A conceptual framework for breast nurses' practice in rural settings : a pragmatic mixed methods study

Breast cancer typically causes significant disease burden for women, often compounded by complex and fragmented cancer care. Breast nursing roles support women by providing supportive care and care coordination. However, most of what we know about breast nursing is from urban settings. Major gaps in knowledge exist around how breast nurses effectively undertake real world practice in rural areas. This thesis addressed an important gap in the literature by comprehensively describing breast nursing practices in naturalistic rural contexts. The study builds on previous breast nursing research by emphasising a focus on rural context, factors influencing nursing practices, and considering whether clients' needs are met (i.e. effectiveness). The research process followed a sequential, explanatory mixed method design to answer the question: What factors are important in shaping rural breast nursing practices, and how do these factors exert their influence on breast nursing and the supportive care outcomes of their clients? Three breast nursing services in varying rural sites are described, and summarised to compare with previous reports of breast nursing. Quantitative data over a one-year period provided descriptions of overall rural breast nursing practices, and consultations with women. During the same time period, clients' supportive care outcomes were gathered through longitudinal surveys of unmet needs. These quantitative results informed semi-structured interviews with rural breast nurses about what they do, and what influences their practices. Together, the quantitative and qualitative findings informed the conceptual framework developed within this thesis. The conceptual framework for rural breast nurse practice incorporates the key interacting features that shape rural breast nursing practices. Client's needs are determined by individual characteristics, circumstances, and journeys which, in turn, influence nursing practices. Nurses' personal and professional features, including their experiences and relationships, individualise rural breast nursing practices. Physical and socio-cultural contextual features within organisations and wider healthcare systems create the parameters that define what is possible within each site. Significantly, features related to clients', nurses', and healthcare providers' availability and accessibility are important to the effectiveness of rural nursing services. This thesis provides unique insight because it considers the context of real world practice and acknowledges the need for diversity in nursing practices to reflect individual settings. It recognises that there are a multitude of influences on nursing practices, and specifically highlights nurse and contextual features, which are generally not acknowledged in the breast nursing literature. Additionally it provides a comprehensive description of rural breast nursing practice whilst acknowledging its place within a system of cancer care. The study outcomes inform the establishment and improvement of rural breast nurse services by identifying the influences of clientele, nurse, and contextual features that should be considered when planning services. A conscious focus on the availability and accessibility of all elements will maximise the quality of interventions and outcomes. Additionally, the outcomes inform the recruitment and education of breast nurses, particularly those in rural areas. Educational programs should specifically aim to develop their candidates' clinical confidence for effective advanced nursing practice. Clinical confidence and relevant experience should be essential criteria for positions. Future research should build knowledge around the need for advanced nurses' educational preparation, skill level, and diplomacy (e.g. what is it and how to teach it) and educational institutions can incorporate this knowledge into curriculums. The significance of the variability in nursing practice identified in this study would also benefit from further research.