices and hospitals because long-term inpatient care is not generally provided by hospitals and hospices. When dying patients need long-term care, residential settings become an option. The level of palliative care in these facilities is dependent on staff training and numbers. In general, staff are not trained in palliative care, neither do they provide the multidisciplinary facets that define palliative care as undertaken by hospices. This paper describes a practice development initiative using storytelling as the vehicle for introducing the concept of the Liverpool Care Pathway (LCP) for the dying patient into residential aged care settings. With the emergence of a reflective paradigm in nursing the concept of storytelling as a teaching/learning tool has grown. Many staff in residential care settings come from diverse ethnic backgrounds where for some, English is their second language. Storytelling therefore can be a useful approach for learning because it can increase their communication skills. The author suggests that the Liverpool Care Pathway for the dying patient is a model that can be translated across care settings, hospice, hospital, and community. It can demonstrate a framework that facilitates multiprofessional communication and documentation and embraces local needs, culture and language to empower health care workers to deliver high quality care to dying patients and their family/whanau and carers. This paper also explores the role of a facilitator as an agent of change and discusses how the interplay of evidence, context and facilitation can result in the successful implementation of the LCP into residential aged care settings.

Abstract: This paper presents an exploration of a foundational goal of palliative care nursing which is to help patients die with dignity. The paper presents this practice exploration as a journey to gain understanding of the concept of dignity; the author notes that it does not avoid the difficulties encountered in practice situations because dying with dignity is unique and curiously also invisible and different for everyone. Much of human life is conducted through stories and much of nursing involves telling and listening to stories. Many of our social institutions are comprised almost entirely of opportunities for telling and retelling stories. Nurses are constantly listening to patients telling them what is going on in their lives and because of this the stories related here are written bold and raw. The three stories explore and reveal in-depth details of nursing practice that evolved and changed after reflection. The paper also reveals and explores the untold and often painful stories that challenge nurses' capacity to offer dignified care. To deepen the exploration towards discovering ways to articulate the complexity of dignity, the author reflected on the nature of the practice changes documented in the stories and then used a range of diverse literature and her love of the paintings and philosophy of a New Zealander, Ralph Hotere, to support her ideas that dignity is indeed a complex phenomenon.

Abstract: The focus of this research was to explore the migrant family's experience in palliative care. In writing this thesis, the author notes that it became evident that cultural safety was a connection that warranted further study in relation to end-of-life nursing care as was illustrated by the intergenerational case study of this migrant family in New Zealand. The use of the case study method of qualitative research enabled the voice of the migrant to be heard and the story of the migrant family's experience to be showcased. The uniqueness of this family's palliative care experience was around the religious and cultural needs and migration as a process of transition from a previous society to a new one. Palliative care was defined by the family approach with strong community support and empowered by culturally safe and appropriate nursing practice. End-of-life illness is a time when cultural perspectives are challenged for patients and their families and religious and cultural practices take on a new priority, regardless of how they have lived life previously. As a migrant nurse living and working in the New Zealand context, the author identifies as an important factor, the nurse-patient interaction as an encounter between two cultural perspectives, the patient's and the nurse as bearer of her own culture. Acknowledging this factor is an important step in developing a culturally safe approach to practice, an approach that proved to be a major ingredient in planning and caring for this patient and his family in end-of-life illness. This study and thesis explores the underpinnings of culturally safe palliative nursing care and identified 'reflexive bracketing' as a useful practice in the process.