Nurse practitioners in rural primary health care in New Zealand : an institutional ethnography : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Albany, New Zealand

Abstract

Nurse practitioners are an effective and appropriate health workforce for delivering health services to underserved and rural populations. Since 2001, New Zealand has been registering nurse practitioners through a robust educational, regulatory, and legislative framework, and from 2014, all nurse practitioners are authorised prescribers. However, the numbers of nurse practitioners working in rural primary health care have been slow to materialise. Despite an ageing demographic, the increasing prevalence of long term conditions, ongoing health inequalities, and a declining rural medical workforce, there remains a persistence to pursue the general practitioner-led model of care. The purpose of this study was to critically examine the work required to establish nurse practitioner services in rural primary health care in New Zealand. Institutional ethnography, developed by Dorothy Smith, provided the overall approach to the inquiry. The activities and experiences of people in local settings are textually organised by the institutional ruling relations. This inquiry explored the work and experiences that nurses undertook on their journey to become nurse practitioners and deliver services in rural primary health care, and how these were institutionally shaped and coordinated. Interviews were initially conducted with nurse practitioners and nurse practitioner candidates as the primary informants. The interviews were analysed using a mapping technique to identify text-based work processes and show connections, tensions, and contradictions with authoritative or ruling texts. Further data was collected through secondary informant interviews and the tracing and identification of texts. The findings revealed that there were multiple texts and discourses being enacted locally, which facilitated or hampered their work to become nurse practitioners. The ongoing institutional domination of medicine retained general practitioner-led primary care, despite policy and nursing professional texts that promoted social justice. Service fragmentation and frequent changes in policy, structure, and management of organisations at local and national level, resulted in further challenges and work processes by the nurse practitioners to maintain and implement services. Together with the lack of a cohesive national policy and implementation framework for nurse practitioners, the opportunity for nurse practitioners to meet the health needs of the rural population of New Zealand continues to be discounted